Case Report
A Case Series of Proton Pump Inhibitor–Induced Hypomagnesemia

https://doi.org/10.1053/j.ajkd.2009.11.019Get rights and content

Proton pump inhibitor (PPI)-induced hypomagnesemia has been recognized since 2006. Our aim was to further characterize the clinical consequences and possible mechanisms of this electrolyte disorder using 4 cases. Two men (aged 63 and 81 years) and 2 women (aged 73 and 62 years) had been using a PPI (esomeprazole, pantoprazole, omeprazole, and rabeprazole, 20-40 mg) for 1-13 years. They developed severe hypomagnesemia (magnesium, 0.30 ± 0.28 mEq/L; reference, 1.40-2.10 mEq/L) with hypocalcemia (calcium, 6.4 ± 1.8 mg/dL), relative hypoparathyroidism (parathyroid hormone, 43 ± 6 pg/mL), and extremely low urinary calcium and magnesium excretion. One patient was admitted with postanoxic encephalopathy after a collapse likely caused by arrhythmia. The others had electrocardiogram abnormalities (prolonged QT interval, ST depression, and U waves). Concomitant hypokalemia (potassium, 2.8 ± 0.1 mEq/L) was considered the trigger for these arrhythmias. Hypomagnesemia-induced kaliuresis (potassium excretion, 65 ± 24 mEq/L) was identified as the cause of hypokalemia. This series of PPI-induced hypomagnesemia shows that this is a generic effect. It also indicates that hypomagnesemia may occur within 1 year of PPI therapy initiation and can have serious clinical consequences, likely triggered by the associated hypokalemia. A high index of suspicion is required in PPI users for unexplained hypomagnesemia, hypocalcemia, hypokalemia, or associated symptoms.

Section snippets

Case Reports

The 4 cases are described next and in Table 1 (showing all laboratory values).

Discussion

This series of 4 patients with PPI-induced hypomagnesemia, hypocalcemia, and hypokalemia adds several new and clinically relevant points.

According to the scale of Naranjo et al,7 the likelihood that the PPIs caused hypomagnesemia was “probable” (Table 1). All cases had additional pathologic states that could have contributed to the degree of hypomagnesemia (partial colectomy,8 diabetes mellitus,9 intestinal lymphangiectasia,10 and ion-exchange resin). However, it seems very unlikely that these

Acknowledgements

The authors thank Drs T. van Gelder and R.H. van Schaik for pharmacogenetic analysis, Dr M.N. Boomgaard for referring case 1, and Dr F.P. van der Dijs for help with retrieving the laboratory values for case 3.

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

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Originally published online as doi:10.1053/j.ajkd.2009.11.019 on May 17, 2010.

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