Rheumatism: Taking cortisone plus gastric protection can reduce bone density

Charité study on the effects of taking proton pump inhibitors (PPI) on the bone health of rheumatism patients

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Berlin, 16 May, 2024

Proton pump inhibitors (PPIs) – also known as stomach protectors or acid blockers – are among the most commonly used medications of all. They are also often prescribed to rheumatism patients. The aim is to prevent stomach problems that can arise from taking certain anti-inflammatory drugs. However, this practice could have negative consequences for bone health: As a study by Charité – Universitätsmedizin Berlin shows, taking PPIs, especially when taken at the same time as cortisone, is associated with an increased risk of osteoporosis. The study has now been published in the specialist journal Mayo Clinic Proceedings*.

Around 3.8 billion daily doses of proton pump inhibitors were prescribed by doctors in Germany in 2022, according to the latest Drug Prescription Report. PPIs such as pantoprazole or omeprazole inhibit the production of stomach acid and are primarily intended for the treatment of stomach ulcers or bleeding, but are also used as a preventative measure. Many patients with rheumatoid arthritis are prescribed PPIs under certain conditions during treatment with glucocorticoids (‘cortisone’) to prevent the stomach lining from becoming inflamed. Some people also take PPIs without consulting a doctor for heartburn or other stomach complaints. They can be obtained over the counter from pharmacies up to a certain dose.

It is known from studies on various diseases that taking PPIs favours the development of bone loss (osteoporosis). In addition, the cortisone often used at the same time in rheumatology can weaken the bones. ‘We therefore asked ourselves whether PPIs also increase the risk of osteoporosis in our rheumatism patients,’ explains the lead author of the study, Dr Andriko Palmowski, a doctor at the Medical Clinic specialising in rheumatology and clinical immunology and research associate at Charité.

Analysing the bone mineral density of 1,500 patients

To find this out, he teamed up with Professor Frank Buttgereit and other colleagues from Charité, the USA and Denmark to analyse the bone health of around 1,500 patients with inflammatory rheumatic diseases. Around half of them took proton pump inhibitors on a daily basis. Bone mineral density and bone microarchitecture were analysed. If the bone density is reduced or changes in the microarchitecture can be found, this indicates osteoporosis.

In fact, bone density was significantly lower in patients taking PPIs than in those not taking PPIs. This correlation also remained when influencing factors such as age or nicotine consumption were statistically taken into account and eliminated. The effect was particularly pronounced when patients took PPIs together with cortisone preparations in a daily dose of at least 7.5 mg. Bone microarchitecture, on the other hand, was not significantly affected. ‘Our results suggest that PPIs lead to a loss of bone mineral density in patients with rheumatoid arthritis,’ says Andriko Palmowski. From this, it can be roughly estimated that the risk of a vertebral fracture increases by around 25 per cent.

Carefully examine the reasons for prescribing gastric protection

The authors of the study now see their medical colleagues as having a duty: ‘Doctors should carefully examine the reasons for prescribing PPIs and discuss the benefits and possible risks with patients – especially if cortisone is prescribed at the same time,’ they conclude. Justified reasons for prescribing PPIs include risk factors that favour the development of peptic ulcers. These risk factors include, for example, taking cortisone and non-steroidal anti-inflammatory drugs such as ibuprofen, diclofenac or aspirin at the same time. On the other hand, those who take cortisone alone and have no other risk factors are more likely not to need gastric protection – according to the medical guideline ‘Drug therapy for multimorbidity’.

‘If simultaneous intake is unavoidable, dietary supplements with vitamin D and calcium can support bone maintenance,’ explains Andriko Palmowski. If long-term cortisone therapy is planned, regular bone density measurements and, if necessary, targeted osteoporosis therapy with medication may be necessary. Patients and doctors should discuss which measures make sense in each individual case.

*Palmowski A et al. Proton Pump Inhibitor Use and Bone Health in Patients With Rheumatic Diseases: A Cross-Sectional Study. Mayo Clinic Proceedings, May 16 2024. doi:10.1016/j.mayocp.2023.12.008

About the study

The study was conducted at Charité’s Department of Rheumatology and Clinical Immunology under the leadership of Dr Andriko Palmowski (first author), Prof Frank Buttgereit (last author and deputy clinic director) and Dr Edgar Wiebe (last author). Other colleagues at Charité, from the USA (University of California San Francisco) and from Denmark (Københavns Universitet, Syddansk Universitet and Odense Universitetshospital) were also involved. Data from 1,495 patients was analysed.

Symbolic image: Drug packages in a pharmacy © Charité | Janine Oswald