From the Guidelines
Proton pump inhibitors (PPIs) should be used with caution in patients with osteogenesis imperfecta (OI), considering the potential risks of decreased calcium absorption and bone remodeling effects, as evidenced by the American Gastroenterological Association's statement on the management of gastroesophageal reflux disease 1. When necessary, PPIs can be used at the lowest effective dose for the shortest duration possible, such as omeprazole 20mg daily or pantoprazole 40mg daily, for specific indications like GERD or peptic ulcer disease.
- Patients with OI already have compromised bone health due to collagen defects, and PPIs may potentially worsen this by reducing calcium absorption through decreased stomach acidity and possibly directly affecting bone remodeling.
- Regular monitoring of bone mineral density is recommended for OI patients on long-term PPI therapy.
- If extended PPI use is necessary, ensure adequate calcium supplementation (1000-1500mg daily) and vitamin D (800-1000 IU daily), preferably calcium citrate which is better absorbed in low-acid environments.
- Consider H2 receptor antagonists like famotidine 20mg twice daily as alternatives when appropriate, as the risk-benefit assessment is particularly important in this population, given the potential bone effects of PPIs could compound the underlying bone fragility characteristic of osteogenesis imperfecta, although the available data show no worrisome safety signals with PPIs 1.
From the FDA Drug Label
5.4 Bone Fracture Several published observational studies suggest that proton pump inhibitor (PPI) therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer) Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines [see Dosage and Administration (2.1), Adverse Reactions (6.3)].
Use of PPI in a patient with osteogenesis imperfecta is not directly addressed in the label. However, considering the association of PPI therapy with an increased risk of osteoporosis-related fractures, caution should be exercised when using PPI in patients with osteogenesis imperfecta, a condition characterized by fragile bones. The lowest dose and shortest duration of PPI therapy should be used, and patients should be managed according to established treatment guidelines to minimize the risk of fractures 2.
From the Research
PPI Use in Osteogenesis Imperfecta Patients
- The use of proton pump inhibitors (PPIs) in patients with osteogenesis imperfecta is a concern due to the potential link between PPIs and osteoporosis, as well as osteoporotic fractures 3, 4.
- Studies have shown that PPI use is a risk factor for the development of osteoporosis and osteoporotic fractures, although the direct pathogenesis remains unclear 3.
- The impact of PPIs on bone regeneration and implant osseointegration has also been investigated, with results suggesting a link between PPI intake and impaired bone regeneration 5.
- However, it is essential to note that the safety of long-term PPI use has been established, with no convincing evidence of increased risk of hip fracture or other adverse effects in most patients 6.
- When considering PPI use in patients with osteogenesis imperfecta, it is crucial to weigh the benefits against the potential risks and to use the lowest effective dose, as well as to be vigilant in regard to the indication for prescribing PPIs 3, 6.
Key Considerations
- The choice of PPI should be based on the individual patient's needs and the specific clinical indication, as well as the strength of evidence supporting the use of a particular PPI 7.
- Patients with osteogenesis imperfecta should be monitored closely for any potential adverse effects of PPI use, including impaired bone regeneration and increased risk of osteoporotic fractures 3, 5.
- Further studies are needed to determine the exact mechanism by which PPIs affect bone health and to establish clear guidelines for PPI use in patients with osteogenesis imperfecta 3, 5.