Impact of Rheumatoid Arthritis and Its Management on Falls, Fracture and Bone Mineral Density in UK Biobank

The Casual Association Inference for the Chain of Falls Risk Factors-Falls-Falls Outcomes: A Mendelian Randomization Study

Previous associations have been observed not only between risk factors and falls but also between falls and their clinical outcomes based on some cross-sectional designs, but their causal associations were still largely unclear. We performed Mendelian randomization (MR), multivariate Mendelian randomization (MVMR), and mediation analyses to explore the effects of falls. Our study data are mainly based on White European individuals (40-69 years) downloaded from the UK Biobank. MR analyses showed that osteoporosis (p = 0.006), BMI (p = 0.003), sleeplessness (p < 0.001), rheumatoid arthritis (p = 0.001), waist circumference (p < 0.001), and hip circumference (p < 0.001) have causal effects on falls. In addition, for every one standard deviation increase in fall risk, the risk of fracture increased by 1.148 (p < 0.001), the risk of stroke increased by 2.908 (p = 0.003), and a 1.016-fold risk increase in epilepsy (p = 0.009). The MVMR found that sleeplessness is an important risk factor for falls. Finally, our mediation analyses estimated the mediation effects of falls on the hip circumference and fracture (p < 0.001), waist circumference and epilepsy (p < 0.001), and sleeplessness and fracture (p = 0.005). Our study inferred the causal effects between risk factors and falls, falls, and outcomes, and also constructed three causal chains from risk factors → falls → falls outcomes.

Chronic arthritides and bone structure: focus on rheumatoid arthritis-an update

Normal bone remodeling depends of a balance between bone forming cells, osteoblasts and bone resorbing cells, the osteoclasts. In chronic arthritides and some inflammatory and autoimmune diseases such as rheumatoid arthritis, there is a great constellation of cytokines produced by pannus that impair bone formation and stimulate bone resorption by inducing osteoclast differentiation and inhibiting osteoblast maturation. Patients with chronic inflammation have multiple causes that lead to low bone mineral density, osteoporosis and a high risk of fracture including circulating cytokines, impaired mobility, chronic administration of glucocorticoids, low vitamin D levels and post-menopausal status in women, among others. Biologic agents and other therapeutic measures to reach prompt remission might ameliorate these deleterious effects. In many cases, bone acting agents need to be added to conventional treatment to reduce the risk of fractures and to preserve articular integrity and independency for daily living activities. A limited number of studies related to fractures in chronic arthritides were published, and future investigation is needed to determine the risk of fractures and the protective effects of different treatments to reduce this risk.

High incidence of clinical fragility fractures in postmenopausal women with rheumatoid arthritis. A case-control study

OBJECTIVES

To estimate the incidence of clinical fragility fractures in postmenopausal women with rheumatoid arthritis (RA) and analyze risk factors for fracture.

METHODS

Incidence of clinical fragility fractures in 330 postmenopausal women with RA was compared to that of a control population of 660 age-matched postmenopausal Spanish women. Clinical fractures during the previous five years were recorded. We analyzed associations with risk factors for fracture in both populations and with disease-related variables in RA patients.

RESULTS

Median age of RA patients was 64 years; median RA duration was eight years. Sixty-nine percent were in remission or on low activity. Eighty-five percent had received glucocorticoids (GCs); 85 %, methotrexate; and 40 %, ≥1 biologic DMARD. Fifty-four patients and 47 controls had ≥1 major osteoporotic fracture (MOF). Incidence of MOFs was 3.55 per 100 patient-year in patients and 0.72 in controls (HR: 2.6). Risk factors for MOFs in RA patients were age, previous fracture, parental hip fracture, years since menopause, BMD, erosions, disease activity and disability, and cumulative dose of GCs. Previous fracture in RA patients was a strong risk for MOFs (HR: 10.37).

CONCLUSION

Of every 100 postmenopausal Spanish women with RA, 3-4 have a MOF per year. This is more than double that of the general population. A previous fracture poses a high risk for a new fracture. Other classic risk factors for fracture, RA disease activity and disability, and the cumulative dose of GCs are associated with fracture development.

Fracture in clinical studies of tofacitinib in rheumatoid arthritis

Background

Preclinical data suggest that tofacitinib would protect bone health in patients with rheumatoid arthritis (RA).

Objective

To assess fracture risk in tofacitinib RA clinical trials.

Design

Post hoc analysis.

Methods

We analyzed pooled data of phase I/II/III and long-term extension studies ('P123LTE cohort'), pooled data of placebo-controlled portions of phase III studies (phase III placebo-controlled cohort), and data from ORAL Surveillance [phase IIIb/IV randomized, open-label trial evaluating tofacitinib 5/10 mg twice daily (BID) vs tumor necrosis factor inhibitor (TNFi) in patients ⩾ 50 years with ⩾ 1 additional cardiovascular risk factor].

Results

In the phase III placebo-controlled cohort, incidence rates (IRs) [95% confidence interval (CI)] of fracture were 2.11 (1.09-3.68), 2.56 (1.23-4.71), and 4.43 (1.78-9.12) per 100 patient-years (PYs) for tofacitinib 5 mg BID, tofacitinib 10 mg BID, and placebo, respectively [tofacitinib 5 mg BID vs placebo: hazard ratio (HR) (95% CI) = 0.55(0.18-1.65); tofacitinib 10 mg BID vs placebo: HR (95% CI) = 0.72 (0.26-2.01)]. In P123LTE, IRs (95% CI) were 2.62 (2.29-2.99) and 2.26 (2.02-2.52) per 100 PY for average tofacitinib 5 and 10 mg BID, respectively. In ORAL Surveillance, IRs (95% CI) were 2.79 (2.34-3.30), 2.87 (2.40-3.40), and 2.27 (1.87-2.74) per 100 PY for tofacitinib 5 mg BID, tofacitinib 10 mg BID, and TNFi, respectively. In ORAL Surveillance, the risk of fracture was numerically higher than TNFi for tofacitinib 5 mg BID [HR (95% CI) = 1.23 (0.96-1.58)] and tofacitinib 10 mg BID [HR (95% CI) = 1.26 (0.97-1.62)]. In ORAL Surveillance, independent predictors of all and osteoporotic fractures with tofacitinib or TNFi included age ⩾ 65, female sex, history of fracture/osteoporosis, and baseline oral corticosteroid use.

Conclusion

This post hoc analysis showed numerically lower fracture risk with tofacitinib versus placebo and numerically greater risk versus TNFi. We did not identify any tofacitinib-specific predictors of fractures, and predictors of fracture were generally aligned with prior literature in the general population and patients with RA. Patients with fracture risk factors should be adequately monitored and treated.

Clinical trial registration

NCT00960440, NCT00847613, NCT00814307, NCT00856544, NCT00853385, NCT01039688, NCT02187055, NCT02831855, NCT00413699, NCT00147498, NCT00413660, NCT00550446, NCT00603512, NCT00687193, NCT00661661, NCT01164579, NCT00976599, NCT01059864, NCT01359150, NCT01262118, NCT01484561, NCT02281552, NCT02147587, NCT02092467.

Proximity to major roads and the incidence of osteoporotic fractures in elderly women: The BONE study in Beijing

Background

There is growing evidence to suggest that living near major roads (and suffering from the air pollution of urban streets) can have an adverse effect on bone health. However, little is known about its relationship to fractures caused by osteoporosis.

Objective

This study was designed to investigate the relationship between residents living near major roads and the incidence of osteoporotic fractures.

Methods

A retrospective cohort of 529 subjects was established based on community populations in older women aged 65-91. All participants lived in Beijing between September 27, 2007 and September 26, 2017. The distance between the residential sites of the subjects and the main roads was determined by the authors. Osteoporotic fracture diagnosis was based on medical histories and imaging examinations (DXA and X-rays). The Cox proportional hazard model was used to assess the association between traffic proximity and osteoporotic fractures, with suitable adjustments for individual and background factors.

Results

The age range of all participants was 65-91 years, with an average age of 75.8 years (and a standard deviation 6.8 years). Of these, 19 (3.59%) suffered from diabetes, and 48 (9%) had hypertension; 85 (14%) families had annual incomes below US $30,000 and 402 (76%) had received a secondary school education or higher. Nearly 25% of people lived within 50 m of a main road, while 50% lived within 300 m. Between 2007 and 2017, a total of 96 osteoporotic fractures were observed. For people living <50 m from a main road, the adjusted hazard ratio (HR) for osteoporotic fractures was 2.509 (95% CI 1.345-4.680), while it was 1.830 (95% CI 1.029-3.255) for those living at a distance of 50-300 m from a main road vs. those living further than 300 m away.

Conclusion

In this community-based cohort, living near a major road was associated with a higher incidence of osteoporotic fractures.

Potential of Health Insurance Claims Data to Predict Fractures in Older Adults: A Prospective Cohort Study

Purpose

In older adults, fractures are associated with mortality, disability, loss of independence and high costs. Knowledge on their predictors can help to identify persons at high risk who may benefit from measures to prevent fractures. We aimed to assess the potential of German claims data to predict fractures in older adults.

Patients and Methods

Using the German Pharmacoepidemiological Research Database (short GePaRD; claims data from ~20% of the German population), we included persons aged ≥65 years with at least one year of continuous insurance coverage and no fractures prior to January 1, 2017 (baseline). We randomly divided the study population into a training (80%) and a test sample (20%) and used logistic regression and random forest models to predict the risk of fractures within one year after baseline based on different combinations of potential predictors.

Results

Among 2,997,872 persons (56% female), the incidence per 10,000 person years of any fracture in women increased from 133 in age group 65–74 years (men: 71) to 583 in age group 85+ (men: 332). The maximum predictive performance as measured by the area under the curve (AUC) across models was 0.63 in men and 0.60 in women and was achieved by combining information on drugs and morbidities. AUCs were lowest in age group 85+.

Conclusion

Our study showed that the performance of models using German claims data to predict the risk of fractures in older adults is moderate. Given that the models used data readily available to health insurance providers in Germany, it may still be worthwhile to explore the cost–benefit ratio of interventions aiming to reduce the risk of fractures based on such prediction models in certain risk groups.

Update on imaging of the cervical spine in rheumatoid arthritis

Rheumatoid arthritis is a multisystem, autoimmune, inflammatory disorder with numerous musculoskeletal manifestations. Involvement of the cervical spine is common and may result in severe complications due to synovitis, erosions, pannus formation, spinal instability and ankylosis. The purpose of this article is to review the current role of imaging in the rheumatoid spine, with emphasis on radiographs and MRI.

Systematic Evaluation of Rheumatoid Arthritis Risk by Integrating Lifestyle Factors and Genetic Risk Scores

Background

Effective identification of high-risk rheumatoid arthritis (RA) individuals is still a challenge. Whether the combined effects of multiple previously reported genetic loci together with lifestyle factors can improve the prediction of RA risk remains unclear.

Methods

Based on previously reported results and a large-scale Biobank dataset, we constructed a polygenic risk score (PRS) for RA to evaluate the combined effects of the previously identified genetic loci in both case-control and prospective cohorts. We then evaluated the relationships between several lifestyles and RA risk and determined healthy lifestyles. Then, the joint effects of healthy lifestyles and genetic risk on RA risk were evaluated.

Results

We found a positive association between PRS and RA risk (OR = 1.407, 95% confidence interval (CI) = 1.354~1.463; HR = 1.316, 95% CI = 1.257~1.377). Compared with the low genetic risk group, the group with intermediate or high genetic risk had a higher risk (OR = 1.347, 95% CI = 1.213~1.496; HR = 1.246, 95% CI = 1.108~1.400) (OR = 2.169, 95% CI = 1.946~2.417; HR = 1.762, 95% CI = 1.557~1.995). After adjusting for covariates, we found protective effects of three lifestyles (no current smoking, regular physical activity, and moderate body mass index) on RA risk and defined them as healthy lifestyles. Compared with the individuals with low genetic risks and favorable lifestyles, those with high genetic risks and unfavorable lifestyles had as high as OR of 4.637 (95%CI = 3.767~5.708) and HR of 3.532 (95%CI = 2.799~4.458).

Conclusions

In conclusion, the integration of PRS and lifestyles can improve the prediction of RA risk. High RA risk can be alleviated by adopting healthy lifestyles but aggravated by adopting unfavorable lifestyles.

Vertebral fractures are increased in rheumatoid arthritis despite recent therapeutic advances: a case-control study

Prevalence and risk factors of vertebral fractures in postmenopausal RA women were assessed in 323 patients and compared with 660 age-matched women. Of patients, 24.15% had at least one vertebral fracture vs.16.06% of controls. Age, glucocorticoids and falls were the main fracture risks. Vertebral fractures were associated with disease severity.

INTRODUCTION

There is little quality data on the updated prevalence of fractures in rheumatoid arthritis (RA) that may have changed due to advances in the therapeutic strategy in recent years. This study was aimed at analysing the prevalence and risk factors of vertebral fractures in postmenopausal women with RA and comparing it with that of the general population.

METHODS

We included 323 postmenopausal women diagnosed with RA from 19 Spanish Rheumatology Departments, randomly selected and recruited in 2018. Lateral radiographs of the thoracic and lumbar spine were obtained to evaluate morphometric vertebral fractures and the spinal deformity index. We analysed subject characteristics, factors related to RA, and fracture risk factors. The control group consisted of 660 age-matched Spanish postmenopausal women from the population-based Camargo cohort.

RESULTS

Seventy-eight (24.15%) RA patients had at least one vertebral fracture. RA patients had increased fracture risk compared with controls (106 of 660, 16.06%) (p = 0.02). Logistic regression analysis showed that age (OR 2.17; 95% CI 1.27-4.00), glucocorticoids (OR 3.83; 95% CI 1.32-14.09) and falls (OR 3.57; 95% CI 1.91-6.86) were the independent predictors of vertebral fractures in RA patients. The subgroup with vertebral fractures had higher disease activity (DAS28: 3.15 vs. 2.78, p = 0.038) and disability (HAQ: 0.96 vs. 0.63, p = 0.049), as compared with those without vertebral fractures.

CONCLUSION

The risk of vertebral fracture in RA is still high in recent years, when compared with the general population. The key determinants of fracture risk are age, glucocorticoids and falls. Patients with vertebral fractures have a more severe RA.

Rheumatoid arthritis and bone health

Rheumatoid arthritis (RA) is an inflammatory arthropathy affecting 1% of the population, with a female predominance. Systemic inflammation is a key component of RA disease; corticosteroids are often required to rapidly control disease activity. Both inflammation and corticosteroids, however, have an adverse effect on bone mineral density, potentially resulting in osteoporosis and an increased risk of fractures. In this article, we describe the link between RA and impaired bone health, together with appropriate strategies to maintain bone density and reduce fracture risk. Key approaches include achieving adequate control of inflammation, minimising corticosteroid use, monitoring bone mineral density and intervening with antiosteoporosis medications when indicated.

Analysis of the Associations between Arthritis and Fall Histories in Korean Adults

(1) Background: the purpose of the present study was to analyze the associations between arthritis and fall histories in Korean adults. (2) Methods: data from the 2015 and 2017 Korean Community Health Survey were analyzed. In total, 322,962 participants aged ≥40 years were included. The participants were divided into two different groups. First, the participants were divided into the ‘arthritis (osteoarthritis or rheumatoid arthritis) for entire life’ and ‘nonarthritis for entire life (comparison I)’ groups. Subsequently, the participants were divided into the ‘current arthritis’ and ‘noncurrent arthritis (comparison II)’ groups. Afterwards, we analyzed the prevalence odds ratios (pORs) of the fall histories of the participants using a logistic regression analysis with the 95% confidence interval (CI). The variables of income, education level, region of residence, smoking status, alcohol consumption, obesity, subjective health status, stress level, physical activity, and sleep hours were adjusted for as covariates. (3) Results: both the arthritis for entire life and current arthritis groups had higher prevalence rates of falls than the comparison I and comparison II groups, respectively (each p < 0.001). The pORs of falling ≥1 time and ≥2 times per year in the arthritis for the entire life group were 1.42 (95% CI = 1.38–1.46) and 1.69 (95% CI = 1.62–1.76), respectively. The adjusted pORs for falling ≥1 time and ≥2 times per year in the current arthritis group were 1.35 (95% CI = 1.31–1.39) and 1.56 (95% CI = 1.50–1.63), respectively. (4) Conclusions: previous arthritis has a significant impact on the risk of falling.

Bone Loss, Osteoporosis, and Fractures in Patients with Rheumatoid Arthritis: A Review

Rheumatoid arthritis (RA) is often characterized by bone loss and fragility fractures and is a frequent comorbidity. Compared with a matched population, RA patients with fractures have more common risk factors of osteoporosis and fragility fractures but also risk factors resulting from the disease itself such as duration, intensity of the inflammation and disability, and cachexia. The inflammatory reaction in the synovium results in the production of numerous cytokines (interleukin-1, interleukin-6, tumor necrosis factor) that activate osteoclasts and mediate cartilage and bone destruction of the joints, but also have a systemic effect leading to generalized bone loss. Regular bone mineral density (BMD) measurement, fracture risk assessment using tools such as the FRAX algorithm, and vertebral fracture assessment (VFA) should be performed for early detection of osteoporosis and accurate treatment in RA patients.

Translating the Strengthening and Stretching for Rheumatoid Arthritis of the Hand Programme from clinical trial to clinical practice: An effectiveness–implementation study

Introduction

The Strengthening and Stretching for Rheumatoid Arthritis of the Hand programme is a hand exercise programme for people with rheumatoid arthritis. It was clinically effective when delivered during a clinical trial but there was a need to evaluate translation into routine care.

Methods

We conducted an effectiveness–implementation study. We adapted the trial training into an online format for National Health Service hand therapists. Educational outcomes included confidence and capability to deliver the programme. Implementation outcomes included training reach and adoption. Therapists were invited to collect clinical outcomes. Patients receiving the programme provided data on function (Michigan Hand Questionnaire function scale), pain and grip strength at baseline, treatment discharge and four-month follow-up.

Results

A total of 790 therapists (188 National Health Service organizations) enrolled in the training; 584/790 (74%) therapists (162 National Health Service organizations) completed the training; 448/790 therapists (145 National Health Service organizations) (57%) evaluated the training and were confident (447/448, 99.8%) and capable (443/448, 99%) to deliver the programme with 85% intending to adopt it (379/448). Follow-up data were provided by 116/448 (26%) therapists. Two-thirds (77/116; 51 National Health Service organizations) reported adopting the programme. One hundred and eighteen patients (15 National Health Service trusts) participated. Patients reported improved function (mean change Michigan Hand Questionnaire scores: 10 (95% CI 6.5–13.6) treatment discharge; 7 (95% CI 3.8–10.2) 4-month follow-up). Grip strength increased 24.5% (left) and 31% (right). Pain was stable.

Discussion

Online training was an effective way to train therapists with good reach. Clinical outcomes were similar to the clinical trial providing preliminary evidence of successful translation into routine care.