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Proton Pump Inhibitors
Increase Risk of Hip Fracture
Many Arthritis Patients Taking NSAIDs Use Proton
Pump Inhibitors
An increased risk of hip fracture has been linked to the use of
proton pump inhibitors, a class of drugs used to treat acid-related
conditions such as heartburn and GERD (gastroesophageal reflux
disease). According to study results published in the December 27,
2006 issue of the Journal of the American Medical Association,
researchers reported that treatment with proton pump inhibitors for
more than one year in people over 50 years old was associated with a
44 percent increased risk of hip fracture.
The risk was 2.6 times higher for long term users of proton pump
inhibitors at high doses. Duration and dosage of proton pump
inhibitor use were both linked to increased hip fracture risk. A
smaller, yet similarly increased risk of hip fracture was also
associated with H2 blockers, also referred to as histamine-2
receptor blockers (e.g. Tagamet and Pepcid).
Of 1,262 elderly patients treated with a proton pump inhibitor for
more than a year, one additional hip fracture a year would be tied
to the use of proton pump inhibitors.
For every 336 elderly patients treated for more than one year with
high doses of proton pump inhibitors, one extra hip fracture a year
would be tied to the proton pump inhibitor drugs.
Proton Pump Inhibitors With NSAIDs
Many arthritis patients also take proton pump inhibitors (e.g.
Nexium, Prevacid, Protonix, and Prilosec) along with nonsteroidal
anti-inflammatory drugs (NSAIDs) to reduce potential
gastrointestinal side effects associated with NSAIDs.
Study results reported in 2003 at the annual meeting of the American
College of Gastroenterology suggested that proton pump inhibitors
significantly reduced the risk of ulcers in patients regularly
taking NSAIDs. The information left some doctors believing that all
patients on NSAIDs should also be taking a proton pump inhibitor,
while others felt only patients who were symptomatic with dyspepsia
should take proton pump inhibitors. Again in 2004 and 2005, when
COX-2 inhibitors (a newer class of NSAIDs touted as causing less
gastrointestinal problems) came under scrutiny regarding
cardiovascular safety issues, many doctors again advised arthritis
patients that a traditional NSAID in combination with a proton pump
inhibitor was the better treatment option.
Should Arthritis Patients Stop Taking Proton Pump Inhibitors?
According to rheumatologist Scott J. Zashin, M.D., "Because NSAIDs
can increase the risk of gastrointestinal bleeding, many patients at
risk for this problem simultaneously take a proton pump inhibitor
such as:
Prilosec (omeprazole)
Nexium (esomeprazole)
Aciphex (rabeprazole)
Prevacid (lansoprazole)
Protonix (pantoprazole)
Risk factors for bleeding include age greater than 60, smokers,
taking corticosteroids, aspirin, Coumadin (warfarin), Plavix (clopidogrel)
or serotonin uptake inhibitors, and those with a prior history of
ulcers or gastrointestinal bleeding. Taking a proton pump inhibitor
may decrease the risk of GI bleeding better than H2 antagonists,
which include:
Pepcid (famotidine)
Tagamet (cimetidine)
Zantac (ranitidine)
The recent study shows that those patients taking the highest dose
of the proton pump inhibitors had an increased risk of osteoporosis
and hip fracture. It is still recommended to have a daily intake of
1000-1500 mg of calcium and 400 IU of vitamin D although many people
may benefit from up to 800 IU, especially if they do not have a
history of kidney stones or an elevated calcium.
Based on this study, I would recommend that patients who need to be
on these drugs have their bone density monitored and if low, check a
vitamin D level and consider additional treatment to maintain bone
strength. Other options include replacing the proton pump inhibitors
with a medication called Cytotec (misoprostol) - a medication that
gives the most benefit in protecting the stomach from ulcers when
taken four times daily. The drug is contraindicated (i.e. should not
be used) in women of childbearing age and may be more likely to
cause other gastrointestinal symptoms. The other option is to find
an alternative treatment so NSAIDs are not needed."
Scott J. Zashin, M.D., is clinical assistant professor at University
of Texas Southwestern Medical School, Division of Rheumatology, in
Dallas, Texas; an attending physician at Presbyterian Hospitals of
Dallas and Plano; a fellow of the American College of Physicians and
the American College of Rheumatology; and a member of the American
Medical Association. Dr. Zashin is author of Arthritis Without Pain
- The Miracle Of TNF Blockers. The book is useful for anyone on one
of the biologic drugs (Enbrel, Remicade, Humira) or considering the
biologic drugs. Read my review of the book.
Sources:
1. Yang, Yu-Xiao. "Long-term Proton Pump Inhibitor Therapy and Risk
of Hip Fracture." JAMA December 27, 2006 <http:/ /jama.ama-assn.org/cgi/content/abstract/296/24/2947>.
2. "Heartburn Drugs Linked to Hip Fracture Risk." MSNBC.com.
December 29, 2006. 31 Dec 2006 <http://www.msnbc.msn.com/id/16358462/>.
3. "Proton Pump Inhibitor May Help Prevent Ulcers in Chronic NSAID
Users." Medscape. October 15, 2003. 31 Dec 2006 <http://www.medscape.com/viewarticle/463022/>.
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