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Chamniansawat S, Suksridechacin N, Thongon N. Current opinion on the regulation of small intestinal magnesium absorption. World J Gastroenterol 2023; 29:332-342. [PMID: 36687126 PMCID: PMC9846944 DOI: 10.3748/wjg.v29.i2.332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/25/2022] [Accepted: 11/19/2022] [Indexed: 01/06/2023] Open
Abstract
Magnesium (Mg2+) has an important role in numerous biological functions, and Mg2+ deficiency is associated with several diseases. Therefore, adequate intestinal absorption of Mg2+ is vital for health. The small intestine was previously thought to absorb digested Mg2+ exclusively through an unregulated paracellular mechanism, which is responsible for approximately 90% of total Mg2+ absorption. Recent studies, however, have revealed that the duodenum, jejunum, and ileum absorb Mg2+ through both transcellular and paracellular routes. Several regulatory factors of small intestinal Mg2+ uptake also have been explored, e.g., parathyroid hormone, fibroblast growth factor-23, apical acidity, proton pump inhibitor, and pH-sensing channel and receptors. The mechanistic factors underlying proton pump inhibitor suppression of small intestinal Mg2+, such as magnesiotropic protein dysfunction, higher mucosal bicarbonate secretion, Paneth cell dysfunction, and intestinal inflammation, are currently being explored. The potential role of small intestinal microbiomes in Mg2+ absorption has also been proposed. In this article, we reviewed the current knowledge on the mechanisms and regulatory factors of small intestinal Mg2+ absorption.
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Affiliation(s)
- Siriporn Chamniansawat
- Division of Anatomy, Department of Medical Sciences, Faculty of Allied Health Sciences, Burapha University, Muang 20131, Chonburi, Thailand
| | - Nasisorn Suksridechacin
- Biodiversity Research Centre, Thailand Institute of Scientific and Technological Research, Khlong Luang 12120, Pathum Thani, Thailand
| | - Narongrit Thongon
- Division of Physiology, Department of Medical Sciences, Faculty of Allied Health Sciences, Burapha University, Muang 20131, Chonburi, Thailand
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Mitra S, Hussain MS, Rahman R, Salam MA, Mazumder T, Farzana S. A survey on the incidence of common musculoskeletal side effects among the patients taking long-term anti-ulcerant therapies in Bangladesh. Toxicol Rep 2022; 9:1796-1805. [DOI: 10.1016/j.toxrep.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/08/2022] [Accepted: 09/16/2022] [Indexed: 10/14/2022] Open
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Hussain MS, Mazumder T. Long-term use of proton pump inhibitors adversely affects minerals and vitamin metabolism, bone turnover, bone mass, and bone strength. J Basic Clin Physiol Pharmacol 2021; 33:567-579. [PMID: 34687598 DOI: 10.1515/jbcpp-2021-0203] [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: 07/02/2021] [Accepted: 10/01/2021] [Indexed: 11/15/2022]
Abstract
Notwithstanding, proton pump inhibitors (PPIs) are one of the most excellent options for different anti-secretory therapy in terms of improved symptomatic outcomes, numerous epidemiological and cohort studies provide evidence of an association between long-term proton PPIs use and increased fracture risk among users. The present attempt aimed to summarize the effect of long-term use of PPIs on musculoskeletal systems by considering the recent claims of different research groups to understand the risk of osteopenia and osteoporosis and to determine the risk factors associated with these complications. We extracted data from various systematic reviews and meta-analyses, cross-sectional studies, prospective studies, case-control studies, cohort studies, and in-vivo and in-vitro studies to observe the consequence of long-term PPIs uses over the patient's bone health. Recent findings suggested that long-term use of PPIs plays an introductory and cabalistic role in the development of osteoporosis mostly hip fractures by disturbing numerous biological pathways and thus able to set up a link between over-prescription of PPIs and bone loss. Frequent administration of PPIs is associated with a significantly worse outcome to bone mineral density (BMD) profile and produce a negative impression on bone health. Since, there are limited data to determine the association of PPIs use and change in BMD, recommending further studies to find out this dissertation.
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Affiliation(s)
- Md Saddam Hussain
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Tanoy Mazumder
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Noakhali, Bangladesh
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Salvo EM, Ferko NC, Cash SB, Gonzalez A, Kahrilas PJ. Umbrella review of 42 systematic reviews with meta-analyses: the safety of proton pump inhibitors. Aliment Pharmacol Ther 2021; 54:129-143. [PMID: 34114655 DOI: 10.1111/apt.16407] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/04/2020] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are widely used to treat and prevent acid-related disorders. Despite high efficacy, PPI safety has been increasingly scrutinised. However, no comprehensive review summarising investigations of various adverse events is available. AIMS To perform an umbrella review to comprehensively assess associations between adverse events and PPI use. METHODS In accordance with PRISMA, an umbrella review of systematic reviews with meta-analyses was conducted. PubMed and EMBASE were searched from 2015 to July 2019. AMSTAR 2 and GRADE were used to assess quality and certainty of evidence. Author-reported quality assessments were also reviewed. RESULTS Forty-two systematic reviews with meta-analyses, supported predominantly by observational evidence, were included. The most comprehensive studies reported statistically significant associations with PPI use for several outcomes, including: fractures (eg, hip; RR = 1.20; 95% CI = 1.14-1.28; n = 2 103 800), kidney disease (eg, acute kidney injury; RR = 1.61; 95% CI = 1.16-2.22; n = 2 396 640), infections (eg, Clostridioides difficile; OR = 1.99; 95% CI = 1.73-2.30; n = 356 683), gastric cancer (OR = 2.50; 95% CI = 1.74-3.85; n = 943 070) and gastrointestinal events (eg, fundic gland polyps; OR = 2.46; 95% CI = 1.42-4.27; n = 40 218). No associations with non-gastric cancers, or neurological disease were concluded, with conflicting evidence for cardiovascular outcomes. Certainty based on GRADE was very low for most outcomes. CONCLUSIONS This review identified several published associations between PPIs and adverse outcomes, however, further investigation is needed to understand their clinical significance and the likelihood of causal relationship. If higher quality evidence is generated substantiating the potential risks, it may be necessary for clinicians to consider alternative treatment strategies, especially when PPI efficacy is suboptimal.
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Affiliation(s)
- Elizabeth M Salvo
- Value & Evidence Division, Marketing and Market Access, EVERSANA, Burlington, ON, Canada
| | - Nicole C Ferko
- Value & Evidence Division, Marketing and Market Access, EVERSANA, Burlington, ON, Canada
| | - Sarah B Cash
- Value & Evidence Division, Marketing and Market Access, EVERSANA, Burlington, ON, Canada
| | - Ailish Gonzalez
- Health Economics and Market Access, Ethicon Inc, Somerville, NJ, USA
| | - Peter J Kahrilas
- Feinberg School of Medicine at Northwestern University, Chicago, IL, USA
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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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The Perilous PPI: Proton Pump Inhibitor as a Cause of Clinically Significant Hypomagnesaemia. J ASEAN Fed Endocr Soc 2021; 35:109-113. [PMID: 33442177 PMCID: PMC7784231 DOI: 10.15605/jafes.035.01.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022] Open
Abstract
Proton pump inhibitors (PPIs) are the mainstay of therapy for all gastric acid related diseases and are commonly used in current clinical practice. Although widely regarded as safe, PPIs have been associated with a variety of adverse effects, including hypomagnesaemia. The postulated mechanism of PPI-related hypomagnesaemia involves inhibition of intestinal magnesium absorption via transient receptor potential melastin (TRPM) 6 and 7 cation channels. PPIinduced hypomagnesaemia (PPIH) has become a well recognized phenomenon since it was first reported in 2006. Clinical concerns arise from growing number of case reports presenting PPIH as a consequence of long-term PPI use, with more than 30 cases published to date. In this article, we report 2 cases of PPIH associated with the use of pantoprazole. Both patients presented with severe hypomagnesaemia and hypocalcaemia. One of them had associated hypokalemia and cardiac arrhythmia. A casual relation with PPIs postulated and supported by resolution of electrolyte abnormalities after discontinuation of PPIs.
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Suksridechacin N, Kulwong P, Chamniansawat S, Thongon N. Effect of prolonged omeprazole administration on segmental intestinal Mg 2+ absorption in male Sprague-Dawley rats. World J Gastroenterol 2020; 26:1142-1155. [PMID: 32231419 PMCID: PMC7093313 DOI: 10.3748/wjg.v26.i11.1142] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/06/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The exact mechanism of proton pump inhibitors (PPIs)-induced hypomagnesemia (PPIH) is largely unknown. Previous studies proposed that PPIH is a consequence of intestinal Mg2+ malabsorption. However, the mechanism of PPIs-suppressed intestinal Mg2+ absorption is under debate.
AIM To investigate the effect of 12-wk and 24-wk omeprazole injection on the total, transcellular, and paracellular Mg2+ absorption in the duodenum, jejunum, ileum, and colon of male Sprague-Dawley rats.
METHODS The rats received 20 mg/kg∙d subcutaneous omeprazole injection for 12 or 24 wk. Plasma and urinary Mg2+, Ca2+, and PO43− levels were measured. The plasma concentrations of 1α,25-dihydroxyvitamin D3 (1α,25(OH)2D3), parathyroid hormone (PTH), fibroblast growth factor 23 (FGF-23), epidermal growth factor (EGF), and insulin were also observed. The duodenum, jejunum, ileum, and colon of each rat were mounted onto individual modified Using chamber setups to study the rates of total, transcellular, and paracellular Mg2+ absorption simultaneously. The expression of transient receptor potential melastatin 6 (TRPM6) and cyclin M4 (CNNM4) in the entire intestinal tract was also measured.
RESULTS Single-dose omeprazole injection significantly increased the intraluminal pH of the stomach, duodenum, and jejunum. Omeprazole injection for 12 and 24 wk induced hypomagnesemia with reduced urinary Mg2+ excretion. The plasma Ca2+ was normal but the urinary Ca2+ excretion was reduced in rats with PPIH. The plasma and urinary PO43− levels increased in PPIH rats. The levels of 1α,25(OH)2D3 and FGF-23 increased, whereas that of plasma EGF decreased in the omeprazole-treated rats. The rates of the total, transcellular, and paracellular Mg2+ absorption was significantly lower in the duodenum, jejunum, ileum, and colon of the rats with PPIH than in those of the control rats. The percent suppression of Mg2+ absorption in the duodenum, jejunum, ileum, and colon of the rats with PPIH compared with the control rats was 81.86%, 70.59%, 69.45%, and 39.25%, respectively. Compared with the control rats, the rats with PPIH had significantly higher TRPM6 and CNNM4 expression levels throughout the intestinal tract.
CONCLUSION Intestinal Mg2+ malabsorption was observed throughout the intestinal tract of rats with PPIH. PPIs mainly suppressed small intestinal Mg2+ absorption. Omeprazole exerted no effect on the intraluminal acidic pH in the colon. Thus, the lowest percent suppression of total Mg2+ absorption was found in the colon. The expression levels of TRPM6 and CNNM4 increased, indicating the presence of a compensatory response to Mg2+ malabsorption in rats with PPIH. Therefore, the small intestine is an appropriate segment that should be modulated to counteract PPIH.
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Affiliation(s)
- Nasisorn Suksridechacin
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, Chonburi 20131, Thailand
| | - Punnisa Kulwong
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, Chonburi 20131, Thailand
| | - Siriporn Chamniansawat
- Division of Anatomy, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, Chonburi 20131, Thailand
| | - Narongrit Thongon
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, Chonburi 20131, 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: 73] [Impact Index Per Article: 14.6] [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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9
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Haider R, Girgis C. Delay in diagnosis of proton pump inhibitor induced hypomagnesaemia: A case series. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2019. [DOI: 10.1016/j.jecr.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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10
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Thongon N, Chamniansawat S. The inhibitory role of purinergic P2Y receptor on Mg 2+ transport across intestinal epithelium-like Caco-2 monolayer. J Physiol Sci 2019; 69:129-141. [PMID: 30032468 PMCID: PMC10717015 DOI: 10.1007/s12576-018-0628-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 07/13/2018] [Indexed: 02/06/2023]
Abstract
The mechanism of proton pump inhibitors (PPIs) suppressing intestinal Mg2+ uptake is unknown. The present study aimed to investigate the role of purinergic P2Y receptors in the regulation of Mg2+ absorption in normal and omeprazole-treated intestinal epithelium-like Caco-2 monolayers. Omeprazole suppressed Mg2+ transport across Caco-2 monolayers. An agonist of the P2Y2 receptor, but not the P2Y4 or P2Y6 receptor, suppressed Mg2+ transport across control and omeprazole-treated monolayers. Omeprazole enhanced P2Y2 receptor expression in Caco-2 cells. Forskolin and P2Y2 receptor agonist markedly enhanced apical HCO3- secretion by control and omeprazole-treated monolayers. The P2Y2 receptor agonist suppressed Mg2+ transport and stimulated apical HCO3- secretion through the Gq-protein coupled-phospholipase C (PLC) dependent pathway. Antagonists of cystic fibrosis transmembrane conductance regulator (CFTR) and Na+-HCO3- cotransporter-1 (NBCe1) could nullify the inhibitory effect of P2Y2 receptor agonist on Mg2+ transport across control and omeprazole-treated Caco-2 monolayers. Our results propose an inhibitory role of P2Y2 on intestinal Mg2+ absorption.
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Affiliation(s)
- Narongrit Thongon
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd, Saensook, Muang, Chonburi, 20131, Thailand.
| | - Siriporn Chamniansawat
- Division of Anatomy, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd, Saensook, Muang, Chonburi, 20131, Thailand
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DiNicolantonio JJ, O'Keefe JH, Wilson W. Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis. Open Heart 2018; 5:e000668. [PMID: 29387426 PMCID: PMC5786912 DOI: 10.1136/openhrt-2017-000668] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/06/2017] [Accepted: 11/07/2017] [Indexed: 12/15/2022] Open
Abstract
Because serum magnesium does not reflect intracellular magnesium, the latter making up more than 99% of total body magnesium, most cases of magnesium deficiency are undiagnosed. Furthermore, because of chronic diseases, medications, decreases in food crop magnesium contents, and the availability of refined and processed foods, the vast majority of people in modern societies are at risk for magnesium deficiency. Certain individuals will need to supplement with magnesium in order to prevent suboptimal magnesium deficiency, especially if trying to obtain an optimal magnesium status to prevent chronic disease. Subclinical magnesium deficiency increases the risk of numerous types of cardiovascular disease, costs nations around the world an incalculable amount of healthcare costs and suffering, and should be considered a public health crisis. That an easy, cost-effective strategy exists to prevent and treat subclinical magnesium deficiency should provide an urgent call to action.
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Affiliation(s)
- James J DiNicolantonio
- Department of Preventive Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - James H O'Keefe
- Department of Preventive Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - William Wilson
- Hospital Medicine, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
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Sivakumar J. Proton pump inhibitor-induced hypomagnesaemia and hypocalcaemia: case review. INTERNATIONAL JOURNAL OF PHYSIOLOGY, PATHOPHYSIOLOGY AND PHARMACOLOGY 2016; 8:169-174. [PMID: 28078056 PMCID: PMC5209446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
Proton pump inhibitor (PPI)-induced hypomagnesaemia is a rare but serious adverse effect of a widely prescribed medication. It has become an increasingly recognised complication since 2006, with the U.S. Food and Drug Administration issuing a warning for this risk with regards to long-term PPI use. We present the case of PPI-associated hypomagnesaemia and hypocalcaemia. A 91 year old male presented with tetany from severe hypomagnesaemia and hypocalcaemia. This condition occurred in the context of 18 months of PPI use, and resolved following cessation of PPI therapy and the replenishment of magnesium and calcium stores. Monitoring of magnesium, calcium and potassium levels is crucial in patients prescribed PPIs long-term; especially the elderly patient.
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Affiliation(s)
- Jonathan Sivakumar
- Discipline of Medicine, The University of Adelaide, Royal Adelaide Hospital Adelaide, South Australia 5000, Australia
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13
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Pasina L, Zanotta D, Puricelli S, Bonoldi G. Seizure and tetany secondary to hypomagnesaemic hypoparathyroidism induced by a proton-pump inhibitor. Eur J Clin Pharmacol 2016; 73:511-512. [PMID: 27896379 DOI: 10.1007/s00228-016-2169-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 11/23/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Luca Pasina
- Pharmacotherapy and Appropriateness of Drug Prescription Unit, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Giuseppe La Masa 19, 20156, Milano, Italy.
| | - Danilo Zanotta
- Internal Medicine II, Ospedale di Circolo, Busto Arsizio, Italy
| | | | - Guido Bonoldi
- Internal Medicine II, Ospedale di Circolo, Busto Arsizio, Italy
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Thongon N, Penguy J, Kulwong S, Khongmueang K, Thongma M. Omeprazole suppressed plasma magnesium level and duodenal magnesium absorption in male Sprague-Dawley rats. Pflugers Arch 2016; 468:1809-1821. [PMID: 27866273 DOI: 10.1007/s00424-016-1905-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 10/18/2016] [Accepted: 11/09/2016] [Indexed: 02/06/2023]
Abstract
Hypomagnesemia is the most concerned side effect of proton pump inhibitors (PPIs) in chronic users. However, the mechanism of PPIs-induced systemic Mg2+ deficit is currently unclear. The present study aimed to elucidate the direct effect of short-term and long-term PPIs administrations on whole body Mg2+ homeostasis and duodenal Mg2+ absorption in rats. Mg2+ homeostasis was studied by determining the serum Mg2+ level, urine and fecal Mg2+ excretions, and bone and muscle Mg2+ contents. Duodenal Mg2+ absorption as well as paracellular charge selectivity were studied. Our result showed that gastric and duodenal pH markedly increased in omeprazole-treated rats. Omeprazole significantly suppressed plasma Mg2+ level, urinary Mg2+ excretion, and bone and muscle Mg2+ content. Thus, omeprazole induced systemic Mg2+ deficiency. By using Ussing chamber techniques, it was shown that omeprazole markedly suppressed duodenal Mg2+ channel-driven and Mg2+ channel-independent Mg2+ absorptions and cation selectivity. Inhibitors of mucosal HCO3- secretion significantly increased duodenal Mg2+ absorption in omeprazole-treated rats. We therefore hypothesized that secreted HCO3- in duodenum decreased luminal proton, this impeded duodenal Mg2+ absorption. Higher plasma total 25-OH vitamin D, diuresis, and urine PO43- were also demonstrated in hypomagnesemic rats. As a compensatory mechanism for systemic Mg2+ deficiency, the expressions of duodenal transient receptor potential melastatin 6 (TRPM6), cyclin M4 (CNNM4), claudin (Cldn)-2, Cldn-7, Cldn-12, and Cldn-15 proteins were enhanced in omeprazole-treated rats. Our findings support the potential role of duodenum on the regulation of Mg2+ homeostasis.
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Affiliation(s)
- Narongrit Thongon
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd., Saensook, Muang, Chonburi, 20131, Thailand.
| | - Jirawat Penguy
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd., Saensook, Muang, Chonburi, 20131, Thailand
| | - Sasikan Kulwong
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd., Saensook, Muang, Chonburi, 20131, Thailand
| | - Kanyanat Khongmueang
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd., Saensook, Muang, Chonburi, 20131, Thailand
| | - Matthana Thongma
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd., Saensook, Muang, Chonburi, 20131, Thailand
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Gould E, Clements C, Reed A, Giori L, Steiner JM, Lidbury JA, Suchodolski JS, Brand M, Moyers T, Emery L, Tolbert MK. A Prospective, Placebo-Controlled Pilot Evaluation of the Effect of Omeprazole on Serum Calcium, Magnesium, Cobalamin, Gastrin Concentrations, and Bone in Cats. J Vet Intern Med 2016; 30:779-86. [PMID: 27062346 PMCID: PMC4913587 DOI: 10.1111/jvim.13932] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/19/2016] [Accepted: 02/25/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Chronic proton pump inhibitor administration has been associated with electrolyte and cobalamin deficiency, disrupted bone homeostasis, hypergastrinemia, and rebound acid hypersecretion in humans. It is unknown if this occurs in cats. OBJECTIVES Prolonged oral omeprazole results in altered bone mineral density or content, serum calcium, magnesium, cobalamin, and gastrin concentrations in healthy cats. ANIMALS Six healthy adult DSH cats. METHODS In a within subjects, before and after design, cats received placebo followed by omeprazole (0.83-1.6 mg/kg PO q12h) for 60 days each. Analysis of serum calcium, magnesium, cobalamin, and gastrin concentrations was performed on days 0, 30, and 60. Bone density and content were evaluated on days 0 and 60 of each intervention. Continuous data were analyzed using a two-way ANOVA (α = 0.006). On day 60 of omeprazole administration, continuous intragastric pH monitoring was performed in 2 cats to evaluate the effects of abrupt withdrawal of omeprazole. RESULTS No significant changes were detected between treatments for any variables, except serum gastrin, which was significantly higher during omeprazole treatment in comparison to placebo (P = 0.002). Evidence of gastric hyperacidity was seen in both cats in which intragastric pH monitoring was performed following cessation of omeprazole. CONCLUSIONS AND CLINICAL IMPORTANCE Although further studies with larger populations of cats will be needed to draw any definitive conclusions, these preliminary results suggest that prolonged PPI treatment results in hypergastrinemia and abrupt PPI withdrawal might result in RAH in cats.
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Affiliation(s)
- E Gould
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
| | - C Clements
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
| | - A Reed
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
| | - L Giori
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
| | - J M Steiner
- Texas A&M University, Gastrointestinal Laboratory, College Station, TX
| | - J A Lidbury
- Texas A&M University, Gastrointestinal Laboratory, College Station, TX
| | - J S Suchodolski
- Texas A&M University, Gastrointestinal Laboratory, College Station, TX
| | - M Brand
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
| | - T Moyers
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
| | - L Emery
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
| | - M K Tolbert
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN
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16
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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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17
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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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18
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Proton Pump Inhibitor Use and Magnesium Concentrations in Hemodialysis Patients: A Cross-Sectional Study. PLoS One 2015; 10:e0143656. [PMID: 26618538 PMCID: PMC4664382 DOI: 10.1371/journal.pone.0143656] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 11/06/2015] [Indexed: 12/15/2022] Open
Abstract
Magnesium concentration is a proven predictor of mortality in hemodialysis patients. Recent reports have indicated that proton pump inhibitor (PPI) use affects serum magnesium levels, however few studies have investigated the relationship between PPI use and magnesium levels in hemodialysis patients. This study aimed to clarify the association between PPI use and serum magnesium levels in hemodialysis patients. We designed this cross sectional study and included 1189 hemodialysis patients in stable condition. Associations between PPI and magnesium-related factors, as well as other possible confounders, were evaluated using a multiple regression model. We defined hypomagnesemia as a value < 2.0 mg/dL, and created comparable logistic regression models to assess the association between PPI use and hypomagnesemia. PPI use is associated with a significantly lower mean serum magnesium level than histamine 2 (H2) receptor antagonists or no acid-suppressive medications (mean [SD] PPI: 2.52 [0.45] mg/dL; H2 receptor antagonist: 2.68 [0.41] mg/dL; no acid suppressive medications: 2.68 [0.46] mg/dL; P = 0.001). Hypomagnesemia remained significantly associated with PPI (adjusted OR, OR: 2.05; 95% CI: 1.14–3.69; P = 0.017). PPI use is associated with an increased risk of hypomagnesemia in hemodialysis patients. Future prospective studies are needed to explore magnesium replacement in PPI users on hemodialysis.
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19
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William JH, Nelson R, Hayman N, Mukamal KJ, Danziger J. Proton-pump inhibitor use is associated with lower urinary magnesium excretion. Nephrology (Carlton) 2015; 19:798-801. [PMID: 25142949 DOI: 10.1111/nep.12330] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2014] [Indexed: 02/06/2023]
Abstract
AIMS Although multiple recent studies have confirmed an association between chronic proton-pump inhibitor (PPI) use and hypomagnesaemia, the physiologic explanation for this association remains uncertain. To address this, we investigated the association of PPI use with urinary magnesium excretion. METHODS We measured 24-hour urine magnesium excretion in collections performed for nephrolithiasis evaluation in 278 consecutive ambulatory patients and determined PPI use from contemporaneous medical records. RESULTS There were 50 (18%) PPI users at the time of urine collection. The mean daily urinary magnesium was 84.6 ± 42.8 mg in PPI users, compared with 101.2 ± 41.1 mg in non-PPI users (P = 0.01). In adjusted analyses, PPI use was associated with 10.54 ± 5.30 mg/day lower daily urinary magnesium excretion (P = 0.05). Diuretic use did not significantly modify the effect of PPI on urinary magnesium. As a control, PPI use was not associated with other urinary indicators of nutritional intake. CONCLUSIONS Our findings suggest that PPI use is associated with lower 24-hour urine magnesium excretion. Whether this reflects decreased intestinal uptake due to PPI exposure, or residual confounding due to decreased magnesium intake, requires further study.
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Affiliation(s)
- Jeffrey H William
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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20
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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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21
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Abstract
Adverse drug reactions (ADRs) represent an important risk for patients and have a significant economic impact on health systems. ADRs are the fifth most common cause of hospital death, with a burden estimated at 197,000 deaths per year in the EU. This has a societal cost of <euro>79 billion per year. Because of this strong impact in public health, regulatory authorities (RAs) worldwide are implementing new pharmacovigilance legislation to promote and protect public health by reducing the burden of ADRs through the detection of safety signals. Although, traditionally, signal detection activities have mainly been performed based on spontaneous reporting from healthcare professionals and national health RAs, the new pharmacovigilance legislation underlines the relevance of other sources of information (such as scientific literature) for the evaluation of the benefit-risk balance of a certain product. This review aims to highlight the relevance of periodic scientific literature screening in the safety signal detection process. The authors present four practical examples where a safety signal that was detected from a literature report had an impact on the lifecycle of a drug. In addition, based on practical experience of the screening of medical and scientific literature for safety purposes, this article analyses the requirements of the new pharmacovigilance guidelines on literature screening and highlights the need for the implementation of a literature review procedure and the main challenges encountered when performing literature screening for safety aspects.
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22
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Chen KP, Lee J, Mark RG, Feng M, Celi LA, Malley BE, Danziger J. Proton pump inhibitor use is not associated with cardiac arrhythmia in critically ill patients. J Clin Pharmacol 2015; 55:774-9. [PMID: 25655574 DOI: 10.1002/jcph.479] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/05/2015] [Accepted: 02/05/2015] [Indexed: 02/06/2023]
Abstract
Hypomagnesemia can lead to cardiac arrythmias. Recently, observational data have linked chronic proton pump inhibitor (PPI) exposure to hypomagnesemia. Whether PPI exposure increases the risk for arrhythmias has not been well studied. Using a large, single-center inception cohort of critically ill patients, we examined whether PPI exposure was associated with admission electrocardiogram readings of a cardiac arrhythmia in more than 8000 patients. There were 25.4% PPI users, whereas 6% were taking a histamine 2 antagonist. In all, 14.0% had a cardiac arrhythmia. PPI use was associated with an unadjusted risk of arrhythmia of 1.15 (95% CI,1.00-1.32; P =.04) and an adjusted risk of arrhythmia of 0.91 (95% CI, 0.77-1.06; P =.22). Among diuretic users (n = 2476), PPI use was similarly not associated with an increased risk of cardiac arrhythmia. In summary, in a large cohort of critically ill patients, PPI exposure is not associated with an increased risk of cardiac arrhythmia.
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Affiliation(s)
- Kenneth P Chen
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joon Lee
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Roger G Mark
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Mengling Feng
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Leo A Celi
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Brian E Malley
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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23
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Lindner G, Funk GC, Leichtle AB, Fiedler GM, Schwarz C, Eleftheriadis T, Pasch A, Mohaupt MG, Exadaktylos AK, Arampatzis S. Impact of proton pump inhibitor use on magnesium homoeostasis: a cross-sectional study in a tertiary emergency department. Int J Clin Pract 2014; 68:1352-7. [PMID: 24898571 DOI: 10.1111/ijcp.12469] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 05/01/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND To date, the use of proton pump inhibitors (PPIs) has been associated with a low risk of hypomagnesaemia and associated adverse outcomes. We hypothesised that a better risk estimate could be derived from a large cohort of outpatients admitted to a tertiary emergency department (ED). METHODS A cross-sectional study was performed in 5118 patients who had measurements of serum magnesium taken on admission to a large tertiary care ED between January 2009 and December 2010. Hypomagnesaemia was defined as a serum magnesium concentration < 0.75 mmol/l. Demographical data, serum electrolyte values, data on medication, comorbidities and outcome with regard to length of hospital stay and mortality were analysed. RESULTS Serum magnesium was normally distributed where upon 1246 patients (24%) were hypomagnesaemic. These patients had a higher prevalence of out-of-hospital PPI use and diuretic use when compared with patients with magnesium levels > 0.75 mmol/l (both p < 0.0001). In multivariable regression analyses adjusted for PPIs, diuretics, renal function and the Charlson comorbidity index score, the association between use of PPIs and risk for hypomagnesaemia remained significant (OR = 2.1; 95% CI: 1.54-2.85). While mortality was not directly related to low magnesium levels (p = 0.67), the length of hospitalisation was prolonged in these patients even after adjustment for underlying comorbid conditions (p < 0.0001). CONCLUSION Use of PPIs predisposes patients to hypomagnesaemia and such to prolonged hospitalisation irrespective of the underlying morbidity, posing a critical concern.
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Affiliation(s)
- G Lindner
- Department of Emergency Medicine, Inselspital University of Bern, Bern, Switzerland
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24
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Zipursky J, Macdonald EM, Hollands S, Gomes T, Mamdani MM, Paterson JM, Lathia N, Juurlink DN. Proton pump inhibitors and hospitalization with hypomagnesemia: a population-based case-control study. PLoS Med 2014; 11:e1001736. [PMID: 25268962 PMCID: PMC4181956 DOI: 10.1371/journal.pmed.1001736] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 08/12/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Some evidence suggests that proton pump inhibitors (PPIs) are an under-appreciated risk factor for hypomagnesemia. Whether hospitalization with hypomagnesemia is associated with use of PPIs is unknown. METHODS AND FINDINGS We conducted a population-based case-control study of multiple health care databases in Ontario, Canada, from April 2002 to March 2012. Patients who were enrolled as cases were Ontarians aged 66 years or older hospitalized with hypomagnesemia. For each individual enrolled as a case, we identified up to four individuals as controls matched on age, sex, kidney disease, and use of various diuretic classes. Exposure to PPIs was categorized according to the most proximate prescription prior to the index date as current (within 90 days), recent (within 91 to 180 days), or remote (within 181 to 365 days). We used conditional logistic regression to estimate the odds ratio for the association of outpatient PPI use and hospitalization with hypomagnesemia. To test the specificity of our findings we examined use of histamine H2 receptor antagonists, drugs with no causal link to hypomagnesemia. We studied 366 patients hospitalized with hypomagnesemia and 1,464 matched controls. Current PPI use was associated with a 43% increased risk of hypomagnesemia (adjusted odds ratio, 1.43; 95% CI 1.06-1.93). In a stratified analysis, the risk was particularly increased among patients receiving diuretics, (adjusted odds ratio, 1.73; 95% CI 1.11-2.70) and not significant among patients not receiving diuretics (adjusted odds ratio, 1.25; 95% CI 0.81-1.91). We estimate that one excess hospitalization with hypomagnesemia will occur among 76,591 outpatients treated with a PPI for 90 days. Hospitalization with hypomagnesemia was not associated with the use of histamine H2 receptor antagonists (adjusted odds ratio 1.06; 95% CI 0.54-2.06). Limitations of this study include a lack of access to serum magnesium levels, uncertainty regarding diagnostic coding of hypomagnesemia, and generalizability of our findings to younger patients. CONCLUSIONS PPIs are associated with a small increased risk of hospitalization with hypomagnesemia among patients also receiving diuretics. Physicians should be aware of this association, particularly for patients with hypomagnesemia. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erin M. Macdonald
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Simon Hollands
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad M. Mamdani
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
- King Saud University, Riyadh, Saudi Arabia
| | - J. Michael Paterson
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada, Canada
| | - Nina Lathia
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - David N. Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- * E-mail:
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25
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Toh JWT, Ong E, Wilson R. Hypomagnesaemia associated with long-term use of proton pump inhibitors. Gastroenterol Rep (Oxf) 2014; 3:243-53. [PMID: 25138239 PMCID: PMC4527261 DOI: 10.1093/gastro/gou054] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 07/15/2014] [Indexed: 12/13/2022] Open
Abstract
Hypomagnesaemia and associated hypocalcaemia and hypoparathyroidism have been increasingly recognised as rare long-term side-effects of proton pump inhibitors (PPIs). The PPIs may inhibit active magnesium (Mg) absorption by interfering with transcellular transient receptor potential melastatin-6 and -7 (TRPM 6 and 7) channels. More recent cell culture studies have suggested concomitant inhibition of passive Mg absorption by omeprazole. After being treated with a range of PPIs, the four patients in our case series developed hypomagnesaemia, which responded to withdrawal of therapy and initiation of Mg replacement. Their clinical course and management demonstrate key aspects of hypomagnesaemia associated with long-term use of PPIs.
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Affiliation(s)
- James Wei Tatt Toh
- General Surgery, Liverpool Hospital, University of New South Wales, Liverpool, New South Wales, Australia,
| | - Evonne Ong
- University of New South Wales Clinical School, Liverpool, New South Wales, Australia and
| | - Robert Wilson
- Upper Gastrointestinal Surgery, Liverpool Hospital, University of New South Wales, Liverpool, New South Wales, Australia
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26
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Wang AK, Sharma S, Kim P, Mrejen-Shakin K. Hypomagnesemia in the intensive care unit: Choosing your gastrointestinal prophylaxis, a case report and review of the literature. Indian J Crit Care Med 2014; 18:456-60. [PMID: 25097359 PMCID: PMC4118512 DOI: 10.4103/0972-5229.136075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We report a case of symptomatic hypomagnesaemia in medical intensive care unit that is strongly related to proton pump inhibitors (PPIs) and provide literature review. A 65-year-old male with severe gastroesophageal reflux on omeprazole 20 mg orally twice a day, who presented to the hospital with abdominal pain, nausea, diarrhea, and new onset seizures. On admission, his serum magnesium level was undetectable. Electrocardiogram showed a new right bundle branch block with a prolonged QT interval. The hypomagnesemia was corrected with aggressive magnesium supplementation and hypomagnesemia resolved only after the PPI was stopped. Neurologic and cardiac abnormalities were corrected. This is a life-threatening case of an undetectable magnesium level strongly associated with PPI use. In critically, ill patients with refractory hypomagnesemia, we advocate considering changing gastrointestinal prophylaxis from a PPI to a histamine-receptor blocker.
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Affiliation(s)
- Aileen K Wang
- Department of Medicine, Queens Hospital Center, Mount Sinai School of Medicine, Jamaica, NY, USA
| | - Shweta Sharma
- Department of Medicine, Queens Hospital Center, Mount Sinai School of Medicine, Jamaica, NY, USA
| | - Paul Kim
- Department of Medicine, Queens Hospital Center, Mount Sinai School of Medicine, Jamaica, NY, USA
| | - Karen Mrejen-Shakin
- Department of Medicine, Queens Hospital Center, Mount Sinai School of Medicine, Jamaica, NY, USA
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27
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Markovits N, Loebstein R, Halkin H, Bialik M, Landes-Westerman J, Lomnicky J, Kurnik D. The association of proton pump inhibitors and hypomagnesemia in the community setting. J Clin Pharmacol 2014; 54:889-95. [PMID: 24771616 DOI: 10.1002/jcph.316] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 02/06/2023]
Abstract
Evidence for the association between hypomagnesemia and proton pump inhibitors (PPIs), highlighted by the 2011 FDA Drug Safety Communication, rests mainly on studies in hospitalized patients. Our objectives were to determine the prevalence of hypomagnesemia and its association with PPIs in the community setting. We performed a retrospective cross-sectional analysis of a large health maintenance organization administrative database, including ambulatory patients with ≥1 serum magnesium concentrations between 2008 and 2011, the lowest referred to as "index magnesium." In cases with any (index magnesium ≤0.7 mmol/L) or severe (≤0.55 mmol/L) hypomagnesemia, we analyzed (vs. controls, >0.7 mmol/L) the association with PPI or H2 -blocker use during the 4-12 months preceding the index magnesium by logistic regression analysis, adjusting for confounders. Among 95,205 subjects, 5,696 (6.0%) had any hypomagnesemia, which was severe in 454 (0.5%), with twofold higher prevalences in those with established risk factors. PPI use during the 4 months preceding the index magnesium was more common in cases of any hypomagnesemia (adjusted OR = 1.66; 95% CI, 1.55-1.78) and severe hypomagnesemia (adjusted OR = 3.79; 2.99-4.82) than in controls without acid suppression. Hypomagnesemia remained significantly associated with PPI use when using H2 -blocker-users as reference (adjusted OR = 1.25 [P = 0.003] and 2.65 [P < 0.001] for any and severe hypomagnesemia, respectively). We conclude that hypomagnesemia is associated with PPI use in ambulatory patients.
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Affiliation(s)
- Noa Markovits
- Department of Pharmacy and Clinical Pharmacology, Maccabi Healthcare Services, Tel Aviv, Israel; Institute of Clinical Pharmacology, Sheba Medical Center, Tel Hashomer, Israel
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28
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Wilhelm SM, Rjater RG, Kale-Pradhan PB. Perils and pitfalls of long-term effects of proton pump inhibitors. Expert Rev Clin Pharmacol 2014; 6:443-51. [PMID: 23927671 DOI: 10.1586/17512433.2013.811206] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This review summarizes the literature regarding long-term adverse effects of proton pump inhibitors (PPIs). A PubMed search (1966 to February 2013) for English language studies was conducted using key terms PPI: omeprazole, esomeprazole, pantoprazole, lansoprazole, dexlansoprazole, rabeprazole, pneumonia, Clostridium difficile, osteoporosis, risk of fractures, thrombocytopenia, rhabdomyolysis, anemia, iron deficiency, hypomagnesemia, vitamin B₁₂ and nephritis. The risk of pneumonia was increased 27-39% in short-term use of PPIs in three meta-analyses. C. difficile infections were also associated with the use of PPIs (odds ratio: 2.15; 95% CI: 1.81-2.55; p < 0.00001). This effect appears to be dose related. The US FDA has recently issued a warning regarding fractures and the impaired magnesium absorption associated with the use of PPI. Thrombocytopenia, iron deficiency, vitamin B12 deficiency, rhabdomyolysis and acute interstitial nephritis have also been reported with the use of PPIs. There is mounting evidence that PPIs are associated with serious adverse effects. Practitioners should be vigilant and counsel patients accordingly.
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Affiliation(s)
- Sheila M Wilhelm
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
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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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Thongon N, Ketkeaw P, Nuekchob C. The roles of acid-sensing ion channel 1a and ovarian cancer G protein-coupled receptor 1 on passive Mg2+ transport across intestinal epithelium-like Caco-2 monolayers. J Physiol Sci 2014; 64:129-39. [PMID: 24375028 PMCID: PMC10717441 DOI: 10.1007/s12576-013-0301-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 12/10/2013] [Indexed: 02/06/2023]
Abstract
Intestinal passive Mg(2+) absorption, which is vital for normal Mg(2+) homeostasis, has been shown to be regulated by luminal proton. We aimed to study the regulatory role of intestinal acid sensors in paracellular passive Mg(2+) transport. Omeprazole enhanced the expressions of acid-sensing ion channel 1a (ASIC1a), ovarian cancer G protein-coupled receptor 1 (OGR1), and transient receptor potential vanilloid 4 in Caco-2 cells. It also inhibited passive Mg(2+) transport across Caco-2 monolayers. The expression and activation of OGR1 resulted in the stimulation of passive Mg(2+) transport via phospholipase C- and protein kinase C-dependent pathways. ASIC1a activation, on the other hand, enhanced apical HCO3 (-) secretion that led, at least in part, by a Ca(2+)-dependent pathway to an inhibition of paracellular Mg(2+) absorption. Our results provided supporting evidence for the roles of OGR1 and ASIC1a in the regulation of intestinal passive Mg(2+) absorption.
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Affiliation(s)
- Narongrit Thongon
- Division of Physiology, Department of Biomedical Sciences, Faculty of Allied Health Sciences, Burapha University, 169 Long-Hard Bangsaen Rd., Saensook, Muang, Chonburi, 20131, Thailand,
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Takeda Y, Doyama H, Tsuji K, Yamada S, Takemura K. Does long-term use of proton pump inhibitors cause hypomagnesaemia in Japanese outpatients? BMJ Open Gastroenterol 2014; 1:e000003. [PMID: 26462261 PMCID: PMC4533322 DOI: 10.1136/bmjgast-2014-000003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 09/10/2014] [Accepted: 09/19/2014] [Indexed: 11/17/2022] Open
Abstract
Aim Hypomagnesaemia has been reported associated with long-term proton pump inhibitor (PPI) treatment. However, there have been no studies in Japanese patients. We therefore assessed the effects of long-term PPI use on serum magnesium concentrations in Japanese patients. Methods Data from 481 outpatients who visited our centre in October and November 2011 were reviewed to determine their underlying diseases, oral medications, including PPIs, and serum magnesium concentrations. The association between PPI use and serum Mg concentrations was assessed by multiple linear regression analysis. Results Serum magnesium concentrations were significantly lower in PPI users (n=199) than in PPI non-users (n=282; 1.86±0.21 vs 1.91±0.19 mg/dL, p<0.01). Multiple linear regression analysis showed that the presence or absence of cirrhosis and PPI use was a significant predictor of magnesium concentration. In evaluating magnesium concentrations among PPI users and non-users with and without cirrhosis, we found that mean serum magnesium concentrations in patients with cirrhosis were significantly lower in PPI users than non-users (1.78±0.22 vs 1.87±0.22 mg/dL, p=0.03). Conclusions Outpatients receiving long-term PPI treatment had significantly lower serum magnesium concentrations than those not treated with PPI. To the best of our knowledge, this study is the first to show hypomagnesaemia in Japanese patients with cirrhosis receiving long-term PPI treatment.
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Affiliation(s)
- Yasuhito Takeda
- Department of Gastroenterology , Ishikawa Prefectural Central Hospital , Ishikawa , Japan
| | - Hisashi Doyama
- Department of Gastroenterology , Ishikawa Prefectural Central Hospital , Ishikawa , Japan
| | - Kunihiro Tsuji
- Department of Gastroenterology , Ishikawa Prefectural Central Hospital , Ishikawa , Japan
| | - Shinya Yamada
- Department of Gastroenterology , Ishikawa Prefectural Central Hospital , Ishikawa , Japan
| | - Kenichi Takemura
- Department of Gastroenterology , Ishikawa Prefectural Central Hospital , Ishikawa , Japan
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Famularo G, Gasbarrone L, Minisola G. Hypomagnesemia and proton-pump inhibitors. Expert Opin Drug Saf 2013; 12:709-16. [PMID: 23808631 DOI: 10.1517/14740338.2013.809062] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) have been linked to clinically symptomatic hypomagnesemia. AREAS COVERED We searched Medline database in all languages using 'proton-pump inhibitors, magnesium, hypomagnesemia and hypomagnesemic hypoparathyroidism' as search terms and other articles were identified through searches of the files of the authors and reference lists from relevant articles. All patients presented with hypomagnesemic hypoparathyroidism, however, they rarely had life-threatening conditions such as malignant ventricular arrhythmias associated with prolonged QT interval, tetany and generalized seizures. Hypomagnesemia was seen with different PPIs, which could suggest a class effect, and was refractory to Mg replacement until PPIs were stopped. Hypomagnesemia may recur after re-challenge with the same or a different PPI and is not clearly dose-related. Mechanisms are poorly understood but PPI-induced hypochlorhydria does not seem involved. Carriers of TRPM6/7 mutations could be at risk. EXPERT OPINION Although mechanism and incidence rate remain unclear, there seems little doubt that PPIs may cause hypomagnesemia. We should obtain blood Mg levels prior to initiation of PPIs when patients are expected to be on treatment for long period of time and in those with other potential causes of hypomagnesemia. Use of H2-blockers may be an appropriate alternative.
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El-Charabaty E, Saifan C, Abdallah M, Naboush A, Glass D, Azzi G, Azzi Y, Khan A, Baydoun H, Rondla C, Parekh N, El-Sayegh S. Effects of proton pump inhibitors and electrolyte disturbances on arrhythmias. Int J Gen Med 2013; 6:515-8. [PMID: 23847429 PMCID: PMC3700779 DOI: 10.2147/ijgm.s46932] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Several case reports have been written regarding the relationship between the use of proton pump inhibitors (PPI) and hypomagnesemia. Some of these reported cases have electrocardiogram abnormalities where electrolytes deficiencies were the contributing factor for these events. This study investigates the correlation between different arrhythmias and the use of PPI and hypomagnesaemia incidence. Four-hundred and twenty-one patients admitted to the critical care unit with unstable angina, non-ST elevation myocardial infarction, and ST-elevation myocardial infarction were included in this study. One-hundred and eighty-four patients (43.8%) received PPI and 237 patients (51.16%) did not, magnesium levels were low (<1.8 mg/dL) in 95 patients (22.5%), and 167 patients (39.6%) developed arrhythmias. The P-values for the regression coefficient association for the use of PPI and the level of magnesium were P = 1.31e(-29) and P = 8e(-102), respectively. The P-values indicate that there is a statistically significant association between the PPI use, magnesium levels, and the occurrence of cardiovascular events, with a strong correlation factor of 0.817. Patients receiving PPIs should be followed closely for magnesium deficiency, especially if they experience acute cardiovascular events, because this may contribute to worsening arrhythmias and further complications.
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Affiliation(s)
- Elie El-Charabaty
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
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Tjon JA, Pe M, Soscia J, Mahant S. Efficacy and safety of proton pump inhibitors in the management of pediatric gastroesophageal reflux disease. Pharmacotherapy 2013; 33:956-71. [PMID: 23712734 DOI: 10.1002/phar.1299] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Proton pump inhibitors (PPIs) are commonly prescribed to infants and children for managing gastroesophageal reflux disease (GERD). Recently published literature illustrates conflicting evidence on the efficacy of PPIs in infants and children. Randomized controlled trials and systematic reviews have demonstrated a lack of efficacy of PPIs, specifically in young infants. Furthermore, emerging evidence also suggests that PPIs are not as benign as once thought, with newer data implicating a potential association of PPIs with an increased risk of respiratory tract infections, gastrointestinal infections, bone fractures, hypomagnesemia, and the occurrence of rebound hyperacidity after discontinuation of PPI therapy. To summarize the emerging data in children, we reviewed the literature to assess the efficacy and safety of PPIs in managing pediatric GERD. Despite conflicting evidence on the efficacy of PPIs, most studies in children demonstrated some benefit when compared with placebo. With respect to the safety of PPIs in children, only a few small studies and case reports indicated a potential association of PPIs with an increased risk of respiratory tract or gastrointestinal infections, bone fractures, and hypomagnesemia; however, many of those studies had their own limitations. From the review, it is clear that further well-designed trials and observational studies are needed to shed more light on the efficacy and safety of PPIs in the pediatric population.
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Affiliation(s)
- James A Tjon
- Division of Pediatric Medicine, Department of Pharmacy, Hospital for Sick Children, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Koulouridis I, Alfayez M, Tighiouart H, Madias NE, Kent DM, Paulus JK, Jaber BL. Out-of-hospital use of proton pump inhibitors and hypomagnesemia at hospital admission: a nested case-control study. Am J Kidney Dis 2013; 62:730-7. [PMID: 23664547 DOI: 10.1053/j.ajkd.2013.02.373] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 02/26/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND Case series suggest that long-term use of proton pump inhibitors (PPIs) is associated with hypomagnesemia, but the current literature lacks systematically collected data. Our aim was to examine whether hypomagnesemia at the time of hospital admission is associated with out-of-hospital use of PPIs. STUDY DESIGN Nested case-control study matched for age and sex. SETTING & PARTICIPANTS Data were collected retrospectively from a tertiary acute-care facility. Eligible cases consisted of 402 adults with hypomagnesemia (serum magnesium <1.4 mEq/L) at the time of hospital admission to medical services, age- and sex-matched with 402 control individuals with normal serum magnesium levels (1.4-2.0 mEq/L). PREDICTOR Out-of-hospital PPI use was identified in the hospital record. An omeprazole equivalent dose was calculated when possible. Covariates included the Charlson-Deyo comorbidity index, diabetes, diuretic use, estimated glomerular filtration rate, and gastroesophageal reflux. OUTCOME Multivariable conditional logistic regression analyses were used to examine the association of PPI use with hypomagnesemia at the time of hospital admission. RESULTS PPI use was not associated with hypomagnesemia (adjusted OR, 0.82; 95% CI, 0.61-1.11). Neither PPI type nor omeprazole equivalent daily dose was associated with hypomagnesemia. Sensitivity analyses of PPI use restricted to patients with esophageal disorders (adjusted OR, 1.00; 95% CI, 0.69-1.45), severe hypomagnesemia (magnesium, ≤1.0 mEq/L; adjusted OR, 0.78; 95% CI, 0.13-4.61), or estimated glomerular filtration rate ≥60 mL/min/1.73 m(2) (adjusted OR, 0.84; 95% CI, 0.53-1.34) were unrevealing. LIMITATIONS Exposure misclassification; hospitalized patients on medical services may not be representative of a broader ambulatory-based population. CONCLUSIONS In a hospital-based adult population, out-of-hospital PPI use is not associated with hypomagnesemia at the time of hospital admission to medical services. In light of these inconclusive results, prospective cohort studies are needed to address this rare potential medication-related adverse effect.
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Affiliation(s)
- Ioannis Koulouridis
- Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St. Elizabeth's Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
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Faulhaber GAM, Ascoli BM, Lubini A, Mossmann M, Rossi G, Geib G, Furlanetto TW. Serum magnesium and proton-pump inhibitors use: a cross-sectional study. Rev Assoc Med Bras (1992) 2013; 59:276-9. [DOI: 10.1016/j.ramb.2012.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 11/04/2012] [Accepted: 12/02/2012] [Indexed: 12/12/2022] Open
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Increasingly hard to swallow--18 years of changing tonsillectomy practice in Northern Ireland. THE ULSTER MEDICAL JOURNAL 2013; 82:121-5. [PMID: 24082292 PMCID: PMC3756871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Luk CP, Parsons R, Lee YP, Hughes JD. Proton pump inhibitor-associated hypomagnesemia: what do FDA data tell us? Ann Pharmacother 2013; 47:773-80. [PMID: 23632281 DOI: 10.1345/aph.1r556] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are a class of medications indicated for the treatment of gastric acid-related diseases. Hypomagnesemia is a rare but serious adverse effect of PPIs. OBJECTIVE To address the association between the use of different PPIs and hypomagnesemia by examining the frequency of occurrence of hypo magnesemia among the reported adverse drug reactions from the Food and Drug Administration (FDA) Adverse Event Reporting System database. METHODS We conducted a cross-sectional study of PPI-associated adverse effect cases reported to the FDA between November 1, 1997, and April 1, 2012. Logistic regression was used to examine the association of sex, age, and different PPIs with hypomagnesemia. χ² analysis was conducted to investigate the association of PPI-associated hypomagnesemia with hypocalcemia and hypokalemia. RESULTS Among 66,102 subjects identified as experiencing 1 or more adverse effects while taking a PPI, 1.0% (n = 693) were reported to have hypomagnesemia. The mean (SD) age of PPI users presenting with hypomagnesemia was 64.4 (12.9) years. Results from logistic regression indicated that, compared with esomeprazole, all other PPIs had a higher rate of hypomagnesemia, with pantoprazole having the highest rate (OR 4.3; 95% CI 3.3-5.7; p < 0.001). The risk of female subjects having hypo magnesemia (OR 0.83; 95% CI 0.71-0.97; p = 0.016) was significantly lower than that of males. Elderly subjects (age >65 years) were at increased risk of PPI-associated hypomagnesemia (OR 1.5; 95% CI 1.2-1.7; p < 0.001). χ² analysis showed strong association between hypomagnesemia and both hypocalcemia (p < 0.001) and hypokalemia (p < 0.001). CONCLUSIONS All PPIs were associated with hypomagnesemia, with esomeprazole having the lowest risk and pantoprazole having the highest risk. The risk of PPI-associated hypomagnesemia was higher in males and the elderly population. Hypocalcemia and hypokalemia commonly coexisted with PPI-associated hypomagnesemia.
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Affiliation(s)
- Chee Phun Luk
- School of Pharmacy, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia
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Danziger J, William JH, Scott DJ, Lee J, Lehman LW, Mark RG, Howell MD, Celi LA, Mukamal KJ. Proton-pump inhibitor use is associated with low serum magnesium concentrations. Kidney Int 2013; 83:692-9. [PMID: 23325090 DOI: 10.1038/ki.2012.452] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although case reports link proton-pump inhibitor (PPI) use and hypomagnesemia, no large-scale studies have been conducted. Here we examined the serum magnesium concentration and the likelihood of hypomagnesemia (<1.6 mg/dl) with a history of PPI or histamine-2 receptor antagonist used to reduce gastric acid, or use of neither among 11,490 consecutive adult admissions to an intensive care unit of a tertiary medical center. Of these, 2632 patients reported PPI use prior to admission, while 657 patients were using a histamine-2 receptor antagonist. PPI use was associated with 0.012 mg/dl lower adjusted serum magnesium concentration compared to users of no acid-suppressive medications, but this effect was restricted to those patients taking diuretics. Among the 3286 patients concurrently on diuretics, PPI use was associated with a significant increase of hypomagnesemia (odds ratio 1.54) and 0.028 mg/dl lower serum magnesium concentration. Among those not using diuretics, PPI use was not associated with serum magnesium levels. Histamine-2 receptor antagonist use was not significantly associated with magnesium concentration without or with diuretic use. The use of PPI was not associated with serum phosphate concentration regardless of diuretic use. Thus, we verify case reports of the association between PPI use and hypomagnesemia in those concurrently taking diuretics. Hence, serum magnesium concentrations should be followed in susceptible individuals on chronic PPI therapy.
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Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Florentin M, Elisaf MS. Proton pump inhibitor-induced hypomagnesemia: A new challenge. World J Nephrol 2012; 1:151-4. [PMID: 24175253 PMCID: PMC3782221 DOI: 10.5527/wjn.v1.i6.151] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 05/27/2012] [Accepted: 09/25/2012] [Indexed: 02/06/2023] Open
Abstract
Proton pump inhibitors (PPIs) are commonly used in clinical practice for the prevention and treatment of peptic ulcer, gastritis, esophagitis and gastroesophageal reflux. Hypomagnesemia has recently been recognized as a side effect of PPIs. Low magnesium levels may cause symptoms from several systems, some of which being potentially serious, such as tetany, seizures and arrhythmias. It seems that PPIs affect the gastrointestinal absorption of magnesium. Clinicians should be vigilant in order to timely consider and prevent or reverse hypomagnesemia in patients who take PPIs, especially if they are prone to this electrolyte disorder.
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Affiliation(s)
- Matilda Florentin
- Matilda Florentin, Moses S Elisaf, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina 45110, Greece
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Thongon N, Krishnamra N. Apical acidity decreases inhibitory effect of omeprazole on Mg(2+) absorption and claudin-7 and -12 expression in Caco-2 monolayers. Exp Mol Med 2012; 44:684-93. [PMID: 22940736 PMCID: PMC3509185 DOI: 10.3858/emm.2012.44.11.077] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Clinical studies reported hypomagnesaemia in long-term omeprazole usage that was probably due to intestinal Mg(2+) wasting. Our previous report demonstrated the inhibitory effect of omeprazole on passive Mg(2+) transport across Caco-2 monolayers. The present study aimed to identify the underlying mechanism of omeprazole suppression of passive Mg(2+) absorption. By using Caco-2 monolayers, we demonstrated a potent inhibitory effect of omeprazole on passive Mg(2+), but not Ca(2+), transport across Caco-2 monolayers. Omeprazole shifted the %maximum passive Mg(2+) transport-Mg(2+) concentration curves to the right, and increased the half maximal effective concentration of those dose-response curves, indicating a lower Mg(2+) affinity of the paracellular channel. By continually monitoring the apical pH, we showed that omeprazole suppressed apical acid accumulation. Neomycin and spermine had no effect on passive Mg(2+) transport of either control or omeprazole treated monolayers, indicating that omeprazole suppressed passive Mg(2+) transport in a calcium sensing receptor (CaSR)-independent manner. The results of western blot analysis showed that omeprazole significantly suppressed claudin (Cldn)-7 and -12, but not Cldn-2, expression in Caco-2 cells. By using apical solution of pH 5.5, 6.0, 6.5, and 7.0, we found that apical acidity markedly increased passive Mg(2+) transport, Mg(2+) affinity of the paracellular channel, and Cldn-7 and -12 expression in Caco-2 monolayers. Apical acidity abolished the inhibitory effect of omeprazole on passive Mg(2+) transport and Cldn-7 and -12 expression. Our results provided the evidence for the regulation of intestinal passive Mg(2+) absorption by luminal acidity-induced increase in Cldn-7 and -12 expression.
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Affiliation(s)
- Narongrit Thongon
- Faculty of Allied Health Sciences Burapha University Chonburi 20131, Thailand.
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Bai JPF, Hausman E, Lionberger R, Zhang X. Modeling and simulation of the effect of proton pump inhibitors on magnesium homeostasis. 1. Oral absorption of magnesium. Mol Pharm 2012; 9:3495-505. [PMID: 23051182 DOI: 10.1021/mp300323q] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prolonged use of proton pump inhibitors has reportedly caused rare clinically symptomatic hypomagnesemia. A review of the literature suggests PPI drugs may impair intestinal magnesium absorption. With the goal of preventing PPI-induced hypomagnesemia, an oral absorption-centric model was developed by referencing literature data. Our modeling with human data reveals that magnesium absorption is substantial in the distal intestine. We then perform simulations by referring to the reported reduction in mid to distal intestinal pH caused by one week of oral esomeprazole, and to reported reduction of the divalent cation-sensitive current when the carboxyl side chains of glutamic and aspartic residues in the binding channels of TRPM6/TRPM7 were neutralized. Our simulations reveal that short-term PPI therapy may cause a very small reduction (5%) in the serum magnesium level, which is qualitatively consistent with the reported 1% reduction in magnesium absorption following 1 week of omeprazole in humans. Simulations provide insight into the benefit of frequent but small dose of magnesium supplementation in maintaining the serum magnesium level when magnesium deficiency occurs.
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Affiliation(s)
- Jane P F Bai
- Office of Generic Drugs, Office of Pharmaceutical Science, §Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, and †Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation, Food and Drug Administration , Rockville, Maryland, United States
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Hess MW, Hoenderop JGJ, Bindels RJM, Drenth JPH. Systematic review: hypomagnesaemia induced by proton pump inhibition. Aliment Pharmacol Ther 2012; 36:405-13. [PMID: 22762246 DOI: 10.1111/j.1365-2036.2012.05201.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 05/14/2012] [Accepted: 06/10/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are a mainstay therapy for all gastric acid-related diseases. Clinical concerns arise from a small but growing number of case reports presenting PPI-induced hypomagnesaemia (PPIH) as a consequence of long-term PPI use. Current opinion is that reduced intestinal magnesium absorption might be involved, but nothing is known on the molecular mechanism underlying PPIH. AIM To investigate whether or not PPIH is a true, long-term drug-class effect of all PPIs and to scrutinise a possible role of comorbidity in its aetiology. Therefore, the primary objective in particular was to investigate serum magnesium dynamics in trials drug withdrawal and re-challenge. The secondary objective was to profile the 'patient at risk'. METHODS We reviewed systematically all currently available case reports on the subject and performed a statistical analysis on extracted data. RESULTS Proton pump inhibitor-induced hypomagnesaemia PPIH is a drug-class effect and occurred after 5.5 years (median) of PPI use, onset was broad and ranged from 14 days to 13 years. Discontinuation of PPIs resulted in fast recovery from PPIH in 4 days and re-challenge led to reoccurrence within 4 days. Histamine-2-receptor antagonists were the preferable replacement therapy in PPIH and prevented reoccurrence of hypomagnesaemia. In PPIH no specific risk profile was identified that was linked to the hypomagnesaemia. CONCLUSIONS The cases of PPIH show severe symptoms of magnesium depletion and identification of its causation was only possible through withdrawal of the PPI. Clinical awareness of PPIH is key to avoid putting patients at risk.
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Affiliation(s)
- M W Hess
- Department of Physiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Lefort A, Arlet P, Bagheri H, Campistron E. [Hypomagnesaemia and hypocalcemia-induced by omeprazole]. Therapie 2012; 67:191-2. [PMID: 22850108 DOI: 10.2515/therapie/2012027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 12/09/2011] [Indexed: 11/20/2022]
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Martínez Faedo C, Bellido Castañeda V, Riestra Fernández M. Hipomagnesemia severa refractaria a la suplementación oral asociada al tratamiento con omeprazol. ACTA ACUST UNITED AC 2012; 59:463-5. [DOI: 10.1016/j.endonu.2011.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/17/2011] [Accepted: 11/21/2011] [Indexed: 10/28/2022]
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von Rahden BHA, Scheurlen M, Filser J, Stein HJ, Germer CT. [Newly recognized side-effects of proton pump inhibitors. Arguments in favour of fundoplication for GERD?]. Chirurg 2012; 83:38-44. [PMID: 21909830 DOI: 10.1007/s00104-011-2173-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Among other indications proton pump inhibitors (PPIs) are used as medical treatment of gastroesophageal reflux disease (GERD) and are the most frequently prescribed and most frequently used drugs in gastroenterology. Until recently PPIs were regarded as very safe and associated with very few side-effects. However, during recent years study results have revealed many severe adverse events associated especially with long-term PPI use. We review the currently available evidence, regarding the side-effects of PPIs and discuss the potential impact on treatment strategies for GERD (conservative treatment vs. antireflux surgery). Currently available data suggest that PPIs are associated with osteoporosis-related fractures, Clostridium difficile associated diarrhea (CDAD), community and hospital-acquired pneumonia, pharmacologic interaction with clopidogrel and acetylsalicylic acid with subsequent increased rate of cardiovascular events, refractory hypomagnesemia and rebound reflux symptoms etc. The risk-benefit ratio of PPIs is increasingly recognized as being less favourable. This leads to a more critical viewpoint and raises the question whether the side-effects of PPIs may outweigh the benefits, especially with long-term use. The side-effects of PPIs seem to make a strong argument in favour of laparoscopic fundoplication in the treatment of GERD.
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Affiliation(s)
- B H A von Rahden
- Klinik für Allgemein-, Viszeral-, Gefäß und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland.
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Gau JT, Yang YX, Chen R, Kao TC. Uses of proton pump inhibitors and hypomagnesemia. Pharmacoepidemiol Drug Saf 2012; 21:553-9. [PMID: 22337212 DOI: 10.1002/pds.3224] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 01/02/2012] [Accepted: 01/04/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE Hypomagnesemia associated with proton pump inhibitor (PPI) therapy has been documented in case reports. We performed a cross-sectional study to examine the association between PPI use and serum magnesium (Mg) levels or hypomagnesemia. METHODS Data were extracted from hospitalized adults with basic metabolic panels and/or serum magnesium levels available during the hospital stays. The first Mg value was used for data analysis. Hypomagnesemia is defined as levels less than 1.7 mg/dL (or 0.70 mmol/L). Multiple linear and logistic regression analyses were used to assess the association between PPI use and Mg levels or hypomagnesemia, respectively. RESULTS Among study patients, PPI users (n = 207) had a mean Mg level of 1.91[SD = 0.34] mg/dL, and non-users (n = 280) 2.00 (0.30) mg/dL, p = 0.004. PPI use was associated with lower serum Mg levels (adjusted coefficient β = -0.10, 95% CI = [-0.16, -0.04]) after adjusting for confounders. PPI use was associated with risk of hypomagnesemia after adjusting for confounders (adjusted OR = 2.50, 95% CI = [1.43, 4.36]). Both standard (1) and high (2 or higher) defined daily dose units of PPI therapy were associated with hypomagnesemia. CONCLUSIONS PPI use was associated with lower serum Mg levels and hypomagnesemia in a population of hospitalized adult patients. Our study supports the general notion that long-term PPI use could be associated with sub-clinical Mg insufficiency or deficiency status.
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Affiliation(s)
- Jen-Tzer Gau
- Department of Geriatric Medicine/Gerontology, Ohio University Heritage College of Osteopathic Medicine (OU-HCOM), Athens, OH 45701, USA.
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Abstract
There have been recent concerns about the safety of proton pump inhibitors (PPIs). We focus here on 3 specific concerns-the possible interaction between PPIs and clopidogrel, the postulated link between PPI use and fractures, and the possibility that long-term PPI use might lead to hypomagnesemia. There is evidence for an in vitro interaction between clopidogrel and at least some PPIs. The Food and Drug Administration (FDA) has warned against the use of certain PPIs by patients on clopidogrel. However, a randomized controlled trial that compared clopidogrel alone with the combination of clopidogrel and omeprazole found no increase in adverse cardiovascular outcomes and a reduction in the rate of adverse gastrointestinal outcomes attributable to omeprazole. PPI use may be a weak risk factor for certain fractures, but the quality of evidence is relatively poor and there is a strong possibility of confounding. The mechanism whereby PPI use might increase fracture risk is unknown. Currently, no additional measures concerning calcium supplementation or bone mineral density monitoring are recommended for patients on a PPI. The FDA has suggested monitoring serum magnesium levels in patients on PPI therapy. The mechanism and frequency of PPI-induced hypomagnesemia are unclear. PPI treatment should not be withheld from patients who genuinely require it, but the PPI should be taken in the lowest effective dose and only for as long as clinically indicated. The same is, of course, true for all medicines. The benefits of PPI therapy greatly outweigh the risks.
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Matsuyama J, Tsuji K, Doyama H, Kim F, Takeda Y, Kito Y, Ito R, Nakanishi H, Hayashi T, Waseda Y, Tsuji S, Takemura K, Yamada S, Okada T, Kanaya H. Hypomagnesemia associated with a proton pump inhibitor. Intern Med 2012; 51:2231-4. [PMID: 22892510 DOI: 10.2169/internalmedicine.51.7748] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Severe hypomagnesemia is a serious clinical condition. Proton pump inhibitor (PPI) induced hypomagnesemia has been recognized since 2006. In March 2011 the U.S. Food and Drug Administration advised that long-term use of PPI can induce hypomagnesemia. We report the first Japanese case of hypomagnesemia associated with chronic use of PPIs in a 64-year-old man hospitalized for nausea, bilateral ankle arthritis, and tremor of the extremities who had convulsions 3 days after admission. Blood analysis showed severe hypomagnesemia. He had been taking rabeprazole (10 mg/day) for 5 years. After stopping rabeprazole and correcting the electrolytes imbalances, his symptoms improved without recurrence.
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Affiliation(s)
- Jun Matsuyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Japan
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Tamura T, Sakaeda T, Kadoyama K, Okuno Y. Omeprazole- and esomeprazole-associated hypomagnesaemia: data mining of the public version of the FDA Adverse Event Reporting System. Int J Med Sci 2012; 9:322-6. [PMID: 22745572 PMCID: PMC3384913 DOI: 10.7150/ijms.4397] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 06/10/2012] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Case reports showing that proton-pump inhibitors (PPIs), omeprazole and esomeprazole, can cause hypomagnesaemia have been accumulating since 2006. In this study, the reports submitted to the Adverse Event Reporting System (AERS) of the US Food and Drug Administration (FDA) were evaluated to assess omeprazole and esomeprazole in terms of susceptibility to hypomagnesaemia. METHODS After a revision of arbitrary drug names and the deletion of duplicated submissions, the reports involving omeprazole and esomeprazole were analyzed. Standardized official pharmacovigilance tools were used for the quantitative detection of a signal, i.e., an association between a drug and an adverse drug event, including the proportional reporting ratio, the reporting odds ratio, the information component given by a Bayesian confidence propagation neural network, and the empirical Bayes geometric mean. RESULTS A total of 22,017,956 co-occurrences were found in 1,644,220 reports from 2004 to 2009, where a co-occurrence was a pair of a drug and an adverse drug event. In total, 818 and 743 adverse drug events were listed as omeprazole- and esomeprazole-associated, with hypomagnesaemia ranking 85th and 135th, respectively. Although both PPIs were associated with hypomagnesaemia, the statistical metrics suggested that the association was more noteworthy for omeprazole. CONCLUSION The data obtained in this study do not provide sufficient evidence to recommend systematic monitoring of magnesium levels in plasma, but chronic exposure to a PPI can lead to severe hypomagnesaemia.
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