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PPIs and Risk for Bone Fractures

PPIs and Risk for Bone Fractures. http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM213307.pdf. Literature Review Title: PPIs and Risk for Bone Fractures. Peter R. McNally, DO, FACP, FACG University Colorado Denver School of Medicine Center for Human Simulation

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PPIs and Risk for Bone Fractures

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  1. PPIs and Risk for Bone Fractures http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM213307.pdf

  2. Literature ReviewTitle: PPIs and Risk for Bone Fractures Peter R. McNally, DO, FACP, FACG University Colorado Denver School of Medicine Center for Human Simulation Aurora, Colorado 80045

  3. Shelly L. Gray, PharmD, MS; Andrea Z. LaCroix, PhD; Joseph Larson, MS; John Robbins, MD;Jane A. Cauley, DrPH; JoAnn E. Manson, MD, DrPH; Zhao Chen, PhD Author Affiliations: School of Pharmacy, University of Washington, Seattle (Dr Gray); Women’s Health Initiative Clinical Coordinating Center, Fred Hutchinson Cancer Research Center, Seattle (Dr LaCroix and Mr Larson); Department of Internal Medicine, University of California at Davis School of Medicine, Sacramento (Dr Robbins); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Cauley); Division of Preventive Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts (Dr Manson); and Division of Epidemiology and Biostatistics, University of Arizona, Tucson (Dr Chen). Proton Pump Inhibitor Use, Hip Fracture, and Change in Bone Mineral Density in Postmenopausal Women. Arch Intern Med. 2010;170;765-771.

  4. Introduction • Proton Pump Inhibitors (PPIs) are potent gastric acid suppressing medications, with millions of PPI prescriptions dispensed annually throughout the world for the treatment GERD. • The effectiveness of PPIs to alleviate symptoms of heartburn and heal esophagitis have lead to the common practice of prescribing PPIs indefinitely for this chronic disorder. • Recent large epidemiologic studies have suggested PPIs potent acid suppression may have a deleterious affect on calcium absorption and bone fracture risk. Yang YX, et al. Long-term PPI therapy and risk of hip fracture. JAMA. 2006;296:2947-2953. Targownik LE, et al. Use of PPIs and risk of osteoporosis-related fractures. CMAJ. 2008;179 :319-326. Yu EW, et al. Acid-suppressive medications and risk of bone loss and fracture in older adults. Calcif Tissue Int. 2008;83 :251- 259.

  5. Introduction • The FDA has recently issued a Broad Safety Communication to Patients, Consumers and Healthcare Professionals: “Possible increased risk of fractures to the hip, wrist, and spine with the use of PPIs.” http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm#SafetyAnnouncement#SafetyAnnouncement

  6. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Aim The authors utilized the ethnically and racially diverse database from the Women’s Health Initiative (WHI) to provide a biological evaluation of fracture risk associated with PPIs among women. Langer RD, et al. The Women’s Health Initiative observational study: baseline characteristics of participants and reliability of baseline measures. Ann Epidemiol. 2003;13 suppl 1:S107-S121. Women’s Health Initiative Study Group. Design of the Women’s Health Initiative clinical trial and observational study. Control Clin Trials. 1998;19:61-109.

  7. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Design: Methods The WHI includes women participants of a prospective Observational Study (OS) and Clinical trials (CTs) of hormone therapy, dietary modification and/or calcium and vitamin D supplementation. • WHI-OS n = 93,676 women • WHI-CTs n = 68,132 women • Women recruited from 40 clinical centers located across the United States from 1993 to 1998. • The study included women enrolled to WHI-OC plus WHI-CTs (n = 161,808) who had no prior hip fracture. • Follow-up for this report was through Sept 2005, mean 7.8 + 1.6 yrs

  8. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Design: Outcome Assessment Fracture • Total fractures • Except: rib, sternum, skull, fingers, toes, & cervical • Self Reported Fractures • Semi to Annual mail &/or telephone questionnaires • Hip fractures: • Central review of radiology reports • Fracture outcomes reported for: • Hip • Clinical spine • Forearm • Wrist • Total fractures

  9. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Design: Outcome Assessment Measurement of Bone Mass Density (BMD) • BMD at total hip, P-A spine and total body measured at baseline in 3 centers • N = 10,833 women • Sites: Pennsylvania, Alabama, Arizona • BMD Measurement • Dual-energy x-ray absorptiometry using Hologic QDR densitometer (Hologic Inc, Waltham, Mass) • Missing data on BMD, PPI use, etc • Complete analysis • Hip n = 6,696 • Spine n = 6,626 • Total body n = 6,677

  10. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Design: Outcome Assessment PPI Exposure • Participants brought all current Rx medications to baseline and 3-yr visit. • Clinic interviewers entered all Rx into the WHI database. • Drugs in the PPI Class: • esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole • Drugs in the H2RA class: • cimetidine, famotidine, nizatidine, and ranitidine. • Duration of use 3 categories: • < 1 year or 1-3 yrs or >3 yrs

  11. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Design: Outcome Assessment COVARIATES • Race, ethnicity, history of fracture, smoking. • Physical fx by 10 item Medical Outcome • BMI • Self reported physical activity (hrs/wk) • Psychoactive medication • Rx: corticosteroid,HRT,bisphosphonate • Dietary Calcium and vitamin D by food history and supplements.

  12. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Design: Methods Statistical Analysis • Χ2 for categorical variables • 2-sample t test for continuous variables • SAS statistical software (V 9.1; SAS Institute Inc, Cary, North Carolina) • Multivariate analysis used for participants with missing covariate data. Hazard ratios (HR) and corresponding 95% confidence intervals (CIs) for fractures among PPI and H2RA users vs. non-users were calculated from Cox proportional hazards survival models for each fracture outcome. • Model 1 adjusted for age, race or ethnicity • Model 2 adjusted for smoking, physical activity, family history of hip fracture, DM, corticosteroid use.

  13. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Results: Demographics

  14. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Results: Demographics

  15. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Results: Demographics

  16. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Results: Demographics

  17. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Results: Risk for Fracture According to PPI and H2RA Use at Baseline

  18. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Results: Risk for Fracture According to PPI and H2RA Use at Baseline

  19. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Results: Adj HRs Related to Duration PPI Use to Incidence of Hip, Clinical Spine, Forearm, Wrist % Tot Fx. 2008 Top 200 generic drugs by total prescriptions. Drug Topics website. Http://drugtopics.modernmedicine.com/drugtopics/data/articlesstandard/drugtopics/192009/597086/article.pdf

  20. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Results: • Cohort at Baseline n =161,806 • 3,396 (2.1%) using PPI • 10,016 (6.2%) using H2RA • PPI users more likely to be obese, have osteoporosis, history of fractures, DM, HRT, Psychoactive Rx, poorer physical function and poorer self reported health.

  21. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Results: Fractures • 1,005,126 person-years of follow up • 1,500 hip fractures • 4,881 forearm or wrist fractures • 2,315 clinical spine fractures • 21,247 total fractures occurred • Annualized rates for Hip fractures were: • 0.15% for nonusers and • 0.19% for PPI medication users.

  22. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Results: Fractures • In Adjusted Models of Fx Risk & PPI use • Hip fractures risk ≠ increased on PPI • 26% ↑ Forearm or wrist fractures on PPI • 47% ↑ Clinical spine fractures on PPI • 25% ↑ Total fractures occurred on PPI • No association between H2RA use and hip, clinical spine, forearm, or wrist, but use assoc with minimal ↑ risk in total fractures.

  23. Δ BMD for Total Hip Gray SL, et al. Arch Intern Med. 2010;170;765-771.

  24. Δ BMD for Total Spine Gray SL, et al. Arch Intern Med. 2010;170;765-771.

  25. Δ BMD for Total Body Gray SL, et al. Arch Intern Med. 2010;170;765-771.

  26. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Conclusions • This very large prospective population-based study of post-menopausal women, showed that PPI use was not significantly associated with increased hazard of incident hip fracture. • ↑ Hip fracture risk was NOT noted with longer duration of PPI use nor for subgroup analysis of women classified by age, BMI, current HRT, calcium intake, or history of non-hip fracture.

  27. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Study Conclusions • However, this study did show that baseline PPI use was associated with an increased risk for other fracture outcomes: • ↑ risk clinical spine fracture ↑ 47% • ↑ risk forearm or wrist fracture ↑ 26% • ↑ total fractures ↑ 25% • Interestingly, total fracture risk in this study cohort was not reduced by calcium supplementation.

  28. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Reviewer Comments Gray, et al, have shown: • That non hip fractures among post menopausal women are increased. However, they do not explain reason for this fracture risk. • Could it be the women in this study with chronic PPI use are more frequently obese, sedentary, depressed on psychoactive medications and these co-variables are the greater risk for increased non-hip bone fracture?

  29. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Reviewer Comments • Results of this study and others are a stern reminder to prescribers of PPIs to have heightened awareness of bone health. • Whether using lower doses of PPI for chronic GERD will mitigate risk for non-hip fractures will require further scrutiny and prospective study.

  30. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Reviewer Comments • Future studies are needed to determine if BMD should be monitored among chronic PPI users, or perhaps subgroups with additional risk factors for osteoporosis and bone fracture should receive counter therapy to avoid bone loss and increased fracture risk.

  31. Gray SL, et al. Arch Intern Med. 2010;170;765-771. Reviewer Conclusions • The clinician is urged to remember that although the risk for bone fracture is increased among post menopausal women on chronic PPI. There may be many other co-founding variables that influence fracture risk. The reader is referred to Screening for Osteoporosis: An Update for the U.S. Preventive Services Task Force Ann Intern Med. 2010;153:99-111. • The recent FDA Alert should remind all prescribers of PPIs to consider evaluation of “bone health” when indefinite PPI therapy is necessary.

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