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Title: Nonsteroidal Anti-Inflammatory Drug Prescriptions Are Associated With Increased Stress Fracture Diagnosis in the US Army Population

Abstract

Stress fractures are common in military personnel and endurance athletes, and nonsteroidal anti-inflammatory drug (NSAID) use is widespread in these populations. NSAIDs inhibit prostaglandin synthesis, which blunts the anabolic response of bone to physical activity and could therefore increase risk of stress fracture. The objective of this study was to determine whether prescribed NSAIDs were associated with stress fracture diagnoses among US Army soldiers. We also aimed to establish whether acetaminophen, an analgesic alternative to NSAIDs, was associated with stress fracture risk. A nested case-control study was conducted using data from the Total Army Injury and Health Outcomes Database from 2002 to 2011 (n = 1,260,168). We identified soldiers with a diagnosis of stress fracture (n = 24,146) and selected 4 controls per case matched on length of military service (n = 96,584). We identified NSAID and acetaminophen prescriptions 180 to 30 days before injury (or match date). We also identified soldiers who participated in basic combat training (BCT), a 10-week period of heightened physical activity at the onset of Army service. Among these individuals, we identified 9088 cases and 36,878 matched controls. Conditional logistic regression was used to calculate incident rate ratios (RR) for stress fracture with adjustment formore » sex. NSAID prescription was associated with a 2.9-fold increase (RR = 2.9, 95% confidence interval [CI] 2.8–2.9) and acetaminophen prescription with a 2.1-fold increase (RR = 2.1, 95% CI 2.0–2.2) in stress fracture risk within the total Army population. The risk was more than 5-fold greater in soldiers prescribed NSAIDs (RR = 5.3, 95% CI 4.9–5.7) and more than 4-fold greater in soldiers prescribed acetaminophen (RR= 4..4, 95% CI 3.9–4.9) during BCT. Our results reveal an association between NSAID and acetaminophen prescriptions and stress fracture risk, particularly during periods of heightened physical activity. Prospective observational studies and randomized controlled trials are needed to support these findings before clinical recommendations can be made.« less

Authors:
 [1];  [1];  [2];  [1];  [1];  [1];  [3];  [4];  [5];  [1]
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  1. Army Research Institute of Environmental Medicine, Natick, MA (United States)
  2. Army Research Institute of Environmental Medicine, Natick, MA (United States); Harvard University, Boston, MA (United States)
  3. Massachusetts General Hospital, Boston, MA (United States)
  4. Massachusetts General Hospital, Boston, MA (United States); Beth Israel Deaconess Medical Center, Boston, MA (United States); Harvard Medical School, Boston, MA (United States)
  5. Army Research Institute of Environmental Medicine, Natick, MA (United States); VA Boston Healthcare System, Boston, MA (United States); Boston University School of Public Health, Boston, MA (United States)
Publication Date:
Research Org.:
Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, TN (United States)
Sponsoring Org.:
USDOE Office of Science (SC); US Army Medical Research and Materiel Command
OSTI Identifier:
1623566
Grant/Contract Number:  
SC0014664
Resource Type:
Accepted Manuscript
Journal Name:
Journal of Bone and Mineral Research
Additional Journal Information:
Journal Volume: 34; Journal Issue: 3; Journal ID: ISSN 0884-0431
Publisher:
Wiley
Country of Publication:
United States
Language:
English
Subject:
60 APPLIED LIFE SCIENCES; endocrinology and metabolism; stress fractures; nonsteroidal anti-inflammatory drugs; NSAID; ibuprofen; bone formation

Citation Formats

Hughes, Julie M., McKinnon, Craig J., Taylor, Kathryn M., Kardouni, Joseph R., Bulathsinhala, Lakmini, Guerriere, Katelyn I., Popp, Kristin L., Bouxsein, Mary L., Proctor, Susan P., and Matheny, Ronald W. Nonsteroidal Anti-Inflammatory Drug Prescriptions Are Associated With Increased Stress Fracture Diagnosis in the US Army Population. United States: N. p., 2018. Web. doi:10.1002/jbmr.3616.
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Hughes, Julie M., McKinnon, Craig J., Taylor, Kathryn M., Kardouni, Joseph R., Bulathsinhala, Lakmini, Guerriere, Katelyn I., Popp, Kristin L., Bouxsein, Mary L., Proctor, Susan P., & Matheny, Ronald W. Nonsteroidal Anti-Inflammatory Drug Prescriptions Are Associated With Increased Stress Fracture Diagnosis in the US Army Population. United States. https://doi.org/10.1002/jbmr.3616
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Hughes, Julie M., McKinnon, Craig J., Taylor, Kathryn M., Kardouni, Joseph R., Bulathsinhala, Lakmini, Guerriere, Katelyn I., Popp, Kristin L., Bouxsein, Mary L., Proctor, Susan P., and Matheny, Ronald W. Fri . "Nonsteroidal Anti-Inflammatory Drug Prescriptions Are Associated With Increased Stress Fracture Diagnosis in the US Army Population". United States. https://doi.org/10.1002/jbmr.3616. https://www.osti.gov/servlets/purl/1623566.
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@article{osti_1623566,
title = {Nonsteroidal Anti-Inflammatory Drug Prescriptions Are Associated With Increased Stress Fracture Diagnosis in the US Army Population},
author = {Hughes, Julie M. and McKinnon, Craig J. and Taylor, Kathryn M. and Kardouni, Joseph R. and Bulathsinhala, Lakmini and Guerriere, Katelyn I. and Popp, Kristin L. and Bouxsein, Mary L. and Proctor, Susan P. and Matheny, Ronald W.},
abstractNote = {Stress fractures are common in military personnel and endurance athletes, and nonsteroidal anti-inflammatory drug (NSAID) use is widespread in these populations. NSAIDs inhibit prostaglandin synthesis, which blunts the anabolic response of bone to physical activity and could therefore increase risk of stress fracture. The objective of this study was to determine whether prescribed NSAIDs were associated with stress fracture diagnoses among US Army soldiers. We also aimed to establish whether acetaminophen, an analgesic alternative to NSAIDs, was associated with stress fracture risk. A nested case-control study was conducted using data from the Total Army Injury and Health Outcomes Database from 2002 to 2011 (n = 1,260,168). We identified soldiers with a diagnosis of stress fracture (n = 24,146) and selected 4 controls per case matched on length of military service (n = 96,584). We identified NSAID and acetaminophen prescriptions 180 to 30 days before injury (or match date). We also identified soldiers who participated in basic combat training (BCT), a 10-week period of heightened physical activity at the onset of Army service. Among these individuals, we identified 9088 cases and 36,878 matched controls. Conditional logistic regression was used to calculate incident rate ratios (RR) for stress fracture with adjustment for sex. NSAID prescription was associated with a 2.9-fold increase (RR = 2.9, 95% confidence interval [CI] 2.8–2.9) and acetaminophen prescription with a 2.1-fold increase (RR = 2.1, 95% CI 2.0–2.2) in stress fracture risk within the total Army population. The risk was more than 5-fold greater in soldiers prescribed NSAIDs (RR = 5.3, 95% CI 4.9–5.7) and more than 4-fold greater in soldiers prescribed acetaminophen (RR= 4..4, 95% CI 3.9–4.9) during BCT. Our results reveal an association between NSAID and acetaminophen prescriptions and stress fracture risk, particularly during periods of heightened physical activity. Prospective observational studies and randomized controlled trials are needed to support these findings before clinical recommendations can be made.},
doi = {10.1002/jbmr.3616},
journal = {Journal of Bone and Mineral Research},
number = 3,
volume = 34,
place = {United States},
year = {Fri Nov 23 00:00:00 EST 2018},
month = {Fri Nov 23 00:00:00 EST 2018}
}
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https://doi.org/10.1002/jbmr.3616
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