Taking cortisone with antacids reduces bone density in patients with rheumatism

Proton pump inhibitors (PPIs), a specific class of antacid drugs, are among the most widely used medications. They are often prescribed to many patient groups, including those who suffer from rheumatism. PPIs are used to prevent stomach problems that may occur with certain anti-inflammatory drugs.

However, this practice may have negative consequences for bone health: according to a study conducted by the Charité—Universitätsmedizin Berlin, taking PPIs, especially along with cortisone, is associated with an increased risk of osteoporosis. The study was published in Mayo Clinic Proceedings.

Doctors in Germany prescribed about 3.8 billion daily doses of proton pump inhibitors in 2022, according to the latest official report on prescription drugs in Germany. PPIs such as pantoprazole and omeprazole inhibit the production of stomach acid. They are primarily intended to treat stomach ulcers or bleeding, but are also used for preventive purposes.

Many patients with rheumatoid arthritis, also known as rheumatic fever, are prescribed PPIs in certain circumstances while being treated with glucocorticoids ("cortisone") to prevent inflammation of the stomach lining. Some people take PPIs even without consulting a doctor to treat conditions such as heartburn or other stomach problems. These drugs are available without a prescription up to a certain dosage.

However, studies of various diseases have shown that taking PPIs may contribute to the development of osteoporosis (loss of bone mineral density). Additionally, cortisone, which is often used concomitantly in rheumatology, can also weaken bones.

“We therefore asked whether PPIs increase the risk of osteoporosis in our patients with rheumatism,” explains Dr. Andrico Palmovsky, first author of the study and a Charité research physician.

Analysis of bone mineral density in 1500 patients

To find out, he and Professor Frank Buttgereit teamed up with other colleagues from Charité, the US and Denmark to study the bone health of about 1,500 patients with inflammatory rheumatic diseases. About half of them took proton pump inhibitors daily. The researchers analyzed bone mineral density and bone microstructure. Decreased bone density and changes in microstructure are indicators of osteoporosis.

The team found that patients taking PPIs did have significantly lower bone density than those not taking them. The correlation persisted even after controlling for factors such as age and smoking. The effect was especially noticeable in patients who took PPIs along with cortisone drugs at a daily dose of at least 7.5 mg. In contrast, there were no significant negative effects on bone microstructure.

"Our results suggest that PPIs lead to loss of bone mineral density in patients with rheumatoid arthritis," Palmowski says. This means an approximately 25% higher risk of vertebral fracture.

Doctors should carefully consider prescribing antacids

The study authors believe their fellow physicians have a special responsibility in light of these findings. "Clinicians should carefully consider the reasons for prescribing PPIs and discuss the benefits and potential risks with patients, especially if cortisone is co-prescribed," they conclude.

Legitimate reasons for prescribing PPIs include risk factors that may contribute to the development of stomach ulcers. These factors include, for example, concomitant use of cortisone with non-steroidal anti-inflammatory drugs (NSAIDs) used to treat rheumatism, such as ibuprofen, diclofenac and even aspirin.

In contrast, those taking cortisone alone without other risk factors generally do not need antacids - according to official German medical prescribing guidelines for patients with multiple diseases.

"If concomitant use is unavoidable, supplements containing vitamin D and calcium may help maintain bone health " explains Palmowski. If long-term treatment with cortisone is planned, regular measurements of bone density and even the prescription of special drugs for the treatment of osteoporosis may be necessary. Patients and doctors must decide together which measures make the most sense in a particular case.