Clinical, In the News / Politics:

Link Revealed: PPI Usage, Smoking and Bone Fractures

By: Ebey P. Soman

Proton pump inhibitors (PPIs) are medications commonly prescribed to treat heartburn, acid reflux disease, and ulcers.  Almost a vast majority of patients in the United States seem to be taking a PPI, either as a prescription or from over-the-counter (OTC).  Researchers recently discovered associations between the long-term use of PPIs and bone fractures.  Now, a new study published in the British Medical Journal (BMJ) revealed more condemning links to bone fractures in a prospective cohort study titled “Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors.”

The study used 79,899 women (aged between 30 and 55) enrolled in the Nurses’ Health Study.  The women provided six-month’s worth of data on their use of PPIs and other risk factors.  The main monitoring outcome was the incidence of hip fractures in women taking PPIs compared to women who did not take PPIs, as well as women who smoked while taking PPIs.  The study showed that the risk of hip fractures in women taking long term PPIs was 2.02 events per 1000 person years, compared with 1.51 events per 1000 person years among women not taking any PPIs.  Women who used PPIs regularly for two years had a 35% increased risk of fractures, with longer usage continuing to increase that risk.

The results in women who smoked or had a history of smoking were even more interesting.  The use of PPIs in this population resulted in a 50% increased risk of hip fracture compared with women who did not take the medication.  The study concluded, “Chronic use of PPIs is associated with increased risk of hip fracture, particularly among women with a history of smoking.”

Dr. John Stevenson, who sits on the medical advisory council of the British Menopause Society, stated that the study shows an association between PPI use and hip fractures, but is not significant enough to warrant a warning against use in patients needing such medications.  However, it is a clear indicator of the need to educate patients on appropriate ways to take PPIs and smoking cessation.

Mr. Dan Greer, the Royal Pharmaceutical Society spokesperson on gastroenterology medicines, stated, “this study strengthens the current recommendations for PPI use, in that for the majority of patients with symptoms of indigestion, PPIs should only be used for short courses (one to two months), with repeat courses offered at the lowest dose that controls symptoms.”

Community pharmacists play a vital role in society as the bridge between the patient and the medical community.  Thus, this is an important opportunity for pharmacists to make headway into counseling patients on proper usage of certain OTC medications, such as PPIs.  It also raises the necessity to push smoking cessation programs and to offer information about making healthy choices to prevent future complications.


  1. BBC News. Ulcer drugs ‘link to fractures.’ Available online: Last accessed 1 Feb 2012.
  2. Khalili H, Huang ES, Jacobson BC, et. al. Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective cohort study. BMJ. 2012 Jan 30;344:e372. doi: 10.1136/bmj.e372.
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