Background/Purpose: Improved disease control for articular manifestations of Rheumatoid arthritis (RA), has resulted in more attention being directed to extra-articular (ExRA) manifestations (cardiovascular events, osteoporosis, lung disease) which contribute to reduced survival. Osteoporosis (OP) is a common ExRA, notable for its risk of fractures, mortality, need for supportive care, chronic impairment, length of stay, and quality of life impairment. Despite this post-fracture outcomes in RA are not well studied.

Methods: We completed a matched cohort study using the West Australian Rheumatic Disease Epidemiology Register, which includes routinely collected longitudinal health data on rheumatoid patients seen in the West Australian hospital system as inpatients or ED patients. We included patient with at least one RA International Classification of Disease code (index date defined at first ICD code) and fracture code (excluding. skull, fingers, toes, and sternum). Post-fracture survival was analysed using Kaplan-Meyer and cox-regression analysis stratified into 1990-2000 (pre-disease modifying anti-rheumatic aka DMARD) and 2000-2010 (post-DMARD), and compared to a rheumatic-disease-free hospitalised cohort.

Results: 2,606 RA (79.3% female) and 3,449 matched controls (80.5% female) with fractures were included for analysis. 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 survival in RA is 34.8% compared to 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. The association between time-to-fracture and post-fracture survival remained significant even after controlling for age, CCI, gender, and site of fracture (p=0.04).

Conclusion: Despite therapeutic advances, post-fracture survival for RA patients worsened between 1990 and 2010, possibly because patients have more severe illnesses, not accounted for in the CCI. Our other finding that shorter time from RA index to fracture is associated with worse post-fracture survival could result from patients with more active RA experiencing more rapid bone loss and more severe comorbidities, which result in earlier mortality. While more research must be done to understand both of these findings, we propose that shorter time to fracture from first RA presentation may be a risk factor for mortality after fracture.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/post-fracture-survival-for-rheumatoid-arthritis-patients-is-not-improving/