Opioids and antidepressants linked to higher fracture risk in rheumatoid arthritis patients

November 5, 2017, American College of Rheumatology

Opioids and selective serotonin reuptake inhibitors, a widely used group of antidepressants, are both associated with higher risk of osteoporotic fractures for patients with rheumatoid arthritis, according to new research findings presented this week at the 2017 ACR/ARHP Annual Meeting in San Diego.

Rheumatoid arthritis (RA) is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.

Chronic inflammation and pain predispose RA to several comorbidities including cardiovascular, mental, and gastrointestinal disorders that lead to the frequent use of multiple medications. Some of these medications have been reported to influence in the general population, but these associations had not been studied in RA patients. Researchers at the University of Nebraska Medical Center in Omaha and the National Data Bank for Rheumatic Diseases in Wichita, Kansas, conducted a study to look at associations of various medications commonly used by RA patients with osteoporotic (OP) fracture risk.

"Even at younger ages, RA is associated with a twofold increased risk of osteoporosis and due to and glucocorticoid use. More importantly, significantly contribute to the disability, health-related costs and mortality with substantially higher complication in RA patients than the general population," said Gulsen Ozen, MD, Research Fellow at the University of Nebraska Medical Center in Omaha and a lead author of the study. "Given the burden of osteoporotic fractures and the suboptimal osteoporosis care, it's highly important to identify factors associated with fracture risk, particularly modifiable ones, in RA patients."

In an observational cohort of RA patients located across the United States, the researchers studied associations between osteoporotic fracture risk and the following medications: disease-modifying antirheumatic drugs (DMARDs), statins, antidepressants (including selective serotonin reuptake inhibitors (SSRIs) and others), proton pump inhibitors (PPI), nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants and antipsychotics. DMARDs were categorized into four groups: methotrexate monotherapy (comparator group), TNF-inhibitors, non-TNF biologics and others, along with a separate glucocorticoid variable. All the other therapies were evaluated separately as either current use versus nonuse and also as short-term (30 days or less) or long-term (1-3 months and 3 months or more) use. The researchers also made adjustments in their analysis for socio-demographics, comorbidities, body-mass index, fracture risk according to FRAX scores and RA severity measures.

Patients from the National Data Bank for Rheumatic Diseases who were selected for the study were 40 years of age or older, and had not had a prior OP fracture from 2001-2016. They were assessed for osteoporotic fractures. The study evaluated 11,049 RA patients. During a median follow-up time of 5.7 years, the researchers found 863 osteoporotic fractures. Patients who developed fractures were significantly older and had higher disease activity, longer disease duration, higher rates of glucocorticoid use, higher fracture risk and more comorbidity at the baseline than those patients who did not experience fractures. Data in this ongoing study has been updated since the abstract was accepted.

The researchers also found significant increases in osteoporotic fracture risk when patients used SSRIs or opioids of any strength. Patients had an increase in their fracture risk starting after just one to 30 days of using opioids. Fracture risk associated with SSRI use started to rise after three months of taking these antidepressants, and the risk was more prominent with long-term use, the study showed. The increased fracture risk linked to use of opioids or SSRIs may be due to an increased risk of falls associated with these medications, the researchers concluded.

"Knowing the risks associated with the use of these medications can guide rheumatologists and other physicians in choosing the most appropriate management strategies in patients, particularly the ones who have a high fracture or fall risk," said Dr. Ozen. "Some medications have important health impacts, and it's impossible to avoid using them. In these situations, it is important that physicians are aware of the fracture risk to apply appropriate screening and preventive measures for osteoporotic fractures. Additionally, careful and regular reviewing of patient medications is an essential part of the RA patient care, as the use of medications that are not indicated anymore brings harm rather than a benefit."

Explore further: Under-reporting of vertebral fractures by radiologists: A missed opportunity

Related Stories

Under-reporting of vertebral fractures by radiologists: A missed opportunity

September 8, 2017
Vertebral fractures are the most common osteoporotic fractures. People with osteoporotic vertebral fragility fractures (VFFs) are at increased risk of future fractures, including potentially devastating and life-threatening ...

Assessment of bone density and fracture history can predict long-term fracture risk

June 21, 2017
Factors such as low bone density and previous fractures are commonly used to predict an individual's risk of experiencing a fracture over the next 10 years. A new analysis has found that a single bone density measurement ...

Sitagliptin not linked to higher fracture risk in diabetes

September 14, 2016
(HealthDay)—Patients with diabetes often have fractures, but sitagliptin is not associated with increased fracture risk, according to a study published online Sept. 8 in Diabetes, Obesity and Metabolism.

Risk of second major osteoporotic fracture is greatest immediately after first fracture

April 17, 2016
Today, at the World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, an international research team presented the preliminary results of a new study which aimed to determine whether the predictive value ...

Seniors with Type 2 diabetes may have increased risk for fracture

September 20, 2017
Though seniors with type 2 diabetes (T2D) tend to have normal or higher bone density than their peers, researchers have found that they are more likely to succumb to fractures than seniors without T2D. In a new study published ...

The deadly news about all osteoporotic fractures

November 27, 2013
It is well known that hip and vertebral fractures increase the risk of premature death. Until now, little has been known about the clinical impact of non-hip, non-vertebral fractures – so new Australian research showing ...

Recommended for you

Research shows diet has little influence on precursor to gout

October 11, 2018
Dietary factors have a far smaller influence on urate levels (a precursor to gout) than previously envisaged, new University of Otago research reveals.

More doctor visits lead to less suicide attempts for fibromyalgia patients

September 19, 2018
Fibromyalgia patients who regularly visit their physicians are much less likely to attempt suicide than those who do not, according to a new Vanderbilt University Medical Center study published in Arthritis Care & Research.

Antioxidant found to be effective in treating mice with osteoarthritis

September 14, 2018
A team of researchers in Belgium and the Netherlands has found that feeding a common antioxidant to test mice was effective in treating osteoarthritis. In their paper published in Science Translational Medicine, the group ...

Researchers find answers as to why some people are at risk of gout

September 12, 2018
University of Otago researchers have helped characterise a genetic variant that enables new understanding of why some people are at risk of gout, a painful and debilitating arthritic disease.

Emotions like anger and sadness may cause pain as well as being a result of it

September 10, 2018
While emotions such as anger or sadness are often thought of as being a result of stress or pain, findings recently published by Penn State researchers suggest that negative or mixed emotions could function as stressors themselves.

Dietary carbohydrates could lead to osteoarthritis, new study finds

August 9, 2018
Do your knees ache? According to new findings from the Oklahoma Medical Research Foundation, your diet could be a culprit.


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.