Risk Factors Associated with Osteoporosis and Fracture in Psoriatic Arthritis
Psoriatic arthritis (PsA) is a chronic inflammatory condition that affects a significant portion of individuals with psoriasis, a skin disorder characterized by red, scaly patches. While PsA primarily targets the joints, leading to pain, swelling, and stiffness, its impact on bone health, particularly osteoporosis and fracture risk, has garnered increasing attention. This article delves into the relationship between PsA and bone health, exploring the prevalence of osteoporosis and fractures in PsA patients, identifying risk factors, and discussing the implications for clinical management.
The prevalence of psoriasis is estimated to be 1% to 3% of the global population, with PsA developing in approximately 19.7% of psoriasis patients worldwide and 14% of Asian patients. PsA presents with diverse skeletal manifestations, including spinal involvement resembling ankylosing spondylitis and peripheral joint destruction similar to rheumatoid arthritis. The interplay between inflammation and bone remodeling in PsA has been a focus of recent research, with evidence suggesting that PsA patients may be at increased risk of osteoporosis and fractures.
Osteoporosis, characterized by reduced bone mineral density (BMD) and increased bone fragility, is a systemic skeletal disorder that predisposes individuals to fractures. The link between PsA and osteoporosis was first proposed in a cross-sectional study by Frediani et al., which observed demineralization in more than two-thirds of PsA patients without axial involvement. Subsequent studies have further explored this association, with varying results. Some studies have reported a higher prevalence of osteoporosis and fractures in PsA patients, while others have found no significant increase in fracture risk.
This study aimed to assess the areal and volumetric BMD, frequency of fractures, and associated risk factors in PsA patients. A total of 100 PsA patients and 100 age- and sex-matched healthy controls were enrolled. Dual-energy X-ray absorptiometry (DXA) was used to measure BMD at the lumbar spine, femoral neck, and total hip. Clinical characteristics, disease activity scores, and fracture occurrences were recorded and analyzed.
The results revealed that PsA patients had significantly lower BMD at the total hip and femoral neck compared to healthy controls (0.809 ± 0.193 vs. 0.901 ± 0.152 g/cm², P = 0.041; 0.780 ± 0.146 vs. 0.865 ± 0.166 g/cm², P = 0.037, respectively). Lumbar spine BMD was negatively correlated with psoriasis duration, swollen joint count, and Disease Activity Score 28-C-reactive protein (DAS28-CRP) (r = -0.503, -0.580, -0.438; P < 0.05). Total hip and femoral neck BMD were negatively correlated with the Health Assessment Questionnaire (HAQ) score (r = -0.521, -0.335; P < 0.05).
Fractures occurred in 29 PsA patients during the follow-up period, with hip fractures being the most common (n = 12). Multivariate logistic regression analysis identified older age (OR 1.132, 95% CI: 1.026–1.248, P < 0.05), higher HAQ score (OR 1.493, 95% CI: 1.214–1.836, P < 0.01), higher disease activity index for PsA (OR 1.033, 95% CI: 1.002–1.679, P < 0.05), and hip joint involvement (OR 6.401, 95% CI: 4.012–44.180, P < 0.05) as significant risk factors for fracture.
The study also found that 72% of PsA patients had reduced BMD (osteopenia or osteoporosis) in at least one site, with 27% having reduced BMD at one site, 16% at two sites, and 12% at all three sites. Osteoporosis was more frequently observed in patients aged 50 years or older (48.0% vs. 24.0%, χ² = 11.87, P = 0.001). Additionally, patients with current glucocorticoid use had a higher frequency of osteoporosis (41.0% vs. 31.0%, χ² = 7.33, P < 0.05).
The correlation between clinical characteristics and BMD was further explored. Univariate analysis showed that PsA patients with lower lumbar BMD were older, had longer psoriasis duration, higher visual analogue scale (VAS), patient global assessment (PGA), evaluator global assessment (EGA), swollen joint count (SJC), tender joint count (TJC), and HAQ scores, as well as higher Psoriasis Area and Severity Index (PASI), DAS28-erythrocyte sedimentation rate (ESR), DAS28-CRP, and Disease Activity Index for PsA (DAPSA) scores (P < 0.05 for all). Patients with lower femoral neck BMD were older, had lower body mass index (BMI), longer psoriasis duration, higher VAS, PGA, EGA, SJC, TJC, HAQ score, ESR, PASI, DAS28-ESR, DAS28-CRP, and DAPSA scores (P < 0.05 for all).
Multivariate logistic regression models were used to identify predictors for reduced BMD and fractures in PsA patients. Older age (OR 40.282, 95% CI: 1.058–33.350, P < 0.05) and longer psoriasis duration (OR 1.061, 95% CI: 1.002–1.125, P < 0.05) were significantly associated with a higher risk of decreased BMD. For fractures, older age, higher HAQ score, hip joint involvement, and higher DAPSA score were significant risk factors.
The findings of this study highlight the importance of monitoring bone health in PsA patients, particularly those with high disease activity, hip joint involvement, and older age. The high prevalence of reduced BMD and fractures in PsA patients underscores the need for routine BMD screening and appropriate management strategies to mitigate fracture risk. Additionally, the role of glucocorticoids in inducing bone loss and fractures warrants careful consideration in the treatment of PsA.
In conclusion, PsA patients are at increased risk of osteoporosis and fractures compared to healthy controls. High disease activity, hip joint involvement, and older age are significant risk factors for reduced BMD and fractures. These findings emphasize the need for comprehensive bone health assessment and management in PsA patients to prevent fractures and improve overall outcomes. Future studies should explore the impact of controlling inflammation and disease activity on BMD and fracture risk in PsA patients.
doi.org/10.1097/CM9.0000000000001810
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