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Posted on 03-27-2012

Morning folks!  I just returned from an osteoporosis symposium in the San Francisco Bay area and learned quite a bit about just how severe the problem of osteoporosis is.  Of course osteoporosis is calcium loss of bone, typically from the inner portion of the bone then begins to affect the outer cortical bone as well.  Proton pump inhibitors (PPIs) come in the form of stomach acid reducing medications such as Prilosec, etc.  These medications are effective and providing comfort by reducing acid (hypochlorhydria) in the stomach however they also interfere with calcium absorption.

This study from the Journal of the American Medical Association looks at the mechanisms and affects these medications have.

From the abstract of the study:

Objective

To determine the association between PPI therapy and risk of hip fracture.

Design, Setting, and Patients
The study cohort consisted of users of proton pump inhibitor therapy and nonusers of acid suppression drugs who were older than 50 years.

Cases included all patients with an incident hip fracture. Controls were selected using incidence density sampling, matched for sex, index date, year of birth, and both calendar period and duration of up-to-standard follow-up before the index date.

Main Outcome Measure
The risk of hip fractures associated with proton pump inhibitor use.

Results
There were 13,556 hip fracture cases and 135,386 controls.

The adjusted odds ratio for hip fracture associated with more than 1 year of PPI therapy was [increased risk by 44% with a range between 30% - 59%].

The risk of hip fracture was significantly increased among patients prescribed long- term high-dose proton pump inhibitors [with an increased risk by 165% with a range between 80% - 290%].

Conclusion
Long-term proton pump inhibitor therapy, particularly at high doses, is associated with an increased risk of hip fracture.

THESE AUTHORS ALSO NOTE:


"More than 47,000 hip fractures occur annually in the United Kingdom." "The mortality rate during the first year after a hip fracture is 20%."

Among those who survived the first year, 20% require nursing home care.

Also, hip fractures require an emergency department visit, hospitalization, surgery, and rehabilitation, incurring huge health care costs.

"The advent of potent acid suppressive medications such as proton pump inhibitors (PPIs) has revolutionized the management of acid-related diseases such as gastroesophageal reflux disease (GERD). Millions of individuals have been using these medications on a continuous or long-term basis."

The hypochlorhydria that occurs from using PPI "could theoretically result in calcium malabsorption."

"Calcium absorption decreases with age while urinary calcium excretion increases." This results in a negative calcium balance in late adulthood. "Thus, cumulative exposure to acid suppression therapy may be the most clinically relevant measure when considering the risk of osteoporosis and fracture." [Important]

RESULTS

The rate of hip fracture was estimated to be 4.0/1000 person-years among patients with more than 1 year of proton pump inhibitor therapy and 1.8/1000 person-years among acid suppression nonusers.

"The risk of hip fracture was markedly increased among long-term users of high-dose proton pump inhibitors therapy compared with acid suppression nonusers." The increased risk was 165%, with a range between 80% - 290%.

COMMENT

"We found a significantly increased risk of hip fracture associated with long- term PPI therapy, particularly among long-term users of high-dose PPI."

"Calcium malabsorption secondary to acid suppressive therapy may potentially explain the positive association."

"Calcium solubility has been believed to be important for its absorption. An acidic environment in the gastrointestinal tract facilitates the release of ionized calcium from insoluble calcium salts."

Data suggest gastric acid may be important for insoluble calcium absorption.

"Osteoporotic fractures are common among the elderly population, and they entail considerable morbidity and mortality."

"In summary, we observed that proton pump inhibitor therapy is associated

with a significantly increased risk of hip fractures, with the highest risk seen among those receiving high-dose proton pump inhibitor therapy."

For elderly patients who require long-term and particularly high-dose proton pump inhibitor therapy, it may be prudent to reemphasize increased calcium intake.

KEY POINTS YOU NEED TO KNOW:

  1. 1)  "More than 47,000 hip fractures occur annually in the United Kingdom."

  2. 2)  "The mortality rate during the first year after a hip fracture is 20%."

  3. 3)  Among those who survived the first year, 20% require nursing home care.

  4. 4)  Hip fractures require an emergency department visit, hospitalization, surgery, and rehabilitation, incurring huge health care costs.

5) "Osteoporotic fractures are common among the elderly population, and they entail considerable morbidity and mortality."

6) Proton pump inhibitors are potent acid suppressive drugs used in the management of acid-related diseases such as gastroesophageal reflux disease. Millions of individuals are using these drugs on a continuous or long-term basis.

7) Proton pump inhibitors interfere with calcium absorption through induction of hypochlorhydria, resulting in osteoporosis and hip fractures.

8) Use of a proton pump inhibitor for more than 1 year increased the risk for hip fracture by 44% with a range between 30% - 59%.

9) Long-term use of high-dose proton pump inhibitors significantly increased the risk for hip fracture by 165% with a range between 80% - 290%.

10) Calcium absorption decreases with age while urinary calcium excretion increases, resulting in a negative calcium balance in late adulthood. Therefore, exposure to acid suppressive drugs may be the "most clinically relevant measure when considering the risk of osteoporosis and fracture." [Important]

11) "In summary, we observed that proton pump inhibitors therapy is associated with a significantly increased risk of hip fractures, with the highest risk seen among those receiving high-dose proton pump inhibitors therapy."

12) For elderly patients who require long-term and particularly high-dose proton pump inhibitors therapy, it may be prudent to reemphasize increased calcium intake.

13) Women who are 50 and over, caucasian, and slender build are at greatest risk and need to have their dexa scan done for bone density.

If you are worried about this and want to act preventatively before this becomes an issue, please call my office and set up an appointment so we can discuss natural alternatives to some of these dangerous medications.

Have a blessed day!

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