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 .
Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting.
OBJECTIVES To determine the prevalence and economic effect of inappropriate proton pump inhibitor ( PPI ) use in an ambulatory care setting . STUDY DESIGN Retrospective medical record review of r and om sample with subgroup analysis . METHODS Patients were categorized according to appropriateness of pharmacotherapy  based on documented upper gastrointestinal tract diagnoses , gastrointestinal or extraesophageal symptoms , or gastroprotection . Adverse events potentially associated with PPI use were identified . RESULTS Of 946 patients in an ambulatory care setting , 35.4 % were given PPI therapy for an appropriately documented upper gastrointestinal tract diagnosis , 10.1 % received PPIs empirically for symptomatic treatment based on extraesophageal symptoms , 18.4 % received PPIs for gastroprotection , and 36.1 % had no documented appropriate indication for PPI therapy . In a subgroup analysis , 48.6 % of patients across all 4 categories received PPIs without documentation of reevaluation of upper gastrointestinal tract symptoms , accounting for 1034 patient-years of PPI use . The total cost of inappropriate PPI use was $ 233,994 based on over-the-counter PPI costs and $ 1,566,252 based on average wholesale price costs . Potentially related adverse events in this cohort included Clostridium difficile – associated diarrhea ( 6 cases ) and community-acquired pneumonia ( 1 case ) , but no cases of hip fracture or vitamin B12 deficiency were identified . CONCLUSIONS Proton pump inhibitors are often overused in the ambulatory care setting without documented valid indications . Inappropriate use of PPIs is associated with substantial cost expenditure and with the potential for adverse events
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 .