Associations between fracture incidence and use of depot medroxyprogesterone acetate and anti-epileptic drugs in women with developmental disabilities

Abstract

Purpose-To evaluate any association between incidence of osteoporotic fractures and use of depot medroxyprogesterone acetate (DMPA) and/or anti-epileptic drugs (AEDs) among women and girls with developmental disabilities.Methods-Cross-sectional population-based observational study of all non-institutionalized females with developmental disabilities age thirteen and older who received fee-for-service Medicaid in Washington State during 2002 (N=6773), using administrative data.Main Findings-In a sample of 6,773 females, 140 women (2%) had an osteoporotic fracture during 2002. Among 340 users of DMPA, 13 (3.8%) had an osteoporotic fracture with an odds ratio of 2.4 (CI 95%, 1.3-4.4) for fracture compared to non-users. Among 1909 users of AEDs, 60 (3.1%) had an osteoporotic fracture with an odds ratio of 1.9 (CI 95%, 1.3-2.6) for fracture compared to non-users. We controlled for age and race (as Caucasian or non-Caucasian).Conclusions-Use of either AEDs or DMPA by women with developmental disabilities is associated with significantly increased incidence of fracture. Women and girls who have developmental disabilities may be poor candidates for DMPA use due to increased risk of fractures. Further research is indicated (1) to determine the specific risks profile of DMPA for this population, (2) to explore alternative means of managing significant menstrual problems and contraceptive needs in this population and (3) to screen current and previous users of DMPA and chronic users of AEDs for osteoporosis risk, regardless of age.Correspondence to: Kathleen C. Watson, watsonkc@u.washington.edu. Support for this study was provided by NINR NIH 5 T32 NR07106-07 and by NINR NIH P30 NR04001.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. People who have developmental disabilities (DD) are at increased risk of fractures due to cooccurrence of low BMD (Aspray et al. 1998;Jaffe, Timell, & Gulanski, 2001;Lohiya, TanFigueroa, & Iannucci, 2004) and increased incidence of falls and other trauma (Hsieh, Heller & Miller, 2001). Developmental disabilities are severe and chronic disabilities which begin before age 22 and are the result of mental retardation, cerebral palsy, epilepsy, autism or a similar condition (U.S. code Title 42, chapter 75, section 6001.5.1, 1992). They include a wide range of both physical and cognitive disabilities and many have associated health problems. NIH Public AccessDocumented risks for low BMD include limited mobility (Lohiya et al. 2004;Tyler, Snyder & Zyzanski, 2000;Jaffe, Timell, Elolia & Thatcher, 2005), use of anti-epileptic drugs (AEDs) (Ray, Papaioan...

Reproductive Hormones and Skeletal Health in Young Women

“…The only other study that relates fractures to DMPA was a recent survey of administrative records of medications and fractures in 6773 women with developmental disabilities who were receiving state aid. The DMPA users had an odds ratio for fracture of 2.4 (19). There have not been any large studies of risk of fracture in postmenopausal women who had past use of DMPA.…”

Update on Medications With Adverse Skeletal Effects

“…16 A single study examining the risk of fractures in a developmentally disabled population found an increased risk associated with depot medroxyprogesterone acetate use. 17 For most women, the risk of bone loss with depot medroxyprogesterone acetate is not enough to prevent its use, especially given the likelihood of bone recovery with cessation. It seems prudent to advise women receiving this contraceptive to consume adequate calcium and vitamin D and engage in weight-bearing exercise for skeletal health.…”

Prescribing Contraception to Women with Intellectual Disabilities: General Practitioners’ Attitudes and Practices

“…It is reasonable for doctors to share their concerns about a girl's vulnerability, not only to sexual intercourse at such a young age, but also to her long term health. Evidence [16] suggests that once they start contraception at such a young age, girls and women with intellectual disabilities tend to remain on it, with all the possible health consequences associated with that.…”

“…Decrease in bone mass during adolescence is of particular concern because adolescents are normally gaining bone density during these years. Losses at this time likely affect bone mass, thus increasing fracture risk later in life [16].…”