TOPLINE:

In patients with polymyalgia rheumatica (PMR) who started glucocorticoids, the use of bisphosphonates was linked to a modest reduction in the risk for fragility fractures, whereas the use of proton pump inhibitors (PPIs) or H2-receptor antagonists (H2RAs) did not offer gastroprotective benefits.

METHODOLOGY:

• Researchers conducted a cross-sectional study and two emulated target trials to assess whether oral bisphosphonates helped protect bone and PPIs or H2RAs were gastro-protective in patients in England with PMR who started glucocorticoids.
• For the cross-sectional analysis, they included 43,091 patients aged 50 years or older (43.6% aged 70-79 years; 61.6% female) with a new diagnosis of PMR between 2010 and 2022. Patients were prescribed prednisolone within 21 days of diagnosis, received a repeat within 90 days, and remained on treatment for at least 90 days.
• The use of calcium and vitamin D supplements, oral bisphosphonates, and PPIs or H2RAs was identified. In the emulated trials, researchers compared “always treated” vs “never treated” for each prophylaxis.
• For the emulated trials, the analysis included 41,826 patients for bisphosphonates (mean age, 73.0 years; 59.7% female) and 22,526 for PPIs or H2RAs (mean age, 73.1 years; 61.3% female).
• Outcomes were fragility fractures of the hip, wrist, humerus, and vertebrae and serious gastrointestinal adverse events (ulceration or bleeding), identified via linked primary care and hospital data at 6, 12, and 18 months, with follow-up up to 5 years.

TAKEAWAY:

• Overall, 67.2% of patients who started prednisolone for PMR were co-prescribed oral bisphosphonates, and 78.6% were co-prescribed PPIs or H2RAs. Men and patients living in more deprived areas were less likely to receive bisphosphonates than their respective peers.
• The estimated 12-month cumulative incidence of fragility fracture was 1.40% with bisphosphonate use vs 2.32% without use (average treatment effect, 0.92 percentage points; P < .001), which translated to one prevented fracture for every 109 patients treated.
• At 6 months, bisphosphonate use was linked to an estimated absolute risk reduction for fragility fracture of 0.43% points (P = .002), and at 18 months, 1.26% points (P < .001).
• The prescription of PPIs or H2RAs was not associated with a lower risk for gastrointestinal ulceration or bleeding at any timepoint.

IN PRACTICE:

“The findings from this study provide new evidence to support these shared decisions, quantifying the magnitude of benefit of bisphosphonates on risk of fragility fracture and suggesting that prophylactic prescription of PPIs/H2RAs could be reduced for this population,” the authors of the study wrote.

SOURCE:

The study was led by Helen Twohig, PhD, Keele University, Staffordshire, England. It was published online on February 10, 2026, in Arthritis & Rheumatology.

LIMITATIONS:

Because diagnosis of PMR is usually challenging, some patients may have been misclassified. Researchers could not capture use of intravenous bisphosphonates, other bone-active drugs, or over-the-counter supplements. They used data only from English primary care, which may have limited the applicability of the findings.

DISCLOSURES:

The study received funding from the National Institute for Health and Care Research (NIHR) School for Primary Care Research. One author reported receiving funding from an NIHR Clinical Lectureship and another from an NIHR Advanced Research Fellowship. Another author reported receiving partial funding from the NIHR Applied Research Collaboration West Midlands.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.