Clinical assessment of the long-term risk of fracture in patients with rheumatoid arthritis.
Open accessAbstract
Objective: To determine whether patients with rheumatoid arthritis (RA) have an increased risk of fracture, and to estimate their long‐term absolute fracture risk. Methods: We studied patients with RA ages ≥40 years in the British General Practice Research Database, each matched by age, sex, calendar time, and practice to 3 control patients. Incident fractures, as recorded in the computerized medical records, were ascertained over a median followup of 7.6 years. The fracture rate in RA patients compared with controls was adjusted for smoking, body mass index (BMI), and several clinical risk factors, and Cox proportional hazards models were used to calculate the relative risk (RR) of fracture in RA. A risk score was then developed to provide an estimate of the 5‐ and 10‐year fracture risk among RA patients. Results: There were 30,262 patients with RA, of whom 2,460 experienced a fracture during followup. Compared with controls, patients with RA had an increased risk of fracture, which was most marked at the hip (RR 2.0, 95% confidence interval [95% CI] 1.8–2.3) and spine (RR 2.4, 95% CI 2.0–2.8). Indicators of a substantially elevated risk of fracture (at the hip) included >10 years' duration of RA (RR 3.4, 95% CI 3.0–3.9), low BMI (RR 3.9, 95% CI 3.1–4.9), and use of oral glucocorticoids (RR 3.4, 95% CI 3.0–4.0). Modeling of the long‐term risk profiles revealed that, for example, in a woman age 65 years with longstanding RA whose risk factors also included low BMI, a history of fracture, and frequent use of oral glucocorticoids, the 5‐year risk of hip fracture was 5.7% (95% CI 5.3–6.1%). Conclusion: Patients with RA are at increased risk of osteoporotic fractures. This increased risk is attributable to a combination of disease activity and use of oral glucocorticoids.
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Systemic bone loss and increased fracture risk are important components of RA.
“In addition to focal bone erosions and periarticular bone loss, systemic bone loss and increased fracture risk are important components of RA (224, 239, 420 -422).”
From Receptor Activator of Nuclear Factor κB Ligand and Osteoprotegerin Regulation of Bone Remodeling in Health and Disease (2008) · cites this paper as [422]
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“In contrast with other peripheral sites, the incidence of wrist fracture decreased in RA as compared to the controls [6,32].”
BackgroundResultPostmenopausal osteoporosis in rheumatoid arthritis: The estrogen deficiency-immune mechanisms link
Sapir‐Koren, R., & Livshits, G. (2017) · Bone · doi:10.1016/j.bone.2017.06.020 · Cited by 97 · see citing works
Deficits in Muscle Mass, Muscle Density, and Modified Associations With Fat in Rheumatoid Arthritis
Baker, J. F., Feldt, J. V., Mostoufi‐Moab, S., Noaiseh, G., Taratuta, E., Kim, W., & Leonard, M. B. (2014) · Arthritis Care & Research · doi:10.1002/acr.22328 · Cited by 97 · see citing works
“We believe that these observations add to previous epidemiologic studies showing greater risk of fracture, joint destruction, and death among RA subjects with low BMI.(27-29) The most severe muscle deficits in RA may be the result of a severe disease phenotype that is toxic to muscle and also associated with greater r…”
InfluentialApproach to the patient with secondary osteoporosis
Hofbauer, L. C., Hamann, C., & Ebeling, P. R. (2010) · European Journal of Endocrinology · doi:10.1530/eje-10-0015 · Cited by 93 · see citing works
Raterman, H. G., & Lems, W. F. (2019) · Drugs & Aging · doi:10.1007/s40266-019-00714-4 · Cited by 93 · see citing works
Osteoporosis and rheumatic diseases
Maruotti, N., Corrado, A., & Cantatore, F. P. (2014) · Reumatismo · doi:10.4081/reumatismo.2014.785 · Cited by 92 · see citing works
“5 fold higher risk of osteoporotic fractures compared to healthy controls (9).”
BackgroundBone Loss in Rheumatoid Arthritis: Systemic, Periarticular, and Focal
Deal, C. L. (2012) · Current Rheumatology Reports · doi:10.1007/s11926-012-0253-7 · Cited by 93 · see citing works
“Bone loss is often a complication of RA, and that loss may be both systemic and local [1, 2].”
BackgroundSmedslund, G., Byfuglien, M. G., Olsen, S. U., & Hagen, K. B. (2010) · Journal of the American Dietetic Association · doi:10.1016/j.jada.2010.02.010 · Cited by 89 · see citing works
Avouac, J., Koumakis, E., Tóth, E., Meunier, M., Maury, E., Kahan, A., Cormier, C., & Allanore, Y. (2012) · Arthritis Care & Research · doi:10.1002/acr.21761 · Cited by 89 · see citing works
“Positive rheumatoid factor 85 (61) Positive anti–CCP-2 antibodies 73 (53) Erosions 104 (75) Conventional DMARD 133 (96) Biotherapy 55 (40) TNF inhibitors 23 (17) Rituximab 19 (13) Abatacept 4 (3) Tocilizumab 9 (6) HAQ score, mean SD 1.”
BackgroundGlucocorticoids, Inflammation and Bone
Güler-Yüksel, M., Hoes, J. N., Bultink, I. E. M., & Lems, W. F. (2018) · Calcified Tissue International · doi:10.1007/s00223-017-0335-7 · Cited by 91 · see citing works
Co-morbidity in patients with early rheumatoid arthritis - inflammation matters
Innala, L., Sjöberg, C., Möller, B., Ljung, L., Smedby, T., Södergren, A., Magnusson, S., Rantapää‐Dahlqvist, S., & Wållberg‐Jonsson, S. (2016) · Arthritis Research & Therapy · doi:10.1186/s13075-016-0928-y · Cited by 87 · see citing works
“Co-morbid conditions that are over-represented in RA patients compared with the general population include cardiovascular disease (CVD) [3, 14–17], interstitial lung disease [18–20], infections [21, 22], gastrointestinal disease [12, 23] and osteoporosis [24, 25].”
BackgroundFrom bone biology to clinical outcome: state of the art and future perspectives
Schett, G., Saag, K., & Bijlsma, J. (2010) · Annals of the Rheumatic Diseases · doi:10.1136/ard.2010.135061 · Cited by 88 · see citing works
“Generalised osteoporosis of the axial and appendicular skeleton in RA leads to an increased risk of fractures (adjusted RR for clinical osteoporotic fractures 1.5 (95% CI 1.4 to 1.6), most marked at the hip (RR 1.3) and spine (RR 2.4)) in patients without recent glucocorticoid (GC) use,”
BackgroundInfluentialSelf-citationMeguid, M. H. A., Hammad, Y. H., Swilam, R. S., & Barakat, M. S. (2012) · Rheumatology International · doi:10.1007/s00296-012-2375-7 · Cited by 85 · see citing works
“It is clear that in RA factors other than glucocorticoid use are also important in the pathogenesis of OP [9].”
BackgroundThe role of interleukin-6 in rheumatoid arthritis-associated osteoporosis
Edwards, C., & Williams, E. (2010) · Osteoporosis International · doi:10.1007/s00198-010-1192-7 · Cited by 90 · see citing works
“[7] showed that patients with RA had an increased risk of fractures at both the hip (risk ratio [RR]=”
BackgroundSystemic effects of IL-6 blockade in rheumatoid arthritis beyond the joints
Jarlborg, M., & Gabay, C. (2021) · Cytokine · doi:10.1016/j.cyto.2021.155742 · Cited by 87 · see citing works
Management of osteoporosis in rheumatoid arthritis patients
Hoes, J. N., Bultink, I. E. M., & Lems, W. F. (2015) · Expert Opinion on Pharmacotherapy · doi:10.1517/14656566.2015.997709 · Cited by 83 · see citing works
The risk of fracture among patients with psoriatic arthritis and psoriasis: a population-based study
Ogdie, A., Harter, L., Shin, D. B., Baker, J. F., Takeshita, J., Choi, H. K., Löve, Þ. J., & Gelfand, J. M. (2017) · Annals of the Rheumatic Diseases · doi:10.1136/annrheumdis-2016-210441 · Cited by 83 · see citing works
RANKL: A therapeutic target for bone destruction in rheumatoid arthritis
Tanaka, S., Tanaka, Y., Ishiguro, N., Yamanaka, H., & Takeuchi, T. (2017) · Modern Rheumatology · doi:10.1080/14397595.2017.1369491 · Cited by 81 · see citing works
“RA patients are known to be at increased risk of osteoporotic fractures [48-51].”
BackgroundConnective tissue diseases, multimorbidity and the ageing lung
Spagnolo, P., Cordier, J.-F., & Cottin, V. (2016) · European Respiratory Journal · doi:10.1183/13993003.00829-2015 · Cited by 84 · see citing works
Raterman, H. G., Bultink, I. E. M., & Lems, W. F. (2020) · Expert Opinion on Pharmacotherapy · doi:10.1080/14656566.2020.1787381 · Cited by 82 · see citing works
Osteoporosis and fractures in rheumatoid arthritis
Wysham, K. D., Baker, J. F., & Shoback, D. (2021) · Current Opinion in Rheumatology · doi:10.1097/bor.0000000000000789 · Cited by 80 · see citing works
“Rheumatoid arthritis (RA) is a chronic inflammatory disease that damages the joints and causes bone demineralization [1], thereby doubling the risk of osteoporotic fractures compared to the general population [2].”
BackgroundBiologic therapies and systemic bone loss in rheumatoid arthritis
Dimitroulas, T., Nikas, S. N., Trontzas, P., & Kitas, G. D. (2013) · Autoimmunity Reviews · doi:10.1016/j.autrev.2013.03.015 · Cited by 78 · see citing works
“Case control studies [18] and a meta-analysis [19] demonstrate that RA almost doubles the risk of hip and vertebral fractures, regardless of whether steroids are used or not.”
BackgroundKim, S. C., Schneeweiß, S., Liu, J. L., & Solomon, D. H. (2011) · Journal of Bone and Mineral Research · doi:10.1002/jbmr.1489 · Cited by 78 · see citing works
“Other sensitivity analyses were performed by including only (1) subjects with a follow-up period of 90 days or longer as a lag time period; (2) female subjects only; (3) persons with prior glucocorticoid use; (4) persons without prior glucocorticoid use; and (5) focusing only on those without a prior fracture.”
BackgroundMethodThe Role of Osteocytes in Inflammatory Bone Loss
Metzger, C. E., & Narayanan, S. A. (2019) · Frontiers in Endocrinology · doi:10.3389/fendo.2019.00285 · Cited by 79 · see citing works
Marder, W., Khalatbari, S. H., Myles, J. D., HENCH, R. P., Lustig, S., Yalavarthi, S., Parameswaran, A., Brook, R. D., & Kaplan, M. J. (2013) · Journal of the American Heart Association · doi:10.1161/jaha.113.000441 · Cited by 77 · see citing works
“RA patients, a group already at heightened risk for osteoporosis due to disease activity and corticosteroid use.(49) PPAR agonist subtypes with selectivity for PPAR-c have been associated with loss of bone density and strength in animal models and in clinical trials, due to unfavorable balance between bone formation a…”
BackgroundVis, M., Haavardsholm, E. A., Bøyesen, P., Haugeberg, G., Uhlig, T., Hoff, M., Woolf, A. D., Dijkmans, B. A. C., Lems, W. F., & Kvien, T. K. (2011) · Osteoporosis International · doi:10.1007/s00198-010-1517-6 · Cited by 76 · see citing works
“5 for all fractures in RA patients compared to healthy controls [4].”
BackgroundWang, Y., Zhao, R. Z., Gu, Z., Dong, C., Guo, G., & Li, L. (2020) · Osteoporosis International · doi:10.1007/s00198-020-05360-w · Cited by 75 · see citing works
“In the treatment of GIO, calcium and vitamin D should be supplemented with anti-osteoporosis treatment [34].”
BackgroundDental implants in patients with rheumatoid arthritis: clinical outcome and peri‐implant findings
Krennmair, G., Seemann, R., & Piehslinger, E. (2010) · Journal Of Clinical Periodontology · doi:10.1111/j.1600-051x.2010.01606.x · Cited by 74 · see citing works
“Patients with RA with or without concomitant corticosteroid treatment will develop localized osteopenia and generalized osteoporosis in 30–50% of all cases (Raisz 1988, van Staa et al. 2006, Nakayama 2007, Haugeberg 2008).”
Osteoclasts, key players in skeletal health and disease
Novack, D., & Mbalaviele, G. (2016) · Microbiology spectrum · doi:10.1128/microbiolspec.mchd-0011-2015 · Cited by 73 · see citing works
Can bone loss in rheumatoid arthritis be prevented?
Vis, M., Güler-Yüksel, M., & Lems, W. F. (2013) · Osteoporosis International · doi:10.1007/s00198-013-2334-5 · Cited by 71 · see citing works
“Earlier studies have shown that patients with RA are also at an increased risk of both vertebral [47, 48] and nonvertebral fractures [49, 50].”
BackgroundBone mineral density in patients with recently diagnosed, active rheumatoid arthritis
Güler-Yüksel, M., Bijsterbosch, J., Goekoop-Ruiterman, Y. P. M., Breedveld, F. C., Allaart, C. F., Vries-Bouwstra, J. K. D., Dijkmans, B. A. C., Lems, W. F., Ronday, H. K., Peeters, A. J., et al. (2007) · Annals of the Rheumatic Diseases · doi:10.1136/ard.2007.070839 · Cited by 73 · see citing works
Solomon, D. H., Finkelstein, J. S., Shadick, N. A., LeBoff, M. S., Winalski, C. S., Stedman, M. R., Glass, R. J., Brookhart, M. A., Weinblatt, M. E., & Gravallese, E. M. (2009) · Arthritis & Rheumatism · doi:10.1002/art.24551 · Cited by 71 · see citing works
Blavnsfeldt, A. G., de Thurah, A. L., Thomsen, M. D., Tarp, S., Langdahl, B. L., & Hauge, E. (2018) · Bone · doi:10.1016/j.bone.2018.06.008 · Cited by 67 · see citing works
Effects of Anti-Tumor Necrosis Factor α (anti-TNF) agents on Bone
Kawai, V., Stein, C. M., Perrien, D., & Griffin, M. (2012) · Current Opinion in Rheumatology · doi:10.1097/bor.0b013e328356d212 · Cited by 63 · see citing works
Characteristics of fracture and related factors in patients with rheumatoid arthritis
Nampei, A., Hashimoto, J., Koyanagi, J., Ono, T., Hashimoto, H., Tsumaki, N., Tomita, T., Sugamoto, K., Nishimoto, N., Ochi, T., et al. (2008) · Modern Rheumatology · doi:10.1007/s10165-008-0032-5 · Cited by 66 · see citing works
Pyroptosis in Osteoblasts: A Novel Hypothesis Underlying the Pathogenesis of Osteoporosis
Tao, Z., Wang, J., Wen, K., Yao, R.-Q., Da, W., Zhou, S., Meng, Y., Qiu, S., Yang, K., Zhu, Y., et al. (2021) · Frontiers in Endocrinology · doi:10.3389/fendo.2020.548812 · Cited by 65 · see citing works
“include low calcium intake (3), estrogen deficiency in postmenopausal women (4, 5), autoimmune diseases, such as rheumatoid arthritis (RA) (6), and the adverse reactions of some drugs, etc.”
BackgroundClinical aspects of vitamin D in the management of rheumatoid arthritis
Leventis, P., & Patel, S. K. (2008) · Lara D. Veeken · doi:10.1093/rheumatology/ken296 · Cited by 63 · see citing works
Skeletal complications of rheumatoid arthritis
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Paskins, Z., Whittle, R., Sultan, A. A., Müller, S., Bucknall, M., Helliwell, T., Hider, S., Roddy, E., & Mallen, C. D. (2018) · BMC Medicine · doi:10.1186/s12916-017-0987-1 · Cited by 62 · see citing works
Effects of inflammation on bone: an update
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Lee, S., Park, Y., Park, S., Kim, T., Choi, H., Lee, S., Kim, S., Lee, S., Kim, G., Lee, J., et al. (2012) · International Journal of Rheumatic Diseases · doi:10.1111/j.1756-185x.2012.01729.x · Cited by 60 · see citing works
Common mechanisms and holistic care in atherosclerosis and osteoporosis
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“falling,((11)) or use of glucocorticoids,((2,12)) other factors, such as a deterioration in bone microstructure and material property that are not captured by aBMD measurements can significantly compromise bone strength((13)) and contribute to the increased fracture risk associated with RA.”
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“Exclusion criteria were as follows: (1) known metabolic disorder that could affect bone metabolism, such as severe renal impairment,”
BackgroundRegulation of bone destruction in rheumatoid arthritis through RANKL-RANK pathways
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Atopic eczema and fracture risk in adults: A population-based cohort study
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RANKL as a therapeutic target of rheumatoid arthritis
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The frequency of and risk factors for osteoporosis in Korean patients with rheumatoid arthritis
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Glucocorticoid-induced osteoporosis
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- Authors
- Staa, T. P. V., Geusens, P., Bijlsma, J. W. J., Leufkens, H. G. M., & Cooper, C.
- Affiliations
- University of Southampton (GB)
- University Medical Center Utrecht (NL)
- Utrecht University (NL)
- Venue
- Arthritis & Rheumatism
- Publisher
- Wiley
- Published
- 2006-09-28
- Volume
- 54
- Issue
- 10
- Pages
- 3104-3112
- ISSN
- 0004-3591 (ISSN-L)
- 1529-0131
- OpenAlex
- W2098986981
- Cited by
- 587
- References
- 39
- Citations by year
- 2026: 8 · 2025: 15 · 2024: 19 · 2023: 21 · 2022: 26 · 2021: 56 · 2020: 44 · 2019: 37 · 2018: 50 · 2017: 40 · 2016: 32 · 2015: 30 · 2014: 34 · 2013: 33 · 2012: 38
- FWCI
- 11.88
- Type
- journal article
- Language
- en
- Open access
- green
- dspace.library.uu.nl
- Licence
- Locations
- Arthritis & Rheumatism (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Document Server@UHasselt (UHasselt) (submittedVersion)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- ePrints Soton (University of Southampton) (submittedVersion)
- Topics
- Health Sciences › Medicine › Rheumatology › Rheumatoid Arthritis Research and Therapies
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Bone health and osteoporosis research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Menopause: Health Impacts and Treatments
- Keywords
- rheumatoid arthritis, fracture risk, osteoporotic fractures, hip fracture, spinal fractures, oral corticosteroids, body mass index, disease duration
- MeSH terms
- Adult, Aged, Aged, 80 and over, Algorithms, Arthritis, Rheumatoid, Female, Glucocorticoids, Humans, Male, Middle Aged, Osteoporosis, Risk Factors, Time Factors, Cohort Studies, Case-Control Studies, Fractures, Bone
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