Selective serotonin-reuptake inhibitor antidepressants increase the risk of falls and hip fractures in elderly people by inhibiting cardiovascular ion channels

Exploring Factors Associated with Falls in Multiple Sclerosis: Insights from a Scoping Review

Multiple sclerosis (MS) is a chronic inflammatory condition that causes demyelination of the central nervous system accompanied by a wide range of symptoms. The high prevalence of falls among patients diagnosed with MS within the initial six months highlights the importance of this issue. The objective of this study is to identify factors associated with falls in MS patients in order to increase awareness and reduce the risk of falls. This scoping review used specific Mesh terms to formulate the literature search around falls and MS using Medline, Google Scholar, Scopus, and Embase search engines. English papers published between 2012 and 2022, studies with a clear definition of falls, McDonald's diagnostic criteria for MS, and those with Expanded Disability Status Scale (EDSS) or Patient Determined Disease Steps (PDDS) scores were included. Critical data from the selected articles were extracted and classified according to the different factors associated with falls in MS patients. Eighteen articles were included in this review. The most important factors associated with falls in MS patients identified were the severity and progression of the disease, mobility and balance problems, bladder dysfunction, fear of falling, fatigue, and cognitive dysfunction. In conclusion, this scoping review yielded the most common factors associated with falls in patients with MS. Study findings can be used to develop future interventions focusing on improving mobility, proprioception, and balance to decrease fall risk and injury amongst MS patients.

Structural enrichment attenuates colitis-associated colon cancer

Colorectal cancer (CRC) is a major public health concern and disproportionately impacts racial/ethnic minority populations in the US. Animal models are helpful in examining human health disparities because many stress-induced human health conditions can be recapitulated using mouse models. Azoxymethane (AOM)/ dextran sodium sulfate (DSS) treatment can be used to model colitis-associated cancers. While colitis-associated cancers account for only 2% of colon cancers, the AOM/DSS model is useful for examining links between inflammation, immunity, and colon cancer. Mice were housed in enriched and impoverished environments for 1-month prior to behavioral testing. Following behavioral testing the mice were subjected to the AOM/DSS model. While our analysis revealed no significant behavioral variances between the impoverished and enriched housing conditions, we found significant effects in tumorigenesis. Enriched mice had fewer tumors and smaller tumor volumes compared to impoverished mice. African Americans are at higher risk for early onset colorectal cancers in part due to social economic status. Furthermore, housing conditions and environment may reflect social economic status. Research aimed at understanding links between social economic status and colorectal cancer progression is important for eliminating disparities in health outcomes.

The Effects of Pain and Analgesic Medications on Blood Pressure

PURPOSE OF REVIEW

To review the blood pressure (BP) effects of pain and analgesic medications and to help interpret BP changes in people suffering from acute or chronic pain.

RECENT FINDINGS

Acute pain evokes a stress response which prompts a transient BP increase. Chronic pain is associated with impaired regulation of cardiovascular and analgesia systems, which may predispose to persistent BP elevation. Also analgesics may have BP effects, which vary according to the drug class considered. Data on paracetamol are controversial, while multiple studies indicate that non-steroidal anti-inflammatory drugs may increase BP, with celecoxib showing a lesser impact. Hypotension has been reported with opioid drugs. Among adjuvants, tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors could be pro-hypertensive due to potentiation of adrenergic transmission. Pain and analgesics may induce a clinically significant BP destabilization. The implications on hypertension incidence and BP control remain unclear and should be explored in future studies.

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.

The complex associations between late life depression, fear of falling and risk of falls. A systematic review and meta-analysis

INTRODUCTION

Depression rates in older people worldwide vary from 10% to 15% of community-dwelling older persons. There are two others problems related to depression in old age, namely the high incidence of falls and the so-called fear of falling (FOF), with a prevalence ranging from 20% to 85%; it was initially considered a post-fall syndrome, which later as a fall-independent event.

AIMS

Study aims to conduct a systematic review and meta-analysis to bridge the existing gap in literature about the association between depressive symptomatology, FOF, use of antidepressant therapy and falls, also identifying a possible effect of the study quality on the outcome.

METHODS

The selection of studies was carried out between May 20, 2020, and July 27, 2020 and only observational clinical trials, written in English, with participants aged more or equal to 60 years affected by diagnosis of depression or treatment for depression mentioned both as a clinical diagnosis in older patient, and as a predictor/consequence of falls were included. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for reporting systematic reviews and meta-analysis, and the protocol was recorded in the International Prospective Register of Systematic Reviews (PROSPERO).

RESULTS AND DISCUSSION

The screening process ultimately led to the inclusion of 18 articles. Many of the included studies showed that depressive symptoms caused the subsequent increase in the number of falls. Results from the meta-analysis had no highlighted association between depression and falls, in contrast to other review and meta-analysis works: our work includes a substantial number of studies, with a relatively recent publication date, including patients diagnosed with depression, clearly evaluating the association between depression and falls. Results all seem to confirm the hypothesis of an interdependent association between the presence of FOF and the risk of fall, despite the high percentage of cross-sectional studies prevents inferring on the direction of the association. Therapeutic interventions aimed at decrease rate of falls reducing depressive symptoms and FOF.

Repeated use of SSRIs potentially associated with an increase on serum CK and CK-MB in patients with major depressive disorder: a retrospective study

There is a large amount of evidence that selective serotonin reuptake inhibitors (SSRIs) are related to cardiovascular toxicity, which has aroused concern regarding their safety. However, few studies have evaluated the effects of SSRIs on cardiac injury biomarkers, such as creatine kinase (CK) and creatine kinase isoenzyme (CK-MB). The purpose of our study was to determine whether SSRIs elevated CK and CK-MB levels of prior medicated depressive patients (PMDP) compared to first-episode drug-naïve depressive patients (FDDPs). We performed an observational and retrospective study involving 128 patients with major depressive disorder. Patients who had never used any type of antidepressant were designated FDDP; patients who had used only one type of SSRI but were not treated after a recent relapse were designated PMDP. Serum CK and CK-MB levels were measured before and after using SSRIs for a period of time. The duration of current treatment in the FDDP and PMDP groups was 16.200 ± 16.726 weeks and 15.618 ± 16.902 weeks, respectively. After SSRI treatment, levels of serum CK in the PMDP group were significantly higher than in the FDDP group. Univariate ANCOVA results revealed that PMDP was 22.313 times more likely to elevate CK (OR 22.313, 95% CI 9.605-35.022) and 2.615 times more likely to elevate CK-MB (OR 2.615, 95% CI 1.287-3.943) than FDDP. Multivariate ANCOVA revealed an interaction between the group and sex of CK and CK-MB. Further pairwise analysis of the interaction results showed that in female patients, the mean difference (MD) of CK and CK-MB in PMDP was significantly greater than that in FDDP (MD = 33.410, P = 0.000, 95% CI 15.935-50.886; MD = 4.613, P = 0.000, 95% CI 2.846-6.381). Our findings suggest that patients, especially females, who had previously used SSRI antidepressants were more likely to have elevated CK and CK-MB, indicators of myocardial muscle injury. Use of SSRIs should not be assumed to be completely safe and without any cardiovascular risks.

The Effect of Sertraline on Hemodynamic Parameters and Nitric Oxide Production in Isolated Rat Hearts Subjected to Ischemia and Reperfusion

Purpose

The aim of the study was to investigate the effect of sertraline on the rat heart during ischemia and reperfusion and to determine its effect on NO production.

Materials and methods

The study was performed on isolated rat hearts. Hearts from three groups were perfused with sertraline at three different concentrations and subjected to global ischemia and reperfusion. Hearts from the other three groups were perfused with the same concentrations of sertraline but without the ischemia/reperfusion process. Two control groups were perfused with the Krebs-Henseleit solution only with and without ischemia/reperfusion process. Coronary flow (CF), heart rate (HR), left ventricular developed pressure (LVDP) and maximum rate of rise of left ventricular pressure (dP/dt max) were measured. Perfusate effluent was collected to determine creatine phosphokinase (CPK) and nitrate plus nitrite (NOx) levels.

Results

In non-ischemic groups, sertraline at the concentration of 10 μmol/L exerts a strong vasodilatory effect on CF, and after a short positive inotropic effect, it exerts a strong inotropic and chronotropic negative effect on isolated rat hearts and causes a direct damage to cardiomyocytes. At the concentration of 1 μmol/L, sertraline exerts an increasing negative inotropic effect. There were no hemodynamic differences between any of groups of hearts subjected to reperfusion. Sertraline had no effect on the nitric oxide concentration in coronary effluent neither in rat hearts subjected to ischemia/reperfusion nor in non-ischemic conditions.

Conclusion

Sertraline at dose 10 μmol/L exerts a strong vasodilatory effect on coronary flow, and after a short positive inotropic effect, it exerts a strong negative effect on isolated rat hearts, causing a direct damage to cardiomyocytes. Sertraline had no effect on the nitric oxide concentration in coronary effluent.

Selective serotonin reuptake inhibitor and selective serotonin and norepinephrine reuptake inhibitor use and risk of fractures in adults: A systematic review and meta-analysis

OBJECTIVE

To evaluate the association between selective serotonin reuptake inhibitor (SSRI) and selective serotonin and norepinephrine reuptake inhibitor (SNRI) use and risk of fractures in older adults.

METHODS

We systematically identified and analyzed observational studies comparing SSRI/SNRI use for depression with non-SSRI/SNRI use with a primary outcome of risk of fractures in older adults. We searched for studies in MEDLINE, PsycINFO, Embase, DARE (Database of Abstracts or Reviews of Effects), the Cochrane Library, and Web of Science clinical trial research registers from 2011 for SSRIs and 1990 for SNRIs to November 29, 2016.

RESULTS

Thirty-three studies met our inclusion criteria; 23 studies were included in meta-analysis: 9 case-control studies and 14 cohort studies. A 1.67-fold increase in the risk of fracture for SSRI users compared with nonusers was observed (relative risk 1.67, 95% CI 1.56-1.79, P = .000). The risk of fracture increases with their long-term use: within 1 year, the risk is 2.9% or 1 additional fracture in every 85 users; within 5 years, the risk is 13.4% or 1 additional fracture in every 19 users. In meta-regression, we found that the increase in risk did not differ across age groups (odds ratio = 1.006; P = .173). A limited number of studies on SNRI use and the risk of fractures prevented us from conducting a meta-analysis.

CONCLUSIONS

Our systematic review showed an association between risk of fracture and the use of SSRIs, especially with increasing use. Age does not increase this risk. No such conclusions can be drawn about the effect of SNRIs on the risk of fracture because of a lack of studies.

Non-Hormonal Replacement Therapy Regimens: Do they have an Effect on Cardiovascular Risk?

INTRODUCTION

Menopause is associated with adverse effects on quality of life of perimenopausal and post-menopausal women. It also has an impact on the development of cardiovascular disease (CVD). Hormonal treatments are the most effective medications for menopausal symptoms relief. Given the fact that hormonal treatments are contraindicated for many women, non-hormonal treatment, such as Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs), gabapentin, pregabalin, clonidine and phytoestrogens, constitute alternative treatments. Nevertheless, little is known about their effects on CVD risk.

METHODS

PubMed, EMBASE and Cochrane Library were searched for the effects of non-hormonal treatment on CVD risk, blood pressure, heart rate, lipids and glucose concentrations, weight gain, cardiovascular events, stroke, mortality and morbidity.

RESULTS

Phytoestrogens, pregabalin and gabapentin seem to have no adverse effects on the cardiovascular system. Phytoestrogens, in particular, seem to reduce CVD risk through many pathways. On the other hand, SSRIs and SNRIs, although effective in reducing menopausal vasomotor symptoms, should be cautiously administered to women with known CVD (e.g. with cardiac arrhythmias, atherosclerotic disease or stroke). As clonidine has been associated with cardiovascular adverse effects, it should be administered only in cases where blood pressure regulation is mandatory.

CONCLUSION

Further research is needed to produce definite conclusions regarding the cardiovascular safety of non-hormonal medications for menopausal symptoms relief.

The association between antidepressant use and orthostatic hypotension in older people: a matched cohort study

Orthostatic hypotension (OH) is often reported as a significant potential adverse effect of antidepressant use but the association between phasic blood pressure (BP) and antidepressants has not yet been investigated. This cross-sectional study compares continuously measured phasic BP and prevalence of OH in a cohort of antidepressant users ≥50 years compared with an age- and sex-matched cohort not taking antidepressants. OH was defined as a drop in systolic BP ≥ 20 mm Hg or in diastolic BP ≥ 10 mm Hg at 30 seconds after standing, measured using continuous beat-to-beat finometry. Multilevel time × group interactions revealed significantly greater systolic and diastolic BP drop in antidepressant users than nonusers at 30 seconds after stand. The prevalence of OH among antidepressant users was 31% (63/206), compared with 17% in nonusers (X² = 9.7; P = .002). Unadjusted logistic regression models demonstrated that selective serotonin reuptake inhibitor use was associated with OH at an odds ratio of 2.11 (95% confidence interval: 1.25-3.57); P = .005, and this association was not attenuated when covariates including cardiac disease and depressive symptom burden were added. There was no statistically significant association between serotonin noradrenaline reuptake inhibitor or tricyclic antidepressant use and OH in unadjusted models although the study was not powered to detect changes within these subgroups. Older people taking antidepressants have a two-fold higher prevalence of OH than nonusers, highlighting the importance of screening the older antidepressant user for OH and dizziness and rationalizing medications to reduce the risk of falls within this vulnerable cohort.

Early Life Stress, Depression And Parkinson's Disease: A New Approach

This review aims to shed light on the relationship that involves exposure to early life stress, depression and Parkinson's disease (PD). A systematic literature search was conducted in Pubmed, MEDLINE, EBSCOHost and Google Scholar and relevant data were submitted to a meta-analysis . Early life stress may contribute to the development of depression and patients with depression are at risk of developing PD later in life. Depression is a common non-motor symptom preceding motor symptoms in PD. Stimulation of regions contiguous to the substantia nigra as well as dopamine (DA) agonists have been shown to be able to attenuate depression. Therefore, since PD causes depletion of dopaminergic neurons in the substantia nigra, depression, rather than being just a simple mood disorder, may be part of the pathophysiological process that leads to PD. It is plausible that the mesocortical and mesolimbic dopaminergic pathways that mediate mood, emotion, and/or cognitive function may also play a key role in depression associated with PD. Here, we propose that a medication designed to address a deficiency in serotonin is more likely to influence motor symptoms of PD associated with depression. This review highlights the effects of an antidepressant, Fluvoxamine maleate, in an animal model that combines depressive-like symptoms and Parkinsonism.

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.

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

BACKGROUND

This population based study investigated the relationship between use of selective serotonin reuptake inhibitors (SSRIs) and hip fractures in the elderly in Taiwan.

METHODS

Analysis of a random sample of 1 million insurance enrollees' data identified 4,891 patients with newly diagnosed hip fractures and 4,891 controls without hip fracture between 2000 and 2011. Both cases and controls were ≥65 years of age and were matched by sex, age, comorbidities, and index year of hip fracture diagnosis. Patients were considered current SSRI users if their last SSRI tablet was taken ≤7 days before the hip fracture diagnosis. Late use of SSRIs was defined as taking the last SSRI tablet ≥8 days before the hip fracture diagnosis. Non-SSRI users comprised individuals who never had an SSRI prescription. Odds ratios (ORs) and 95% confidence intervals (CIs) for hip fracture associated with SSRI use was estimated by multivariate unconditional logistic regression.

RESULTS

After adjustment for covariants, multivariate regression analysis showed that the adjusted OR of hip fracture was 2.17 for current SSRI users (95% CI: 1.60-2.93) compared with those who never used SSRIs. The adjusted OR was 1.11 for individuals with late use of SSRIs (95% CI: 0.96-1.28) and was not significant.

CONCLUSIONS

Current use of SSRIs was associated with a 2.17-fold increase in the odds of hip fracture in the elderly in Taiwan. Clinicians should consider the possibility of SSRI-associated hip fracture among old people currently taking SSRIs.

Effects of depression and antidepressant medications on hip fracture: A population-based cohort study in Taiwan

This study was conducted to investigate the effects of depression and antidepressant medications on hip fracture. The database of the Taiwan National Health Insurance with medical records of more than 1,000,000 individuals was searched for patients who had hip fracture with or without depression from 1998 to 2009. Patients with the following conditions were excluded: hip fracture due to cancer or traffic accidents, hip fracture that occurred before the diagnosis of depression, and use of antidepressants before the diagnosis of depression. A matched cohort of 139,110 patients was investigated, including 27,822 (17,309 females; 10,513 males) with depression and 111,288 (69,236 females; 42,052 males) without depression (1:4 randomly matched with age, sex, and index date). Among these patients, 232 (158 females and 74 males) had both hip fracture and depression, and 690 (473 females and 217 males) had hip fracture only. The Cox proportional-hazards regression method was used to determine the effect of depression on hip fracture. The hazard ratio (HR) for each clinical parameter was calculated after adjusting for confounders including sex, age, Charlson comorbidity index, urbanization, osteoporosis, and antidepressants. Results showed that patients with major depressive disorder had a 61% higher incidence of hip fracture than those without depression (HR 1.61, 95% confidence interval [CI] 1.19-2.18, P = 0.002). The risk of hip fracture for patients with less severe depressive disorder (dysthymia or depressive disorder, not otherwise specified) was not statistically higher than that of patients with no depression (HR 1.10, 95% CI = 0.91-1.34, P = 0.327). Among the patients with depression, females had a 49% higher incidence for hip fracture than males (HR 1.49, 95% CI 1.30-1.72, P < 0.001). The incidence of hip fracture also increased with age and Charlson comorbidity index scores. Analyses of both all (139,110) patients and only patients (27,822) with depression revealed that antidepressants had no negative impact on the incidence of hip fracture. In conclusion, major depression was found to be a risk factor for hip fracture and that use of antidepressants had no adverse effect on hip fracture in the Taiwanese population.

Integrated information for integrated care in the general practice setting in Italy: using social network analysis to go beyond the diagnosis of frailty in the elderly

BACKGROUND

Frailty has been defined in different ways and several diagnostic tools exist, but most of them are not applicable in routine primary care. Nonetheless, general practitioners (GPs) have a natural advantage in identifying frailty, due to their continued access to patients, patient-centered approach and training. GPs have also an advantage in conducting population-based evaluation as consequence of their role of gatekeepers of the health care system. This paper aims to identify those socio-demographic and clinical profiles and the relative information sources that, from the GPs' perspective, act as frailty markers, not solely as a diagnosis of state but as the ability to identify a patient's trajectory, over time, through the aging process.

METHODS

This study was performed as a survey within a population aged 75 and over, attending 148 GPs in Italy. A total of 23,996 patients were classified by GPs in distinct frailty status, without the use of a specific evaluation tool, but only referring to general indications. Co-morbidity was objectively assessed by a record-linkage with previous hospitalizations, in order to assess the occurrence of previous illnesses that could be associated with the likelihood of being identified as frails or at risk. The methodological approach is based on social network analysis (SNA), suited to explore relational aspects of complex phenomena.

RESULTS

Our findings reveal that GPs are able to perform low cost population-based evaluation, by exploiting the advantages of their approach to patients, combined with the information derived from their daily practice and from other sources currently available.

CONCLUSION

We believe that informative integration among different sources of available data can provide a comprehensive picture of the health state of patients in a shorter time and at lower cost. The identification of limited patient trajectories based on these observations can enable the development of critical biomarkers/diagnostics and prognostic indicators that will enhance patient care and potentially reduce inappropriate healthcare use. We also believe that network analysis is an extremely flexible research tool and a rich theoretical paradigm, and it may be used in the healthcare planning.

Medications Are Associated with Falls in People with Multiple Sclerosis: A Prospective Cohort Study

BACKGROUND

Medication use is associated with falls in many populations, but the relationship between medications and falls in people with multiple sclerosis (MS) is not well understood.

METHODS

The number and types of medications used by 248 ambulatory adults with MS in the United States (n = 53) and Australia (n = 195) were assessed. Participants completed fall diaries for 6 months. Associations between number and type of medications reported and falls, adjusting for age, disease severity, comorbidities, sex, and country, were evaluated using multiple logistic regression.

RESULTS

Participants reported taking a median of three medications and two supplements. A total of 143 participants (58%) fell at least once in the 6 months, and 110 (44%) experienced one or more injurious falls. The adjusted relative odds of a fall or an injurious fall increased by 13% (P = .048) and 11% (P = .049), respectively, for each medication and by 43% (P = .015) and 55% (P = .001) for each neurologically active medication. Reported use of MS disease-modifying therapy was associated with 48% decreased odds of falling (P = .035) but not significantly decreased odds of injurious falls.

CONCLUSIONS

Reporting use of more medications and more neurologically active medications is associated with falls and injurious falls in people with MS. Close evaluation of the need for each medication, with associated minimization of neurologically active medications in patients with MS, may help prevent falls. Use of MS disease-modifying therapies may be associated with fewer falls. This relationship needs further evaluation.

Cause or Effect? Selective Serotonin Reuptake Inhibitors and Falls in Older Adults: A Systematic Review

A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship--causation or effect--cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRIs lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, well-designed experimental studies are required to address this question definitively.

Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults

BACKGROUND

polypharmacy is an important risk factor for falls, but recent studies suggest only when including medications associated with increasing the risk of falls.

DESIGN

a prospective, population-based cohort study.

SUBJECTS

6,666 adults aged ≥50 years from The Irish Longitudinal study on Ageing.

METHODS

participants reported regular medication use at baseline. Any subsequent falls, any injurious falls and the number of falls were reported 2 years later. The association between polypharmacy (>4 medications) or fall risk-increasing medications and subsequent falls or injurious falls was assessed using modified Poisson regression. The association with the number of falls was assessed using negative binomial regression.

RESULTS

during follow-up, 231 falls per 1,000 person-years were reported. Polypharmacy including antidepressants was associated with a greater risk of any fall (adjusted relative risk (aRR) 1.28, 95% CI 1.06-1.54), of injurious falls (aRR 1.51, 95% CI 1.10-2.07) and a greater number of falls (adjusted incident rate ratio (aIRR) 1.60, 95% CI 1.19-2.15), but antidepressant use without polypharmacy and polypharmacy without antidepressants were not. The use of benzodiazepines was associated with injurious falls when coupled with polypharmacy (aRR 1.40, 95% CI 1.04-1.87), but was associated with a greater number of falls (aIRR 1.32, 95% CI 1.05-1.65), independent of polypharmacy. Other medications assessed, including antihypertensives, diuretics and antipsychotics, were not associated with outcomes.

CONCLUSION

in middle-aged and older adults, polypharmacy, including antidepressant or benzodiazepine use, was associated with injurious falls and a greater number of falls.

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

Background

Risk factors for hip fracture are well studied because of the negative impact on patients and the community, with mortality in the first year being almost 30% in the elderly. Age, gender and fall risk-increasing drugs, identified by the National Board of Health and Welfare in Sweden, are well known risk factors for hip fracture, but how multimorbidity level affects the risk of hip fracture during use of fall risk-increasing drugs is to our knowledge not as well studied. This study explored the relationship between use of fall risk-increasing drugs in combination with multimorbidity level and risk of hip fracture in an elderly population.

Methods

Data were from Östergötland County, Sweden, and comprised the total population in the county aged 75 years and older during 2006. The odds ratio (OR) for hip fracture during use of fall risk-increasing drugs was calculated by multivariate logistic regression, adjusted for age, gender and individual multimorbidity level. Multimorbidity level was estimated with the Johns Hopkins ACG Case-Mix System and grouped into six Resource Utilization Bands (RUBs 0–5).

Results

2.07% of the study population (N = 38,407) had a hip fracture during 2007. Patients using opioids (OR 1.56, 95% CI 1.34-1.82), dopaminergic agents (OR 1.78, 95% CI 1.24-2.55), anxiolytics (OR 1.31, 95% CI 1.11-1.54), antidepressants (OR 1.66, 95% CI 1.42-1.95) or hypnotics/sedatives (OR 1.31, 95% CI 1.13-1.52) had increased ORs for hip fracture after adjustment for age, gender and multimorbidity level. Vasodilators used in cardiac diseases, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers and renin-angiotensin system inhibitors were not associated with an increased OR for hip fracture after adjustment for age, gender and multimorbidity level.

Conclusions

Use of fall risk-increasing drugs such as opioids, dopaminergic agents, anxiolytics, antidepressants and hypnotics/sedatives increases the risk of hip fracture after adjustment for age, gender and multimorbidity level. Fall risk-increasing drugs, high age, female gender and multimorbidity level, can be used to identify high-risk patients who could benefit from a medication review to reduce the risk of hip fracture.

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

BACKGROUND

Risk factors for hip fracture are well studied because of the negative impact on patients and the community, with mortality in the first year being almost 30% in the elderly. Age, gender and fall risk-increasing drugs, identified by the National Board of Health and Welfare in Sweden, are well known risk factors for hip fracture, but how multimorbidity level affects the risk of hip fracture during use of fall risk-increasing drugs is to our knowledge not as well studied. This study explored the relationship between use of fall risk-increasing drugs in combination with multimorbidity level and risk of hip fracture in an elderly population.

METHODS

Data were from Östergötland County, Sweden, and comprised the total population in the county aged 75 years and older during 2006. The odds ratio (OR) for hip fracture during use of fall risk-increasing drugs was calculated by multivariate logistic regression, adjusted for age, gender and individual multimorbidity level. Multimorbidity level was estimated with the Johns Hopkins ACG Case-Mix System and grouped into six Resource Utilization Bands (RUBs 0-5).

RESULTS

2.07% of the study population (N = 38,407) had a hip fracture during 2007. Patients using opioids (OR 1.56, 95% CI 1.34-1.82), dopaminergic agents (OR 1.78, 95% CI 1.24-2.55), anxiolytics (OR 1.31, 95% CI 1.11-1.54), antidepressants (OR 1.66, 95% CI 1.42-1.95) or hypnotics/sedatives (OR 1.31, 95% CI 1.13-1.52) had increased ORs for hip fracture after adjustment for age, gender and multimorbidity level. Vasodilators used in cardiac diseases, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers and renin-angiotensin system inhibitors were not associated with an increased OR for hip fracture after adjustment for age, gender and multimorbidity level.

CONCLUSIONS

Use of fall risk-increasing drugs such as opioids, dopaminergic agents, anxiolytics, antidepressants and hypnotics/sedatives increases the risk of hip fracture after adjustment for age, gender and multimorbidity level. Fall risk-increasing drugs, high age, female gender and multimorbidity level, can be used to identify high-risk patients who could benefit from a medication review to reduce the risk of hip fracture.

Medication-induced osteoporosis: screening and treatment strategies

Drug-induced osteoporosis is a significant health problem and many physicians are unaware that many commonly prescribed medications contribute to significant bone loss and fractures. In addition to glucocorticoids, proton pump inhibitors, selective serotonin receptor inhibitors, thiazolidinediones, anticonvulsants, medroxyprogesterone acetate, aromatase inhibitors, androgen deprivation therapy, heparin, calcineurin inhibitors, and some chemotherapies have deleterious effects on bone health. Furthermore, many patients are treated with combinations of these medications, possibly compounding the harmful effects of these drugs. Increasing physician awareness of these side effects will allow for monitoring of bone health and therapeutic interventions to prevent or treat drug-induced osteoporosis.

Factors associated with falls among older adults living in institutions

Background

Falls have enormous impact in older adults. Yet, there is insufficient evidence regarding the effectiveness of preventive interventions in this setting. The objectives were to measure the frequency of falls and associated factors among older people living institutions.

Methods

Data were obtained from a survey on a probabilistic sample of residents aged ≥65 years, drawn in 1998-99 from institutions of Madrid (Spain). Residents, their caregivers, and facility physicians were interviewed. Fall rates were computed based on the number of physician-reported falls in the preceding 30 days. Adjusted rate ratios were computed using negative binomial regression models, including age, sex, cognitive status, functional dependence, number of diseases, and polypharmacy.

Results

The final sample comprised 733 residents. The fall rate was 2.4 falls per person-year (95% confidence interval [CI], 2.04-2.82). The strongest risk factor was number of diseases, with an adjusted rate ratio (RR) of 1.32 (95% CI, 1.17-1.50) for each additional diagnosis. Other variables associated with falls were: urinary incontinence (RR = 2.56 [95% CI, 1.32-4.94]); antidepressant use (RR = 2.32 [95% CI, 1.22-4.40]); arrhythmias (RR = 2.00 [95% CI, 1.05-3.81]); and polypharmacy (RR = 1.07 [95% CI, 0.95-1.21], for each additional medication). The attributable fraction for number of diseases (with reference to those with ≤ 1 condition) was 84% (95% CI, 45-95%).

Conclusions

Number of diseases was the main risk factor for falls in this population of institutionalized older adults. Other variables associated with falls, probably more amenable to preventive action, were urinary incontinence, antidepressants, arrhythmias, and polypharmacy.

Virtual slides

The virtual slide(s) for this article can be found here:

http://www.diagnosticpathology.diagnomx.eu/vs/3916151157277337

Risk of nonvertebral fractures among elderly postmenopausal women using antidepressants

OBJECTIVE

To examine the association between antidepressants, including TCAs, SSRIs, and miscellaneous antidepressants and the risk of nonvertebral fractures among women with osteoporosis.

MATERIALS AND METHODS

This study was a post-hoc analysis of pooled data from two international, phase III, randomized, placebo-controlled, double-blind studies (the Spinal Osteoporosis Therapeutic Intervention [SOTI] and TReatment Of Peripheral OSteoporosis [TROPOS]). A nested case-control study was performed in the placebo treated population. Adjusted logistic regression models were used to estimate the risk of nonvertebral fracture associated with the use of antidepressants.

RESULTS

After 3 years of follow-up, 391 nonvertebral fractures cases were identified and matched to 1955 controls. Compared with non-users of antidepressants, antidepressants use was associated with an increased risk of nonvertebral fractures (adjusted OR=1.64; 95%CI, 1.03-2.62]). Particularly, there was a 2-fold risk increase (95%CI, 1.07-3.79) of nonvertebral fracture for current users of SSRIs and a 2.1-fold risk increase for subjects who were current users of TCAs (95%CI, 1.02-4.30). Among patients categorized as recent or past users, none of the classes of antidepressants were statistically associated with increased risk of nonvertebral fracture.

CONCLUSIONS

Our findings confirm that both SSRIs and TCAs increase the risk of nonvertebral fracture in current users.

Use of selective serotonin reuptake inhibitors and risk of fracture: a systematic review and meta-analysis

Previous studies have reported inconsistent findings regarding the association between the use of selective serotonin reuptake inhibitors (SSRIs) and the risk of fracture. We identified relevant studies by searching three electronic databases (MEDLINE, EMBASE, and the Cochrane Library) from their inception to October 20, 2010. Two evaluators independently extracted data. Because of heterogeneity, we used random-effects meta-analysis to obtain pooled estimates of effect. We identified 12 studies: seven case-control studies and five cohort studies. A meta-analysis of these 12 observational studies showed that the overall risk of fracture was higher among people using SSRIs (adjusted odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.51-1.90, I(2 ) = 89.9%). Subgroup analysis by adjusted number of key risk factors for osteoporotic fracture showed a greater increased fracture risk in those adjusted for fewer than four variables (adjusted OR = 1.83, 95% CI 1.57-2.13, I(2)  = 88.0%) than those adjusted for four or more variables (adjusted OR = 1.38, 95% CI 1.27-1.49, I(2)  = 46.1%). The pooled ORs anatomical site of fracture in the hip/femur, spine, and wrist/forearm were 2.06 (95% CI 1.84-2.30, I(2 ) = 62.3%), 1.34 (95% CI 1.13-1.59, I(2 ) = 48.5%), and 1.51 (95% CI 1.26-1.82, I(2 ) = 76.6%), respectively. Subgroup analysis by exposure duration revealed that the strength of the association decreased with a longer window of SSRI administration before the index date. The risk of fracture was greater within 6 weeks before the index date (adjusted OR = 3.83, 95% CI 1.96-7.49, I(2 ) = 41.5%) than 6 weeks or more (adjusted OR = 1.60, 95% CI 0.93-2.76, I(2 ) = 63.1%). Fracture risk associated with SSRI use may have a significant clinical impact. Clinicians should carefully consider bone mineral density screening before prescribing SSRIs and proper management for high-risk populations.

Selective serotonin reuptake inhibitor treatment and risk of fractures: a meta-analysis of cohort and case-control studies

Studies on use of selective serotonin reuptake inhibitors (SSRIs) and risk of fracture have yielded inconsistent results. This meta-analysis, which pooled results from 13 qualifying cohort and case-control studies, found that SSRIs were associated with a significantly increased risk of fractures.

INTRODUCTION

This study was conducted to assess whether people who take SSRIs are at an increased risk of fracture.

METHODS

We conducted a meta-analysis of observational studies. Relevant studies published by February 2010 were identified through literature searches using MEDLINE (from 1966), EMBASE (from 1988), PsycINFO (from 1806), and manual searching of reference lists. Only cohort or case-control studies that examined the association of SSRIs and risk of fracture and bone loss were included. Data were abstracted independently by two investigators using a standardized protocol; disagreements were resolved by consensus. Random effects models were used for pooled analysis due to heterogeneity in the studies.

RESULTS

Thirteen studies met inclusion criteria. Overall, SSRI use was associated with a significantly increased risk of fracture (relative risk, RR, 1.72; 95% CI [1.51, 1.95]; P < 0.001). An increased fracture risk associated with SSRIs also was observed in the three studies that adjusted for bone mineral density (RR, 1.70; 95% CI [1.28, 2.25]; P < 0.001) and in the four studies that adjusted for depression (RR 1.74; 95% CI [1.28, 2.36]; P < 0.001). SSRI use was not associated with bone loss in the two cohort studies of women (P = 0.29). The overall association between SSRI use and fracture risk was weaker (RR, 1.40; 95% CI [1.22, 1.61]), though still significant (P < 0.001) in analyses that accounted for apparent publication bias.

CONCLUSIONS

Use of SSRIs is associated with increased risk of fracture. The SSRIs may exert an increased risk of fracture independent of depression and bone mineral density.

Do SSRIs play a role in decreasing bone mineral density?

Osteoporosis is expected to increase as our population pyramid shifts toward old age. It is associated with increased risk of fractures, leading to complications of limitation of ambulation, loss of independence, and chronic pain. Depression is also a common occurrence in the elderly population. Currently, up to 35% of residents in long term care may experience either major depression or clinically significant depressive symptoms. Selective serotonin receptor inhibitors constitute 62% of all antidepressant drug prescribing. Recently, serotonin transporters have been described in bone, raising the question of whether medications that block serotonin reuptake could affect bone metabolism and ultimately affect osteoporosis-related fractures. Current evidence suggests that depression, particularly in the setting of selective serotonin receptor inhibitors use, should be considered as an addition to the list of risk factors prompting clinicians to evaluate bone health status.

Antidepressants and fracture risk in older adults: a comparative safety analysis

We examined variations in fracture rates among patients initiated on antidepressant drug treatment as identified from Medicare data in two US states and assessed whether the observed variation could be explained by affinity for serotonin transport receptors. We used Cox proportional hazards models to compare fracture rates of the hip, humerus, pelvis, wrist, and a composite of these, among propensity score-matched cohorts of users of secondary amine tricyclics, tertiary amine tricyclics, selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants. As compared with secondary amine tricyclics, SSRIs showed the highest association with composite fracture rate (hazard ratio 1.30; 95% confidence interval (CI) 1.12-1.52), followed by atypical antidepressants (hazard ratio 1.12; 95% CI 0.96-1.31) and tertiary amine tricyclics (hazard ratio 1.01; 95% CI 0.87-1.18). The results were robust to sensitivity analyses. Although SSRI use was associated with the highest rate of fractures, variation in fracture risk across specific antidepressant medications did not depend on affinity for serotonin transport receptors.

The adverse skeletal effects of selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are a widely used group of antidepressants (ADs) with reported potential detrimental effects on bone mineral density (BMD) and increased fracture risk. Here, a comprehensive review of the in vitro, in vivo and clinical studies to date was carried out using the medical search engines MEDLINE (1950 to September 2010) and EMBASE (1980 to September 2010). Serotonin (5-HT) receptors have been identified on osteoclast, osteoblast and osteocyte cell lines. The effect of SSRIs on bone formation and resorption appears to be governed by the activation of a number of 5-HT receptors on osteoblasts and osteoclasts via endocrine, autocrine/paracrine and neuronal pathways. In vitro, in vivo and clinical collective data appears to indicate that SSRIs have a negative effect on bone at the therapeutic dose levels widely used for the treatment of depression in current clinical practice. Caution may therefore have to be employed with the use of SSRIs in patients at an increased risk of falls and osteoporosis. Further studies are needed in order to fully elicit the role of SSRIs in bone formation and their effects in the low oestrogen state.

A review of SSRIs and SNRIs in neuropathic pain

IMPORTANCE OF THE FIELD

Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs) are becoming increasingly used in the treatment of neuropathic pain and fibromyalgia. However, they are not without adverse effects and their efficacy has not been clear because of conflicting evidence.

AREAS COVERED IN THIS REVIEW

We have examined the current evidence on the efficacy of SSRIs and SNRIs in the treatment of neuropathic pain and fibromyalgia. Relevant randomized, placebo-controlled studies were identified through a MEDLINE search of English-language literature from January 1990 to December 2009.

WHAT THE READER WILL GAIN

The evidence for efficacy of SSRIs in the treatment neuropathic pain is moderate at best. However, SNRIs, venlafaxine and duloxetine have been shown to be effective in the treatment of painful diabetic neuropathy and polyneuropathy. With fibromyalgia, both SSRIs (fluoxetine and paroxetine) and SNRIs (duloxetine and milnacipran) have been shown to improve pain relief, function and quality of life.

TAKE HOME MESSAGE

SSRIs and SNRIs may be considered in the treatment of neuropathic pain if treatment with tricyclic antidepressants and anticonvulsants fails, or if there are contraindications to these drugs. There is also sufficient evidence to indicate that SNRIs are effective in the treatment of fibromyalgia and may be considered early in the treatment of fibromyalgia.

Effect of sertraline on ouabain-induced arrhythmia in isolated guinea-pig atria

BACKGROUND

The effect of sertraline a selective serotonin reuptake inhibitor antidepressant was studied on ouabain-induced toxicity (arrhythmia) in spontaneously beating isolated guinea-pig atria.

METHODS

The guinea-pig atrium was dissected out and suspended in modified Krebs solution under physiological conditions. Drugs were added into solutions. The changes in rate and force of contractions were measured using a physiograph.

RESULTS

Sertraline (2-16 microg/mL) caused a dose-dependent decrease in the rate of contractions (17-46%) and in the contractile force (26-48%). Ouabain alone (1.2 microg/mL) produced arrhythmia at 7.8 min and asystole at 22 min. Pre- administration of the atria with sertraline (8 microg/mL) significantly increased the time required to produce arrhythmia by ouabain to 20.5 min, prolonged the beating of atria to more than 64.5 min and delayed the occurrence of asystolia. The pattern of contractile force induced by sertraline + ouabain was more regular than that produced by ouabain alone.

CONCLUSIONS

These findings indicate that sertraline produces direct cardiac action, probably due to the inhibition of cardiac Na(+) and Ca(2+) channels. Our results suggest that sertraline may reduce the membrane conduction through inhibition of ionic channels which decrease ouabain-induced arrhythmia.

Problems associated with long-term treatment with selective serotonin reuptake inhibitors

Although the selective serotonin reuptake inhibitors (SSRIs), which are now widely used as a first-line treatment for depression and many other psychiatric conditions, are generally well tolerated, they are not devoid of side effects. Most short-term treatment-related side effects of SSRIs are transient and disappear after a few days or weeks. However, following long-term treatment with the SSRIs, some serious adverse events may occur. Some of them can be difficult to recognise because they can resemble residual symptoms of depression. The most serious can be life threatening. They all have a negative influence on the patient's quality of life and are frequently a prime reason for a lack of long-term compliance with the associated increased risk of recurrence of a depressive episode. This article is an overview of the more common adverse events, which are seen with non-acute treatment with the SSRIs.

Risk of fractures with selective serotonin-reuptake inhibitors or tricyclic antidepressants

OBJECTIVE

To evaluate the literature associating the risk of fracture during antidepressant therapy.

DATA SOURCES

Literature was identified via MEDLINE (1970-August 2008) using the search terms selective serotonin-reuptake inhibitors, tricyclic antidepressants, antidepressants, and fracture. Reference citations from publications identified were also reviewed. All articles in English identified from the data sources were evaluated.

DATA SYNTHESIS

Selective serotonin-reuptake inhibitors (SSRIs) are generally prescribed over other classes of antidepressants because they are considered to be relatively safer. Recent evidence, however, suggests that SSRIs may be associated with an increased risk of fractures. Thirteen clinical studies were identified in the literature search (7 case controls, 5 prospective cohorts, 1 cross-sectional). Most studies compared SSRIs with tricyclic antidepressants (TCAs) and found similar or greater risk of fracture associated with use of an SSRI. This risk appeared to be highest at the beginning of therapy with TCAs and eventually diminished. SSRI risk tended to increase slightly over time. No risk was seen with other classes of antidepressants. However, the number of patients using antidepressants was low.

CONCLUSIONS

There may be a possible correlation with SSRI or TCA use and risk of fracture. Prospective, randomized controlled trials with sufficient patient samples are needed to verify this finding.

Assessment of the prescription of antidepressant drugs in elderly nursing home patients: a clinical and laboratory follow-up investigation

The aim of the study was to investigate the use of antidepressant drugs among elderly people in nursing homes. Elderly residents who where found to have been prescribed at least one antidepressant drug according to the specific medication dispensing system were identified in 8 nursing homes in the county of Ostergötland, Sweden. Data were collected from the medical record forms at the nursing home. Blood samples were drawn for the assessment of drug concentration, blood chemistry parameters and cytochrome P450 expression. At least one antidepressant drug was prescribed to 38% of elderly people in the nursing home studied. A total of 71 patients were evaluated, 80% women and 20% men. The median age was 84 years (range, 71-100 years). Indications for antidepressant drug treatment were found on 96% of medical record forms (depression, 60%); however, information relating to when treatment was initiated could not be found on 34% of medical record forms and a clear time schedule for how long this drug treatment was planned to continue could not be found either. A possible adverse effect of antidepressant drug treatment was retrieved in at least 77% of patients. Polypharmacotherapy was common; median number of drugs per patient was 11. Concentrations of drugs were higher than expected in 73%. Most patients were medicated with citalopram (n = 44). A clear interindividual variability of concentrations at each dose level was found for citalopram and for the metabolites desmethylcitalopram and didesmethylcitalopram. A significant correlation was found between the estimation of creatinine clearance and concentration-dose ratio of citalopram. Poor metabolizers, who had been prescribed an antidepressant drug that are substrate for the cytochrome P450 isoenzyme examined, have higher concentrations of prescribed antidepressant drug than do non-poor metabolizers in relation to dose. An increase in quality contribution to follow-up at antidepressant medications is needed. A more frequent clinical use of therapeutic drug monitoring and pharmacogenetic tests in addition to therapeutic drug monitoring may be one important tool in this process.

Selective serotonin reuptake inhibiting antidepressants are associated with an increased risk of nonvertebral fractures

BACKGROUND

Fractures related to osteoporosis and falling constitute a major health problem in the elderly population. Exposure to antidepressants is associated with an increased risk of falls and fractures, but most previous studies incriminate tricyclic antidepressants (TCAs) rather than selective serotonin reuptake inhibitors (SSRIs).

OBJECTIVE

To examine the association between antidepressants, including TCAs, SSRIs, and other antidepressants and the risk of nonvertebral fractures in elderly.

DESIGN

Prospective population-based cohort study.

SETTING

The Rotterdam Study, consisting of 7983 individuals aged 55 years and older.

PARTICIPANTS

All persons from the Rotterdam Study.

RESULTS

One thousand two hundred nineteen persons experienced a nonvertebral fracture, 25 during TCA use and 18 during SSRI use. After adjustment for age, sex, lower-limb disability, and depression, the risk of nonvertebral fracture was 2.35 (95% confidence interval, 1.32-4.18) for current users of SSRIs compared with nonusers of antidepressants. Multiple adjusting for many possible risk factors did not affect the association. To deal with potential confounding by indication, we subsequently restricted the analysis to antidepressant users (n = 1217). Compared with past users of TCAs or SSRIs, current users of SSRIs had a 2.07-fold (95% confidence interval, 1.23-3.50) increased risk of fracture, which further increased with prolonged use. In this analysis, depressive state at baseline and during follow-up did not play a role, suggesting absence of confounding by indication. The use of TCAs was associated with an increased fracture risk that decreased with prolonged use.

CONCLUSIONS

Not only users of TCAs but also of SSRIs have a significantly increased risk of nonvertebral fractures, in SSRI users especially after prolonged use. Despite fewer early adverse effects of SSRIs, physicians treating elderly depressive patients should be aware of the unfavorable long-term consequence of SSRIs on fracture risk.

Anxiolytic- and antidepressant-like activities of H-Dmt-Tic-NH-CH(CH2-COOH)-Bid (UFP-512), a novel selective delta opioid receptor agonist

Knockout and pharmacological studies have shown that delta opioid peptide (DOP) receptor signalling regulates emotional responses. In the present study, the in vitro and in vivo pharmacological profile of the DOP ligand, H-Dmt-Tic-NH-CH(CH2-COOH)-Bid (UFP-512) was investigated. In receptor binding experiments performed on membranes of CHO cells expressing the human recombinant opioid receptors, UFP-512 displayed very high affinity (pKi 10.20) and selectivity (>150-fold) for DOP sites. In functional studies ([35S]GTP gamma S binding in CHOhDOP membranes and electrically stimulated mouse vas deferens) UFP-512 behaved as a DOP selective full agonist showing potency values more than 100-fold higher than DPDPE. In vivo, in the mouse forced swimming test, UFP-512 reduced immobility time both after intracerebroventricular (i.c.v.) and intraperitoneal (i.p.) administration. Similar effects were recorded in rats. Moreover, UFP-512 evoked anxiolytic-like effects in the mouse elevated plus maze and light-dark aversion assays. All these in vivo actions of UFP-512 were fully prevented by the selective DOP antagonist naltrindole (3 mg/kg, s.c.). In conclusion, the present findings demonstrate that UFP-512 behaves as a highly potent and selective agonist at DOP receptors and corroborate the proposal that the selective activation of DOP receptors elicits robust anxiolytic- and antidepressant-like effects in rodents.

Medication as a risk factor for falls: critical systematic review

BACKGROUND

Falls in older people are associated with poor prognosis. Medication use is a potential cause of falls. Our aim was to systemically review all original articles examining medication use as a risk factor for falls or fall-related fractures in people aged >/=60 years.

METHODS

We searched English articles in Medline (1996-2004) indexed under "falls" or "accidental falls" and "pharmaceutical preparations" or specific groups of drugs. We excluded studies not meeting the age criterion, not controlled with nonusers of target medicines or nonfallers, or with no clear definition of target medication.

RESULTS

Twenty-eight observational studies and one randomized controlled trial met the inclusion criteria. The number of participants ranged from 70 to 132,873. The outcome measure was a fall in 22 studies and a fracture in 7 studies. The main group of drugs associated with an increased risk of falling was psychotropics: benzodiazepines, antidepressants, and antipsychotics. Antiepileptics and drugs that lower blood pressure were weakly associated with falls.

CONCLUSIONS

Central nervous system drugs, especially psychotropics, seem to be associated with an increased risk of falls. The quality of observational studies needs to be improved, for many appear to lack even a clear definition of a fall, target medicines, or prospective follow-up. Many drugs commonly used by older persons are not systematically studied as risk factors for falls.

Specific serotonin reuptake inhibition in major depressive disorder adversely affects novel markers of cardiac risk

There exists a growing body of evidence linking depression with cardiovascular events, although the mechanisms responsible remain unknown. We investigated the role of the autonomic nervous system and inflammation in the link between coronary heart disease and major depressive disorder (MDD), and examined the cardiac risk modification following pharmacological treatment of depression. We measured cardiac baroreflex function, heart rate variability, pulse pressure and high sensitivity C-reactive protein (hsCRP), all of which have an impact on cardiac risk, pre- and post-treatment in 25 patients with MDD, with no history of coronary heart disease, and in 15 healthy subjects. Treatment consisted of selective serotonin reuptake inhibitors for approximately 12 weeks. No significant differences were observed between untreated MDD patients and healthy subjects in blood pressure, heart rate, baroreflex sensitivity or heart rate variability. Pulse pressure and hsCRP, however, were significantly elevated in patients with MDD prior to treatment (p=0.023 and p=0.025, respectively). Moreover, while pharmacotherapy was effective in alleviating depression, surprisingly, each of cardiac baroreflex function, heart rate variability, pulse pressure and hsCRP was modified (p<0.05) in a manner likely to increase cardiac risk. In conclusion, this study demonstrated higher pulse pressure and hsCRP plasma levels in patients with MDD, which might contribute to increased cardiac risk. Following treatment vagal activity was reduced, as indicated by reductions in baroreflex sensitivity and heart rate variability, accompanied by increases in pulse pressure and plasma hsCRP levels. Mechanisms potentially responsible for generating cardiac risk in patients treated with selective serotonin reuptake inhibitors may need to be therapeutically targeted to reduce the incidence of coronary heart disease in this population.

Depressive symptoms as a risk factor for unintentional injury: a cohort study in a rural county

OBJECTIVE

The authors used data from a population based prospective cohort study to determine if depressive symptoms predicted incidence of unintentional injury.

METHODS

The Keokuk County Rural Health Study, based in Iowa, is a prospective cohort study of health status that includes injury outcomes. Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression Scale at the beginning of the study on 1493 participants. Quarterly follow up phone calls were made to measure injury incidence.

RESULTS

471 injuries were reported for an overall injury rate of 9.8 per 100 person-years. Crude injury rates were significantly higher for those with depressive symptoms (p = 0.0003). Those with depressive symptoms had a 41% increased risk for injury after controlling for antidepressant medication use, gender, prior injury, income, and sleepiness (RR = 1.41, 95% CI 1.10 to 1.80). Depressive symptoms remained a risk factor for injury regardless of current antidepressant medication use (no medication use, RR = 1.43, 95% CI 1.09 to 1.88; medication use, RR = 1.31, 95% CI 0.76 to 2.26).

CONCLUSIONS

Depressive symptoms were found to be risk factors for unintentional injury. Medical practitioners should consider talking about safety with their patients, especially those reporting symptoms of depression, and recognize that an increased risk for injury remains until the depressive symptoms subside.

Can selective serotonin inhibitor drugs in elderly patients in nursing homes be reduced?

OBJECTIVE

To investigate whether treatment with selective serotonin reuptake inhibitors (SSRIs) could be withdrawn for elderly residents who had been on treatment for at least one year and to evaluate a method for systematic drug review.

DESIGN

Open, prospective, interventional study.

SETTING

Four counties in Sweden.

SUBJECTS

Elderly residents at 19 nursing homes, with ongoing treatment with SSRIs for more than one year.

MAIN OUTCOME MEASURES

Clinical evaluation, registration of drugs used and rating with Montgomery-Asberg Depression Rating Scale (MADRS). A semi-structured telephone interview with 15 participating physicians and 19 nurses.

RESULTS

About one-third of all 822 residents in the nursing homes had ongoing antidepressant treatment, predominantly with SSRIs; 75% of them had been treated with SSRIs for at least one year and 119 (60%) of these were considered eligible for the study. The intervention was judged successful in 52% of these residents of whom 88% had a MADRS rating of less than 20 points. The GPs and the nurses experienced the method as practicable.

CONCLUSIONS

Withdrawal of SSRI treatment was successful in the majority of cases. The MADRS may be a valuable addition to clinical evaluation when deciding whether to end or continue SSRI treatment.

Adverse cardiovascular events in antidepressant trials involving high-risk patients: a systematic review of randomized trials

OBJECTIVE

To examine whether selective serotonin reuptake inhibitor (SSRI) antidepressants were associated with an increased or decreased risk of cardiovascular adverse events (AEs).

METHODS

We conducted a systematic review of randomized controlled trials published between 1967 and May 2005 that treated patients with cardiac disease, diabetes mellitus, stroke, geriatric age, nicotine dependence, alcoholism, HIV infection, and obesity. We defined serious AEs as death due to a cardiovascular cause, heart failure, stroke, transient ischemic attack, and myocardial infarction. Nonserious AEs were defined as palpitations, chest pain, angina, arrhythmia, hypertension, hypotension-syncope, and unspecified cardiovascular or neurologic events. Adverse event rates were calculated in 4 groups: SSRIs, tricyclic antidepressants (TCAs), other active therapies, and placebo.

RESULTS

Stroke and cardiac patients were the highest-risk groups for cardiovascular AEs. We were unable to detect differences in odds between SSRI and placebo for both serious (odds ratio [OR] 0.69; 95% confidence interval [CI], 0.39 to 1.21) and nonserious (OR 1.18; 95% CI, 0.90 to 1.57) cardiovascular AEs. There was a significant decrease in the odds of nonserious cardiovascular AEs (OR 0.46; 95% CI, 0.24 to 0.86, P = 0.02) for patients receiving SSRIs, compared with TCAs. Over one-half of the selected trials did not report the presence or absence of cardiovascular events.

CONCLUSIONS

This systematic review of antidepressant trials in high-risk patients did not determine whether SSRIs are associated with a greater or lesser risk of cardiovascular AEs. Reasons for this conclusion include the rarity of serious AEs, the lack of large trials in these patients, and a lack of adequate reporting of AEs in published trials. Further trials assessing the risk of cardiovascular AEs and better trial reporting are needed.

Long-term serotonin administration leads to higher bone mineral density, affects bone architecture, and leads to higher femoral bone stiffness in rats

New evidence suggests a control of bone mass by the central nervous system. We have previously shown that functional serotonin receptors are present in bone cells and that serotonin stimulates proliferation of osteoblast precursor cells in vitro. In the present study we investigated the effects of serotonin on bone tissue in vivo. Ten, 2-month-old female Sprague-Dawley rats were injected with serotonin subcutaneously (s.c.) (5 mg/kg) once daily for 3 months, controls received saline. Using microdialysis and HPLC, free circulating serotonin levels were measured. DXA scans were made after 3 months of serotonin administration. Bone architecture and mechanical properties were investigated by micro-computed tomography (microCT), histomorphometry, and mechanical testing. A long-lasting hyperserotoninemia with a >10-fold increase in serotonin appeared. Total body BMD was significantly higher (0.1976+/-0.0015 vs. 0.1913+/-0.0012 g/cm2) in rats receiving serotonin. Cortical thickness (Ct.Th) measured by microCT analysis was also higher, whereas trabecular bone volume (BV) was lower. Interestingly, the perimeter and cross-sectional moment of inertia (MOI), a proxy for geometrical bone strength, were the same in both groups. These data suggest that serotonin reduces resorption or/and increases apposition of endosteal bone. Mechanical testing showed that femoral stiffness was higher in serotonin-dosed animals. The energy absorption also seemed slightly, but not significantly higher. In conclusion, hyperserotoninemia led to a higher BMD, altered bone architecture and higher femural bone stiffness in growing rats, demonstrating that serotonin may have important effects on bone in vivo.

SSRIs and cognitive performance in a working sample

BACKGROUND

Studies of the impact of antidepressant use on cognitive performance have frequently been carried out among the elderly or on healthy volunteers. Comparatively little research has considered their impact on a relatively young, working population, particularly within the context of everyday life.

AIMS

To examine any association between SSRI use and cognitive performance, mood and human error at work.

METHODS

SSRI users and controls completed a battery of laboratory based computer tasks measuring mood and cognitive function pre- and post-work at the start and end of a working week. They also completed daily diaries reporting their work performance.

RESULTS

SSRI use was associated with memory impairment: specifically poorer episodic, though not working or semantic memory. Effects of SSRI use on recognition memory seemed to vary according to the underlying psychopathology, while effects on delayed recall were most pronounced among those whose symptoms had not (yet) resolved. There were no detrimental effects on psychomotor speed, attention, mood or perceived human error at work.

CONCLUSIONS

The findings lend support to the SSRIs comparative safety, even among workers, particularly as the symptoms of the underlying psychopathology are successfully addressed. Possible memory impairments may, however, be found in those taking SSRIs.

Psychotropic medication use and accidents, injuries and cognitive failures

BACKGROUND

Psychotropic medication has the potential to impair psychomotor and cognitive function, and several medications have well documented links to increased accident and injury susceptibility. Those developed more recently have many fewer side effects. However, there is little work examining any association between psychotropic medication use and safety within the context of other demographic, health and lifestyle factors.

AIMS

To examine and compare any associations between psychotropic medication use (including benzodiazepines, tricyclics and SSRIs) and accidents, injuries and cognitive failures in a community sample.

METHODS

A postal questionnaire survey was conducted among people selected at random from the electoral registers of Cardiff and Merthyr Tydfil.

RESULTS

Psychotropic medication use was associated with accidents, injuries and cognitive failures, particularly among those who already had higher levels of other risk factors and/or continuing mental health problems.

CONCLUSIONS

The well established associations between accidents and injuries and older psychotropic medications were replicated. SSRIs, however, were relatively safer. The study also highlighted the need to consider any effect of psychotropic medication within the context of both mental health status and other factors.