using bisphosphonates with proton pump inhibitors (PPIs)

Last edited 04/2023 and last reviewed 05/2023

• no interaction between bisphosphonates and PPIs is documented, the increased risk of fractures when given together should be reviewed and managed

• The UK Summary of Product Characteristics (SPC) for bisphosphonates state that atypical fractures of the femur have been reported with bisphosphonate therapy, primarily in individuals receiving long-term treatment for osteoporosis

A summary of NHS guidance Using bisphosphonates with proton pump inhibitors (PPIs) is presented:

PPIs

• the UK SPCs for PPIs state that 'proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in the elderly or in presence of other recognised risk factors. Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10-40%. Some of this increase may be due to other risk factors.
• patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium’.

• individuals taking bisphosphonates should be reviewed after 5 years of treatment with alendronic acid, risedronate sodium or ibandronic acid, and after 3 years of treatment with zoledronic acid.

Based on fracture-risk assessment, continuation beyond 5 years can generally be recommended for the following individuals:

• over 75 years of age
• history of previous hip or vertebral fracture
• one or more fragility fractures during treatment
• on long-term glucocorticoid treatment

NICE guidance states that QFracture and FRAX can both be used to assess risk fracture for individuals taking bisphosphonates.

• if starting a bisphosphonate in individuals established on PPIs, the PPI should be reviewed to see if this is still required. Some individuals may have been started a PPI for gastro-protection against a medicine that has been stopped
• consider a dose reduction or an alternative agent for individuals still requiring gastro-protection

• suggested to consider whether an H2RA would be more appropriate to prescribe than a PPI

For full guidance then consult Using bisphosphonates with proton pump inhibitors (PPIs)

Reference:

• NHS Specialist Pharmacy Service (April 2023). Using bisphosphonates with proton pump inhibitors (PPIs)