|
RHEUMATOLOGIC DISORDERS Arthur
A. Schuna, Section Advisor
GASTROENTEROLOGIC DISORDERS C. Wayne Weart,
Section Advisor
Do PPIs and H2-blockers increase the risk of hip
fractures?
Key point: Results from a large, population-based,
retrospective analysis concluded that proton pump inhibitors (PPIs) and
histamine-2 (H2)-receptor blockers are associated with an
increased risk of hip fracture; this risk was increased with higher
doses and longer duration of use.
Finer points: Douglas Corley, MD, PhD, of Kaiser
Permanente’s research division presented results of a nested,
case–control study assessing the association between PPIs and
H2-blockers and risk of hip fracture at the 2009 Digestive
Disease Week Meeting in Chicago. Corley used data from the Northern
California Kaiser Permanente electronic database to identify patients
with a hip fracture diagnosis (cases, n = 33,752) and matched these
patients in a ratio of approximately 4:1 to controls based on gender,
age, duration of membership/first year of enrollment, and race (n =
130,471). Corley evaluated the dose of PPIs and H2-blockers,
duration of use, and controlled for potential cofounding variables such
as smoking.
Corley reported that cases were 30% more likely than controls to have
taken PPIs for at least 2 years (odds ratio [OR] 1.30 [95% CI
1.21–1.39]) and 18% more likely to have consumed
H2-blockers for 2 years (1.18 [1.08–1.28]). In
addition, he noted that risk of fracture was increased with higher doses
and longer duration of use (2.39 [1.40–4.08] for more than 1.5
doses/day for 8 to 10 years), but also reported that some increased risk
was noted in patients taking these agents for 1 year.
What you need to know: A few observational studies
have been published assessing the association between acid inhibitory
medications, primarily PPIs, and risk of fractures. In 2006, Yang and
colleagues published a case–control study in JAMA that
concluded that the risk of hip fracture was significantly increased
among patients given long-term PPI therapy; they noted that the strength
of this association increased with increasing duration of PPI use (more
than 1 to 4 years). In 2008, Targownik and colleagues published a
case–control study and concluded that long-term exposure to PPI
therapy, defined as 7 or more years, was significantly associated with
an increased risk of osteoporosis-related fracture (OR 1.92
[1.16–3.18], P = 0.011); however, no association was
noted for patients with 1 to 6 years of PPI use. The primary mechanism
behind this association is thought to be impaired intestinal calcium
absorption because of profound acid suppression. Based on current data,
clinicians should determine if these agents are being used for
appropriate indications, at appropriate doses, and for an appropriate
duration of time. For patients who clearly need these therapies (e.g.,
PPIs for gastrointestinal bleeding), clinicians may need to consider
additional therapies including more soluble calcium salts such as
calcium citrate, vitamin D, and bisphosphonates; avoid calcium
carbonate. Although the association between acid-suppressing agents and
hip fracture is not concrete, minimizing any potential risks is
essential.
What your patients need to know: Tell patients that
some data suggest the use of PPIs and H2-blockers may
increase their risk of fracture. Counsel them on appropriate use of
these agents, with the goal of therapy being achieving desired outcomes
with the lowest effective dose for the shortest duration of time. The
importance of maintaining an adequate intake of calcium and vitamin D
while receiving acid-suppressing therapy should also be reviewed with
patients.
Sources:
Related resource on www.pharmacist.com:
Alex Egervary (aegervary@aphanet.org)
Posted June 24, 2009
|
