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Cortisone administration with antacids reduces bone density in patients with rheumatism
Last reviewed: 02.07.2025
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Proton pump inhibitors (PPIs), a class of antacid medications, are among the most widely used medications. They are often prescribed to many groups of patients, including those with rheumatic fever. PPIs are used to prevent stomach problems that can occur with some anti-inflammatory medications.
However, this practice may have negative consequences for bone health: Taking PPIs, especially in combination with cortisone, is associated with an increased risk of osteoporosis, according to a study conducted by Charité-Universitätsmedizin Berlin. The study was published in the journal Mayo Clinic Proceedings.
According to the latest official report on prescription drugs in Germany, doctors in Germany prescribed around 3.8 billion daily doses of proton pump inhibitors in 2022. PPIs such as pantoprazole and omeprazole inhibit the production of stomach acid. They are primarily intended to treat stomach ulcers or bleeding, but are also used for preventive purposes.
Many patients with rheumatoid arthritis, also known as rheumatism, are prescribed PPIs in certain circumstances when they are being treated with glucocorticoids ("cortisone") to prevent inflammation of the stomach lining. Some people take PPIs without even consulting a doctor to treat conditions such as heartburn or other stomach problems. These drugs are available over the counter up to a certain dosage.
However, studies of various diseases have shown that taking PPIs can contribute to the development of osteoporosis (loss of bone mineral density). In addition, cortisone, which is often used simultaneously in rheumatology, can also weaken bones.
"We therefore asked ourselves whether PPIs increase the risk of osteoporosis in our patients with rheumatism," explains Dr. Andrico Palmovsky, first author of the study and a physician-researcher at Charité.
Bone mineral density analysis in 1500 patients
To find out, he and Professor Frank Buttgereit teamed up with other colleagues from Charité, the US and Denmark to study the bone health of around 1,500 patients with inflammatory rheumatic diseases. Around half of them were taking proton pump inhibitors daily. The researchers analysed bone mineral density and bone microstructure. Reduced bone density and changes in microstructure are indicators of osteoporosis.
The team found that patients taking PPIs did indeed have significantly lower bone density than those not taking them. The correlation held even after controlling for factors such as age and smoking. The effect was particularly pronounced in patients taking PPIs along with cortisone medications at a daily dose of at least 7.5 mg. In contrast, there were no significant negative effects on bone microstructure.
"Our results suggest that PPIs lead to loss of bone mineral density in patients with rheumatoid arthritis," Palmowski says. That translates into about a 25 percent higher risk of vertebral fracture.
Physicians should carefully consider prescribing antacids.
The study authors believe their physician colleagues have a special responsibility in light of these findings. "Physicians should carefully consider the reasons for prescribing PPIs and discuss the benefits and potential risks with patients, particularly if cortisone is co-administered," they conclude.
Legitimate reasons for prescribing PPIs include risk factors that may contribute to the development of stomach ulcers. These factors include, for example, taking cortisone at the same time as nonsteroidal anti-inflammatory drugs (NSAIDs) used to treat rheumatism, such as ibuprofen, diclofenac, and even aspirin.
In contrast, those taking cortisone alone without other risk factors generally do not need antacids - according to official German medical guidelines for prescribing medications for patients with multiple diseases.
"If concomitant use is unavoidable, vitamin D and calcium supplements can help maintain bone health," explains Palmowski. If long-term cortisone treatment is planned, regular bone density measurements and even prescription of osteoporosis medications may be necessary. Patients and doctors should decide together which measures make the most sense in their individual cases.