Atopic Eczema–Associated Fracture Risk and Oral Corticosteroids: A Population-Based Cohort Study

Julian Matthewman,Kathryn E Mansfield,Daniel Prieto-Alhambra,Amy R Mulick,Liam Smeeth,Katherine E Lowe,Richard J Silverwood,Sinéad M Langan

doi:10.1016/j.jaip.2021.09.026

Abstract

BackgroundEvidence suggests adults with atopic eczema have increased fracture risk. However, it is unclear whether oral corticosteroids explain the association.ObjectiveTo assess to what extent oral corticosteroids mediate the relationship between atopic eczema and fractures.MethodsWe conducted a cohort study using English primary care (Clinical Practice Research Datalink) and hospital admissions (Hospital Episode Statistics) records (1998-2016) including adults (18+) with atopic eczema matched (age, sex, and general practice) with up to five adults without atopic eczema.We used Cox regression to estimate hazard ratios (HRs) for specific major osteoporotic fractures (hip, spine, pelvis, wrist) and for any-site fracture comparing individuals with atopic eczema to those without, adjusting for six different definitions of time-updated oral corticosteroid use (ever any prescription, ever high dose, and recent, cumulative, current or peak dose).ResultsWe identified 526,808 individuals with atopic eczema and 2,569,030 without. We saw evidence of an association between atopic eczema and major osteoporotic fractures (e.g., spine HR 1.15 99%CI 1.08–1.22; hip HR 1.11 99%CI 1.08–1.15) that remained after additionally adjusting for oral corticosteroids (e.g., cumulative corticosteroid dose: spine HR 1.09 99%CI 1.03–1.16; hip HR 1.09 99%CI 1.06–1.12). Fracture rates were higher in people with severe atopic eczema compared to people without even after adjusting for oral corticosteroids (e.g., spine HR [99%CI]: confounder adjusted 2.31 [1.91–2.81]; additionally adjusted for cumulative dose 1.71 [1.40–2.09]).ConclusionOur findings suggest that little of the association between atopic eczema and major osteoporotic fractures is explained by oral corticosteroid use.

Highlights

Atopic eczema, referred to as atopic dermatitis, is common[1] and characterized by rash and itching
We saw evidence of an association between atopic eczema and major osteoporotic fractures that remained after adjusting for oral corticosteroids
Our findings suggest that little of the association between atopic eczema and major osteoporotic fractures is explained by oral corticosteroid use

Summary

Introduction

Referred to as atopic dermatitis, is common (affecting up to 10% of adults)[1] and characterized by rash and itching. A common comorbidity in people with atopic eczema, is commonly treated with oral steroids,[15,16] and may confound the relationship between atopic eczema and fractures. Evidence suggests adults with atopic eczema have increased fracture risk. It is unclear whether oral corticosteroids explain the association. OBJECTIVE: To assess to what extent oral corticosteroids mediate the relationship between atopic eczema and fractures. We used Cox regression to estimate hazard ratios (HRs) for specific major osteoporotic fractures (hip, spine, pelvis, or wrist) and for any-site fracture comparing individuals with atopic eczema with those without, adjusting for 6 different definitions of time-updated oral corticosteroid use (ever any prescription, ever high-dose, and recent, cumulative, current, or peak dose)

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Conclusion