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Philippoteaux C, Paccou J, Chazard E, Cortet B. Proton pump inhibitors, bone and phosphocalcic metabolism. Joint Bone Spine 2024; 91:105714. [PMID: 38458487 DOI: 10.1016/j.jbspin.2024.105714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/10/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Proton pump inhibitors (PPIs) are widely used for acid-related gastrointestinal disorders; however, concerns have arisen about their prolonged and inappropriate use. Although generally considered safe, recent evidence has linked PPI use with an increased risk of kidney disease, stomach cancer, pneumonia, dementia, cardiovascular events and potential bone health problems. This systematic review examines the effects of PPIs on bone health, including osteoporosis and changes in phosphocalcic and magnesium metabolism, through a comprehensive analysis of the recent literature. The relationship between PPIs, bone mineral density and fracture risk, especially in populations with comorbidities, is complex and we propose a focus based on recent data. Studies of the effect of PPI use on bone mineral density have shown mixed results and require further investigation. Observational studies have indicated an increased risk of fractures, particularly vertebral fractures, associated with PPI use. Recent meta-analyses have confirmed an association between PPI use and hip fractures with a dose-dependent effect. More recently, PPIs have been associated with serious disturbances in phosphocalcic and magnesium metabolism that require careful management and discontinuation. Proton pump inhibitor-induced hypomagnesemia (PPIH) is a well-established phenomenon. In addition, hypocalcemia secondary to severe hypomagnesemia has been described. Despite growing evidence of PPI-related risks, further research is essential to better understand the complex mechanisms, as most data are from observational studies and do not establish a causal relationship. This review emphasizes the need for judicious prescription practices, particularly in long-term use scenarios and rheumatological contexts.
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Affiliation(s)
- Cécile Philippoteaux
- Rheumatology Department, Lille University Hospital, Lille, France; Public Health Department, University Lille, CHU de Lille, ULR 2694, CERIM, METRICS, Lille, France.
| | - Julien Paccou
- Rheumatology Department, Lille University Hospital, Lille, France; Rheumatology Department, Lille University, Lille University Hospital, MabLab, Lille, France
| | - Emmanuel Chazard
- Public Health Department, University Lille, CHU de Lille, ULR 2694, CERIM, METRICS, Lille, France
| | - Bernard Cortet
- Rheumatology Department, Lille University Hospital, Lille, France; Rheumatology Department, Lille University, Lille University Hospital, MabLab, Lille, France
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Händel MN, Cardoso I, von Bülow C, Rohde JF, Ussing A, Nielsen SM, Christensen R, Body JJ, Brandi ML, Diez-Perez A, Hadji P, Javaid MK, Lems WF, Nogues X, Roux C, Minisola S, Kurth A, Thomas T, Prieto-Alhambra D, Ferrari SL, Langdahl B, Abrahamsen B. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ 2023; 381:e068033. [PMID: 37130601 PMCID: PMC10152340 DOI: 10.1136/bmj-2021-068033] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To review the comparative effectiveness of osteoporosis treatments, including the bone anabolic agents, abaloparatide and romosozumab, on reducing the risk of fractures in postmenopausal women, and to characterise the effect of antiosteoporosis drug treatments on the risk of fractures according to baseline risk factors. DESIGN Systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. DATA SOURCES Medline, Embase, and Cochrane Library to identify randomised controlled trials published between 1 January 1996 and 24 November 2021 that examined the effect of bisphosphonates, denosumab, selective oestrogen receptor modulators, parathyroid hormone receptor agonists, and romosozumab compared with placebo or active comparator. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials that included non-Asian postmenopausal women with no restriction on age, when interventions looked at bone quality in a broad perspective. The primary outcome was clinical fractures. Secondary outcomes were vertebral, non-vertebral, hip, and major osteoporotic fractures, all cause mortality, adverse events, and serious cardiovascular adverse events. RESULTS The results were based on 69 trials (>80 000 patients). For clinical fractures, synthesis of the results showed a protective effect of bisphosphonates, parathyroid hormone receptor agonists, and romosozumab compared with placebo. Compared with parathyroid hormone receptor agonists, bisphosphonates were less effective in reducing clinical fractures (odds ratio 1.49, 95% confidence interval 1.12 to 2.00). Compared with parathyroid hormone receptor agonists and romosozumab, denosumab was less effective in reducing clinical fractures (odds ratio 1.85, 1.18 to 2.92 for denosumab v parathyroid hormone receptor agonists and 1.56, 1.02 to 2.39 for denosumab v romosozumab). An effect of all treatments on vertebral fractures compared with placebo was found. In the active treatment comparisons, denosumab, parathyroid hormone receptor agonists, and romosozumab were more effective than oral bisphosphonates in preventing vertebral fractures. The effect of all treatments was unaffected by baseline risk indicators, except for antiresorptive treatments that showed a greater reduction of clinical fractures compared with placebo with increasing mean age (number of studies=17; β=0.98, 95% confidence interval 0.96 to 0.99). No harm outcomes were seen. The certainty in the effect estimates was moderate to low for all individual outcomes, mainly because of limitations in reporting, nominally indicating a serious risk of bias and imprecision. CONCLUSIONS The evidence indicated a benefit of a range of treatments for osteoporosis in postmenopausal women for clinical and vertebral fractures. Bone anabolic treatments were more effective than bisphosphonates in the prevention of clinical and vertebral fractures, irrespective of baseline risk indicators. Hence this analysis provided no clinical evidence for restricting the use of anabolic treatment to patients with a very high risk of fractures. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019128391.
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Affiliation(s)
- Mina Nicole Händel
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Isabel Cardoso
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Cecilie von Bülow
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Occupational Science, User Perspectives and Community-Based Interventions, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jeanett Friis Rohde
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Anja Ussing
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Sabrina Mai Nielsen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Adolfo Diez-Perez
- Department of Internal Medicine, Institut Hospital del Mar of Medical Investigation, Autonomous University of Barcelona and CIBERFES (Frailty and Healthy Aging Research Network), Instituto Carlos III, Barcelona, Spain
| | - Peyman Hadji
- Frankfurt Centre of Bone Health, Frankfurt and Philipps-University of Marburg, Marburg, Germany
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Xavier Nogues
- IMIM (Hospital del Mar Medical Research Institute), Parc de Salut Mar, Pompeu Fabra University, Barcelona, Spain
| | - Christian Roux
- INSERM U 1153, Hospital Paris-Centre, University of Paris, Paris, France
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic, and Cardiovascular Sciences, Rome University, Rome, Italy
| | - Andreas Kurth
- Department of Orthopaedic and Trauma Surgery, Marienhaus Klinikum Mainz, Major Teaching Hospital, University Medicine Mainz, Mainz, Germany
| | - Thierry Thomas
- Université Jean Monnet Saint-Étienne, CHU de Saint-Etienne, Rheumatology Department, INSERM U1059, F-42023, Saint-Etienne, France
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Bente Langdahl
- Departments of Clinical Medicine and of Endocrinology and Internal Medicine, Aarhus University, Aarhus, Denmark
| | - Bo Abrahamsen
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
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Lespessailles E, Toumi H. Proton Pump Inhibitors and Bone Health: An Update Narrative Review. Int J Mol Sci 2022; 23:ijms231810733. [PMID: 36142643 PMCID: PMC9504265 DOI: 10.3390/ijms231810733] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Proton pump inhibitors (PPIs) are an antacid drug often used in acid-related disorders. They decrease acid secretion in the stomach by blocking an enzyme called H+/K+ ATPase which controls acid production. Introduced to the market in 1989, their use has increased rapidly worldwide and they are now among the top 10 most prescribed drugs in the United States. As of 2015, the FDA has already approved six drugs of this class (omeprazole, esomeprazole, lansoprazole, dexlansoprazole, pantoprazole and rabeprazole). Recently, the risks and benefits of long-term PPI use were questioned and many studies indicated that their use should be carefully considered, especially in young patients, whose treatment with these drugs could last many years. Even greater concerns have been raised about a potential positive association between PPIs and osteoporotic fracture risk including the hip, spine and wrist. Although based on observational studies, there is substantial evidence associating the long-term use of PPIs and fracture. This relationship is only partially admitted due to the lack of consistent effects of PPIs on bone mineral density loss. Therefore, this narrative review aimed to discuss the recent findings pertaining to the risk of osteoporotic fracture associated with PPIs, in particular prolonged use, and to call for further research to elucidate the mechanisms associated with this bone fragility.
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Zheng Z, Johansson H, Harvey NC, Lorentzon M, Vandenput L, Liu E, Kanis JA, McCloskey EV. Potential Adverse Effect of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) on Bisphosphonate Efficacy: An Exploratory Post Hoc Analysis From a Randomized Controlled Trial of Clodronate. J Bone Miner Res 2022; 37:1117-1124. [PMID: 35441396 PMCID: PMC9487988 DOI: 10.1002/jbmr.4548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/27/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) have been reported to have weak but beneficial effects on bone health, including fracture risk, but many epidemiological studies are likely confounded. We explored the relationship between NSAIDs and fracture risk in a post hoc analysis of a well-documented, randomized, placebo-controlled study of the bisphosphonate, clodronate, in which treatment reduced osteoporotic fracture risk by 23%. Concurrent medication use at baseline was used to identify those prescribed oral NSAIDs. Only verified, incident fractures were included in the analysis. A total of 1082 (20.8%) women reported use of NSAIDs at baseline. They were slightly, but significantly, younger (mean 79 versus 80 years, p = 0.004), heavier (mean 66.7 versus 64.7 kg, p < 0.001) than nonusers, with slightly higher femoral neck bone mineral density (FN-BMD, 0.66 versus 0.64 g/cm2 , p < 0.001). In an adjusted model, NSAID use was associated with a significant increase in osteoporotic fracture risk over the 3-year study period (hazard ratio [HR] 1.27; 95% confidence interval [CI], 1.01-1.62; p = 0.039). However, this increase in risk was not statistically significant in the placebo group (HR 1.11; 95% CI, 0.81-1.52). In women receiving clodronate, the effect of the bisphosphonate to reduce osteoporotic fracture risk was not observed in those receiving NSAIDs (HR 0.95; 95% CI, 0.65-1.41; p = 0.81) in contrast to those not using NSAIDs (HR 0.71; 95% CI, 0.58-0.89; p = 0.002). In a subset with hip BMD repeated at 3 years, BMD loss during clodronate therapy was greater in those women receiving NSAIDs than in nonusers (eg, total hip -2.75% versus -1.27%, p = 0.078; femoral neck -3.06% versus -1.12%, p = 0.028), and was not significantly different from that observed in women receiving placebo. The efficacy of the bisphosphonate, clodronate, to reduce fracture risk was largely negated in those receiving NSAIDs. Although the mechanism is unclear, this clinically significant observation requires exploration in studies of commonly used bisphosphonates. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Zhangan Zheng
- Mellanby Centre for Musculoskeletal Research, Medical Research Council (MRC) Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Department of Oncology & MetabolismUniversity of SheffieldSheffieldUK
- Department of Trauma and Spine SurgeryThe Second People's Hospital of WuhuWuhuChina
| | - Helena Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
- Mary McKillop Institute for Health ResearchAustralian Catholic UniversityMelbourneVICAustralia
| | - Nicholas C. Harvey
- MRC Lifecourse Epidemiology CentreUniversity of SouthamptonSouthamptonUK
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
- Mary McKillop Institute for Health ResearchAustralian Catholic UniversityMelbourneVICAustralia
| | - Liesbeth Vandenput
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
- Mary McKillop Institute for Health ResearchAustralian Catholic UniversityMelbourneVICAustralia
| | - Enwu Liu
- Mary McKillop Institute for Health ResearchAustralian Catholic UniversityMelbourneVICAustralia
| | - John A. Kanis
- Mary McKillop Institute for Health ResearchAustralian Catholic UniversityMelbourneVICAustralia
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
| | - Eugene V. McCloskey
- Mellanby Centre for Musculoskeletal Research, Medical Research Council (MRC) Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Department of Oncology & MetabolismUniversity of SheffieldSheffieldUK
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
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Briganti SI, Naciu AM, Tabacco G, Cesareo R, Napoli N, Trimboli P, Castellana M, Manfrini S, Palermo A. Proton Pump Inhibitors and Fractures in Adults: A Critical Appraisal and Review of the Literature. Int J Endocrinol 2021; 2021:8902367. [PMID: 33510787 PMCID: PMC7822697 DOI: 10.1155/2021/8902367] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/11/2022] Open
Abstract
Despite the large number of patients worldwide being on proton pump inhibitors (PPIs) for acid-related gastrointestinal disorders, uncertainty remains over their long-term safety. Particularly, the potential side effects of these drugs on bone health have been evaluated in the last years. The purpose of our narrative review is to gather and discuss results of clinical studies focusing on the interactions between PPIs and fracture risk. Data generated mainly from nested case-control studies and meta-analysis suggest that long-term/high-dose PPIs users are characterized by an increased risk of fragility fractures, mainly hip fractures. However, in these studies, the PPIs-induced bone impairment is often not adjusted for different confounding variables that could potentially affect bone health, and exposure to PPIs was reported using medical prescriptions without adherence evaluation. The mechanisms of the PPI-related bone damage are still unclear, but impaired micronutrients absorption, hypergastrinemia, and increased secretion of histamine may play a role. Clinicians should pay attention when prescribing PPIs to subjects with a preexistent high risk of fractures and consider antiosteoporotic drugs to manage this additive effect on the bone. However, further studies are needed to clarify PPIs action on the bone.
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Affiliation(s)
| | - Anda Mihaela Naciu
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Gaia Tabacco
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Roberto Cesareo
- Unit of Metabolic Diseases, Department of Internal Medicine, S. Maria Goretti Hospital, 04100 Latina, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Pierpaolo Trimboli
- Scienza Biomediche, Università Della Svizzera Italiana (USI), Lugano, Switzerland
| | - Marco Castellana
- Population Health Unit, National Institute of Gastroenterology “Saverio de Bellis”, Research Hospital, Bari, Italy
| | - Silvia Manfrini
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
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Aleraij S, Alhowti S, Ferwana M, Abdulmajeed I. Effect of proton pump inhibitors on bone mineral density: A systematic review and meta-analysis of observational studies. Bone Rep 2020; 13:100732. [PMID: 33299906 PMCID: PMC7701953 DOI: 10.1016/j.bonr.2020.100732] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 09/10/2020] [Accepted: 11/03/2020] [Indexed: 02/07/2023] Open
Abstract
Despite the fact that proton pump inhibitors (PPIs) are one of the most prescribed medications, several epidemiological studies have reported many adverse effects related to their long-term usage. Nevertheless, there were inconsistent findings in the literature with regard to PPI use and bone mineral density (BMD) change. The aim of this systematic review and meta-analysis is to evaluate the association between the use of PPIs and change in BMD. The PubMed/MEDLINE, EMBASE, Cochrane and CINAHL databases were searched up to March 2019. Ten studies fulfilled the eligibility criteria (4761 cases and 30,809 controls), from which the mean difference and mean annualized percent change in BMD were pooled using RevMan 5.3.5 The results showed no statistically significant association between PPI users and non-users in mean annualized percent change in BMD (0.06; 95% CI -0.07, 0.18) with moderate heterogeneity (I2: 63%). There was a statistically significant reduction in the mean BMD difference among PPI users (-0.03; 95% CI -0.04, -0.01) with no substantial heterogeneity (I2: 26%). This meta-analysis reported inconsistent results regarding the use of PPIs and BMD loss. Thus, the effect of PPIs on BMD needs to be elucidated by other studies, and healthcare providers should prescribe PPIs with caution considering their unfavorable consequences on bone health.
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Affiliation(s)
- Sara Aleraij
- Department of Family Medicine and PHC, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Sultan Alhowti
- Department of Family Medicine and PHC, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mazen Ferwana
- Department of Family Medicine and PHC, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- National and Gulf Center for Evidence Based Health Practices, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Imad Abdulmajeed
- Department of Family Medicine and PHC, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
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Kendler DL, Marin F, Geusens P, López-Romero P, Lespessailles E, Body JJ, Minisola S. Psychotropic medications and proton pump inhibitors and the risk of fractures in the teriparatide versus risedronate VERO clinical trial. Bone 2020; 130:115113. [PMID: 31654779 DOI: 10.1016/j.bone.2019.115113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/05/2019] [Accepted: 10/17/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND VERO is a fracture endpoint study in women with established osteoporosis that showed reduction in the risks of new vertebral fractures (VFx) and clinical fractures in women randomized to teriparatide compared with risedronate. Patients on psychotropic drugs (hypnotics, benzodiazepines and antidepressants [selective serotonin- and norepinephrine-reuptake inhibitors: SSRIs and SNRIs]) and proton pump inhibitors (PPIs) may be at a higher risk of fractures. We studied the association of exposure to these medications with the risk of fractures in the VERO study cohort, including an assessment of their potential interactions with the assigned clinical trial drugs. METHODS A total of 1360 postmenopausal women with at least 2 moderate or 1 severe VFx and bone mineral density T-score ≤-1.50 were randomized to subcutaneous daily teriparatide (20μg) or oral weekly risedronate (35mg) in a double-blind, double-dummy, 2-year trial. In thispost-hoc analysis, multivariable log-binomial and Cox proportional hazards regression models were used to estimate adjusted risk ratios (RR) or hazard ratios (HR) for the exposure to these concomitant medications with the occurrence of incident fractures. We also assessed treatment effect modifications on anti-fracture efficacy driven by the use of these medications. RESULTS There were 406 (29.9 %), 347 (25.5 %) and 176 (12.9 %) subjects taking PPIs, benzodiazepines/hypnotics, and SSRIs/SNRIs during the study, respectively. For all fracture endpoints, the greater risk reduction of teriparatide versus risedronate did not significantly differ within the categories of psychotropic drugs and PPIs. Multivariable analysis showed that the risk of pooled new and worsened VFx was higher in PPI users than in non-PPI users (RR: 1.57; p=0.032), regardless of the study treatment. Benzodiazepine/hypnotic drug users showed an increased risk of clinical fractures (HR: 1.71; p=0.026) and non-vertebral fragility fractures (NVFFx, HR: 1.89; p=0.017), regardless of the study treatment. Increases in the risk of clinical fractures (HR: 1.93; p=0.018) and NVFFx (HR: 2.16; p=0.011) were also observed in SSRI/SNRI users, regardless of the study treatment. CONCLUSION In postmenopausal women with severe osteoporosis, the superior anti-fracture efficacy of teriparatide compared with risedronate was consistent regardless of psychotropic or PPI drugs use. Patients taking psychotropic drugs and PPIs showed a higher risk for NVFFx and VFx respectively, compared to those not on these medications.
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Affiliation(s)
| | | | - Piet Geusens
- Maastricht University Medical Center, Maastricht, The Netherlands.
| | | | - Eric Lespessailles
- Regional Hospital of Orleans and University of Orleans, Orleans, France.
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Nassar Y, Richter S. Proton-pump Inhibitor Use and Fracture Risk: An Updated Systematic Review and Meta-analysis. J Bone Metab 2018; 25:141-151. [PMID: 30237993 PMCID: PMC6135649 DOI: 10.11005/jbm.2018.25.3.141] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/30/2018] [Accepted: 07/06/2018] [Indexed: 02/07/2023] Open
Abstract
Background This study's objective was to evaluate the association between proton-pump inhibitor (PPI) use and bone fracture incidence and bone mineral density (BMD) by meta-analyzing the estimates reported by epidemiological and cohort studies. Methods Data were acquired from studies identified after a literature search in electronic databases. Odds ratios (ORs), hazard ratios (HRs), and risk ratios (RRs) between PPI use and bone fracture incidence were pooled under the random effects model, and meta-analysis of standardized mean differences between PPI users and controls in cross-sectional values and BMD changes was conducted. Results Thirty-three studies fulfilled the eligibility criteria. These studies provided data from 2,714,502 individuals with a mean age of 66.91 years (95% confidence interval [CI], 63.37–70.46); 33.21% (95% CI, 30.44–35.99) were males and 64.61% (95% CI, 60.73–68.49) were females. Overall, fracture incidence was 22.04% (95% CI, 16.10–27.97) in PPI users and 15.57% (95% CI, 12.28–18.86) in controls. The overall effect size of the point estimate was 1.28 (95% CI, 1.22–1.35) between PPI use and bone fracture incidence. There was a trend towards increased fracture incidence from short duration use: OR 1.29 (95% CI, 1.19–1.40), medium duration use: OR 1.33 (95% CI, 1.12–1.55) and long duration use: OR 1.62 (95% CI, 1.33–1.90). There was no significant difference in the standardized mean differences between PPI users and controls, either in cross-sectional BMD values or in the BMD change observed in longitudinal studies. Conclusions Pooling of ORs, HRs, and RRs suggested that PPI use might increase fracture risk. However, there was no effect of PPI use on BMD.
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Affiliation(s)
- Yousef Nassar
- Department of Medicine, Albany Medical Center, Albany, New York, USA
| | - Seth Richter
- Department of Medicine, Albany Medical Center, Albany, New York, USA
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Neuerburg C, Mittlmeier L, Schmidmaier R, Kammerlander C, Böcker W, Mutschler W, Stumpf U. Investigation and management of osteoporosis in aged trauma patients: a treatment algorithm adapted to the German guidelines for osteoporosis. J Orthop Surg Res 2017; 12:86. [PMID: 28595648 PMCID: PMC5465580 DOI: 10.1186/s13018-017-0585-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 05/23/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Osteoporosis-associated fractures are of increasing importance in trauma surgery. Systematic diagnostics and treatment of osteoporosis during a hospital stay, however, remain inadequate. Therefore, a specific algorithm for diagnosing and treating osteoporosis in trauma surgery patients was developed based on the DVO (German Osteology Society) guideline for osteoporosis from 2014. METHODS In a first step, the individuals' age and risk profile for osteoporosis is identified considering specific fractures indicating osteoporosis and risk factors assessed by a specific questionnaire. In addition, physical activity, risk of falls, dietary habits and the individuals' medication are considered. Basic osteoporosis laboratory tests, a bone densitometry by dual-energy X-ray absorptiometry (DXA) and, if needed, X-rays of the spine are carried out to identify prevalent vertebral body fractures. RESULTS Based on the treatment algorithm adapted to the new guidelines for osteoporosis in the majority of proximal femoral fractures, treatment of osteoporosis could already be indicated without prior DXA. In case of preexisting glucocorticoid therapy, a history of previous fractures or other risk factors according to the risk questionnaire, the threshold of treatment has to be adjusted given the table of T-scores. CONCLUSIONS The treatment algorithm for diagnosing and treating osteoporosis in in-patient trauma surgery patients can help identify high-risk patients systematically and efficiently. As a result, osteoporosis-associated fractures or failure of osteosynthesis could be reduced, yet a prospective validation of the algorithm has to be completed.
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Affiliation(s)
- Carl Neuerburg
- Department of General, Trauma and Reconstruction Surgery, Munich University Hospital LMU, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany
| | - Lena Mittlmeier
- Department of General, Trauma and Reconstruction Surgery, Munich University Hospital LMU, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany
| | - Ralf Schmidmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstruction Surgery, Munich University Hospital LMU, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany
- Department of Trauma Surgery, Medical University, Innsbruck, Austria
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstruction Surgery, Munich University Hospital LMU, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany
| | - Wolf Mutschler
- Department of General, Trauma and Reconstruction Surgery, Munich University Hospital LMU, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany
| | - Ulla Stumpf
- Department of General, Trauma and Reconstruction Surgery, Munich University Hospital LMU, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany
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Abstract
PURPOSE OF REVIEW The purpose of the review is to provide an update on recent advances in the evidence based on proton pump inhibitors (PPI) as a possible cause of osteoporosis and osteoporotic fractures. This review focuses, in particular, on new studies published in the last 18 months and a discussion of these findings and how this has influenced our understanding of this association, the clinical impact and the underlying pathophysiology. RECENT FINDINGS New studies have further strengthened existing evidence linking use of PPIs to osteoporosis. Short-term use does not appear to pose a lower risk than long-term use. There is a continued lack of conclusive studies identifying the pathogenesis. Direct effects on calcium absorption or on osteoblast or osteoclast action cannot at present plausibly explain the mechanism. SUMMARY The use of PPIs is a risk factor for development of osteoporosis and osteoporotic fractures. However, as the direct pathogenesis remains unclear, specific points of intervention are lacking, other than being vigilant in regard to the indication for prescribing PPIs and to use the lowest effective dose where PPIs cannot be avoided.
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Shamliyan TA, Middleton M, Borst C. Patient-centered Outcomes with Concomitant Use of Proton Pump Inhibitors and Other Drugs. Clin Ther 2017; 39:404-427.e36. [PMID: 28189362 DOI: 10.1016/j.clinthera.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE We performed a systematic review of patient-centered outcomes after the concomitant use of proton pump inhibitors (PPIs) and other drugs. METHODS We searched 4 databases in July 2016 to find studies that reported mortality and morbidity after the concomitant use of PPIs and other drugs. We conducted direct meta-analyses using a random-effects model and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. FINDINGS We included data from 17 systematic reviews and meta-analyses, 16 randomized controlled trials, and 16 observational studies that examined the concomitant use of PPIs with medications from 10 drug classes. Low-quality evidence suggests that the use of PPIs is associated with greater morbidity when administered with antiplatelet drugs, bisphosphonates, antibiotics, anticoagulants, metformin, mycophenolate mofetil, or nelfinavir. Concomitant PPIs reduce drug-induced gastrointestinal bleeding and are associated with greater docetaxel and cisplatin response rates in patients with metastatic breast cancer. For demonstrated statistically significant relative risks and benefits from concomitant PPIs, the magnitudes of the effects are small, with <100 attributable events per 1000 patients treated, and the effects are inconsistent among specific drugs. Among individual PPIs, the concomitant use of pantoprazole or esomeprazole, but not omeprazole or lansoprazole, is associated with an increased risk for all-cause mortality, nonfatal myocardial infarction, or stroke. Clopidogrel is associated with a greater risk for myocardial infarction compared with prasugrel. Conflicting results between randomized controlled trials and observational studies and high risk for bias in the body of evidence lessened our confidence in the results. IMPLICATIONS Available evidence suggests a greater risk for adverse patient outcomes after the concomitant use of PPIs and medications from 9 drug classes and warns against inappropriate drug combinations.
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Affiliation(s)
- Tatyana A Shamliyan
- Evidence-Based Medicine Center, Quality Assurance, Elsevier, Philadelphia, Pennsylvania.
| | - Maria Middleton
- Evidence-Based Medicine Center, Elsevier, Philadelphia, Pennsylvania
| | - Clarissa Borst
- Clinical Drug Information, Elsevier, Philadelphia, Pennsylvania
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12
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Lodato F, Poluzzi E, Raschi E, Piccinni C, Koci A, Olivelli V, Napoli C, Corvalli G, Nalon E, De Ponti F, Zoli M. Appropriateness of Proton Pump Inhibitor (PPI) prescription in patients admitted to hospital: Attitudes of general practitioners and hospital physicians in Italy. Eur J Intern Med 2016; 30:31-36. [PMID: 26926561 DOI: 10.1016/j.ejim.2016.01.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/25/2016] [Accepted: 01/29/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Proton pump inhibitor (PPI) prescriptions have raised concern for both huge increase of health expenditure and possible long-term adverse effects. OBJECTIVE To evaluate appropriateness of PPI prescription in ambulatory and hospital care. DESIGN Observational cohort study. PATIENTS Patients admitted to the Internal Medicine Unit of Bologna S. Orsola Hospital between 15/09/2013 and 15/12/2013. Data on clinical condition and drug therapy were collected at three time points: admission (reflecting GP's prescription), hospital stay and discharge. MAIN MEASURES Appropriateness of PPI use was evaluated as follows: (1) agreement between PPI use/non-use and appropriate clinical condition; (2) in PPI users, assessment of Medication Appropriateness Index (MAI). Differences in appropriateness among time points were analyzed by chi-square test. Logistic regression model was used to identify possible determinants of PPI appropriateness. KEY RESULTS Among 280 patients, 56% received PPI at least once in the three time points. Appropriateness, according to indication of use, was similar between admission and hospital stay (61% vs. 62%; p=0.82) and between hospital stay and discharge (62% vs. 59%; p=0.94). MAI score showed important, although statistically non-significant, change in appropriateness between admission and hospital stay (20% vs. 28%; p=0.16). Age≥65 was always associated with appropriate PPI use (up to OR=4.37; p<0.01), whereas cardiovascular comorbidity and conditions requiring analgesic treatment influenced appropriateness only at admission (OR=3.84; p<0.01 and OR=0.34; p<0.01, respectively). CONCLUSIONS Hospital clinicians only rarely reconsidered GP's choice to prescribe PPI. Room for improvement in PPI appropriateness is represented by (1) assessing gastrointestinal risk in each patient under analgesics and anti-inflammatory drugs, and (2) short-term re-evaluation of PPI prescription after discharge.
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Affiliation(s)
- Francesca Lodato
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Carlo Piccinni
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Ariola Koci
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Valentina Olivelli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Chiara Napoli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Giulia Corvalli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Elena Nalon
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Marco Zoli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
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13
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Identifikation, Diagnostik und leitliniengerechte Osteoporosetherapie (DVO) unfallchirurgischer Patienten. Unfallchirurg 2015; 118:913-24. [DOI: 10.1007/s00113-015-0071-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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14
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Nyandege AN, Slattum PW, Harpe SE. Risk of Fracture and the Concomitant Use of Bisphosphonates With Osteoporosis-Inducing Medications. Ann Pharmacother 2015; 49:437-47. [DOI: 10.1177/1060028015569594] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective: To review the literature on the concomitant use of bisphosphonates and medications that can influence bone metabolism and potentially attenuate bisphosphonate antifracture efficacy. Data Sources: MEDLINE and CINAHL were searched for articles published in English through December 2014 using the following terms: bisphosphonates, bone density conservation agents, acid-suppressive therapy, levothyroxine, thiazolidinediones (TZDs), selective serotonin reuptake inhibitors (SSRIs), bone fractures. Study Selection and Data Extraction: Studies were included if they reported results of concomitant use of any listed medications with bisphosphonates and risk of fractures and focused on women. Articles that focused generally on the use of one of the listed medications and fractures without explicitly examining the potential antifracture efficacy or attenuation of bisphosphonates were excluded. Data Synthesis: A total of 6 relevant studies were identified. Four epidemiological studies reported a statistically significant dose-dependent increase in the risk of fractures when bisphosphonates and acid-suppressive drugs were used together. One post hoc analysis of clinical trial data suggested no attenuation of the antifracture effects of bisphosphonates when used concomitantly with acid-suppressive therapy. One study involving bisphosphonates and SSRIs noted a statistically significant association between fracture risk and SSRI use. No study examining TZDs or levothyroxine with bisphosphonates was identified. Conclusions: Existing research suggests potential attenuation of bisphosphonate antifracture efficacy among patients taking acid-suppressive medications. Based on their pharmacological actions, TZDs, SSRIs, and levothyroxine have similar implications. The paucity of evidence in the literature associating the attenuation of bisphosphonate antifracture efficacy when combined with other medications suggests that further investigation is needed.
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Affiliation(s)
| | | | - Spencer E. Harpe
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA
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15
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Kann PH, Hadji P, Bergmann RS. [Pharmacogenic osteoporosis beyond cortisone. Proton pump inhibitors, glitazones and diuretics]. Z Rheumatol 2015; 73:323-8. [PMID: 24728601 DOI: 10.1007/s00393-013-1286-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND [corrected] There are many drugs which can cause osteoporosis or at least favor its initiation. The effect of hormones and drugs with antihormonal activity, such as glucocorticoids and aromatase inhibitors, on initiation of osteoporosis is well known. In addition, proton pump inhibitors, glitazones and diuretics also influence the formation of osteoporosis. MATERIAL AND METHODS The results of currently available studies on the correlation between proton pump inhibitors, glitazones and diuretics on formation of osteoporosis were evaluated and summarized. RESULTS Proton pump inhibitors and glitazones increase the risk for osteoporotic fractures. Loop diuretics may slightly increase fracture risk, whereas thiazides were shown to be osteoprotective by reducing fracture probability on a relevant scale. CONCLUSION Proton pump inhibitors should not be prescribed without serious consideration and then only as long as necessary. Alternatively, the administration of the less effective H2 antagonists should be considered when possible due to the reduction of acid secretion. Because the long-term intake of thiazides is associated with a clinically relevant reduction in the risk of fractures and they are economic and well-tolerated, prescription can be thoroughly recommended within the framework of differential diagnostic considerations in an appropriate clinical context. The briefly increased risk of falling immediately after starting diuretic therapy is the only point which needs to be considered.
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Affiliation(s)
- P H Kann
- Zentrum für Innere Medizin - Bereich Endokrinologie & Diabetologie, Philipps-Universität Marburg/Universitätsklinikum Marburg UKGM, 35033, Marburg, Deutschland,
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16
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17
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Abstract
OPINION STATEMENT There are 34 studies in almost 2 million participants that have reported on the association between proton pump inhibitor (PPI) therapy and risk of fracture. There is substantial variation between the results of each study but systematic reviews of the data suggest overall there is an association between PPI therapy and risk of fracture. The magnitude of the association is modest and is most likely due to confounding factors as patients prescribed PPI therapy tend to be more frail with more risk factors for fractures than those not given these drugs. There is no clear dose-response relationship and there is no association between PPI therapy and risk of fracture in those at highest risk. Finally, there is no clear mechanism through which PPI therapy increases the risk of fracture, as recent randomized trials show no impact of PPI therapy on calcium absorption and there is no association between PPI therapy and risk of osteoporosis. We therefore feel there is insufficient evidence to change PPI prescribing habits based on risk of fracture. Similarly, we do not recommend bone mineral density investigations for patients taking PPI therapy other than would be normally indicated. There is no evidence to support prescription of calcium and/or vitamin D in patients simply because they are taking PPI therapy. As with all medications, we only recommend prescribing PPI therapy when there is a clear indication that benefit will outweigh risk and at the lowest effective dose. Patients should be regularly assessed as to whether acid suppression is still required.
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Affiliation(s)
- Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, 1280 Main Street West, Health Sciences Center, area 3V3, Hamilton, Ontario, L8S 4K1, Canada,
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18
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Canadian Association of Gastroenterology position statement: hip fracture and proton pump inhibitor therapy-a 2013 update. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:593-5. [PMID: 24251323 DOI: 10.1155/2013/321379] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Masclee GMC, Sturkenboom MCJM, Kuipers EJ. A Benefit–Risk Assessment of the Use of Proton Pump Inhibitors in the Elderly. Drugs Aging 2014; 31:263-82. [DOI: 10.1007/s40266-014-0166-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Keller J, Schinke T. The role of the gastrointestinal tract in calcium homeostasis and bone remodeling. Osteoporos Int 2013; 24:2737-48. [PMID: 23536255 DOI: 10.1007/s00198-013-2335-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/25/2013] [Indexed: 12/11/2022]
Abstract
While skeletal biology was approached in a rather isolated fashion in the past, an increasing understanding of the interplay between extraskeletal organs and bone remodeling has been obtained in recent years. This review will discuss recent advances in the field that have shed light on how the gastrointestinal tract and bone relate to each other. In particular, the importance of the GI tract in maintaining calcium homeostasis and skeletal integrity will be reviewed as impaired gastric acid production represents a major public health problem with possible implications for sufficient calcium absorption. Osteoporosis, the most prevalent bone disease worldwide, is caused not only by intrinsic defects affecting bone cell differentiation and function but also by a large set of extrinsic factors including hormonal disturbances, malnutrition, and iatrogenic drug application. Given the skeletal requirements of calcium, amino acids, and energy for bone turnover and renewal, it is not surprising that the gastrointestinal (GI) tract is of major importance for skeletal integrity.
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Affiliation(s)
- J Keller
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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