The Number 1 Recommendation
1. PPIs can be used in patients with bone density loss. The committee decided, on the basis of the weighted evidence, to make a strong recommendation that PPI use is not contraindicated in patients with bone density loss.
Remember, the US Food and Drug Administration made a label change on PPIs, saying that the loss of bone density has been described. The odds ratios for hip fracture, wrist fracture, and cervical spine fracture were increased in PPI users. We have previously reviewed longitudinal data suggesting that that is not the case. The committee decided that this was not an issue as it relates to our ongoing use of PPIs in patients who were defined as potentially having osteopenia.
If your patients have other risks, you should reevaluate whether they need their PPIs. The committee didn't say whether it was a factor or not, but again, the risk in most of these people is stratified, on the basis of their entry level to PPI exposure, family history, use of steroids, use of benzodiazepines, gender, age, et cetera. Inactivity, obesity, smoking, and a number of other things all play into hip fracture- and bone fracture-related risks.
The committee suggested that PPIs can be used in patients with bone density loss. This is one of the top questions I get when I see patients who need PPIs.
Closing Remarks
What I've done for you is give you the top 10 recommendations. I hope that these have been meaningful to you and that you can apply them to your practice. If you are keenly interested, delve into the 54 recommendations. It is a very well-done document, very evidence-based, and graded by the evidence. Hopefully it puts the recommendations into perspective for you and gives you a little bit of data for your next discussion with your GERD patient who is relying on PPI therapy.
I'm Dr. David Johnson. Thanks again for listening.