Background Proton pump inhibitors (PPI) are effective in many indications. Nevertheless, some serious adverse effects associated with prolonged exposure, including an increase in fracture risk, have occurred. This would be explained by two main mechanisms: decreased absorption of calcium secondary to decreased gastric acidity and inhibition of proton pump of osteoclasts reducing bone resorption.
The Frax score assess the 10-year probability of osteoporotic fracture or hip fracture in subjects older than 40 years.
Objectives The aim of our study was to evaluate the usefulness in our practice of this score in patients under long-term PPI.
Methods We included patients who had been taking PPI for at least one year. In all patients, we specified the indication and duration of PPI. We then looked for the main personal or family risk factors for osteoporosis. Bone mineral density (BMD) was performed in all patients and frax score was calculated for those older than 40 years.
Results Fifty-two patients were included in our study. The mean age was 49.5±14.55 years [21 - 84 years] with a sex ratio of 0.48. Long-term PPI were indicated in 75% (n=39) of patients for gastroesophageal reflux, in 11.5% (n=6) for chronic gastritis with failure of Helicobacter Pylori eradication, in 3.8% (n=2) for persistent epigastralgia, in 5.7% (n=3) for functional dyspepsia and finally in 3.8% (n=2) of patients in prophylaxis of gastroduodenal lesions in chronic use of NSAIDs. The mean duration of intake was 45.4 months [12–240 months]. The main osteoporotic risk factors were tobacco in 25%, alcohol in 12%, physical inactivity in 42% and dysthyroidism in 6% of cases. In our study, 20 women among the 35 included (57% of cases) were already menopausal. An osteoporotic fracture in a first-degree relative was noted in 23% of cases, including one parent reporting two fractures. A history of fragility fracture was observed in 11 patients (21%) including 3 men and 8 women. The mean daily calcium intake was 567.2±327.6 mg /d [230 -2315 mg /d]. Calcium intake was insufficient in 94% of patients. BMD was normal in 15 patients (29% of cases) while 71% (n=37) had low BMD. In our population, age (p=0.02), calcium intake (p=0.029) and menopause (p<0.0001) were significantly related to low BMD. The duration of PPI intake was negatively correlated with BMD. Patients taking PPI for at least 30 months were 6.5 times more likely to have low BMD (95% CI [1.5–27.4]). The mean FRAX score for major osteoporotic fractures in 37 patients older than 40 years was 1.08±0.84% [0.3–3.3%]. For hip fractures, the mean score was 0.26±0.29% [0–1.4%]. There was a significant correlation between mean Frax score and BMD (p<0.0001). None patient had a patent or subclinical fracture during the follow-up period.
Conclusions Our study shows an increased risk of fracture in patients under long-term PPI, especially if they have other osteoporotic risk factors. In this context, Frax score is a simple and non-invasive tool for assessing fracture risk in these patients and to adapt screening strategy for sub-clinical fractures.
Disclosure of Interest None declared
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