Opioids and Antidepressants Are Linked to Higher Fracture Risk in Rheumatoid Arthritis Patients

Patients with rheumatoid arthritis (RA) experience chronic pain, inflammation and stiffness in their joints, as well as possible inflammation in their organs. Because of the inflammation and pain, patients with RA have higher risk of cardiovascular, mental and gastrointestinal disorders, and they frequently take multiple concurrent medications, some of which have been found to increase fracture risk in other patient populations.

Researchers at the University of Nebraska Medical Center in Omaha and the National Data Bank for Rheumatic Diseases in Wichita, Kansas, sought to determine whether an association exists between medications commonly used for RA and osteoporotic fractures. They found that opioids and selective serotonin reuptake inhibitors (SSRIs) are associated with a twofold higher risk of fractures in patients with RA, and they shared their findings with colleagues at the 2017 annual meeting of the American College of Rheumatology (ACR) and the Association of Rheumatology Health Professionals (ARHP).

The observational cohort study examined 11,049 U.S. patients with RA in the National Data Bank for Rheumatic Diseases who were 40 years of age or older and had not had a prior osteoporotic fracture between 2001 and 2016. Researchers looked for a link between osteoporotic fracture risk and the following medications: disease-modifying antirheumatic drugs, statins, antidepressants, proton pump inhibitors, nonsteroidal anti-inflammatory drugs, anticonvulsants and antipsychotics. The analysis adjusted for sociodemographic factors, comorbidities, body mass index, fracture risk and RA severity.

During a median follow-up of 5.7 years, 863 osteoporotic fractures occurred. Patients who experienced fractures were significantly older and had higher disease activity, longer disease duration, higher rates of glucocorticoid use, higher fracture risk, and more comorbidity at baseline than patients who did not have fractures.

Osteoporotic fracture risk was significantly higher for patients who used SSRIs or opioids of any dose. Risk was higher after just one to 30 days of opioid use and three months after initiation of SSRIs. Longer-term use increased risk further, the authors reported, adding that increased fracture risk might be linked to an increased risk of falls associated with such medications.

Gulsen Ozen, MD, research fellow at the University of Nebraska Medical Center in Omaha and a lead author of the study, encouraged healthcare providers to consider how the findings might affect individual patient care. “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,” he said. “Additionally, careful and regular reviewing of patient medications is an essential part of RA patient care, as the use of medications that are not indicated anymore brings harm rather than benefit.”