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Costa NDSD, Lima LS, Galiciolli MEA, Ribeiro DHF, Ribeiro MM, Garica GDPJ, Marçal IS, Silva JFD, Pereira ME, Oliveira CS, Guiloski IC. Drug-induced osteoporosis and mechanisms of bone tissue regeneration through trace elements. J Trace Elem Med Biol 2024; 84:127446. [PMID: 38615498 DOI: 10.1016/j.jtemb.2024.127446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/16/2024]
Abstract
Osteoporosis is associated with an imbalance in bone formation, with certain drugs used in disease treatment being implicated in its development. Supplementation with trace elements may contribute to bone regeneration, offering an alternative approach by enhancing bone mineral density (BMD) and thereby thwarting the onset of osteoporosis. This review aims to assess the mechanisms through which trace elements such as copper (Cu), iron (Fe), selenium (Se), manganese (Mn), and zinc (Zn) are linked to increased bone mass, thus mitigating the effects of pharmaceuticals. Our findings underscore that the use of drugs such as aromatase inhibitors (AIs), proton pump inhibitors (PPIs), antiretrovirals, glucocorticoids, opioids, or anticonvulsants can result in decreased BMD, a primary contributor to osteoporosis. Research indicates that essential elements like Cu, Fe, Se, Mn, and Zn, through various mechanisms, can bolster BMD and forestall the onset of the disease, owing to their protective effects. Consequently, our study recommends a minimum daily intake of these essential minerals for patients undergoing treatment with the aforementioned drugs, as the diverse mechanisms governing the effects of trace elements Cu, Fe, Mn, Se, and Zn facilitate bone remodeling.
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Affiliation(s)
- Nayara de Souza da Costa
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Luíza Siqueira Lima
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Maria Eduarda Andrade Galiciolli
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Deborah Helen Fabiano Ribeiro
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Milena Mariano Ribeiro
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Gisele de Paula Júlia Garica
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Isabela Saragioto Marçal
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Juliana Ferreira da Silva
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Meire Ellen Pereira
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Cláudia Sirlene Oliveira
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Izonete Cristina Guiloski
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80035-000, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil.
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Smaoui H, Chtourou L, Jallouli D, Jemaa SB, Karaa I, Boudabbous M, Moalla M, Gdoura H, Mnif L, Amouri A, Akrout R, Ayadi F, Baklouti S, Tahri N. Effect of long-term proton pump inhibitors on phosphocalcium metabolism and bone mineral density. Future Sci OA 2024; 10:FSO977. [PMID: 38841182 PMCID: PMC11152587 DOI: 10.2144/fsoa-2023-0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/14/2024] [Indexed: 06/07/2024] Open
Abstract
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.
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Affiliation(s)
- Hend Smaoui
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Lassaad Chtourou
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Dana Jallouli
- Laboratory of Biochemistry, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Samar Ben Jemaa
- Department of Rhumatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Iheb Karaa
- Laboratory of Biochemistry, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Mouna Boudabbous
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Manel Moalla
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Hela Gdoura
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Leila Mnif
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Ali Amouri
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Rim Akrout
- Department of Rhumatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Fatma Ayadi
- Laboratory of Biochemistry, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Sofien Baklouti
- Department of Rhumatology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Nabil Tahri
- Department of Gastroenterology & Hepatology, Hedi Chaker University Hospital, Sfax, Tunisia
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Kuyl EV, Parel PM, Agarwal AR, Gu A, Harris AB, Rao S, Golladay GJ, Thakkar SC. The Association Between Oral Bone Mineral Density-Reducing Medications and the Risk of 2-Year Implant-Related Complications Following Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00209-2. [PMID: 38467202 DOI: 10.1016/j.arth.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Certain medications interfere with the bone remodeling process and may potentially increase the risk of complications after total knee arthroplasty (TKA). As patients undergoing TKA may be taking these bone mineral density (BMD)-reducing medications, it is unclear as to whether and which medications impact TKA outcomes. Therefore, the purpose of this study was to observe the impact of various BMD-reducing medications on 2-year implant-related complications following TKA. METHODS A retrospective analysis of patients undergoing primary TKA was conducted using a national administrative claims database. Patients were identified if they were taking any known BMD-reducing medication and were compared to control patients. To control for confounders associated with taking multiple agents, multivariable logistic regression analyses were conducted for each 2-year outcome (all-cause revision, loosening-indicated revision, and periprosthetic fracture--indicated revision), with the output recorded as odds ratios (ORs). RESULTS In our study, 502,927 of 1,276,209 TKA patients (39.4%) were taking at least one BMD-reducing medication perioperatively. On multivariable analysis, medications associated with a higher likelihood of 2-year all-cause revision included first- and second-generation antipsychotics (SGAs) (OR: 1.42 and 1.26, respectively), selective serotonin reuptake inhibitors (SSRIs) (OR: 1.14), glucocorticoids (1.13), and proton pump inhibitors (PPIs) (OR: 1.23) (P < .05 for all). Medications associated with a higher likelihood of 2-year periprosthetic fracture included SGAs (OR: 1.51), SSRIs (OR: 1.27), aromatase inhibitors (OR: 1.29), and PPIs (OR: 1.42) (P < .05 for all). CONCLUSIONS Of the drug classes observed, the utilization of perioperative PPIs, SSRIs, glucocorticoids, first-generation antipsychotics, and SGAs was associated with the highest odds of all-cause revision. Our findings suggest a relationship between these medications and BMD-related complications; however, further studies should seek to determine the causality of these relationships.
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Affiliation(s)
- Emile-Victor Kuyl
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Philip M Parel
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrew B Harris
- Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Sandesh Rao
- Washington Orthopaedics and Sports Medicine, Washington, District of Columbia
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
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Bhatnagar MS, Choudhari S, Pawar D, Sharma A. Long-Term Use of Proton-Pump Inhibitors: Unravelling the Safety Puzzle. Cureus 2024; 16:e52773. [PMID: 38389608 PMCID: PMC10882567 DOI: 10.7759/cureus.52773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
Globally, over 25% of the population suffers from acid-related disorders such as dyspepsia or gastroesophageal reflux disease (GERD), and around 7.6% of Indians report having GERD symptoms on a frequent enough basis to warrant a diagnosis. Over the past three decades, proton-pump inhibitors (PPIs) have been the mainstay of medical therapy for acid-peptic diseases like GERD, etc. Additionally, they are frequently prescribed for prophylactic purposes and in conjunction with non-steroidal anti-inflammatory drugs. PPIs are generally prescribed for four to eight weeks. However, it may be prescribed for patients with comorbidities and multiple medications for a longer period of time. While this remains true in terms of effectiveness, concerns have been raised about the safety of long-term PPI use and the serious adverse effects that may result. Some of the observational and population-based cohort studies have shown an association between long-term use of PPIs and an increased risk of pneumonia, major cardiovascular events, dementia, vitamin B12 deficiency, bone fractures, gastric cancer, and kidney injury, among others. This review analyzes the clinical data supporting the long-term use of PPIs and takes a deep dive into whether these several emerging long-term concerns apply to the currently available PPIs in India. We have summarized a vast array of studies, including randomized trials, cohort studies, and meta-analyses, that report low or high incidences of major health risks linked with PPIs and have assessed their appropriateness over a given period.
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da Maia TF, de Camargo BG, Pereira ME, de Oliveira CS, Guiloski IC. Increased Risk of Fractures and Use of Proton Pump Inhibitors in Menopausal Women: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13501. [PMID: 36294082 PMCID: PMC9603342 DOI: 10.3390/ijerph192013501] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/01/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
Proton pump inhibitors (PPIs) can directly interfere with osteoclastic function, induce hypergastrinemia, and inhibit calcium absorption, leading to reduced bone mineral density (BMD), a measure of bone metabolism that may be associated with the risk of fractures. The current study involves a systematic review and meta-analysis aimed at assessing the relationship between prolonged use of PPI drugs and fractures in menopausal women. A systematic search and meta-analysis were performed on PubMed, Scopus, and Science Direct databases according to PRISMA guidelines. Two independent reviewers analyzed the articles. The five articles found in the databases, which met the eligibility criteria, covered participants who were menopausal women aged between 56 and 78.5 years, using or not using a PPI for a minimum of 12 months. All studies showed an increase in the rate of fractures related to using PPIs, as an outcome. Prolonged use of PPIs in menopausal women can affect bone metabolism and cause fractures. However, other factors, such as the use of other classes of drugs, obesity, low weight, poor diet, replacement hormones, and comorbidities, should also be considered for assessing the risk of fractures.
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Affiliation(s)
- Thuila Ferreira da Maia
- Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
| | - Bruna Gafo de Camargo
- Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
| | - Meire Ellen Pereira
- Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
| | - Cláudia Sirlene de Oliveira
- Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
| | - Izonete Cristina Guiloski
- Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
- Instituto de Pesquisas Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
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Is there an association between proton pump inhibitors and radiomorphometric parameters of the mandible? A preliminary study. Oral Radiol 2022; 38:586-593. [PMID: 35119594 DOI: 10.1007/s11282-022-00593-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study aimed to analyze the association between the use of proton pump inhibitors (PPIs) and radiomorphometric parameters of trabecular and cortical bone of the mandible. METHODS A total of 64 patients (37 females and 27 males) using PPIs (PPI group) and 64 age- and gender-matched healthy individuals (control group) were included in this study. The analyzed radiomorphometric parameters were fractal dimension (FD), mandibular cortical width (MCW), and mandibular cortical index (MCI). RESULTS There were no significant differences in the mean FDs of selected regions and MCW between the two groups (p > 0.05). The mean MCW was 1.95 mm in the PPI group and 2 mm in the control group. The MCI C3 category, which represents the most porous state of the mandibular cortex, was 2.5 times more frequent in the PPI group (p = 0.002). PPI use duration did not correlate with FD or MCW. No significant differences were observed in FD, MCW, and MCI distribution according to PPI type (p > 0.05). CONCLUSIONS Although not all radiomorphometric parameters indicated osteoporotic effects of PPI use, the mandibular cortex of PPI users is prone to erosive defects.
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Do proton pump inhibitors affect the biomechanical efficiency of implant?- a systematic review. J Oral Biol Craniofac Res 2022; 12:656-661. [PMID: 36052118 DOI: 10.1016/j.jobcr.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/13/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose This systematic review was executed to determine the influence of proton pump inhibitors on biomechanical efficiency of dental implants. Materials and methods The comprehensive online literature search was conducted on digital database of Pubmed, Cochrane database and EBSCO host, Web of Science and Scopus from 2010 to 2021(Dec).The studies included in our research comprised of randomized controlled trials and animal studies. Literature review, Letter to the editor, short communication and studies not related to the dental implants were excluded. A total of 6 studies were finalized and included in the systemic review. Result The proton pump inhibitors have a negative influence on the bone metabolism and adversely affect the Osseointegration of the dental implants. Further they reduce the biomechanical efficiency of dental implant which ultimately results in their failure. Conclusion Proton pump inhibitors are a risk factor for dental implant survival. This conclusion has been drawn from the limited research available. Hence well designed prospective randomized controlled trials should be carried out on a large population including the users and non-users, to more thoroughly elucidate the effect of proton pump inhibitor on osseointegration process of dental implants.
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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; 14:e28429. [PMID: 36176864 PMCID: PMC9512296 DOI: 10.7759/cureus.28429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Chronic proton-pump inhibitor (PPI) prescription is on the rise in the last decade with an increased prevalence in the elderly population. For most patients, this class of drugs is the primary treatment for various diseases. Even though PPIs are generally safe, long-term use has been associated with multiple adverse effects like bone fractures. The extent of the association between PPI and fracture is still unclear in women aged between 50 and 65 years. Besides, many other variables and risk factors must be accounted for in the analysis of this relation. Methods This is a retrospective case-control study looking at women 50-65 years of age who presented to Genesys Health for a low-impact fall. Data were extracted from electronic medical records and fracture outcomes; PPI therapy exposure and duration were determined. Chi-square analysis was performed to determine the association between chronic PPI therapy and fracture outcome and independently analyzed for major risk factors of osteoporosis, including smoking, low body mass index, and cancer. Results Patients in the chronic PPI therapy group were found to have a decreased fracture outcome overall in each subcategory of risk factors. When adjusting for all risk factors, there was a significant but weak association between chronic PPI therapy and increased fracture outcome. Conclusion With different results from previous studies, this study sheds new light on this debate. More studies need to be carried out to determine the association between chronic PPI therapy and fracture outcomes in postmenopausal women.
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Raoul JL, Edeline J, Simmet V, Moreau-Bachelard C, Gilabert M, Frénel JS. Long-Term Use of Proton Pump Inhibitors in Cancer Patients: An Opinion Paper. Cancers (Basel) 2022; 14:cancers14051156. [PMID: 35267464 PMCID: PMC8909698 DOI: 10.3390/cancers14051156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Jean-Luc Raoul
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, 44805 Saint-Herblain, France; (C.M.-B.); (J.-S.F.)
- Correspondence:
| | - Julien Edeline
- Department of Medical Oncology, Centre E Marquis, 35000 Rennes, France;
| | - Victor Simmet
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, 49055 Angers, France;
- Department of Medical Oncology, Centre Hospitalier de Cholet, 49300 Cholet, France
| | - Camille Moreau-Bachelard
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, 44805 Saint-Herblain, France; (C.M.-B.); (J.-S.F.)
| | - Marine Gilabert
- Department of Medical Oncology, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland;
| | - Jean-Sébastien Frénel
- Department of Medical Oncology, Institut de Cancérologie de l’Ouest, 44805 Saint-Herblain, France; (C.M.-B.); (J.-S.F.)
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Cheng Z, Liu Y, Ma M, Sun S, Ma Z, Wang Y, Yu L, Qian X, Sun L, Zhang X, Liu Y, Wang Y. Lansoprazole-induced osteoporosis via the IP3R- and SOCE-mediated calcium signaling pathways. Mol Med 2022; 28:21. [PMID: 35183103 PMCID: PMC8858482 DOI: 10.1186/s10020-022-00448-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background Many clinical studies have shown a correlation between proton pump inhibitors (PPIs) and osteoporosis or fractures. The purpose of this study was to establish a murine model of chronic oral PPI administration to verify whether PPIs caused bone metabolic impairment and investigate the relevant molecular mechanism underlying the effects of PPIs on MC3T3-E1 murine osteoblasts. Methods A lansoprazole-induced bone loss model was used to investigate the damaging effects of PPIs. In vivo, immunohistochemistry, Hematoxylin–Eosin (HE) staining, micro-CT analysis, and blood biochemical analyses were used to evaluate the effect of lansoprazole on bone injury in mice. In vitro, the effects of lansoprazole and related signaling pathways in MC3T3-E1 cells were investigated by CCK-8 assays, EdU assays, flow cytometry, laser confocal microscopy, patch clamping, reverse transcription-quantitative polymerase chain reaction and Western blotting. Results After 6 months of lansoprazole gavage in ICR mice, the micro-CT results showed that compared with that in the vehicle group, the bone mineral density (BMD) in the high-dose group was significantly decreased (P < 0.05), and the bone microarchitecture gradually degraded. Biochemical analysis of bone serum showed that blood calcium and phosphorus were both decreased (P < 0.01). We found that long-term administration of lansoprazole impaired skeletal function in mice. In vitro, we found that lansoprazole (LPZ) could cause calcium overload in MC3T3-E1 cells leading to apoptosis, and 2-APB, an inhibitor of IP3R calcium release channel and SOCE pathway, effectively blocked increase in calcium caused by LPZ, thus protecting cell viability. Conclusions Longterm administration of LPZ induced osteoporotic symptoms in mice, and LPZ triggered calcium increases in osteoblasts in a concentration-dependent manner. Intracellular calcium ([Ca2+]i) persisted at a high concentration, thereby causing endoplasmic reticulum stress (ERS) and inducing osteoblast apoptosis.
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Rosenberg V, Tzadok R, Chodick G, Kariv R. Proton pump inhibitors long term use-trends and patterns over 15 years of a large health maintenance organization. Pharmacoepidemiol Drug Saf 2021; 30:1576-1587. [PMID: 34453456 DOI: 10.1002/pds.5352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/05/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPI) are used for a variety of indications. Despite reported associations with undesirable effects, their long-term use is on the rise, while appropriate indications, dose, and treatment duration may deviate from guideline recommendations. OBJECTIVES Primary to examine the annual patterns of PPI use. Secondary- to assess indications for initiating PPI treatment, long-term use, and factors associated with long-term use in a large Israeli health maintenance organization. METHODS A historical cohort study of 528 420 eligible PPI users during 2000-2015, analyzed PPI use using defined daily doses and the proportion of patients covered method. Data on indications for treatment initiation, clinical and socio-demographic parameters were captured as well. A multivariable logistic-regression model was used to identify factors associated with long-term use of PPI. RESULTS The annual incidence rates of patients initiating PPI treatment were relatively constant, ranging between 2.4% and 3.1% of the adult population, with a monotonic increase in annual consumption and prevalence (reaching 12.7% in 2015). Reflux, functional symptoms, and Helicobacter pylori eradication were the most common indications for initiating PPI therapy. However, 27% of patients had no recorded indication for treatment. Fifteen percent of patients used PPI for over 6 months, especially in older age groups. CONCLUSIONS Utilization of PPI increases steadily, mainly due to chronic use. Prolonged consumption is associated with specific clinical indications and older age. Health organizations should encourage awareness of appropriate use among physicians, specifically in the elderly, patients with reflux, and those with functional disorders.
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Affiliation(s)
- Vered Rosenberg
- Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Roie Tzadok
- Department of Internal Medicine H, Sourasky Medical Center, Tel Aviv, Israel
| | - Gabriel Chodick
- Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Revital Kariv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Sourasky Medical Center, Tel Aviv, Israel
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Do patients with gastroesophageal reflux disease exhibit compromised bone quality prior to proton pump inhibitor therapy? Bone Rep 2021; 14:101095. [PMID: 34095362 PMCID: PMC8167151 DOI: 10.1016/j.bonr.2021.101095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/15/2021] [Accepted: 05/18/2021] [Indexed: 11/24/2022] Open
Abstract
Patients with gastroesophageal reflux disease (GERD) are routinely treated with proton pump inhibitors (PPIs), despite many reports of increased fracture risk associated with PPI use. Notably, the skeletal properties in patients with GERD prior to PPI therapy have not been addressed. We hypothesized that PPI-naïve GERD patients have bone impairment, and that short-term treatment with PPI has minimal skeletal effects. To test this, 17 (12 men/5 women) GERD patients age 32–73 years, not previously exposed to PPI, and 17 age- and sex-matched controls were enrolled from September 2010 to December 2012. Bone mineral density (BMD) at lumbar spine, femoral neck, total hip, and trabecular bone score (TBS) at the lumbar spine, a marker of bone microarchitecture, were measured by dual X-ray absorptiometry. Markers of bone turnover and calcium homeostasis, and gastric hormones were analyzed. The same parameters were measured after three months of treatment with the PPI pantoprazole. The GERD patients displayed a significantly lower TBS at baseline than controls (1.31 ± 0.11 vs. 1.43 ± 0.07, p = 0.0006). Total hip and femoral neck BMD were lower in patients compared to controls, however, not significantly (p = 0.09 and 0.12, respectively). CTX was non-significantly higher in GERD patients at baseline (p = 0.11). After three months, changes in BMD, TBS and CTX did not differ between the groups. In conclusion, this is the first report demonstrating compromised bone quality and inferior BMD in PPI-naïve GERD patients. Treatment with pantoprazole did not influence bone parameters, indicating that short-term use with this PPI is safe for the skeleton. Previous studies have reported an increased fracture risk in PPI users. Patients with GERD had compromised bone quality before starting PPI. Three months treatment with pantoprazole did not influence bone parameters.
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Briganti SI, Naciu AM, Tabacco G, Cesareo R, Napoli N, Trimboli P, Castellana M, Manfrini S, Palermo A. Proton Pump Inhibitors and Fractures in Adults: A Critical Appraisal and Review of the Literature. Int J Endocrinol 2021; 2021:8902367. [PMID: 33510787 PMCID: PMC7822697 DOI: 10.1155/2021/8902367] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/11/2022] Open
Abstract
Despite the large number of patients worldwide being on proton pump inhibitors (PPIs) for acid-related gastrointestinal disorders, uncertainty remains over their long-term safety. Particularly, the potential side effects of these drugs on bone health have been evaluated in the last years. The purpose of our narrative review is to gather and discuss results of clinical studies focusing on the interactions between PPIs and fracture risk. Data generated mainly from nested case-control studies and meta-analysis suggest that long-term/high-dose PPIs users are characterized by an increased risk of fragility fractures, mainly hip fractures. However, in these studies, the PPIs-induced bone impairment is often not adjusted for different confounding variables that could potentially affect bone health, and exposure to PPIs was reported using medical prescriptions without adherence evaluation. The mechanisms of the PPI-related bone damage are still unclear, but impaired micronutrients absorption, hypergastrinemia, and increased secretion of histamine may play a role. Clinicians should pay attention when prescribing PPIs to subjects with a preexistent high risk of fractures and consider antiosteoporotic drugs to manage this additive effect on the bone. However, further studies are needed to clarify PPIs action on the bone.
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Affiliation(s)
| | - Anda Mihaela Naciu
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Gaia Tabacco
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Roberto Cesareo
- Unit of Metabolic Diseases, Department of Internal Medicine, S. Maria Goretti Hospital, 04100 Latina, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Pierpaolo Trimboli
- Scienza Biomediche, Università Della Svizzera Italiana (USI), Lugano, Switzerland
| | - Marco Castellana
- Population Health Unit, National Institute of Gastroenterology “Saverio de Bellis”, Research Hospital, Bari, Italy
| | - Silvia Manfrini
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
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Association between anti-acid therapies and advanced fibrosis in type 2 diabetics with biopsy-proven non-alcoholic fatty liver disease. Indian J Gastroenterol 2020; 39:591-598. [PMID: 33219985 PMCID: PMC9254737 DOI: 10.1007/s12664-020-01087-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUNDS AND AIMS Data on associations of antacid therapies with advanced fibrosis (AF) in patients with non-alcoholic fatty liver disease (NAFLD) are limited. We aimed to assess the association of histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) with AF in NAFLD patients with underlying type 2 diabetes (T2D). METHODS We retrospectively reviewed patient's charts with T2D who had a liver biopsy for suspected NAFLD. Fibrosis stages were determined as F0-F4, AF being F3-4. Laboratory data and use of various medications within 24 months of liver biopsies were used for the analysis. Univariable and multivariable logistic regression analyses were performed to assess any association. RESULTS Our cohort consisted of 1008 T2D patients with biopsy-proven NAFLD. Sixty-six percent were female, 86.2% were Caucasian, and median HbA1C was 6.4%. AF was present in 32% of the patients. Thirty-four percent were on H2RAs and 60.6% were on PPI therapy (p < 0.001) for a median duration of 3.6 [0.10, 3.8] (p = 0.20) and 45.6 [0.80, 15.4] (p = 0.17) months, respectively. On multivariable logistic regression analysis being on H2RAs was associated with a 68% lower risk of AF (odds ratio [OR] [95%CI]: 0.32 [0.24, 0.44]) (p < 0.001), but use of PPIs showed a trend towards higher risk of AF (OR [95%CI]: 1.4 [1.00, 1.8]) (p = 0.053). CONCLUSION Our study suggests that H2RAs are associated with lower risk of AF in NAFLD patients with underlying diabetes and should be considered as the first-line antacid therapy in these patients. Risk stratification should be done if PPIs are indicated in high-risk diabetics with NAFLD.
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Liu Y, Zhu X, Li R, Zhang J, Zhang F. Proton pump inhibitor utilisation and potentially inappropriate prescribing analysis: insights from a single-centred retrospective study. BMJ Open 2020; 10:e040473. [PMID: 33243802 PMCID: PMC7692833 DOI: 10.1136/bmjopen-2020-040473] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES This study aimed to characterise the prescribing patterns and evaluate the appropriateness of the prescribed proton pump inhibitors (PPIs) in adult patients via a review of electronic medical records in a single-centred hospital. DESIGN All patients admitted to the outpatient department of Jinshan Hospital, Fudan University, Shanghai, between 1 January 2018 and 31 December 2018 were evaluated. Individuals aged 18 years or above and with at least one dispensing for PPIs were identified as PPI users. New PPI users were defined as a subject who did not receive any dispensing for PPIs in the year prior to the index date. Baseline characteristics of PPI users and their therapies were described by treatment indication, economic indicators and co-prescription, overall and separately. SETTING The prescription database was retrieved from the hospital information system of Jinshan Hospital, Fudan University. RESULTS Among 18 435 identified PPI users in 2018, 14 219 patients (aged 18 years or above) who had at least one dispensing PPIs were new users (77%), and among them, men accounted for 47%. The mean treatment duration was 23 days. Omeprazole was the most commonly prescribed drug. PPIs are inappropriately prescribed in 50% (13 589/25 850) of prescriptions. Prescription appropriateness analysis indicated that the unapproved indications for PPI new users accounted for 47%; among them, the proportion of gastritis diagnosis was 34%. The proportion of PPI new users with co-prescription of glucocorticosteroids (GCs) who have risk factors accounted for 24% and lower than other co-prescription. A majority of PPI users (73%) reported high-dose PPI prescription. The defined daily dose of oral pantoprazole was the highest, and injectable omeprazole had the highest defined daily cost. In contrast, only the drug utilisation index value of oral esomeprazole was less than 1.0. CONCLUSION The results indicate the challenge of PPI use was accompanied by unapproved indications, frequent inappropriate co-prescription with GCs and excessive dosages. Efforts should be paid to promote rational use and ensure the choice of suitable PPI therapy in the future.
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Affiliation(s)
- Yujuan Liu
- Clinical Pharmacy Department, Jinshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Xian Zhu
- Emergency Department, Jinshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Rongxin Li
- Emergency Department, Jinshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jun Zhang
- Clinical Pharmacy Department, Jinshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Feng Zhang
- Emergency Department, Jinshan Hospital Affiliated to Fudan University, Shanghai, China
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Vinnakota DN, Kamatham R. Effect of proton pump inhibitors on dental implants: A systematic review and meta-analysis. J Indian Prosthodont Soc 2020; 20:228-236. [PMID: 33223692 PMCID: PMC7654198 DOI: 10.4103/jips.jips_283_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 01/11/2020] [Accepted: 02/24/2020] [Indexed: 01/15/2023] Open
Abstract
Aim The present systematic review aims to determine the evidence on the impact of proton pump inhibitors (PPIs) on dental implants. Settings and Design This secondary qualitative and quantitative research was done using a pre-specified question and inclusion criteria. Materials and Methods A systematic search was conducted in electronic databases such as PubMed, Ovid, and Cochrane. All the studies that assessed the effect of PPIs on dental implants were included, irrespective of the design. Literature review, letter to editors, short commentaries, and opinion articles were excluded. Results and Statistical Analysis Used A total of three publications fulfilled the inclusion criteria. All these included articles were retrospective cohort studies; the methodological quality was assessed using Newcastle-Ottawa scale. A total of 452 implants were placed in 149 PPI users, whereas 6798 were positioned in 2241 nonusers. Of these, 43 and 212 implants failed in users and nonusers, respectively (odds ratio: 2.91, 95% confidence interval: 2.06-4.11). The meta-analysis was performed using the statistical software Review Manager, and a fixed-effect model was used to obtain the odds ratio. The success rate of implants based on age, gender, smoking, and bone augmentation could be combined only from two studies, which revealed a considerable effect of these factors. Conclusion As far as the available evidence is considered, it seems as if the usage of PPI has a detrimental effect on the success of dental implants. This influence needs justification as none of the included studies segregated the data based on confounding factors. Hence, there is a need to conduct well-designed, prospective, randomized clinical trials with balanced confounding factors to derive a proper conclusion.
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Affiliation(s)
- Dileep Nag Vinnakota
- Department of Prosthodontics, Narayana Dental College, Nellore, Andhra Pradesh, India
| | - Rekhalakshmi Kamatham
- Department of Pedodontics and Preventive Dentistry, Narayana Dental College, Nellore, Andhra Pradesh, India
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Park JH, Lee J, Yu SY, Jung JH, Han K, Kim DH, Rhee J. Comparing proton pump inhibitors with histamin-2 receptor blockers regarding the risk of osteoporotic fractures: a nested case-control study of more than 350,000 Korean patients with GERD and peptic ulcer disease. BMC Geriatr 2020; 20:407. [PMID: 33059626 PMCID: PMC7565339 DOI: 10.1186/s12877-020-01794-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/27/2020] [Indexed: 12/18/2022] Open
Abstract
Background Patients with peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD) are more likely to receive long-term therapy with proton pump inhibitors (PPIs). This study aimed to investigate the risk of osteoporotic fractures in PPI users compared to histamine-2 receptor antagonist (H2RA) users and the association between fractures and the duration and regular use of PPI. Methods A population-based, nationwide nested case-control study from January 2006 to December 2015 was performed using Korean National Health Insurance Service claims data. We included patients ≥50 years of age, without previous fractures, newly prescribed with PPI or H2RA, and diagnosed with PUD or GERD from 2006 to 2015. Patients with osteoporotic fracture (n = 59,240) were matched with the non-fracture control group (n = 296,200) at a 1:5 ratio based on sex, age, cohort entry date, follow-up duration, and bisphosphonate use. The osteoporotic fractures were defined using the diagnostic codes of claims data (M80, M81, M82, M484, M485, S220, S221, S320, S327, S422, S423, S525, S526, S72). Results The higher the cumulative use of PPIs, the higher the osteoporotic fracture risk (P for trend < 0.001). The risk of osteoporotic fracture in the patients whose cumulative use of PPI was more than 1 year was higher than that of others (OR: 1.42, 95% CI: 1.32–1.52). Patients who regularly used PPI in the recent 1 year had a higher risk of osteoporotic fracture than exclusive H2RA users (OR: 1.37, 95% CI: 1.26–1.50). Conclusions The risk of osteoporotic fracture increased with the duration of PPI use, especially when PPI was used for ≥1 year and regularly in the recent 1 year.
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Affiliation(s)
- Joo-Hyun Park
- Department of Family Medicine, Korea University Ansan Hospital, Korea University College of Medicine, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Jessie Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Su-Yeon Yu
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Jin-Hyung Jung
- Department of Biostatics, Catholic University College of Medicine, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Do-Hoon Kim
- Department of Family Medicine, Korea University Ansan Hospital, Korea University College of Medicine, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea.
| | - Jinnie Rhee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea.
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Fisher L, Fisher A, Smith PN. Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review). J Clin Med 2020; 9:E3253. [PMID: 33053671 PMCID: PMC7600664 DOI: 10.3390/jcm9103253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/28/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023] Open
Abstract
Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.
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Affiliation(s)
- Leon Fisher
- Department of Gastroenterology, Frankston Hospital, Peninsula Health, Melbourne 3199, Australia
| | - Alexander Fisher
- Department of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra 2605, Australia;
- Department of Orthopedic Surgery, The Canberra Hospital, ACT Health, Canberra 2605, Australia;
- Australian National University Medical School, Canberra 2605, Australia
| | - Paul N Smith
- Department of Orthopedic Surgery, The Canberra Hospital, ACT Health, Canberra 2605, Australia;
- Australian National University Medical School, Canberra 2605, Australia
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Min YW, Lee YC, Kim K, Ryu S, Hong KS, Jeon HH, Kim YS, Park JH, Son HJ, Rhee PL. Proton pump inhibitor use is associated with hip fracture development: a nationwide population-based cohort study. Korean J Intern Med 2020; 35:1084-1093. [PMID: 31671930 PMCID: PMC7487306 DOI: 10.3904/kjim.2018.331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/13/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Effect of proton pump inhibitor (PPI) use on the risk of hip fracture is controversial. This study aimed to clarify the association between PPI use and hip fracture risk using a large cohort. METHODS This study recruited participants from the nationwide cohort (n = 1,025,340). After exclusion of participants who had hip fractures or were aged less than 40 years during the baseline period (2002 to 2004), 371,806 participants were followed to 2013. Participants prescribed PPIs for more than 90 days during baseline period were defined as users. Fracture cases were defined when participants were hospitalized with claims of a hip fracture. RESULTS During 4,159,343 person-years of follow-up, fractures developed more often in PPI users than in nonusers (relative risk [RR], 1.787; 95% confidence interval [CI], 1.260 to 2.534; p = 0.002). The results persisted after adjusting for age, sex, and many drugs relevant to osteoporosis or influential in bone health. Furthermore, fracture risk associated with PPI use increased with duration of use (p trend < 0.001). The fully adjusted RRs of hip fracture development were 1.350 (95% CI, 1.203 to 1.515) for 1- to 90-day users, 1.487 (95% CI, 0.957 to 2.311) for 91- to 180-day users, and 1.771 (95% CI, 0.931 to 3.368) for > 180-day users. The positive association between PPI use and fracture was also confirmed in a subgroup with health screening data where further adjustment for body mass index, smoking status, alcohol consumption, and physical activity was available (adjusted RR, 2.025; 95% CI, 1.151 to 3.564, p = 0.014). CONCLUSION PPI use is associated with hip fracture development.
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Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeong Chan Lee
- Department of Digital Health, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University, Seoul, Korea
| | - Kyunga Kim
- Department of Digital Health, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University, Seoul, Korea
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Seungho Ryu
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung Sub Hong
- Department of Gastroenterology, Mediplex Sejong Hospital, Incheon, Korea
| | - Han Ho Jeon
- Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Ilsan, Korea
| | - Yong Sung Kim
- Department of Gastroenterology, Wonkwang Digestive Disease Research Institute, Wonkwang University Sanbon Hospital, Gunpo, Korea
| | - Jong Heon Park
- Big Data Steering Department, National Health Insurance Service, Wonju, Korea
| | - Hee Jung Son
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Hee Jung Son, M.D. Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail:
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence to Poong-Lyul Rhee, M.D. Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail:
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20
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Proton pump inhibitor use and risk of hip fracture in patients with type 2 diabetes. Sci Rep 2020; 10:14081. [PMID: 32826941 PMCID: PMC7443131 DOI: 10.1038/s41598-020-70712-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/03/2020] [Indexed: 01/10/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) is associated with a high rate of comorbidity, including osteoporosis and peptic ulcers. Proton pump inhibitors (PPIs) are a group of acid-suppressing drugs commonly used for treating peptic ulcers. However, observational studies have reported an association between PPI therapy and osteoporotic fractures. This study investigated the association between PPI use and hip fracture (HFx) among patients with T2DM. We conducted this population-based propensity-matched retrospective cohort study using the National Health Insurance Research Database in Taiwan. Patients newly diagnosed with T2DM between 2000 and 2008 were identified. After excluding those who previously used PPIs or suffered HFx, 398,885 patients were recruited (44,341 PPI users; 354,544 non-users). HFx risk data from 2000 to 2013 were collected to calculate the cumulative rate of HFx in these two groups. Sensitivity analyses were conducted to evaluate the effects of PPI dose. After propensity score matching of 1:4, 44,431 and 177,364 patients were assigned to the PPI user and non-user groups, respectively. PPI user group showed an increased risk of HFx with an adjusted hazard ratio of 1.41 (95% CI 1.29–1.54) without dose–response relationship. Thus, there is an increased risk of HFx in patients with T2DM receiving long-term PPI treatment.
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Perry IE, Sonu I, Scarpignato C, Akiyama J, Hongo M, Vega KJ. Potential proton pump inhibitor-related adverse effects. Ann N Y Acad Sci 2020; 1481:43-58. [PMID: 32761834 DOI: 10.1111/nyas.14428] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/31/2020] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
Abstract
Proton pump inhibitors (PPIs) are one of the most common medications taken by patients worldwide. PPIs are used to treat acid-related disorders, including gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori infection, and nonsteroidal anti-inflammatory drug/stress ulceration. For some of these diseases, long-term treatment is necessary. With such prolonged use, concern and investigation into potential adverse effects has increased. In addition, data are available regarding potential anticancer effects of PPIs, especially regarding solid tumors. The aim of this review is to assess the literature on PPIs with regard to common concerns, such as drug-drug interactions, the intestinal microbiome, dementia and central nervous system disease, and osteoporosis, as well as to highlight potential negative and positive impacts of the drug in cancer.
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Affiliation(s)
- Issac E Perry
- Division of Gastroenterology and Hepatology, Augusta University-Medical College of Georgia, Augusta, Georgia
| | - Irene Sonu
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City, California
| | - Carmelo Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta.,Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - Junichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Michio Hongo
- Department of Comprehensive Medicine, Tohoku University School of Medicine, Sendai, Miyagi, Japan.,Department of Medicine, Kurokawa General Hospital, Kurokawa, Miyagi, Japan
| | - Kenneth J Vega
- Division of Gastroenterology and Hepatology, Augusta University-Medical College of Georgia, Augusta, Georgia
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Park JH, Song YM, Jung JH, Han K. Comparative analysis of the risk of osteoporotic fractures with proton pump inhibitor use and histamine-2 receptor antagonist therapy in elderly women: A nationwide population-based nested case-control study. Bone 2020; 135:115306. [PMID: 32126312 DOI: 10.1016/j.bone.2020.115306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 12/29/2022]
Abstract
The influence of proton pump inhibitors (PPIs) on the risk of osteoporotic fractures remains to be elucidated, especially in the Asian population. This study evaluated the risk of osteoporotic fractures in elderly female Korean PPI users compared to histamine-2 receptor antagonist (H2RA) users, as well as the relationship between fractures and the duration, dose, and pattern of use of PPI. We screened a nationwide cohort of elderly Korean women who underwent bone mineral density measurements during their 66-year-old life-transition medical examination between 2009 and 2014. Study subjects included 8903 cases diagnosed with new osteoporotic fractures and 44,515 matched controls (1:5 ratio based on cohort entry date, follow-up duration, and baseline osteoporosis status) without fractures. They were followed up until 2015. Information on the exposure to PPI or H2RA, occurrence of fracture, and covariates were obtained from the Korean National Health Insurance Service data. Covariate-adjusted odds ratio (aOR) and 95% confidence interval (CI) were estimated using conditional logistic regression analysis. PPI use was associated with an increased risk of osteoporotic fractures (aOR: 1.13, 95% CI: 1.07, 1.18) compared with H2RA-only use. Increasing duration of PPI use was positively associated with the risk of osteoporotic fracture [aOR (95% CI) of long-term PPI use (≥1 year): 1.3 (1.09, 1.56)]. Recent PPI use within the last year was associated with an increased risk of fracture (aOR: 1.31, 95% CI: 1.23, 1.38), whereas remote PPI use was not (aOR: 0.98, 95% CI: 0.92, 1.04). The risk of fracture did not increase with the increasing cumulative PPI dose. Compared with the use of H2RA alone, PPI use was associated with an increased risk of osteoporotic fractures in elderly Korean women, particularly among those who had used PPI within the last year or for more than one year.
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Affiliation(s)
- Joo-Hyun Park
- Department of Family Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Yun-Mi Song
- Department of Family Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Jin-Hyung Jung
- Department of Biostatics, Catholic University College of Medicine, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
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Hoff M, Skovlund E, Skurtveit S, Meyer HE, Langhammer A, Søgaard AJ, Syversen U, Forsmo S, Abrahamsen B, Schei B. Proton pump inhibitors and fracture risk. The HUNT study, Norway. Osteoporos Int 2020; 31:109-118. [PMID: 31741023 DOI: 10.1007/s00198-019-05206-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022]
Abstract
UNLABELLED Proton pump inhibitors (PPIs) have been linked to increased risk of fracture; the data have, however, been diverging. We did not find any increased risk of fractures among users of PPIs in a Norwegian population of 15,017 women and 13,241 men aged 50-85 years with detailed information about lifestyle and comorbidity. INTRODUCTION Proton pump inhibitors (PPIs) are widely prescribed and have been linked to increased risk of fracture. METHODS We used data from the Nord-Trøndelag Health Study (HUNT3), The Fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, including 15,017 women and 13,241 men aged 50-85 years. The study population was followed from the date of participating in HUNT3 (2006-2008) until the date of first fracture (forearm or hip), death, or end of study (31 December 2012). The Cox proportional hazards model with time-dependent exposure to PPIs was applied, and each individual was considered as unexposed until the first prescriptions was filled. To be included, the prescription of PPIs should minimum be equivalent to 90 defined daily doses (DDD) in the period. Individuals were defined as exposed until 6 months after end of drug supply. RESULTS The proportion of women and men using PPIs was 17.9% and 15.5%, respectively. During a median of 5.2 years follow-up, 266 women and 134 men had a first hip fracture and 662 women and 127 men, a first forearm fracture. The combined rate/1000 patient-years for forearm and hip fractures in women was 49.2 for users of PPIs compared with 64.1 among non-users; for men 18.6 and 19.8, respectively. The hazard ratios with 95% confidence interval for the first forearm or hip fracture among users of PPIs in the age-adjusted analysis were 0.82 (0.67-1.01) for women and 1.05 (0.72-1.52) for men. Adjusting for age, use of anti-osteoporotic drugs, and FRAX, the HR declined to 0.80 (0.65-0.98) in women and 1.00 (0.69-1.45) in men. CONCLUSIONS Use of PPIs was not associated with an increased risk of fractures.
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Affiliation(s)
- M Hoff
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PB 8905, 7491, Trondheim, Norway.
- Department of Rheumatology, St Olavs Hospital, Trondheim, Norway.
| | - E Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PB 8905, 7491, Trondheim, Norway
- Norwegian Institute of Public Health, Oslo, Norway
| | - S Skurtveit
- Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - H E Meyer
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - A Langhammer
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PB 8905, 7491, Trondheim, Norway
| | - A J Søgaard
- Norwegian Institute of Public Health, Oslo, Norway
| | - U Syversen
- Department of Endocrinology, St. Olavs Hospital, Trondheim, Norway
- Department of Clinical and and Molecular Medicine, NTNU, Trondheim, Norway
| | - S Forsmo
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PB 8905, 7491, Trondheim, Norway
| | - B Abrahamsen
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
- Odense Patient Data Explorative Network, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - B Schei
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PB 8905, 7491, Trondheim, Norway
- Department of Gynecology, St Olavs Hospital, Trondheim, Norway
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Ghebre YT. Proton Pump Inhibitors and Osteoporosis: Is Collagen a Direct Target? Front Endocrinol (Lausanne) 2020; 11:473. [PMID: 32793122 PMCID: PMC7387407 DOI: 10.3389/fendo.2020.00473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 06/16/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
- Yohannes T. Ghebre
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, United States
- Department of Medicine, Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, United States
- *Correspondence: Yohannes T. Ghebre
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Lee L, Ramos-Alvarez I, Ito T, Jensen RT. Insights into Effects/Risks of Chronic Hypergastrinemia and Lifelong PPI Treatment in Man Based on Studies of Patients with Zollinger-Ellison Syndrome. Int J Mol Sci 2019; 20:ijms20205128. [PMID: 31623145 PMCID: PMC6829234 DOI: 10.3390/ijms20205128] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 02/07/2023] Open
Abstract
The use of proton pump inhibitors (PPIs) over the last 30 years has rapidly increased both in the United States and worldwide. PPIs are not only very widely used both for approved indications (peptic ulcer disease, gastroesophageal reflux disease (GERD), Helicobacter pylori eradication regimens, stress ulcer prevention), but are also one of the most frequently off-label used drugs (25–70% of total). An increasing number of patients with moderate to advanced gastroesophageal reflux disease are remaining on PPI indefinitely. Whereas numerous studies show PPIs remain effective and safe, most of these studies are <5 years of duration and little data exist for >10 years of treatment. Recently, based primarily on observational/epidemiological studies, there have been an increasing number of reports raising issues about safety and side-effects with very long-term chronic treatment. Some of these safety issues are related to the possible long-term effects of chronic hypergastrinemia, which occurs in all patients taking chronic PPIs, others are related to the hypo-/achlorhydria that frequently occurs with chronic PPI treatment, and in others the mechanisms are unclear. These issues have raised considerable controversy in large part because of lack of long-term PPI treatment data (>10–20 years). Zollinger–Ellison syndrome (ZES) is caused by ectopic secretion of gastrin from a neuroendocrine tumor resulting in severe acid hypersecretion requiring life-long antisecretory treatment with PPIs, which are the drugs of choice. Because in <30% of patients with ZES, a long-term cure is not possible, these patients have life-long hypergastrinemia and require life-long treatment with PPIs. Therefore, ZES patients have been proposed as a good model of the long-term effects of hypergastrinemia in man as well as the effects/side-effects of very long-term PPI treatment. In this article, the insights from studies on ZES into these controversial issues with pertinence to chronic PPI use in non-ZES patients is reviewed, primarily concentrating on data from the prospective long-term studies of ZES patients at NIH.
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Affiliation(s)
- Lingaku Lee
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA.
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka 812-8582, Japan.
| | | | - Tetsuhide Ito
- Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital, International University of Health and Welfare 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan.
| | - Robert T Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA.
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Farhat N, Fortin Y, Haddad N, Birkett N, Mattison DR, Momoli F, Wu Wen S, Krewski D. Systematic review and meta-analysis of adverse cardiovascular events associated with proton pump inhibitors used alone or in combination with antiplatelet agents. Crit Rev Toxicol 2019; 49:215-261. [DOI: 10.1080/10408444.2019.1583167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Nawal Farhat
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Yannick Fortin
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nisrine Haddad
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nicholas Birkett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Donald R. Mattison
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Risk Sciences International, Ottawa, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Shi Wu Wen
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Daniel Krewski
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Risk Sciences International, Ottawa, Canada
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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. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E1571. [PMID: 31060319 PMCID: PMC6540255 DOI: 10.3390/ijerph16091571] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 12/11/2022]
Abstract
The number of patients with gastroesophageal problems taking proton pump inhibitors (PPIs) is increasing. Several studies suggested a possible association between PPIs and fracture risk, especially hip fractures, but the relationship remains contentious. This review aimed to investigate the longitudinal studies published in the last five years on the relationship between PPIs and fracture risk. The mechanism underlying this relationship was also explored. Overall, PPIs were positively associated with elevated fracture risk in multiple studies (n = 14), although some studies reported no significant relationship (n = 4). Increased gastrin production and hypochlorhydria are the two main mechanisms that affect bone remodeling, mineral absorption, and muscle strength, contributing to increased fracture risk among PPI users. As a conclusion, there is a potential relationship between PPIs and fracture risks. Therefore, patients on long-term PPI treatment should pay attention to bone health status and consider prophylaxis to decrease fracture risk.
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Affiliation(s)
- Benjamin Ka Seng Thong
- Department of Pharmacology, Universiti Kebangsaan Malaysia Medical Centre, Cheras 56000, Malaysia.
| | - Soelaiman Ima-Nirwana
- Department of Pharmacology, Universiti Kebangsaan Malaysia Medical Centre, Cheras 56000, Malaysia.
| | - Kok-Yong Chin
- Department of Pharmacology, Universiti Kebangsaan Malaysia Medical Centre, Cheras 56000, Malaysia.
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Costa P, Boeing T, Somensi LB, Cury BJ, Espíndola VL, França TCS, de Almeida MO, Arruda C, Bastos JK, da Silva LM, de Andrade SF. Hydroalcoholic extract from Baccharis dracunculifolia recovers the gastric ulcerated tissue, and p-coumaric acid is a pivotal bioactive compound to this action. Biofactors 2019; 45:479-489. [PMID: 30974027 DOI: 10.1002/biof.1503] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/26/2019] [Indexed: 12/28/2022]
Abstract
Baccharis dracunculifolia is a medicinal plant native to southeastern Brazil and is the main botanical source used by bees (Apis mellifera) in the manufacture of green propolis and display similar gastroprotective action and chemical profile. This article reports the healing gastric ulcer activity of the hydroethanolic extract of B. dracunculifolia (HEBD) in an acetic acid-induced ulcer model. In addition to the extract, the isolated compounds ferulic acid, p-coumaric acid, caffeic acid, baccharin, and aromadendrin-4'-O-methyl ether were also assayed. HEBD at a dose of 300 mg/kg reduced the ulcerated area by 49.4% after treatment for 7 days, twice a day. Histological analyses revealed that the margins and base of the ulcer obtained significant regeneration, and periodic acid Schiff base staining showed a 78.2% increase in the mucin levels. The action on the enzymatic antioxidant system demonstrated an increased activity of superoxide dismutase and glutathione-S-transferase, in addition to raising glutathione reduced levels and myeloperoxidase activity. HEBD did not show cytotoxicity in the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenylterazole bromine test. In vitro, HEBD inhibited the H+ /K+ -ATPase enzyme and showed antioxidant activity in the 2,2 diphenyl-1-picryllydrazyl test. Regarding the isolated compounds, oral administration of p-coumaric acid (15 mg/kg) reduced the ulcerated area by 66.2%. The results suggest that HEBD recovers the gastric ulcerated tissue, raising mucus and antioxidant enzyme levels, and reducing the H+ /K+ -ATPase activity. In addition, the findings confirm that p-coumaric acid is a pivotal bioactive compound on the gastric healing effects elicited by HEBD. © 2019 BioFactors, 45(3):479-489, 2019.
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Affiliation(s)
- Philipe Costa
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
| | - Thaise Boeing
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
| | - Lincon Bordignon Somensi
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
| | - Benhur Judah Cury
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
| | - Vanessa Lopes Espíndola
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
| | - Tauani Caroline Santos França
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
| | - Marília Oliveira de Almeida
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Caroline Arruda
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Jairo Kenupp Bastos
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Luisa Mota da Silva
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
| | - Sérgio Faloni de Andrade
- Programa de Pós-Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas, Universidade do Vale do Itajaí, Itajaí, South Carolina, Brazil
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Abstract
PURPOSE OF REVIEW This review discusses the monitoring aimed at achieving good long-term outcomes in people dependent on home parenteral nutrition (HPN). RECENT FINDINGS There have been recent studies highlighting the importance of treating low bone mineral density in HPN-dependent patients, methods of screening for liver disease, assessment of quality of life (QoL) and the need for early assessment for intestinal transplantation and growth factor therapy. SUMMARY High-quality HPN services require expert multidisciplinary teams with a focus on strict aseptic catheter care protocols alongside regular monitoring and management of clinical, laboratory and patient-related factors. Areas that should be considered in the routine monitoring of HPN include regular laboratory measurements, QoL, assessment for intestinal failure-associated liver disease, treatment of metabolic bone disease and consideration of evolving treatments, alongside management of any underlying condition leading to intestinal failure.
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Affiliation(s)
- Martyn Dibb
- Royal Liverpool University Hospital, Liverpool
| | - Simon Lal
- Salford Royal Hospital, Salford, England, UK
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30
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He HS, Li BY, Chen QT, Song CY, Shi J, Shi B. Comparison of the Use of Vonoprazan and Proton Pump Inhibitors for the Treatment of Peptic Ulcers Resulting from Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis. Med Sci Monit 2019; 25:1169-1176. [PMID: 30755541 PMCID: PMC6381807 DOI: 10.12659/msm.911886] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Currently, proton pump inhibitors (PPIs) are the first-line treatment for ulcers resulting from endoscopic submucosal dissection (ESD). Vonoprazan is a new oral potassium-competitive acid blocker (P-CAB). The aim of this systematic review and meta-analysis was to compare the efficacy, safety, and tolerance of vonoprazan with PPIs in the treatment of peptic ulcers resulting from ESD. MATERIAL AND METHODS Published results of randomized clinical trials (RCTs) comparing vonoprazan with PPIs in the treatment of ulcers resulting from ESD were identified up to March 2018. The main clinical endpoints evaluated were healing rate and adverse events. The meta-analysis included quality assessment of the studies, statistical analysis of endpoints, and sensitivity analysis using Revman version 5.3 meta-analysis software. RESULTS Systematic literature review identified seven published studies that included 548 patients. Five studies were published as full-text manuscripts, and two studies were published as abstracts. Meta-analysis of the vonoprazan treatment, compared with PPI treatment, for ESD showed that the pooled relative risk (RR) of healing rate was 0.64 (95% CI, 0.33-1.22) for the 4-week study group and 0.98 (95% CI, 0.84-1.15) for the 8-week study group. The RR for adverse events was 0.65 (95% CI, 0.31-1.38) (P>0.05). No statistical evidence of publication bias was found. CONCLUSIONS The findings of the systematic review and meta-analysis showed that the efficacy of vonoprazan was comparable with PPIs for the treatment of peptic ulcers following ESD. Further studies are required to support the safety and efficacy of vonoprazan compared with different types of PPIs.
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Affiliation(s)
- Hui-Si He
- Naval Clinical Medicine Grade 2014, Basic Medical College, Second Military Medical University, Shanghai, China (mainland)
| | - Bing-Yang Li
- Naval Clinical Medicine Grade 2014, Basic Medical College, Second Military Medical University, Shanghai, China (mainland)
| | - Qi-Tong Chen
- Department of Emergency Medicine, Changzheng Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Chun-Yan Song
- Department of Pathology, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Jian Shi
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Bin Shi
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China (mainland)
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Liu J, Li X, Fan L, Yang J, Wang J, Sun J, Wang Z. Proton pump inhibitors therapy and risk of bone diseases: An update meta-analysis. Life Sci 2018; 218:213-223. [PMID: 30605646 DOI: 10.1016/j.lfs.2018.12.058] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/12/2018] [Accepted: 12/29/2018] [Indexed: 01/29/2023]
Abstract
AIMS Large observational studies have yielded conflicting results regarding whether the use of proton pump inhibitors (PPI) increases the risk of bone diseases. Here, we performed a meta-analysis to examine the link between PPI and risk of bone fractures, osteoporosis and bone mineral density (BMD) loss. MATERIALS AND METHODS We systematically performed a search for published reports on PubMed, EMBASE and the Cochrane Library. We considered articles published in English, and restricted the search to studies on human participants. Studies that reported adjusted Hazard ratio (HR) estimates with 95% confidence intervals (CI) for the associations of interest were included. Data from the articles which can be used to estimate standardized mean difference (SMD) were also obtained and utilized to assess the risk of BMD loss. KEY FINDINGS Compared with patients not taking PPI, those taking PPI, had the increased risk of developing any-site fractures (HR: 1.30; 95%CI: 1.16 to 1.45), hip fracture (HR:1.22; 95%CI:1.15 to 1.31), spine fracture (HR:1.49; 95%CI:1.31 to 1.68), and osteoporosis (HR:1.23; 95%CI:1.06 to 1.42) based on a random model, but there was no correlation with developing BMD loss in the femoral (SMD: -0.27; 95%CI: -0.62 to 0.09), or in the spine (SMD: -0.06; 95%CI: -0.54 to 0.41). SIGNIFICANCE Results of this meta-analysis suggest that PPI may moderately increase the risk of any-site, hip, spine fracture. Due to the widespread use of PPI and the impact of fractures on human health, clinicians should carefully evaluate the patient condition before prescribing PPI therapy.
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Affiliation(s)
- Jian Liu
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xianqing Li
- Department of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lei Fan
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jie Yang
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jiecong Wang
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jiaming Sun
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Zhenxing Wang
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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Hung WT, Teng YH, Yang SF, Yeh HW, Yeh YT, Wang YH, Chou MY, Chou MC, Chan CH, Yeh CB. Association between Proton Pump Inhibitor Use and CNS Infection Risk: A Retrospective Cohort Study. J Clin Med 2018; 7:jcm7090252. [PMID: 30200363 PMCID: PMC6162834 DOI: 10.3390/jcm7090252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 02/06/2023] Open
Abstract
This study investigated the incidence of central nervous system (CNS) infection following the use of proton pump inhibitors (PPIs). A retrospective cohort study was conducted in Taiwan by using data from the National Health Insurance Research Database. We identified and enrolled 16,241 patients with CNS infection who used PPIs (PPI users). The patients were individually propensity score matched (1:1) according to age, sex, hypertension, hyperlipidemia, Charlson comorbidity index (CCI), H2 blocker, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid, and immunosuppressant use with 16,241 controls (PPI nonusers). A Cox proportional hazards model was used to estimate adjusted hazard ratio (aHR) for CNS infection in the PPI users and nonusers. After adjustment for other confounding factors, the incidence of CNS infection in the PPI users was 2.23-fold higher than that in the PPI nonusers (95% CI = 1.27⁻3.94). In addition, the PPI users exhibited a higher risk of CNS infection than the nonusers in the hypertension and CCI = 1 groups (aHR = 3.80, 95% CI = 1.40⁻10.32; aHR = 2.47, 95% CI = 1.07⁻5.70 in the PPI users and nonusers, respectively). In conclusions, according to these results, we concluded that the incidence of CNS infection was higher in the PPI users than in the nonusers.
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Affiliation(s)
- Wei-Te Hung
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
- Department of Anesthesiology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
| | - Ying-Hock Teng
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
| | - Han-Wei Yeh
- School of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan.
| | - Ying-Tung Yeh
- Graduate School of Dentistry, Chung Shan Medical University, Taichung 40201, Taiwan.
- School of Dentistry, Chung Shan Medical University, Taichung 40201, Taiwan.
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
| | - Ming-Yung Chou
- School of Dentistry, Chung Shan Medical University, Taichung 40201, Taiwan.
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
| | - Ming-Chih Chou
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
| | - Chi-Ho Chan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
- Department of Microbiology and Immunology, Chung Shan Medical University, Taichung 40201, Taiwan.
| | - Chao-Bin Yeh
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
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33
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Nassar Y, Richter S. Proton-pump Inhibitor Use and Fracture Risk: An Updated Systematic Review and Meta-analysis. J Bone Metab 2018; 25:141-151. [PMID: 30237993 PMCID: PMC6135649 DOI: 10.11005/jbm.2018.25.3.141] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/30/2018] [Accepted: 07/06/2018] [Indexed: 02/07/2023] Open
Abstract
Background This study's objective was to evaluate the association between proton-pump inhibitor (PPI) use and bone fracture incidence and bone mineral density (BMD) by meta-analyzing the estimates reported by epidemiological and cohort studies. Methods Data were acquired from studies identified after a literature search in electronic databases. Odds ratios (ORs), hazard ratios (HRs), and risk ratios (RRs) between PPI use and bone fracture incidence were pooled under the random effects model, and meta-analysis of standardized mean differences between PPI users and controls in cross-sectional values and BMD changes was conducted. Results Thirty-three studies fulfilled the eligibility criteria. These studies provided data from 2,714,502 individuals with a mean age of 66.91 years (95% confidence interval [CI], 63.37–70.46); 33.21% (95% CI, 30.44–35.99) were males and 64.61% (95% CI, 60.73–68.49) were females. Overall, fracture incidence was 22.04% (95% CI, 16.10–27.97) in PPI users and 15.57% (95% CI, 12.28–18.86) in controls. The overall effect size of the point estimate was 1.28 (95% CI, 1.22–1.35) between PPI use and bone fracture incidence. There was a trend towards increased fracture incidence from short duration use: OR 1.29 (95% CI, 1.19–1.40), medium duration use: OR 1.33 (95% CI, 1.12–1.55) and long duration use: OR 1.62 (95% CI, 1.33–1.90). There was no significant difference in the standardized mean differences between PPI users and controls, either in cross-sectional BMD values or in the BMD change observed in longitudinal studies. Conclusions Pooling of ORs, HRs, and RRs suggested that PPI use might increase fracture risk. However, there was no effect of PPI use on BMD.
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Affiliation(s)
- Yousef Nassar
- Department of Medicine, Albany Medical Center, Albany, New York, USA
| | - Seth Richter
- Department of Medicine, Albany Medical Center, Albany, New York, USA
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Thietart S, Louati K, Gatfosse M, Sornay-Rendu E, Gaigneux E, Lemeunier L, Delmaire P, Riviere S, Mahevas T, Sellam J, Berenbaum F, Fain O, Roland C, Mekinian A. Overview of osteo-articular involvement in systemic sclerosis: Specific risk factors, clinico-sonographic evaluation, and comparison with healthy women from the French OFELY cohort. Best Pract Res Clin Rheumatol 2018; 32:591-604. [DOI: 10.1016/j.berh.2019.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Buchheit T, Zura R, Wang Z, Mehta S, Della Rocca GJ, Steen RG. Opioid exposure is associated with nonunion risk in a traumatically injured population: An inception cohort study. Injury 2018; 49:1266-1271. [PMID: 29801700 DOI: 10.1016/j.injury.2018.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/21/2018] [Accepted: 05/02/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Certain common medications are associated with an elevated risk of fracture and recent data suggests that medications can also increase nonunion risk. Medication use is a modifiable nonunion risk factor, but it is unknown whether risk accrues solely to chronic medication use or whether there is also risk inherent to acute use. METHODS Multivariate logistic regression was used in an inception cohort to calculate odds ratios (OR) for fracture nonunion associated with medication use, in context with other risk factors demonstrated to influence nonunion. Patient-level health claims for medical and drug expenses were compiled from a payer database. Patients were included if they had a fracture coded in 2011, with continuous enrollment for 1 month prior to and 12 months after fracture. The database contained demographic descriptors, treatment procedures per CPT codes, co-morbidities per ICD-9 codes, and prescriptions per National Drug Codes. Chronic medication use was defined as ≥30 days of prescription prior to fracture with ≥1 day afterward; acute use was any other prescription. RESULTS Most non-analgesic medications were safe in acute or chronic use, but risk of nonunion was elevated for a wide range of analgesics. Overall, 45,085 fractures (14.6% of fractures) affected patients using chronic opioids. Nonunion OR was elevated for acute and chronic use of Schedule 2 opioids including acetaminophen/oxycodone, hydromorphone, oxycodone, and acetaminophen/hydrocodone bitartrate, as well as Schedule 3-5 opioids including tramadol (all, p < 0.0001). The highest ORs were associated with chronic administration of Schedule 2 opioids. DISCUSSION Most medications do not increase nonunion risk, but acute and chronic use of NSAIDs or opioids was associated with impaired fracture healing. There is particular risk in prescribing opioid analgesics for fracture, though literature suggests that roughly half of opioid-naïve patients receive such a prescription. CONCLUSIONS Patients evaluated in this study were not a random sample of Americans; they may approximate a random sample of the Emergency Department population in the United States. Thus, trauma patients may represent a population enriched for nonunion risk factors. Opioids impair recovery from injury; if they also predispose to injury, the ongoing opioid epidemic could presage an increase in nonunion prevalence.
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Affiliation(s)
- Thomas Buchheit
- Dept. of Anesthesiology, Duke University Medical Center, Durham, NC, United States.
| | - Robert Zura
- Dept. of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA, United States.
| | - Zhe Wang
- Dept. of Statistics, North Carolina State University, Raleigh, NC, United States.
| | - Samir Mehta
- Dept. of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
| | - Gregory J Della Rocca
- Dept. of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, United States.
| | - R Grant Steen
- Dept. of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA, United States.
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Machado-Duque ME, Castaño-Montoya JP, Medina-Morales DA, Castro-Rodríguez A, González-Montoya A, Machado-Alba JE. Drugs With Anticholinergic Potential and Risk of Falls With Hip Fracture in the Elderly Patients: A Case-Control Study. J Geriatr Psychiatry Neurol 2018. [PMID: 29528764 DOI: 10.1177/0891988718757370] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND/OBJECTIVE To determine the association between the use of anticholinergic drugs and the risk of falls with hip fracture in a population older than 60 years. METHODS A case-control study in patients older than 60 years with a diagnosis of hip fracture. All drugs dispensed during the previous 30 days were identified. Sociodemographic, clinical, pharmacological (drugs according to the Anticholinergic Risk Scale [ARS]), and polypharmacy variables were analyzed. MEASUREMENTS Falls with hip fracture and type of drug according to the ARS. RESULTS A total of 300 patients with hip fracture and 600 controls were included. The mean age was 81.6 ± 8.9 years, with female predominance (71.3%). The use of drugs with moderate (odds ratio [OR]: 1.97, 95% confidence interval [CI]: 1.19-3.27) or high ARS scores (OR: 1.83, 95% CI: 1.13-2.96) increased the probability of fracture. CONCLUSIONS There was an association between the use of drugs with anticholinergic properties and the probability of hip fracture in elderly patients and it was possible to establish the level of risk.
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Affiliation(s)
- Manuel E Machado-Duque
- 1 Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Juan Pablo Castaño-Montoya
- 1 Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Diego A Medina-Morales
- 1 Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Alejandro Castro-Rodríguez
- 1 Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Alexandra González-Montoya
- 1 Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
| | - Jorge E Machado-Alba
- 1 Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
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Abstract
Treatment with proton-pump inhibitors (PPIs) might be associated with neuropsychological side effects. We examined the association between use of PPIs and depressive symptoms in an elderly population. Mood was assessed by the 30-item Geriatric Depression Scale (GDS) in all 344 inhabitants of Tuscania (Italy) aged 75 years and over, without exclusion criteria; depression was defined by a GDS score ≥11. Use of PPIs was associated with a higher GDS score in linear regression analysis (B = 2.43; 95% CI = 0.49-4.38; p = 0.014) after adjusting; also, use of PPIs was associated with increased adjusted probability of depression in logistic regression (OR = 2.38; 95% CI = 1.02-5.58; p = 0.045). Higher PPIs dosages were associated with increased probability of depression (p for trend = 0.014). This association was independent of the diagnosis of peptic disease, as well as the use of antidepressant medications. No association was found between use of H2-blockers or antacids and the GDS score. Calculation of the population attributable risk indicated that 14% of depression cases could be avoided by withdrawal of PPIs. Use of PPIs might represent a frequent cause of depression in older populations; thus, mood should be routinely assessed in elderly patients on PPIs.
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Watts NB. Adverse bone effects of medications used to treat non-skeletal disorders. Osteoporos Int 2017; 28:2741-2746. [PMID: 28752332 DOI: 10.1007/s00198-017-4171-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 07/20/2017] [Indexed: 12/11/2022]
Abstract
There is a growing list of medications used to treat non-skeletal disorders that cause bone loss and/or increase fracture risk. This review discusses glucocorticoids, drugs that reduce sex steroids, antidiabetic agents, acid-reducing drugs, selective serotonin reuptake inhibitors, and heparin. A number of drugs are known to cause bone loss, increase fracture risk, or both. These drugs should be used in the lowest dose necessary to achieve the desired benefit and for the shortest time necessary, but in many cases, long-term treatment is required. Effective countermeasures are available for some.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, 4760 E. Galbraith Rd., Suite 212, Cincinnati, OH, 45236, USA.
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Lewis PO, Lundberg TS, Tharp JL, Runnels CW. Implementation of Global Strategies to Prevent Hospital-Onset Clostridium difficile Infection: Targeting Proton Pump Inhibitors and Probiotics. Ann Pharmacother 2017; 51:848-854. [DOI: 10.1177/1060028017694050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Proton pump inhibitors (PPIs) have been identified as a significant risk factor for the development of Clostridium difficile infection (CDI). Probiotics given concurrently with antibiotics have been shown to have a moderate impact on preventing CDI. Objective: To evaluate the effectiveness of hospital-wide interventions designed to reduce PPI use and increase probiotics and whether these interventions were associated with a change in the incidence of hospital onset (HO)-CDI. Methods: This retrospective cohort study compared 2 fiscal years: July 2013 to June 2014 (FY14) and July 2014 to June 2015 (FY15). In July of FY15, global educational initiatives were launched targeting PPIs. Additionally, a HO-CDI prevention bundle was added to antibiotic-containing order sets targeting probiotics. Overall PPI use, probiotic use, and incidence of HO-CDI were recorded and compared for each cohort. Charts were also reviewed for patients who developed HO-CDI for the presence and appropriateness of a PPI and presence of probiotics. Results: The interventions resulted in a decrease in PPI use by 14% or 96 doses/1000 patient days (TPD; P = 0.0002) and a reduction in IV PPI use by 31% or 71 doses/TPD ( P = 0.0008). Probiotic use increased by 130% or 126 doses/TPD ( P = 0.0006). The incidence of HO-CDI decreased by 20% or 0.1 cases/TPD ( P = 0.04). Conclusions: A collaborative, multifaceted educational initiative directed at highlighting the risks associated with PPI use was effective in reducing PPI prescribing. The implementation of a probiotic bundle added to antibiotic order sets was effective in increasing probiotic use. These interventions were associated with a decrease in incidence of HO-CDI.
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Wang L, Li M, Cao Y, Han Z, Wang X, Atkinson EJ, Liu H, Amin S. Proton Pump Inhibitors and the Risk for Fracture at Specific Sites: Data Mining of the FDA Adverse Event Reporting System. Sci Rep 2017; 7:5527. [PMID: 28717153 PMCID: PMC5514095 DOI: 10.1038/s41598-017-05552-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 05/10/2017] [Indexed: 02/06/2023] Open
Abstract
Proton pump inhibitors (PPIs) are widely used to treat gastric acid-related disorders. Concerns have been raised about potential fracture risk, especially at the hip, spine and wrist. However, fracture risk at other bone sites has not been as well studied. We investigated the association between PPIs and specific fracture sites using an aggregated knowledge-enhanced database, the Food and Drug Administration Adverse Event Reporting System Data Mining Set (AERS-DM). Proportional reporting ratio (PRR) was used to detect statistically significant associations (signals) between PPIs and fractures. We analyzed both high level terms (HLT) and preferred terms (PT) for fracture sites, defined by MedDRA (Medical Dictionary for Regulatory Activities). Of PPI users reporting fractures, the mean age was 65.3 years and the female to male ratio was 3.4:1. Results revealed signals at multiple HLT and PT fracture sites, consistent for both sexes. These included fracture sites with predominant trabecular bone, not previously reported as being associated with PPIs, such as 'rib fractures', where signals were detected for overall PPIs as well as for each of 5 generic ingredients (insufficient data for dexlansoprazole). Based on data mining from AERS-DM, PPI use appears to be associated with an increased risk for fractures at multiple sites.
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Affiliation(s)
- Liwei Wang
- Department of Medical Informatics, School of Public Health, Jilin University, Changchun, 130021, Jilin Province, China.
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, 55901 MN, USA.
| | - Mei Li
- Department of Medical Informatics, School of Public Health, Jilin University, Changchun, 130021, Jilin Province, China
| | - Yuying Cao
- Department of Medical Informatics, School of Public Health, Jilin University, Changchun, 130021, Jilin Province, China
| | - Zhengqi Han
- National Science Library, Chinese Academy of Science, Beijing, 100190, China
| | - Xueju Wang
- Department of Pathology, The Third Hospital of Jilin University, Changchun, 130033, Jilin province, China
| | - Elizabeth J Atkinson
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, 55901 MN, USA
| | - Hongfang Liu
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, 55901 MN, USA.
| | - Shreyasee Amin
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, 55901 MN, USA.
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, 55901 MN, USA.
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Abstract
PURPOSE OF REVIEW The purpose of the review is to provide an update on recent advances in the evidence based on proton pump inhibitors (PPI) as a possible cause of osteoporosis and osteoporotic fractures. This review focuses, in particular, on new studies published in the last 18 months and a discussion of these findings and how this has influenced our understanding of this association, the clinical impact and the underlying pathophysiology. RECENT FINDINGS New studies have further strengthened existing evidence linking use of PPIs to osteoporosis. Short-term use does not appear to pose a lower risk than long-term use. There is a continued lack of conclusive studies identifying the pathogenesis. Direct effects on calcium absorption or on osteoblast or osteoclast action cannot at present plausibly explain the mechanism. SUMMARY The use of PPIs is a risk factor for development of osteoporosis and osteoporotic fractures. However, as the direct pathogenesis remains unclear, specific points of intervention are lacking, other than being vigilant in regard to the indication for prescribing PPIs and to use the lowest effective dose where PPIs cannot be avoided.
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de la Coba Ortiz C, Argüelles Arias F, Martín de Argila de Prados C, Júdez Gutiérrez J, Linares Rodríguez A, Ortega Alonso A, Rodríguez de Santiago E, Rodríguez-Téllez M, Vera Mendoza MI, Aguilera Castro L, Álvarez Sánchez Á, Andrade Bellido RJ, Bao Pérez F, Castro Fernández M, Giganto Tomé F. Proton-pump inhibitors adverse effects: a review of the evidence and position statement by the Sociedad Española de Patología Digestiva. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:207-24. [PMID: 27034082 DOI: 10.17235/reed.2016.4232/2016] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. OBJECTIVE The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. MATERIAL AND METHODS A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. RESULTS Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. CONCLUSIONS PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.
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Affiliation(s)
| | | | | | - Javier Júdez Gutiérrez
- Departamento de Gestión del Conocimiento, Sociedad Española de Patología Digestiva SEPD, España
| | | | - Aida Ortega Alonso
- UGC Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, España
| | | | - Manuel Rodríguez-Téllez
- UGC Intercentros de Aparato Digestivo , Hospital Universitario Virgen de la Macarena (HUVM), España
| | | | | | - Ángel Álvarez Sánchez
- Servicio de Aparato Digestivo, Hospital Clínico San Carlos. Universidad Complutense de Madrid., España
| | - Raúl Jesús Andrade Bellido
- Unidad de Gestión Clinica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, España
| | | | | | - Froilán Giganto Tomé
- Servicio de Aparato Digestivo, Hospital Universitario Central de Asturias, España
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Krasniqi E, Koni M, Tschan H, Krasniqi B, Kabashi A, Boshnjaku A. Musculoskeletal Health of 40-65 Year Old Males and Females in Kosova and the Impact of N05B, A02B (PPI, H2RA), H02AB and Lifestyle Factors on It. Med Arch 2016; 70:359-363. [PMID: 27994297 PMCID: PMC5136431 DOI: 10.5455/medarh.2016.70.359-363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 10/11/2016] [Indexed: 11/30/2022] Open
Abstract
Background: This observational, cross-sectional study investigates the impact of medication usage, physical activity (PA) and nutritional status on musculoskeletal health (MSH) in males and females aged 40-65 in the population of a post conflict, developing country. Methods: Bone Mineral Density (BMD), T-score and Z-score at distal forearm regions (measured by DEXA scan), together with isometric hand grip strength (dynamometer) were evaluated in a total of 162 subjects (53 Males, average age 55.15±7.12 and 109 Females, 54.27±5.1). Additionally, bio-anthropometric assessments, medication usage, PA level and nutritional status were assessed. Results: Significant differences (p<0.05) were found in total subjects Body Mass Index (BMI), PA, BMD, T-score and Hand grip between genders. 42% of total participants met the diagnostic criteria of, out of which 6.8% with T-score below -2, while no cases of Osteoporosis was recorded. N05B Anxiolytics and A02B Drugs for peptic ulcer and gastro-oesophageal reflux disease medication groups consumption turned to have no significant differences (p>0.05) in BMD, T-score, and hand grip in total population, except for A02B where p<0.05 were found in Hand grip, as well as between female consumers and no consumers in all variables. Meanwhile, in total subjects consuming H02AB Glucocorticoids p<0.05 were observed in BMD and T-score, but not on hand grip. Conclusions: This study shows a low risk for MSH problems amongst the studied population in Kosova, while the consumption of H02AB medication group in both genders and A02B in females only for extended periods might effect MSH, therefore appropriate benefit/risk assessment should be made before prescribing these medications, notwithstanding age, gender, PA or nutritional status.
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Affiliation(s)
- Ermira Krasniqi
- Medical University of Tirana, Faculty of Medical Technical Sciences, Tirana, Albania; Medical Sciences College Rezonanca, Prishtinë, Kosovo
| | - Mynyr Koni
- Medical University of Tirana, Faculty of Medical Technical Sciences, Tirana, Albania; University of Tirana, Faculty of Natural Sciences, Tirana, Albania
| | - Harald Tschan
- University of Vienna, Faculty of Natural Sciences/Life Sciences, Vienna, Austria
| | | | - Antigona Kabashi
- Medical University of Tirana, Faculty of Medical Technical Sciences, Tirana, Albania
| | - Arben Boshnjaku
- University of Vienna, Faculty of Natural Sciences/Life Sciences, Vienna, Austria
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Arj A, Razavi Zade M, Yavari M, Akbari H, Zamani B, Asemi Z. Proton pump inhibitors use and change in bone mineral density. Int J Rheum Dis 2016; 19:864-8. [DOI: 10.1111/1756-185x.12866] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Abbas Arj
- Department of Gastroenterology; Kashan University of Medical Sciences; Kashan Iran
| | - Mohsen Razavi Zade
- Department of Gastroenterology; Kashan University of Medical Sciences; Kashan Iran
| | - Maryam Yavari
- Department of Gastroenterology; Kashan University of Medical Sciences; Kashan Iran
| | - Hossein Akbari
- Department of Biostatistics; Kashan University of Medical Sciences; Kashan Iran
| | - Batol Zamani
- Department of Autoimmune Diseases Research Center; Kashan University of Medical Sciences; Kashan Iran
- Department of Internal Medicine; Kashan University of Medical Sciences; Kashan Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases; Kashan University of Medical Sciences; Kashan Iran
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Sumer F, Sengul Aycicek G, Arik G, Kara O, Canbaz B, Ulger Z. Can We Equate All Proton Pump Inhibitors with One Another? J Am Geriatr Soc 2016; 64:1150-1. [PMID: 27225378 DOI: 10.1111/jgs.14121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Fatih Sumer
- Division of Geriatrics, Faculty of Internal Medicine, Gazi University, Ankara, Turkey
| | - Gozde Sengul Aycicek
- Division of Geriatrics, Faculty of Internal Medicine, Gazi University, Ankara, Turkey
| | - Gunes Arik
- Division of Geriatrics, Faculty of Internal Medicine, Gazi University, Ankara, Turkey
| | - Ozgur Kara
- Division of Geriatrics, Faculty of Internal Medicine, Gazi University, Ankara, Turkey
| | - Busra Canbaz
- Division of Geriatrics, Faculty of Internal Medicine, Gazi University, Ankara, Turkey
| | - Zekeriya Ulger
- Division of Geriatrics, Faculty of Internal Medicine, Gazi University, Ankara, Turkey
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Pirsl F, Curtis LM, Steinberg SM, Tella SH, Katić M, Dobbin M, Hsu J, Hakim FT, Mays JW, Im AP, Pulanić D, Mitchell SA, Baruffaldi J, Masuch L, Halverson DC, Gress RE, Barsony J, Pavletic SZ. Characterization and Risk Factor Analysis of Osteoporosis in a Large Cohort of Patients with Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2016; 22:1517-1524. [PMID: 27118572 DOI: 10.1016/j.bbmt.2016.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/16/2016] [Indexed: 01/23/2023]
Abstract
The National Institutes of Health Chronic Graft-versus-Host Disease (cGVHD) Consensus Project Ancillary and Supportive Care Guidelines recommend annual assessment of bone mineral density (BMD) to monitor bone health. The study of osteoporosis in patients with cGVHD has been limited to small numbers of patients, and the guidelines are based on experience with other chronic diseases and expert opinion. We hypothesized that the prevalence of osteoporosis is high in a cohort of 258 patients with moderate to severe cGVHD because of prolonged exposure to risk factors for osteoporosis after allogeneic hematopoietic stem cell transplantation. We defined osteoporosis using BMD criteria (T-score ≤-2.5) at 3 anatomic sites-the femoral neck (FN), lumbar spine (LS), and total hip (TH)-and characterized risk factors through univariate and multivariate analyses. We found that low body weight (FN, P < .0001; LS, P = .0002; TH, P < .0001), malnutrition (FN, P = .0002; LS, P = .03; TH, P = .0076), higher platelet count (FN, P = .0065; TH, P = .0025), higher average National Institutes of Health organ score (FN, P = .038), higher prednisone dose (LS, P = .032), lower complement component 3 (LS, P = .0073), and physical inactivity (FN, P = .01) were associated with osteoporosis in at least 1 site. T-scores were significantly lower in the FN compared with the LS or TH (P < .0001 for both). The prevalence of osteoporosis and osteopenia was high (17% and 60%, respectively), supporting current recommendations for frequent monitoring of BMD. The association of higher platelet count in patients with cGVHD and osteoporosis has not been reported previously and represents a new area of interest in the study of osteoporosis after allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Filip Pirsl
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lauren M Curtis
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Seth M Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sri Harsha Tella
- National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Mašenjka Katić
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Marnie Dobbin
- Clinical Nutrition Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jennifer Hsu
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Fran T Hakim
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jacqueline W Mays
- Oral and Pharyngeal Cancer Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Annie P Im
- Adult Hematopoietic Stem Cell Transplant Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dražen Pulanić
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb and University of Zagreb School of Medicine, Zagreb, Croatia; Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Sandra A Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Judy Baruffaldi
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Licia Masuch
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - David C Halverson
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ronald E Gress
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Julianna Barsony
- Division of Endocrinology and Metabolism, Department of Medicine, Georgetown University Medical Center, Washington, DC
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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Wu CH, Tung YC, Chai CY, Lu YY, Su YF, Tsai TH, Kuo KL, Lin CL. Increased Risk of Osteoporosis in Patients With Peptic Ulcer Disease: A Nationwide Population-Based Study. Medicine (Baltimore) 2016; 95:e3309. [PMID: 27100415 PMCID: PMC4845819 DOI: 10.1097/md.0000000000003309] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
To investigate osteoporosis risk in patients with peptic ulcer disease (PUD) using a nationwide population-based dataset. This Taiwan National Health Insurance Research Database (NHIRD) analysis included 27,132 patients aged 18 years and older who had been diagnosed with PUD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 531-534) during 1996 to 2010. The control group consisted of 27,132 randomly selected (age- and gender)-matched patients without PUD. The association between PUD and the risk of developing osteoporosis was estimated using a Cox proportional hazard regression model. During the follow-up period, osteoporosis was diagnosed in 2538 (9.35 %) patients in the PUD group and in 2259 (8.33 %) participants in the non-PUD group. After adjusting for covariates, osteoporosis risk was 1.85 times greater in the PUD group compared to the non-PUD group (13.99 vs 5.80 per 1000 person-years, respectively). Osteoporosis developed 1 year after PUD diagnosis. The 1-year follow-up period exhibited the highest significance between the 2 groups (hazard ratio [HR] = 63.44, 95% confidence interval [CI] = 28.19-142.74, P < 0.001). Osteoporosis risk was significantly higher in PUD patients with proton-pump-inhibitors (PPIs) use (HR = 1.17, 95% CI = 1.03-1.34) compared to PUD patients without PPIs use. This study revealed a significant association between PUD and subsequent risk of osteoporosis. Therefore, PUD patients, especially those treated with PPIs, should be evaluated for subsequent risk of osteoporosis to minimize the occurrence of adverse events.
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Affiliation(s)
- Chieh-Hsin Wu
- From the Graduate Institute of Medicine (C-HW, C-YC, Y-YL, C-LL), Department of Public Health and Environmental Medicine (Y-CT), Department of Pathology (C-YC), Department of Neurosurgery, Faculty of Medicine, College of Medicine (C-LL), Department of Neurosurgery (C-HW, Y-FS, T-HT, K-LK, C-LL), Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University (C-YC), Institute of Biomedical Sciences, National Sun Yat-Sen University (C-YC), Department of Dermatology, Kaohsiung Veterans General Hospital (Y-YL), and Cosmetic Applications and Management Department, Yuh-Ing Junior College of Health Care & Management, Kaohsiung, Taiwan (Y-YL)
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