Ten-year fracture risk by FRAX and osteoporotic fractures in patients with systemic autoimmune diseases

Abstract

The Fracture Risk Assessment Tool (FRAX) has been used universally for the purpose of fracture risk assessment. However, the predictive capacity of FRAX for autoimmune diseases remains inconclusive. This study aimed to compare the applicability of FRAX for autoimmune disease patients. This retrospective study recruited rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and primary Sjögren syndrome (pSS) patients with bone mineral density (BMD) tests. Patients with any osteoporotic fractures were identified. Taiwan-specific FRAX with and without BMD were then calculated. In total, 802 patients (451 RA, 233 SLE and 118 pSS) were enrolled in this study. The cumulative incidences of osteoporotic fractures in the RA, SLE and pSS patients were 43.0%, 29.2% and 33.1%, respectively. For those with a previous osteoporotic fracture, T-scores were classified as low bone mass. Overall, the patients’ 10-year probability of major fracture risk by FRAX without BMD was 15.8%, which then increased to 20.3% after incorporation of BMD measurement. When analyzed by disease group, the fracture risk in RA patients was accurately predicted by FRAX. In contrast, current FRAX, either with or without BMD measurement, underestimated the fracture risk both in SLE and pSS patients, even after stratification by age and glucocorticoid treatment. For pSS patients with major osteoporotic fractures, FRAX risks imputed by RA were comparable to major osteoporotic fracture risks of RA patients. Current FRAX accurately predicted fracture probability in RA patients, but not in SLE and pSS patients. RA-imputed FRAX risk scores could be used as a temporary substitute for SLE and pSS patients.

Keywords

FRAX osteoporosis osteoporotic fracture pSS RA SLE

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References

Tang

Griffith

Qin

et al.

SLE disease per se contributes to deterioration in bone mineral density, microstructure and bone strength. Lupus 2013; 22: 1162–1168.

van Staa

Leufkens

Abenhaim

Zhang

Cooper

. Oral corticosteroids and fracture risk: Relationship to daily and cumulative doses. Rheumatology (Oxford) 2000; 39: 1383–1389.

Carli

Tani

Spera

et al.

Risk factors for osteoporosis and fragility fractures in patients with systemic lupus erythematosus. Lupus Sci Med 2016; 3: e000098–e000098.

Lee

Sung

Choi

et al.

The frequency of and risk factors for osteoporosis in Korean patients with rheumatoid arthritis. BMC Musculoskelet Disord 2016; 17: 98–98.

Hauser

Riches

Wilson

Horne

Ralston

. Prevalence and clinical prediction of osteoporosis in a contemporary cohort of patients with rheumatoid arthritis. Rheumatology (Oxford) 2014; 53: 1759–1766.

Rentero

Amigo

Chozas

et al.

Prevalence of fractures in women with rheumatoid arthritis and/or systemic lupus erythematosus on chronic glucocorticoid therapy. BMC Musculoskelet Disord 2015; 16: 300–300.

Pasoto

Augusto

Alvarenga

et al.

Cortical bone density and thickness alterations by high-resolution peripheral quantitative computed tomography: Association with vertebral fractures in primary Sjogren’s syndrome. Rheumatology (Oxford) 2016; 55: 2200–2211.

Zhu

Liao

Zhang

. Impaired bone health in patients with primary Sjogren’s syndrome [abstract]. Arthritis Rheumatol 2016; 68(suppl 10)): https://acrabstracts.org/abstract/impaired-bone-health-in-patients-with-primary-sjogrens-syndrome/. Accessed February 27, 2019.

Wainwright

Marshall

Ensrud

et al.

Hip fracture in women without osteoporosis. J Clin Endocrinol Metab 2005; 90: 2787–2793.

10.

World Health Organization. Assessment of osteoporosis at the primary health care level. WHO, Geneva, www.who.int/chp/topics/rheumatic/en/index.html (2007).

11.

Aletaha

Neogi

Silman

et al.

2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010; 62: 2569–2581.

12.

Petri

Orbai

Alarcón

et al.

Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012; 64: 2677–2686.

13.

Vitali

Bombardieri

Jonsson

et al.

Classification criteria for Sjögren’s syndrome: A revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002; 61: 554–558.

14.

Evans

Zdebik

Ciurtin

Walsh

. Renal involvement in primary Sjögren’s syndrome. Rheumatology (Oxford) 2015; 54: 1541–1548.

15.

Sandhya

Danda

Rajaratnam

Thomas

. Sjögren’s, renal tubular acidosis and osteomalacia—an Asian Indian series. Open Rheumatol J 2014; 8: 103–109.

16.

Both

Zillikens

Hoorn

et al.

Bone mineral density in Sjögren syndrome patients with and without distal renal tubular acidosis. Calcif Tissue Int 2016; 98: 573–579.

17.

Kim

Schneeweiss

Liu

et al.

Risk of osteoporotic fracture in a large population-based cohort of patients with rheumatoid arthritis. Arthritis Res Ther 2010; 12: R154–R154.

18.

Ghazi

Kolta

Briot

Fechtenbaum

Paternotte

Roux

. Prevalence of vertebral fractures in patients with rheumatoid arthritis: Revisiting the role of glucocorticoids. Osteoporos Int 2012; 23: 581–587.

19.

Meng

Yuan

. Evaluating osteoporotic fracture risk with the Fracture Risk Assessment Tool in Chinese patients with rheumatoid arthritis. Medicine (Baltimore) 2017; 96: e6677–e6677.

20.

Wang

Yan

Liu

et al.

Fracture risk and bone mineral density levels in patients with systemic lupus erythematosus: A systematic review and meta-analysis. Osteoporos Int 2016; 27: 1413–1423.

21.

Jacobs

Korswagen

Schilder

et al.

Six-year follow-up study of bone mineral density in patients with systemic lupus erythematosus. Osteoporos Int 2013; 24: 1827–1833.

22.

Goldring

. Inflammatory signaling induced bone loss. Bone 2015; 80: 143–149.

23.

Alele

Kamen

. The importance of inflammation and vitamin D status in SLE-associated osteoporosis. Autoimmun Rev 2010; 9: 137–139.

24.

Shaw

Gravallese

. Mediators of inflammation and bone remodeling in rheumatic disease. Semin Cell Dev Biol 2016; 49: 2–10.

25.

Natsui

Tanaka

Suda

et al.

High-dose glucocorticoid treatment induces rapid loss of trabecular bone mineral density and lean body mass. Osteoporos Int 2006; 17: 105–108.

26.

Krieger

Bushinsky

Frick

. Cellular mechanisms of bone resorption induced by metabolic acidosis. Semin Dial 2003; 16: 463–466.

27.

Tam

Griffith

et al.

High prevalence of asymptomatic vertebral fractures in Chinese women with systemic lupus erythematosus. J Rheumatol 2009; 36: 1646–1652.

28.

Eriksen

Díez-Pérez

Boonen

. Update on long-term treatment with bisphosphonates for postmenopausal osteoporosis: A systematic review. Bone 2014; 58: 126–135.

29.

Iwamoto

Okamoto

Tsuji

et al.

Denosumab is effective toward glucocorticoid-induced osteoporosis patients complicated with rheumatic diseases regardless of prior anti-osteoporotic drugs. J Bone Miner Metab 2019; 37: 554–562.

30.

Watt

Thompson

Le Riche

Pope

. There is still a care gap in osteoporosis management for patients with rheumatoid arthritis. Joint Bone Spine 2014; 81: 347–351.

31.

Furuya

Hosoi

Saito

et al.

Fracture risk assessment and osteoporosis treatment disparities in 3,970 Japanese patients with rheumatoid arthritis. Clin Rheumatol 2011; 30: 1105–1111.

32.

Cheng

McDonald-Blumer

Boire

et al.

Care gap in patients with early inflammatory arthritis with a high fracture risk identified using FRAX®. J Rheumatol 2010; 37: 2221–2225.