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Gommers LMM, Hoenderop JGJ, de Baaij JHF. Mechanisms of proton pump inhibitor-induced hypomagnesemia. Acta Physiol (Oxf) 2022; 235:e13846. [PMID: 35652564 PMCID: PMC9539870 DOI: 10.1111/apha.13846] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022]
Abstract
Proton pump inhibitors (PPIs) reliably suppress gastric acid secretion and are therefore the first-line treatment for gastric acid-related disorders. Hypomagnesemia (serum magnesium [Mg2+ ] <0.7 mmol/L) is a commonly reported side effect of PPIs. Clinical reports demonstrate that urinary Mg2+ excretion is low in PPI users with hypomagnesemia, suggesting a compensatory mechanism by the kidney for malabsorption of Mg2+ in the intestines. However, the exact mechanism by which PPIs cause impaired Mg2+ absorption is still unknown. In this review, we show that current experimental evidence points toward reduced Mg2+ solubility in the intestinal lumen. Moreover, the absorption pathways in both the small intestine and the colon may be reduced by changes in the expression and activity of key transporter proteins. Additionally, the gut microbiome may contribute to the development of PPI-induced hypomagnesemia, as PPI use affects the composition of the gut microbiome. In this review, we argue that the increase of the luminal pH during PPI treatment may contribute to several of these mechanisms. Considering the fact that bacterial fermentation of dietary fibers results in luminal acidification, we propose that targeting the gut microbiome using dietary intervention might be a promising treatment strategy to restore hypomagnesemia in PPI users.
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Affiliation(s)
- Lisanne M. M. Gommers
- Department of Physiology, Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen the Netherlands
| | - Joost G. J. Hoenderop
- Department of Physiology, Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen the Netherlands
| | - Jeroen H. F. de Baaij
- Department of Physiology, Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen the Netherlands
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Abdel-Hameed AR, Ahmed MF, Elsantawy AA, Mohammad MB. Prevalence, risk factors and impact of proteinuria-associated hypomagnesemia in chronic kidney disease patients: cross-sectional study. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-021-00083-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypomagnesemia is a predictor of progression and mortality of chronic kidney disease (CKD) patients. However, limited data is available about the prevalence and kidney-related risk factors of hypomagnesemia in the CKD patients. We aimed to investigate the prevalence and risk factors of low serum magnesium level associated with proteinuria and its impact on CKD patients. This cross-sectional study enrolled 100 CKD patients with different stages according to estimated glomerular filtration rate (eGFR), divided into 2 groups (proteinuric and non-proteinuric) in the period from February 2020 to August 2020.
Results
The number of participants in this study was 100 subjects, 50 patients were proteinuric and 50 patients had no proteinuria. The study participants’ serum magnesium levels ranged from 1.2 to 2.7 mg/dL. Fourteen (28%) of proteinuric individuals had a serum magnesium level of less than 1.8 mg/dL. Hypomagnesemic patients had significantly higher urine albumin creatinine ratio (UACR) (2071 mg/g vs. 812 mg/g, P<0.001), significantly higher CRP (48 mg/L vs. 12 mg/L, P<0.001), and lower mean hemoglobin levels as well (10.4 g/dL vs. 10.91 g/dL, P= 0.044). Serum magnesium level showed negative correlation with UACR (r=−0.504, P<0.001), parathyroid hormone (r=−0.276, P=0.005), and CRP (r=−0.505, P<0.001).
Conclusions
Hypomagnesemia is a frequent electrolyte disorder in patients with CKD. Hypomagnesemia is independently associated with proteinuria. Hypomagnesemia is a risk factor of inflammation, anemia and hyperparathyroidism in pre-dialysis CKD population.
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Recart DA, Ferraris A, Petriglieri CI, Alonso Serena M, Bonella MB, Posadas-Martinez ML. Prevalence and risk factors of long-term proton pump inhibitors-associated hypomagnesemia: a cross-sectional study in hospitalized patients. Intern Emerg Med 2021; 16:711-717. [PMID: 33001349 DOI: 10.1007/s11739-020-02501-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/05/2020] [Indexed: 02/06/2023]
Abstract
Proton pump inhibitors (PPI)-related hypomagnesemia is a potentially life-threatening adverse event first described in 2006. PPIs are widely used in the general population. Information regarding prevalence and risk factors is scarce. We conducted a cross-sectional study in inpatients to evaluate prevalence and associated factors with hypomagnesemia in chronic PPIs users. This is a cross-sectional study of hospitalized adult patients with chronic use of PPIs from January 01, 2012, to December 31, 2018. Chronic use was defined as taking PPIs at least 6 months before hospital admittance. Data were collected from informatized medical records from a University Hospital (Hospital Italiano de Buenos Aires). Hypomagnesemia was defined as a value equal to or less than 1.7 mg/dl. The first hospitalization measurement was retrieved. Thirty-six percent of patients (95% CI 30-43) with chronic PPI use presented hypomagnesemia at admission. Patients with hypomagnesemia presented a higher prevalence of chronic kidney disease (18.6% vs 8%, p < 0.05), more use of oral magnesium supplementation (20.9% vs 8%, p < 0.05), use of corticosteroids (32.6% vs 19.3%, p = 0.06) and calcineurin inhibitors (17.4% vs 6.7%, p < 0.05). Regarding laboratory findings, they presented lower hematocrit (28.7% vs 32.8%, p < 0.05), phosphatemia (3 mg/dl vs 3.4 mg/dl, p < 0.05), natremia (135 mg/dl vs 136 mg/dl, p < 0.05) and albumin levels (2.8 g/dl vs 3.2 g/dl p < 0.05) when compared to those who presented normomagnesemia. Hypocalcemia was more frequent among patients with hypomagnesemia (57% vs 38.7%, p < 0.05). In the multivariate analysis, hyponatremia, decreasing levels of hematocrit (odds ratio, OR 0.93-CI 95% 0.88-0.98) and malignant bone compromise (OR 2.83-CI 95% 1.04-7.7) were associated with hypomagnesemia. Adult patients with long-term use of PPIs have a high prevalence of hypomagnesemia. Increasing age, female sex, concomitant use of drugs that impair tubular function and chronic kidney disease may enhance this phenomenon. Anemia, hyponatremia and malignant bone compromise were associated factors with PPIs-related hypomagnesemia.
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Affiliation(s)
- Delfina Ana Recart
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina.
| | - Augusto Ferraris
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
- Pharmacology Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Marina Alonso Serena
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
| | - Maria Belen Bonella
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
| | - Maria Lourdes Posadas-Martinez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
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Aydın Yoldemir Ş, Zeren Ozturk G, Akarsu M, Ozcan M. Is there a correlation between hypomagnesemia linked to long-term proton pump inhibitor use and the active agent? Wien Klin Wochenschr 2021; 134:104-109. [PMID: 33751184 DOI: 10.1007/s00508-021-01834-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 02/13/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND One of the electrolyte disorders considered to be linked to proton pump inhibitors (PPI) use is hypomagnesemia. The aim of this study was to assess the incidence of hypomagnesemia linked to long-term PPI use and the correlation with active agents. METHODS The study included 305 patients aged over 18 years with PPI use of 1 year or longer and attending the internal diseases clinic for any reason from April 2019 to December 2019. A survey study was performed about the demographic characteristics and PPI use of patients. Laboratory parameters, such as the hemogram, magnesium, phosphorus, calcium and vitamin B12 concentrations were recorded. Magnesium concentrations were measured by a colorimetric method. RESULTS Of the patients 140 (45.9%) were female and 165 (54.1%) were male. The most commonly used PPI active agent was pantoprazole. The duration of PPI use varied from 1-25 years with a mean of 4.31 ± 4.52 years. Of the patients 51.5% reported no medication side effects. The most commonly observed side effect was constipation (n = 98, 32.1%). The mean magnesium concentration was 1.95 ± 0.02 mg/dL. Hypomagnesemia was identified in 65 (21.3%) patients and the incidence increased as age and duration of use increased. Patients using omeprazole had significantly lower magnesium levels compared to patients using pantoprazole, rabeprazole, esomeprazole and lansoprazole. CONCLUSION In light of the data obtained it was concluded that hypomagnesemia linked to PPI use is associated with the type of PPI. While patients using rabeprazole had the lowest rates, those using omeprazole had significantly higher rates of hypomagnesemia. Additionally, there was a proportional correlation between age and duration of use with the risk of development of hypomagnesemia.
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Affiliation(s)
- Şengül Aydın Yoldemir
- Department of Internal Medicine, University of Health Sciences Okmeydanı Training and Research Hospital, Istanbul, Turkey.
| | - Guzin Zeren Ozturk
- Departament of Family Medicine, University of Health Sciences, Istanbul Şişli Hamidiye Etfal Health Practice and Research Center, Istanbul, Turkey
| | - Murat Akarsu
- Department of Internal Medicine, University of Health Sciences Okmeydanı Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Ozcan
- Department of Internal Medicine, University of Health Sciences Okmeydanı Training and Research Hospital, Istanbul, Turkey
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Assessing the Impact on Health of Pharmacovigilance Activities: Example of Four Safety Signals. Drug Saf 2021; 44:589-600. [PMID: 33606201 DOI: 10.1007/s40264-021-01047-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The impact of pharmacovigilance activities on public health remains under-investigated, and measuring the impact on health of pharmacovigilance activities for a specific safety signal is challenging. OBJECTIVE To gain more insight into the methodological challenges and the data required, we assessed the impact of pharmacovigilance on public health for four identified product-specific safety signals using publicly available data in the Netherlands. The assessment was on the impact of the intertwined and complementary steps of the pharmacovigilance pathways. METHODS The impact of pharmacovigilance on public health was assessed using the assessment support tool and 'open data' from the Netherlands for four different types of pharmacovigilance safety signals: (1) off-label use of cyproterone acetate/ethinyloestradiol (CPA/EE) and thrombotic risk after pharmacovigilance measures after 2014; (2) pergolide and the risk of cardiac valvulopathy after pharmacovigilance activities in 2003; (3) proton pump inhibitors and the risk of hypomagnesaemia after pharmacovigilance activities in 2011; (4) rosiglitazone withdrawal from the market because of cardiovascular effects in 2010. RESULTS For the signals on CPA/EE and pergolide, a crude estimation of the impact could be made with varying degrees of assumptions based on the risk described in the literature and utilisation data. CONCLUSION This article highlights the methodological challenges and the data required to assess the impact of product-specific safety signals. A structured assessment support tool can be used as a guide for the necessary data elements and steps needed for the measurement or estimation of impact of pharmacovigilance activities on public health, provided that the appropriate data are available.
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Taylor DM, Date PA, Ugoni A, Smith JL, Spencer WS, de Tonnerre EJ, Yeoh MJ. Risk variables associated with abnormal calcium, magnesium and phosphate levels among emergency department patients. Emerg Med Australas 2019; 32:303-312. [PMID: 31847050 DOI: 10.1111/1742-6723.13411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 10/09/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The utility of calcium, magnesium and phosphate measurement in the ED is limited. We aimed to determine clinical risk variables for abnormal levels of these electrolytes in order to inform the development of an ordering guideline. METHODS We performed a retrospective, observational study of patients who presented to a tertiary referral ED between January and June 2017. Adult patients who had serum calcium, magnesium or phosphate tests completed during their ED stay were included. Presenting symptoms and signs, comorbidities, medication use and laboratory values were extracted from the medical record. Patients with missing data items were excluded. Logistic regression models determined clinical risk variables associated with low and high levels of each electrolyte. RESULTS A total of 33 120 adults presented during the study period. Of the 1679 calcium, 1576 magnesium and 1511 phosphate tests, 228 (13.6%), 158 (10.0%) and 387 (25.6%) were abnormal, respectively. Significant risk variables (P < 0.05) for abnormal levels were: hypocalcaemia - vomiting, perioral numbness, hand/foot spasm, calcium and phosphate supplements and chemotherapy (odds ratio [OR] range 5.9-17.3); hypercalcaemia - female sex, vomiting, polyuria, confusion, hyperparathyroidism, cancer and type 1 diabetes (OR range 2.3-9.7); hypomagnesemia - female sex, proton pump inhibitor use, tacrolimus use, alcohol abuse and type 2 diabetes (OR range 2.2-13.1); hypermagnesemia - lethargy, thiazide use and chronic kidney disease (OR range 4.3-4.5); hypophosphatemia - nausea, seizure and glucocorticoid use (OR range 1.7-2.1); and hyperphosphataemia - polyuria, diuretics and chronic kidney disease (OR range 1.9-5.0). CONCLUSION A range of demographic, comorbid, medication and clinical variables are associated with abnormal calcium, magnesium and phosphate levels. These findings will inform the development of clinical guidelines to rationalise calcium, magnesium and phosphate testing. Justification may be required for testing patients with no risk variables.
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Affiliation(s)
- David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick A Date
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
| | - Antony Ugoni
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Erik J de Tonnerre
- Northern Sydney Local Health District, NSW Health, Sydney, New South Wales, Australia
| | - Michael J Yeoh
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
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Proton-Pump Inhibitors and Hypomagnesaemia in Kidney Transplant Recipients. J Clin Med 2019; 8:jcm8122162. [PMID: 31817776 PMCID: PMC6947083 DOI: 10.3390/jcm8122162] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023] Open
Abstract
Proton-pump inhibitors (PPIs) are commonly used after kidney transplantation and there is rarely an incentive to discontinue treatment. In the general population, PPI use has been associated with hypomagnesaemia. We aimed to investigate whether PPI use is associated with plasma magnesium, 24-h urinary magnesium excretion and hypomagnesaemia, in kidney transplant recipients (KTR). Plasma magnesium and 24-h urinary magnesium excretion were measured in 686 stable outpatient KTR with a functioning allograft for ≥1 year from the TransplantLines Food and Nutrition Biobank and Cohort-Study (NCT02811835). PPIs were used by 389 KTR (56.6%). In multivariable linear regression analyses, PPI use was associated with lower plasma magnesium (β: −0.02, P = 0.02) and lower 24-h urinary magnesium excretion (β: −0.82, P < 0.001). Moreover, PPI users had a higher risk of hypomagnesaemia (plasma magnesium <0.70 mmol/L), compared with non-users (Odds Ratio (OR): 2.12; 95% confidence interval (CI) 1.43–3.15, P < 0.001). This risk tended to be highest among KTR taking high PPI dosages (>20 mg omeprazole Eq/day) and was independent of adjustment for potential confounders (OR: 2.46; 95% CI 1.32–4.57, P < 0.005). No interaction was observed between PPI use and the use of loop diuretics, thiazide diuretics, tacrolimus, or diabetes (Pinteraction > 0.05). These results demonstrate that PPI use is independently associated with lower magnesium status and hypomagnesaemia in KTR. The concomitant decrease in urinary magnesium excretion indicates that this likely is the consequence of reduced intestinal magnesium absorption. Based on these results, it might be of benefit to monitor magnesium status periodically in KTR on chronic PPI therapy.
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Srinutta T, Chewcharat A, Takkavatakarn K, Praditpornsilpa K, Eiam-Ong S, Jaber BL, Susantitaphong P. Proton pump inhibitors and hypomagnesemia: A meta-analysis of observational studies. Medicine (Baltimore) 2019; 98:e17788. [PMID: 31689852 PMCID: PMC6946416 DOI: 10.1097/md.0000000000017788] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous meta-analyses have suggested that there might be an association between the use of proton pump inhibitors (PPIs) and the development of hypomagnesemia, although the conclusions were no definitive. METHODS To provide an update on this topic, we performed a meta-analysis of all observational studies that examined the association between the use of PPIs and the development of hypomagnesemia. A literature search was conducted in MEDLINE, Scopus and Cochrane Central Register of Controlled Trials (January 1970 to June 2018) to identify observational studies that examined the association between the use of PPIs and the incidence and prevalence of hypomagnesemia. STUDY ELIGIBILITY CRITERIA In the absence of randomized controlled trials, we focused primarily on observational studies, including cross-sectional, case-control, retrospective, and prospective cohort studies. There was no limitation on sample size or study duration. Random-effect models meta-analyses were used to compute pooled unadjusted and adjusted odds ratios (ORs) for binary variables. RESULTS Sixteen observational studies were identified, including 13 cross-sectional studies, 2 case-control studies, and 1 cohort study, with a total of 131,507 patients. The pooled percentage of PPI users was 43.6% (95% confidence interval [CI] 25.0%, 64.0%). Among PPI users, 19.4% (95% CI 13.8%, 26.5%) had hypomagnesemia compared to 13.5% (95% CI 7.9%, 22.2%) among nonusers. By meta-analysis, PPI use was significantly associated with hypomagnesemia, with a pooled unadjusted OR of 1.83 (95% CI 1.26, 2.67; P = .002) and a pooled adjusted OR of 1.71 (95% CI 1.33, 2.19; P < .001). In subgroup analyses, high-dose PPI use was associated with higher odds for hypomagnesemia relative to low-dose PPI use (pooled adjusted OR 2.13; 95% CI 1.26, 3.59; P = .005). CONCLUSION Our findings are in support of the results of the previous meta-analyses. Furthermore, we found a dose-response between the PPI use and development of hypomagnesemia.
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Affiliation(s)
- Thawin Srinutta
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Api Chewcharat
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth's Medical Center
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Research Unit for Metabolic Bone Disease in CKD patients, Chulalongkorn University, Bangkok, Thailand
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Al-Aly Z, Maddukuri G, Xie Y. Proton Pump Inhibitors and the Kidney: Implications of Current Evidence for Clinical Practice and When and How to Deprescribe. Am J Kidney Dis 2019; 75:497-507. [PMID: 31606235 DOI: 10.1053/j.ajkd.2019.07.012] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
Proton pump inhibitors (PPIs), long thought to be safe, are associated with a number of nonkidney adverse health outcomes and several untoward kidney outcomes, including hypomagnesemia, acute kidney injury, acute interstitial nephritis, incident chronic kidney disease, kidney disease progression, kidney failure, and increased risk for all-cause mortality and mortality due to chronic kidney disease. PPIs are abundantly prescribed, rarely deprescribed, and frequently purchased over the counter. They are frequently used without medical indication, and when medically indicated, they are often used for much longer than needed. In this In Practice review, we summarize evidence linking PPI use with adverse events in general and adverse kidney outcomes in particular. We review the literature on the association of PPI use and risk for hypomagnesemia, acute kidney injury, acute interstitial nephritis, incident chronic kidney disease, kidney disease progression, end-stage kidney disease, and death. We provide an assessment of how this evidence should inform clinical practice. We review the impact of this evidence on patients' perception of risk, synthesize PPI deprescription literature, and provide our recommendations on how to approach PPI use and deprescription.
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Affiliation(s)
- Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of St. Louis, Saint Louis, MO; Department of Medicine, Washington University School of Medicine, Saint Louis, MO; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO.
| | - Geetha Maddukuri
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of St. Louis, Saint Louis, MO
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Date PA, Smith JL, Spencer WS, de Tonnerre EJ, Yeoh MJ, Taylor DM. Utility of calcium, magnesium and phosphate testing in the emergency department. Emerg Med Australas 2019; 32:39-44. [PMID: 31155837 DOI: 10.1111/1742-6723.13332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine how frequently calcium (Ca), magnesium (Mg) and phosphate (PO4 ) tests change ED patient management. METHODS We undertook a retrospective observational study in an Australian tertiary referral ED. We enrolled adult patients (aged ≥18 years) who presented between 1 January and 30 June 2017 and who had a serum Ca, Mg or PO4 test ordered and completed during their ED stay. Patient symptoms, medical history, electrolyte levels and ED management changes were extracted from the electronic medical record. RESULTS Of the 33 120 adults presented during the study period, 1716 (5.2%, 95% confidence interval [CI] 5.0-5.4) had at least one Ca, Mg or PO4 test completed in the ED. This included 4776 individual electrolyte tests, of which 776 (16.2%, 95% CI 15.2-17.3) were abnormal. Fifty-six (7.2% [95% CI 5.5-9.3] of patients with abnormal tests, 1.2% [95% CI 0.9-1.5] of all tests) tests were associated with a change in ED management. Twenty-six out of 1683 (1.5%) Ca levels were low with six (23.1%) management changes; 203 (12.1%) were high with 10 (4.9%) management changes. One hundred and twenty-eight out of 1579 (8.1%) Mg levels were low with 33 (25.8%) management changes; 30 (1.9%) were high with no management changes. Two hundred and twenty-five out of 1514 (14.9%) PO4 levels were low with six (2.7%) management changes; 164 (10.8%) were high with one (0.6%) management change. Fifty (2.9%) patients had management changes despite normal electrolyte levels. CONCLUSION Ca, Mg and PO4 testing is common. However, the yield of clinically significant abnormal levels is low and patient management is rarely changed. Testing of these electrolytes needs to be rationalised.
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Affiliation(s)
| | | | | | - Erik J de Tonnerre
- Northern Sydney Local Health District, NSW Health, Sydney, New South Wales, Australia
| | - Michael J Yeoh
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Liao S, Gan L, Mei Z. Does the use of proton pump inhibitors increase the risk of hypomagnesemia: An updated systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15011. [PMID: 30921222 PMCID: PMC6456119 DOI: 10.1097/md.0000000000015011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are commonly used in the treatment of acid-related diseases; however, the association between the use of PPIs and potential risk of hypomagnesemia is controversial. METHODS In the present study, databases including PubMed, EMBASE, MEDLINE, PsycINFO, CINAHL, the Cochrane Library, and 4 Chinese databases were searched since the inception until April 2018. Previous observational studies on the incidence of hypomagnesemia in individuals exposed to PPIs were included. RESULTS This systematic review involved 15 studies including 129,347 participants, and the sample size varied from 52 to 95,205. Meta-analysis of 14 studies indicated that the use of PPIs increased the risk of hypomagnesemia [RR, 1.44, 95% CI, 1.13-1.76; I, 85.2%]. Subgroup analysis revealed that the use of PPI was not associated with the incidence of hypomagnesemia in outpatients [RR, 1.49; 95% CI, 0.83-2.14; I, 41.4%] and hospitalized patients [RR, 1.05; 95% CI, 0.81-1.29; I, 62.1%], respectively. The use of PPIs was not related to the risk of hypomagnesemia based on the cut-off values of 1.8 mg/dL [RR, 1.73; 95% CI, 0.87-2.58; I, 65.2%], 1.7 mg/dL [RR, 1.48; 95% CI, 0.90-2.06; I, 87.6%], and 1.6 mg/dL [RR, 0.98; 95% CI, 0.69-1.27; I, 67.9%]. CONCLUSION The association between the exposure to PPI and the incidence of hypomagnesemia remained unclear. Due to the remarkable heterogeneity in previous studies, a definitive conclusion could not be drawn. Further research should be conducted to investigate the relationship between the use of individual PPI and potential risk of hypomagnesemia, and a dose-response analysis may be required.
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Affiliation(s)
- Shengtao Liao
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Li Gan
- Department of Anatomy, North Sichuan Medical College, Nanchong, Sichuan, P.R. China
| | - Zhechuan Mei
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing
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Adverse outcomes of long-term use of proton pump inhibitors: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:1395-1405. [PMID: 30028775 DOI: 10.1097/meg.0000000000001198] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The association between the long-term use of proton pump inhibitors (PPIs) and the risks of various diseases remains controversial. Therefore, the primary objective of this study was to quantify the associations as presented in the literature and to also provide this information to healthcare professionals and patients about their potentially adverse effects. In July 2016, we searched through Medline (PubMed), Embase, and the Cochrane Library from inception using common keywords. We included observational studies that provided risk estimates on the long-term use of PPIs and their adverse effects. Overall, 43 studies were included in the systematic review, of which 28 studies were also included in the random effect meta-analysis. Odds of community-acquired pneumonia, hip fracture, and colorectal cancer were 67% [odds ratio (OR)=1.67; 95% confidence interval (CI): 1.04-2.67], 42% (OR=1.42; 95% CI: 1.33-1.53), and 55% (OR=1.55; 95% CI: 0.88-2.73) higher in patients with long-term PPIs use compared with patients who did not use PPIs. Although the use of PPIs provides short-term health benefits, their prolonged use is associated with minor and also potentially major adverse health outcomes. Hence, we strongly recommend that the prescription of PPIs should be done with caution to improve the medication's efficacy and patients' safety.
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Ago R, Shindo T, Banshodani M, Shintaku S, Moriishi M, Masaki T, Kawanishi H. Hypomagnesemia as a predictor of mortality in hemodialysis patients and the role of proton pump inhibitors: A cross-sectional, 1-year, retrospective cohort study. Hemodial Int 2016; 20:580-588. [PMID: 27329549 DOI: 10.1111/hdi.12437] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/10/2016] [Indexed: 11/29/2022]
Abstract
Introduction This study aimed to evaluate the association between proton pump inhibitor (PPI) use and serum magnesium levels, and the role of hypomagnesemia and PPI use as a risk factor for mortality in hemodialysis patients. Methods An observational study, including a cross-sectional and 1-year retrospective cohort study. The study comprised 399 hemodialysis patients at a single center, and was conducted from January to September 2014. Multiple linear regression analysis was used to investigate the independent relationship between serum magnesium levels and baseline demographic and clinical variables, including PPI and histamine-2 receptor antagonist use. Cox regression model was used to identify lower serum magnesium level and PPI as a predictor of 1-year mortality. Findings Serum magnesium levels were lower with PPI use than non-PPI use (2.39 ± 0.36 vs. 2.56 ± 0.39 mg/dL, P < 0.001). Multiple linear regression analysis showed that PPI use, low serum albumin levels, and low serum potassium and high-sensitivity C-reactive protein (hs-CRP) levels were significantly associated with low serum magnesium levels. A total of 29 deaths occurred during the follow-up period. According to Cox regression analysis stratified by hs-CRP, only high serum hs-CRP levels (>4.04 mg/L) in association with low serum magnesium levels was an independent risk factor for 1-year mortality (hazard ratio: 2.92; 95% CI: 1.53-6.40, P < 0.001). Discussion Serum magnesium levels are lower in PPI use. In the inflammatory state, a low serum magnesium level is a significant predictor of mortality in hemodialysis patients.
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Affiliation(s)
- Rika Ago
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan. .,Department of Nephrology, Miyoshi Central Hospital, 531 Higashisakeya-cho, Miyoshi, Hiroshima, 728-8502, Japan.
| | - Toshihiro Shindo
- Department of Nephrology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Masataka Banshodani
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan
| | - Sadanori Shintaku
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan
| | - Misaki Moriishi
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hideki Kawanishi
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan.,Faculty of Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Mikolasevic I, Milic S, Stimac D, Zaputovic L, Lukenda Zanko V, Gulin T, Jakopcic I, Klaric D, Gulin M, Orlic L. Is there a relationship between hypomagnesemia and proton-pump inhibitors in patients on chronic hemodialysis? Eur J Intern Med 2016; 30:99-103. [PMID: 26905320 DOI: 10.1016/j.ejim.2016.01.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 01/16/2016] [Accepted: 01/29/2016] [Indexed: 11/19/2022]
Abstract
AIM We investigated the association among long-term proton-pump inhibitors (PPIs) use with serum magnesium (Mg) levels in chronic hemodialysis (HD) patients, as well as possible association among PPI use and increased risk of cardiovascular (CVD) morbidity in HD patients. METHODS Of 418 HD patients that were screened for inclusion, 136 were excluded due to incomplete medical data, duration of renal replacement therapy (RRT) for less than 12months, use of Mg-based-phosphate binders or other Mg-based medications or either to presence of chronic increased GI losses. Among 282 patients included in the study, 170 patients were on PPIs. RESULTS Serum Mg levels were significantly lower among PPI users vs. non-users (0.94±0.2 vs. 1.03±0.2mmol/L; p<0.0001). The median duration of PPI use was 27±9.6months (range from 12 to 108) and it was not significantly associated with Mg levels (r=0.116; p=0.167). Additionally, residual renal function didn't show a significant correlation with Mg concentration (r=-0.102; p=NS) in both groups of patients. The use of PPIs was an independent and strong predictor of low Mg concentrations even in multivariate analysis (OR 3.05; 95% CI 1.2498-7.4594, p=0.01). On the other hand, the daily dose of PPIs was not associated with low Mg levels. PPI users had a higher rate of adverse CVD events during the 1 year of follow-up in comparison to non-PPI users but that difference wasn't statistically significant (17.6% vs. 10.7%; p=0.110). CONCLUSION We have found a significant association between PPI use and lower serum Mg levels in chronic HD patients.
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Affiliation(s)
- I Mikolasevic
- Department of Nephrology, Dialysis and Kidney Transplantation, UHC Rijeka, Croatia; Department of Gastroenterology, UHC Rijeka, Croatia.
| | - S Milic
- Department of Gastroenterology, UHC Rijeka, Croatia
| | - D Stimac
- Department of Gastroenterology, UHC Rijeka, Croatia
| | - L Zaputovic
- Department of Cardiology, UHC Rijeka, Croatia
| | - V Lukenda Zanko
- Department of Internal Medicine, General Hospital "Josip Benčević", Slavonski Brod, Croatia
| | - T Gulin
- Department of Nephrology and Dialysis, Sestre Milosrdnice University Hospital
| | | | - D Klaric
- Zadar General Hospital, Zadar, Croatia
| | - M Gulin
- Šibenik General Hospital, Šibenik, Croatia
| | - L Orlic
- Department of Nephrology, Dialysis and Kidney Transplantation, UHC Rijeka, Croatia
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Low Prevalence of Hypomagnesemia in Long-term Recipients of Proton Pump Inhibitors in a Managed Care Cohort. Clin Gastroenterol Hepatol 2016; 14:317-21. [PMID: 26499924 DOI: 10.1016/j.cgh.2015.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic intake of proton pump inhibitors (PPI) has been associated with hypomagnesemia, but prevalence of PPI-associated hypomagnesemia is not known. METHODS We examined the prevalence of hypomagnesemia among long-term PPI recipients by using a large health maintenance organization database. We collected data on 10,167 participants eligible for chronic drug prescriptions from 2008 through 2013. Adult subjects receiving continuous PPI therapy for ≥ 6 months between 2008 and 2013 and ≥ 1 serum magnesium determination(s) were identified. Patients with any magnesium levels less than 1.6 mg/dL were selected for analysis; those with recognizable causes of altered magnesium homeostasis were excluded. RESULTS Five hundred ninety participants received long-term PPIs, and 414 (70.2%) met the inclusion criteria for a total exposure of 2293 PPI-years (average, 5.7 years/subject). Of these patients, 57 (13.8%) had ≥ 1 low serum magnesium; 5 were no longer on PPIs, and 44 had other recognizable causes for hypomagnesemia (25 receiving diuretics, 8 with chronic diarrhea, 8 with chronic kidney disease, and 3 with malignancies). Of the 8 remaining patients (7 female; mean age, 71.2 ± 13.4 years; mean daily medications, 5.4 ± 1.1), mild hypomagnesemia (range, 1.2-1.5 mg/dL) was noted in 13.9% of 289 measurements. All 8 patients had normal serum levels of magnesium at their final measurement. CONCLUSIONS In the absence of known precipitating factors, chronic PPI use does not appear to be associated with hypomagnesemia.
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Begley J, Smith T, Barnett K, Strike P, Azim A, Spake C, Richardson T. Proton pump inhibitor associated hypomagnasaemia - a cause for concern? Br J Clin Pharmacol 2016; 81:753-8. [PMID: 26613375 DOI: 10.1111/bcp.12846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/05/2015] [Accepted: 11/12/2015] [Indexed: 12/28/2022] Open
Abstract
AIMS In recent years, there have been a number of case reports of severe hypomagnesaemia associated with proton pump inhibitor (PPI) use, such that both the FDA and MHRA have issued drug safety warnings. They have recommended periodic serum magnesium testing in patients prescribed PPIs but provide no guidance on timing of these measurements. METHODS To our knowledge, we are the first to perform a prospective study to explore specifically proton pump inhibitor associated hypomagnesaemia (PPIAH). We followed 56 patients new to PPIs prospectively as well as a further 100 patients on long term PPIs cross-sectionally to identify what factors may be influencing the development of significant hypomagnesaemia. RESULTS For the prospective arm of the study, we measured serum magnesium levels prior to starting a PPI and again at regular intervals for the next 8 months. For the cross-sectional arm of the study we measured serum magnesium levels on patients on PPI therapy ranging from less than 1 year to over 5 years. CONCLUSION We found that, although there was a significant downward trend in serum magnesium levels in patients new to PPI therapy with time, clinically relevant hypomagnesaemia was not readily identifiable on regular blood testing. We did however identify patients on concurrent diuretic therapy as being at higher risk and so would recommend regular serum magnesium testing alongside their regular renal function monitoring on a more frequent basis such as annually.
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Affiliation(s)
- Joe Begley
- Department of Clinical Biochemistry, Royal Bournemouth Hospital, Bournemouth
| | - Trevor Smith
- Department of Gastroenterology, Southampton Universities Hospital, Southampton
| | - Kirsty Barnett
- Department of Gastroenterology, Royal Bournemouth Hospital, Bournemouth
| | - Paul Strike
- Department of Statistics, Salisbury Hospital, Salisbury
| | - Adnan Azim
- Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth
| | - Claire Spake
- Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth
| | - Tristan Richardson
- Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth.,Centre of Postgraduate Medical Research and Education, Bournemouth University, Bournemouth, UK
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William JH, Danziger J. Magnesium Deficiency and Proton-Pump Inhibitor Use: A Clinical Review. J Clin Pharmacol 2015; 56:660-8. [DOI: 10.1002/jcph.672] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 10/30/2015] [Indexed: 12/11/2022]
Affiliation(s)
| | - John Danziger
- Division of Nephrology; Beth Israel Deaconess Medical Center; Boston MA
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Misra PS, Alam A, Lipman ML, Nessim SJ. The relationship between proton pump inhibitor use and serum magnesium concentration among hemodialysis patients: a cross-sectional study. BMC Nephrol 2015; 16:136. [PMID: 26268579 PMCID: PMC4535779 DOI: 10.1186/s12882-015-0139-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 08/03/2015] [Indexed: 01/24/2023] Open
Abstract
Background Observational data suggest that serum magnesium (Mg) concentration is inversely related to vascular calcification and hyperparathyroidism among patients with end-stage renal disease (ESRD). In recent years, there have been several case reports of hypomagnesemia due to use of proton-pump inhibitors (PPI), with the hypomagnesemia attributed to inappropriate gastrointestinal (GI) Mg loss. We hypothesized that the tendency to GI Mg loss is more common than is currently reported. Since patients with ESRD have little to no renal Mg loss to affect serum Mg concentration, dialysis patients are an interesting population in whom to study the relationship between PPI use and serum Mg levels. Methods Using a single-center cross-sectional design, we studied 155 prevalent hemodialysis (HD) patients. Serum Mg concentration for each patient was determined based on the mean of 3 consecutive serum Mg levels drawn at 6 week intervals. PPI use at the time of the blood tests was documented. The relationship between PPI use and Mg concentration was determined in unadjusted analyses, as well as after adjustment for age, gender, race, cause of ESRD, diabetes, time on HD and dialysate Mg concentration. Results 55 % of patients were on PPIs at the time of the study. The majority of patients (62 %) used a dialysate Mg (in mmol/L) of 0.5, and the remainder (38 %) used a dialysate Mg of 0.375. Serum Mg levels were significantly lower among PPI users vs. non-users (0.93 vs. 1.02 mmol/L, p < 0.001). This finding persisted after stratifying for dialysate Mg concentration, and after multivariable adjustment (p < 0.001). In addition, more PPI users vs. non-users had a Mg level < 1 mmol/L (79 % vs. 43 %) and a Mg level < 0.8 mmol/L (16 % vs. 4 %). There was a non-significant trend toward increased time on PPI being associated with lower serum Mg levels (p = 0.067). Conclusion Among HD patients, PPI users have lower serum Mg levels as compared with non-users. Further research is required to determine whether the magnitude of change in Mg levels among PPI users is associated with adverse outcomes.
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Affiliation(s)
- Paraish S Misra
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada.
| | - Ahsan Alam
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada. .,Department of Medicine, Division of Nephrology, Royal Victoria Hospital, Montreal, Canada.
| | - Mark L Lipman
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada. .,Department of Medicine, Division of Nephrology, Jewish General Hospital, 3755 Cote-Sainte-Catherine Road, Room G-225.1, Montreal, QC, H3T 1E2, Canada.
| | - Sharon J Nessim
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada. .,Department of Medicine, Division of Nephrology, Jewish General Hospital, 3755 Cote-Sainte-Catherine Road, Room G-225.1, Montreal, QC, H3T 1E2, Canada.
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Kieboom BCT, Kiefte-de Jong JC, Eijgelsheim M, Franco OH, Kuipers EJ, Hofman A, Zietse R, Stricker BH, Hoorn EJ. Proton pump inhibitors and hypomagnesemia in the general population: a population-based cohort study. Am J Kidney Dis 2015; 66:775-82. [PMID: 26123862 DOI: 10.1053/j.ajkd.2015.05.012] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/01/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Proton pump inhibitor (PPI) use has been associated with hypomagnesemia in case reports and hospital-based cohort studies. Our objective was to determine whether PPI use is associated with hypomagnesemia in the general population and whether this is also found in histamine 2 receptor antagonist (H2RA) users. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 9,818 individuals from the general population (Rotterdam Study). PREDICTOR PPI use and H2RA use compared to no use. OUTCOMES & MEASUREMENTS Serum magnesium and hypomagnesemia (serum magnesium ≤ 1.44 mEq/L). Analyses were adjusted for age, sex, body mass index, kidney function, comorbid conditions, and alcohol and diuretic use. RESULTS Serum magnesium level was 0.022 mEq/L lower in PPI users (n=724; 95% CI, -0.032 to -0.014 mEq/L) versus those with no use. PPI use was associated with increased risk of hypomagnesemia (n=36; OR, 2.00; 95% CI, 1.36-2.93) compared to no use. Effect modification was found between the use of PPIs and loop diuretics; in participants using loop diuretics (n=270), PPI use was associated with a further increased risk of hypomagnesemia (n=5; OR, 7.22; 95% CI, 1.69-30.83) compared to no use. The increased risk with PPIs was only seen after prolonged use (range, 182-2,618 days; OR, 2.99; 95% CI, 1.73-5.15). Including dietary magnesium intake into the model did not alter results (available for 2,504 participants, including 231 PPI users). H2RA users (n=250) also had a lower serum magnesium level (-0.016 [95% CI, -0.032 to -0.002] mEq/L) and increased risk of hypomagnesemia (n=12; OR, 2.00; 95% CI, 1.08-3.72) compared to those with no use, but no interaction with loop diuretics. LIMITATIONS Cross-sectional analysis with single serum magnesium measurement. CONCLUSIONS PPI use is associated with hypomagnesemia in the general population. Prolonged PPI use and concomitant loop diuretic use are associated with a stronger risk increase. Similar but weaker associations were found in H2RA users, except for interaction with loop diuretics.
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Affiliation(s)
- Brenda C T Kieboom
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Inspectorate of Health Care, Utrecht, the Netherlands
| | - Jessica C Kiefte-de Jong
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Leiden University College, The Hague, the Netherlands
| | - Mark Eijgelsheim
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Robert Zietse
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Inspectorate of Health Care, Utrecht, the Netherlands.
| | - Ewout J Hoorn
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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Hypomagnesemia Induced by Long-Term Treatment with Proton-Pump Inhibitors. Gastroenterol Res Pract 2015; 2015:951768. [PMID: 26064102 PMCID: PMC4434191 DOI: 10.1155/2015/951768] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/16/2015] [Indexed: 12/30/2022] Open
Abstract
In 2006, hypomagnesemia was first described as a complication of proton-pump inhibitors. To address this issue, we systematically reviewed the literature. Hypomagnesemia, mostly associated with hypocalcemic hypoparathyroidism and hypokalemia, was reported in 64 individuals on long-term proton-pump inhibitors. Hypomagnesemia recurred following replacement of one proton-pump inhibitor with another but not with a histamine type-2 receptor antagonist. The association between proton-pump inhibitors and magnesium metabolism was addressed in 14 case-control, cross-sectional studies. An association was found in 11 of them: 6 reports found that the use of proton-pump inhibitors is associated per se with a tendency towards hypomagnesemia, 2 found that this tendency is more pronounced in patients concurrently treated with diuretics, carboplatin, or cisplatin, and 2 found a relevant tendency to hypomagnesemia in patients with poor renal function. Finally, findings likely reflecting decreased intestinal magnesium uptake were observed on treatment with proton-pump inhibitors. Three studies did not disclose any relationship between magnesium metabolism and treatment with histamine type-2 receptor antagonists. In conclusion, proton-pump inhibitors may cause hypomagnesemia. In these cases, switching to a histamine type-2 receptor antagonist is advised.
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Denny JT, Pantin E, Chiricolo A, Tse J, Jan T, Chaudhry M, Barsoum S, Denny AM, Papp D, Morgan SL. Lower incidence of hypo-magnesemia in surgical intensive care unit patients in 2011 versus 2001. J Clin Med Res 2015; 7:253-6. [PMID: 25699122 PMCID: PMC4330018 DOI: 10.14740/jocmr2101w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2015] [Indexed: 01/11/2023] Open
Abstract
Background Hypo-magnesemia is described to occur in as many as 65% of intensive care unit (ICU) patients. Magnesium (Mg) is a cofactor in over 300 enzymatic reactions involving energy metabolism, protein, and nucleic acid synthesis. The membrane pump that creates the electrical gradient across the cell membrane is dependent on Mg, and it is important in the activity of electrically excitable tissues. Since Mg regulates the movement of calcium in smooth muscle cells, it is also important in peripheral vascular tone and blood pressure. Studies have linked hypo-magnesemia to multiple chronic diseases and to a higher mortality rate. Methods To explore trends within our own tertiary care surgical ICU, we sampled our patients’ laboratory records in 2001 and in 2011. Hypo-magnesemia in our ICU is defined as an Mg less than 2.0 mg/dL. Results This retrospective review of all SICU patients from October to December revealed that there was a significant increase (P < 0.01) in the patients with their serum Mg level measured between 2001 (89%) and 2011 (95%). There was a significant decrease (P < 0.001) in patients with hypomagnesemia (< 2 mg/dL) between 2001 (47.5%) and 2011 (33.0%). On the other hand, there was a significant increase (P < 0.001) in patients with normal serum Mg level (> 2 mg/dL) between 2001 (52.5%) and 2011 (67.0%). Conclusions There was not only more monitoring of Mg in 2011, but a lower incidence of hypo-Mg compared to 2001. Possible explanations include changing patterns of antibiotic and diuretic use, less amphotericin use, more frequent laboratory surveillance, and better trained ICU practitioners.
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Affiliation(s)
- John T Denny
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Enrique Pantin
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Antonio Chiricolo
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - James Tse
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Thomas Jan
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Mohammad Chaudhry
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Sylviana Barsoum
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Angela M Denny
- Rutgers Graduate School of Nursing, 65 Bergen Street, Newark, NJ 07107, USA
| | - Denes Papp
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Sharon L Morgan
- Rutgers Robert Wood Johnson Medical School, 3100 CAB, 125 Paterson Street, New Brunswick, NJ 08901, USA
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Park CH, Kim EH, Roh YH, Kim HY, Lee SK. The association between the use of proton pump inhibitors and the risk of hypomagnesemia: a systematic review and meta-analysis. PLoS One 2014; 9:e112558. [PMID: 25394217 PMCID: PMC4230950 DOI: 10.1371/journal.pone.0112558] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/08/2014] [Indexed: 01/03/2023] Open
Abstract
Background Although many case reports have described patients with proton pump inhibitor (PPI)-induced hypomagnesemia, the impact of PPI use on hypomagnesemia has not been fully clarified through comparative studies. We aimed to evaluate the association between the use of PPI and the risk of developing hypomagnesemia by conducting a systematic review with meta-analysis. Methods We conducted a systematic search of MEDLINE, EMBASE, and the Cochrane Library using the primary keywords “proton pump,” “dexlansoprazole,” “esomeprazole,” “ilaprazole,” “lansoprazole,” “omeprazole,” “pantoprazole,” “rabeprazole,” “hypomagnesemia,” “hypomagnesaemia,” and “magnesium.” Studies were included if they evaluated the association between PPI use and hypomagnesemia and reported relative risks or odds ratios or provided data for their estimation. Pooled odds ratios with 95% confidence intervals were calculated using the random effects model. Statistical heterogeneity was assessed with Cochran’s Q test and I2 statistics. Results Nine studies including 115,455 patients were analyzed. The median Newcastle-Ottawa quality score for the included studies was seven (range, 6–9). Among patients taking PPIs, the median proportion of patients with hypomagnesemia was 27.1% (range, 11.3–55.2%) across all included studies. Among patients not taking PPIs, the median proportion of patients with hypomagnesemia was 18.4% (range, 4.3–52.7%). On meta-analysis, pooled odds ratio for PPI use was found to be 1.775 (95% confidence interval 1.077–2.924). Significant heterogeneity was identified using Cochran’s Q test (df = 7, P<0.001, I2 = 98.0%). Conclusions PPI use may increase the risk of hypomagnesemia. However, significant heterogeneity among the included studies prevented us from reaching a definitive conclusion.
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Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Yan Kim
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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