Risk of fragility fracture among patients with late-onset psoriasis: a UK population-based study
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).
This study aimed to examine fracture risk in patients with late-onset psoriasis and investigate the effect of methotrexate on fracture risk.
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.
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).
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.
KeywordsFracture Methotrexate Osteoporosis Psoriasis
The authors wish to thank Dr John Belcher, Prof Kelvin Jordan, and Prof George Peat for methodological support.
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.
Compliance with ethical standards
Conflicts of interest
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.
- 2.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 58:1031–1042CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Henseler T, Christophers E Psoriasis of early and late onset: characterization of two types of psoriasis vulgaris. J Am Acad Dermatol 13:450–456, 1985Google Scholar
- 11.National Institute for Health and Care Excellence (2012) Psoriasis: assessment and managementGoogle Scholar
- 12.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 75:499–510CrossRefPubMedGoogle Scholar
- 19.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 118:155–163CrossRefPubMedGoogle Scholar