911 - Unintended Consequences; Increased Prescription of Narcotic Analgesics for OA in the Elderly Is Associated with Increased Falls and Fractures in the Post-Vioxx Era

Monday, November 7, 2011: 9:00 AM-6:00 PM
Hall F2 - Poster Hall (McCormick Place West)
Lydia Rolita, NYU School of Medicine, New York, NY, Adele Spegman, Geisinger Health System, Danville, PA and Bruce N. Cronstein, New York Univ Medical Center, New York, NY
Presentation Number: 911

Background/Purpose: Narcotic analgesics (NA) have long been used to treat pain although a number of alternatives have been developed, including selective COX-2 inhibitors. In 2004 Merck withdrew Rofecoxib from the market due to cardiovascular events and subsequent guidelines for treating chronic pain by the AHA and AGS recommend short-term narcotic analgesic use as the first step in managing chronic pain. Falls in the elderly are common and because NA contribute to falls in the elderly we determined whether prescriptions for NA for elderly patients were increased after COX-2 inhibitors were taken off the market and whether the incidence of falls/fractures changed in these patients.

Methods: Records of all patients >65yo with a diagnosis of OA (>10,000 patients) over the years 2001-2009 were identified in the Geisinger EMR data warehouse for analysis. Diagnoses of falls and fractures were identified by ICD 9 codes. Three analgesic prescription groups were identified: NA with or without other analgesics, COX-2 alone or with other analgesics, and NSAIDS, others and none. Other factors analyzed were age, gender, and Charlson Index Score of comorbidities (CI).

Results: From 2001-2004, patients receiving only NA prescriptions increased from 8% to 20% of the population and doubled again to 40% by 2009. COX-2 usage was low in this population (8%). The incidence of falls/fractures increased from less than 1% of all patients in 2001 to 4% in 2009 (Fig 2) and appears to be associated with the increased use of narcotic analgesics (Figure 2). Across all groups, patients with falls were older (78.1±6.6 v 73.8±6.3), yet in the NA group only, patients with falls had higher CI. The influence of age and comorbidities on falls were examined using conditional logistic regression; no fall patients were matched 3:1 to fall patients according to age and CI at time of fall. Falls risk increased with NA use in both study periods. In 2005-2009 when compared with: COX-2, NA use was associated with a 3.7 OR (2.6, 5.4; p < .001) and with NSAID a 4.4 OR for falls (3.9, 4.9; p < .001).

Conclusion: After Vioxx was taken off the market there was a marked increase in the prescription of narcotic analgesics. Falls and fractures in this elderly population with OA increased markedly and all of the increase in falls were in patients prescribed narcotic analgesics. These findings strongly indicate that recommendations for the treatment of chronic pain be re-evaluated.

http://acr.confex.com/data/abstract/acr/2011/Paper_22911_abstract_21085_0.gif


Keywords: COX inhibitors and nonsteroidal antiinflammatory drugs (NSAIDs)

Disclosure: L. Rolita, None; A. Spegman, None; B. N. Cronstein, Eli Lilly & Co.; UCB ;Pfizer; Vilcek Foundation; Probably others I don’t remember , 6, Patent, Canfite Pharma; Bristol-Myers Squibb; Tap Pharmaceuticals; Prometheus laboratories; Regeneration (Westat, DSMB); Endocyte; Savient. , 5, Canfite Piophamaceuticals, 1, NIH; Vilcek Foundation; URL Pharma, 2 .