During a follow-up visit, the nurse practitioner reviews the medication list of a patient with osteoporosis and notes they have been taking the same medications for the past year. Which of the following medications raises the most concern?
Omeprazole is a proton pump inhibitor (PPI) that reduces stomach acid production. While beneficial for conditions like GERD and peptic ulcers, long-term PPI use beyond 2 months is associated with an increased risk of fractures, particularly hip, wrist, and spine fractures. Stomach acid is necessary for calcium solubilization and absorption, and PPIs decrease gastric acidity, impairing calcium uptake. Alendronate (Fosamax) is a bisphosphonate that reduces fracture risk by inhibiting osteoclast-mediated bone resorption. However, rare long-term risks include atypical femoral fractures and osteonecrosis of the jaw (ONJ). Raloxifene (Evista) is a selective estrogen receptor modulator (SERM) that reduces vertebral fracture risk in postmenopausal osteoporosis by mimicking estrogen’s protective effects on bone. Denosumab (Prolia) is a RANK ligand inhibitor that decreases bone resorption, reducing fracture risk. However, discontinuing denosumab without transition therapy can lead to rebound bone loss and increased fracture risk.
When evaluating osteoporosis medications, remember that PPIs, corticosteroids, and certain anticonvulsants (e.g., phenytoin, carbamazepine) can contribute to bone loss and thus increase the risk of fractures. Consider calcium and vitamin D supplementation if a patient requires long-term PPI therapy.