Improved disease control and reduced articular manifestations of Rheumatoid arthritis (RA), has shifted attention towards extra-articular (ExRA) manifestations. Osteoporosis is a common ExRA, notable for its risk of fractures, mortality, need for supportive care, and impaired quality of life. Despite this fracture outcomes in RA are not well studied.
We completed a matched cohort study using the West Australian (WA) Rheumatic Disease Epidemiology Register, which includes longitudinal health data on rheumatoid patients seen in WA hospitals (inpatients or ED patients). Patients with at least one RA and one fracture International Classification of Disease code (excluding. skull, fingers, toes, and sternum) are included. Survival is analysed using Kaplan-Meyer and cox-regression analysis stratified into 1990-2000 (pre-disease-modifying-anti-rheumatics aka DMARD) and 2000-2010 (post-DMARD), and compared to a rheumatic-disease-free hospitalised cohort.
2,606 RA (79.3% female) and 3,449 control (80.5% female) fracture patients are included. Mean CCI at first fracture in RA was 1.67 (95% CI 1.59-1.75) vs 1.52 (95% CI 1.46-1.57) in controls (p>0.05). Five-year post-fracture is 34.8% (RA) and 43.9% in controls (p<0.001). One-year post-fracture survival in RA decreased from 79.6% to 72.6% (1990-2000 to 2000-2010, p<0.001). Fractures within one year of RA index were associated with worse survival (HR 3.17, 95% CI 1.08-9.29), compared to fractures 5-10 years post-RA-index (p=0.04).
Despite therapeutic advances, post-fracture survival for RA patients worsened between 1990 and 2010, possibly because of increasingly severe comorbidities, not accounted for in the CCI. Further, shorter time from RA index to fracture appears to be associated with worse survival, potentially reflecting an association between more active RA disease, more rapid bone loss, and more severe comorbidities. While more research is required, we propose that shorter time to fracture from first RA presentation may be a risk factor for mortality after fracture.