The magnitude of the association is modest and is most likely due to confounding factors as patients prescribed PPI therapy  tend to be more frail with more risk factors for fractures than those not given these drugs .
There is no clear dose – response relationship and there is no association between PPI therapy and risk of fracture in those at highest risk .
Finally , there is no clear mechanism through which PPI therapy increases the risk of fracture , as recent r and omized trials show no impact of PPI therapy on calcium absorption and there is no association between PPI therapy and risk of osteoporosis .
We therefore feel there is insufficient evidence to change PPI prescribing habits based on risk of fracture .
There is no evidence to support prescription of calcium and /or vitamin D in patients simply because they are taking PPI therapy .
Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: results from the Women's Health Initiative.
BACKGROUND Proton pump inhibitor ( PPI ) medications have been inconsistently shown to be associated with  osteoporotic fractures .  We examined the association of PPI use with bone outcomes ( fracture , bone mineral density [ BMD ] ) . METHODS This prospect i ve analysis included 161 806 postmenopausal women 50 to 79 years old , without history of hip fracture , enrolled in the Women 's Health Initiative ( WHI ) Observational Study and Clinical Trials with a mean ( SD ) follow-up of 7.8 ( 1.6 ) years . Analyses were conducted for 130 487 women with complete information .  Medication information was taken directly from drug containers during in-person interviews ( baseline , year 3 ) . The main outcome measures were self-reported fractures ( hip [ adjudicated ] , clinical spine , forearm or wrist , and total fractures ) and for a sub sample ( 3 densitometry sites ) , 3-year change in BMD . RESULTS During 1 005 126 person-years of follow-up , 1500 hip fractures , 4881 forearm or wrist fractures , 2315 clinical spine fractures , and 21 247 total fractures occurred . The multivariate-adjusted hazard ratios for current PPI use were 1.00 ( 95 % confidence interval [ CI ] , 0.71 - 1.40 ) for hip fracture , 1.47 ( 95 % CI , 1.18 - 1.82 ) for clinical spine fracture , 1.26 ( 95 % CI , 1.05 - 1.51 ) for forearm or wrist fracture , and 1.25 ( 95 % CI , 1.15 - 1.36 ) for total fractures . The BMD measurements did not vary between PPI users and nonusers at baseline . Use of PPIs was associated with only a marginal effect on 3-year BMD change at the hip ( P = .05 ) but not at other sites . CONCLUSION Use of PPIs was not associated with hip fractures but was modestly associated with clinical spine , forearm or wrist , and total fractures
The magnitude of the association is modest and is most likely due to confounding factors as patients prescribed PPI therapy  tend to be more frail with more risk factors for fractures than those not given these drugs .
There is no clear dose – response relationship and there is no association between PPI therapy and risk of fracture in those at highest risk .
Finally , there is no clear mechanism through which PPI therapy increases the risk of fracture , as recent r and omized trials show no impact of PPI therapy on calcium absorption and there is no association between PPI therapy and risk of osteoporosis .
We therefore feel there is insufficient evidence to change PPI prescribing habits based on risk of fracture .
There is no evidence to support prescription of calcium and /or vitamin D in patients simply because they are taking PPI therapy .