This study aimed to examine fracture risk in patients with late-onset psoriasis. A cohort study was conducted using primary care records from the Clinical Practice Research Datalink. Psoriasis patients had a 10% increased risk of fracture compared to matched controls (hazard ratio (HR) = 1.10; 95% confidence interval (CI) 1.04, 1.16). This study aimed to examine fracture risk in patients with late-onset psoriasis and investigate the effect of methotrexate on fracture risk. A cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident (new onset) diagnoses of psoriasis, were identified from 1990 to 2004 and followed up until 2015. For each exposed individual, up to four age-, gender-, and practice-matched controls were randomly selected. Incidence rates of fragility fracture (hip, vertebral, spine, radius or unspecified site) per 10,000 person-years were calculated and hazard rates were compared to the unexposed using Cox regression models. The risk of fracture was also estimated, within the exposed group for patients receiving/not receiving methotrexate. Twenty-four thousand two hundred nineteen patients with psoriasis and 94,820 controls were identified. The absolute rate of fracture in psoriasis patients was 58 per 10,000 person-years (95% CI 55, 61) and 53 per 10,000 person-years in the matched controls (CI 52, 54). Psoriasis patients had a 10% increased risk of fracture compared to their matched controls (HR = 1.10; 95% CI 1.04, 1.16). Methotrexate use was not associated with increased risk (HR = 0.91; 95% CI 0.72, 1.15). Identifying additional clinical factors associated with increased fracture risk is important in improving fracture risk stratification. Further work is needed to determine the relationship between age of onset of psoriasis and fracture risk, explore causative explanations, and identify if existing fracture risk stratification tools underestimate fracture risk in patients with psoriasis.

Background Psoriasis is a common inflammatory skin disease affecting 2–4% of the population and of these a subset will develop an associated inflammatory arthritis (psoriatic arthritis - PsA). An increased risk of osteoporosis has previously been reported in psoriasis patients but the risk of fracture in patients with both psoriasis and PsA has not been established. Objectives To estimate the effect of psoriasis, and PsA, on the risk of fracture using a large electronic primary health care database. Methods A matched cohort study was conducted utilizing data from the Clinical Practice Research Datalink, a large UK database of primary care medical records. The exposed population was defined as psoriasis patients aged over 40 years with an incident diagnosis between 1990–2004, who were followed up until 2015. Four unexposed patients were matched to each exposed based on age, sex and general practice. The incidence rate of fracture were calculated as the number of incident diagnoses per 10,000 person-years, stratified by sex. Hazard ratios (HR) and 95% confidence intervals were estimated using a Cox proportional hazards model to compare the hazard rate between the exposed and unexposed, adjusting for BMI, alcohol consumption, smoking status, Charlson comorbidity index and steroid use. Fracture risk was estimated for patients with both psoriasis and PsA, identified as patients with an incident diagnosis of psoriasis and a diagnosis of PsA between 1990–2004. Results 24,219 patients with psoriasis and 94,820 controls were included in the study. The mean age was 59 years at study entry and just over half (51%) of the patients were male. The incidence rate of fracture was 58.4 (95% CI:55.6–61.3) and 53.1 (51.7–54.5) per 10,000 person-years for the exposed and unexposed, respectively. After adjusting for confounding factors, patients with psoriasis had 12% increased risk of fracture (HR: 1.12; 95% CI: 1.06–1.19) compared to the matched unexposed group. The risk was slightly higher in males (1.22 (1.09–1.36)) than females (1.09 (1.03–1.17)). Among those with psoriasis, 4.1% were also diagnosed with PsA. An increased risk of 45% was found in those exposed to both psoriasis and PsA compared to the unexposed group (1.45 (1.09–1.94)). Conclusions This study reports for the first time, an increase in fracture risk in patients with psoriasis. A higher risk was found in males than females and the risk was further increased if the patient also had PsA. These findings suggest that fracture risk assessment needs to be considered for individuals with psoriasis and PsA. Acknowledgements This study was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice (NIHR-RP-2014–04–026). TH is funded by an NIHR Clinical Lectureship in General Practice. AAS is funded by an NIHR Postdoctoral Fellowship. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Disclosure of Interest None declared

Background Gout is the most common type of inflammatory arthritis, affecting 2.4% of adults in the UK and is associated with a number of co-morbidities. Our understanding of the association between gout and fracture risk is limited with previous studies offering conflicting results. Objectives To determine the risk of fracture among gout patients and assess the potential impact of urate-lowering therapy (ULT) on fracture risk. Methods Utilising primary care records from Clinical Practice Research Datalink we identified patients with gout between 1990 and 2004 who were followed up until 2015. Each gout patient was individually matched to 5 individuals without gout based on age, sex, and registered practice. Absolute rate (AR) of fracture and hazard ratios (HR) were calculated using Cox regression models. We further stratified our analysis by age, gender and ULT prescription. Results We matched 35,857 patients with incident gout to 148,407 controls. Overall, we found no increased risk of fracture among gout patients compared to controls. However, men with no evidence of ULT had higher absolute risk of fracture compared to controls (AR=39 versus 26 per 10,000 person-years) corresponding to a 23% (HR=1.23; 95% CI 1.12–1.36) increased risk. The risk was particularly high for vertebral (HR=1.50; 95% CI 1.20–1.87) and wrist fracture (HR=1.45; 95% CI 1.21–1.74). Those treated with ULT had a 12% (HR=0.88; 95% CI 0.79–0.98) lower risk of fracture. Similar findings were not observed for women. Conclusions We found higher risk of vertebral and wrist fractures among men with gout not prescribed ULT. Those prescribed ULT had lower risk of fracture compared to the general population. Further research is needed to understand the role of ULT in fracture prevention. Acknowledgements CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice. TH is funded by a NIHR Clinical Lectureship in General Practice and AAS is funded by NIHR Postdoctoral Fellowship. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health Disclosure of Interest None declared