RICHMOND, VA—How much does systemic glucocorticoid exposure increase fracture among patients with newly-diagnosed inflammatory and immune-modulated conditions, including rheumatoid arthritis.

The study in the Journal of Bone and Mineral Research used administrative data to look at patients with RA, asthma/chronic obstructive pulmonary disease, inflammatory bowel disease, multiple sclerosis, lupus and sarcoidosis patients, aged 18 to 64. All had benefits coverage 12 or more months before diagnosis from Jan. 1, 2005, to Dec. 31, 2012, and the glucocorticoid users were new to therapy.1

The study team, including researchers from the McGuire VAMC in Richmond, followed the patients to either clinical fracture, cancer diagnosis, or Dec. 31, 2012.

Researchers noted that fracture incidence rates (IRs) per 1000 person-years were stratified by prednisone equivalent doses, and that models assessed risk by daily and cumulative dose, and by time since discontinuation, adjusted for baseline characteristics.

Results indicated that most patients (72% of 403,337) had glucocorticoid exposure; 52% were younger than 50. The risk of any osteoporotic fracture was elevated at doses greater than 5 mg/day (IR 9.33; 95% CI, 7.29 to 11.77) vs. 0 mg/day (IR 4.87 (95% CI, 4.72 to 5.02), the study found.

The increase in fracture rates affected both those under 50 and 50 and older, with a dose of more than 5 mg/day. In both age groups, fracture risk also increased with increasing cumulative exposure, being approximately 2.5-fold higher at cumulative dose of 5400 mg or greater compared to less than 675 mg.

At 5400 mg or greater cumulative dosage, the study determined that IR values were 5.69 (95% CI, 4.32 to 7.35) in patients younger than 50 and 17.10 (95% CI, 14.97 to 19.46) in older patients.

“Fracture risk decreased significantly within months following glucocorticoid discontinuation,” the researchers wrote. “In patients with a variety of inflammatory conditions, fracture risk increased at doses as low as <5 mg/day. Risk increased with increasing cumulative exposure and decreased soon following glucocorticoid discontinuation. Trends were similar between patients older and younger than 50 years.”

1. Balasubramanian A, Wade SW, Adler RA, Saag K, Pannacciulli N, Curtis JR. Glucocorticoid Exposure and Fracture Risk in a Cohort of US Patients With Selected Conditions. J Bone Miner Res. 2018 Jun 20. doi: 10.1002/jbmr.3523. [Epub ahead of print] PubMed PMID: 29924418.