Dexlansoprazole and Esomeprazole Do Not Affect Bone Homeostasis in Healthy Postmenopausal Women

Gastroenterology 2019;-:1–9

Dexlansoprazole and Esomeprazole Do Not Affect Bone Homeostasis in Healthy Postmenopausal Women Q7

Karen E. Hansen,1,* Jeri W. Nieves,2,* Sai Nudurupati,3 David C. Metz,4 and Maria Claudia Perez3 1

School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin; 2Mailman School of Public Health, Columbia University, New York, New York; 3Takeda Development Center Americas, Inc., Deerfield, Illinois; and 4Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania BACKGROUND & AIMS: Epidemiological studies have associated proton pump inhibitor (PPI) therapy with osteoporotic fractures, but it is not clear if PPIs directly cause osteoporosis. We evaluated the effect of dexlansoprazole and esomeprazole on bone turnover, bone mineral density (BMD), true fractional calcium absorption (TFCA), serum and urine levels of minerals, and levels of parathyroid hormone (PTH) in healthy postmenopausal women. METHODS: We performed a prospective, multicenter, double-blind study of 115 healthy, postmenopausal women (45 to 75 years of age) from November 4, 2010, through August 7, 2014. Women were randomized to groups given dexlansoprazole (60 mg), esomeprazole (40 mg), or placebo daily for 26 weeks. We measured plasma levels of procollagen type 1 N-terminal propeptide (P1NP) and C-terminal telopeptide of type 1 collagen (CTX) at 0 (baseline), 13, and 26 weeks. Primary outcomes were percent change in P1NP and CTX between weeks 0 and 26. We also measured changes in serum and urine levels of mineral, BMD, PTH (all subjects), and TFCA (n ¼ 30). RESULTS: Between baseline and week 26, there were no significant within-group differences in markers of bone turnover; there was a nonsignificant increase in CTX levels in the dexlansoprazole group (0.12 ng/mL). The esomeprazole and dexlansoprazole groups had significantly increased levels of P1NP (18.2% and 19.2%, respectively) and CTX (22.0% and 27.4%, respectively) at week 26 compared with the placebo group, although these values remained within normal ranges. There were no statistically significant differences between groups in serum or urine levels of minerals, BMD, or PTH at week 26. PPI therapy did not reduce TFCA. CONCLUSIONS: In a prospective study of postmenopausal women, we found significant increases in markers of bone turnover in women given PPI therapy compared with women given placebo, but levels remained within the normal reference range. We found no significant differences among groups in changes in BMD, PTH, serum or urine levels of minerals, or TFCA. Our findings indicate that 26 weeks of treatment with a PPI has no clinically meaningful effects on bone homeostasis. Clinicaltrials.gov no: NCT01216293

or antacids.2 As a result, several PPIs are available over the counter. However, observational studies suggest that longterm PPI therapy is associated with osteoporotic fractures, hypomagnesemia, and vitamin B12 deficiency.2,3 A large body of epidemiological data has detected an association between PPI use and fracture risk.4,5 The clinical importance of this association is unclear because odds ratios are low, there is no consistent dose-response relationship, and confounding factors exist in many studies.4 Although a plausible mechanism explaining a causal relationship between PPI use and fracture has not been definitively established,4 hypotheses include decreased calcium absorption due to hypochlorhydria,6,7 osteoclast V-ATPase inhibition, increased activity of parathyroid hormone (PTH) induced by hypergastrinemia,8,9 and decreased magnesium absorption.4,10–13 Mixed results also have been reported for bone mineral density (BMD) in relation to PPI use.14–17 Some studies evaluating PPI effects on vitamin B12 and calcium absorption found a decrease associated with PPI use,18–20 whereas others showed no effect.7,21–23 We evaluated the effects of PPIs on bone homeostasis in postmenopausal women, a population with the highest prevalence of osteoporosis and related fractures.24,25 We measured bone turnover, BMD, true fractional calcium absorption (TFCA), PTH, and serum and urine mineral levels in women at baseline and 26 weeks after randomization to placebo or 2 potent PPIs, dexlansoprazole and esomeprazole. Bone turnover markers were the primary study outcome, as they are consensus standard markers for assessment of bone resorption (C-terminal telopeptide of type 1 collagen [CTX]) and formation (procollagen type 1 Nterminal propeptide [P1NP]) related to both fracture risk and monitoring osteoporosis medications.26,27 We also measured bone-specific alkaline phosphatase (BsAP) and urinary N-terminal telopeptide (NTx), which have shown

*Authors share co-first authorship

Keywords: Clinical Trial; Proton Pump Inhibitor; Osteoporosis; Intestinal Calcium Absorption.

P

roton pump inhibitors (PPIs) have been widely used for decades to treat acid-related diseases.1 PPIs exhibit a well-established safety profile and reduce gastric acid more effectively than histamine-2 receptor antagonists

Abbreviations used in this paper: AE, adverse event; BMD, bone mineral density; BsAP, bone-specific alkaline phosphatase; CI, confidence interval; CTX, C-terminal telopeptide of type 1 collagen; NTx, N-terminal telopeptide; P1NP, procollagen type 1 N-terminal propeptide; PPI, proton pump inhibitor; PTH, parathyroid hormone; TFCA, true fractional calcium absorption; 25(OH)D, 25-hydroxyvitamin D. © 2018 by the AGA Institute 0016-5085/$36.00 https://doi.org/10.1053/j.gastro.2018.11.023

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significant associations with BMD response to osteoporosis therapies.28

Methods Study Design We conducted a phase 4, randomized, double-blind, placebo-controlled study in healthy postmenopausal women from November 4, 2010 (first participant in) to August 7, 2014 (last participant out), at 12 US centers. Institutional review board approval and participant consent were obtained before the study. This study was funded by Takeda Pharmaceuticals International, Inc. Takeda Pharmaceuticals International, Inc., was responsible for and sponsored the study design, data collection, data interpretation, and writing of this article. All authors had access to the study data and reviewed and approved the final manuscript. Eligible women were between 45 and 75 years of age, with body mass index between 18 and 30 kg/m2 and with no menses for at least 5 years. Eligibility requirements included bone turnover markers and clinical laboratory evaluations within normal postmenopausal ranges (postmenopausal follicle-stimulating hormone levels 23 IU/L; creatinine clearance 50 mL/min; BMD T-score > ‒2.0 at the total hip, femoral neck, and lumbar spine by dual-energy x-ray absorptiometry); and willingness to take daily supplements of vitamin D and calcium carbonate (CaCO3). Participants could not use medications and substances with a potential effect on bone homeostasis during the study (Supplementary Table 1). Further eligibility criteria and BMD screening methods are reported in the Supplementary Methods. The study consisted of a 12-week screening period, a 26week treatment period, and a follow-up visit at week 52 for BMD assessment. Dietary assessment was performed between the screening period and week 13 to assess calcium and

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vitamin D3 intake. Participants were given vitamin D3 to maintain 25-hydroxyvitamin D (25[OH]D) levels 32 ng/mL and calcium carbonate 600 mg/d to maintain a total (diet plus supplement) intake of 1200 mg/d. Participants were randomly assigned to receive placebo, dexlansoprazole 60 mg once daily, or esomeprazole 40 mg once daily in a 1:1:1 ratio for 26 weeks, with study medication dispensed in bottles in a double-blind fashion. P1NP, CTX, urine NTx, and BsAP were measured at 0, 13, and 26 weeks. Serum samples were analyzed for P1NP using an electrochemiluminescence immunoassay on the Elecsys 2010 automated analyzer (Roche Diagnostics, Indianapolis, IN) and for BsAP using an enzyme immunoassay with the Metra BsAP enzyme immunoassay kit (Quidel, San Diego, CA). Plasma samples were analyzed for CTX using an electrochemiluminescence immunoassay with the beta-crosslaps immunoassay kit on the Elecsys 2010 automated analyzer. Urine samples were analyzed for NTx using an enzyme-linked immunosorbent assay with the Osteomark kit (Wampole Laboratories, Waltham, MA) and read on a SpectraMax microplate spectrophotometer. Subjects were instructed to fast without taking study medication, calcium, or vitamin D3 supplements for a minimum of 8 hours before all laboratory tests (excluding first screening visit). BMD was measured in each subject using the same Hologic bone densitometer at baseline (‒12 weeks), 26, and 52 weeks. Calcium and vitamin D3 supplements were to be taken with the first meal of the day, approximately 1 hour after study drug administration. A comprehensive schedule of study procedures is reported in Supplementary Table 2. Our primary outcomes were changes in bone formation and bone resorption. Changes in bone turnover precede changes in BMD and predict harmful (or beneficial) effects of an intervention on BMD.29–31 We selected P1NP and CTX as our primary measures of bone formation and resorption, as they change more quickly with pharmacologic interventions.29–32 We had no pilot data on PPI-mediated changes in bone turnover by which to calculate a potential sample size for the study. However, withinsubject changes in the bone resorption marker CTX can be as high as 36%.33 We therefore selected a sample size of 240 subjects so that the width of the 95% confidence interval (CI) for the difference in the percent change from baseline in each of the markers between PPI and placebo was restricted to no more than 30%. Finally, we chose a study duration of 6 months, as this is the duration of therapy for dexlansoprazole approved by the Food and Drug Administration. In addition, a 6-month exposure would minimize risks to participants while still providing sensitive information about bone turnover and alterations in mineral homeostasis resulting from PPI therapy. The primary outcome was percent change from baseline to week 26 in the bone formation marker P1NP and the bone resorption marker CTX. The secondary endpoint was percent change from baseline to week 26 in urine NTx (resorption marker) and BsAP (formation marker). Additional endpoints included the 13-week percent change in P1NP and CTX; the 26and 52-week percent change in femoral neck, total hip, and lumbar spine BMD, and the incidence of fractures, including clinical vertebral fractures. We also measured 26-week changes in 24-hour urinary calcium and magnesium excretion, serum PTH, calcium, phosphorus, magnesium, and 25(OH)D. A TFCA study was performed at baseline and 6 months in a subset of participants using dual stable 44Ca (oral) and 42Ca

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Dexlansoprazole, Esomeprazole in Bone Homeostasis

(intravenous) isotopes34 and an inpatient 24-hour urine collection. The inpatient diet provided during the 24-hour TFCA study period matched the participants’ outpatient diet based on 4-day food diaries (additional information regarding the TFCA substudy is provided in the Supplementary Methods section). Adverse events (AEs) were classified according to Medical Dictionary for Regulatory Activities and by event severity.

Statistical Analyses The safety data set included all participants who received at least 1 dose of the study drug. The pharmacodynamic data set included all participants who had baseline and post-baseline values for any primary or secondary endpoint. Assuming a standard deviation of percent change from baseline levels to be no more than 40% for each bone turnover marker, a sample size of 80 participants per arm provided a 95% CI of the estimated difference between PPI and placebo that extended no more than 15% in each direction, with an allowance for up to 30% dropouts. After all study visits were completed, one of the trial sites (site 6019) was disqualified by the Food and Drug Administration, and all data collected at site 6019 were excluded from these analyses. Even without this site, the 95% CI for the between-arm percent change in all bone turnover markers was 33% wide, which is still comparable to the original assumption (95% CI to have a width not to exceed 30%). All differences in percent change from baseline endpoints between dexlansoprazole or esomeprazole and placebo were estimated using the nonparametric Hodges-Lehmann estimator and the Moses method for the 95% CI. Comparisons were considered statistically significant if the 95% CI excluded zero.

Results Subjects Of the 556 women screened at 11 centers, 115 were enrolled, and 93 participants completed the study

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(Supplementary Figure 1). No substantial differences in baseline demographics were observed between treatment groups (Table 1). Most participants (>90%) were white, with mean age of 62 ± 6 years, and mean body mass index of 25.2 ± 2.8 kg/m2. Subjects’ serum 25(OH)D levels were 39 ± 10 ng/mL at randomization. The calcium absorption substudy enrolled 34 participants (30 completing) with demographics and baseline characteristics representative of the overall study population. Mean study drug compliance was >95% in each treatment group. The incidence of the most common concurrent medical conditions relevant to study outcomes (osteoarthritis, osteopenia, and back pain) was comparable across treatment groups. The proportion of subjects with protocol deviations was also comparable across treatment groups (placebo 76%, dexlansoprazole 68%, and esomeprazole 74%) and primarily attributed to deviations in visit windows, which did not affect the overall outcome of the study.

Bone Biomarkers In all treatment arms, bone turnover remained within the normal reference range for postmenopausal women at baseline, 13, and 26 weeks. Levels of P1NP, BsAP, CTX, and NTx showed little change from baseline, and final values remained within the normal range for this population (Figure 1). Bone formation, as assessed by P1NP, showed a statistically significant increase in the dexlansoprazole group at week 26 (19.2%; 95% CI 7.0%–30.2%) and the esomeprazole group at week 26 (18.2%; 95% CI 6.7%–30.4%) relative to placebo (Table 2). Levels of the formation marker BsAP also increased significantly in the dexlansoprazole group at week 26 (6.8%; 95% CI 0.4%–12.8%) and at week 26 in the esomeprazole group (7.2%; 95% CI 0.6%–12.9%) relative to placebo. Week 13 changes in P1NP and BsAP values in the esomeprazole group were not statistically significant.

Table 1.Baseline Demographics

Mean age (SD), ya Range Race, n (%) White Black/African American Otherb Mean BMI (SD), kg/m2 Range Current drinker, n (%) Serum calcium at randomization, mean (SD), mg/dL Range Serum vitamin D at randomization, mean (SD), ng/mL Range

Placebo, n ¼ 41

Dexlansoprazole, 60 mg QD, n ¼ 38

Esomeprazole, 40 mg QD, n ¼ 35

All subjects, N ¼ 114

61.2 (5.6) 5173

62.4 (6.7) 5275

63.2 (5.1) 5474

62.2 (5.9) 5175

37 (90) 2 (5) 2 (5) 25.6 (2.6) 21.330.9 30 (73) 9.5 (0.4) 8.610.1 40 (9) 2969

34 (90) 2 (5) 2 (5) 24.5 (3.0) 18.231.3 31 (82) 9.5 (0.3) 9.010.1 40 (12) 2687

33 (94) 2 (6) 0 25.7 (2.6) 19.630.7 27 (77) 9.6 (0.3) 9.110.2 36 (9) 1955

104 (91) 6 (5) 4 (4) 25.2 (2.8) 18.231.3 88 (77) 9.5 (0.3) 8.610.3 39 (10) 1987

BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); QD, once daily; SD, standard deviation. a n ¼ 40 for placebo for age, because age was calculated at first dose and 1 participant was not dosed. b Other races included American Indian/Alaska Native, Asian, or multiracial.

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Figure 1. Bone turnover markers. Top and bottom of boxes represent first and third quartiles; the interior line represents the median. Whiskers terminate at 1.5 times (interquartile range) below the first quartile or above the third quartile. Horizontal dotted lines indicate upper and lower bound of normal range for women aged 45 to 75 years (A); upper and lower bound of normal range for women aged 45 to 110 years (B); upper bound of normal range for all women (lower bound ¼ 0) (C); and upper and lower bound of normal range for all women (D). BCE, bone collagen equivalent; Cr, creatinine.

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Resorption (CTX levels) significantly increased in the dexlansoprazole group at weeks 13 (15.9%; 95% CI 4.9%– 29.6%) and 26 (27.4%; 95% CI 12.7%–43.0%) and in the esomeprazole group at weeks 13 (16.1%; 95% CI 5.0%– 27.0%) and 26 (22.0%; 95% CI 8.4%–35.7%) relative to placebo. For NTx, the only statistically significant difference from placebo occurred at week 26 in the dexlansoprazole group (20.1%; 95% CI 4.0%–34.4%; Table 2). Within-group 26-week changes in bone turnover markers did not show statistically significant differences from baseline, except for a small increase in CTX levels in the dexlansoprazole group (0.12 ng/mL; 95% CI 0.03–0.23 ng/mL).

BMD and Fracture We detected no statistically significant between-group changes in lumbar spine, total hip, or femoral neck BMD at 26 and 52 weeks (Table 3). No subject experienced a 26week decrease in lumbar spine, femoral neck, or total hip BMD >0.021 g/cm2. A 73-year-old woman randomized to dexlansoprazole experienced a 3% decrease in spine BMD, but her T-score at the spine was þ0.6 even after the decrease. No fractures occurred during the treatment period. One woman randomized to dexlansoprazole sustained a traumatic foot fracture at week 52 because of a car accident. A humerus fracture (circumstance unknown) occurred at week 23 in one woman randomized to esomeprazole; she withdrew from the study after 17 weeks of treatment because of worsening fatigue that was considered to be drug related.

Calcium Absorption, Mineral, and Hormone Levels Serum calcium and phosphorus concentrations remained stable and normal, with no between-arm changes. Likewise, we detected no statistically significant betweengroup changes in serum magnesium, 25(OH)D, or 24-hour

urinary calcium or magnesium levels (Supplementary Table 3), and all values remained stable and normal. As expected, serum gastrin levels increased in participants randomized to PPI therapy, with median week 26 differences of 80 ng/mL (dexlansoprazole) and 85 ng/mL (esomeprazole) relative to placebo (Supplementary Table 3).10,35 No statistically significant between-group changes in PTH were found (Supplementary Table 3). Likewise, there was no correlation between PPI-related changes in gastrin and PTH during the study. In the substudy population, there were no decreases in TFCA in participants randomized to PPI therapy (Supplementary Table 4). The only statistically significant increase in TFCA relative to placebo occurred in the esomeprazole group (þ0.06; 95% CI 0.02–0.11).

Safety The median duration of treatment was comparable among groups. AEs were reported for 39% (16/41), 45% (17/38), and 37% (13/35) of participants in the placebo, dexlansoprazole, and esomeprazole groups, respectively. Most AEs (93%) were classified as being mild or moderate. The most frequently reported AEs were diarrhea and upper respiratory tract infection with placebo; diarrhea with dexlansoprazole; and urinary tract infection, dyspepsia, and upper respiratory tract infection with esomeprazole. The frequency of drug-related AEs within treatment groups was 9% (3/34; placebo), 30% (9/30; dexlansoprazole), and 48% (13/27; esomeprazole). AEs resulting in discontinuation were reported for 1 individual in the placebo group (diarrhea), 4 individuals in the dexlansoprazole group (diarrhea, 3; leukopenia, 1), and 2 individuals in the esomeprazole group (nausea and fatigue). The only drug-related serious AE, nephrolithiasis, occurred in a dexlansoprazole participant at day 142 and

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Table 2.Percent Change From Baseline to Weeks 13 and 26 for Biomarkers of Bone Homeostasis

Dexlansoprazole 60 mg QD

Placebo

Esomeprazole 40 mg QD

Dexlansoprazole vs placebo

Esomeprazole vs placebo

Week 13, n ¼ 38

Week 26, n ¼ 32

Week 13, n ¼ 36

Week 26, n ¼ 31

Week 13, n ¼ 34

Week 26, n ¼ 26

Week 13

Week 26

Week 13

Week 26

7.2 (21.9) ‒1.44 (15.0)

‒0.4 (24.1) 0.5 (14.1)

21.4 (31.1) 7.7 (12.0)

19.3 (41.0) 8.7 (20.1)

11.5 (28.8) 4.4 (15.0)

16.9 (37.4) 6.2 (17.8)

12.3 (3.1 to 22.8) 6.5 (0.9 to 11.4)

19.2 (7.0 to 30.2) 6.8 (0.4 to 12.8)

5.8 (‒4.0 to 14.7) 3.1 (‒1.7 to 8.7)

18.2 (6.7 to 30.4) 7.2 (0.6 to 12.9)

2.7 (20.0) 5.5 (27.3)

2.4 (29.2) ‒6.1 (36.2)

18.8 (48.8) 14.6 (36.7)

29.5 (39.8) 16.9 (39.7)

18.7 (32.7) 13.4 (26.9)

24.0 (30.3) 6.2 (40.3)

15.9 (4.9 to 29.6) 6.6 (‒6.6 to 19.2)

27.4 (12.7 to 43.0) 20.1 (4.0 to 34.4)

16.1 (5.0 to 27.0) 7.6 (‒2.4 to 18.2)

22.0 (8.4 to 35.7) 11.6 (‒2.7 to 28.3)

IQR, interquartile range; QD, once daily. a Difference estimated with Hodges-Lehmann estimate; 95% CIs of the differences calculated by the Moses method. Percent change values were considered statistically significant if the 95% CI excluded zero (reported in bold text).

Table 3.Changes From Baseline in BMD Placebo, n ¼ 38a

Lumbar spine, g/cm2 Week 26 Week 52 Total hip, g/cm2 Week 26 Week 52 Femoral neck, g/cm2 Week 26 Week 52

Dexlansoprazole 60 mg QD, n ¼ 36a

Esomeprazole 40 mg QD, n ¼ 34a

Difference in percent change vs placebo (95% CIb)

n

Median percent change (IQR)b

n

Median percent change (IQR)b

n

Median percent change (IQR)c

Dexlansoprazole vs placebo

Esomeprazole vs placebo

19 17

0.104 (5.029) ‒0.392 (2.362)

19 18

‒2.236 (4.345) ‒0.537 (3.469)

20 18

‒1.182 (3.024) 0.793 (2.913)

‒0.888 (‒3.263 to 1.084) ‒0.112 (‒1.657 to 1.846)

0.840 (‒2.755 to 1.061) 1.344 (‒0.202 to 3.171)

26 23

‒0.181 (1.707) 0.109 (1.849)

27 25

‒1.045 (2.402) ‒0.441 (1.983)

24 23

‒0.774 (2.336) ‒0.109 (1.721)

‒0.664 (‒1.482 to 0.240) ‒0.344 (‒1.168 to 0.587)

‒0.358 (‒1.272 to 0.501) ‒0.004 (‒0.682 to 0.972)

26 23

‒0.688 (2.823) 0.000 (3.892)

27 25

‒1.861 (3.002) ‒0.437 (2.598)

24 23

‒1.515 (3.802) 0.000 (4.647)

‒0.966 (‒2.360 to 0.482) ‒0.237 (‒1.565 to 1.221)

‒0.434 (‒1.879 to 1.056) 0.285 (‒1.250 to 2.165)

IQR, interquartile range; QD, once daily. a Some scans were not evaluable and were excluded from the BMD analyses, which led to fewer participants than for other parameters. b Difference estimated with Hodges-Lehmann estimate. 95% CIs of the differences calculated by the Moses method. c Percent change calculated either from baseline to week 26 or from week 26 to week 52.

Dexlansoprazole, Esomeprazole in Bone Homeostasis

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Formation P1NP, ng/mL BsAP, U/L Resorption CTX, ng/mL NTx (corrected)

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Difference vs placebo (95% CI)a

Median (IQR) of percent change

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lasted for 37 days and then resolved. Analysis of the passed stone indicated it was 91% calcium oxalate, and although classified as drug related, it could also have been caused by concomitant calcium or vitamin D supplementation. Three serious AEs deemed unrelated to study drugs were breast cancer (n ¼ 1, dexlansoprazole), aortic dissection (n ¼ 1, dexlansoprazole), and hip arthroplasty (n ¼ 1, placebo).

Discussion CLINICAL AT

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Recent population-based epidemiological studies have generated conflicting results about a relationship between chronic PPI therapy and fracture risk.4,5,11–13,36 Low odds ratios (<2), lack of dose response, biological implausibility, and uncontrolled potential confounders limit any firm conclusions about the causal nature between PPI therapy and osteoporosis.37,38 Although some studies have detected an association between PPI use and fractures in postmenopausal women, prospective studies have found no differences in BMD between PPI users and nonusers.14,25,39 We undertook this prospective, double-blind, randomized, placebo-controlled trial to evaluate the effects of PPIs on bone homeostasis in healthy postmenopausal women. Overall, we found no evidence of bone loss among healthy postmenopausal women who received dexlansoprazole or esomeprazole for 26 weeks compared with those who received placebo. PPI therapy was associated with increases in both bone formation (P1NP increased 17% to 19%; BsAP increased 6% to 9%) and bone resorption (CTX increased 24% to 30%; corrected NTx increased 6% to 17%) compared with placebo. However, absolute changes within treatment groups were small and largely remained within the range expected for postmenopausal women. In adults, uncoupled bone resorption and formation with a net increase in resorption results in bone loss and decreased BMD, leading to osteoporosis.40,41 In the current trial, resorption and formation appeared to remain coupled over 26 weeks, with increases in both formation and resorption. Furthermore, there were no significant betweenarm differences in BMD during 26 weeks of PPI therapy or at 52 weeks from baseline. The very small within-subject changes in BMD observed in this study were consistent with expected changes in postmenopausal women (1% to 2% bone loss per year during the first 5 to 8 years after menopause).42 Our data are consistent with a Canadian longitudinal study that found no association between PPI use and BMD loss over 10 years, and with the Study of Women’s Health Across the Nation (SWAN), a longitudinal study of 2068 premenopausal or early premenopausal women, that found no difference in BMD change in PPI users compared with nonusers.14,39 Gastrin-induced PTH production leading to excess bone resorption has been proposed as a mechanism to explain PPI effects on bone homeostasis.8,9,43 Gastrin levels were increased with PPI administration in this study (an increase from baseline of 80–85 pg/mL), but there were no corresponding increases in PTH levels in either PPI treatment

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group. Likewise, serum calcium, urine calcium, and serum phosphorus levels remained stable and normal during the study, with no between-arm changes. Together, these data suggest that hypergastrinemia had no effect on PTH, calcium, or phosphorus concentrations. Another proposed mechanism by which PPIs might influence bone homeostasis is through reduced calcium absorption due to increased gastric pH.7 TFCA, the proportion of a given dose of calcium actually absorbed, is approximately 25% in adult men and nonpregnant women across a wide age range44 and declines on average by 0.2% per year after age 40.45 Calcium is absorbed in the intestinal tract by passive transport and by active transport that requires adequate vitamin D status.46 The pH of the small intestine is nearly neutral, which suggests that gastric pH would not affect calcium absorption.7 Our results support this theory. Serum 25(OH)D levels were stable throughout the study, which suggests that vitamin D metabolism did not influence the TFCA results. Median TFCA values ranged from 16% to 20% across the 3 treatment groups at the baseline and week 26 assessments, as expected in this population.44,45 Consistent with another study of 30-day administration of omeprazole,7 26-week PPI administration was not associated with a decreased TFCA in postmenopausal women. Although rare, hypomagnesemia has been reported in patients treated with PPIs for at least 3 months (in most cases after a year of therapy).47,48 In this study, neither PPI reduced serum or urine magnesium, and no clinically significant effects on 24-hour urine magnesium levels were observed for subjects in the TFCA substudy. There were no significant safety concerns identified in this study. The proportion of subjects with at least 1 AE was comparable in the 3 treatment groups, and the incidence of individual AEs in each of the treatment groups was low and consistent with previously reported AEs in randomized, placebo-controlled PPI studies.49–51 No fractures were reported within 30 days after the last dose of study drug, although 1 traumatic foot fracture (dexlansoprazole) and 1 humerus fracture (esomeprazole) occurred at day 359 and day 161, respectively, both after the patients took the last dose of study drug. Most of the AEs that resulted in discontinuation of the active study drug were consistent with the known AE profiles for these drugs. The serious AE reported during the study (nephrolithiasis in the dexlansoprazole group) was possibly consistent with the supplementation of calcium and vitamin D throughout the study. No other clinically important findings were noted in the postdose clinical laboratory safety measures, physical examination, vital signs, or electrocardiogram results. Strengths of this study include the prospective, randomized, placebo-controlled study design, use of multiple bone turnover markers, use of standard methods to measure BMD, and use of a gold standard method to measure TFCA. In addition, we standardized vitamin D status and calcium intake in all subjects, so that PPI or placebo therapy was the only intervention during the trial. We also acknowledge limitations of this study. The first limitation is a relatively small sample size. We initially recruited 235

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women into the trial, only to learn after completion of the trial that one site’s data were unreliable. Had all 235 women’s data been available for analysis, we likely would have observed smaller CIs around the study outcomes of bone turnover, BMD, and TFCA. Even with a smaller sample size, ours is the only study in which participants were randomized to PPI or placebo with the specific objective of measuring multiple parameters of skeletal health. The ultimate goal was to identify a potential mechanism whereby PPI therapy might increase the risk of fracture. Thus, we feel that our study adds important information to the literature on PPI and fracture. The second limitation of our study is the short duration of exposure to PPI therapy. We designed this study to evaluate the direct effects of PPIs on skeletal health. We chose bone turnover as our primary outcome because changes in bone turnover precede changes in BMD and serve as an early marker of adverse (or beneficial) interventions. We had no pilot data regarding the effects of PPIs on bone turnover by which to calculate a potential sample size for the study. However, within-subject changes in the bone resorption marker CTX can be as high as 36%.33 Thus, we selected a sample size of 240 subjects, so that the width of the 95% CI for the difference in the percent change from baseline in each of the markers between dexlansoprazole or esomeprazole and placebo was restricted to no more than 30%. Despite having only 115 subjects with valid data, the width of the 95% CI for the between-arm changes in bone turnover markers were still 33%. Finally, we studied healthy postmenopausal women and cannot state whether study outcomes might differ in other populations.

Conclusions Overall, this prospective, randomized, double-blind clinical trial detected minimal changes in bone homeostasis related to 26 weeks of PPI therapy. Increases in bone turnover were detected, but formation and resorption both increased and remained coupled. There were no PPIassociated declines in BMD, serum or urine mineral levels, PTH, or TFCA. Our study provides strong evidence against PPI-mediated alterations in calcium absorption or mineral homeostasis. If there is a causal relationship between PPI and fracture, that relationship is not mediated by the most common metabolic pathways predisposing to fracture. The findings reported here suggest that PPI use alone may not be a reason for postmenopausal women to have additional bone density evaluations. The US Preventive Services Task Force recommends screening for osteoporosis in women aged 65 years and older, as well as in younger women with comparable or greater fracture risk.52

Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www.gastrojournal.org, and at https://doi.org/10.1053/j. gastro.2018.11.023.

7

References 1. Klok RM, Postma MJ, van Hout BA, et al. Meta-analysis: comparing the efficacy of proton pump inhibitors in short-term use. Aliment Pharmacol Ther 2003;17:1237– 1245. 2. Gill JM, Player MS, Metz DC. Balancing the risks and benefits of proton pump inhibitors. Ann Fam Med 2011; 9:200–202. 3. Moayyedi P, Leontiadis GI. The risks of PPI therapy. Nat Rev Gastroenterol Hepatol 2012;9:132–139. 4. Leontiadis GI, Moayyedi P. Proton pump inhibitors and risk of bone fractures. Curr Treat Options Gastroenterol 2014;12:414–423. 5. Targownik LE, Lix LM, Metge CJ, et al. Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ 2008;179:319–326. 6. Corleto VD, Festa S, Di Giulio E, et al. Proton pump inhibitor therapy and potential long-term harm. Curr Opin Endocrinol Diabetes Obes 2014;21:3–8. 7. Hansen KE, Jones AN, Lindstrom MJ, et al. Do proton pump inhibitors decrease calcium absorption? J Bone Miner Res 2010;25:2786–2795. 8. Grimelius L, Johansson H, Lundqvist G, et al. The parathyroid glands in experimentally induced hypergastrinemia in the rat. Scand J Gastroenterol 1977; 12:739–744. 9. Gagnemo-Persson R, Hakanson R, Sundler F, et al. Growth of the parathyroid glands in omeprazole-treated chickens. Scand J Gastroenterol 1994;29:493–497. 10. Yang YX. Proton pump inhibitor therapy and osteoporosis. Curr Drug Saf 2008;3:204–209. 11. Vestergaard P, Rejnmark L, Mosekilde L. Proton pump inhibitors, histamine H2 receptor antagonists, and other antacid medications and the risk of fracture. Calcif Tissue Int 2006;79:76–83. 12. Yang YX, Lewis JD, Epstein S, et al. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006;296:2947–2953. 13. Andersen BN, Johansen PB, Abrahamsen B. Proton pump inhibitors and osteoporosis. Curr Opin Rheumatol 2016;28:420–425. 14. Solomon DH, Diem SJ, Ruppert K, et al. Bone mineral density changes among women initiating proton pump inhibitors or H2 receptor antagonists: a SWAN cohort study. J Bone Miner Res 2015;30:232–239. 15. Yu EW, Blackwell T, Ensrud KE, et al. Acid-suppressive medications and risk of bone loss and fracture in older adults. Calcif Tissue Int 2008;83:251–259. 16. Arj A, Razavi Zade M, Yavari M, et al. Proton pump inhibitors use and change in bone mineral density. Int J Rheum Dis 2016;19:864–868. 17. Amoako AO, Jafilan L, Nasiri P, et al. Correlation of bone mineral density scores and proton pump inhibitors use in the elderly. Curr Rheumatol Rev 2016;12:162–166. 18. O’Connell MB, Madden DM, Murray AM, et al. Effects of proton pump inhibitors on calcium carbonate absorption in women: a randomized crossover trial. Am J Med 2005; 118:778–781.

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19. Lam JR, Schneider JL, Zhao W, et al. Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA 2013;310:2435–2442. 20. Dharmarajan TS, Kanagala MR, Murakonda P, et al. Do acid-lowering agents affect vitamin B12 status in older adults? J Am Med Dir Assoc 2008;9:162–167. 21. Serfaty-Lacrosniere C, Wood RJ, Voytko D, et al. Hypochlorhydria from short-term omeprazole treatment does not inhibit intestinal absorption of calcium, phosphorus, magnesium or zinc from food in humans. J Am Coll Nutr 1995;14:364–368. 22. Koop H, Bachem MG. Serum iron, ferritin, and vitamin B12 during prolonged omeprazole therapy. J Clin Gastroenterol 1992;14:288–292. 23. Wright MJ, Sullivan RR, Gaffney-Stomberg E, et al. Inhibiting gastric acid production does not affect intestinal calcium absorption in young, healthy individuals: a randomized, crossover, controlled clinical trial. J Bone Miner Res 2010;25:2205–2211. 24. World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a WHO study group. Geneva, Switzerland: World Health Organization, 1994. WHO Technical Report Series, No. 843. Available at: http://apps.who.int/iris/ handle/10665/39142. Accessed May 31, 2018. 25. Gray SL, LaCroix AZ, Larson J, et al. Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: results from the Women’s Health Initiative. Arch Intern Med 2010; 170:765–771. 26. Morris HA, Eastell R, Jorgesen NR, et al. Clinical usefulness of bone turnover marker concentrations in osteoporosis. Clin Chim Acta 2016;467:34–41. 27. Vasikaran S, Eastell R, Bruyère O, et al. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Osteoporos Int 2011;22:391–420. 28. Wheater G, Elshahaly M, Tuck SP, et al. The clinical utility of bone marker measurements in osteoporosis. J Transl Med 2013;11:201. 29. Black DM, Greenspan SL, Ensrud KE, et al. The effects of parathyroid hormone and alendronate alone or in combination in postmenopausal osteoporosis. N Engl J Med 2003;349:1207–1215. 30. Chen P, Satterwhite JH, Licata AA, et al. Early changes in biochemical markers of bone formation predict BMD response to teriparatide in postmenopausal women with osteoporosis. J Bone Miner Res 2005;20:962–970. 31. Lindsay R, Nieves JW, Formica M, et al. Randomized controlled study of effect of parathyroid hormone on vertebral-bone mass and fracture incidence among postmenopausal women on oestrogen with osteoporosis. Lancet 1997;350:550–555. 32. Garnero P, Hausherr E, Chapuy MC, et al. Markers of bone resorption predict hip fracture in elderly women: the EPIDOS Prospective Study. J Bone Miner Res 1996; 11:1531–1538. 33. Szulc P, Naylor K, Hoyle NR, et al. Use of CTX-1 and P1NP as bone turnover markers: National Bone Health Alliance recommendations to standardize sample

34.

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41. 42.

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45.

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49.

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handling and patient preparation to reduce analytical variability. Osteoporos Int 2017;28:2541–2556. Hansen KE, Johnson RE, Chambers KR, et al. Treatment of vitamin D insufficiency in postmenopausal women: a randomized clinical trial. JAMA Intern Med 2015; 175:1612–1621. Larson GM, Sullivan HW, Rayford P. Omeprazoleinduced hypergastrinemia: role of gastric acidity. J Surg Res 1986;40:504–509. Kaye JA, Jick H. Proton pump inhibitor use and risk of hip fractures in patients without major risk factors. Pharmacotherapy 2008;28:951–959. Moayyedi P, Cranney A. Hip fracture and proton pump inhibitor therapy: balancing the evidence for benefit and harm. Am J Gastroenterol 2008;103:2428–2431. Moayyedi P, Yuan Y, Leontiadis G. on behalf of the CAG Clinical Affairs. Canadian Association of Gastroenterology position statement: hip fracture and proton pump inhibitor therapy: a 2013 update. Can J Gastroenterol 2013;27:593–595. Targownik LE, Leslie WD, Davison KS, et al. The relationship between proton pump inhibitor use and longitudinal change in bone mineral density: a population-based study [corrected] from the Canadian Multicentre Osteoporosis Study (CaMos). Am J Gastroenterol 2012;107:1361–1369. Camacho P, Kleerekoper M. Biochemical markers of bone turnover. In: Favus MJ, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. 6th ed. Washington, DC: American Society for Bone and Mineral Research, 2006. Watts NB. Clinical utility of biochemical markers of bone remodeling. Clin Chem 1999;45:1359–1368. Manolagas SC. Birth and death of bone cells: basic regulatory mechanisms and implications for the pathogenesis and treatment of osteoporosis. Endocr Rev 2000;21:115–137. Raggatt LJ, Partridge NC. Cellular and molecular mechanisms of bone remodeling. J Biol Chem 2010; 285:25103–25108. Hunt CD, Johnson LK. Calcium requirements: new estimations for men and women by cross-sectional statistical analyses of calcium balance data from metabolic studies. Am J Clin Nutr 2007;86:1054–1063. Heaney RP, Recker RR, Stegman MR, et al. Calcium absorption in women: relationships to calcium intake, estrogen status, and age. J Bone Miner Res 1989; 4:469–475. Van Cromphaut SJ, Dewerchin M, Hoenderop JG, et al. Duodenal calcium absorption in vitamin D receptorknockout mice: functional and molecular aspects. Proc Natl Acad Sci U S A 2001;98:13324–13329. Assadi F. Hypomagnesemia: an evidence-based approach to clinical cases. Iran J Kidney Dis 2010; 4:13–19. Regolisti G, Cabassi A, Parenti E, et al. Severe hypomagnesemia during long-term treatment with a proton pump inhibitor. Am J Kidney Dis 2010;56:168–174. Kuipers EJ, Sung JJ, Barkun A, et al. Safety and tolerability of high-dose intravenous esomeprazole for

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901 902 903 904 905 906 907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 955 956 957 958 959 960

961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020

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prevention of peptic ulcer rebleeding. Adv Ther 2011; 28:150–159. 50. Peura DA, Metz DC, Dabholkar AH, et al. Safety profile of dexlansoprazole MR, a proton pump inhibitor with a novel dual delayed release formulation: global clinical trial experience. Aliment Pharmacol Ther 2009;30:1010–1021. 51. Metz DC, Howden CW, Perez MC, et al. Clinical trial: dexlansoprazole MR, a proton pump inhibitor with dual delayed-release technology, effectively controls symptoms and prevents relapse in patients with healed erosive oesophagitis. Aliment Pharmacol Ther 2009;29:742–754. 52. US Preventive Services Task Force. Screening for osteoporosis: US Preventive Services Task Force recommendation statement. Ann Intern Med 2011;154:356–364.

Health, Room 4124 MFCB, 1685 Highland Avenue, Madison, WI 53705. Q1 e-mail: [email protected]; fax: 608-263-7353.

Received August 23, 2018. Accepted November 8, 2018.

Funding This study was funded by Takeda Pharmaceuticals International, Inc. Takeda Pharmaceuticals International, Inc., was responsible for and sponsored the study design, data collection, data interpretation, and writing of this Q3 manuscript.

Reprint requests Address requests for reprints to: Karen E. Hansen, MD, MS, Associate Professor of Medicine, University of Wisconsin School of Medicine & Public

Acknowledgments This study was supported by Takeda Development Center Americas, Inc, Q6 Deerfield, Illinois. Medical writing assistance was provided by Nikhilesh Sanyal, PhD, and Jacob Edelstein, PhD, of inVentiv Medical Communications, LLC, a Syneos Health group company, and supported by Takeda Development Center Americas, Inc. Sai Nudurupati’s current affiliation: AbbVie Inc, North Chicago, Illinois. Author contributions: Drs Hansen, Nudurupati, Metz, and Perez contributed to the study design. Drs Hansen and Nieves contributed to the data collection. Drs Hansen, Nieves, Nudurupati, Metz, and Perez contributed to data interpretation and writing the manuscript. Conflicts of interest Dr Hansen was paid for her work as a consultant in the design and conduct of the study and received a grant to conduct the study. Dr Nieves received a research grant from Takeda to conduct this research. Dr Nudurupati was an employee of Takeda Pharmaceuticals at the time this study was conducted. Dr Metz received administrative and editorial support for study design and Q2 analysis of the data. Dr Perez is employed by Takeda Pharmaceuticals.

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Supplementary Methods Study Randomization and Blinding Randomization of patients in a 1:1:1 ratio to dexlansoprazole 60-mg capsules, esomeprazole 40-mg capsules, or placebo was scheduled and maintained using an interactive voice-activated response system. Patients were randomized using a blocked design stratified by vitamin D3 supplementation (low or high) required by the subject at the screening visit (week 12) after the result of 25(OH)D was received, and the entire block of randomization numbers was assigned to each site. The investigational drug blind (double-blind) was maintained using the interactive voiceactivated response system and was not broken except for reasons of medical necessity.

Additional Inclusion and Exclusion Criteria Participants could not take over-the-counter PPIs within 9 months of study start or during the study, apart from study medication. Participants were ineligible if they had PTH or thyroid-stimulating hormone levels outside of the reference range for the testing laboratory at week ‒12; a 25(OH)D level <10 ng/mL at week ‒12 or <32 ng/mL at week ‒2; a disorder strongly associated with osteoporosis; a clinical history of fragility of wrist, hip, spine, or leg fractures; or a family history of genetic bone disorders. Participants who used any nicotine-containing products within 3 months of study start also were excluded. Potential candidates also were excluded if they had <2 evaluable vertebrae or a condition that interfered with dual-energy x-ray absorptiometry measurement (ie, hip replacement, vertebral deformity, or severe lumbar scoliosis). Glucocorticoids, immunosuppressants, antiepileptics, selective serotonin reuptake inhibitors, lithium, bisphosphonates, loop and thiazide diuretics, PPIs, histamine-2 receptor antagonists, antacids, systemic fluoride, aromatase inhibitors, antidiabetic treatments, RANK ligand inhibitors, estrogen therapy, hormone replacement therapy, lowmolecular-weight heparin, warfarin, clopidogrel, oral antifungals, and multivitamins could not be used for up to 1 year before the study.

Calcium Absorption Substudy Design A 4-day food diary was completed by all substudy participants. On day ‒1 and week 26, participants arrived at the research ward at 7 AM while fasting. With breakfast,

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participants received a 600-mg calcium supplement, along with 2 stable calcium isotopes (8 mg of 44Ca by mouth in calcium-fortified apple juice and 3 mg of 42Ca intravenously), and consumed food for the next 24 hours that replicated the macronutrient and micronutrient content of their regular diet, including kilocalories, calcium, carbohydrates, protein, fat, fiber, vitamin D3, sodium, magnesium, caffeine, and oxalate. Uneaten food was bagged and weighed to be assessed by a nutritionist for calcium intake. Research nurses collected all urine for 24 hours during an inpatient stay. Urine was frozen at ‒70 Celsius and analyzed in batches to determine the concentrations of 42Ca and 44Ca relative to 43Ca. The inpatient diet provided during the 24hour TFCA study period matched the participants’ outpatient intake of kilocalories, calcium, carbohydrates, protein, fat, fiber, vitamin D3, sodium, magnesium, caffeine (servings per day), and oxalate (servings per day). TFCA was calculated using the formula of Eastell and colleagues1: TFCA ¼

% excess 44Ca ðoralÞ % excess 42Ca ðintravenousÞ natural abundance 44Ca dose 42Ca   natural abundance 42Ca dose 44Ca

Quality Control Quality control via 10 repeated scans of the Bona Fide Phantom (BioClinica, Inc, Newtown, PA) within each center resulted in a coefficient of variance <0.5% during the study. There were no changes in dual-energy x-ray absorptiometry machines and no equipment issues noted. Monitoring visits were made to study sites periodically during the study to ensure that the protocol was followed. Protocol deviations were made only to eliminate immediate hazard to study participants and were documented in source documents. Quality assurance audits were done by the sponsor or regulatory agencies, such as the US Food and Drug Administration. The study was conducted according to ethical principles based on the Declaration of Helsinki and the international Guideline for Good Clinical Practice.

Supplementary Reference 1. Eastell R, Vieira NE, Yergey AL, et al. One-day test using stable isotopes to measure true fractional calcium absorption. J Bone Miner Res 1989;4:463–468.

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Supplementary Figure 1. Disposition of participants (CONSORT flowchart). QD, once daily. Volunteers screened: Numbers exclude the subjects from one site that was disqualified by the US Food and Drug Administration.

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Supplementary Table 1.Excluded Medications and Substances FLA 5.5.0 DTD
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Excluded medications Systemic glucocorticoids (eg, prednisone, cortisone, hydrocortisone, dexamethasone) Topical glucocorticoids Inhaled glucocorticoidsa Immunosuppressors Antiepileptic agents, SSRIs, and lithium Oral bisphosphonates Loop and thiazide diuretics PPIs, over-the-counter PPIs (more than 3 doses per month) H2RAs, antacids Intravenous bisphosphonates Systemic fluoride treatment, PTH analog Aromatase inhibitors, antidiabetic treatments RANK ligand inhibitors Systemic estrogen therapy or hormone replacement therapyb Selective estrogen-receptor modulator (tamoxifen and raloxifene) Low-molecular-weight heparin (dalteparin, enoxaparin, tinzaparin) Warfarin Clopidogrel Oral antifungals Multivitamins and other vitamins/supplements containing calcium or vitamin D3 other than what was required per protocol

Period of exclusion 6 mo before screening (visit 1) and through last dose of study drug Topical glucocorticoids were allowed during the study as long as the use did not exceed more than the equivalent of 5 mg/d prednisone for more than 14 d Inhaled glucocorticoids were allowed during the study as long as the use did not exceed 21 d in a 3-mo period or 42 d in 1 y through last dose of study drug 2 mo before screening (visit 1) and through last dose of study drug 3 mo before screening (visit 1) and through last dose of study drug Use within 1 y before screening (visit 1) and through last dose of study drug Use within 1 y before screening (visit 1) and through last dose of study drug 6 mo before screening (visit 1) and through last dose of study drug From screening (visit 1) through last dose of study drug Ever taken Ever taken 1 y before screening (visit 1) and through last dose of study drug 6 mo before screening (visit 1) and through last dose of study drug 1 y before screening (visit 1) and through last dose of study drug 3 mo before screening (visit 1) and through last dose of study drug 3 mo before screening (visit 1) and through last dose of study drug 3 mo before screening (visit 1) and through last dose of study drug 1 mo before screening (visit 1) and through last dose of study drug 2 mo before screening (visit 1) and through last dose of study drug Screening (visit 1) and through last dose of study drug

Gastroenterology Vol.

H2RA, histamine 2-receptor antagonist; RANK, receptor activator of nuclear factor kappa-B ligand; SSRI, selective serotonin-reuptake inhibitor. a Inhaled glucocorticoids were allowed during the study as long as the use did not exceed 21 consecutive days. b Local vaginal estrogen was permitted.

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1381 1382 1383 1384 1385 1386 1387 1388 1389 1390 1391 1392 1393 1394 1395 1396 1397 1398 1399 1400 1401 1402 1403 1404 1405 1406 1407 1408 1409 1410 1411 1412 1413 1414 1415 1416 1417 1418 1419 1420 1421 1422 1423 1424 1425 1426 1427 1428 1429 1430 1431 1432 1433 1434 1435 1436 1437 1438 1439 1440

1441 1442 1443 1444 1445 1446 1447 1448 1449 1450 1451 1452 1453 1454 1455 1456 1457 1458 1459 1460 1461 1462 1463 1464 1465 1466 1467 1468 1469 1470 1471 1472 1473 1474 1475 1476 1477 1478 1479 1480 1481 1482 1483 1484 1485 1486 1487 1488 1489 1490 1491 1492 1493 1494 1495 1496 1497 1498 1499 1500 -

Supplementary Table 2.Schedule of Study Procedures

Study procedure or assessmenta

Visit 1

Visit 2

Visit 3

Wk ‒12

Wk ‒2

Day ‒1

X X X X X

Day 1

Treatment Visit 4

Visit 5

Wk 13

Wk 26 or early termination

X X

X X X X X

X X

X

X X

Follow-up BMD

X

X X X

X X X X X X

X X X X X

X

Wk 52

X X

X

X X

X X X X

X

X X

X

BMI, body mass index; CrCl, creatinine clearance; DXA, dual-energy x-ray absorptiometry; ECG, electrocardiogram; FSH, follicle-stimulating hormone. a All laboratory tests required an 8-hour fast except at week 12. b BMI calculation performed at visit 1 (week ‒12) only. c Urine NTx samples were collected in clinic with the second fasting void of the day during visit 2, visit 4, and visit 5. For visit 5, the second fasting void of the day was defined as the first void of the day after completion of the 24-hour urine collection. For visit 2 and visit 4, the second fasting void of the day was defined as the first void after 6 AM.

Dexlansoprazole, Esomeprazole in Bone Homeostasis

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Medical history, demographics, and concurrent medical conditions Physical examination, vital signs, ECG Height and BMI calculationb Clinical laboratory tests (chemistry, hematology, and urinalysis) BMD by DXA 24-hour urine calcium excretion, magnesium excretion and 24-hour urine creatininec Urine magnesium Estimated CrCl calculation Gastrin FSH P1NP, CTX, urine NTx,c BsAP Serum phosphorus, calcium, albumin, and magnesium 25(OH)D PTH AE monitoring Dispense double-blind treatments (dexlansoprazole 60 mg, esomeprazole 40 mg, or placebo) Calcium absorption substudy

Randomization

2019

Screening

9.e4

1501 1502 1503 1504 1505 1506 1507 1508 1509 1510 1511 1512 1513 1514 1515 1516 1517 1518 1519 1520 1521 1522 1523 1524 1525 1526 1527 1528 1529 1530 1531 1532 1533 1534 1535 1536 1537 1538 1539 1540 1541 1542 1543 1544 1545 1546 1547 1548 1549 1550 1551 1552 1553 1554 1555 1556 1557 1558 1559 1560

1561 1562 1563 1564 1565 1566 1567 1568 1569 1570 1571 1572 1573 1574 1575 1576 1577 1578 1579 1580 1581 1582 1583 1584 1585 1586 1587 1588 1589 1590 1591 1592 1593 1594 1595 1596 1597 1598 1599 1600 1601 1602 1603 1604 1605 1606 1607 1608 1609 1610 1611 1612 1613 1614 1615 1616 1617 1618 1619 1620 9.e5 Hansen et al

Supplementary Table 3.Baseline and Week 26 Median Urinary Calcium, Serum Calcium, Phosphorus, Magnesium, Urine Magnesium, PTH, Serum Vitamin D, and Gastrin Levels Dexlansoprazole 60 mg QD, n ¼ 36

Placebo, n ¼ 38 FLA 5.5.0 DTD
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Difference from n Median (range) baseline (95% CI)a n – 1.0 (‒5.0 to 7.0)

n

Median (range)

Difference from baseline (95% CI)a

Difference vs placebo (95% CI)a Dexlansoprazole vs placebo

Esomeprazole vs placebo

30 28.5 (18.0–60.0) – 25 29.0 (11.0–73.0) – – – 30 105.5 (32.0–684.0) 78.0 (56.0 to 99.0) 25 113.0 (30.0–892.0) 84.0 (64.0 to 108.0) 79.5 (55.0 to 106.0) 85.0 (66.0 to 110.0)

– 1 (‒4 to 7)

30 29

27 (15–77) 31 (16–82)

– 1 (‒4 to 8)

31 26

31 (15–48) 33 (20–57)

– 3 (‒2 to 9)

– 1 (‒3 to 4)

– 2 (‒2 to 7)

– ‒26 (‒66 to 16)

29 29

174 (59–346) 112 (24–286)

– ‒50 (‒92 to ‒11)

24 24

121 (57–355) 103 (23–242)

– ‒34 (‒84 to 1)

– ‒17 (‒59 to 21)

– ‒8 (‒64 to 27)

– 0.0 (‒0.2 to 0.2)

32 31

9.5 (9.0–10.1) 9.5 (8.8–10.0)

– 0.0 (‒0.2 to 0.2)

30 26

9.6 (9.1–10.3) 9.6 (9.1–10.1)

– ‒0.1 (‒0.2 to 0.1)

– 0.0 (‒0.2 to 0.2)

– 0.0 (‒0.3 to 0.2)

– 0.0 (‒0.2,0.2)

32 31

3.8 (3.2–4.9) 3.9 (3.0–5.1)

– 0.1 (‒0.1 to 0.3)

30 26

3.9 (3.1–4.5) 4.0 (3.5–4.7)

– 0.0 (‒0.1 to 0.2)

– 0.0 (‒0.2 to 0.2)

– ‒0.1 (‒0.3 to 0.2)

– ‒0.2 (‒1.4 to 1.0)

32 31

3.6 (1–18) 3.7 (1–8)

– ‒0.3 (‒1.5 to 1.0)

31 26

3.6 (1–13) 3.1 (1–12)

– ‒0.1 (‒1.5 to 0.9)

– ‒0.3 (‒1.6 to 0.9)

– ‒0.3 (‒1.6 to 1.0)

– 0.0 (‒0.1 to 0.1)

32 31

1.7 (1.4- 2.0) 1.7 (1.5–1.9)

– 0.0 (‒0.1 to 0.0)

30 26

1.8 (1.6–2.0) 1.8 (1.5–2.1)

– 0.0 (‒0.1 to 0.0)

– 0.0 (‒0.1 to 0.0)

– 0.0 (‒0.1 to 0.0)

– ‒2 (‒6 to 2)

32 30

38 (26–87) 40 (27–50)

31 26

35 (19–55) 38 (22–49)

– 1 (‒3 to 5)

– 2 (‒2 to 6)

– 3 (‒2 to 8)

– 4 (‒1 to 9)

QD, once daily. a Difference from baseline or placebo estimated using Hodges-Lehmann estimate; 95% CIs of the differences in actual values calculated by the Moses method. Comparisons were considered statistically significant if the 95% CI excluded zero (reported in bold text).

Q5

Gastroenterology Vol.

Serum gastrin, pg/mL Baseline 28 27.5 (13.0–325.0) Week 26 28 30.5 (15.0–703.0) PTH, pg/mL Baseline 36 28 (16- 53) Week 26 32 30 (15–70) Urinary calcium, mg/dL Baseline 29 145 (42–325) Week 26 29 119 (14–326) Serum calcium, mg/dL Baseline 36 9.5 (8.6–10.1) Week 26 32 9.5 (8.1–10.5) Serum phosphorus, mg/dL Baseline 36 3.8 (2.8–4.2) Week 26 32 3.8 (3.2–5.2) Urine magnesium, mEq/L Baseline 35 3.7 (0–8) Week 26 31 3.3 (1–8) Serum magnesium, mEq/L Baseline 36 1.7 (1.5–2.0) Week 26 32 1.7 (1.4–2.0) 25(OH)D, ng/mL Baseline 36 39 (29–69) Week 26 32 36 (25–56)

Median (range)

Difference from baseline (95% CI)a

Esomeprazole 40 mg QD, n ¼ 34

-,

No. -

1621 1622 1623 1624 1625 1626 1627 1628 1629 1630 1631 1632 1633 1634 1635 1636 1637 1638 1639 1640 1641 1642 1643 1644 1645 1646 1647 1648 1649 1650 1651 1652 1653 1654 1655 1656 1657 1658 1659 1660 1661 1662 1663 1664 1665 1666 1667 1668 1669 1670 1671 1672 1673 1674 1675 1676 1677 1678 1679 1680

0.16 (0.10 to 0.29) 0.17 (0.08 to 0.27) ‒0.02 (‒0.08 to 0.07) ‒

0.18 0.19 0.02 0.03

(0.11 to 0.24) (0.11 to 0.29) (‒0.04 to 0.10) (‒0.02 to 0.08)

Dexlansoprazole 60 mg QD, n ¼ 9 0.19 0.20 0.07 0.06

(0.10 to 0.23) (0.14 to 0.30) (‒0.07 to 0.08) (0.02 to 0.11)

QD, once daily. a Difference estimated with Hodges-Lehmann estimate. Change values were considered statistically significant if the 95% CI excluded zero (reported in bold text).

Baseline, median (range) Week 26, median (range) Change, median (range) Difference between treatment vs placebo (95% CI)a

Placebo, n ¼ 12

Esomeprazole 40 mg QD, n ¼ 10

1681 1682 1683 1684 1685 1686 1687 1688 1689 1690 1691 1692 1693 1694 1695 1696 1697 1698 1699 1700 1701 1702 1703 1704 1705 1706 1707 1708 1709 1710 1711 1712 1713 1714 1715 1716 1717 1718 1719 1720 1721 1722 1723 1724 1725 1726 1727 1728 1729 1730 1731 1732 1733 1734 1735 1736 1737 1738 1739 1740

Supplementary Table 4.True Fractional Calcium Absorption Change From Baseline to Week 26

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2019 Dexlansoprazole, Esomeprazole in Bone Homeostasis

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9.e6

1741 1742 1743 1744 1745 1746 1747 1748 1749 1750 1751 1752 1753 1754 1755 1756 1757 1758 1759 1760 1761 1762 1763 1764 1765 1766 1767 1768 1769 1770 1771 1772 1773 1774 1775 1776 1777 1778 1779 1780 1781 1782 1783 1784 1785 1786 1787 1788 1789 1790 1791 1792 1793 1794 1795 1796 1797 1798 1799 1800