Fractures in Patients with SSc
By Zsuzsanna McMahan, MD, MHS
Why was this study done? To minimize disability due to systemic sclerosis (SSc), it’s important to prevent and manage complications. Many SSc complications and related medications may increase the risk for osteoporosis and fracture. We sought to identify modifiable risk factors for fracture in patients with SSc to improve their quality of life and identify ways to minimize the long-term economic burden.
Study methods? Patients were part of an observational study as participants in FORWARD, a longitudinal, observational, patient-driven database for which a primary questionnaire is distributed to patients twice yearly. From this database we identified patients with SSc, as well as age- and gender-matched patients with osteoarthritis (OA) for comparison. The primary outcome was major osteoporotic fracture. Multivariable Cox proportional hazard models were used to examine the risk factors for fractures or osteoporosis in the SSc and control groups after adjusting for age and body mass index (BMI).
Key findings? We observed a higher fracture rate in patients with SSc relative to OA comparators. Comorbidity burden and higher physical disability were strongly associated with a high fracture rate in both scleroderma and OA. Diabetes and renal disease were also determined to increase fracture rates in patients with SSc, even after adjusting for age and BMI. After adjustment, significant disability and comorbidity burden were most strongly associated with fracture in SSc.
Main conclusions? Several specific factors are associated with fracture in patients with SSc. In particular, disability—as measured by Health Assessment Questionnaire-Disability Index (HAQ-DI)—is a particularly strong indicator of fracture rate, which suggests that improving the functional status of patients with SSc, when possible, may lead to better long-term outcomes.
Implications for patients? Physical disability is associated with a high fracture rate in patients with SSc. Musculoskeletal involvement is common in SSc and can lead to disability. Various therapeutic rehabilitation programs are reported to improve the function of patients with SSc, and home-based physical exercise regimens are reported to decrease disability and improve strength. These actionable interventions may help reduce fracture risk, but the optimal timing and application of such interventions remains unclear.
Implications for clinicians? Patients with high Rheumatic Disease Comorbidity Indices are more likely to have fractures than patients with fewer comorbidities. Early diagnosis and appropriate management of comorbidities in patients with SSc should be a priority, and interventions, such as multidisciplinary rehabilitation, may reduce the long-term fracture risk. A low threshold to screen for causes of disability and a focus on minimizing such complications may benefit high-risk patients.