PPI and hypomagnesemia

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Proton pump inhibitors and Hypomagnesemia 


Proton pump inhibitors (PPI) such as pantoprazole, omeprazole, esomeprazole, rabeprazole and lansoprazole are commonly used in clinical practices for prophylaxis and treatment of gastritis, esophagitis, gastroesophageal reflux disease (GERD).


Proton pump inhibitors (PPIs) are a group of drugs that are commonly used in prevention and treatment of dyspeptic symptoms associated with gastritis, esophagitis, esophageal reflux and peptic ulcer. A few examples of PPIs are omeprazole, esomeprazole, pantoprazole, and rabeprazole.


They work by inhibiting gastric acid secretion through irreversible binding to hydrogen-potassium ATPase pump of parietal cell membrane. Through inhibition of the proton pumps, the final step of acid production is halted, preventing further acid secretion into the stomach.


Long term use of PPIs has been associated with the risk of hypomagnesemia. Though the exact mechanism was not eluvidated yet, it was hypothesized that chronic use of PPIs impair intestinal magnesium absorption.


Hypomagnesemia is associated with neuromuscular disturbances such as seizure, cramps and arrythmias. Hence, when a patient on chronic use of PPIs presents to you with complaints of neuromuscular symptoms, always bear in mind that PPIs can be one of the risk factors.


It is common that PPIs are continued for a long duration though it may bring about adverse effects. 


So what can we do about this issue?


Fret not, magnesium supplementation can be given at a dose of 250-400mg daily to compensate the magnesium malabsorption due to PPI use.


Vitamin B12 can also be given in a dose of 400-500 micrograms per day as chronic use of PPIs can lead to vitamin B12 deficiency. This is attributed to the fact that the release of vitamin B12 from protein requires acidic environment, which is impaired by chronic use of PPIs.


Reference:

1. Saris, N.E., Karppanen, H., Khawaja, J.A., Lewenstam, A.. (2000).Magnesium. An update on physiological, clinical and analytical aspects. Clin Chim Acta, 294(1–26)

2. Mackay, J.D., Bladon, P.T..(2010). Hypomagnesaemia due to proton-pump inhibitor therapy: a clinical case series. QJM, 103(387–395)

3. Kuipers, M.T., Thang, H.D., Arntzenius, A.B.. (2009). Hypomagnesaemia due to use of proton pump inhibitors--a review. Neth J Med, 67(169–172)

4. Florentin, M., & Elisaf, M. S. (2012). Proton pump inhibitor-induced hypomagnesemia: A new challenge. World journal of nephrology, 1(6), 151–154.

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