Gabapentinoids & increased risk of hip fractures

[Joolsg]

A new study shows an increased risk of hip fractures in the elderly on gabapentinoids. This shouldn't be too much of a worry as long as the risk is explained and assessed by your doctor when considering which meds to prescribe. But it may be more appropriate to prescribe opioids if a patient is particularly frail.

www1.racgp.org.au/newsgp/cl....

[SueJohnson]

I gathered that in most cases it was prescribed for neuropathic pain in which case they would be taking gabapentin 3 times a day so would be up during the day when falls would be most likely to occur. Opioids can also cause falls in older adults and in many cases are prescribed so they are effective during the daytime to avoid withdrawal effects. If doctors warn older adults when prescribing gabapentin as you suggest and since side effects show up early with gabapentin, my own feeling is I don't think frail patients should be given opioids instead of gabapentin.

[Joolsg in reply to SueJohnson]

It's a worry either way. After dopamine agonists, many patients are in their 70s, 80s & 90s and the only 2 effective classes of meds are gabapentinoids or opioids.That's why there's a desperate need for research & repurposing meds or new meds for RLS.

[SueJohnson in reply to Joolsg]

There is dipyridamole although it doesn't work for all.

[amrob123 in reply to SueJohnson]

I'm not convinced that side effects necessarily show up early with gabapentin. Of course there is the initial sedation that one gets used to, but my experience with pregabalin has been the converse. Most of the side effects that i experience today have emerged with long term use and as i have gotten older, i seem to tolerate it less. And i'm not even 50.

Going by another gabapentinoid forum that i'm on, my experience is far from unique.

[SueJohnson in reply to amrob123]

I agree but the dizziness and balance problems show up early and that was what I was referring to. I should have been more specific.

[UsableThought in reply to SueJohnson]

I agree with Sue & amrob123 on this one. The authors of the study, in the “Discussion” section, cite statistics which indicate that the risk with the gabapentin class of drugs for fall is less than the risk for many other commonly administered meds including opioids:

“Our results highlight that patients had 30% increased odds of hip fractures within 60 days of gabapentinoid dispensing. By comparison, previous case-crossover studies on hip fractures demonstrated 124% increased odds with antidepressant use, 47% increased odds with antipsychotic use, 55% to 75% increased odds with benzodiazepine use, and 62% increased odds with opioid use.”

Personally, I am aware of a small but real increased possibility of me falling - this is during the nighttime, when I get up to pee or whatever; I have noticed I feel groggy on waking where I didn’t when younger, and so I take care to have a couple of small flashlights on my bedside table, to support myself with my hands against a wall if need be, etc. And I also monitor how well my balance is during the day - nowhere near as good when I was younger. Plus there are exercises & activities one can do to help with balance, e.g. tai chi, which I have studied off and on.

And obviously for most of us, the risk of fall is at its highest (as the study seems to acknowledge) within the first few weeks of a new med, or a big dose increase; after that sedative side effects seem to lessen. However, as nocturne points out, this unfortunately is not the case for everyone. Providers & patients need to watch out for this possibility.

When I think about it, my RLS specialist did not warn me about the risk of falls when she started prescribing methadone on top of my Horizant 600 mg. The dose was very low at the start (5 mg) but since I was also taking the Horizant, I think she would have done well to suggest I be careful with balance, esp. at night. But I have noticed that specialists, even if they are up to date with treatment options, have a kind of careless arrogance about them - basically a very narrow view of their responsibility. For example, my specialist knew very little about sleep apnea, and so it was left to me to realize I was probably suffering from it due to the combination of meds she prescribed; she got angry when I suggested that she should have been watching out for it too. I got a sleep study which verified I had it. To her it wasn’t part of her responsibility, even though she was the prescribing doctor. I made a truce with her because there is no better specialist in my area that I could switch to, but now I am much more aware of her limitations.

Back to the risk of falls: might this be something we should at least mention to folks who are new to the forum, when they start asking questions about the best meds to take for RLS? Not to say “don’t take these meds!!” but rather “Be aware of the risk early on” and maybe a link to tips about fall prevention for the elderly? What do you all think?

- Randy

[SueJohnson in reply to UsableThought]

Where is the discussion section ? I don't see it.

[UsableThought in reply to SueJohnson]

Go to the study (not the article on the study) and either scroll down or use the navigation menu:

jamanetwork.com/journals/ja...

[SueJohnson in reply to UsableThought]

Thank you.

[nocturne]

Hi Joolsg,

Thank you so much for posting this! I'm unable to even tolerate 100 mg. of Gabapentin, because even that low dose makes me dizzy and affects my vision. I'm on acetaminophen-codeine #3 instead, which, although not perfect (it takes over an hour to kick in), it has not caused any side effects, and I can still wake up and go to work in the morning.

I also have severe osteoporosis and am at risk for spontaneous fractures. I will start daily injections of Tymlos in the new year when my new drug coverage takes effect. I'm very grateful that you provided new information regarding gabapentin, since ignorant doctors still lecture me about needing to "get used to it." Now, I can counter them by stating that it will increase my risk of fractures. Thank you! : )

[amrob123]

Thanks for sharing this article Jools. It's good to be aware of all of the risks so we can make informed choices.

[SleeplessinMO]

oh no! God forbid we should prescribe opiates!!! 🙄 It’s so irritating, this intense terror of opiate pain medication. I too, am on the Gabapentin, because my arthritis pain is so severe & it appears pain docs are out of options.

[Purpleyam]

My RLS is controlled with a combo of Gabapentin plus Tramadol. But... now even more things to worry about with taking Gabapentin long term. I'm already dealing with hair loss, elevated heart rate, now fracture risk. 😮‍💨

[Joolsg in reply to Purpleyam]

It's just something to be aware of. Ensure your medical team know and arrange bone scans if necessary.

[SueJohnson in reply to Purpleyam]

Since you have been on gabapentin for awhile you already know if it makes you dizzy, uncoordinated or affects your balance which is what leads to falls and hip fractures.

[Purpleyam in reply to SueJohnson]

Hi Sue,True, and fortunately I have very good balance and I keep working on maintaining it.