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Medications and Fracture Risk in Patients with RA

Publish date:

Use of opioids, selective serotonin reuptake inhibitors (SSRIs) and glucocorticoids were associated with increased risk of any fracture in patients with rheumatoid arthritis (RA), a new study found, whereas statins and tumor necrosis factor-α inhibitors (TNFi) were associated with decreased vertebral fractures. Patients with RA without prior fracture were assessed for osteoporosis-related site fractures. DMARD exposure was assessed in 4 mutually exclusive groups: methotrexate monotherapy-reference; TNFi; non-TNFi biologics; and others. Researchers found:

  • During median 3.0 years of follow-up in 11,412 patients, 914 fractures were observed.
  • Adjusted models demonstrated a significant fracture risk increase with the use of any dose glucocorticoids ≥3 months, opioids, and SSRIs.
  • Fracture risk with opioids increased within 1 month of use and with SSRIs >3 months of use.
  • Statins were associated with reduction in vertebral fracture risk only.

Citation:

Ozen G, et al. Medications associated with fracture risk in patients with rheumatoid arthritis. Annals of the Rheumatic Diseases. [Published online ahead of print May 15, 2019. doi: 10.1136/annrheumdis-2019-215328.

Commentary:

RA is well known for its association with osteoporosis and fracture, exacerbated by long-term steroid use. The present study uses a national registry to evaluate the risk of any fracture and also any osteoporotic fracture (e.g. hip, vertebra, or arm). In addition to the expected risk factors of age, female sex, and cumulative glucocorticoid dose, use of opioids, SSRIs, antipsychotics, and benzodiazepines was also associated with higher risk of fracture, even after a relatively short exposure (>30 days opioid use, > 3 months SSRI use). On the other hand, use of PPIs unexpectedly was not associated with fracture risk. Despite the potentially important information regarding risk of fracture with short-term opioid use, possibly due to risk of falls, the lack of confirmation of PPI risk, despite the long duration of follow-up, suggests the presence of additional confounding factors. —Arundathi Jayatilleke, MD

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