There was a comment on the recent article about Revlimid and GI side effects that said myeloma patients should avoid proton pump inhibitors (PPIs) because they decrease the absorption of minerals such as calcium.
Is this true? I've never heard this advice. In fact, I've seen descriptions for clinical trials for myeloma patients where it says that the trial participants are expected to take PPIs (e.g., http://clinicaltrials.gov/show/NCT01665794).
From what I've read, there seems to be some evidence suggesting that PPIs may reduce iron absorption, but the effect on calcium absorption seems less clear cut. One review from May 2013 that I just read said:
"There is no good evidence to establish that PPI use has a significant risk for bone density loss or osteoporotic-related fractures. Accordingly, the data on bone density loss and osteoporotic fractures would not support that PPI therapy be discontinued in patients taking PPIs for appropriate indications at appropriate doses. Supplemental calcium is not recommended or justified solely because of PPI use."
DA Johnson and EC Oldfield, "Reported Side Effects and Complications of Long-term Proton Pump Inhibitor Use: Dissecting the Evidence," Clinical Gastroenterology and Hepatology, May 2013 (full text).
I can understand being concerned about the potential effects of PPI use if you're going to be taking the drugs forever. But should someone with myeloma really avoid PPIs if they help reduce side effects while on treatment?
Moderator's Note: Proton pump inhibitors are "anti-heartburn" drugs such as omeprazole (Prilosec / Losec), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex, Pariet).
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Re: Proton pump inhibitors - should they be avoided?
As well as PPI's, interesting to know about a different category of drugs, bile acid sequestrants, as used in the British study. They are available for patients with gastric problems too.
When I used PPI's, it was for a short period of time to deal with acid reflux associated with side effects of chemotherapy.
When I used PPI's, it was for a short period of time to deal with acid reflux associated with side effects of chemotherapy.
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Nancy Shamanna - Name: Nancy Shamanna
- Who do you know with myeloma?: Self and others too
- When were you/they diagnosed?: July 2009
Re: Proton pump inhibitors - should they be avoided?
Hi Ian,
PPI's are a medication to help reduce reflux and are often required to reduce the side effects of other medications. I can understand you being concerned about their specific side effects. Life with multiple myeloma seems to become a constant round of medication and side effects.
I review my meds freqently with my doctor or specialist to make sure nothing on my list is taken longer than required. When I started to have symptoms and started taking PPIs, I commenced on lowest dose and stopped after 2 weeks and found they were no longer required. When new meds started or symptoms returned, I went through the same process and found they could be stopped with no problems. Had to take a higher dose through SCT recently, but have since reduced dose and plan to stop soon.
This is how it was recommended to me by a doctor as the method used for reflux from food and seems to have worked well. With reflux from food, a change of diet can help, but we can't always stop or change medication and the side effects can be a problem.
I'm unsure of the calcium or iron effects but understand it can lower magnesium in some people.
Jen
PPI's are a medication to help reduce reflux and are often required to reduce the side effects of other medications. I can understand you being concerned about their specific side effects. Life with multiple myeloma seems to become a constant round of medication and side effects.
I review my meds freqently with my doctor or specialist to make sure nothing on my list is taken longer than required. When I started to have symptoms and started taking PPIs, I commenced on lowest dose and stopped after 2 weeks and found they were no longer required. When new meds started or symptoms returned, I went through the same process and found they could be stopped with no problems. Had to take a higher dose through SCT recently, but have since reduced dose and plan to stop soon.
This is how it was recommended to me by a doctor as the method used for reflux from food and seems to have worked well. With reflux from food, a change of diet can help, but we can't always stop or change medication and the side effects can be a problem.
I'm unsure of the calcium or iron effects but understand it can lower magnesium in some people.
Jen
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NZMum - Name: NZMum
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: March2014
- Age at diagnosis: 49
Re: Proton pump inhibitors - should they be avoided?
The absorption of calcium requires an acid medium and therefor the controversy associated with PPI's as well as H2 blockers like famotidine (Pepcid), Zantac (ranitidine), etc. These drugs block the production of acid in the stomach and therefor raise the pH, and reduce the complete absorption of calcium.
Since the acid blockade is never 100%, we are talking about relative malabsorption of calcium here. With extended use of PPI's or H2's, in someone severely calcium deficient, there is greater concern for calcium deficiency and probably an issue to discuss with your doctor. With short term intermittent use of these drugs the problem is diminished greatly.
Remember, since calcium itself is an antacid (see Tums), it's absorption is self limiting by the fact that it will raise stomach pH. The recommended max dose of calcium is 500 mg at a time to maximize absorption. Take your calcium in divided doses throughout the day at 500 mg at a time to maximize absorption.
Calcium also has a chelating (binding) effect on many medications and can tie them up and reduce or prevent their absorption. Calcium is best administered by itself on a relatively empty stomach.
Since the acid blockade is never 100%, we are talking about relative malabsorption of calcium here. With extended use of PPI's or H2's, in someone severely calcium deficient, there is greater concern for calcium deficiency and probably an issue to discuss with your doctor. With short term intermittent use of these drugs the problem is diminished greatly.
Remember, since calcium itself is an antacid (see Tums), it's absorption is self limiting by the fact that it will raise stomach pH. The recommended max dose of calcium is 500 mg at a time to maximize absorption. Take your calcium in divided doses throughout the day at 500 mg at a time to maximize absorption.
Calcium also has a chelating (binding) effect on many medications and can tie them up and reduce or prevent their absorption. Calcium is best administered by itself on a relatively empty stomach.
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Dano - Who do you know with myeloma?: Me
- When were you/they diagnosed?: Jan 2014
- Age at diagnosis: 65
Re: Proton pump inhibitors - should they be avoided?
Thanks, everyone, for your comments and feedback.
I can understand being concerned about potential side effects of long-term PPI use. There are few medications I would NOT be concerned about taking long term.
The comment on the article, however, made the flat statement: "Proton pump inhibitors are not recommended because they decrease the absorption of minerals like the all-important calcium."
As I said earlier, I found this confusing because I've never heard of myeloma patients being told to avoid PPIs. And the more we discuss it here, the more that statement seems like an extrapolation someone made from an article in some general health publication, speculating about POTENTIAL side effects of PPI use. I would be surprised if a myeloma specialist told this person never to take PPIs.
Dano - I had never thought of the role stomach acid levels play in the digestion of calcium. Are they particularly important to calcium digestion, compared to, say, the digestion of proteins?
I ask because, as I understand it, stomach acid also plays an important role in protein absorption in the body. So I'm a little confused as to why there's a particular focus on calcium. Perhaps it's just because calcium, for obvious reasons, is particularly important to myeloma patients.
For now, I'm not convinced there's any evidence that myeloma patients shouldn't take PPIs when they're needed. Sure, extended use may be something to think about. But I'm not seeing any cause for a blanket ban.
Or am I missing something?
I can understand being concerned about potential side effects of long-term PPI use. There are few medications I would NOT be concerned about taking long term.
The comment on the article, however, made the flat statement: "Proton pump inhibitors are not recommended because they decrease the absorption of minerals like the all-important calcium."
As I said earlier, I found this confusing because I've never heard of myeloma patients being told to avoid PPIs. And the more we discuss it here, the more that statement seems like an extrapolation someone made from an article in some general health publication, speculating about POTENTIAL side effects of PPI use. I would be surprised if a myeloma specialist told this person never to take PPIs.
Dano - I had never thought of the role stomach acid levels play in the digestion of calcium. Are they particularly important to calcium digestion, compared to, say, the digestion of proteins?
I ask because, as I understand it, stomach acid also plays an important role in protein absorption in the body. So I'm a little confused as to why there's a particular focus on calcium. Perhaps it's just because calcium, for obvious reasons, is particularly important to myeloma patients.
For now, I'm not convinced there's any evidence that myeloma patients shouldn't take PPIs when they're needed. Sure, extended use may be something to think about. But I'm not seeing any cause for a blanket ban.
Or am I missing something?
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