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

When you take a proton pump inhibitor (PPI) for heartburn or ulcers, you’re probably not thinking about your bones. But if you’ve been on these meds for years, there’s a quiet risk you should know about: fractures. It’s not a scare tactic-it’s backed by data from millions of patients. And if you’re over 65, female, or have other risk factors, this isn’t something you can ignore.

What Are Proton Pump Inhibitors?

PPIs are drugs like omeprazole (Prilosec), esomeprazole (Nexium), and pantoprazole (Protonix). They work by shutting down the acid-producing pumps in your stomach lining. For people with severe GERD, peptic ulcers, or Barrett’s esophagus, they’re life-changing. But here’s the catch: they were never meant to be taken for decades.

When PPIs first hit the market in the late 1980s, doctors were told to prescribe them for 4 to 8 weeks. Today, nearly 70% of PPI prescriptions are for long-term use-often without a clear medical reason. In the U.S. alone, about 15 million people take them every year. Many are on them because they started for a short issue and never stopped.

The Bone Connection: What the Research Shows

Since 2006, over a dozen large studies have looked at whether long-term PPI use increases fracture risk. The results? It’s not a huge risk for everyone-but it’s real for some.

A 2019 meta-analysis in the Journal of Bone and Mineral Research found that people who took PPIs for more than a year had a modest but significant increase in hip, spine, and wrist fractures. The risk didn’t show up right away. It built up over time. After five years of daily use, the chance of a hip fracture went up by about 60%. After seven years? It nearly quadrupled.

One study tracking over 50,000 people over 50 found that those on PPIs had a 27% higher risk of hip fracture compared to those on H2 blockers (like famotidine). For those on higher doses, the risk jumped to 67%. Another study focused on postmenopausal women-already at higher risk for osteoporosis-and found a 35% increased risk of hip fracture with long-term PPI use.

It’s not just one study. The FDA reviewed seven major studies in 2010 and found six showed a link. One didn’t. But the ones that did showed clear patterns: longer use = higher risk. Higher dose = higher risk.

Why Would Stomach Acid Affect Your Bones?

This is where it gets interesting. Your stomach needs acid to absorb calcium-especially calcium carbonate, the most common form in supplements. When PPIs lower stomach acid, calcium doesn’t dissolve as well. That means less gets into your bloodstream.

But here’s the twist: not all studies show a drop in calcium levels. Some found only a tiny, temporary dip. So why the fractures?

Researchers think it’s more than just calcium. PPIs may also affect how bone cells work. High acid suppression can cause your body to make more gastrin, a hormone that might interfere with bone remodeling. It could also trigger more histamine, which activates bone-breaking cells called osteoclasts. The result? Your bones don’t rebuild as well as they should.

And here’s the kicker: calcium citrate doesn’t need stomach acid to absorb. If you’re on PPIs long-term, switching from calcium carbonate to calcium citrate can help. But it’s not a magic fix.

Who’s Most at Risk?

Not everyone on PPIs will break a bone. But some people are far more vulnerable:

• Women over 65
• People with low body weight (under 57 kg)
• Those who’ve had a previous fracture
• People taking corticosteroids (like prednisone)
• Anyone on high-dose PPIs for more than a year

The American Geriatrics Society lists PPIs as potentially inappropriate for older adults when used long-term without a clear reason. The Endocrine Society says if you’re on PPIs for more than 8 weeks and have any of those risk factors, you should get a bone density scan (DEXA scan).

What About Other Acid Reducers?

H2 blockers-like ranitidine or famotidine-are older drugs that also reduce stomach acid, but not as completely as PPIs. Studies show they don’t carry the same fracture risk. In fact, one large 2020 study found no increase in overall fractures with H2 blockers, even in kids.

That doesn’t mean H2 blockers are perfect. They’re less effective for severe GERD. But for mild heartburn, they might be a safer long-term option.

If you’re on PPIs because you’ve been told to “just take it daily,” ask your doctor: could an H2 blocker work instead? Especially if you’re not dealing with ulcers or Barrett’s esophagus.

What Should You Do?

If you’ve been on a PPI for more than a year, here’s what to do:

1. Ask your doctor if you still need it. Many people take PPIs long after their original problem is gone.
2. If you do need it, use the lowest dose possible. Some people can cut their dose in half and still feel fine.
3. Try intermittent dosing. Instead of daily, take it every other day or only when symptoms flare up.
4. Switch to calcium citrate if you’re taking calcium supplements. Avoid calcium carbonate.
5. Get enough vitamin D (800-1000 IU daily) and protein. Both help bone strength.
6. Ask about a bone density test if you’re over 65 or have other risk factors.

Don’t stop PPIs cold turkey. That can cause rebound acid hypersecretion-your stomach overproduces acid, making symptoms worse. Talk to your doctor about tapering safely.

The Bigger Picture: Benefits vs. Risks

Let’s be clear: PPIs save lives. For people with bleeding ulcers, severe GERD, or esophageal damage, they’re essential. The fracture risk is real, but small for most people. The American Gastroenterological Association says the benefits usually outweigh the risks-if the drug is used correctly.

The problem isn’t PPIs themselves. It’s how often they’re misused. In 2022, nearly half of all long-term PPI prescriptions were still inappropriate. That’s not because doctors are careless. It’s because stopping them is hard. Patients feel better, assume they’re cured, and don’t go back. Doctors don’t always follow up.

That’s changing. Since 2015, long-term PPI prescriptions among Medicare patients dropped by almost 20%. More doctors are asking, “Do you still need this?”

What’s Next?

A major NIH study called PPI-BONE is tracking 15,000 people over five years. Results are expected in mid-2025. This study is designed to control for confounding factors like diet, activity, and other medications-something earlier studies couldn’t do well.

Until then, the best advice is simple: use PPIs only when necessary, at the lowest dose, for the shortest time possible. And if you’re on them long-term, don’t ignore your bones.