• rheumatoid arthritis
• disease activity
• treatment
• osteoporosis

We appreciate the interest shown by Dr Chen1 concerning our recent study on medications associated with fracture risk in patients with rheumatoid arthritis (RA).2 We would like to clarify some issues Chen et al indicated.

First, we agree that osteoporotic fractures are more common in patients with inflammatory diseases. However, in our study, we excluded all patients with prevalent fractures to estimate the risk related to new fractures. Our study only shows the osteoporosis site fracture incidence in patients with RA. As we indicated in our manuscript, the incidence rate of osteoporotic fractures in our cohort is similar to a recent meta-analysis of 25 cohort studies in patients with RA.3

Second, it is possible that high-intensity statin regimens may prevent fractures better than moderate-intensity ones especially if the protective effects are assumed to be due to anti-inflammatory properties of statins. Moreover, as Chen et al indicate, some antihypertensives may have protective effects on osteoporotic fracture risk. However, the only randomised controlled trial for this association is with thiazide diuretics4 5 of which effect is also more biologically plausible compared with other antihypertensives.6 The fracture risk change with high-intensity statins and antihypertensives should be investigated further in patients with RA.

Lastly, we appreciate the comment about our outcome-only osteoporosis site fractures. It is well-known that patients with RA have increased fall risk, which can also cause fractures. Unfortunately, we do not have any data for the level of trauma and fall risk other than disability scores. Regardless, we believe that including all types of fractures would make our outcome very heterogeneous. A significant trauma could cause a fracture in any patient even in the absence of risk factors. We are planning to collect more data regarding fall risk to better assess the fracture risk in our cohort.