Tramadol Medication and the practicing physician

A recent paper published in the JAMA on March 2019, discussed the high mortality risk associated with the use of Tramadol to relief pain in Osteoarthritis.

A study included 88 902 patients with degenerative arthritis who were given an initial prescription of Tramadol. It has demonstrated that a significantly increased risk of mortality over the year compared to patients taking other medications. A Hazard Ratio was developed for Naproxen (Hazard ratio HR: 1.71), Diclofenac (1.88), celecoxib (1.70), and etoricoxib (2.04). Tramadol was not compared to codeine (0.94).

A propensity score was matched by Chao Zen MD, PHD of the department of Orthopedics at Xiangya Hospital, Central South University, Changsha, Hunan China and colleagues while he limited the analysis to patients aged 50 and more with a diagnosis of osteoarthritis knee, hip, or hand. He excluded patients who had a history of cancer or opioid use.

Guidelines from the American Academy of Orthopedic Surgeons guidelines as well as the American College of Rheumatology both recommended Tramadol along with an anti-inflammatory as first-line therapy for patients suffering from osteoarthritis. So this study reviewed the use of tramadol and the mortality rate associated to patients suffering from osteoarthritis. 

Individuals aged fifty-year-old and older, found in a general practice data based in United Kingdom were used for the study from January 2000 to December 2015. All causes of mortality within the year initiating the Tramadol were compared to the other 5 medications. The data from the UK’s Health Improvement Network of electronic medical records include more than 11 million patients in 580 general practices. 44,451 patients were prescribed Tramadol (n=44451), naproxen (n=12397), diclofenac (n=8512), celecoxib (n=5674), etoricoxib (n=2946) or codeine (n=16922).

During the first year follow-up, 278 deaths (23.5/1000 persons-years) occurred in the Tramadol cohort and 164 (13.8/1000 persons-years) occurred within the Naproxen cohort and mortality was higher for Tramadol compared to Diclofenac (36.2/1000 persons-years). Tramadol was also associated with a higher all-cause mortality rate compared with celecoxib (31.2/1000 persons-years) or naproxen (9.7 deaths/1000 person-years) or for etoricoxib (25.7/1000 persons-years. No statistical difference in all-cause mortality was observed between Tramadol and Codeine.

The study concludes that initial prescriptions for osteoarthritis in patient older than 50 years were associated with a significantly higher rate of mortality over the first year of follow up compared to the commonly prescribed other anti-inflammatory medications. Codeine was not used in this study.

Daniel H Solomon, MD, MPH, professor of Medicine at Harvard Medical School Section-chief of Clinical Sciences, Division of Rheumatology, Brigham and Women Hospital, Boston Massachusetts reported that clinicians and patients should be aware of the risks with tramadol interactions with Naproxen, Celecoxib, Diclofenac, etoricoxib and codeine.

We reviewed this paper to help the physicians in practice to avoid the combination of Tramadol and another anti-inflammatory while treating for the first time a patient with Osteoarthritis.
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JAMA March 2019

Medscape Medical News Janice Kelly 3-12-19

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