What are the recommendations for patients taking Prilosec (omeprazole) regarding osteoporosis risk?

Recommendations for Patients Taking Prilosec (Omeprazole) Regarding Osteoporosis Risk

Patients taking Prilosec (omeprazole) long-term should be monitored for bone mineral density loss and offered preventive measures due to the increased risk of osteoporosis and fractures associated with proton pump inhibitor use. 1, 2

Risk Assessment

• Long-term PPI use is associated with an increased risk of bone complications, particularly decreased bone mineral density (BMD) and higher fracture risk 2, 3
• Risk factors that increase osteoporosis concern in PPI users include:
  • Age ≥50 years 2
  • Postmenopausal status in women 2
  • Insufficient calcium intake (≤550mg/day) 2
  • PPI use duration ≥30 months 2, 4
  • Higher doses of PPIs (showing a dose-response relationship) 5

Preventive Recommendations

• All patients on long-term Prilosec should ensure adequate age-appropriate dietary and supplemental intake of calcium and vitamin D 6
• Weight-bearing exercise should be encouraged for all patients taking Prilosec 6
• Avoidance of smoking and excessive alcohol consumption (>10 servings per week) is strongly recommended 7, 6
• Patients should be prescribed the lowest effective dose of Prilosec for the shortest duration needed 1

Monitoring Recommendations

• Consider baseline bone mineral density (BMD) testing via dual-energy X-ray absorptiometry (DXA) for patients who will be on long-term Prilosec therapy, especially those with additional risk factors 4, 8
• For patients on long-term therapy (>1 year), BMD testing should be performed every 2 years, or more frequently if medically necessary 6
• FRAX tool may be used to quantify the risk estimates for osteoporotic fracture in adults taking Prilosec long-term 7, 6

Management of Patients with Identified Risk

• For patients with moderate, high, or very high fracture risk who require continued Prilosec therapy:
  • Oral bisphosphonates (alendronate or risedronate) are recommended as first-line treatments 6
  • Denosumab or zoledronate may be considered as second-line treatments 6
  • For very high-risk patients, consider bone-forming agents (teriparatide, abaloparatide) followed by anti-resorptive therapy 6

Important Considerations and Pitfalls

• The FDA label for Prilosec explicitly warns about bone fracture risk: "People who take multiple daily doses of PPI medicines for a long period of time (a year or longer) may have an increased risk of fractures of the hip, wrist, or spine" 1
• Different PPIs may have varying effects on bone health - studies suggest esomeprazole and rabeprazole may have higher associated fracture risks than other PPIs 5
• Patients should be informed about the risk but not discontinue their medication without consulting their healthcare provider, as the benefits may outweigh the risks in many cases 1, 3
• Sequential therapy is recommended after stopping certain osteoporosis medications to prevent rebound bone loss 7

Special Populations

• Patients with chronic kidney disease on hemodialysis should be monitored more closely as they showed significantly lower BMD values when on PPI therapy 8
• Patients on glucocorticoid therapy who also take PPIs require particularly careful monitoring due to compounded risk 7
• Cancer patients receiving treatments that cause bone loss who are also on PPIs should be considered for more frequent monitoring 7