PPI's, Acid Reflux, Osteoporosis and Osteopenia

Let's talk about acid reflux. This is a very real and uncomfortable problem for many adults. Medications called proton pump inhibitors (PPIs) are widely prescribed to treat acid reflux. You may recognize the brand names of Prilosec, Prevacid, Omeprazole, or Nexium.

But are these medications hurting your bone health?

In 2019, a review of studies over the previous 5 years looked into the link between long-term PPI use and fracture risk. Three studies, in particular, focused on post-menopausal women, and in each of the studies, the risk of fracture in this population was increased. Reasons for the possible effect include the possibility of PPIs interfering with mineral absorption or osteoblast and osteoclast bone balance. The review concluded that people who take PPIs should have their bone health monitored regularly.
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In 2022, Park et al. compiled retrospective data to evaluate the effect of long-term PPI use, osteoporosis, and fracture. The population of adults over 50 who took PPIs for more than 180 days, were noted to have a significant association with osteoporosis, but their results looking at hip fractures were inconsistent.

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Also in 2022, a retrospective case-control study by Patel et. al. came out with findings that contradicted these other studies. The authors found a decreased risk of fracture in women aged 50-65 who were taking PPIs. While it is always good to question results and move science along, this study had some serious limitations. The biggest limitation, stated by the authors, was the distribution of women who were taking PPIs: "Only 18.9% were identified to have been on chronic PPI as opposed to about 81.1% not on PPI therapy."
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​Takeaway: Take this article with a grain of salt. Let's wait for a good randomized controlled study to come out before we throw out the previous findings.

In December 2023, the Use of Proton Pump Inhibitors and Risk of Fracture in Adults: A Review of Literature was published. The authors of this study concluded that although observational studies show a relationship between long-term PPI use and bone fracture, the only group that showed a significant risk of fracture were women over 60 with a prior history of fracture.

What about your Trabecular Bone Score (TBS)?

In 2019, Shin and colleagues found that women between the ages of 40-89 who had used PPIs had a lower TBS than women who had not used them in the past.

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​Big takeaways -
If you have been taking PPIs for a long time (greater than 180 days), you should be aware of the potential for your bone health to be affected.

You may need to advocate for more frequent DEXA scans and see if you can get a trabecular bone score with your DEXA scans, especially if you have already fractured.

The research is still in progress for how PPIs affect bone health in post-menopausal women.

I will continue to watch the research and hope to see more quality studies on this come out in the near future.

✅ That's it. As always, my references are listed below.
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I hope you found this helpful.
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In health,
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Andrea Trombley PT, DPT
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​References​
Park, D. H., Seo, S. I., Lee, K. J., Kim, J., Kim, Y., Seo, W. W., Lee, H. S., Shin, W. G., & Yoo, J. J. (2022). Long-term proton pump inhibitor use and risk of osteoporosis and hip fractures: A nationwide population-based and multicenter cohort study using a common data model. Journal of gastroenterology and hepatology, 37(8), 1534–1543. https://doi.org/10.1111/jgh.15879
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Patel N, Fayed M, Faldu P, Maroun W, Chandarana J. Chronic Proton-Pump Inhibitor Therapy and Fracture Risk in Women Aged Between 50 and 65 years: A Retrospective Case-Control Study. Cureus. 2022 Aug 26;14(8):e28429. doi: 10.7759/cureus.28429. PMID: 36176864; PMCID: PMC9512296.

Paudel, Y., Najam, B., Desai, H. N., Illango, J., Seffah, K. D., Kumar, M., Naveen, N., Pachchipulusu, V. K., & Penumetcha, S. S. (2023). Use of Proton Pump Inhibitors and Risk of Fracture in Adults: A Review of Literature. Cureus, 15(12), e49872. https://doi.org/10.7759/cureus.49872
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Thong BKS, Ima-Nirwana S, Chin KY. Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved. Int J Environ Res Public Health. 2019 May 5;16(9):1571. doi: 10.3390/ijerph16091571. PMID: 31060319; PMCID: PMC6540255.

Shin, Y. H., Gong, H. S., & Baek, G. H. (2019). Lower Trabecular Bone Score is Associated With the Use of Proton Pump Inhibitors. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry, 22(2), 236–242. https://doi.org/10.1016/j.jocd.2018.06.008
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