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

Millions of Americans take proton pump inhibitors (PPIs) every day to manage heartburn, GERD, or ulcers. These drugs-like omeprazole, esomeprazole, and pantoprazole-are powerful, effective, and often life-changing for people with chronic acid reflux. But there’s a quiet, growing concern: long-term use might be quietly weakening your bones.

What Are Proton Pump Inhibitors?

PPIs work by shutting down the acid pumps in your stomach lining. They’re not antacids that just neutralize acid-they stop acid production at the source. That’s why they work better and longer than older drugs like H2 blockers (ranitidine, famotidine). When they came out in the late 1980s, doctors thought they were safe for short-term use. But today, many people take them for months or even years. The FDA originally approved them for 4 to 8 weeks. Yet, studies show that 60-70% of PPI prescriptions are for longer than that, often without clear medical need.

The Fracture Risk Connection

Starting around 2006, large population studies began to show a pattern: people who took PPIs for a long time had more bone fractures-especially in the hip, spine, and wrist. One study found that long-term users had nearly double the risk of hip fractures compared to non-users. Another looked at over 50,000 people over 50 and found that PPI users had a 27% higher chance of breaking a hip than those using H2 blockers. The risk didn’t jump right away. It built up slowly. After five years of daily use, the risk started to climb. After seven years, it more than quadrupled in some groups.

It’s not just about age. Postmenopausal women on long-term PPIs had a 35% higher risk of hip fractures. That’s significant. Why? Because their bones are already more fragile. And if you’re on steroids, have low body weight, or have had a fracture before, your risk goes up even more.

Why Would Stomach Acid Affect Your Bones?

This is where it gets interesting. Your stomach needs acid to absorb calcium. Most calcium supplements-like calcium carbonate-require an acidic environment to dissolve and be absorbed. If PPIs are lowering your stomach acid too much, your body might not be getting enough calcium from food or pills. That’s a problem because your bones are constantly being rebuilt. If you don’t have enough calcium, your body pulls it from your bones to keep your heart and muscles working. Over time, that weakens your skeleton.

But it’s not that simple. Some studies found no real drop in calcium absorption in PPI users. Others suggest another mechanism: PPIs may cause your body to make more gastrin, a hormone that can trigger bone breakdown. There’s also evidence that histamine changes in the gut might affect bone cells directly. The truth? We still don’t fully understand how this works. But the link between long-term PPI use and fractures is real-and it’s backed by multiple large studies.

Not All Acid Reducers Are the Same

H2 blockers like famotidine (Pepcid) also reduce stomach acid-but they don’t shut down pumps the way PPIs do. They’re weaker and shorter-acting. And here’s the kicker: studies show H2 blockers don’t carry the same fracture risk. One big study comparing over 100,000 kids found no overall increase in fractures with H2 blockers, but a small rise in lower-limb fractures with PPIs. In adults, switching from PPIs to H2 blockers might lower your fracture risk-especially if you don’t need strong acid suppression.

That’s why doctors now ask: Do you really need a PPI? Or could a lower-dose H2 blocker, lifestyle changes, or even just avoiding late-night meals work just as well?

Who’s Most at Risk?

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

• Women over 65, especially postmenopausal
• People with low body weight (under 125 pounds)
• Those with a history of fractures
• People taking corticosteroids (like prednisone)
• Anyone on high-dose PPIs for more than a year

If you fit even one of these categories and have been on PPIs for over 8 weeks, you should talk to your doctor about your bone health. It’s not about stopping the medication-it’s about making sure you’re not adding unnecessary risk.

What Should You Do?

If you’re on a PPI and worried about your bones, here’s what to do:

1. Ask if you still need it. Many people take PPIs long after their symptoms are gone. Your doctor can help you try tapering off or switching to on-demand use.
2. Use the lowest dose possible. You don’t need 40mg of omeprazole if 20mg works. Lower dose = lower risk.
3. Take calcium citrate, not calcium carbonate. Calcium citrate doesn’t need stomach acid to absorb. It’s the better choice if you’re on a PPI.
4. Get enough vitamin D. Aim for 800-1000 IU daily. Your body needs it to use calcium.
5. Consider 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.

Don’t stop your PPI cold turkey. Suddenly stopping can cause rebound acid reflux. Work with your doctor to taper off safely.

The Bigger Picture

It’s easy to panic when you hear ‘PPIs cause fractures.’ But here’s the truth: the absolute risk is still low. For every 1,000 people on long-term PPIs, maybe 2-3 extra fractures happen per year. That’s not nothing-but it’s not a disaster either. The real issue is unnecessary use. If you don’t have GERD, ulcers, or Barrett’s esophagus, you probably don’t need a PPI. And if you do, you can still use it safely-with the right precautions.

Doctors are catching on. Between 2015 and 2021, long-term PPI prescriptions dropped by nearly 20% among Medicare patients. That’s progress. But nearly half of prescriptions are still inappropriate. That means millions of people are taking these drugs without clear benefit-and possibly increasing their fracture risk.

What’s Next?

A major NIH study called PPI-BONE is tracking 15,000 people over five years. Results are expected in mid-2025. That study will control for more variables than ever before-diet, activity, other meds, genetics-and could finally tell us how big the real risk is.

In the meantime, the American Gastroenterological Association, the Endocrine Society, and the FDA all agree: use PPIs only when needed, at the lowest dose, for the shortest time possible. And if you’re at risk for fractures, take steps to protect your bones.

There’s no reason to fear PPIs if you’re using them correctly. But if you’re taking them out of habit, or because you’ve been on them for years without a check-up-it’s time to ask: Is this still helping me? Or is it quietly hurting me?