Proton Pump Inhibitors and Osteoporosis: What You Need to Know About Fracture Risk

Every year, millions of Americans take proton pump inhibitors (PPIs) to manage heartburn, acid reflux, or ulcers. These drugs-like omeprazole, esomeprazole, and lansoprazole-are powerful, effective, and often sold over the counter. But behind their popularity lies a quiet, growing concern: PPIs and osteoporosis. Could something meant to calm your stomach be quietly weakening your bones?

How PPIs Work (and Why That Might Hurt Your Bones)

PPIs work by shutting down the acid pumps in your stomach lining. Less acid means less heartburn. Simple, right? But your stomach acid isn’t just there to digest food-it’s also your body’s first step in absorbing key minerals, especially calcium. When you take a PPI for weeks or months, your stomach becomes less acidic. And that’s where things get tricky.

Most calcium supplements, like calcium carbonate, need stomach acid to break down and get absorbed. Without enough acid, your body struggles to pull calcium from the supplement into your bloodstream. Over time, your bones start to lose calcium because they’re not getting enough to rebuild themselves. That’s not a sudden crash-it’s a slow leak. And over years, that leak can add up.

The Evidence: Real Numbers, Real Risk

The data doesn’t sugarcoat it. Multiple large studies have shown a clear pattern:

• A 2019 meta-analysis in the Journal of Bone and Mineral Research found that long-term PPI users had a modest but real increase in hip, spine, and wrist fractures.
• One study tracked people who took PPIs for seven or more years and found their hip fracture risk jumped to 4.55 times higher than non-users.
• Even at lower doses, the risk climbs: low-dose users saw a 17% increase, while high-dose users saw up to a 30% higher risk of upper femur fractures.
• Postmenopausal women on long-term PPIs had a 35% higher chance of hip fracture, according to a 2019 study.

It’s not just about how long you take them-it’s about how much. Higher doses = higher risk. And it’s not just older adults. A 2020 study of over 110,000 children found a 22% higher risk of lower-limb fractures in kids aged 6-12 on PPIs.

Is It Just PPIs? What About H2 Blockers?

Not all acid reducers are the same. H2 blockers like famotidine (Pepcid) and ranitidine (Zantac) work differently. They don’t shut down acid production completely-just dial it down. And guess what? Studies show they don’t carry the same fracture risk.

One major study compared over 50,000 PPI users to 50,000 H2 blocker users. The PPI group had a 27% higher risk of hip fracture. That’s not a small difference. It’s a signal that the problem isn’t just less acid-it’s how much acid you’re losing.

And here’s the kicker: the FDA reviewed seven studies in 2010. Six showed increased fracture risk with PPIs. One didn’t. The difference? The study that didn’t find a link didn’t account for other risk factors like age, steroid use, or prior fractures. That’s why experts say: it’s not the PPI alone. It’s the PPI plus other risks.

Who’s Most at Risk?

If you’re wondering whether you should be worried, ask yourself these questions:

• Are you over 65?
• Are you a postmenopausal woman?
• Do you have a history of fractures?
• Do you take steroids or have low body weight (under 125 lbs)?
• Have you been on PPIs for more than a year?

If you answered yes to any of these, your risk is higher. That doesn’t mean you have to stop your medication. But it does mean you need to be proactive.

What Can You Do? Practical Steps

Here’s what the experts recommend if you’re on long-term PPIs:

1. Use the lowest dose possible. Many people stay on high doses long after they don’t need them. Talk to your doctor about stepping down.
2. Try intermittent dosing. Instead of daily, try taking it every other day or only when symptoms flare up.
3. Switch to calcium citrate. Unlike calcium carbonate, citrate doesn’t need stomach acid to absorb. It’s the better choice if you’re on PPIs.
4. Get enough vitamin D. Your body needs vitamin D to use calcium. Aim for at least 800 IU daily-more if you’re over 70 or have low sun exposure.
5. Get a bone density test. If you’re over 65, female, or have other risk factors, ask your doctor about a DEXA scan. It’s quick, painless, and tells you if your bones are thinning.

The American Geriatrics Society says PPIs should be avoided in older adults unless absolutely necessary. The Endocrine Society says if you’re on PPIs for more than 8 weeks and have other risk factors, get tested. These aren’t vague suggestions-they’re guidelines based on hard data.

What About the Benefits?

Let’s be clear: PPIs save lives. For someone with severe GERD, a bleeding ulcer, or Zollinger-Ellison syndrome, the benefits far outweigh the risks. The problem isn’t PPIs themselves-it’s overuse. Studies show that 60-70% of PPI prescriptions are for conditions that don’t require long-term treatment.

Many people take them for years because they started for a short-term issue and never stopped. That’s why the FDA added a fracture warning to labels in 2011. That’s why prescribing rates dropped 19% between 2015 and 2021. Awareness is working.

The Bigger Picture: It’s Not Just About Calcium

Some researchers think there’s more going on than just calcium absorption. PPIs may also trigger excess gastrin (a hormone that controls acid), which could mess with bone-building cells. Others point to histamine changes that might speed up bone breakdown. But here’s the catch: studies measuring actual calcium absorption in PPI users show mixed results. Some show a small dip. Others show no change at all.

So is it calcium? Or something else? Or both? The answer isn’t settled yet. But the fracture data is consistent enough to act on.

What’s Next?

A major NIH-funded study called PPI-BONE is tracking 15,000 people over five years. Results are expected in early 2025. That study will control for confounding factors like diet, activity, and other meds-something past studies struggled with.

Until then, the advice stays simple: don’t take PPIs longer than you need to. If you’ve been on them for years, talk to your doctor about whether you still need them. If you do, make sure you’re getting enough calcium (citrate form) and vitamin D. And if you’re at risk for osteoporosis, get your bone density checked.

There’s no need to panic. But there’s every reason to be informed.