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24-05-2019 | Rheumatology | News | Article

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Opioids, SSRIs, glucocorticoids implicated in RA fracture risk

medwireNews: US research shows that the use of opioids, selective serotonin reuptake inhibitors (SSRIs), or glucocorticoids may increase the risk for all types of osteoporotic fracture in patients with rheumatoid arthritis (RA).

By contrast, statins and tumor necrosis factor (TNF) inhibitors were associated with a decreased vertebral fracture risk, report Kaleb Michaud (National Data Bank for Rheumatic Diseases, Wichita, Kansas, USA) and colleagues in the Annals of the Rheumatic Diseases.

Michaud and co-authors explain that “[o]steoporotic fractures are the third greatest cause of mortality in patients with RA, after pulmonary and cardiac disease, and the second cause of disability after depression.”

“Thus, identifying the modifiable risk factors for fractures, particularly medications in RA, is important,” they add.

In the current study, which included a median 3 years of follow-up, 914 major osteoporotic fractures (vertebra, hip, forearm and humerus) occurred in 11,412 individuals with RA from the US-based longitudinal FORWARD registry who had no previous history of fracture.

After stratification by baseline fracture risk and adjustment for potential confounders, patients using glucocorticoids for 3 months or longer had a significantly higher fracture risk than nonusers, at hazard ratios (HRs) of 1.26 for doses below 7.5 mg/day and 1.57 for doses of 7.5 mg/day or higher.

Weak opioid and SSRI use were each associated with a significant 1.37-fold increased risk for any fracture relative to nonuse, while the risk was 1.53-fold higher among strong opioid users versus nonusers.

The researchers found fracture risk with opioids was highest during the first month of use (HR=1.66 vs 1.35 for >3 months) and was greater for vertebral than nonvertebral fractures (HR=1.83 vs 1.29).

SSRI use versus nonuse was also associated with a greater risk for vertebral than nonvertebral fracture (HR=1.50 vs 1.22), but in contrast to opioid use, the risk for any fracture increased with increasing duration and only reached statistical significance after 3 months of use (HR=1.25).

Conversely, statins and TNF inhibitors were significantly associated with reduced risk for vertebral fractures only, at HRs of 0.77 and 0.72, respectively, and there was no association between fracture risk and use of proton pump inhibitors or psychotropic medications other than SSRIs.

Based on their findings Michaud et al “suggest a regular review of the necessity of the medications being used” in patients with RA, particularly as these individuals have “frequent occurrence of chronic pain, mood disorders, [and] polypharmacy” as well as an already heightened risk for fracture and falls.

They add that in the current opioid epidemic era “opioid use should be minimised for pain management in RA […] to avoid fractures and other devastating consequences.”

Furthermore, “[g]iven the underuse of statins for cardiovascular disease in RA, the protective association against vertebral fractures may be encouraging for statin prescriptions in patients with RA,” the researchers conclude.

By Laura Cowen

medwireNews is an independent medical news service provided by Springer Healthcare. © 2019 Springer Healthcare part of the Springer Nature group

Ann Rheum Dis 2019; doi:10.1136/annrheumdis-2019-215328

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