Abstract
Summary
This study aimed to examine fracture risk in patients with late-onset psoriasis. A cohort study was conducted using primary care records from the Clinical Practice Research Datalink. Psoriasis patients had a 10% increased risk of fracture compared to matched controls (hazard ratio (HR) = 1.10; 95% confidence interval (CI) 1.04, 1.16).
Introduction
This study aimed to examine fracture risk in patients with late-onset psoriasis and investigate the effect of methotrexate on fracture risk.
Methods
A cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident (new onset) diagnoses of psoriasis, were identified from 1990 to 2004 and followed up until 2015. For each exposed individual, up to four age-, gender-, and practice-matched controls were randomly selected. Incidence rates of fragility fracture (hip, vertebral, spine, radius or unspecified site) per 10,000 person-years were calculated and hazard rates were compared to the unexposed using Cox regression models. The risk of fracture was also estimated, within the exposed group for patients receiving/not receiving methotrexate.
Results
Twenty-four thousand two hundred nineteen patients with psoriasis and 94,820 controls were identified. The absolute rate of fracture in psoriasis patients was 58 per 10,000 person-years (95% CI 55, 61) and 53 per 10,000 person-years in the matched controls (CI 52, 54). Psoriasis patients had a 10% increased risk of fracture compared to their matched controls (HR = 1.10; 95% CI 1.04, 1.16). Methotrexate use was not associated with increased risk (HR = 0.91; 95% CI 0.72, 1.15).
Conclusions
Identifying additional clinical factors associated with increased fracture risk is important in improving fracture risk stratification. Further work is needed to determine the relationship between age of onset of psoriasis and fracture risk, explore causative explanations, and identify if existing fracture risk stratification tools underestimate fracture risk in patients with psoriasis.
This is a preview of subscription content, log in via an institution to check access.
References
Alamanos Y, Voulgari PV, Drosos AA (2008) Incidence and prevalence of psoriatic arthritis: a systematic review. J Rheumatol 35:1354–1358
Kimball AB, Gladman D, Gelfand JM, Gordon K, Horn EJ, Korman NJ, Korver G, Krueger GG, Strober BE, Lebwohl MG (2008) National Psoriasis Foundation clinical consensus on psoriasis co-morbidities and recommendations for screening. J Am Acad Dermatol 58:1031–1042
Van Staa T, Geusens P, Bijlsma J, Leufkens H, Cooper C (2006) Clinical assessment of the long-term risk of fracture in patients with rheumatoid arthritis. Arthritis Rheumatism 54:3104–3112
Mundy GR (2007) Osteoporosis and inflammation. Nutr Rev 65:S147–S151
Preston SJ, Diamond T, Scott A, Laurent MR (1993) Methotrexate osteopathy in rheumatic disease. Ann Rheum Dis 52:582–585
Dreiher J, Weitzman D, Cohen AD (2009) Psoriasis and osteoporosis: a sex-specific association? J Invest Dermatol 129:1643–1649
Modalsli E, Åsvold B, Romundstad P, Langhammer A, Hoff M, Forsmo S, Naldi L, Saunes M (2017) Psoriasis, fracture risk and bone mineral density: the HUNT Study, Norway. Br J Dermatol 176:1162–1169
Ogdie A, Harter L, Shin D, Baker J, Takeshita J, Choi HK, Love TJ, Gelfand JM (2017) The risk of fracture among patients with psoriatic arthritis and psoriasis: a population-based study. Ann Rheum Dis 76:882–885
Springate D, Parisi R, Kontopantelis E, Reeves D, Griffiths C, Ashcroft D (2017) Incidence, prevalence and mortality of patients with psoriasis: a UK population-based cohort study. Br J Dermatol 176:650–658
Henseler T, Christophers E Psoriasis of early and late onset: characterization of two types of psoriasis vulgaris. J Am Acad Dermatol 13:450–456, 1985
National Institute for Health and Care Excellence (2012) Psoriasis: assessment and management
Gossec L, Smolen JS, Ramiro S, de Wit M, Cutolo M, Dougados M, Emery P, Landewe R, Oliver S, Aletaha D, Betteridge N, Braun J, Burmester G, Canete JD, Damjanov N, FitzGerald O, Haglund E, Helliwell P, Kvien TK, Lories R, Luger T, Maccarone M, Marzo-Ortega H, McGonagle D, McInnes IB, Olivieri I, Pavelka K, Schett G, Sieper J, van den Bosch F, Veale DJ, Wollenhaupt J, Zink A, van der Heijde D (2016) European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis 75:499–510
Vestergaard P, Rejnmark L, Mosekilde L (2006) Methotrexate, azathioprine, cyclosporine, and risk of fracture. Calcif Tissue Int 79(2):69–75
Herrett E, Gallagher AM, Bhaskaran K, Forbes H, Mathur R, van Staa T, Smeeth L (2015) Data Resource Profile: Clinical Practice Research Datalink (CPRD). Int J Epidemiol 44(3):827–836
Huerta C, Rivero E, Rodriguez LA (2007) Incidence and risk factors for psoriasis in the general population. Arch Dermatol 143:1559–1565
Kanis J, Johnell O, Odén A, Johansson H, McCloskey E (2008) FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporosis Int 19:385–397
Gerdes S, Zahl VA, Weichenthal M, Mrowietz U (2010) Smoking and alcohol intake in severely affected patients with psoriasis in Germany. Dermatology 220:38–43
Xu X, Su L, Gao Y, Ding Y (2017) The prevalence of nonalcoholic fatty liver disease and related metabolic comorbidities was associated with age at onset of moderate to severe plaque psoriasis: a cross-sectional study. PLoS One 12:e0169952
Reich K, Mössner R, Neumann C, König IR, Westphal G, Ziegler A (2002) Promoter polymorphisms of the genes encoding tumor necrosis factor-α and interleukin-1β are associated with different subtypes of psoriasis characterized by early and late disease onset. J Invest Dermatol 118:155–163
Van Staa T, Abenhaim L, Cooper C, Zhang B, Leufkens H (2000) The use of a large pharmacoepidemiological database to study exposure to oral corticosteroids and risk of fractures: validation of study population and results. Pharmacoepidemiol Drug Saf 9:359–366
Giangregorio LM, Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA (2012) FRAX underestimates fracture risk in patients with diabetes. J Bone Miner Res 27:301–308
Acknowledgements
The authors wish to thank Dr John Belcher, Prof Kelvin Jordan, and Prof George Peat for methodological support.
Funding
This study was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR, grant number 256). CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice, which also supports AAS (NIHR-RP-2014-04-026). TH is funded by an NIHR Clinical Lectureship in General Practice. MB is funded by the NIHR School for Primary Care Research (SPCR) Capacity Building Award – Fellowship.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None.
Ethics approval and consent
This study was approved by the Independent Scientific Advisory Committee of the CPRD (protocol 15_165RA) on 18th May 2016, before data analysis was conducted. Ethical approval is not needed for database studies and ISAC provide the necessary regulatory approvals. Each practice in CPRD has consented to be included; patients within each consented practice are automatically included.
Electronic supplementary material
ESM 1
(DOCX 25 kb)
Rights and permissions
About this article
Cite this article
Paskins, Z., Whittle, R., Abdul Sultan, A. et al. Risk of fragility fracture among patients with late-onset psoriasis: a UK population-based study. Osteoporos Int 29, 1659–1664 (2018). https://doi.org/10.1007/s00198-018-4491-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00198-018-4491-z