Background/Purpose: Steroids are used in a proportion of patients with rheumatoid arthritis (RA). Steroids are known to cause a decrease in bone mineral density (BMD), although our recent study suggests a potential for a paradoxically protective effect. We set out to determine if traditional fracture risk factors for fracture are appropriate in those with RA who have been treated with steroids. The objective of this study was to determine what factors influence fracture in those with rheumatoid arthritis (RA) having received steroid therapy and those who have not, as well as comparing to see if the patterns of fractures are different among those treated with steroids compared to those who have not.

Methods: patients with rheumatoid arthritis (RA) who underwent a DEXA scan at a regional scanner in the North West of England between 2004 and 2021. Demographic data of these patients were collected, including steroid use, alcohol consumption, smoking, secondary osteoporosis, etc., along with the classic FRAX™ risk factors. Bone mineral density (BMD), Z scores and T scores were collected. Group comparisons were performed using t-tests for continuous variables and Chi squared tests for categorical variables, comparing those treated with steroids (past or current) and those not.

Results: 2855 patients were included in the study. Of these patients, 2313 (81.0%) were female, the mean age at scanning was 66.1 (SD ±12.5). Corticosteroid use, either current or prior was reported in 947 patients (33.2%). Fractures were observed in 309 (32.6%) of steroid users and 693 (36.3%) of non-users. Steroid use was not associated with an increase in fractures, rather a reduction – although not statistically significant (p = 0.057). Interestingly, among 758 patients currently being treated with steroids, 228 (30.0%) had fractures, compared to those not currently on steroids there were 2097 patients with 774 (36.9%) of those having a fracture. This is suggestive of a protective effect of current steroid use against fracture (p < 0.01), although causality cannot be inferred.The patterns of fractures similar between those having steroid therapy and not, other than forearm fractures which were more common in those without steroid treatment (p = 0.032).Traditional FRAX™ factors were not found to be good predictors of fracture in this cohort of patients using steroids, other than femoral neck BMD (p < 0.01) and family history of fracture (p < 0.01), which both significantly increased fracture risk. Higher total body fat percentage was found to increase fracture risk in both groups of patients (p < 0.01), weight was not statistically significant in either group.

Conclusion: Classical FRAX™ risk fractures were not significant predictors of fracture in those on steroids with RA, other than family history and femoral neck BMD. The best predictors of fractures in this cohort were bone mineral density analysis, family history, height loss and total fat percentage. Fracture patterns were similar between those with and without prior or current steroids, other than fractures of the forearm, which were less likely in those steroids on steroids. Further modelling is needed to determine odds ratios of risk factors at specific sites .

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/retrospective-analysis-of-factors-associated-with-fracture-in-2855-patients-with-rheumatoid-arthritis-stratified-by-steroid-use/