PPIs associated with decreased bone health in some patients with rheumatic disease

Among patients with rheumatic disease taking glucocorticoids at a dose of more than 7.5 mg of prednisone equivalent per day, concurrent proton-pump inhibitor (PPI) use was linked to lower bone mineral density at the spine and femoral neck, a cross-sectional study found.

Proton-pump inhibitors (PPIs) may affect bone health in patients with rheumatic diseases who are taking higher doses of glucocorticoids, a recent study found.

Researchers performed a cross-sectional study using data from a prospective single-center cohort of patients with inflammatory rheumatic and musculoskeletal diseases to evaluate the effect of daily PPI use on bone mineral density (BMD) and bone microarchitecture as measured by the trabecular bone score. BMD of the left femoral neck and the lumbar spine and the trabecular bone score were the primary outcomes. Inverse probability weighting was used to adjust for potential confounders, including age, sex, body mass index, current and cumulative glucocorticoid dose, and C-reactive protein levels. The results were published May 16 by Mayo Clinic Proceedings.

Overall, 1,495 patients were included in the study (75% women; mean age, 62.6 years). Forty-nine percent regularly used PPIs and 63% regularly used glucocorticoids. A total of 37.5% had rheumatoid arthritis, 25% had connective tissue diseases, 16% had polymyalgia rheumatica, 14% had spondyloarthropathies, and 7% had another inflammatory rheumatic or musculoskeletal disease. Mean T-scores for the left femoral neck and lumbar spine were −1.15 and −0.79, respectively; mean trabecular bone score was 1.29.

Patients who used PPIs had lower BMD at both the spine (adjusted difference in T-score, −0.25 [95% CI, −0.47 to −0.04]; P=0.02) and femoral neck (adjusted difference in T-score, −0.17 [95% CI, −0.35 to 0.01]; P=0.07). Differences in BMD between patients who did and did not use PPIs were statistically significant only for those who concurrently used glucocorticoids at a dose above 7.5 mg of prednisone equivalent per day versus those who did not. Trabecular bone score was similar between patients who used PPIs and those who did not (P=0.97).

The study could not prove causation and did not have reliable information on duration of PPI use, among other limitations, the authors noted. They concluded that PPI use is associated with decreased BMD in patients with inflammatory rheumatic and musculoskeletal diseases.

"Clinicians should be aware of this risk especially in higher dose GC [glucocorticoid] users and in other patients with an increased risk of [osteoporosis]," they wrote. "Bone health should be monitored carefully in patients with [inflammatory rheumatic and musculoskeletal diseases], especially those taking both higher dose GCs and PPIs."