The use of tramadol in older patients is associated with a higher risk of hip fracture compared with the use of codeine or commonly used nonsteroidal anti-inflammatory drugs (NSAIDs), say researchers recently writing in in the Journal of Bone and Mineral Research.
Pain is highly prevalent among the elderly population. Due to the adverse effects of commonly used NSAIDs and safety concerns of traditional opioids, tramadol, a weak opioid, has been considered as an alternative pain relief medication. Several professional organizations have recommended tramadol for the treatment of osteoarthritis, ﬁbromyalgia pain, and chronic low-back pain, but the drug’s safety proﬁle, such as risk of fracture, remains unclear. Few, if any, studies have compared the risk of hip fracture, which ranks among the top 10 leading causes of disability globally, among tramadol initiators with that among initiators of other commonly used analgesics.
“We compared the risk of incident hip fracture among tramadol initiators with the initiators of one of the following medications: codeine (another commonly used weak opioid), naproxen or ibuprofen (commonly used nonselective NSAIDs), celecoxib, or etoricoxib (cyclooxygenase-2 [COX-2] inhibitors) by conducting ﬁve propensity score–matched cohort studies,” wrote the authors, led by Yuqing Zhang, D.Sc., of Harvard Medical School in Massachusetts.
The population-based cohort study included 146,956 individuals in the U.K. aged 50 years or older without a history of hip fracture, cancer, or opioid use disorder enrolled in The Health Improvement Network. Participants had initiated tramadol between 2000 to 2017 and were matched to the same number of patients who initiated codeine during the same period. Equal-numbered groups were also matched between tramadol and naproxen (115,109 in each group) or ibuprofen (107,438 per group), or celecoxib (43,130 per group) or etoricoxib (27,689 per group). Participants in the matched groups had a mean age of 65 years and 56.9 percent were women.
For the primary outcome was incident hip fracture over one year, the risk was higher for tramadol compared with codeine (hazard ratio [HR], 1.28, 95% confidence interval [CI] 1.13 to 1.46), with 518 cases of hip fracture (3.7 per 1000 person-years) in the tramadol group and 401 (2.9 per 1000 person-years) in the codeine group. The risk of hip fracture was also higher in the tramadol group than in the naproxen (2.9/1000 person-years for tramadol, 1.7/1000 person-years for naproxen; HR = 1.69, 95% CI 1.41 to 2.03), ibuprofen (3.4/1000 person-years for tramadol, 2.0/1000 person-years for ibuprofen; HR = 1.65, 95% CI 1.39 to 1.96), celecoxib (3.4/1000 person-years for tramadol, 1.8/1000 person-years for celecoxib; HR = 1.85, 95% CI 1.40 to 2.44), or etoricoxib (2.9/1000 person-years for tramadol, 1.5/1000 person-years for etoricoxib; HR = 1.96, 95% CI 1.34 to 2.87) group.
“The initiation of tramadol was associated with a higher risk of hip fracture than the initiation of codeine and commonly used NSAIDs.
“Considering the signiﬁcant impact of hip fracture on morbidity, mortality, and health care cost, our results point to the need to consider tramadol’s associated risk of fracture in clinical practice and treatment guidelines,” the authors wrote.
Jie Wei, Nancy E Lane, Marcy B Bolster, et al. “Association of Tramadol Use With Risk of Hip Fracture.” Journal of Bone and Mineral Research. February 5, 2020. DOI: 10.1002/jbmr.3935