The Threat of Opioids and SSRIs in Rheumatoid Arthritis

Because rheumatoid arthritis causes intense inflammation, bone loss and fractures are not uncommon. However, it has recently been discovered that opioids and SSRIs can even further raise the risk.

Increased threat

Among those who do not have rheumatoid arthritis, the body usually undergoes a process referred to as "remodeling" to keep the bones healthy. During this process, osteoclasts and osteoblasts are responsible for removing old existing bone and forming a new, stronger, bone. By this process, the bone mass remains at a constant - but with those with RA who are unable to complete this process, bone loss and fractures are common due to the harm of inflammation.

Women who have RA are also commonly impacted by osteoporosis, which offers a heightened fracture risk as well. When women approach their menopausal years, the risk becomes even higher.

Now, it has been found that those who take opioids or SSRIs are also placing themselves at a higher risk.

Opioids and SSRIs

At the 2017 ACR/ARHP Annual Meeting in San Diego, findings were revealed that opioids and selective serotonin reuptake inhibitors, or SSRIs, pose a risk, for those with rheumatoid arthritis.

The revelation was discovered by researchers at the National Data Bank for Rheumatic Diseases in Wichita, Kansas and the University of Nebraska Medical Center in Omaha. They found that those with RA have a predisposition to other sometimes fatal threats, such as mental, cardiovascular, or GI disorders due to their chronic inflammation and severe pain. These disorders are capable of inspiring the use of medications such as opioids or SSRIs, which have been shown to increase the risk of fractures in the general population - but the researchers decided to look into how exactly they impacted people with rheumatoid arthritis. The study was not limited to opioids and SSRIs, but included other medications that are often taken by those with rheumatoid arthritis who possess an increased risk for osteoporotic fracture - opioids and SSRIs were simply those which had the most significant results.

Gulsen Ozen, MD is the lead author of the study, as well as a Research Fellow at the University of Nebraska Medical Center in Omaha. He explained their interest in the topic, "even at younger ages, RA is associated with a twofold increased risk of osteoporosis and fractures due to chronic inflammation and glucocorticoid use. More importantly, osteoporotic fractures significantly contribute to the disability, health-related costs and mortality with substantially higher complication in RA patients than the general population ... 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.”

Throughout the nation, an observational cohort of patients took place. The interactions and associations of disease-modifying antirheumatic drugs, or DMARDs and osteoporotic fracture risks. The drugs included antidepressants (including SSRIs), statins, antipsychotics, NSAIDs, proton pump inhibitors, and anticonvulsants. DMARDs were divided into TNF-inhibitors, non-TNF biologics, methotrexate monotherapy (a comparator group), as well as a few others. They were compounded by a glucocorticoid variable, apart from the primary DMARD. Any therapy separate from these would be considered in isolation, either classified as current use or nonuse, as well as short-term versus long-term.

Read on to learn more about this study and what it means for rheumatoid arthritis patients.