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Tan CM, Juurlink DN. Navigating Drug Interactions with Proton Pump Inhibitors. JAMA Netw Open 2024; 7:e2419818. [PMID: 38980682 DOI: 10.1001/jamanetworkopen.2024.19818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Affiliation(s)
- Carolyn M Tan
- Division of Clinical Pharmacology & Toxicology, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - David N Juurlink
- Division of Clinical Pharmacology & Toxicology, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
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Ali K, Ali AA, Jaikaransingh V. Severe Hypomagnesemia Caused by Proton-Pump Inhibitors in a Patient With an Ostomy. Cureus 2024; 16:e55856. [PMID: 38590468 PMCID: PMC11001418 DOI: 10.7759/cureus.55856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/09/2024] [Indexed: 04/10/2024] Open
Abstract
Proton pump inhibitors (PPIs) are commonly used for many gastrointestinal issues, such as gastroesophageal reflux disease (GERD), peptic ulcer disease, and Zollinger-Ellison syndrome. Many patients are on life-long daily therapy with this class of medications. The adverse effects of long-term use of PPI have been studied, and over the last two decades, a link between hypomagnesemia and PPI has been established. In addition, other electrolyte derangements can also ensue, such as hypokalemia and hypocalcemia. Losses through the gastrointestinal or renal systems may also be responsible for this electrolyte disturbance. In this case, we present a "perfect storm" of a patient who, in addition to having ongoing gastrointestinal losses through an ostomy, had severe hypomagnesemia to less than 1 mg/dL compounded by PPI use. Through its unique mechanism of action on intestinal epithelial cells, PPI use in certain settings can potentially be catastrophic. Severe hypomagnesemia may manifest as tetany, convulsions, tremors, arrhythmias, or torsades de pointes.
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Affiliation(s)
- Kabeer Ali
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Aleem A Ali
- Gastroenterology and Hepatology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Vishal Jaikaransingh
- Nephrology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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Relvas R, Ferreira Monteiro N, Vale Rodrigues R, Cruz D. Thinking Outside the Box: A Case of Persistent Symptomatic Hypomagnesemia. Cureus 2024; 16:e54260. [PMID: 38496092 PMCID: PMC10944336 DOI: 10.7759/cureus.54260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Although present in a significant number of people, hypomagnesemia is still an undervalued diagnosis. Therefore, its awareness and comprehensive etiological investigation become imperative. Among its multiple possible causes, drug iatrogenesis plays an important and often overlooked role. Here, we present a case of a 78-year-old female with recurrent bouts of severe hypomagnesemia of unknown origin, which, after an extensive study, was determined to be induced by proton pump inhibitors (PPIs). As such, our goal is to raise awareness of the potential risk of this side effect even in monotherapy, as well as to elucidate its underlying mechanisms, which are still not fully understood. Furthermore, it is intended to foster a systematic therapeutic review in these patients and raise discussion about the potential benefits of systematic magnesium monitoring in patients on long-term PPIs.
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Affiliation(s)
- Rita Relvas
- Internal Medicine, Hospital de Cascais, Lisbon, PRT
| | | | | | - Diogo Cruz
- Internal Medicine, Hospital de Cascais, Lisbon, PRT
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Zipursky JS, Everett K, Calzavara A, Gomes T, Juurlink DN. New Persistent Opioid Use After Childbirth. Obstet Gynecol 2023; 142:1440-1449. [PMID: 37917933 DOI: 10.1097/aog.0000000000005432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To examine factors associated with new persistent opioid use after childbirth. METHODS We conducted a population-based cohort study of individuals who initiated opioid therapy within 7 days of discharge from hospital after delivery between September 1, 2013, and September 30, 2021. The primary outcome was new persistent opioid use , which was defined as one or more prescriptions for an opioid within 90 days of the first postpartum prescription and one or more subsequent opioid prescriptions in the 91-365 days afterward. We used multivariable logistic regression to assess patient-, pregnancy-, and prescription-related factors associated with new persistent opioid use after delivery. RESULTS We identified 118,694 unique deliveries after which opioids were initiated, including 99,399 cesarean (83.7%) and 19,295 vaginal (16.3%) deliveries. Among mothers who initiated an opioid after delivery, 1,282 (10.8/1,000 deliveries) met our definition of new persistent opioid use in the subsequent year. Rates of new persistent opioid use were appreciably higher after vaginal (16.0/1,000) compared with cesarean (9.8/1,000) deliveries. Each additional 30 morphine milligram equivalents in the initial opioid prescription was associated with an increased risk of new persistent use after cesarean (adjusted odds ratio [aOR] 1.06, 95% CI 1.04-1.08) and vaginal (aOR 1.05, 95% CI 1.02-1.08) delivery. A concomitant benzodiazepine prescription after cesarean delivery was associated with a markedly increased risk of persistent opioid use (aOR 2.69, 95% CI 1.60-4.52). CONCLUSION Among people who filled an opioid prescription after delivery, about 1% displayed evidence of persistent opioid use in the subsequent year. Initial prescriptions for large quantities of opioids and a concurrent benzodiazepine prescription may be important modifiable risk factors to prevent new persistent opioid use after delivery.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, ICES, the Sunnybrook Research Institute, the Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, and the Leslie Dan Faculty of Pharmacy and the Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Yang W, Lian X, Chen H. The association of serum magnesium with infection in new-onset systemic lupus erythematosus patients. Lupus 2023; 32:380-387. [PMID: 36595713 DOI: 10.1177/09612033221149884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To assess the association of serum magnesium with infection in new-onset systemic lupus erythematosus (SLE) patients. METHODS We conducted a single-center retrospective cohort study of new-onset SLE patients from 2012 to 2021. The hospitalized SLE patients were divided into infection and noninfection groups. Logistic regression analysis was conducted to examine the association of hypomagnesemia with infection. RESULTS A total of 476 new-onset SLE patients were included, with 299 cases in the infection group and 177 cases in the noninfection group. The patients were mostly females (81.7%). The average age at diagnosis was 43.7 years. The median duration was 1.0 month. The prevalence of hypomagnesemia (<0.70), normomagnesemia (0.70-1.10), and hypermagnesemia (>1.10) in new-onset SLE patients was 14.3%, 83.4%, and 2.3%, respectively. The prevalence of hypomagnesemia was 18.4% in the infection group and 7.3% in the noninfection group (p = .001). The baseline value of serum magnesium was 0.819 mmol/L, with values of 0.799 mmol/L in the infection group and 0.854 mmol/L in the noninfection group (p = .000). The following clinical variables were significantly different between the two groups (p < .05): age, duration, hospitalization stay, fever, serositis, and SLE Disease Activity Index 2000 (SLEDAI 2K). The laboratory parameters, including hemoglobin, white blood cell count, albumin level, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin, and complement C3 were also significantly different between the two groups (p < .05). The mortality was 4.4% (21/476), with 20 cases occurring in the infection group. Logistic regression analysis showed that hypomagnesemia was associated with an increased risk of infection (p = .001) and poor prognosis (p = .015). CONCLUSION Hypermagnesemia was rare in new-onset SLE patients. Hypomagnesemia was common and was associated with an increased risk of infection in new-onset SLE patients.
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Affiliation(s)
- Wenfang Yang
- Department of Nephrology, 117893Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Xuejian Lian
- Department of Nephrology, 117893Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hongpu Chen
- Department of Rheumatology, 117893Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
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Seah S, Tan YK, Teh K, Loh WJ, Tan PT, Goh LC, Malakar RD, Aw TC, Lau CS, Dhalliwal T, Kui SL, Kam JW, Khoo J, Tay TL, Tan E, Au V, Soh SB, Zhang M, King TF, Gani L, Puar TH. Proton-pump inhibitor use amongst patients with severe hypomagnesemia. Front Pharmacol 2023; 14:1092476. [PMID: 36794273 PMCID: PMC9922884 DOI: 10.3389/fphar.2023.1092476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
Introduction: Long-term proton pump inhibitor (PPI) use has been associated with hypomagnesemia. It is unknown how frequently PPI use is implicated in patients with severe hypomagnesemia, and its clinical course or risk factors. Methods: All patients with severe hypomagnesemia from 2013 to 2016 in a tertiary center were assessed for likelihood of PPI-related hypomagnesemia using Naranjo algorithm, and we described the clinical course. The clinical characteristics of each case of PPI-related severe hypomagnesemia was compared with three controls on long-term PPI without hypomagnesemia, to assess for risk factors of developing severe hypomagnesemia. Results: Amongst 53,149 patients with serum magnesium measurements, 360 patients had severe hypomagnesemia (<0.4 mmol/L). 189 of 360 (52.5%) patients had at least possible PPI-related hypomagnesemia (128 possible, 59 probable, two definite). 49 of 189 (24.7%) patients had no other etiology for hypomagnesemia. PPI was stopped in 43 (22.8%) patients. Seventy (37.0%) patients had no indication for long-term PPI use. Hypomagnesemia resolved in most patients after supplementation, but recurrence was higher in patients who continued PPI, 69.7% versus 35.7%, p = 0.009. On multivariate analysis, risk factors for hypomagnesemia were female gender (OR 1.73; 95% CI: 1.17-2.57), diabetes mellitus (OR, 4.62; 95% CI: 3.05-7.00), low BMI (OR, 0.90; 95% CI: 0.86-0.94), high-dose PPI (OR, 1.96; 95% CI: 1.29-2.98), renal impairment (OR, 3.85; 95% CI: 2.58-5.75), and diuretic use (OR, 1.68; 95% CI: 1.09-2.61). Conclusion: In patients with severe hypomagnesemia, clinicians should consider the possibility of PPI-related hypomagnesemia and re-examine the indication for continued PPI use, or consider a lower dose.
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Affiliation(s)
- Sherry Seah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yen Kheng Tan
- Doctor of Medicine Programme, Duke-NUS (National University School) Medical School, Singapore, Singapore
| | - Kevin Teh
- Department of Gastroenterology, Changi General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Pei Ting Tan
- Department of Clinical Trial Research Unit, Changi General Hospital, Singapore, Singapore
| | - Leng Chuan Goh
- Department of Pharmacy, Changi General Hospital, Singapore, Singapore
| | | | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Chin Shern Lau
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Trishpal Dhalliwal
- Department of Internal Medicine, Changi General Hospital, Singapore, Singapore
| | - Swee Leng Kui
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Jia Wen Kam
- Department of Clinical Trial Research Unit, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Vanessa Au
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Shui Boon Soh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Thomas F. King
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Linsey Gani
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Troy H. Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore,*Correspondence: Troy H. Puar,
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Gommers LMM, Hoenderop JGJ, de Baaij JHF. Mechanisms of proton pump inhibitor-induced hypomagnesemia. Acta Physiol (Oxf) 2022; 235:e13846. [PMID: 35652564 PMCID: PMC9539870 DOI: 10.1111/apha.13846] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022]
Abstract
Proton pump inhibitors (PPIs) reliably suppress gastric acid secretion and are therefore the first-line treatment for gastric acid-related disorders. Hypomagnesemia (serum magnesium [Mg2+ ] <0.7 mmol/L) is a commonly reported side effect of PPIs. Clinical reports demonstrate that urinary Mg2+ excretion is low in PPI users with hypomagnesemia, suggesting a compensatory mechanism by the kidney for malabsorption of Mg2+ in the intestines. However, the exact mechanism by which PPIs cause impaired Mg2+ absorption is still unknown. In this review, we show that current experimental evidence points toward reduced Mg2+ solubility in the intestinal lumen. Moreover, the absorption pathways in both the small intestine and the colon may be reduced by changes in the expression and activity of key transporter proteins. Additionally, the gut microbiome may contribute to the development of PPI-induced hypomagnesemia, as PPI use affects the composition of the gut microbiome. In this review, we argue that the increase of the luminal pH during PPI treatment may contribute to several of these mechanisms. Considering the fact that bacterial fermentation of dietary fibers results in luminal acidification, we propose that targeting the gut microbiome using dietary intervention might be a promising treatment strategy to restore hypomagnesemia in PPI users.
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Affiliation(s)
- Lisanne M. M. Gommers
- Department of Physiology, Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen the Netherlands
| | - Joost G. J. Hoenderop
- Department of Physiology, Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen the Netherlands
| | - Jeroen H. F. de Baaij
- Department of Physiology, Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen the Netherlands
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Proton pump inhibitor therapy and risk of knee replacement surgery: a general population-based cohort study. Osteoarthritis Cartilage 2022; 30:559-569. [PMID: 35031493 PMCID: PMC8940684 DOI: 10.1016/j.joca.2021.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Proton pump inhibitors (PPIs) are among the most commonly used medications for patients with osteoarthritis (OA). Various types of PPIs have different impacts on lowering serum magnesium level that may affect knee OA progression. We aimed to compare the risk of clinically relevant endpoint of knee replacement (KR) among initiators of five different PPIs with that among histamine-2 receptor antagonist (H2RA) initiators. DESIGN Among patients with knee OA (≥50 years) in The Health Improvement Network database in the UK we conducted five sequential propensity-score matched cohort studies to compare the risk of KR over 5-year among patients who initiated omeprazole (n = 2,672), pantoprazole (n = 664), lansoprazole (n = 3,747), rabeprazole (n = 751), or esomeprazole (n = 827) with those who initiated H2RA. RESULTS The prevalence of PPI prescriptions among participants with knee OA increased from 12.7% in 2000-44.0% in 2017. Two-hundred-and-seventy-four KRs (30.8/1,000 person-years) occurred in omeprazole initiators and 230 KRs (25.4/1,000 person-years) in H2RA initiators. Compared with H2RA initiators, the risk of KR was 21% higher in omeprazole initiators (hazard ratio [HR] = 1.21,95% confidence interval [CI]:1.01-1.44). Similar results were observed when pantoprazole use was compared with H2RA use (HR = 1.38,95%CI:1.00-1.90). No such an increased risk of KR was observed among lansoprazole (HR = 1.06,95%CI:0.92-1.23), rabeprazole (HR = 0.97,95%CI:0.73-1.30), or esomeprazole (HR = 0.83,95%CI:0.60-1.15) initiators compared with that among H2RA initiators. CONCLUSIONS In this population-based cohort study, initiation of omeprazole or pantoprazole use was associated with a higher risk of KR than initiation of H2RA use. This study raises concern regarding an unexpected risk of omeprazole and pantoprazole on accelerating OA progression.
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Rooney MR, Bell EJ, Alonso A, Pankow JS, Demmer RT, Rudser KD, Chen LY, Lutsey PL. Proton Pump Inhibitor Use, Hypomagnesemia and Risk of Cardiovascular Diseases: The Atherosclerosis Risk in Communities (ARIC) Study. J Clin Gastroenterol 2021; 55:677-683. [PMID: 33471493 PMCID: PMC7921206 DOI: 10.1097/mcg.0000000000001420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/01/2020] [Indexed: 12/10/2022]
Abstract
GOALS The goal of this study was to evaluate whether proton pump inhibitor (PPI) use is cross-sectionally associated with hypomagnesemia and whether hypomagnesemia mediates the prospective association between PPIs and cardiovascular disease (CVD) risk. BACKGROUND Use of PPIs has been associated with hypomagnesemia, primarily in case reports or within insurance databases. Both PPI use and low serum magnesium (Mg) have been associated with modestly higher CVD risk. Yet, the interrelation between PPI use and Mg in relation to CVD risk is unclear. STUDY The 4436 Atherosclerosis Risk in Communities participants without prevalent CVD at visit 5 (baseline, 2011-2013) were included. Multivariable relative risk regression was used for cross-sectional analyses between PPI and hypomagnesemia prevalence (≤0.75 mmol/L). Incident CVD (defined by atrial fibrillation, coronary heart disease, CVD mortality, heart failure, stroke) was identified through 2017. Multivariable Cox regression was used to examine the PPI-CVD association. RESULTS Participants were mean±SD aged 75±5 years; 63% were women, 23% Black, and 24% were PPI users. PPI users had 1.24-fold (95% confidence interval: 1.08-1.44) higher prevalence of hypomagnesemia than nonusers. Over a median 5 years of follow-up, 684 incident CVD events occurred. PPI users had higher CVD risk [hazard ratio (95% confidence interval) 1.31 (1.10-1.57)] than nonusers. The effect estimate was largely unchanged when hypomagnesemia was added to the model as a potential mediator. CONCLUSIONS In this elderly community-based study, PPI users had a higher prevalence of hypomagnesemia than in nonusers. PPI users also had higher CVD risk than nonusers; however, it appears unlikely that hypomagnesemia explains associations of PPIs with CVD risk.
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Affiliation(s)
- Mary R Rooney
- Division of Epidemiology and Community Health
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | | | - Kyle D Rudser
- Division of Biostatistics, School of Public Health, University of Minnesota
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN
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Chong RQ, Gelissen I, Chaar B, Penm J, Cheung JMY, Harnett JE. Do medicines commonly used by older adults impact their nutrient status? EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100067. [PMID: 35480616 PMCID: PMC9031754 DOI: 10.1016/j.rcsop.2021.100067] [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: 07/10/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 01/04/2023] Open
Abstract
Background Chronic health conditions and polypharmacy are common among the older population and associated with increased risks of adverse events, medicine-interactions, geriatric syndromes, falls and mortality. Poor nutrition is also common in older people. Causal associations between medication use and older people's nutrient status is seldom discussed. Objectives The objectives of this review were to summarise the literature reporting associations between medicines commonly prescribed to older adults and nutrient deficiencies, and to discuss the clinical implications and management. Methods Medicine information resources (n = 5) were searched for information about nutrient deficiencies associated with common medicines used by older people and listed within the top 50 medicines prescribed by volume on the Australian Pharmaceutical Benefits Scheme. This was followed by a search for clinical studies published on PubMed from inception to April 2020. Data was extracted, tabulated and summarised with clinical information relevant to pharmacists and clinicians involved in the care of older people taking medicines. Results A total of 23 clinical studies were identified reporting medicine-induced nutrient deficiencies in older adults. Vitamin B12, sodium, magnesium were identified as the 3 main nutrients susceptible to deficiency by medicines used to treat cardiovascular disease, neurological conditions, gastrointestinal conditions, and diabetes. The coenzyme CoQ10 was depleted by statins.Conclusion: Certain medicines commonly prescribed to older adults are associated with nutrient deficiencies that may be clinically significant. Given the high prevalence of comorbidities and polypharmacy it is possible that some of these individual drug-induced nutrient deficiencies are compounded, warranting both clinical and research attention.
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Affiliation(s)
- Rui Qi Chong
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Ingrid Gelissen
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Betty Chaar
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Jonathan Penm
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Janet MY Cheung
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Joanna E. Harnett
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
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Abstract
Magnesium (Mg2+) plays an essential role in many biological processes. Mg2+ deficiency is therefore associated with a wide range of clinical effects including muscle cramps, fatigue, seizures and arrhythmias. To maintain sufficient Mg2+ levels, (re)absorption of Mg2+ in the intestine and kidney is tightly regulated. Genetic defects that disturb Mg2+ uptake pathways, as well as drugs interfering with Mg2+ (re)absorption cause hypomagnesemia. The aim of this review is to provide an overview of the molecular mechanisms underlying genetic and drug-induced Mg2+ deficiencies. This leads to the identification of four main mechanisms that are affected by hypomagnesemia-causing mutations or drugs: luminal transient receptor potential melastatin type 6/7-mediated Mg2+ uptake, paracellular Mg2+ reabsorption in the thick ascending limb of Henle's loop, structural integrity of the distal convoluted tubule and Na+-dependent Mg2+ extrusion driven by the Na+/K+-ATPase. Our analysis demonstrates that genetic and drug-induced causes of hypomagnesemia share common molecular mechanisms. Targeting these shared pathways can lead to novel treatment options for patients with hypomagnesemia.
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Recart DA, Ferraris A, Petriglieri CI, Alonso Serena M, Bonella MB, Posadas-Martinez ML. Prevalence and risk factors of long-term proton pump inhibitors-associated hypomagnesemia: a cross-sectional study in hospitalized patients. Intern Emerg Med 2021; 16:711-717. [PMID: 33001349 DOI: 10.1007/s11739-020-02501-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/05/2020] [Indexed: 02/06/2023]
Abstract
Proton pump inhibitors (PPI)-related hypomagnesemia is a potentially life-threatening adverse event first described in 2006. PPIs are widely used in the general population. Information regarding prevalence and risk factors is scarce. We conducted a cross-sectional study in inpatients to evaluate prevalence and associated factors with hypomagnesemia in chronic PPIs users. This is a cross-sectional study of hospitalized adult patients with chronic use of PPIs from January 01, 2012, to December 31, 2018. Chronic use was defined as taking PPIs at least 6 months before hospital admittance. Data were collected from informatized medical records from a University Hospital (Hospital Italiano de Buenos Aires). Hypomagnesemia was defined as a value equal to or less than 1.7 mg/dl. The first hospitalization measurement was retrieved. Thirty-six percent of patients (95% CI 30-43) with chronic PPI use presented hypomagnesemia at admission. Patients with hypomagnesemia presented a higher prevalence of chronic kidney disease (18.6% vs 8%, p < 0.05), more use of oral magnesium supplementation (20.9% vs 8%, p < 0.05), use of corticosteroids (32.6% vs 19.3%, p = 0.06) and calcineurin inhibitors (17.4% vs 6.7%, p < 0.05). Regarding laboratory findings, they presented lower hematocrit (28.7% vs 32.8%, p < 0.05), phosphatemia (3 mg/dl vs 3.4 mg/dl, p < 0.05), natremia (135 mg/dl vs 136 mg/dl, p < 0.05) and albumin levels (2.8 g/dl vs 3.2 g/dl p < 0.05) when compared to those who presented normomagnesemia. Hypocalcemia was more frequent among patients with hypomagnesemia (57% vs 38.7%, p < 0.05). In the multivariate analysis, hyponatremia, decreasing levels of hematocrit (odds ratio, OR 0.93-CI 95% 0.88-0.98) and malignant bone compromise (OR 2.83-CI 95% 1.04-7.7) were associated with hypomagnesemia. Adult patients with long-term use of PPIs have a high prevalence of hypomagnesemia. Increasing age, female sex, concomitant use of drugs that impair tubular function and chronic kidney disease may enhance this phenomenon. Anemia, hyponatremia and malignant bone compromise were associated factors with PPIs-related hypomagnesemia.
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Affiliation(s)
- Delfina Ana Recart
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina.
| | - Augusto Ferraris
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
- Pharmacology Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Marina Alonso Serena
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
| | - Maria Belen Bonella
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
| | - Maria Lourdes Posadas-Martinez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Teniente General Perón 4190 avenue, Buenos Aires, Argentina
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Workeneh BT, Uppal NN, Jhaveri KD, Rondon-Berrios H. Hypomagnesemia in the Cancer Patient. KIDNEY360 2020; 2:154-166. [PMID: 35368816 PMCID: PMC8785729 DOI: 10.34067/kid.0005622020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/11/2020] [Indexed: 02/04/2023]
Abstract
Hypomagnesemia is a common medical problem that contributes to the morbidity and mortality of patients with cancer. This review summarizes magnesium physiology and highlights the mechanisms underlying magnesium disturbances due to cancer and cancer treatment. The causes of hypomagnesemia can be categorized according to the pathophysiologic mechanism: decreased intake, transcellular shift, gastrointestinal losses, and kidney losses. Patients with cancer are at risk for opportunistic infections, frequently experience cardiovascular complications, and often receive classes of medications that cause or exacerbate hypomagnesemia. Also, cancer-specific therapies are responsible for hypomagnesemia, including platinum-based chemotherapy, anti-EGF receptor mAbs, human EGF receptor-2 target inhibitors (HER2), and calcineurin inhibitors. Urinary indices, such as the fractional excretion of magnesium, can provide useful information about the etiology. The management of hypomagnesemia depends on the magnitude of hypomagnesemia and the underlying cause. We recommended checking serum magnesium at the beginning of treatment and as part of routine monitoring throughout cancer treatment. Opportunities exist for potential research and practice improvement, including further characterization of hypomagnesemia regarding the clinical effect on cancer outcomes, preventing hypomagnesemia in patients receiving high-risk anticancer agents, and developing effective therapeutic strategies.
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Affiliation(s)
- Biruh T. Workeneh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nupur N. Uppal
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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14
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Mazereeuw G, Gomes T, Macdonald EM, Greaves S, Li P, Mamdani MM, Redelmeier DA, Juurlink DN. Oxycodone, Hydromorphone, and the Risk of Suicide: A Retrospective Population-Based Case-Control Study. Drug Saf 2020; 43:737-743. [PMID: 32328907 DOI: 10.1007/s40264-020-00924-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Opioids have been increasingly associated with suicide, but whether they are independent contributors is unclear. Oxycodone and hydromorphone are commonly prescribed high-potency opioids that can differentially affect mood. OBJECTIVE The objective of this study was to explore whether oxycodone and hydromorphone are differentially associated with suicide. METHODS We conducted a retrospective population-based case-control study in Ontario, Canada, from 1992 to 2014. Using coronial data, we defined case subjects as individuals who died by suicide involving an opioid overdose. Each of these was matched with up to four controls who died of accidental opioid overdose. We ascertained exposure to oxycodone, hydromorphone, and other opioids from postmortem toxicology testing. We used odds ratios and 95% confidence intervals to examine whether opioid-related suicide was disproportionately associated with oxycodone relative to hydromorphone. RESULTS We identified 438 suicides and 1212 accidental deaths, each of which involved either oxycodone or hydromorphone but not both. The median age at death was 49 years and 51% were men. After adjusting for a history of self-harm, psychiatric illness, and exposure to other opioids, we found that oxycodone was more strongly associated with suicide than hydromorphone (adjusted odds ratio 1.59; 95% confidence interval 1.20-2.11). In a secondary analysis, we observed a trend of similar magnitude in which combined exposure to oxycodone and hydromorphone was more strongly associated with suicide than hydromorphone alone (adjusted odds ratio 1.68; 95% confidence interval 0.92-3.09). CONCLUSIONS While preliminary, these findings support the possibility that some high-potency opioids might independently influence the risk of suicide in susceptible individuals.
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Affiliation(s)
- Graham Mazereeuw
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Erin M Macdonald
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Simon Greaves
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Ping Li
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Muhammad M Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training, Toronto, ON, Canada
| | | | - David N Juurlink
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue G106, Toronto, ON, M4N 3M5, Canada.
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15
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Sutton SS, Magagnoli J, Cummings T, Hardin JW. The Association between the Use of Proton Pump Inhibitors and the Risk of Hypomagnesemia in a National Cohort of Veteran Patients with HIV. J Int Assoc Provid AIDS Care 2020; 18:2325958218821652. [PMID: 30798693 PMCID: PMC6748508 DOI: 10.1177/2325958218821652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objectives: To examine the risk of hypomagnesemia of HIV-positive patients adherent to proton pump
inhibitors (PPIs). Methods: A cohort study utilizing the Veterans Affairs Informatics and Computing Infrastructure
was conducted on patients with (1) a complete antiretroviral therapy, (2) a serum
magnesium measure during the study period, and (3) adherent to PPIs. Statistical
analyses evaluated baseline characteristics between cohorts and a Cox proportional
hazards model evaluating the association of hypomagnesemia while adjusting for baseline
covariates. Results: A total of 6047 patients met the study inclusion criteria, 329 patients in the PPI
cohort and 5718 patients in the non-PPI cohort. The stratified Cox proportional hazards
model results revealed that the risk of hypomagnesemia for the PPI cohort is 3.16 times
higher compared to the non-PPI cohort (adjusted hazard ratio = 3.16, 95% confidence
interval = 2.56-3.9). Conclusions: Proton pump inhibitors medication usage in HIV-positive patients is associated with a
higher risk of hypomagnesemia compared to non-PPI patients.
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Affiliation(s)
- S Scott Sutton
- 1 Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, College of Pharmacy, Columbia, SC, USA.,2 Dorn Research Institute, WJB Dorn Veterans Affairs Medical Center, Columbia, SC, USA
| | - Joseph Magagnoli
- 2 Dorn Research Institute, WJB Dorn Veterans Affairs Medical Center, Columbia, SC, USA
| | - Tammy Cummings
- 3 WJB Dorn Veterans Affairs Medical Center, Columbia, SC, USA
| | - James W Hardin
- 4 Biostatistics Division, Department of Epidemiology & Biostatistics, University of South Carolina, Columbia, SC, USA
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16
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Guedes JVM, Aquino JA, Castro TLB, Augusto de Morais F, Baldoni AO, Belo VS, Otoni A. Omeprazole use and risk of chronic kidney disease evolution. PLoS One 2020; 15:e0229344. [PMID: 32130255 PMCID: PMC7055824 DOI: 10.1371/journal.pone.0229344] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/04/2020] [Indexed: 12/26/2022] Open
Abstract
RATIONALE, AIMS AND OBJECTIVES In recent years, the use of proton pump inhibitors (PPI), especially omeprazole, has been associated with development of chronic kidney disease (CKD). These drugs are widely used worldwide. Although some studies have found an association between the use of PPI and the onset of acute renal failure and CKD. This study aims to analyze the association between the continuous use of omeprazole and the progression of CKD in adult and elderly individuals. METHOD A retrospective cohort study was conducted with patients followed up at a nephrology clinic in Brazil, in 2016 and 2017. Information about clinical and sociodemographic data, health behaviors, and medication use were collected from all patients diagnosed with CKD through consultation of medical charts and the Brazilian health information system (SIS). The participants were allocated into two groups: users and non-users of omeprazole, and the progression of CKD was then evaluated for each group. In the bivariate analysis, the Mann-Whitney U test to compare the quantitative variables between groups, and the Pearson/Fisher two-tailed chi-square test to compare the categorical variables were applied. Multivariate analysis was performed using Cox regression. RESULTS A total of 199 CKD patients were attended in the polyclinic, and of these, 42.7% were omeprazole users. There was a higher percentage of CKD progression in users (70.6%) compared to non-users (10.5%). The hazard ratio was 7.34 (CI: 3.94-13.71), indicating a higher risk of progression to worse stages of CKD in omeprazole users than in non-users. As for the other variables, no statistically significant difference was found between groups (p > 0.05). CONCLUSION An association between omeprazole use and progression of CKD stage was identified, showing a higher risk of disease evolution among omeprazole users.
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Affiliation(s)
- João Victor Marques Guedes
- Department of Health Sciences, Federal University of São João Del-Rei (UFSJ), Divinópolis, Minas Gerais, Brazil
| | - Jéssica Azevedo Aquino
- Department of Health Sciences, Federal University of São João Del-Rei (UFSJ), Divinópolis, Minas Gerais, Brazil
| | | | - Flávio Augusto de Morais
- Department of Nephrology, Ambulatory of Municipal Polyclinic of Divinopolis, Divinópolis, Minas Gerais, Brazil
| | - André Oliveira Baldoni
- Department of Health Sciences, Federal University of São João Del-Rei (UFSJ), Divinópolis, Minas Gerais, Brazil
| | - Vinícius Silva Belo
- Department of Health Sciences, Federal University of São João Del-Rei (UFSJ), Divinópolis, Minas Gerais, Brazil
| | - Alba Otoni
- Department of Health Sciences, Federal University of São João Del-Rei (UFSJ), Divinópolis, Minas Gerais, Brazil
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17
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Abstract
A substantial volume of literature exists linking proton pump inhibitor (PPI) use with a multitude of serious adverse events. There is uncertainty, however, over whether these associations are clinically important. Excessive concern about PPI-related adverse events may leave patients at risk of harm by leaving acid-related upper gastrointestinal disease untreated. Conversely, the risk of treatments may outweigh the benefits if any of the purported adverse events are directly caused by PPI use; this is of particular concern where indications for PPI use are not present. In this paper, we review the studies which have reported associations between adverse events and PPI use, discuss the proposed mechanisms of action, grade the confidence in whether these associations are truly causal, and provide advice regarding balancing the benefits of PPI use against their possible harms.
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Affiliation(s)
- Evan Elias
- Section of Gastroenterology, Department of Internal Medicine, Rady School of Medicine, University of Manitoba, 805G-715 McDermot Avenue, Winnipeg, MB, R3E 3P4, Canada
| | - Laura E Targownik
- Section of Gastroenterology, Department of Internal Medicine, Rady School of Medicine, University of Manitoba, 805G-715 McDermot Avenue, Winnipeg, MB, R3E 3P4, Canada.
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18
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Srinutta T, Chewcharat A, Takkavatakarn K, Praditpornsilpa K, Eiam-Ong S, Jaber BL, Susantitaphong P. Proton pump inhibitors and hypomagnesemia: A meta-analysis of observational studies. Medicine (Baltimore) 2019; 98:e17788. [PMID: 31689852 PMCID: PMC6946416 DOI: 10.1097/md.0000000000017788] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous meta-analyses have suggested that there might be an association between the use of proton pump inhibitors (PPIs) and the development of hypomagnesemia, although the conclusions were no definitive. METHODS To provide an update on this topic, we performed a meta-analysis of all observational studies that examined the association between the use of PPIs and the development of hypomagnesemia. A literature search was conducted in MEDLINE, Scopus and Cochrane Central Register of Controlled Trials (January 1970 to June 2018) to identify observational studies that examined the association between the use of PPIs and the incidence and prevalence of hypomagnesemia. STUDY ELIGIBILITY CRITERIA In the absence of randomized controlled trials, we focused primarily on observational studies, including cross-sectional, case-control, retrospective, and prospective cohort studies. There was no limitation on sample size or study duration. Random-effect models meta-analyses were used to compute pooled unadjusted and adjusted odds ratios (ORs) for binary variables. RESULTS Sixteen observational studies were identified, including 13 cross-sectional studies, 2 case-control studies, and 1 cohort study, with a total of 131,507 patients. The pooled percentage of PPI users was 43.6% (95% confidence interval [CI] 25.0%, 64.0%). Among PPI users, 19.4% (95% CI 13.8%, 26.5%) had hypomagnesemia compared to 13.5% (95% CI 7.9%, 22.2%) among nonusers. By meta-analysis, PPI use was significantly associated with hypomagnesemia, with a pooled unadjusted OR of 1.83 (95% CI 1.26, 2.67; P = .002) and a pooled adjusted OR of 1.71 (95% CI 1.33, 2.19; P < .001). In subgroup analyses, high-dose PPI use was associated with higher odds for hypomagnesemia relative to low-dose PPI use (pooled adjusted OR 2.13; 95% CI 1.26, 3.59; P = .005). CONCLUSION Our findings are in support of the results of the previous meta-analyses. Furthermore, we found a dose-response between the PPI use and development of hypomagnesemia.
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Affiliation(s)
- Thawin Srinutta
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Api Chewcharat
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth's Medical Center
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Research Unit for Metabolic Bone Disease in CKD patients, Chulalongkorn University, Bangkok, Thailand
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Lee L, Ramos-Alvarez I, Ito T, Jensen RT. Insights into Effects/Risks of Chronic Hypergastrinemia and Lifelong PPI Treatment in Man Based on Studies of Patients with Zollinger-Ellison Syndrome. Int J Mol Sci 2019; 20:ijms20205128. [PMID: 31623145 PMCID: PMC6829234 DOI: 10.3390/ijms20205128] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 02/07/2023] Open
Abstract
The use of proton pump inhibitors (PPIs) over the last 30 years has rapidly increased both in the United States and worldwide. PPIs are not only very widely used both for approved indications (peptic ulcer disease, gastroesophageal reflux disease (GERD), Helicobacter pylori eradication regimens, stress ulcer prevention), but are also one of the most frequently off-label used drugs (25–70% of total). An increasing number of patients with moderate to advanced gastroesophageal reflux disease are remaining on PPI indefinitely. Whereas numerous studies show PPIs remain effective and safe, most of these studies are <5 years of duration and little data exist for >10 years of treatment. Recently, based primarily on observational/epidemiological studies, there have been an increasing number of reports raising issues about safety and side-effects with very long-term chronic treatment. Some of these safety issues are related to the possible long-term effects of chronic hypergastrinemia, which occurs in all patients taking chronic PPIs, others are related to the hypo-/achlorhydria that frequently occurs with chronic PPI treatment, and in others the mechanisms are unclear. These issues have raised considerable controversy in large part because of lack of long-term PPI treatment data (>10–20 years). Zollinger–Ellison syndrome (ZES) is caused by ectopic secretion of gastrin from a neuroendocrine tumor resulting in severe acid hypersecretion requiring life-long antisecretory treatment with PPIs, which are the drugs of choice. Because in <30% of patients with ZES, a long-term cure is not possible, these patients have life-long hypergastrinemia and require life-long treatment with PPIs. Therefore, ZES patients have been proposed as a good model of the long-term effects of hypergastrinemia in man as well as the effects/side-effects of very long-term PPI treatment. In this article, the insights from studies on ZES into these controversial issues with pertinence to chronic PPI use in non-ZES patients is reviewed, primarily concentrating on data from the prospective long-term studies of ZES patients at NIH.
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Affiliation(s)
- Lingaku Lee
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA.
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka 812-8582, Japan.
| | | | - Tetsuhide Ito
- Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital, International University of Health and Welfare 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan.
| | - Robert T Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA.
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20
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Al-Aly Z, Maddukuri G, Xie Y. Proton Pump Inhibitors and the Kidney: Implications of Current Evidence for Clinical Practice and When and How to Deprescribe. Am J Kidney Dis 2019; 75:497-507. [PMID: 31606235 DOI: 10.1053/j.ajkd.2019.07.012] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
Proton pump inhibitors (PPIs), long thought to be safe, are associated with a number of nonkidney adverse health outcomes and several untoward kidney outcomes, including hypomagnesemia, acute kidney injury, acute interstitial nephritis, incident chronic kidney disease, kidney disease progression, kidney failure, and increased risk for all-cause mortality and mortality due to chronic kidney disease. PPIs are abundantly prescribed, rarely deprescribed, and frequently purchased over the counter. They are frequently used without medical indication, and when medically indicated, they are often used for much longer than needed. In this In Practice review, we summarize evidence linking PPI use with adverse events in general and adverse kidney outcomes in particular. We review the literature on the association of PPI use and risk for hypomagnesemia, acute kidney injury, acute interstitial nephritis, incident chronic kidney disease, kidney disease progression, end-stage kidney disease, and death. We provide an assessment of how this evidence should inform clinical practice. We review the impact of this evidence on patients' perception of risk, synthesize PPI deprescription literature, and provide our recommendations on how to approach PPI use and deprescription.
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Affiliation(s)
- Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of St. Louis, Saint Louis, MO; Department of Medicine, Washington University School of Medicine, Saint Louis, MO; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO.
| | - Geetha Maddukuri
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of St. Louis, Saint Louis, MO
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21
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Yap MH, Yip G, Edwards A, D'Intini V, Tong E. Appropriateness of proton pump inhibitor use in patients admitted under the general medical unit. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Gary Yip
- Alfred Health General Medicine Unit Melbourne Australia
| | | | | | - Erica Tong
- Alfred Health Pharmacy Melbourne Australia
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22
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Adverse outcomes of long-term use of proton pump inhibitors: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:1395-1405. [PMID: 30028775 DOI: 10.1097/meg.0000000000001198] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The association between the long-term use of proton pump inhibitors (PPIs) and the risks of various diseases remains controversial. Therefore, the primary objective of this study was to quantify the associations as presented in the literature and to also provide this information to healthcare professionals and patients about their potentially adverse effects. In July 2016, we searched through Medline (PubMed), Embase, and the Cochrane Library from inception using common keywords. We included observational studies that provided risk estimates on the long-term use of PPIs and their adverse effects. Overall, 43 studies were included in the systematic review, of which 28 studies were also included in the random effect meta-analysis. Odds of community-acquired pneumonia, hip fracture, and colorectal cancer were 67% [odds ratio (OR)=1.67; 95% confidence interval (CI): 1.04-2.67], 42% (OR=1.42; 95% CI: 1.33-1.53), and 55% (OR=1.55; 95% CI: 0.88-2.73) higher in patients with long-term PPIs use compared with patients who did not use PPIs. Although the use of PPIs provides short-term health benefits, their prolonged use is associated with minor and also potentially major adverse health outcomes. Hence, we strongly recommend that the prescription of PPIs should be done with caution to improve the medication's efficacy and patients' safety.
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23
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Chowdhry M, Shah K, Kemper S, Zekan D, Carter W, McJunkin B. Proton pump inhibitors not associated with hypomagnesemia, regardless of dose or concomitant diuretic use. J Gastroenterol Hepatol 2018. [PMID: 29514412 DOI: 10.1111/jgh.14141] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Proton pump inhibitors (PPIs) are among the most commonly prescribed medications worldwide, with dramatic efficacy for upper gastrointestinal acid-related disorders. In recent years, however, the safety of long-term PPI use has been questioned. One issue based on scant and conflicting literature is the possibility of PPI-related hypomagnesemia. Our purpose was to assess for any clinically significant alteration in serum magnesium levels in large groups of patients taking different PPIs in varying doses, with or without diuretics. METHODS This was a retrospective review of patient records at time of hospitalization, from February 2012 to December 2014. Two thousand four hundred patients were randomly selected from a pool of 12 058 magnesium levels performed at or within 24 h of hospital admission. Patients were categorized in six groups based on outpatient PPI and/or diuretic use. The main outcome studied was hypomagnesemia, defined as serum magnesium level < 1.6 mg/dL. RESULTS Mean magnesium levels were normal in PPI users (1.84 ± 0.29 mg/dL [normal 1.6 to 2.5 mg/dL]) and PPI nonusers (1.85 ± 0.30 mg/dL), P = 0.40, and there was no statistical difference in the prevalence of hypomagnesemia (14.7% vs 15.1%, P = 0.77). In separate groups, there were also no significant differences in serum magnesium levels between those taking PPIs of varying doses, with or without concomitant diuretics, and those not taking PPIs or diuretics. CONCLUSION Regardless of PPI dosage or concomitant diuretics prescribed, magnesium levels were unaffected. Routine screening of serum magnesium in PPI patients appears unnecessary.
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Affiliation(s)
- Monica Chowdhry
- Department of Internal Medicine, West Virginia University Health Sciences Center, Charleston Division/Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Kuldeep Shah
- Department of Internal Medicine, West Virginia University Health Sciences Center, Charleston Division/Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Suzanne Kemper
- Department of Internal Medicine, West Virginia University Health Sciences Center, Charleston Division/Charleston Area Medical Center, Charleston, West Virginia, USA
| | - David Zekan
- Department of Internal Medicine, West Virginia University Health Sciences Center, Charleston Division/Charleston Area Medical Center, Charleston, West Virginia, USA
| | - William Carter
- Department of Internal Medicine, West Virginia University Health Sciences Center, Charleston Division/Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Brittain McJunkin
- Department of Internal Medicine, West Virginia University Health Sciences Center, Charleston Division/Charleston Area Medical Center, Charleston, West Virginia, USA
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24
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Singh A, Cresci GA, Kirby DF. Proton Pump Inhibitors: Risks and Rewards and Emerging Consequences to the Gut Microbiome. Nutr Clin Pract 2018; 33:614-624. [PMID: 30071147 DOI: 10.1002/ncp.10181] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In recent years, proton pump inhibitors (PPIs) have been criticized for their various adverse interactions and side effects, creating a dilemma among practitioners regarding their use. Our goal is to review the proper use and possible side effects that might be caused by or associated with PPI use. Conclusions were drawn based on the evidence supporting or refuting short-term and long-term adverse events associated with PPI use. We also looked for the evidence regarding effects of PPIs on gut microbiota and their overall safety profile. Although there are significant discrepancies in the current literature regarding various adverse effects associated with PPI use, current data suggest that PPI use is not associated with an increased risk of bone fractures, community-acquired pneumonia, cardiovascular events, hypocalcemia, and gastric malignancies. A mild increased risk of vitamin B12 deficiency and chronic kidney disease, and a moderate increase in the risk of rebound hypersecretion, small intestinal bacterial overgrowth, and enteric infections, including Clostridium difficile, has been noted with PPI therapy. PPI's link with dementia and spontaneous bacterial peritonitis is not clear and requires further investigation. When used appropriately, PPIs are safe medications and are associated with minimal side effects. A clear indication and potential short-term and long-term side effects should be considered before starting PPI therapy.
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Affiliation(s)
- Amandeep Singh
- Department of Gastroenterology and Hepatology, Center for Human Nutrition, Diegstive Disease and Survery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gail A Cresci
- Department of Gastroenterology and Hepatology, Center for Human Nutrition, Diegstive Disease and Survery Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Pathobiology, Learner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Department of Gastroenterology and Hepatology, Center for Human Nutrition, Diegstive Disease and Survery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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25
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Haastrup PF, Thompson W, Søndergaard J, Jarbøl DE. Side Effects of Long-Term Proton Pump Inhibitor Use: A Review. Basic Clin Pharmacol Toxicol 2018; 123:114-121. [PMID: 29658189 DOI: 10.1111/bcpt.13023] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/05/2018] [Indexed: 12/13/2022]
Abstract
Proton pump inhibitors (PPIs) are widely used, and concerns about overuse have been raised. Therefore, side effects are important to be aware of and several suggested side effects of long-term use have been studied. In this MiniReview, we sum up the evidence of side effects related to long-term PPI treatment. Suspected side effects are mainly related to increased susceptibility to infections, secondary hypergastrinaemia, impeded absorption of micronutrients or idiosyncratic reactions. Most of the potential side effects have only been evaluated in observational studies demonstrating conflicting and weak associations with a substantial risk of confounding. However, a high probability of causality seems to be established for the side effects increased risk of gastrointestinal infections and rebound acid hypersecretion following discontinuation of treatment due to secondary hypergastrinaemia. The risk of side effects should not be a reason to withhold PPIs from patients with a true indication, and worry about poorly proven side effects should not lead to unnecessary discontinuation. The most important safety issue regarding PPI therapy is to critically evaluate the indication when initiating treatment and reconsidering the indication in long-term-treated patients.
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Affiliation(s)
- Peter Fentz Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
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Abstract
Proton-pump inhibitors (PPIs) are the most effective therapy for the full spectrum of gastric-acid-related diseases. However, in the past decade, a steadily increasing list of complications following long-term use of PPIs has been reported. Their potent acid-suppressive action induces several structural and functional changes within the gastric mucosa, including fundic gland polyps, enterochromaffin-like cell hyperplasia and hypergastrinaemia, which can be exaggerated in the presence of Helicobacter pylori infection. As discussed in this Review, most associations of PPIs with severe adverse events are not based on sufficient evidence because of confounding factors and a lack of plausible mechanisms. Thus, a causal relationship remains unproven in most associations, and further studies are needed. Awareness of PPI-associated risks should not lead to anxiety in patients but rather should induce the physician to consider the appropriate dosing and duration of PPI therapy, including long-term monitoring strategies in selected groups of patients because of their individual comorbidities and risk factors.
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Common single nucleotide polymorphisms in transient receptor potential melastatin type 6 increase the risk for proton pump inhibitor-induced hypomagnesemia: a case-control study. Pharmacogenet Genomics 2017; 27:83-88. [PMID: 27926584 DOI: 10.1097/fpc.0000000000000259] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Proton pump inhibitors (PPIs) are effective drugs for the treatment of gastric acid-related disorders. Serious adverse events are rare for PPIs, but recent data suggest that PPIs cause hypomagnesemia. The aim of this study was to estimate the frequency of PPI-induced hypomagnesemia and to define the risk factors for its development. MATERIALS AND METHODS A total of 133 chronic users of PPIs were enrolled and patients were distinguished on the basis of their serum Mg concentrations. Common single nucleotide polymorphisms (SNPs) in the candidate gene, transient receptor potential melastatin type 6 (TRPM6), were screened. RESULTS Seventeen out of 133 patients had PPI-induced hypomagnesemia. The duration of PPI use was longer in those with hypomagnesemia (7.7 vs. 5.2 years). Two common SNPs in TRPM6 (rs3750425 and rs2274924) increased the risk for PPI-induced hypomagnesemia by 5.8-fold. CONCLUSION We found hypomagnesemia in 13% of PPI users. SNPs in TRPM6 drive the risk of developing hypomagnesemia during chronic PPI use.
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Vaezi MF, Yang YX, Howden CW. Complications of Proton Pump Inhibitor Therapy. Gastroenterology 2017; 153:35-48. [PMID: 28528705 DOI: 10.1053/j.gastro.2017.04.047] [Citation(s) in RCA: 291] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/21/2017] [Accepted: 04/24/2017] [Indexed: 02/08/2023]
Abstract
Safety issues associated with proton pump inhibitors (PPIs) have recently attracted widespread media and lay attention. Gastroenterologists are frequently asked about the appropriateness of PPI therapy for specific patients. Furthermore, some patients may have had PPI therapy discontinued abruptly or inappropriately due to safety concerns. Faced with such a wide variety of potentially serious adverse consequences, prescribers need to evaluate the evidence objectively to discern the likelihood that any reported association might actually be causal. Here, we review many of the proposed adverse consequences of PPI therapy and apply established criteria for the determination of causation. We also consider the potential contribution of residual confounding in many of the reported studies. Evidence is inadequate to establish causal relationships between PPI therapy and many of the proposed associations. Residual confounding related to study design and the overextrapolation of quantitatively small estimates of effect size have probably led to much of the current controversy about PPI safety. In turn, this has caused unnecessary concern among patients and prescribers. The benefits of PPI therapy for appropriate indications need to be considered, along with the likelihood of the proposed risks. Patients with a proven indication for a PPI should continue to receive it in the lowest effective dose. PPI dose escalation and continued chronic therapy in those unresponsive to initial empiric therapy is discouraged.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Yu-Xiao Yang
- Division of Gastroenterology and Center for Clinical Epidemiology and Biostatistics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colin W Howden
- Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee
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29
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Morris C, Pillans P. Proton pump inhibitor-associated hypomagnesaemia and hypocalcaemia. Aust Prescr 2017; 40:79-80. [PMID: 28507402 DOI: 10.18773/austprescr.2017.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Christopher Morris
- Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane
| | - Peter Pillans
- School of Medicine, University of Queensland, Brisbane
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30
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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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31
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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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32
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Ago R, Shindo T, Banshodani M, Shintaku S, Moriishi M, Masaki T, Kawanishi H. Hypomagnesemia as a predictor of mortality in hemodialysis patients and the role of proton pump inhibitors: A cross-sectional, 1-year, retrospective cohort study. Hemodial Int 2016; 20:580-588. [PMID: 27329549 DOI: 10.1111/hdi.12437] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/10/2016] [Indexed: 11/29/2022]
Abstract
Introduction This study aimed to evaluate the association between proton pump inhibitor (PPI) use and serum magnesium levels, and the role of hypomagnesemia and PPI use as a risk factor for mortality in hemodialysis patients. Methods An observational study, including a cross-sectional and 1-year retrospective cohort study. The study comprised 399 hemodialysis patients at a single center, and was conducted from January to September 2014. Multiple linear regression analysis was used to investigate the independent relationship between serum magnesium levels and baseline demographic and clinical variables, including PPI and histamine-2 receptor antagonist use. Cox regression model was used to identify lower serum magnesium level and PPI as a predictor of 1-year mortality. Findings Serum magnesium levels were lower with PPI use than non-PPI use (2.39 ± 0.36 vs. 2.56 ± 0.39 mg/dL, P < 0.001). Multiple linear regression analysis showed that PPI use, low serum albumin levels, and low serum potassium and high-sensitivity C-reactive protein (hs-CRP) levels were significantly associated with low serum magnesium levels. A total of 29 deaths occurred during the follow-up period. According to Cox regression analysis stratified by hs-CRP, only high serum hs-CRP levels (>4.04 mg/L) in association with low serum magnesium levels was an independent risk factor for 1-year mortality (hazard ratio: 2.92; 95% CI: 1.53-6.40, P < 0.001). Discussion Serum magnesium levels are lower in PPI use. In the inflammatory state, a low serum magnesium level is a significant predictor of mortality in hemodialysis patients.
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Affiliation(s)
- Rika Ago
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan. .,Department of Nephrology, Miyoshi Central Hospital, 531 Higashisakeya-cho, Miyoshi, Hiroshima, 728-8502, Japan.
| | - Toshihiro Shindo
- Department of Nephrology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Masataka Banshodani
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan
| | - Sadanori Shintaku
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan
| | - Misaki Moriishi
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hideki Kawanishi
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, 3-30 Nakajimacho, Naka-ku, Hiroshima, 730-8655, Japan.,Faculty of Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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33
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Othman F, Card TR, Crooks CJ. Proton pump inhibitor prescribing patterns in the UK: a primary care database study. Pharmacoepidemiol Drug Saf 2016; 25:1079-87. [DOI: 10.1002/pds.4043] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/24/2016] [Accepted: 05/06/2016] [Indexed: 01/12/2023]
Affiliation(s)
- Fatmah Othman
- Division of Epidemiology and Public Health; The University of Nottingham; Nottingham UK
| | - Timothy R. Card
- Division of Epidemiology and Public Health; The University of Nottingham; Nottingham UK
| | - Colin J. Crooks
- Division of Epidemiology and Public Health; The University of Nottingham; Nottingham UK
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34
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William JH, Danziger J. Proton-pump inhibitor-induced hypomagnesemia: Current research and proposed mechanisms. World J Nephrol 2016; 5:152-157. [PMID: 26981439 PMCID: PMC4777786 DOI: 10.5527/wjn.v5.i2.152] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 11/20/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Since the early reports nearly a decade ago, proton-pump inhibitor-induced hypomagnesemia (PPIH) has become a well-recognized phenomenon. While many observational studies in the inpatient and outpatient populations have confirmed the association of PPI exposure and serum magnesium concentrations, there are no prospective, controlled studies to support causation. Molecular mechanisms of magnesium transporters, including the pH-dependent regulation of transient receptor potential melastatin-6 transporters in the colonic enterocyte, have been proposed to explain the effect of PPIs on magnesium reabsorption, but may be a small part of a more complicated interplay of molecular biology, pharmacology, and genetic predisposition. This review explores the current state of research in the field of PPIH and the proposed mechanisms of this effect.
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35
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Pasina L, Zanotta D, Puricelli S, Bonoldi G. Acute neurological symptoms secondary to hypomagnesemia induced by proton pump inhibitors: a case series. Eur J Clin Pharmacol 2016; 72:641-3. [PMID: 26874835 DOI: 10.1007/s00228-016-2024-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/08/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Luca Pasina
- Pharmacotherapy and Appropriateness of Drug Prescription Unit, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Via Giuseppe La Masa, 19, 20156, Milan, 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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36
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Low Prevalence of Hypomagnesemia in Long-term Recipients of Proton Pump Inhibitors in a Managed Care Cohort. Clin Gastroenterol Hepatol 2016; 14:317-21. [PMID: 26499924 DOI: 10.1016/j.cgh.2015.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic intake of proton pump inhibitors (PPI) has been associated with hypomagnesemia, but prevalence of PPI-associated hypomagnesemia is not known. METHODS We examined the prevalence of hypomagnesemia among long-term PPI recipients by using a large health maintenance organization database. We collected data on 10,167 participants eligible for chronic drug prescriptions from 2008 through 2013. Adult subjects receiving continuous PPI therapy for ≥ 6 months between 2008 and 2013 and ≥ 1 serum magnesium determination(s) were identified. Patients with any magnesium levels less than 1.6 mg/dL were selected for analysis; those with recognizable causes of altered magnesium homeostasis were excluded. RESULTS Five hundred ninety participants received long-term PPIs, and 414 (70.2%) met the inclusion criteria for a total exposure of 2293 PPI-years (average, 5.7 years/subject). Of these patients, 57 (13.8%) had ≥ 1 low serum magnesium; 5 were no longer on PPIs, and 44 had other recognizable causes for hypomagnesemia (25 receiving diuretics, 8 with chronic diarrhea, 8 with chronic kidney disease, and 3 with malignancies). Of the 8 remaining patients (7 female; mean age, 71.2 ± 13.4 years; mean daily medications, 5.4 ± 1.1), mild hypomagnesemia (range, 1.2-1.5 mg/dL) was noted in 13.9% of 289 measurements. All 8 patients had normal serum levels of magnesium at their final measurement. CONCLUSIONS In the absence of known precipitating factors, chronic PPI use does not appear to be associated with hypomagnesemia.
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37
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Chen BB, Prasad C, Kobrzynski M, Campbell C, Filler G. Seizures Related to Hypomagnesemia: A Case Series and Review of the Literature. Child Neurol Open 2016; 3:2329048X16674834. [PMID: 28503619 PMCID: PMC5417264 DOI: 10.1177/2329048x16674834] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 09/13/2016] [Accepted: 09/22/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Childhood seizures have various nonneurological etiologies. The patient's magnesium levels should be measured when evaluating afebrile seizures. The purpose of the current case series is to describe a systematic approach for diagnosing hypomagnesemia using 3 recent patient cases. METHODS This case series describes 3 patients with unprovoked hypomagnesemia-associated seizures. The authors describe the differential diagnosis, pathophysiology, and the workup of hypomagnesemia-associated seizures. RESULTS Hypomagnesemia contributed to the cause of the seizures in all 3 cases. Various causes of hypomagnesemia were investigated, including genetic etiologies. All 3 patients were maintained at a magnesium level >0.65 mmol/L, which improved or eliminated the seizures. SIGNIFICANCE Magnesium levels should always be measured when trying to determine the etiology of seizures. Hypomagnesemia and afebrile seizures should be treated with the goal of maintaining a magnesium concentration >0.65 mmol/L. Although rare, genetic causes of hypomagnesemia should be considered, once common causes of hypomagnesemia are ruled out.
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Affiliation(s)
- Becky Biqi Chen
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Chitra Prasad
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Children’s Health Research Institute, London, Ontario, Canada
| | - Marta Kobrzynski
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Craig Campbell
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Children’s Health Research Institute, London, Ontario, Canada
- Department of Epidemiology and Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Children’s Health Research Institute, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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38
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Stark CM, Nylund CM. Side Effects and Complications of Proton Pump Inhibitors: A Pediatric Perspective. J Pediatr 2016; 168:16-22. [PMID: 26409307 DOI: 10.1016/j.jpeds.2015.08.064] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/10/2015] [Accepted: 08/26/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Christopher M Stark
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Cade M Nylund
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD.
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39
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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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40
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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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41
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Chien LN, Huang YJ, Shao YHJ, Chang CJ, Chuang MT, Chiou HY, Yen Y. Proton pump inhibitors and risk of periampullary cancers--A nested case-control study. Int J Cancer 2015; 138:1401-9. [PMID: 26488896 PMCID: PMC4738410 DOI: 10.1002/ijc.29896] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/06/2015] [Indexed: 12/14/2022]
Abstract
Considerable attention has been focused on long-term use of proton pump inhibitor (PPI) medications in relation to increased risk of cancer via stimulation of DNA-damaged cells. The aim of this study is to examine the dose-dependent effect of PPI on periampullary cancers in a national population-based cohort. A nested case-control analysis was constructed based on Taiwan's National Health Insurance Research Database and the Taiwan Cancer Registry between the years 2000 and 2010. Cases involving patients diagnosed with periampullary cancers were selected and controls were matched to cases according to age, sex and observational period. A "PPI user" was defined as any patient receiving more than 28 cumulative defined daily doses as measured by prescription drug claims. Conditional logistic regression analysis was conducted to calculate odds ratios (ORs) and 95% confidence intervals (CIs) according to the level of PPI exposure. A total of 7,681 cases and 76,762 matched controls were included with a mean follow-up period of 6.6 years (SD: 2.0). The odds of PPI exposure in patients with periampullary cancers were higher than that of control patients with an adjusted OR of 1.35 (95% CIs: 1.16-1.57). Our results also showed that PPI exposure was slightly linked to periampullary cancers in dose-dependent manner. A similar association was observed in patients who solely took PPI but no eradication therapy for Helicobacter pylori infection. Long-term PPI use was associated with an increased risk of periampullary cancers in the current population-based study. Physicians must weigh potential risks of long-term maintenance against therapeutic benefit.
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Affiliation(s)
- Li-Nien Chien
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Yan-Jiun Huang
- Department of General Surgery, Taipei Medical University Hospital, Taipei, Taiwan.,Ph.D. Program for Translational Medicine, Taipei Medical University & Academia Sinica, Taipei, Taiwan
| | - Yu-Hsuan Joni Shao
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
| | - Chen-Jung Chang
- Department of Gastroenterology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ming-Tsang Chuang
- School of Public Health, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Yun Yen
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
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42
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Pasina L, Zanotta D, Puricelli S, Djignefa DC, Bonoldi G. Proton pump inhibitors and risk of hypomagnesemia. Eur J Intern Med 2015; 26:e25-6. [PMID: 26165831 DOI: 10.1016/j.ejim.2015.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 06/29/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Luca Pasina
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", 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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43
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Misra PS, Alam A, Lipman ML, Nessim SJ. The relationship between proton pump inhibitor use and serum magnesium concentration among hemodialysis patients: a cross-sectional study. BMC Nephrol 2015; 16:136. [PMID: 26268579 PMCID: PMC4535779 DOI: 10.1186/s12882-015-0139-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 08/03/2015] [Indexed: 01/24/2023] Open
Abstract
Background Observational data suggest that serum magnesium (Mg) concentration is inversely related to vascular calcification and hyperparathyroidism among patients with end-stage renal disease (ESRD). In recent years, there have been several case reports of hypomagnesemia due to use of proton-pump inhibitors (PPI), with the hypomagnesemia attributed to inappropriate gastrointestinal (GI) Mg loss. We hypothesized that the tendency to GI Mg loss is more common than is currently reported. Since patients with ESRD have little to no renal Mg loss to affect serum Mg concentration, dialysis patients are an interesting population in whom to study the relationship between PPI use and serum Mg levels. Methods Using a single-center cross-sectional design, we studied 155 prevalent hemodialysis (HD) patients. Serum Mg concentration for each patient was determined based on the mean of 3 consecutive serum Mg levels drawn at 6 week intervals. PPI use at the time of the blood tests was documented. The relationship between PPI use and Mg concentration was determined in unadjusted analyses, as well as after adjustment for age, gender, race, cause of ESRD, diabetes, time on HD and dialysate Mg concentration. Results 55 % of patients were on PPIs at the time of the study. The majority of patients (62 %) used a dialysate Mg (in mmol/L) of 0.5, and the remainder (38 %) used a dialysate Mg of 0.375. Serum Mg levels were significantly lower among PPI users vs. non-users (0.93 vs. 1.02 mmol/L, p < 0.001). This finding persisted after stratifying for dialysate Mg concentration, and after multivariable adjustment (p < 0.001). In addition, more PPI users vs. non-users had a Mg level < 1 mmol/L (79 % vs. 43 %) and a Mg level < 0.8 mmol/L (16 % vs. 4 %). There was a non-significant trend toward increased time on PPI being associated with lower serum Mg levels (p = 0.067). Conclusion Among HD patients, PPI users have lower serum Mg levels as compared with non-users. Further research is required to determine whether the magnitude of change in Mg levels among PPI users is associated with adverse outcomes.
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Affiliation(s)
- Paraish S Misra
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada.
| | - Ahsan Alam
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada. .,Department of Medicine, Division of Nephrology, Royal Victoria Hospital, Montreal, Canada.
| | - Mark L Lipman
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada. .,Department of Medicine, Division of Nephrology, Jewish General Hospital, 3755 Cote-Sainte-Catherine Road, Room G-225.1, Montreal, QC, H3T 1E2, Canada.
| | - Sharon J Nessim
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada. .,Department of Medicine, Division of Nephrology, Jewish General Hospital, 3755 Cote-Sainte-Catherine Road, Room G-225.1, Montreal, QC, H3T 1E2, Canada.
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Kieboom BCT, Kiefte-de Jong JC, Eijgelsheim M, Franco OH, Kuipers EJ, Hofman A, Zietse R, Stricker BH, Hoorn EJ. Proton pump inhibitors and hypomagnesemia in the general population: a population-based cohort study. Am J Kidney Dis 2015; 66:775-82. [PMID: 26123862 DOI: 10.1053/j.ajkd.2015.05.012] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/01/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Proton pump inhibitor (PPI) use has been associated with hypomagnesemia in case reports and hospital-based cohort studies. Our objective was to determine whether PPI use is associated with hypomagnesemia in the general population and whether this is also found in histamine 2 receptor antagonist (H2RA) users. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 9,818 individuals from the general population (Rotterdam Study). PREDICTOR PPI use and H2RA use compared to no use. OUTCOMES & MEASUREMENTS Serum magnesium and hypomagnesemia (serum magnesium ≤ 1.44 mEq/L). Analyses were adjusted for age, sex, body mass index, kidney function, comorbid conditions, and alcohol and diuretic use. RESULTS Serum magnesium level was 0.022 mEq/L lower in PPI users (n=724; 95% CI, -0.032 to -0.014 mEq/L) versus those with no use. PPI use was associated with increased risk of hypomagnesemia (n=36; OR, 2.00; 95% CI, 1.36-2.93) compared to no use. Effect modification was found between the use of PPIs and loop diuretics; in participants using loop diuretics (n=270), PPI use was associated with a further increased risk of hypomagnesemia (n=5; OR, 7.22; 95% CI, 1.69-30.83) compared to no use. The increased risk with PPIs was only seen after prolonged use (range, 182-2,618 days; OR, 2.99; 95% CI, 1.73-5.15). Including dietary magnesium intake into the model did not alter results (available for 2,504 participants, including 231 PPI users). H2RA users (n=250) also had a lower serum magnesium level (-0.016 [95% CI, -0.032 to -0.002] mEq/L) and increased risk of hypomagnesemia (n=12; OR, 2.00; 95% CI, 1.08-3.72) compared to those with no use, but no interaction with loop diuretics. LIMITATIONS Cross-sectional analysis with single serum magnesium measurement. CONCLUSIONS PPI use is associated with hypomagnesemia in the general population. Prolonged PPI use and concomitant loop diuretic use are associated with a stronger risk increase. Similar but weaker associations were found in H2RA users, except for interaction with loop diuretics.
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Affiliation(s)
- Brenda C T Kieboom
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Inspectorate of Health Care, Utrecht, the Netherlands
| | - Jessica C Kiefte-de Jong
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Leiden University College, The Hague, the Netherlands
| | - Mark Eijgelsheim
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Robert Zietse
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Inspectorate of Health Care, Utrecht, the Netherlands.
| | - Ewout J Hoorn
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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Atkinson NSS, Reynolds DJM, Travis SPL. 'Lemonade Legs': Why do Some Patients Get Profound Hypomagnesaemia on Proton-Pump Inhibitors? Intest Res 2015; 13:227-32. [PMID: 26130997 PMCID: PMC4479737 DOI: 10.5217/ir.2015.13.3.227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 12/14/2022] Open
Abstract
Proton pump inhibitors (PPIs) are widely used though an association with hypomagnesaemia and hypocalcaemia has only been described since 2006. Patients typically present after years of stable dosing with musculoskeletal, neurological or cardiac arrhythmic symptoms, but it is likely that many cases are under-recognised. Magnesium levels resolve rapidly on discontinuation of PPI therapy and hypomagnesaemia recurs rapidly on rechallenge with any agent in the class. The cellular mechanisms of magnesium homeostasis are increasingly being understood, including both passive paracellular absorption through claudins and active transcellular transporters, including the transient receptor potential channels (TRPM6) identified in the intestine and nephron. PPIs may alter luminal pH by modulating pancreatic secretions, affecting non-gastric H+K+ATPase secretion, altering transporter transcription or channel function. A small reduction in intestinal absorption appears pivotal in causing cumulative deficiency. Risk factors have been associated to help identify patients at risk of this effect but clinical vigilance remains necessary for diagnosis.
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Affiliation(s)
- Nathan S S Atkinson
- Translational Gastroenterology Unit and Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - D John M Reynolds
- Department of Acute General Medicine, Oxford University Hospitals Trust, University of Oxford, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit and Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
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46
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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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47
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Bardou M, Fortinsky KJ. Safety of medication options for treating pediatric esophagitis. Expert Opin Drug Saf 2015; 14:1087-96. [DOI: 10.1517/14740338.2015.1040389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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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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