Use of Selective Serotonin Reuptake Inhibitors and Risk of Hip Fracture in the Elderly: A Case-Control Study in Taiwan

Risk of osteoporotic fractures in menopausal women with common mental health diagnoses prescribed SSRIs/SNRIs: cohort and self-controlled case series analyses

In a population-based cohort study of menopausal women with common mental health diagnoses, SSRIs/SNRIs were associated with a 32% increased risk of osteoporotic fractures. The risk of osteoporotic fractures was particularly increased for longer periods of treatment with SSRIs/SNRIs (> 5 years) and in younger menopausal women (< 50 years old).

PURPOSE

To investigate the association between selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) and the risk of osteoporotic fractures (OF) in menopausal women with common mental health diagnoses (CMHD).

METHODS

We conducted the study with two designs (cohort and self-controlled case series [SCCS]), using the IQVIA Medical Research Database (IMRD) UK. The source population comprised women aged ≥ 50 years and women with a record indicating menopause (< 50 years). All women had a recorded CMHD. For the cohort analysis, the risk of OFs was estimated by comparing women prescribed SSRIs/SNRIs (exposed) to those not exposed. Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CIs). For the SCCS, women acted as their own controls; periods of exposure to SSRIs/SNRIs were compared to periods of non-exposure using conditional Poisson regression to estimate incidence rate ratios (IRR) with 95% CIs.

RESULTS

We identified 292,848 women, of whom 35,222 experienced OFs within a median follow-up of 6.01 years. We found strong evidence of an association between SSRIs/SNRIs and the risk of OFs (adjusted HR = 1.32, 95% CI:1.29-1.35). Compared to periods of no exposure, SSRIs/SNRIs increased the risk of OFs during the first 30 days (IRR = 1.38, 95% CI:1.26-1.51), during the first 90 days (IRR = 1.58, 95% CI: 1.48-1.69), and the remaining exposure (IRR = 1.42, 95% CI:1.37-1.48).

CONCLUSIONS

In a population of menopausal women with CMHDs, the prescribing of SSRIs/SNRIs antidepressants was associated with a higher risk of OFs. Careful assessment of osteoporosis risk needs to be considered when treating menopausal women with SSRIs/SNRIs antidepressants.

Late-life depression: Epidemiology, phenotype, pathogenesis and treatment before and during the COVID-19 pandemic

Late-life depression (LLD) is one of the most common mental disorders among the older adults. Population aging, social stress, and the COVID-19 pandemic have significantly affected the emotional health of older adults, resulting in a worldwide prevalence of LLD. The clinical phenotypes between LLD and adult depression differ in terms of symptoms, comorbid physical diseases, and coexisting cognitive impairments. Many pathological factors such as the imbalance of neurotransmitters, a decrease in neurotrophic factors, an increase in β-amyloid production, dysregulation of the hypothalamic-pituitary-adrenal axis, and changes in the gut microbiota, are allegedly associated with the onset of LLD. However, the exact pathogenic mechanism underlying LLD remains unclear. Traditional selective serotonin reuptake inhibitor therapy results in poor responsiveness and side effects during LLD treatment. Neuromodulation therapies and complementary and integrative therapies have been proven safe and effective for the treatment of LLD. Importantly, during the COVID-19 pandemic, modern digital health intervention technologies, including socially assistive robots and app-based interventions, have proven to be advantageous in providing personal services to patients with LLD.

Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment

Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.

Antidepressants and Vertebral and Hip Risk Fracture: An Updated Systematic Review and Meta-Analysis

Although antidepressant drugs appear to play an active role in increasing fracture risk, their weight is still unclear. We conducted a PRISMA compliant systematic review and meta-analysis through PubMed/Scopus/Cochrane libraries and registered with PROSPERO (registration number CRD42021254006) to investigate the relationship between antidepressant drugs categories, including SSRIs, SNRIs, and TCAs, and the risk of hip and vertebral fractures. After screening 3122 items, we finally found 26 papers for qualitative analysis and 11 for quantitative synthesis. A total of 15,209,542 adult and elderly patients were identified, with a mean follow-up of 51 months and a major prevalence of women. We identified results largely for SSRIs, with only a small amount of data for SNRIs, TCAs, and NaSSA. No data were found among the most recent categories of antidepressants, such as vortioxetine and esketamine. All included studies reported hip fractures, while three of them also included vertebral fractures. Overall, we observed a significant effect of SSRIs on fracture risk with a mean effect of 0.98 (95% CI = 0.75–1.20). This meta-analysis reveals that the use of SSRIs increases the risk of fractures. Clinicians’ awareness in antidepressant prescription should optimize their potential while reducing this risk.

Secondary Osteoporosis and Metabolic Bone Diseases

Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.

Use of serotonin reuptake inhibitors and risk of subsequent bone loss in a nationwide population-based cohort study

This study examined whether the use of SRIs is associated with an increased risk of bone loss using a nested case-control design with a nationwide population-based cohort in Korea. Using the Korean National Health Screening Cohort, subjects newly diagnosed with osteoporosis or osteopenia (n = 55,799) were matched with controls (n = 278,995) at a ratio of 1:5. We stratified the participants by their time-dependent use of SRIs and sex and controlled for various confounders, including lifestyle habits, laboratory data, and comorbidities. Conditional logistic regression showed that both recent and former users of SRIs had an increased risk of subsequent bone loss compared with non-users: men [recent users: odds ratio (OR) 1.35, 95% confidential interval (CI) 1.20, 1.53; former-users: OR 1.10, 95% CI 1.01, 1.20]; women (recent users: OR 1.38, 95% CI 1.28-1.48; former-users: OR 1.07, 95% CI 1.02, 1.21). The use of SRIs was associated with an increased risk of bone loss in both men and women. In particular, the association was stronger in recent users. These findings provide population-level evidence for the risk of bone loss associated with SRI exposure and highlight the importance of monitoring the bone health of SRI users.

An update on antidepressant pharmacotherapy in late-life depression

Introduction: Clinically important depressive symptoms that occur in adults over age 60 are often termed late-life depression (LLD). LLD poses challenges for treating clinicians in both detection and treatment. Antidepressants are the most common first-line treatment approach. Older adults are at an increased risk of adverse effects because of polypharmacy.Areas covered: This article summarizes the challenges and approaches when using pharmacotherapy in LLD with a focus on newer data that have become available during the last five years. While no new antidepressants have become available during this period, a review of the literature summarizes advances in the knowledge of the adverse effects associated with various antidepressants and on the potential contribution of pharmacogenetic tools when prescribing antidepressants to older patients.Expert opinion: During the past 5 years, most of the literature relevant to the pharmacotherapy of MDD in older patients has focused on adverse effects. In particular, the effects of antidepressants on cognition and bone are emerging as important areas for clinical attention and further investigation. There is also an emerging literature on the potential role of pharmacogenetic testing in patients with MDD, though recommendations for use in older adults await larger studies that demonstrate its efficacy and cost-effectiveness.

Effects of selective serotonin reuptake inhibitors and other antidepressant drugs on the risk of hip fracture: a case-control study in an elderly Mediterranean population

OBJECTIVES

To describe the association between exposure to different antidepressant drugs and hip fracture in an elderly Mediterranean population.

METHODS

Cases were all patients aged 50-95 years admitted to the emergency room of our hospital with hip fracture not related to a high intensity trauma during 2010. For each case, four controls were identified from primary care electronic medical records matched by age (±3 years), gender, date of consultation at the primary care centre (±1 month) and primary care centre. Pharmacological treatments received within the previous 5 years were retrieved from the prescription records. Crude and adjusted risks associated with exposures were calculated by conditional logistic regression. ORs were adjusted by matching variables and by significant risk factors identified in the bivariate analysis (prescription of ≥4 drugs, osteoporosis, diabetes mellitus and previous fracture).

RESULTS

136 cases and 544 controls were analysed. Adjusted OR (95% CI) for hip fracture associated with exposure to any antidepressants was 2.42 (1.24 to 4.73); for selective serotonin reuptake inhibitors (SSRIs) it was 3.52 (1.67 to 7.41), for non-selective monoamine reuptake inhibitors 1.07 (0.18 to 6.46) and for other antidepressants 0.82 (0.27 to 2.48). Sertraline (OR 3.88 (1.15 to 13.09)) was the only active principle with significant adjusted risk. When only exposures >6 months were considered, significant risks persisted for SSRIs (OR 2.64 (1.10 to 6.37)).

CONCLUSIONS

The results of this study are coincident with other studies in which SSRIs, but not other types of antidepressants, are associated with an increased risk of hip fracture in our setting.

Fracture risk increased by concurrent use of central nervous system agents in older people: Nationwide case-crossover study

BACKGROUND

Multiple medication use among older patients is reported to increase fracture risk. But this association is unclear in different subgroups and has not been confirmed by a case-crossover study, which can eliminate measurable and unmeasurable time-invariant confounders.

OBJECTIVE

To estimate the fragility fracture risk associated with concurrent use of multiple central nervous system (CNS) agents in older patients using a case-crossover design.

METHODS

This study targeted almost all patients aged ≥65 years in Japan who incurred fragility fractures from May 2013 to September 2014, based on the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB Japan). Conditional logistic regression analysis estimated the risk of fragility fracture associated with the daily number of CNS agents, including subgroup analyses stratified by sex, age, and fracture location.

RESULTS

For 446,101 patients, the adjusted odds ratios (ORs) of fragility fracture increased almost linearly with number of CNS agents; 0, 0-1, 1-2, 2-3, 3-4, 4-5, and >5: OR reference, 1.21 (95% confidence interval, 1.18-1.23), 1.40 (1.35-1.46), 1.58 (1.49-1.67), 1.89 (1.74-2.05), 1.80 (1.60-2.03), and 1.90 (1.61-2.23; trend p < 0.001), respectively. A similar trend was observed for several subgroups, especially in males and those aged ≥85 years, showing marked linearity.

CONCLUSIONS

The increased risk of fragility fracture associated with the use of multiple CNS agents was robust in older people in Japan.

Alliance between selective serotonin reuptake inhibitors and fracture risk: an updated systematic review and meta-analysis

PURPOSE

In the past few years, several fracture-related events have been reported with chronic use of selective serotonin reuptake inhibitors (SSRIs) throughout the globe. Hence, an updated systematic review and meta-analysis was necessary to ascertain the risk involved. The present work evaluated the association of SSRIs with the risk of fracture in adults.

METHODS

We systematically searched PubMed, Cochrane library, and Google Scholar for observational studies on the same from inception to April 2019. Screening, data extraction, and risk of bias assessment were conducted independently by 2 authors.

RESULTS

We assessed 69 studies out of which 37 (14 case-control, 23 cohorts) were included. Our results showed that SSRIs were significantly associated with an increased fracture risk (relative risk of 1.62, 95% CI 1.52-1.73; P < 0.000; I² = 90.8%). The relative risk values for case-control and cohort studies were found to be 1.80 (95% CI 1.58-2.03; P < 0.000; I² = 93.2%) and 1.51 (95% CI 1.39-1.64; P < 0.000; I² = 88.0%) respectively. Subgroup analysis showed that association of risk of fracture persisted regardless of geographical location, study design, risk factors, defined daily dose, SSRI use duration, site of the fracture, period of study and after adjusting for depression, physical activity, gender, and age group. The sensitivity analysis data shows that the studies adjusted for bone mineral density and osteoporosis show lesser fracture risk.

CONCLUSION

Our findings suggests that SSRIs may be associated with an increased fracture risk; hence, bone health should be taken into consideration while prescribing this class of drugs.

Evaluating the association between avascular necrosis of femoral head and oral corticosteroids use in Taiwan

The aim of this study was to assess a correlation between avascular necrosis of femoral head and oral corticosteroids use in the general population in Taiwan. A population-based case-control study was performed to analyze the database of Taiwan National Health Insurance Program. The study consisted of 3002 subjects aged 20 to 84 with newly diagnosed avascular necrosis of femoral head between 2000 and 2013 as the cases and 11279 sex-matched and age-matched subjects without avascular necrosis of femoral head as the matched controls. Use of oral corticosteroids was defined as subjects who had at least a prescription for oral corticosteroids before the index date. No use of oral corticosteroids was defined as subjects who did not have a prescription for oral corticosteroids before the index date. The logistic regression model revealed that subjects with avascular necrosis of femoral head were 1.65 times more likely to be exposed to oral corticosteroids than those subjects without avascular necrosis of femoral head (OR 1.65, 95% CI = 1.51-1.80). A sub-analysis revealed that there was a significant association between avascular necrosis of femoral head and increasing cumulative duration of oral corticosteroids for each additional month of use (OR 1.03, 95% CI = 1.02-1.03). A significant association is detected between avascular necrosis of femoral head and oral corticosteroids use in the general population in Taiwan. There is a duration-dependent effect of oral corticosteroids use on the risk of avascular necrosis of femoral head. Clinicians should be aware of the risk of avascular necrosis of femoral head when oral corticosteroids are prescribed for a long time.

Drugs Causing Bone Loss

Drugs may cause bone loss by lowering sex steroid levels (e.g., aromatase inhibitors in breast cancer, GnRH agonists in prostate cancer, or depot medroxyprogestone acetate - DMPA), interfere with vitamin D levels (liver inducing anti-epileptic drugs), or directly by toxic effects on bone cells (chemotherapy, phenytoin, or thiazolidinedions, which diverts mesenchymal stem cells from forming osteoblasts to forming adipocytes). However, besides effects on the mineralized matrix, interactions with collagen and other parts of the unmineralized matrix may decrease bone biomechanical competence in a manner that may not correlate with bone mineral density (BMD) measured by dual energy absorptiometry (DXA).Some drugs and drug classes may decrease BMD like the thiazolidinediones and consequently increase fracture risk. Other drugs such as glucocorticoids may decrease BMD, and thus increase fracture risk. However, glucocorticoids may also interfere with the unmineralized matrix leading to an increase in fracture risk, not mirrored in BMD changes. Some drugs such as selective serotonin reuptake inhibitors (SSRI), paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDs) may not per se be associated with bone loss, but fracture risk may be increased, possibly stemming from an increased risk of falls stemming from effects on postural balance mediated by effects on the central nervous system or cardiovascular system.This paper performs a systematic review of drugs inducing bone loss or associated with fracture risk. The chapter is organized by the Anatomical Therapeutic Chemical (ATC) classification.

Selective Serotonin Reuptake Inhibitor Use and Hip Fracture Risk Among Patients on Hemodialysis

RATIONALE & OBJECTIVE

Use of selective serotonin reuptake inhibitors (SSRIs) has been associated with hip fracture risk in the general population. This study examined this relationship among patients with kidney failure treated by hemodialysis, a unique high-risk subpopulation, within which the impact of SSRIs on hip fracture risk remains unexplored.

STUDY DESIGN

Case-control study.

SETTINGS & PARTICIPANTS

Eligible cases of hip fracture among maintenance hemodialysis patients between January 1, 2009, and September 30, 2015, were identified using the US Renal Data System. Each case was matched on index date with 10 eligible controls. To be eligible, study participants needed to have more than 1 year of Medicare Parts A and B coverage and more than 3 years of Part D coverage. For a separate examination of new short-term SSRI exposure, we selected cases and controls with more than 18 months of Part D coverage and no prior antidepressant use for 1 year.

EXPOSURE

During the 3-year Part D coverage period, use of SSRIs characterized as any (≥1 prescription filled), low, moderate, and high use (<20%, 20%-<80%, and≥80% of days covered by filled prescriptions, respectively).

OUTCOME

We selected cases using International Classification of Diseases, Ninth Revision codes 820.xx and 821.xx. In addition to 1 of these codes tied to a hospitalization, we required a corresponding surgical procedural code within 7 days of diagnosis.

ANALYTIC APPROACH

Conditional logistic regression to estimate unadjusted and multivariable-adjusted ORs and 95% CIs.

RESULTS

We identified 4,912 cases and 49,120 controls. SSRI use was associated with increased hip fracture risk (adjusted OR, 1.25; 95% CI, 1.17-1.35). Risk for fracture was estimated for any, low, moderate, and high SSRI use: adjusted conditional ORs were 1.25 (95% CI, 1.17-1.35), 1.20 (95% CI, 1.08-1.32), 1.31 (95% CI, 1.18-1.43), and 1.26 (95% CI, 1.12-1.41), respectively. The association between hip fracture events and SSRI use was also seen in the examination of new short-term use (adjusted OR, 1.43; 95% CI, 1.23-1.67).

LIMITATIONS

Biomarkers of mineral bone disorder were not captured and accounted for in this analysis.

CONCLUSIONS

We demonstrated an association between increased hip fracture risk and both long- and new short-term SSRI use. The stronger association with new short-term use may suggest an acute mechanism potentially related to falls.

Effect of selective serotonin reuptake inhibitors on markers of bone loss

Several preclinical and clinical studies show that selective serotonin reuptake inhibitors (SSRI's) are associated with bone loss and an increase in fracture risk, not many reports on their effect on bone turnover markers. This cross-sectional study evaluated the effect of SSRIs treatment on bone turnover markers in Indian population for the first time. Inclusion criteria were subjects of either sex and age 18-45 years undergoing treatment with an SSRI for at least 3 months, regardless of the indication. The results were compared with age-matched healthy controls. A total of 141 subjects were screened out of which 85 were enrolled, 44 in treatment and 41 in the control group. Serum Procollagen Type 1 Amino Terminal Propeptide (P1NP) levels were decreased in patients on SSRI treatment whereas no change was observed in the beta-C-terminal telopeptide (β-CTX) and receptor activator of nuclear factor kappa-Β ligand (RANKL) levels suggesting that these drugs can reduce bone formation but not resorption. Patients on SSRI treatment also showed reduced pCREB levels indicating that reduced bone formation is possibly through the gut mediated pathway. Our study suggests that SSRIs treatment at therapeutic doses may have a deteriorating effect on bone requiring caution in patients with additional risk factors.

Association between colorectal cancer and thiazolidinediones administration in a case-control study

OBJECTIVES

This study was designed to assess whether there was an association between colorectal cancer and thiazolidinediones use.

METHODS

A population-based case-control study was performed using the database of the Taiwan National Health Insurance Program. The case group consisted of 20218 type 2 diabetic subjects aged 20 to 84 years with newly diagnosed colorectal cancer between 2000 and 2011. The date of a subject being diagnosed with colorectal cancer was defined as the index date. The control group consisted of 20218 randomly selected type 2 diabetic subjects aged 20 to 84 years without colorectal cancer between 2000 and 2011. A subject who had at least a prescription of thiazolidinediones before the index date was defined as "ever used". A subject who did not have a prescription of thiazolidinediones before the index date was defined as "never used". The odds ratio (OR) and 95% confidence interval (CI) was used to estimate the association between colorectal cancer and thiazolidinediones use by the multivariable logistic regression model.

RESULTS

After adjustment for potential confounders, the odds of thiazolidinediones use in cases with colorectal cancer were lower than the odds of thiazolidinediones use in subjects without colorectal cancer (adjusted OR 0.94, 95% CI 0.89-0.99).

CONCLUSIONS

The odds of thiazolidinediones use in cases with colorectal cancer were lower than subjects without colorectal cancer. A prospective study is required to test whether thiazolidinediones use has a protective effect against colorectal cancer.

Selective serotonin reuptake inhibitor use in hip fracture patients: a Danish nationwide prevalence study

Background and purpose - Selective serotonin reuptake inhibitors (SSRIs) are often used in the elderly and are associated with adverse effects. Therefore, it is important to ascertain the prevalence of SSRI use in fragile and surgery-treated hip fracture patients. Methods - This population-based prevalence study included Danish hip fracture patients aged ≥ 65 years operated in 2006-2016 (n = 68,607) and matched individuals from the background population (n = 343,020). Using Poisson regression, prevalence risk ratios (PRRs) with 95% confidence intervals (CIs) were estimated to compare hip fracture patients with the general population, and to estimate the association between hip fracture patient characteristics and SSRI prescriptions. Results - The prevalence of SSRI use among hip fracture patients was 23% compared with 12% in the general population. During 2006-2016, the prevalence decreased from 26% to 18% among hip fracture patients and from 13% to 10% in the general population. Factors associated with SSRI use in hip fracture patients were age 75-84 years (PRR 1.18, CI 1.13-1.23), age ≥ 85 years (PRR 1.17, CI 1.11-1.22), female sex (PRR 1.13, CI 1.09-1.17), unmarried status (PRR 1.15, CI 1.11-1.19), living in a residential institution (PRR 2.30, CI 2.19-2.40), Charlson comorbidity index (CCI) score 1-2 (PRR 1.50, CI 1.45-1.55), CCI score 3+ (PRR 1.62, CI 1.55-1.69), and several medications. Interpretation - The prevalence of SSRI use was high among hip fracture patients compared with the general population. Our data stress the importance of continued clinical awareness of frailty, comorbidity, and polypharmacy of hip fracture patients and the potentially adverse drug effects of SSRI treatment.

Association between tamoxifen use and acute myocardial infarction in women with breast cancer

The relationship between tamoxifen use and acute myocardial infarction in women with breast cancer remains uncertain. The goal of the study was to assess whether tamoxifen use could be associated with acute myocardial infarction in women with breast cancer in Taiwan.A population-based case-control study was conducted to analyze the database of the Taiwan National Health Insurance Program. Totally, 489 women with breast cancer aged 20 to 84 years having the first episode of acute myocardial infarction from 2000 to 2011 were found as the cases. In addition, 1718 women with breast cancer aged 20 to 84 years without any type of ischemic heart disease were selected as the matched controls. Ever use of tamoxifen was classified as the studied women who had at least a prescription for tamoxifen before the index date. Never use of tamoxifen was classified as the studied women who never had a prescription for tamoxifen before the index date. We used the multivariable logistic regression model to estimate the odds ratio (OR) and 95% confidence interval (CI) for acute myocardial infarction associated with tamoxifen use.In a multivariable-adjusted analysis, women with acute myocardial infarction were 1.71 times more likely to be exposed to tamoxifen than those women without acute myocardial infarction (adjusted OR 1.71, 95% CI 1.38-2.13).The odds of tamoxifen use are 1.71 times higher in women with acute myocardial infarction versus those women without acute myocardial infarction in Taiwan.

Case-control study examining the association between herpes zoster and oral corticosteroids use in older adults

INTRODUCTION

Little research focuses on the association between herpes zoster and oral corticosteroids use in older adults. The aim of the study was to explore this issue.

METHODS

We performed a case-control study using the database of the Taiwan National Health Insurance Program. There were 10,912 participants aged 65 years and older with newly diagnosed herpes zoster in 2000-2013 as the cases. We randomly selected 42,676 sex-matched and age-matched participants without herpes zoster as the controls. Ever use of oral corticosteroids was defined as participants who at least had a prescription for oral corticosteroids before the index date. Never use was defined as participants who did not have a prescription for oral corticosteroids before the index date. The odds ratio (OR) and 95% confidence interval (CI) for herpes zoster associated with oral corticosteroids use were estimated using the logistic regression model.

RESULTS

The adjusted OR of herpes zoster was 3.13 for participants with ever use of oral corticosteroids (95% CI 2.84-3.46), compared with never use. In a further analysis, the adjusted ORs of herpes zoster were 3.10 for cumulative duration of oral corticosteroids use < 12 months (95% CI 2.81-3.42) and 3.65 for cumulative duration ≥ 12 months (95% CI 3.20-4.18).

CONCLUSIONS

Older adults with oral corticosteroids use are associated with a threefold increase in odds of herpes zoster in Taiwan. There is a duration-related effect of oral corticosteroids use on the risk of herpes zoster.

Weight loss might be an early clinical feature of undiagnosed human immunodeficiency virus infection in Taiwan

BACKGROUND/OBJECTIVE

Little research is available on the relationship between weight loss and human immunodeficiency virus (HIV) infection in Taiwan. We hope to evaluate whether weight loss could be an early clinical feature of undiagnosed HIV infection in Taiwan.

METHODS

We conducted a retrospective population-based cohort study using the database of the Taiwan National Health Insurance (NHI) Program. There were 4748 male subjects aged 1-84 with newly diagnosed weight loss as the weight loss group from 1998-2012 and 18982 age-matched male subjects without weight loss as the non-weight loss group. The incidence of HIV infection at the end of 2013 was measured in both groups. The multivariable Cox proportional hazards regression model was used to measure the hazard ratio (HR) and 95% confidence interval (CI) for HIV risk associated with weight loss.

RESULTS

The overall incidence of HIV infection was 3.79-fold higher in the weight loss group than in the non-weight loss group (6.83 vs. 1.80 per 10000 person-years, 95% CI 3.41, 4.21). The incidence was the highest during the first 6 months of follow-up in the weight loss group (39.0 per 10000 person-years). After adjusting for confounding factors, the adjusted HR of HIV infection was 3.63 (95% CI 1.77, 7.44) for the weight loss group, compared with the non-weight loss group.

CONCLUSION

Weight loss might be an early clinical feature of undiagnosed HIV infection in Taiwan. Male patients with weight loss who have risk factors for HIV infection should be recommended to regularly be tested for HIV infection.

Synergistic effect of oral corticosteroids use on risk of hepatocellular carcinoma in high risk populations

OBJECTIVE

Little evidence is available on the relationship between oral corticosteroids use and hepatocellular carcinoma. The objective of this study was to investigate whether oral corticosteroids use correlates with the risk of hepatocellular carcinoma in high risk populations in Taiwan.

METHODS

Using representative claims database established from the Taiwan National Health Insurance Program with a population coverage rate of 99.6%, we identified 102,182 subjects aged 20-84 years with newly diagnosed hepatocellular carcinoma in 2000-2011 as the cases and 102,182 randomly selected subjects aged 20-84 years without hepatocellular carcinoma as the matched controls.

RESULTS

In subjects with any one of comorbidities including alcohol-related disease, chronic liver disease, and diabetes mellitus, the adjusted OR of hepatocellular carcinoma was 29.9 (95% CI 28.7, 31.1) for subjects with never use of oral corticosteroids, and the adjusted OR would increase to 33.7 (95% CI 32.3, 35.3) for those with ever use of oral corticosteroids. The adjusted OR of hepatocellular carcinoma was 1.03 for subjects with increasing cumulative duration of oral corticosteroids use for every one year (95% CI 1.01, 1.06), with a duration-dependent effect. The largest OR occurred in subjects with ever use of oral corticosteroids and concurrently comorbid with alcohol-related disease, chronic liver disease, and diabetes mellitus (adjusted OR 122.7, 95% CI 108.5, 138.8).

CONCLUSION

There is a synergistic effect between oral corticosteroids use and the traditional risk factors on the risk of hepatocellular carcinoma. People with risk factors for hepatocellular carcinoma should receive regular ultrasound surveillance, particularly when they currently use oral corticosteroids.

Association between oral corticosteroid use and pyogenic liver abscesses in a case-control study

BACKGROUND AND AIM

There are no epidemiological studies focusing on the association between oral corticosteroid use and pyogenic liver abscesses. The aim of the study was to assess whether oral corticosteroid use is associated with increased odds of pyogenic liver abscesses in adults in Taiwan.

METHODS

This retrospective population-based case-control study was conducted to analyze the database of the Taiwan National Health Insurance Program from 2000 to 2013. Subjects aged 20 to 84 years with their first episode of pyogenic liver abscesses were assigned as the cases (n = 881). Randomly selected subjects without pyogenic liver abscesses aged 20 to 84 years were selected as the controls (n = 3207). A multivariable logistic regression model was used to assess the odds ratio and 95% confidence interval for the correlation of oral corticosteroid use with pyogenic liver abscesses.

RESULTS

After regulating for confounders, the adjusted odds ratio of pyogenic liver abscesses was 1.40 for subjects currently using oral corticosteroids (95% confidence interval 1.14, 1.70), compared with subjects who never used them. Upon further analysis, the adjusted odds ratio of pyogenic liver abscesses was 1.03 for subjects with current use of oral corticosteroids when increasing dosage for every one mg (95% CI 1.01, 1.06).

CONCLUSION

Although the findings are not unexpected, they are important because they suggest that current use of oral corticosteroids is significantly associated with increased odds of developing pyogenic liver abscesses in adults in Taiwan, with a dose-dependent effect.

Drugs With Anticholinergic Potential and Risk of Falls With Hip Fracture in the Elderly Patients: A Case-Control Study

BACKGROUND/OBJECTIVE

To determine the association between the use of anticholinergic drugs and the risk of falls with hip fracture in a population older than 60 years.

METHODS

A case-control study in patients older than 60 years with a diagnosis of hip fracture. All drugs dispensed during the previous 30 days were identified. Sociodemographic, clinical, pharmacological (drugs according to the Anticholinergic Risk Scale [ARS]), and polypharmacy variables were analyzed.

MEASUREMENTS

Falls with hip fracture and type of drug according to the ARS.

RESULTS

A total of 300 patients with hip fracture and 600 controls were included. The mean age was 81.6 ± 8.9 years, with female predominance (71.3%). The use of drugs with moderate (odds ratio [OR]: 1.97, 95% confidence interval [CI]: 1.19-3.27) or high ARS scores (OR: 1.83, 95% CI: 1.13-2.96) increased the probability of fracture.

CONCLUSIONS

There was an association between the use of drugs with anticholinergic properties and the probability of hip fracture in elderly patients and it was possible to establish the level of risk.

Case-Control Study Examining the Association between Selective Serotonin Reuptake Inhibitors Use and Hepatocellular Carcinoma

Objectives: The purpose of the study was to assess the relationship between selective serotonin reuptake inhibitors use and hepatocellular carcinoma in Taiwan.

Methods: Using the database of the Taiwan National Health Insurance Program, we conducted a case-control study to identify 4901 subjects aged 20 years and more with newly diagnosed hepatocellular carcinoma in 2000–2013 as the cases. We randomly selected 19604 subjects aged 20 years and more without hepatocellular carcinoma as the controls. Both cases and controls were matched with sex and age. Ever use of selective serotonin reuptake inhibitors was defined as a subject who had at least a prescription for selective serotonin reuptake inhibitors before index date. Never use was defined as a subject who never had a prescription for selective serotonin reuptake inhibitors before index date. The odds ratio (OR) and 95% confidence interval (CI) for hepatocellular carcinoma associated with selective serotonin reuptake inhibitors use was estimated by the multivariable logistic regression model.

Results: Among subjects with any one of the comorbid conditions associated with hepatocellular carcinoma, the adjusted OR of hepatocellular carcinoma was 0.89 (95% CI 0.75, 1.06) for subjects with ever use of selective serotonin reuptake inhibitors, comparing with never use.

Conclusion: The findings indicate that among subjects with any one of the comorbid conditions associated with hepatocellular carcinoma, no significant association can be detected between selective serotonin reuptake inhibitors use and hepatocellular carcinoma.

Head and neck cancer associated with increased rate of pulmonary tuberculosis in a population-based cohort study

The objective of this study was to examine the incidence and hazard ratio (HR) of pulmonary tuberculosis in patients with head and neck cancer in Taiwan.This population-based retrospective cohort study was conducted to analyze the database of the Taiwan National Health Insurance Program. There were 2522 subjects aged 20 to 84 years with newly diagnosed head and neck cancer as the head and neck cancer group between 2000 and 2012, and 10,064 randomly selected sex- and age-matched subjects without any cancer as the noncancer group. The incidence of pulmonary tuberculosis at the end of 2013 was estimated in both groups. A multivariable Cox proportional hazards regression model was used to estimate the HR and 95% confidence interval (CI) for pulmonary tuberculosis being associated with head and neck cancer.The overall incidence of pulmonary tuberculosis was 2.86-fold greater in the head and neck cancer group than that in the noncancer group (4.70 vs 1.64 per 1000 person-years, 95% CI, 2.53-3.24). After adjusting for confounding factors, the adjusted HR of pulmonary tuberculosis became 2.90 for the head and neck cancer group (95% CI, 2.11-3.99), compared with the noncancer group. In addition, male (adjusted HR 2.27, 95% CI, 1.29-4.00) and age (increase for 1 year, adjusted HR 1.06, 95% CI, 1.05-1.08) were associated with pulmonary tuberculosis.Head and neck cancer is significantly associated with 2.90-fold increased hazard of pulmonary tuberculosis in Taiwan, compared with the general population.

Use of Oral Corticosteroids and Risk of Hip Fracture in the Elderly in a Case-Control Study

Aim: Little is known regarding the relationship between use of oral corticosteroids and hip fracture in the elderly in Taiwan. The aim of the study was to examine this issue.

Methods: A retrospective population-based case-control study using the database of the Taiwan National Health Insurance Program (2000–2013) was conducted. We identified 4538 individuals aged ≥ 65 years with newly diagnosed hip fracture as the cases. We randomly selected 4538 individuals without hip fracture as the control subjects. The cases and the control subjects were matched with sex, age, comorbidities, and the year of index date. Individuals who never had a prescription for oral corticosteroids were defined as never use. Individuals who ever had at least one prescription for oral corticosteroids were defined as ever use. The odds ratio (OR) and 95% confidence interval (CI) of hip fracture associated with oral corticosteroids use was estimated by a multivariable unconditional logistic regression analysis.

Results: After adjustments for potential confounding factors, the multivariable logistic regression model showed that the adjusted OR of hip fracture was 1.17 for individuals with ever use of oral corticosteroids (95%CI 1.08, 1.28), compared to those with never use of oral corticosteroids. An sub-analysis showed that for every 1-mg increase in cumulative dose of oral corticosteroids, the adjusted OR of hip fracture was 1.01 (95% CI 1.01, 1.02). The adjusted ORs were 1.31 (95% CI 1.17, 1.47) for cumulative exposure to oral corticosteroids ≥ 3 months and 1.09 (95% CI 0.98, 1.20) for cumulative exposure < 3 months.

Conclusion: We conclude that oral corticosteroids use is associated with a trivial but statistically significant increase in risk of hip fracture in Taiwan. Additionally, the results suggest that there are dose-response and duration-response effects of oral corticosteroids on the risk of hip fracture. The results confirm our understanding of oral corticosteroid-associated hip fracture in the elderly.

Nation-based case-control study investigating the relationship between oral corticosteroids use and pulmonary tuberculosis

BACKGROUND AND OBJECTIVE

No published formal study focuses on the relationship between oral corticosteroids use and pulmonary tuberculosis in Taiwan. The aim of the study was to investigate whether oral corticosteroids use was associated with increased odds of pulmonary tuberculosis.

METHODS

The retrospective, nation-based, case-control study was conducted to analyze the database of the Taiwan National Health Insurance Program between 2000 and 2013. Subjects aged 20 to 84years with newly diagnosed pulmonary tuberculosis were defined as the cases (n=6021). Randomly selected subjects without pulmonary tuberculosis aged 20 to 84years were defined as the controls (n=6021). Subjects who never had a prescription for oral corticosteroids were defined as never use. Subjects who ever had a prescription for oral corticosteroids were defined as ever use.

RESULTS

After adjustment for confounders, the adjusted odds ratio of pulmonary tuberculosis was 1.91 for subjects with even use of oral corticosteroids (95% confidence interval 1.73, 2.11), comparing with never use. The adjusted odds ratio of pulmonary tuberculosis was 1.03 for subjects with increasing cumulative dose of oral corticosteroids for per milligram (95% confidence interval 1.02, 1.03), comparing with never use. In addition, the adjusted odds ratios of pulmonary tuberculosis were 1.83 (95% CI 1.65, 2.02) for subjects with cumulative duration of oral corticosteroids<3months, and 2.12 (95% CI 1.87, 2.40) for subjects with cumulative duration≥3months, comparing with never use.

CONCLUSION

Though the finding is not unexpected, use of oral corticosteroids is significantly associated with 1.9-fold increased odds of pulmonary tuberculosis, independent of other risk comorbidities. There are dose-dependent and duration-dependent effects of oral corticosteroids use on the risk of pulmonary tuberculosis.

Glaucoma correlates with increased risk of Parkinson's disease in the elderly: a national-based cohort study in Taiwan

BACKGROUND/OBJECTIVE

Very little is known about the association between glaucoma and Parkinson's disease in the elderly. The objective of this study was to determine whether glaucoma is associated with Parkinson's disease in older people in Taiwan.

METHODS

A retrospective cohort study was conducted to analyze the Taiwan National Health Insurance Program database from 2000 to 2010. We included 4330 subjects aged 65 years or older with newly diagnosed glaucoma as the glaucoma group, and 17,000 randomly selected subjects without a glaucoma diagnosis as the non-glaucoma group. Both groups were matched for sex, age, other comorbidities, and index year of glaucoma diagnosis. The incidence of Parkinson's disease at the end of 2011 was measured. A multivariable Cox proportional hazard regression model was used to measure the hazard ratio and 95% confidence intervals for Parkinson's disease associated with glaucoma.

RESULTS

The overall incidence of Parkinson's disease was 1.28-fold higher in the glaucoma group than that in the non-glaucoma group (7.73 vs. 6.02 per 1000 person-years; 95% confidence interval 1.18, 1.40). After controlling for potential confounding factors, the adjusted hazard ratio of Parkinson's disease was 1.23 for the glaucoma group (95% confidence interval 1.05, 1.46), compared with the non-glaucoma group.

CONCLUSIONS

Older people with glaucoma correlate with a small but statistically significant increase in the risk for Parkinson's disease. Whether glaucoma may be a non-motor feature of Parkinson's disease in older people requires further research to confirm.

Serotonin reuptake inhibitors and bone health: A review of clinical studies and plausible mechanisms

Selective serotonin reuptake inhibitors (SSRIs) are currently the treatment of choice in depression and constitute major portion of prescription in depressive patients. The role of serotonin receptors in bone is emerging, raising certain questions regarding the effect of blockade of serotonin reuptake in the bone metabolism. Clinical studies have reported an association of SSRI antidepressants which with increase in fracture and decrease in bone mineral density. This review focus on recent evidence that evaluate the association of SSRIs with the risk of fracture and bone mineral density and also the probable mechanisms that might be involved in such effects.

Glaucoma may be a non-memory manifestation of Alzheimer's disease in older people

BACKGROUND

The purpose of this paper was to examine whether glaucoma could be a non-memory manifestation of Alzheimer's disease in older people.

METHODS

We conducted a population-based, retrospective, case-control study to analyze the database of the Taiwan National Health Insurance Program. There were 1,351 subjects ≥65 years old with newly diagnosed Alzheimer's disease as the cases, and 5,329 subjects without any type of dementias as the controls during 2000-2011. The odds ratio (OR) and 95% confidence interval (CI) for the risk of Alzheimer's disease associated with glaucoma was estimated by the multivariable unconditional logistic regression model.

RESULTS

After controlling for confounders, the multivariable logistic regression model demonstrated that the adjusted OR of Alzheimer's disease was 1.50 in subjects with glaucoma (95% CI 1.19, 1.89), compared to subjects without glaucoma.

CONCLUSIONS

Older people with glaucoma are associated with 1.5-fold increased odds of Alzheimer's disease in Taiwan. Glaucoma may be a non-memory manifestation of Alzheimer's disease in older people. Further research is needed to confirm this issue.

Risk of Hip Fracture in Older People Using Selective Serotonin Reuptake Inhibitors and Other Psychoactive Medicines Concurrently: A Matched Case-Control Study in Australia

Background

Few studies have assessed the risk of hip fracture following concurrent use of psychoactive medicines, and none has investigated combinations with selective serotonin reuptake inhibitors.

Objectives

To assess the risk of hip fracture in older people as a result of concurrent use of selective serotonin reuptake inhibitors and other psychoactive medicines.

Methods

A matched case–control design was employed. Cases were Australian Government Department of Veterans’ Affairs beneficiaries aged over 65 years who experienced a hip fracture between 2009 and 2012. Each case was matched with up to four randomly selected controls of the same age (±2 years) and sex. Medicine-hip fracture associations were estimated via conditional logistic regression. The relative excess risk due to interaction (RERI) was calculated to determine whether combined effects differed from the sum of individual effects.

Results

There were 8828 cases and 35,310 controls. The median age of subjects was 88 years and 63% were women. The risk of hip fracture was elevated for all medicines assessed individually, most notably selective serotonin reuptake inhibitors (initiation: odds ratio [OR] = 2.7, 95% confidence interval [CI] 2.1, 3.6) and opioids (initiation: OR = 2.3, 95% CI 1.9, 2.9). Combinations associated with an increased odds of hip fracture included addition of benzodiazepines to selective serotonin reuptake inhibitor therapy (OR = 3.0, 95% CI 1.9, 4.8; RERI = 0.9, 95% CI −0.5, 2.3), concurrent use of both opioids and selective serotonin reuptake inhibitors (OR = 2.2, 95% CI 1.9, 2.6; RERI = 0.1, 95% CI −0.3, 0.5), addition of opioids to selective serotonin reuptake inhibitor therapy (OR = 3.2, 95% CI 1.8, 5.5; RERI = −0.1, 95% CI −2.0, 1.7), and initiation of both benzodiazepines and selective serotonin reuptake inhibitors (OR = 4.7, 95% CI 1.7, 13; RERI = 1.3, 95% CI −3.8, 6.3). The RERI results suggested that the effect of each of these medicine combinations equalled the sum of the effects of individual medicine use.

Conclusions

In older people, the concurrent use of selective serotonin reuptake inhibitors and other psychoactive medicines increased the risk of hip fracture as much as the sum of the risks owing to individual medicine use. Our results highlight the need for prescribers to consider the sedative burden of medicines in each older patient as well as the potential for an additive risk of hip fracture when initiating additional psychoactive therapy.