Prevalence and risk factors of long-term proton pump inhibitors-associated hypomagnesemia: a cross-sectional study in hospitalized patients

Effects of Long-Term Proton Pump Inhibitor Use on Serum Electrolytes and Vitamin Levels: A Quasi-experimental Study in Pakistan

Objective The study aims to investigate the effects of long-term proton pump inhibitor (PPI) use on various micronutrients and electrolytes as compared to other acid-suppressive therapies in the South Asian population. Study design and setting This quasi-experimental study was conducted at the Department of Family Medicine in a a tertiary care setup in Rawalpindi, Pakistan from January 2022 to March 2023. Materials and methods Forty-nine patients with known gastric acid secretion-related disorders were randomized in two groups. The PPI group was treated with oral omeprazole, while the non-PPI group were given sucralfate and famotidine. Patients were followed up for a period of 12 months and levels of sodium, potassium, calcium, magnesium, phosphate, iron, vitamin B12, folate and vitamin D were checked using blood samples at baseline, three-, six-, and 12-month duration. Results The results showed that patients in the PPI group had significantly lower levels of magnesium (1.46 ± 0.15 mEq/L vs. 1.70 ± 0.14 mEq/L, p<0.01), calcium (8.96 ± 0.42 mg/dL vs. 9.50 ± 0.48 mg/dL respectively, p<0.01), and vitamin B12 (329.5 ± 134.7 pg/mL vs. 462.30 ± 193.7 pg/mL, p=0.009) as compared to non-PPI group at 12-month duration. Levels of other electrolytes and minerals did not show significant differences amongst both groups. Conclusion The study indicates that long-term PPI use is associated with lower levels of magnesium, calcium and vitamin B12 levels. Therefore, healthcare providers should consider monitoring these micronutrient levels in patients on long-term PPI therapy to prevent potential nutritional deficiencies.

Evaluation of the Prevalence of Hypomagnesemia and the Related Risk Factors in Patients Admitted to a Referral Heart Hospital in Isfahan

Background

Magnesium is one of the most abundant cations in the body and plays a vital role in the function of the cardiovascular system. Hypomagnesemia can cause severe and dangerous cardiovascular complications. Also, since drugs that can lead to hypomagnesemia are commonly prescribed to cardiac patients, we decided to investigate the prevalence of hypomagnesemia in the population of cardiac patients to be aware of the prevalence of this condition as an important risk factor for cardiovascular events.

Materials and Methods

This study is a retrospective cross-sectional study of an analytical-observational type with a fundamental-applied approach, in which by recording the information of patients in pre-designed forms, the prevalence of hypomagnesemia in them and also the prevalence of hypomagnesemia separation of different heart diseases and the relationship of hypomagnesemia with age, sex, glomerular filtration rate (GFR), and drugs used have been evaluated.

Results

A total of 982 patients were included in the study, of which 636 were men and 346 were women. The average age of the patients in this study was 63 years. Hypomagnesemia was observed in 138 patients (14%), and the prevalence of hypomagnesemia in patients with ventricular arrhythmias was 40%. It was also observed that only 47% of the patients with hypomagnesemia received magnesium, and the rest were not treated.

Conclusion

This study highlights the importance of magnesium status and its relationship with various clinical factors in the studied population. This emphasizes the need to increase attention to hypomagnesemia, especially among vulnerable groups such as women and older adults.

Why think twice before prescribing proton pump inhibitors

Proton pump inhibitors (PPIs) represent a class of drugs most prominently known for their use in acid-related disorders. Omeprazole, a drug belonging to this class, is among the top 10 most prescribed drugs in the USA. PPIs have a direct effect on the gastric pH and therefore on the gastric mucosa. This review aims to present the most common adverse effects PPIs have on the gastric mucosa in particular.

CONCLUSION

PPIs affect the composition of gut and gastric microbiota and will eventually modulate the immune response.

WHAT IS KNOWN

• Proton-pump inhibitors are amonth the most frequent prescirbed drugs becasue of their well demonstrated efficacy in acid-related disorders. • Because of their mode of action and their metabolism, a large spectrum of adversee effects have been reported.

WHAT IS NEW

• Although the well-known success of PPIs in the wide spectrum of all acid-related conditions should not refrain health care professionals to use them when indicated, insufficient attention is given to the multiple adverse effects reported for this class of drugs. • Well designed prospective trials collecting adverse effects are required, since most studies reporting adverse effects are retrospective, are biassed and have methodological issues.

Proton pump inhibitor-induced hypomagnesemia, a rare cause of reversible delirium: A case report with literature review

RATIONALE

Hypomagnesemia is associated with multiple electrolyte disturbances such as hypokalemia, hypocalcemia and hypoparathyroidism. Proton pump inhibitors (PPIs) are widely used in gastrointestinal disorders and are generally considered safe by clinicians. However, it is unusual side effect of hypomagnesemia is potentially under-recognized. Delirium is usually thought to be a clue of cerebrovascular disease, and the association between delirium and hypomagnesemia is unexpected. We describe a patient used PPI with hypomagnesemia showed normal parathyroid hormone (PTH) despite hypocalcemia and reversible delirium. To enhance clinicians' vigilance, we performed a literature review on cerebellar syndromes due to hypomagnesemia.

PATIENT CONCERNS

A 74-year-old woman was admitted to our hospital with intermittent nausea, vomiting, hand tremors, and delirium.

DIAGNOSIS

Laboratory analysis showed hypokalemia, hypomagnesemia, and normal parathyroid hormone despite hypocalcemia, physical examination showed horizontal nystagmus and the brain MRI was negative. Surprising, detailed medical history revealed that the etiology was the usage of omeprazole.

INTERVENTIONS

Omeprazole was discontinued and oral supplementation with magnesium, calcium, and potassium was administered.

OUTCOMES

Delirium quickly disappeared and the serum potassium, magnesium, and calcium levels gradually normalized; at discharge, nystagmus gradually disappeared, and plasma electrolyte levels were stable at follow-up.

LESSONS

Hypomagnesemia is associated with a variety of neurological symptoms up to life-threatening conditions if left untreated; as Mg is not present in routine electrolyte panels, hypoparathyroidism, hypokalemia, and delirium may be a clue, and physicians must be alert to consider PPI as a potential cause of unexplained hypomagnesemia, and timely treatment to avoid sequelae.

Effect of long-term proton pump inhibitors on phosphocalcium metabolism and bone mineral density

Aim: Although Proton pump inhibitors (PPIs) are well-tolerated, their long-term use may be associated with decreased bone mass. Methods: This is a case-control study including patients treated with PPIs (>1 year) and control subjects who have not received PPIs treatment. Results: A total of 90 patients and 90 matched controls were included. PPIs use was associated with hypocalcemia and hypomagnesemia. Vitamin D3 deficiency and hyperparathyroidism were associated with PPIs use. Long-term PPIs use was significantly associated with decreased bone density. Risk factors of decreased bone mineral density (BMD) included age >50 years, menopause, lack of sun exposure, double PPIs dose, daily intake, post-meal intake and association with a mucoprotective agent. Conclusion: Our results highlight the risk of decreased BMD in patients on long-term PPIs treatment.

Exploratory Study of Pharmacists' Monitoring Methods Based on Left Ventricular Function for Hypermagnesemia by Magnesium Oxide in Heart Failure

Serum magnesium (Mg) monitoring in patients with heart failure (HF) receiving magnesium oxide (MgO) is not adequately performed. Furthermore, the relationship between left ventricular function (LVF) and hypermagnesemia in HF is unknown. Here, we investigated the efficacy of serum Mg monitoring by protocol-based pharmaceutical management (PBPM) and the effect of LVF on hypermagnesemia. This protocol is for patients with an estimated glomerular filtration rate of <45 mL/min, receiving MgO, and admitted to the cardiology unit. The pharmacist includes the measurement of Mg when a blood test is ordered for a patient by their physician. Rates of serum Mg measurement and hypermagnesemia detection were compared at 2 years pre-PBPM (n = 88) and at 2 years post-PBPM (n = 55). LVF parameters and reported factors for hypermagnesemia were selected as explanatory factors on multivariate logistic regression. The measurement rate of serum Mg concentration significantly increased from 19.3% pre-PBPM to 80.0% post-PBPM (P < .001). The detection rate of hypermagnesemia also increased from 3.4% to 27.3%, respectively (P < .001). Our results suggest that serum Mg monitoring by PBPM may contribute to the early detection of hypermagnesemia and prevent its progression in HF. According to logistic regression, the adjusted odds ratio for hypermagnesemia with an exacerbation of HF was 9.57 (95% confidence interval: 1.594-57.477, P = .014), and the E/e' > 15, an index of reduced left ventricular diastolic capacity, was 6.46 (95% confidence interval: 1.291-32.364, P = .023). We propose that serum Mg monitoring should be performed during exacerbations of HF in patients with left ventricular diastolic dysfunction, with a pharmacist's assistance.

Long-Term Use of Proton Pump Inhibitors in Cancer Patients: An Opinion Paper

Simple Summary

Proton pump inhibitors are frequently used in cancer patients to alleviate some symptoms, epigastric pain or heartburn. However, acid suppression decreases the absorption of some oral-targeted anticancer treatments (tyrosine kinase inhibitors, CDK4/6 inhibitors) and induces changes in the gut microbiome. Recent data are showing that these interactions have important clinical impacts and medical oncologists and patients must be aware of these possible interactions.

Abstract

Multikinase inhibitors (MKIs), and particularly tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (CPIs), are currently some of the major breakthroughs in cancer treatment. Proton pump inhibitors (PPIs) revolutionised the treatment of acid-related diseases, but are frequently overused for epigastric pain or heartburn. However, long-term acid suppression from using PPIs may lead to safety concerns, and could have a greater impact in cancer patients undergoing therapy, like bone fractures, renal toxicities, enteric infections, and micronutrient deficiencies (iron and magnesium). Moreover, acid suppression may also affect the pharmacokinetics of drugs (at least during acid suppression) and decrease the absorption of many molecularly-targeted anticancer therapies, which are mostly weak bases with pH-dependent absorption. This type of drug-drug interaction may have detrimental effects on efficacy, with major clinical impacts described for some orally administrated targeted therapies (erlotinib, gefitinib, pazopanib, palbociclib), and conflicting results with many others, including capecitabine. Furthermore, the long-term use of PPIs results in severe alterations to the gut microbiome and recent retrospective analyses have shown that the benefit of using CPIs was suppressed in patients treated with PPIs. These very expensive drugs are of great importance because of their efficacy. As the use of PPIs is not essential, we must apply the precautionary principle. All these data should encourage medical oncologists to refrain from prescribing PPIs, explaining to patients the risks of interaction in order to prevent inappropriate prescription by another physician.

Genetic and drug-induced hypomagnesemia: different cause, same mechanism

Magnesium (Mg2+) plays an essential role in many biological processes. Mg2+ deficiency is therefore associated with a wide range of clinical effects including muscle cramps, fatigue, seizures and arrhythmias. To maintain sufficient Mg2+ levels, (re)absorption of Mg2+ in the intestine and kidney is tightly regulated. Genetic defects that disturb Mg2+ uptake pathways, as well as drugs interfering with Mg2+ (re)absorption cause hypomagnesemia. The aim of this review is to provide an overview of the molecular mechanisms underlying genetic and drug-induced Mg2+ deficiencies. This leads to the identification of four main mechanisms that are affected by hypomagnesemia-causing mutations or drugs: luminal transient receptor potential melastatin type 6/7-mediated Mg2+ uptake, paracellular Mg2+ reabsorption in the thick ascending limb of Henle's loop, structural integrity of the distal convoluted tubule and Na+-dependent Mg2+ extrusion driven by the Na+/K+-ATPase. Our analysis demonstrates that genetic and drug-induced causes of hypomagnesemia share common molecular mechanisms. Targeting these shared pathways can lead to novel treatment options for patients with hypomagnesemia.

Common Pitfalls in the Management of Patients with Micronutrient Deficiency: Keep in Mind the Stomach

Micronutrient deficiencies are relatively common, in particular iron and cobalamin deficiency, and may potentially lead to life-threatening clinical consequences when not promptly recognized and treated, especially in elderly patients. The stomach plays an important role in the homeostasis of some important hematopoietic micronutrients like iron and cobalamin, and probably in others equally important such as ascorbic acid, calcium, and magnesium. A key role is played by the corpus oxyntic mucosa composed of parietal cells whose main function is gastric acid secretion and intrinsic factor production. Gastric acid secretion is necessary for the digestion and absorption of cobalamin and the absorption of iron, calcium, and probably magnesium, and is also essential for the absorption, secretion, and activation of ascorbic acid. Several pathological conditions such as Helicobacter pylori-related gastritis, corpus atrophic gastritis, as well as antisecretory drugs, and gastric surgery may interfere with the normal functioning of gastric oxyntic mucosa and micronutrients homeostasis. Investigation of the stomach by gastroscopy plus biopsies should always be considered in the management of patients with micronutrient deficiencies. The current review focuses on the physiological and pathophysiological aspects of gastric acid secretion and the role of the stomach in iron, cobalamin, calcium, and magnesium deficiency and ascorbate homeostasis.