Page 28 - MRS Abstracts March 2023

bisphosphonates for multiple vertebral fractures. She had multiple fractures in metatarsals, fibula, distal tibia, patella over the last 8 years. She was reluctant to stop her Methotrexate and Prednisolone. She was treated with Teriparatide followed by Denosumab.
4. A 73-year-old female with rheumatoid arthritis was on Methotrexate for 20 years. She had multiple fractures (calcaneum, talus, cuboid, distal tibia). She had osteoporosis. She was treated with Teriparatide, Denosumab and then Zoledronate. She continued to have multiple fractures (tibial plateau, distal tibia, fibula, midfoot, hindfoot). Methotrexate was continued to avoid flare of her arthritis.
Osteomalacia was excluded in all the patients.
Discussion:
Methotrexate osteopathy has been reported with low to moderate doses of Methotrexate used for RA. Patients frequently suffer from multiple and bilateral fractures. BMD was normal in 3 of our 4 patients.
Mice studies have shown decreased osteoblast activity, trabecular bone resistance to mechanical stress due to disruption in integrin dependent pathway by Methotrexate.
This explains the predilection for insufficiency fractures in weight bearing bones. Stopping the Methotrexate has shown to help heal the fractures in a recent systematic review. Some patients may require anabolic and/or anti-resorptive drugs.
Conclusions:
Insufficiency fractures in lower limbs and unexplained bone pain around the joint in RA patients on Methotrexate should make us suspect Methotrexate osteopathy.
Key points:
Unexplained bone pain in lower limbs around the joint in RA patients on Methotrexate could indicate insufficiency fractures.