SSRIs, opioids increase risk for osteoporotic fractures in RA

Kaleb Michaud

SAN DIEGO — Patients with rheumatoid arthritis are at higher risk for osteoporotic fractures if they are taking opioids or selective serotonin reuptake inhibitors, according to data from a press release issued at the American College of Rheumatology Annual Meeting.

“With RA, it is well-known that the risk for osteoporotic fracture is doubled. The assumption has always been that it comes from the inflammation, but also mainly the treatment of the disease with the use of prednisone and steroids,” Kaleb Michaud, PhD, associate professor of internal medicine in the division of rheumatology at University of Nebraska Medical Center, said during a press conference. “But, there are many other comorbidities associated with the disease and inflammation that require follow-up treatment, and those treatments are found to be associated with osteoporotic fracture in the general population, but haven’t been looked at in the RA population.”

During a press conference at the American College of Rheumatology Annual Meeting, Kaleb Michaud, PhD, emphasized that if physicians are managing pain with opioids, even in the short-term, they should be aware of the fracture risk.

Source: Healio.com

Michaud and colleagues from the National Data Bank for Rheumatic Diseases in Wichita, Kansas, examined the association between medications commonly used by patients with RA and the risk for osteoporotic fracture. Specifically, the researchers looked at disease-modifying antirheumatic drugs (methotrexate monotherapy-reference, tumor necrosis factor inhibitors, non-TNFi biologics and others; there was a separate glucocorticoid variable). Statins, antidepressants, proton pump inhibitors, opioids (weak and strong), NSAIDs, anticonvulsants and antipsychotics were evaluated separately, they wrote.

The study included 11,002 patients with RA aged 40 years or older without prior osteoporotic fracture from 2001 to 2016. Median follow-up was 5.4 years, during which time the researchers observed 863 osteoporotic fractures. The researchers adjusted for sociodemographic factors, comorbidities, BMI, fracture risk by FRAX, and RA severity measures using Cox proportional hazard models.

Patients who developed fractures were significantly older, had longer disease duration, higher disease activity, higher glucocorticoid use, higher FRAX scores at baseline and more comorbidities than patients without fractures, according to the abstract.

According to results of the adjusted models, there was a significant increase in the risk of osteoporotic fractures associated with glucocorticoids used for at least 3 months at any dose, SSRIs (HR = 1.35), and opioids at any strength (weak: HR = 1.48; strong: HR = 1.78). The increased risk of osteoporotic fracture began between days 1 and 30 of opioid use (HR = 1.99) compared with SSRIs, which began after 3 months of use (HR = 1.25).

“The main point here is when you’re managing pain with opioids, even in the short-term, physicians should be aware of the fracture risk, and the necessity of all these medications should always be regularly reviewed by the rheumatologist because there are consequences in addition to the increased risk associated with a patient having RA itself,” Michaud said. – by Stacey Adams

Reference:
Ozen G, et al. Abstract 2783. Presented at: the American College of Rheumatology Annual Meeting; Nov. 3-8, 2017; San Diego.

Disclosures: The authors report no relevant financial disclosures.