An evaluation of the importance of gastric acid secretion in the absorption of dietary calcium

Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement

Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.

CYP2C19 genotypes and osteoporotic fractures in long-term users of proton pump inhibitors: A hospital-based study

Proton pump inhibitors (PPIs) are commonly prescribed medications. The existing data suggest that individuals at a high risk of fractures have been exposed to high doses of PPIs for prolonged durations. CYP2C19 plays a pivotal role in metabolism of PPIs and thereby influences their pharmacokinetic profile. Hence, we hypothesize that CYP2C19 genotypes may be associated with fragility fracture among PPIs users due to PPI exposure. This study aimed to investigate the association between CYP2C19 genotypes, bone mineral density (BMD), and osteoporotic fracture in a hospital-based population. This retrospective cohort study enrolled patients who were prescribed long-term PPIs at Taichung Veterans General Hospital using data extracted from the Taiwan Precision Medicine Initiative between January 2010 and April 2021. Associations between CYP2C19 phenotypes, comorbidities, and fractures in PPI users were analyzed. We enrolled 1518 long-term PPI users; 571 (38%), 727 (48%), and 220 (14%) CYP2C19 normal metabolizers (NMs), intermediate metabolizers (IMs), and poor metabolizers (PMs), respectively. Among them, 49 (3.2%) patients developed fractures within the 1-year follow-up period; 20 (3.5%) fractures in NMs, 24 (3.3%) in IMs, and 5 (2.3%) in PMs, respectively. No significant difference was observed among CYP2C19 genotypes and fracture. Additionally, BMD measurements during the 1-year follow-up period were made available among 75 participants. No significant difference in BMD between CYP2C19 PMs and non-PMs was found. This real-world, hospital-based study concludes that CYP2C19 PMs/IMs are not associated with an increased risk for fractures or reduced BMD in individuals on long-term PPI therapy.

Pantoprazole-Induced Bone Loss through Gastrin Secretion: A Stereological Study

Background

Recent researches have failed to uncover a clear explanation for proton pump inhibitors' bone-loss effects. In light of pantoprazole's effects on gastrin secretion, the goal of this study was to see if it caused bone loss through gastrin secretion.

Methods

Forty male rats were divided into control, octreotide (Oct), pantoprazole (Pan), and pantoprazole plus octreotide (Pan+Oct) groups. Serum calcium, phosphorous, alkaline phosphatase, parathyroid hormone, and gastrin were measured before and three months after the treatment, and bone densitometry was examined. The rats' femoral bones were examined stereologically at the end of the investigation.

Results

The Pan group had considerably greater levels of serum alkaline phosphatase, parathyroid hormone (PTH), and gastrin, but this was prevented in the presence of Oct, a gastrin secretion inhibitor. All parameters of femoral bone densitometry in the Pan group were significantly lower than the control after treatment which was considerably inhibited in the presence of Oct. Furthermore, when compared to the control and Oct groups, the rats in the Pan group had a lower trabecular volume, femur bone weight, and volume, as well lower number of osteocytes. The amount of osteoclasts, on the other hand, was much higher in the Pan group than in the other groups.

Conclusion

Overall findings revealed that pantoprazole caused bone loss, which could be prevented by adding octreotide. Because these detrimental effects were not detected in rats given both Oct and Pan, it was suggested that the effect of Pan on bone was produced by a hypergastrinemic condition.

Effect of limestone particle size on performance, eggshell quality, bone strength, and in vitro/in vivo solubility in laying hens: a meta-analysis approach

Numerous publications over the past 5 decades have investigated the effect of limestone particle size (LmPS) on production performance, bone mineralization, and limestone solubilization in laying hens. Coarse limestone particles have been shown to improve eggshell quality and bone mineralization. However, there is a large variability of responses in birds to this factor, indicating the need to better quantify the effect of modulating factors related to coarse particles that could explain this variability. The objective of this meta-analysis was to study the impact of LmPS on the digestive and metabolic fate of Ca to optimize its utilization by laying hens. Fifty-eight papers published between 1971 and 2019, including 71 experiments were included in this study. Four categories of dependent variables were identified: Ca solubility, production performance, eggshell quality, and bone strength. Independent variables tested were LmPS and age. Results showed that the in vitro solubilization of limestone linearly decreased (P < 0.001; R² = 0.91) while in vivo solubilization linearly increased with LmPS (P < 0.001; R² = 0.91). Coarse limestone particles were retained longer in the gizzard (P < 0.001; R² = 0.60), inducing higher solubilization by gastric juices than fine limestone. LmPS showed no effect on production performance while all eggshell quality parameters increased with LmPS (P < 0.001; R² > 0.91): increasing specific gravity by 0.8%, eggshell thickness by 1.1%, and eggshell breaking strength by 3% when increasing from 0.15 mm to 1.5 mm. LmPS had an effect on tibia breaking strength dependently of age (Age × LmPS, P < 0.001; R² = 0.89): coarse limestone particles increased tibia breaking strength with aging compared to fine limestone particles. The current study renders it possible to quantify the effects of age and LmPS on eggshell quality and tibia breaking strength. This work showed an interaction between eggshell quality and bone strength and showed that LmPS increases bone strength in older laying hens.

Use of acid-suppressive drugs and risk of fracture in children and young adults: a meta-analysis of observational studies

BACKGROUND

Acid-suppressive drugs (ASDs) are being used by increasing number of children and young adults. However, evidence for a relationship between ASD use and the risk of fracture in these groups of patients is conflicting. We conducted a meta-analysis to evaluate the risk of fracture in children and young adults exposed to ASDs.

METHODS

A literature search was performed using the PUBMED, EMBASE, and Cochrane Library databases from inception to November 2020. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated to determine the relationship of ASD use with fracture risk in children and young adults.

RESULTS

Six studies reporting the outcomes of more than 900,000 children and young adults with ASD use were included in the meta-analysis. The pooled RR for fracture with the use of proton pump inhibitors (PPIs) versus non-use of these medications was 1.17 (95% CI = 1.1-1.25; P < 0.001) in children and 1.2 (95% CI = 0.87-1.65; P = 0.272) in young adults. By contrast, the use of histamine H2-receptor antagonists (H2RAs) was not significantly associated with fracture risk in children (RR, 1.08, 95% CI = 0.99-1.17; P = 0. 083) or young adults (RR, 1.08, 95% CI = 0.82-1.42; P = 0.589). Significant statistical and clinical heterogeneity among studies were determined for the main analysis and most of the subgroup analyses.

CONCLUSIONS

Our study provides evidence linking PPI use to an increased risk of fracture in children. Thus, the use of PPIs in these patients should be carefully considered. However, randomized controlled studies are needed to determine causality and the role of unmeasured/residual confounding factors in this association.

Effect of proton pump inhibitors on dental implants: A systematic review and meta-analysis

Aim

The present systematic review aims to determine the evidence on the impact of proton pump inhibitors (PPIs) on dental implants.

Settings and Design

This secondary qualitative and quantitative research was done using a pre-specified question and inclusion criteria.

Materials and Methods

A systematic search was conducted in electronic databases such as PubMed, Ovid, and Cochrane. All the studies that assessed the effect of PPIs on dental implants were included, irrespective of the design. Literature review, letter to editors, short commentaries, and opinion articles were excluded.

Results and Statistical Analysis Used

A total of three publications fulfilled the inclusion criteria. All these included articles were retrospective cohort studies; the methodological quality was assessed using Newcastle-Ottawa scale. A total of 452 implants were placed in 149 PPI users, whereas 6798 were positioned in 2241 nonusers. Of these, 43 and 212 implants failed in users and nonusers, respectively (odds ratio: 2.91, 95% confidence interval: 2.06-4.11). The meta-analysis was performed using the statistical software Review Manager, and a fixed-effect model was used to obtain the odds ratio. The success rate of implants based on age, gender, smoking, and bone augmentation could be combined only from two studies, which revealed a considerable effect of these factors.

Conclusion

As far as the available evidence is considered, it seems as if the usage of PPI has a detrimental effect on the success of dental implants. This influence needs justification as none of the included studies segregated the data based on confounding factors. Hence, there is a need to conduct well-designed, prospective, randomized clinical trials with balanced confounding factors to derive a proper conclusion.

Magnesium oxide and hip fracture in the elderly: a population-based retrospective cohort analysis

Using national insurance claims of Taiwan, we found that magnesium oxide (MgO) use is associated with an increased risk of hip fracture in the elderly. Further studies are warranted to explore the mechanisms associated with MgO use that lead to hip fracture.

PURPOSE

The purpose of this study was to investigate the association between MgO use and hip fracture risk in the elderly (age > 65 years).

METHODS

This nationwide population-based retrospective study was conducted from 1996 to 2013. Individuals with (n = 26,069) and without (n = 26,069) MgO use were enrolled after propensity score matching. Primary outcome was a hip fracture. After adjusting for age, sex, comorbidities, and medications, multivariate Cox proportional hazards regression models were used to calculate incidences and risk of hip fracture [hazard ratio (HR)].

RESULTS

During the mean follow-up duration of 4.8 years in the MgO cohort and 5.7 years in the non-MgO cohort, respectively 1547 and 1107 cases developed a hip fracture. MgO use was identified as a risk factor for hip fracture in both univariate [crude HR, 1.68; 95% confidence interval (CI), 1.55-1.81; p < 0.001] and multivariate [adjusted HR (aHR), 1.66; 95% CI, 1.54-1.80; p < 0.001] Cox proportional hazards regression models. The cumulative incidence of hip fracture was significantly higher in the MgO cohort than in the non-MgO cohort (1.23 per 100 person-years vs. 0.74 per 100 person-years, logrank test, p < 0.001).

CONCLUSION

MgO use is an independent risk factor for hip fracture in the elderly.

Porous Inorganic and Hybrid Systems for Drug Delivery: Future Promise in Combatting Drug Resistance and Translation to Botanical Applications

BACKGROUND

Porous micro- and nanoparticles have the capacity to encapsulate a large quantity of therapeutics, making them promising delivery vehicles for a variety of applications. This review aims to highlight the latest development of inorganic and hybrid (inorganic/ organic) particles for drug delivery with an additional emphasis on combatting drug resistant cancer. We go one step further and discuss delivery applications beyond medicinal delivery, as there is generally a translation from medicinal delivery to botanic delivery after a short lag time.

METHODS

We undertook a search of relevant peer-reviewed publications. The quality of the relevant papers was appraised using standard tools. The characteristics of the papers are described herein, and the relevant material and therapeutic properties are discussed.

RESULTS

We discuss 4 classes of porous particles in terms of drug delivery and theranostics. We specifically focus on silica, calcium carbonate, metal-phenolic network, and metalorganic framework particles. Other relevant biomedically relevant applications are discussed and we highlight outstanding therapeutic results in the relevant literature.

CONCLUSION

The findings of this review confirm the importance of studying and utilizing porous particles for therapeutic delivery. Moreover, we show that the properties of porous particles that make them promising for medicinal drug delivery also make them promising candidates for agro-industrial applications.

Deficiency of micronutrients in patients affected by chronic atrophic autoimmune gastritis: A single-institution observational study

BACKGROUND

Chronic atrophic autoimmune gastritis (CAAG) leads to vitamin B₁₂ deficiency, but other micronutrient deficiencies are largely understudied.

AIMS

To investigate the prevalence of micronutrient deficiencies in CAAG patients and their potential relationship with the grading of gastric atrophy or entero-chromaffin-like cells hyperplasia or body mass index (BMI).

METHODS

From 2005 to 2016 a number of CAAG patients underwent regular follow-up with annual blood testing and upper gastrointestinal tract endoscopy every years.

RESULTS

Out of the 122 CAAG patients checked (100 F; median age 65 years), 76 presented nutritional deficiencies, single in 24 and multiple in 52 cases: a deficiency of B₁₂ and iron showed in 42 patients, 25-OH vitamin D lacked in 76 and folic acid in 6 cases. 25-OH vitamin D levels directly correlated with B₁₂ levels and were significantly lower in patients with macronodular than in those with linear or micronodular hyperplasia. No significant correlation was observed between B₁₂, folic acid or ferritin levels and BMI, blood gastrin levels, the grading of gastric atrophy or ECL cells hyperplasia.

CONCLUSIONS

25-OH vitamin D deficiency was the main one in CAAG patients: its correlation with B₁₂ deficiency may indicate underlying shared pathogenic mechanisms, although further studies are needed to confirm this hypothesis.

Analysis of postmarketing safety data for proton-pump inhibitors reveals increased propensity for renal injury, electrolyte abnormalities, and nephrolithiasis

Proton pump inhibitors, PPIs, are widely prescribed and sold globally. Although initially intended for time-limited treatment of acute disorders, such as gastric ulcers and esophagitis, PPIs are now commonly used for prolonged durations and are considered safe for over the counter access. Recent studies have raised concern over associations between PPI use and acute kidney injury, chronic kidney disease, end-stage renal disease, and electrolyte abnormalities. The growing concern over potentially serious adverse drug reactions warrants an evaluation of post marketing surveillance data. In this study of over ten million FDA Adverse Event Reporting System records, we provided evidence of kidney injury and electrolyte imbalances in an alarming number of patients taking PPIs. Additionally, we assessed differences between specific PPIs and observed significant electrolyte and renal abnormalities for each individual drug with varying magnitudes.

Atrophic Gastritis as a Risk Factor for Bone Loss in Premenopausal Women in Their 40s: A Retrospective Cohort Study

This study assessed the effects of atrophic gastritis on bone mineral density (BMD) in premenopausal women in their 40s. We performed a retrospective analysis of medical records of premenopausal women in their 40s who underwent a health checkup, esophagogastroduodenoscopy, and bone densitometry at least thrice, 24 months apart, between January 2006 and December 2016. Based on first-visit esophagogastroduodenoscopy results, patients were divided into atrophic and non-atrophic gastritis groups; BMD changes over time were analyzed. Patients were further divided into subgroups depending on atrophic gastritis persistence; differences and absolute changes in BMD were assessed. BMD in both groups exhibited group-by-time interaction (p < 0.001). After adjusting for confounding factors, the mean BMD was significantly different at the 24-month and the 48-month follow-up (p = 0.049, p < 0.001, respectively). Subgroup analysis after adjusting for confounding factors showed a mean BMD of 1.128 and 1.104 at baseline, 1.110 and 1.100 at the 24-month follow-up, and 1.106 and 1.065 at the 48-month follow-up for persistent atrophic and non-atrophic gastritis groups, respectively. The difference between mean BMD was not significant at baseline (p = 0.171), but was significant at the 24-month and 48-month follow-ups (p = 0.044 and p < 0.001, respectively). Absolute changes in BMD over 48 months were - 0.010 and - 0.051 for the two subgroups, which was significantly different (p < 0.001). Atrophic gastritis reduces BMD in premenopausal women in their 40s. Patients with atrophic gastritis exhibited lower BMD than patients without, and patients with persistent atrophic gastritis exhibited a greater decrease in BMD.

Relevance of vitamin D deficiency in patients with chronic autoimmune atrophic gastritis: a prospective study

Background

Chronic autoimmune atrophic gastritis (CAAG) is an autoimmune disease characterized by hypo/achlorhydria. A role of CAAG in the pathogenesis of nutritional deficiencies has been reported, therefore we hypothesized a possible association between CAAG and 25-OH-Vitamin D [25(OH)D] deficiency. Aim of the present study is to evaluate the prevalence of 25(OH)D deficiency in CAAG patients. Methods: 87 CAAG patients (71 females; mean age 63.5 ± 12.8 years) followed at our Centre from January 2012 to July 2015 were consecutively evaluated. 25(OH)D, vitamin B₁₂, parathormone, and calcium were measured in all the CAAG patients. The results were compared with a control group of 1232 healthy subjects.

Results

In the CAAG group the mean 25(OH)D levels were significantly lower than in the control group (18.8 vs. 27.0 ng/ml, p < 0.0001). 25(OH)D levels < 20 ng/ml was observed in 57 patients, while levels < 12.5 ng/ml in 27 patients. A significant correlation between vitamin B₁₂ values at diagnosis and 25(OH)D levels was observed (r_s = 0.25, p = 0.01). Interestingly, the CAAG patients with moderate/severe gastric atrophy had lower 25(OH)D values as compared to those with mild atrophy (11.8 vs. 20 ng/ml; p = 0.0047). Moreover, the 25(OH)D levels were significantly lower in CAAG patients with gastric carcinoid as compared to those without gastric carcinoid (11.8 vs. 19.8 ng/ml; p = 0,0041).

Conclusion

Data from the present study showed a significant reduction of 25(OH)D levels in CAAG patients and a possible impairment of vitamin D absorption in CAAG may be postulated. Any implication to the genesis of gastric carcinoids remains to be elucidated.

Proton Pump Inhibitors, Histamine-2 Receptor Antagonists, and Hip Fracture Risk among Patients on Hemodialysis

BACKGROUND AND OBJECTIVES

An association between proton pump inhibitor (PPI) use and hip fracture risk has been described in the general population, where the primary causative hypothesis focuses on impaired gastrointestinal calcium absorption. The impact of acid suppressor use on hip fracture risk in a high-risk subset, patients with ESKD requiring hemodialysis, is unknown and could help further distinguish the reason for higher susceptibility among PPI users.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the US Renal Data System, we identified all hip fracture events recorded between 2009 and 2014 among patients dependent on hemodialysis. Eligible cases were matched on index date with ten controls. We identified PPI and histamine-2 receptor antagonist use from Medicare Part D claims covering 3 years before the index date and stratified according to proportion of days covered by filled prescriptions. Using logistic regression with multiple imputation for missing data, we estimated unadjusted and multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

We studied 4551 cases and 45,510 controls. Patients were older, more likely to be female and white, and had shorter dialysis vintage; fewer were obese. A larger proportion of patients had any prior PPI (70% versus 63%) or histamine-2 receptor antagonist (25% versus 23%) use. Use of PPI was associated with higher risk of hip fracture (adjusted OR, 1.19; 95% CI, 1.11 to 1.28). This association remained within subgroups of low, moderate, and high PPI use, yielding adjusted ORs of 1.16 (95% CI, 1.06 to 1.27), 1.21 (95% CI, 1.11 to 1.31), and 1.19 (95% CI, 1.08 to 1.31), respectively.

CONCLUSIONS

Among patients with ESKD on hemodialysis, PPIs and not histamine-2 receptor antagonists were associated with hip fracture events.

Discontinuing Long-Term PPI Therapy: Why, With Whom, and How?

Proton pump inhibitors (PPIs) are among the most widely used class of drugs prescribed over the long term in all of clinical medicine with 8-10% of ambulatory adults have been prescribed a PPI in the past 30 days. However, numerous studies have raised doubts about the long term safety of PPI use. The purpose of this review is threefold: (i) To provide an overview of the current evidence demonstrating associations between PPI use and adverse health outcomes and the likelihood of the associations being causal (Why?); (ii) To be able to identify long-term PPI users in whom the intensity of PPI therapy could be reduced or in whom PPIs could be eliminated outright (Who?); and (iii) To provide strategies on how to reduce or stop chronic PPI therapy while maintaining symptom control and reducing the risk for symptom or upper GI disease recurrence (How?).

Vitamin D and intestinal calcium transport after bariatric surgery

Bariatric surgery is a highly effective treatment for obesity, but it may have detrimental effects on the skeleton. Skeletal effects are multifactorial but mediated in part by nutrient malabsorption. While there is increasing interest in non-nutritional mechanisms such as changes in fat-derived and gut-derived hormones, nutritional factors are modifiable and thus represent potential opportunities to prevent and treat skeletal complications. This review begins with a discussion of normal intestinal calcium transport, including recent advances in our understanding of its regulation by vitamin D, and areas of continued uncertainty. Human and animal studies of vitamin D and intestinal calcium transport after bariatric surgery are then summarized. In humans, even with optimized 25-hydroxyvitamin D levels and recommended calcium intake, fractional calcium absorption decreased dramatically after Roux-en-Y gastric bypass (RYGB). In rats, intestinal calcium absorption was lower after RYGB than after sham surgery, despite elevated 1,25-dihyroxyvitamin D levels and intestinal gene expression evidence of vitamin D responsiveness. Such studies have the potential to shed new light on the physiology of vitamin D and intestinal calcium transport. Moreover, understanding the effects of bariatric surgery on these processes may improve the clinical care of bariatric surgery patients.

Long-Term Proton Pump Inhibitor Use Is Not Associated With Changes in Bone Strength and Structure

OBJECTIVES

Multiple studies have reported an association between proton pump inhibitor (PPI) use and fracture. However, the causality of this association is questionable, as there is not a well defined mechanism of action, nor is there evidence of an effect on PPIs on areal bone mineral density (aBMD) using dual photon X-ray absorptiometry (DXA). It is possible that PPIs may induce changes in bone structure which would predispose to fracture in the absence of changes in aBMD. We used three-dimensional quantitative computed tomography (3D-QCT) imaging to determine if long-term PPI use was associated with structural changes in bone independent of aBMD.

METHODS

We enrolled a sample of long-term (≥5 years) PPI users matched to a similar cohort of persons with no PPI use in the previous 5 years. All subjects underwent assessment of aBMD using DXA, volumetric BMD using 3D-QCT, as well as markers of bone metabolism. Measures of bone strength, including buckling ratio and section modulus, were also compared between the two samples.

RESULTS

104 subjects were enrolled (52 PPI users and 52 PPI non-users). There were no differences detected in standard BMD, volumetric BMD, markers of bone metabolism or measures of bone strength between the two groups.

CONCLUSIONS

Long-term PPI use is not associated with any changes in bone mineral density or bone strength that would predispose to an increased risk of fracture. These findings provide further evidence that the association between PPI use and fracture is not causal.

Diagnosis and therapy of osteoporosis in geriatric trauma patients: an update

Demographic changes confront clinicians with an increasing number of orthogeriatric patients. These patients present with comorbidities, which force their surgeons to take into consideration their medical condition. A major risk factor for fractures in orthogeriatric patients is osteoporosis in combination with frailty. To prevent subsequent fractures in these patients, we need to pay attention to adequate osteoporosis treatment in orthogeriatric patients. There is a huge treatment gap. In Germany, 77% of patients with osteoporosis are not treated adequately. Even after fragility fractures, a low percentage of patients receive a specific osteoporosis therapy. Secondary prevention is of great importance in the treatment of these patients. Diagnostics and treatment should be already initiated with the admission to the hospital. Treatment decisions need to be made individually based on the risk profile of the patients. After discharge, it is important to involve the patients’ general practitioners and to follow up on patients regularly to improve their compliance and to ensure adequate therapy. Establishing a fracture liaison service helps coordinating osteoporosis treatment during hospitalization and after discharge. Subsequent fractures can be reduced; therefore, it is an effective service for secondary prevention. The present article provides an overview of how an efficient identification and subsequent treatment of osteoporosis can be achieved in aged trauma patients.

Role of Proton Pump Inhibitors in Calcium Absorption, Bone Resorption, and Risk of Hip Fracture

Objective:

To review the influence of proton pump inhibitors (PPIs) on calcium absorption, bone remodeling, and fracture risk.

Data Sources:

A search via MEDLINE (1966–April 2007) was performed using the search terms proton pump inhibitors, omeprazole, calcium absorption, calcium malabsorption, bone resorption, and fracture risk.

Study Selection and Data Extraction:

English-language literature, including abstracts, preclinical and clinical trials, and review articles, were identified from the data sources and reviewed.

Data Synthesis:

Data on the effect of PPIs on calcium absorption are conflicting; however, the majority of data indicate that PPIs decrease intestinal calcium absorption, which could negatively affect bone strength. In particular, calcium carbonate may be more difficult to absorb in an environment with elevated pH due to PPI use. Data on the role of PPIs in osteoclast function are also conflicting, with one human study indicating decreased bone resorption due to inhibition of osteoclast function and another human study indicating no association between PPIs and osteoclast function. The risk of fracture with PPI use was evaluated in 2 studies, and both studies found an increased risk of fracture of 14–44% after PPI use.

Conclusions:

PPI use may increase a patient's risk of fracture. Additional studies are needed before causality can be established.

A Proton Pump Inhibitor's Effect on Bone Metabolism Mediated by Osteoclast Action in Old Age: A Prospective Randomized Study

Background/Aims

Proton pump inhibitors (PPIs) act by irreversibly binding to the H⁺-K⁺-ATPase of the proton pump in parietal cells and may possibly affect the vacuolar H⁺-ATPase in osteoclasts.

Methods

We investigated the effect of 8 weeks of PPI treatment on the parameters of bone turnover and compared PPI with revaprazan, which acts by reversibly binding to H⁺-K⁺-ATPase in proton pumps. This study was a parallel randomized controlled trial. For 8 weeks, either a PPI or revaprazan was randomly assigned to patients with gastric ulcers. The parameters of bone turnover were measured at the beginning of and after the 8-week treatment period.

Results

Twenty-six patients (PPI, n=13; revaprazan, n=13) completed the intention-to-treat analysis. After the 8-week treatment period, serum calcium and urine deoxypyridinoline (DPD) were increased in the PPI group (serum calcium, p=0.046; urine DPD, p=0.046) but not in the revaprazan group. According to multivariate linear regression analysis, age ≥60 years was an independent predictor for the changes in serum calcium and urine DPD.

Conclusions

In elderly patients, administering a PPI for 8 weeks altered bone parameters. Our study suggested that PPIs might directly alter bone metabolism via the vacuolar H⁺-ATPase in osteoclasts.

Cytotoxicity, Uptake Behaviors, and Oral Absorption of Food Grade Calcium Carbonate Nanomaterials

Calcium is the most abundant mineral in human body and essential for the formation and maintenance of bones and teeth as well as diverse cellular functions. Calcium carbonate (CaCO₃) is widely used as a dietary supplement; however, oral absorption efficiency of CaCO₃ is extremely low, which may be overcome by applying nano-sized materials. In this study, we evaluated the efficacy of food grade nano CaCO₃ in comparison with that of bulk- or reagent grade nano CaCO₃ in terms of cytotoxicity, cellular uptake, intestinal transport, and oral absorption. Cytotoxicity results demonstrated that nano-sized CaCO₃ particles were slightly more toxic than bulk materials in terms of oxidative stress and membrane damage. Cellular uptake behaviors of CaCO₃ nanoparticles were different from bulk CaCO₃ or Ca²⁺ ions in human intestinal epithelial cells, showing efficient cellular internalization and elevated intracellular Ca²⁺ levels. Meanwhile, CaCO₃ nanoparticles were efficiently transported by microfold (M) cells in vitro model of human intestinal follicle-associated epithelium, in a similar manner as Ca²⁺ ions did. Biokinetic study revealed that the biological fate of CaCO₃ particles was different from Ca²⁺ ions; however, in vivo, its oral absorption was not significantly affected by particle size. These findings provide crucial information to understand and predict potential toxicity and oral absorption efficiency of food grade nanoparticles.

The fate of calcium carbonate nanoparticles administered by oral route: absorption and their interaction with biological matrices

BACKGROUND

Orally administered particles rapidly interact with biological fluids containing proteins, enzymes, electrolytes, and other biomolecules to eventually form particles covered by a corona, and this corona potentially affects particle uptake, fate, absorption, distribution, and elimination in vivo. This study explored relationships between the biological interactions of calcium carbonate particles and their biokinetics.

METHODS

We examined the effects of food grade calcium carbonates of different particle size (nano [N-Cal] and bulk [B-Cal]: specific surface areas of 15.8 and 0.83 m(2)/g, respectively) on biological interactions in in vitro simulated physiological fluids, ex vivo biofluids, and in vivo in gastrointestinal fluid. Moreover, absorption and tissue distribution of calcium carbonates were evaluated following a single dose oral administration to rats.

RESULTS

N-Cal interacted more with biomatrices than bulk materials in vitro and ex vivo, as evidenced by high fluorescence quenching ratios, but it did not interact more actively with biomatrices in vivo. Analysis of coronas revealed that immunoglobulin, apolipoprotein, thrombin, and fibrinogen, were the major corona proteins, regardless of particle size. A biokinetic study revealed that orally delivered N-Cal was more rapidly absorbed into the blood stream than B-Cal, but no significant differences were observed between the two in terms of absorption efficiencies or tissue distributions. Both calcium carbonates were primarily present as particulate forms in gastrointestinal fluids but enter the circulatory system in dissolved Ca(2+), although both types showed partial phase transformation to dicalcium phosphate dihydrate. Relatively low dissolution (about 4%), no remarkable protein-particle interaction, and the major particulate fate of calcium carbonate in vivo gastrointestinal fluids can explain its low oral absorption (about 4%) regardless of particle size.

CONCLUSION

We conclude that calcium carbonate nanoparticles can act more actively with biological matrices in vitro and ex vivo, but that in vivo, their biological interactions and biokinetics are not affected by particle size.

Inhibitory effects of deoxynivalenol on gastric secretion in rats

Deoxynivalenol (DON) is a common mycotoxin produced by Fusarium sp. in cereals and foods. Ingestion of contaminated foodstuffs can cause digestive disorders in various animals. Many researchers focus on its toxicity and the pathological damage and absorptive function in the intestines. However, the effect of DON on gastric function is still unclear. The objective of the current study was to evaluate the impact of DON on gastric secretion. Rats were gavaged with DON at the dose of 0, 1, 5, and 25 mg/kg of body weight (bw). Gastric fluids were gathered by pylorus ligation 0.5 h after DON exposure. The results indicate that the volume of gastric fluid decreased by 25, 51, and 61% compared with the control, respectively. The pH increased to 3.2, 3.81, and 6.65 in the 1, 5, and 25 mg/kg bw DON group, compared with the control (1.9). To examine the mucosal injuries, the stomach tissues were made into hematoxylin and eosin slides. Histopathology observations suggest that no mucosal lesions were observed until DON exposure at 25 mg/kg bw. Additionally, the gastrin secretion in the fluids and mRNA expression in tissues were determined by the radioimmunoassay and real-time PCR assay, respectively. The results indicated that both significantly decreased in DON-exposed rats compared with the control. Taken together, DON exposure reduced gastric secretion in rats. Low gastrin secretion and mRNA expression play a major role, unless mucosal lesions by high DON exposure are present.

A high-calcium diet failed to rescue an osteopenia phenotype in claudin-18 knockout mice

We have recently demonstrated that mice with disruption of claudin‐18 (Cldn‐18) gene exhibited osteopenia due to increased bone resorption (BR). In this study, we found that gastric pH was significantly higher in Cldn‐18 knockout (KO) mice compared to heterozygous control mice at 10 weeks of age. To test the possibility that the increased BR in the Cldn‐18 KO mice fed a normal‐Ca diet is a consequence of decreased Ca absorption caused by increased stomach pH, we subjected KO and control mice to a normal‐Ca and high‐Ca diet at birth. Serum Ca levels were significantly lower in Cldn‐18 KO mice compared to control mice at a normal‐Ca diet but not at high‐Ca diet. Dual energy X‐ray absorptiometry revealed that a high‐Ca diet significantly increased lumbar bone mineral density (BMD), but had no effect on femur/tibia BMD in both Cldn‐18 KO and control mice compared to a normal‐Ca diet. While a high‐Ca diet did not affect volumetric BMD, trabecular, and cortical parameters of the lumbar vertebra (LV) as measured by μCT, the size of the LV did increase, in both genotypes due to reduced BR. Comparison of the skeletal phenotype of high‐Ca Cldn‐18 KO and control mice revealed that an osteopenia phenotype seen at a normal‐Ca diet was still maintained at different skeletal sites in the KO mice till 10 weeks of age. In conclusion, our findings suggest that increased BR is likely caused by direct effects of a lack of Cldn‐18 on osteoclasts rather than gastric pH changes.

In this study, we examined if calcium deficiency caused by low‐gastric acidity was the cause of osteopenia phenotype observed in claudin‐18 (Cldn‐18) knockout (KO) mice. Our findings that high‐calcium diet did not rescue the osteopenia phenotype in Cldn‐18 KO mice suggest that increased bone resorption is likely caused by direct effects of a lack of Cldn‐18 on osteoclasts rather than gastric pH changes.

Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications

Proton pump inhibitors (PPIs) remain the superior choice worldwide in antisecretory therapy in the evidence-based treatment of upper gastrointestinal disorders including gastroesophageal reflux disease, erosive esophagitis, dyspepsia and peptic ulcer disease. PPI overutilization in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. Nonjudicious use of PPIs creates both preventable financial as well as medical concerns. PPIs have been associated with an increased risk of vitamin and mineral deficiencies impacting vitamin B12, vitamin C, calcium, iron and magnesium metabolism. While these risks are considered to be relatively low in the general population, they may be notable in elderly and malnourished patients, as well as those on chronic hemodialysis and concomitant PPI therapy. No current evidence recommends routine screening or supplementation for these potential vitamin and mineral deficiencies in patients on either short- or long-term PPI therapy. Reducing inappropriate prescribing of PPIs can minimize the potential risk of vitamin and mineral deficiencies.

Influence of gastrectomy on cortical and cancellous bones in rats

The aim of the present study was to examine the influence of gastrectomy (GX) on cortical and cancellous bones in rats. Twenty male Sprague-Dawley rats were randomized into the two groups of 10 animals each: a sham operation (control) group and a GX group. Seven weeks after surgery, the bone mineral content and density (BMC and BMD, resp.) and the mechanical strength of the femur were determined, and bone histomorphometric analyses were performed on the tibia. GX induced decreases in the BMC, BMD, ultimate force, work to failure, and stiffness of the femoral distal metaphysis and the BMC, BMD, and ultimate force of the femoral diaphysis. GX induced a decrease in cancellous bone mass, characterized by an increased osteoid thickness, osteoid surface, osteoid volume, and bone formation. GX also induced a decrease in cortical bone mass, characterized by increased endocortical bone resorption. The GX induced reductions in the bone mass and strength parameters were greater in cancellous bone than in cortical bone. The present study showed that the response of bone formation, resorption, and osteoid parameters to GX and the degree of GX-induced osteopenia and the deterioration of bone strength appeared to differ between cortical and cancellous bones in rats.

Indications and safety of proton pump inhibitor drug use in patients with cancer

INTRODUCTION

Although the exact prevalence of proton pump inhibitor (PPI) use in cancer patients is not known, it is generally perceived to be widespread. PPIs are generally well tolerated and carry an excellent safety profile. However, increasing and longer term PPI use has raised concerns about the risk of pneumonia, bone fractures and enteric infections, and a possible interaction with clopidogrel that could increase the risk of cardiovascular events.

AREAS COVERED

We conducted a PubMed search of English language articles addressing the safety and adverse events associated with PPI use with particular emphasis in cancer patients.

EXPERT OPINION

PPIs, frequently used in cancer patients, are generally well tolerated and carry an excellent safety profile. PPI-induced acid suppression may increase the risk of Clostridium difficile or other enteric infections, nutritional deficiencies and community acquired pneumonia, all particularly important in cancer patients. The indications for PPI use in cancer patients should be carefully reviewed prior to use.

The effect of proton pump inhibitors on fracture risk: report from the Canadian Multicenter Osteoporosis Study

A large Canadian cohort was studied over 10 years to see if proton pump inhibitor (PPI) use increased the risk of sustaining a fragility fracture. We found an increased risk of fracture in individuals who used PPIs. The risk remained after controlling for other known fracture risk factors.

INTRODUCTION

Multiple retrospective studies have linked proton pump inhibitor use with increased risk of fragility fracture. We prospectively studied the association between PPI use and fracture in a large cohort over a 10-year period while controlling for known fracture risk factors.

METHODS

We studied 9,423 participants in the Canadian Multicenter Osteoporosis Study. The cohort was formed in 1995-1997 and followed for 10 years with monitoring for incident nontraumatic fracture and PPI use. Cox regression analyses were used to assess the association between PPI use and incident fracture risk.

RESULTS

PPI use, coded as a time-dependent variable, was associated with a shorter time to first nontraumatic fracture, hazard ratio (HR)=1.75 (95% confidence interval (CI) 1.41-2.17, p<0.001). After controlling for multiple risk factors, including femoral neck bone density, the association remained significant, HR=1.40 (95% CI 1.11-1.77, p=0.004). Similar results were obtained after controlling for bisphosphonate use, using PPI "ever" use, or when the outcome was restricted to hip fracture.

CONCLUSIONS

In this large prospective population-based cohort study, we found an association between PPI use and increased risk of fragility fracture. Although the increased risk found was modest, this finding is important, given the high prevalence of PPI use and the excess morbidity and mortality associated with osteoporosis-related fractures.

Chronic proton pump inihibitor therapy and calcium metabolism

Proton pump inhibitors (PPIs) have been widely used since their introduction in the late 1980s because they are highly effective for acid-related conditions. However, some recent epidemiological studies have suggested a positive association between PPI therapy and the risk of osteoporotic fractures. The potential mechanisms underlying this association may be related to the physiologic effects of chronic acid suppression on calcium metabolism. First, chronic hypergastrinemia induced by PPI therapy may lead to parathyroid hyperplasia, resulting in increased loss of calcium from the bone. Second, profound gastric acid suppression may reduce the bioavailability of calcium for intestinal absorption. I will review the published evidence regarding these potential links and discuss their clinical implications.

Calcium metabolism and correcting calcium deficiencies

Calcium is the most abundant cation in the human body, of which approximately 99% occurs in bone, contributing to its rigidity and strength. Bone also functions as a reservoir of Ca for its role in multiple physiologic and biochemical processes. This article aims to provide a thorough understanding of the absorptive mechanisms and factors affecting these processes to enable one to better appreciate an individual's Ca needs, and to provide a rationale for correcting Ca deficiencies. An overview of Ca requirements and suggested dosing regimens is presented, with discussion of various Ca preparations and potential toxicities of Ca treatment.

The relationship between proton pump inhibitor use and longitudinal change in bone mineral density: a population-based study [corrected] from the Canadian Multicentre Osteoporosis Study (CaMos)

OBJECTIVES

Proton pump inhibitor (PPI) use has been identified as a risk factor for hip and vertebral fractures. Evidence supporting a relationship between PPI use and osteoporosis remains scant. Demonstrating that PPIs are associated with accelerated bone mineral density (BMD) loss would provide supportive evidence for a mechanism through which PPIs could increase fracture risk.

METHODS

We used the Canadian Multicentre Osteoporosis Study data set, which enrolled a population-based sample of Canadians who underwent BMD testing of the femoral neck, total hip, and lumbar spine (L1-L4) at baseline, and then again at 5 and 10 years. Participants also reported drug use and exposure to risk factors for osteoporosis and fracture. Multivariate linear regression was used to determine the independent association of PPI exposure and baseline BMD, and on change in BMD at 5 and 10 years.

RESULTS

In all, 8,340 subjects were included in the baseline analysis, with 4,512 (55%) undergoing year 10 BMD testing. After adjusting for potential confounders, PPI use was associated with significantly lower baseline BMD at the femoral neck and total hip. PPI use was not associated with a significant acceleration in covariate-adjusted BMD loss at any measurement site after 5 and 10 years of follow-up.

CONCLUSIONS

PPI users had lower BMD at baseline than PPI non-users, but PPI use over 10 years did not appear to be associated with accelerated BMD loss. The reasons for discordant findings between PPI use at baseline and during follow-up require further study.

Overutilization of proton-pump inhibitors: what the clinician needs to know

Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders, including gastroesophageal reflux disease, dyspepsia, and peptic ulcer disease. The effectiveness of PPIs has led to overutilization in multiple treatment arenas, exposing patients to an increasing number of potential risks. The overutilization of PPIs in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. PPI overutilization in the inpatient setting is often a result of inappropriate stress ulcer prophylaxis (SUP) in nonintensive care unit patients, and failure to discontinue SUP prior to hospital discharge. Potential consequences of prolonged PPI therapy include hypergastrinemia, enterochromaffin-like cell hyperplasia, and parietal cell hypertrophy, leading to rebound acid hypersecretion. PPIs have been linked via retrospective studies to increased risk of enteric infections including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fracture, nutritional deficiencies, and interference with metabolism of antiplatelet agents. Reducing inappropriate prescribing of PPIs in the inpatient and outpatient settings can minimize potential for adverse events, and foster controllable cost expenditure.

Recent safety concerns with proton pump inhibitors

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.

Risk of fracture and pneumonia from acid suppressive drugs

A recently published systematic review and meta-analysis, incorporating all relevant studies on the association of acid suppressive medications and pneumonia identified up to August 2009, revealed that for every 200 patients, treated with acid suppressive medication, one will develop pneumonia. They showed the overall risk of pneumonia was higher among people using proton pump inhibitors (PPIs) [adjusted odds ratio (OR) = 1.27, 95% CI: 1.11-1.46, I² = 90.5%] and Histamine_-2 receptor antagonists (H₂RAs) (adjusted OR = 1.22, 95% CI: 1.09-1.36, I² = 0.0%). In the randomized controlled trials, use of H₂RAs was associated with an elevated risk of hospital-acquired pneumonia (relative risk 1.22, 95% CI: 1.01-1.48, I² = 30.6%). Another meta-analysis of 11 studies published between 1997 and 2011 found that PPIs, which reduce stomach acid production, were associated with increased risk of fracture. The pooled OR for fracture was 1.29 (95% CI: 1.18-1.41) with use of PPIs and 1.10 (95% CI: 0.99-1.23) with use of H₂RAs, when compared with non-use of the respective medications. Long-term use of PPIs increased the risk of any fracture (adjusted OR = 1.30, 95% CI: 1.15-1.48) and of hip fracture risk (adjusted OR = 1.34, 95% CI: 1.09-1.66), whereas long-term H₂RA use was not significantly associated with fracture risk. Clinicians should carefully consider when deciding to prescribe acid-suppressive drugs, especially for patients who are already at risk for pneumonia and fracture. Since it is unnecessary to achieve an achlorhydric state in order to resolve symptoms, we recommend using the only minimum effective dose of drug required to achieve the desired therapeutic goals.

Proton pump inhibitor-induced hypocalcemic seizure in a patient with hypoparathyroidism

OBJECTIVE

To report a case of proton pump inhibitor-induced hypocalcemic seizure in a patient with hypoparathyroidism.

METHODS

We describe the clinical history, physical examination findings, and laboratory values of the patient and briefly review the relevant literature.

RESULTS

A 48-year-old woman with a history of postsurgical hypoparathyroidism who was taking calcium carbonate, 1500 mg 3 times daily, and cholecalciferol, 1200 IU daily, presented with a generalized seizure in the setting of hypocalcemia 12 days after initiating therapy with the proton pump inhibitor lansoprazole. Physical examination revealed a positive Chvostek sign. Electrocardiogram was notable for a prolonged QT(c) interval of 576 milliseconds. Laboratory data were notable for the following values: total serum calcium, 5.3 mg/dL; ionized calcium, 2.51 mg/dL; and intact parathyroid hormone, 5.8 pg/mL. The patient's condition responded to therapy with intravenous calcium gluconate, oral calcium carbonate, and calcitriol. As an outpatient she remained asymptomatic off lansoprazole, treated with calcium carbonate and calcitriol.

CONCLUSIONS

Caution should be exercised in prescribing proton pump inhibitors to patients with a history of hypoparathyroidism treated with calcium carbonate supplementation because severe hypocalcemia is a potential adverse effect.

Calcium citrate and vitamin D in the treatment of osteoporosis

The combination of calcium with vitamin D (vitamin D(3) [colecalciferol]) forms the basis of preventive and therapeutic regimens for osteoporosis. A number of studies have suggested that the combination of calcium and vitamin D is effective when administered at respective dosages of at least 1200 mg and 800 IU per day, although efficacy is, as expected, affected by patient compliance. Overall, treatment with this combination appears to be effective in reducing the incidence of non-vertebral and hip fractures. Also, in all drug studies (of antiresorptive and anabolic agents and strontium ranelate) that demonstrated a reduction in risk of osteoporotic fractures, patients also took calcium and vitamin D supplements. An important finding in this regard is that vitamin D levels have been demonstrated to be inadequate in more than half of women treated for osteoporosis in the US and Europe. The capacity of the small intestine to absorb calcium salts depends on the solubility and ionization of the salts. These properties vary for different salts, with fasting calcium citrate absorption being greater than that of calcium lactogluconate and calcium carbonate. Calcium citrate formulations taken between meals may help to prevent abdominal distension and flatulence, as well as minimize the risk of renal calculus formation, thus helping to optimize patient compliance. Therefore, calcium citrate combined with vitamin D is the combination of choice for the prevention or treatment of osteoporosis.

The relationship among proton pump inhibitors, bone disease and fracture

INTRODUCTION

There is growing concern about a possible association between the use of proton pump inhibitors (PPIs) and the development of fragility fractures, most notably hip and vertebral fractures. As PPIs are widely used in clinical practice, this association is of paramount clinical importance.

AREAS COVERED

The authors review the published papers analyzing the relationship between PPI use and the occurrence of fragility fractures. The authors also explore the data supporting possible mechanisms through which PPIs may increase the risk of fracture, including the effects of PPIs on calcium homeostasis, bone mineral density and direct effects of PPIs on bone metabolism.

EXPERT OPINION

Overall, though multiple observational studies have demonstrated an association between PPIs and fragility fractures, the lack of a proven mechanism through which PPIs increase the risk of fracture suggests that this association may not be causal. At this time, the authors do not recommend discontinuing PPIs in patients with a history of fracture or those at increased risk of fracture. However, clinicians should still endeavor to avoid using PPIs in situations where benefits are minimal or clinical indications are lacking.

Use of acid-suppressive drugs and risk of fracture: a meta-analysis of observational studies

PURPOSE

Previous studies have reported inconsistent findings regarding the association between the use of acid-suppressive drugs such as proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H(2)RAs) and fracture risk. We investigated this association using meta-analysis.

METHODS

We searched MEDLINE (PubMed), EMBASE, and the Cochrane Library from inception through December 2010 using common key words. We included case-control, nested case-control, and cohort studies. Two evaluators independently reviewed and selected articles. We determined pooled effect estimates by using random-effects meta-analysis, because of heterogeneity.

RESULTS

Of 1,809 articles meeting our initial inclusion criteria, 5 case-control studies, 3 nested case-control studies, and 3 cohort studies were included in the final analyses. The pooled odds ratio (OR) for fracture was 1.29 (95% confidence interval [CI], 1.18-1.41) with use of PPIs and 1.10 (95% CI, 0.99-1.23) with use of H(2)RAs when compared with nonuse of the respective medications. Long-term use of PPIs increased the risk of any fracture (adjusted OR = 1.30; 95% CI, 1.15-1.48) and hip fracture risk (adjusted OR = 1.34; 95% CI, 1.09-1.66), whereas long-term H(2)RA use was not significantly associated with fracture risk.

CONCLUSIONS

We found possible evidence linking PPI use to an increased risk of fracture, but no association between H(2)RA use and fracture risk. Widespread use of PPIs with the potential risk of fracture is of great importance to public health. Clinicians should carefully consider their decision to prescribe PPIs for patients already having an elevated risk of fracture because of age or other factors.

Update on medications with adverse skeletal effects

Patients rely on their primary care physician to manage multiple, often chronic medical conditions that require prescription medications. Balancing the risk to benefit of treatments can be challenging and requires that the primary care physician stay abreast of new information regarding risks and benefits. The number of medications with reported adverse effects on skeletal health is expanding. This review focuses on medications recently added to the list of "bad to the bone" drugs and on recent advances in management of glucocorticoid-induced osteoporosis. A practical approach to assessing and managing the skeletal risks is outlined.

Adverse effects of long-term proton pump inhibitor therapy

Proton pump inhibitors have an excellent safety profile and have become one of the most commonly prescribed class of drugs in primary and specialty care. Long-term, sometimes lifetime, use is becoming increasingly common, often without appropriate indications. This paper is a detailed review of the current evidence on this important topic, focusing on the potential adverse effects of long-term proton pump inhibitor use that have generated the greatest concern: B12 deficiency; iron deficiency; hypomagnesemia; increased susceptibility to pneumonia, enteric infections, and fractures; hypergastrinemia and cancer; drug interactions; and birth defects. We explain the pathophysiological mechanisms that may underlie each of these relationships, review the existing evidence, and discuss implications for clinical management. The benefits of proton pump inhibitor use outweigh its risks in most patients. Elderly, malnourished, immune-compromised, chronically ill, and osteoporotic patients theoretically could be at increased risk from long-term therapy.

Association of long-term proton pump inhibitor therapy with bone fractures and effects on absorption of calcium, vitamin B12, iron, and magnesium

Proton pump inhibitors (PPI) are one of the most widely used classes of drugs. PPIs have a very favorable safety profile, and it is unusual for a patient to stop them because of side effects. However, with increasing numbers of patients chronically taking PPIs for gastroesophageal reflux disease and other common, persistent conditions, the long-term potential adverse effects are receiving increasing attention. An insufficiently studied area receiving much attention is the long-term effect of chronic acid suppression on the absorption of vitamins and nutrients. This increased attention results from the reported potential adverse effect of chronic PPI treatment leading to an increased occurrence of bone fractures. Interest in this area has led to examination of the effects of PPIs on calcium absorption/metabolism and numerous cohort, case-control, and prospective studies of their ability to affect bone density and cause bone fractures. In this article, these studies are systematically examined, as are studies of the effects of chronic PPI use on absorption of VB(12), iron, and magnesium. Studies in each area have led to differing conclusions, but when examined systematically, consistent results of several studies support the conclusion that long-term adverse effects on these processes can have important clinical implications.

Proton pump inhibitors and fracture risk: true effect or residual confounding?

Fracture is a major contributor to human morbidity and mortality, especially in the elderly. It has been discussed in the literature that conditions associated with decreased stomach acidity may lead to a decrease in intestinal calcium absorption and, consequently, to an increased fracture risk. In recent years, several observational studies reported a slightly increased fracture risk in association with the use of proton pump inhibitors (PPIs) and/or histamine H(2) receptor antagonists. It was the objective of this review to critically assess the available evidence linking PPI use to an increased fracture risk. A MEDLINE and EMBASE search from 1960 to June 2010 was performed to identify the relevant articles using predefined search terms. Because (i) there is no proven mechanism, (ii) the reported magnitude of the risk elevation associated with the use of PPIs was only weak, and (iii) the likelihood of residual confounding despite adjustment for known co-morbidities and drug use cannot be ruled out, we conclude that the currently available literature does not support the notion that the use of PPIs is causally related to a materially increased fracture risk in humans.