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 .
Do Proton Pump Inhibitors Decrease Calcium Absorption?
Proton pump inhibitors ( PPIs ) increase  osteoporotic fracture  risk presumably via hypochlorhydria and consequent reduced fractional calcium absorption ( FCA ) . Existing studies provide conflicting information regarding the direct effects of PPIs on FCA . We evaluated the effect of PPI therapy on FCA . We recruited women at least 5 years past menopause who were not taking acid suppressants . Participants underwent three 24-hour inpatient FCA studies using the dual stable isotope method . Two FCA studies were performed 1 month apart to establish baseline calcium absorption . The third study occurred after taking omeprazole ( 40 mg/day ) for 30 days . Each participant consumed the same foods during all FCA studies ; study meals replicated subjects ' dietary habits based on 7-day diet diaries . Twenty-one postmenopausal women ages 58 ± 7 years ( mean ± SD ) completed all study visits . Seventeen women were white , and 2 each were black and Hispanic . FCA ( mean ± SD ) was 20 % ± 10 % at visit 1 , 18 % ± 10 % at visit 2 , and 23 % ± 10 % following 30 ± 3 days of daily omeprazole ( p = .07 , ANOVA ) . Multiple linear regression revealed that age , gastric pH , serum omeprazole levels , adherence to omeprazole , and 25-hydroxyvitamin D levels were unrelated to changes in FCA between study visits 2 and 3 . The 1,25-dihydroxyvitamin D3 level at visit 2 was the only variable ( p = .049 ) associated with the change in FCA between visits 2 and 3 . PPI-associated hypochlorhydria does not decrease FCA following 30 days of continuous use . Future studies should focus on identifying mechanisms by which PPIs increase the risk of osteoporotic fracture . © 2010 American Society for Bone and Mineral Research
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 .