LOGIC No 1: March 2017 | Page 25

however , not all studies have shown an association between PPI use for acid suppression and fractures leading to osteoporosis and / or reduced bone mineral density [ 7,8 ]. This suggests that fractures may be due to factors independent of clinical diagnosed osteoporosis . It is believed that PPI use may cancel the beneficial effects of bisphosphonates [ 1 ].
Studies also suggest that PPI use decreases magnesium absorption [ 5 , 9,10 ] and lower magnesium ( hypomagnesemia ) levels are known to inhibit calcium absorption [ 6 ]. It has also been suggested that hypomagnesemia is worse when patients were administered PPI ’ s compared to those using histamine- 2 receptor antagonists ( H 2 RAs , examples include ; cimetidine , famotidine and ranitidine ) [ 9,10 ]. Furthermore , the addition of loop diuretics with either a PPI or H 2 RA results in higher incidence of hypomagnesemia [ 10 ]. Magnesium and calcium are thought to be necessary for bone and musculoskeletal health , therefore , hypomagnesemia as a result of PPI use will impact on elderly falls [ 11 ].
Over the past 10 years there has been a move away from using H 2 RAs to PPIs which has resulted in an alarming increase in the use of PPIs [ 12,13 ]. A small study of 212 patients ’ identified that 75 % of PPI prescriptions were for prophylactic use [ 12 ]. However , the New Zealand medicines datasheet for Omeprazole ( listed on the Ministry of Health , Medsafe website ) does not include prophylactic use of PPIs [ 14 ]. Furthermore , prescriptions of 447 consecutive hospitalisations for falls identified 58 % of patients were on PPIs and 27 % inappropriately ( as per current guidelines ) or with no clinical indication [ 15,16 ]. The study also found that 68 % of patients were on PPI doses much higher than recommended in guidelines and 42 % could have had a lower dose [ 16 ]. Unfortunately , medication discontinuation date was only documented in 5 % of medication charts [ 15 ].
Large retrospective studies have shown that patients on PPIs were more likely to have a fractured hip compared to those on H 2 RAs ( PPIs ( OR = 1.30 , 95 % CI = 1.21 to 1.39 ) and H 2 RAs ( OR = 1.18 , 95 % CI = 1.08 to 1.29 ) [ 17 ]). Risks were further compounded in the elderly population [ 17,18 ]. Medication duration of more than two years and with higher dosages also increased the risks [ 17 ]. Cea Soriano and co-workers showed an increase in risk of fractures with current or long term PPI use , however no increase was seen with H 2 RA [ 19 ]. Kwok and co-authors suggest greater risk of hip , spine and other fractures with PPIs compared to those patients on H 2 RAs with the greatest and most significant risk being spine fractures [ 20 ]. Longer duration of PPI use ( over three years ) was associated with much greater risk [ 20 ]. These results
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