Treatment Of Metabolic Bone Diseases Research Articles

Clinical review 114: hot topic. The role of receptor activator of nuclear factor-kappaB ligand and osteoprotegerin in the pathogenesis and treatment of metabolic bone diseases.

Clinical review 114: hot topic. The role of receptor activator of nuclear factor-kappaB ligand and osteoprotegerin in the pathogenesis and treatment of metabolic bone diseases.

Cellular and molecular mechanisms of action of bisphosphonates.

Bisphosphonates currently are the most important class of antiresorptive agents used in the treatment of metabolic bone diseases, including tumor-associated osteolysis and hypercalcemia, Paget's disease, and osteoporosis. These compounds have high affinity for calcium and therefore target to bone mineral, where they appear to be internalized selectively by bone-resorbing osteoclasts and inhibit osteoclast function. This article reviews the pharmacology of bisphosphonates and the relation between the chemical structure of bisphosphonates and antiresorptive potency, and describes recent new discoveries of their molecular mechanisms of action in osteoclasts. Bisphosphonates can be grouped into two pharmacologic classes with distinct molecular mechanisms of action. Nitrogen-containing bisphosphonates (the most potent class) act by inhibiting the mevalonate pathway in osteoclasts, thereby preventing prenylation of small GTPase signaling proteins required for osteoclast function. Bisphosphonates that lack a nitrogen in the chemical structure do not inhibit protein prenylation and have a different mode of action that may involve the formation of cytotoxic metabolites in osteoclasts or inhibition of protein tyrosine phosphatases. Bisphosphonates are highly effective inhibitors of bone resorption that selectively affect osteoclasts. After more than 30 years of clinical use, their molecular mechanisms of action are only just becoming clear.

Metabolic bone disease: Lessons from knockout mice

The advent of gene targeting technology in mouse embryonic stem cells has revolutionized the study of developmental biology in mammals. This review aims to highlight genetically engineered (knockout) mice characterized primarily by alterations of the bony skeleton. We will examine how information gained from these mutants has contributed to our understanding of the molecular defects affecting skeletal homeostasis and how this information can now be used to provide us with a more effective therapeutic armamentarium for the treatment of metabolic bone diseases, such as osteoporosis. Drug Dev. Res. 49:159–166, 2000. © 2000 Wiley-Liss, Inc.

Analysis of an adenine nucleotide-containing metabolite of clodronate using ion pair high-performance liquid chromatography–electrospray ionisation mass spectrometry

Clodronate belongs to the family of bisphosphonates, which are synthetic analogues of pyrophosphate. Bisphosphonates are widely used in the treatment of metabolic bone diseases. Some bisphosphonates, including clodronate, can be metabolized in cells into non-hydrolysable nucleotide analogues. In this paper, we describe a new method for extraction and quantitation of the clodronate metabolite in cell lysates by using ion-pairing HPLC method that is compatible with negative ion electrospray ionization mass spectrometry (ESI-MS). The method was used for detection of the metabolite of clodronate in extracts from RAW 264 macrophage cells after treatment with clodronate.

1,25-dihydroxyvitamin D3 as well as its analogue OCT lower blood calcium through inhibition of bone resorption in hypercalcemic rats with continuous parathyroid hormone-related peptide infusion.

The effects of 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] and its analogue 22-oxa-1,25(OH)2D3 (22-oxacalcitriol) (OCT) on calcium and bone metabolism were examined in an animal model of hypercalcemia with continuous infusion of parathyroid hormone-related peptide (PTHrP), to determine whether active vitamin D could counteract the skeletal action of PTHrP in addition to its reported effect in suppressing the production of PTHrP in cancer cells. Parathyroid glands were removed from 8-week-old Sprague-Dawley rats to eliminate the confounding effects of endogenous PTH. Animals were then continuously infused with human PTHrP(1-34) at a constant rate via osmotic minipumps for 2 weeks, and at the same time treated orally or intravenously with OCT or 1,25(OH)2D3 four to nine times during the 2-week period. Under these conditions, OCT and, surprisingly, 1,25(OH)2D3 alleviated hypercalcemia in a dose-dependent manner. 1,25(OH)2D3 and OCT suppressed the urinary excretion of deoxypyridinoline, although they did not affect renal calcium handling, suggesting that the antihypercalcemic effect is attributable to the inhibition of bone resorption. These active vitamin D compounds also counteracted the effects of PTHrP at the proximal renal tubules, as reflected by a decrease in phosphate excretion. Histomorphometric analysis of bone revealed a dose-related decrease in parameters of bone resorption. These results suggest that 1,25(OH)2D3 as well as OCT has the potential to alleviate hypercalcemia, at least in part, through the inhibition of bone resorption in hypercalcemic rats with constant PTHrP levels. We propose that the main function of active vitamin D in high bone-turnover states is to inhibit bone resorption, and this may have important implications for the understanding of the role of active vitamin D in the treatment of metabolic bone diseases, such as osteoporosis.

Effects of TGFβ and BFGF on the differentiation of human bone marrow stromal fibroblasts

Adipocytes and osteoblasts have common origins from fibroblastic stem cells. Consequently, modulation of the processes of adipogenesis and osteogenesis has implications for the possible treatment of metabolic bone diseases, such as osteoporosis, in which medullary fat accumulates and trabecular bone volume decreases. It is likely that the balance between these two systems is affected by particular endogenous growth factors which are known to affect bone metabolism. We have therefore investigated the effects of transforming growth factor beta (TGFβ), basic fibroblast growth factor (bFGF) and dexamethasone (Dex) on cultured human bone marrow (HBM) fibroblastic cells to observe the effects on adipogenesis and osteogenesis. In the absence of fetal calf serum (FCS), TGFβ caused a dose-dependent increase in cell growth and alkaline phosphatase activity (AP); however, in the presence of FCS growth was inhibited at high concentrations and AP unaffected. TGFβ increased matrix proteoglycan and collagen synthesis. bFGF inhibited AP and increased colony number and size, while Dex treatment increased AP activity and colony number, and both factors in combination resulted in an additive increase in growth. Dex-induced adipocyte formation was accelerated but not increased by bFGF. A significant inhibition of adipogenesis by TGFβ was observed within 7 days. These results demonstrate the importance of biological factors known to be involved in bone remodelling in the regulation of osteogenesis and adipogenesis.

Nitrogen-containing bisphosphonates inhibit the mevalonate pathway and prevent post-translational prenylation of GTP-binding proteins, including Ras.

Bisphosphonates are currently the most important class of antiresorptive drugs used for the treatment of metabolic bone diseases. Although the molecular targets of bisphosphonates have not been identified, these compounds inhibit bone resorption by mechanisms that can lead to osteoclast apoptosis. Bisphosphonates also induce apoptosis in mouse J774 macrophages in vitro, probably by the same mechanisms that lead to osteoclast apoptosis. We have found that, in J774 macrophages, nitrogen-containing bisphosphonates (such as alendronate, ibandronate, and risedronate) inhibit post-translational modification (prenylation) of proteins, including the GTP-binding protein Ras, with farnesyl or geranylgeranyl isoprenoid groups. Clodronate did not inhibit protein prenylation. Mevastatin, an inhibitor of 3-hydroxy-3-methylglutatyl (HMG)-CoA reductase and hence the biosynthetic pathway required for the production of farnesyl pyrophosphate and geranylgeranyl pyrophosphate, also caused apoptosis in J774 macrophages and murine osteoclasts in vitro. Furthermore, alendronate-induced apoptosis, like mevastatin-induced apoptosis, could be suppressed in J774 cells by the addition of farnesyl pyrophosphate or geranylgeranyl pyrophosphate, while the effect of alendronate on osteoclast number and bone resorption in murine calvariae in vitro could be overcome by the addition of mevalonic acid. These observations suggest that nitrogen-containing bisphosphonate drugs cause apoptosis following inhibition of post-translational prenylation of proteins such as Ras. It is likely that these potent antiresorptive bisphosphonates also inhibit bone resorption by preventing protein prenylation in osteoclasts and that enzymes of the mevalonate pathway or prenyl protein transferases are the molecular targets of the nitrogen-containing bisphosphonates. Furthermore, the data support the view that clodronate acts by a different mechanism.

Section Review: Oncologic, Endocrine & Metabolic: Drugs in development for the treatment of metabolic bone disease

The development of potent inhibitors of bone resorption has revolutionised the treatment of common metabolic bone diseases. In the near future, bisphosphonates provide the best means to achieve appropriate clinical responses in Paget's disease and tumour-related bone diseases. In addition to bisphosphonates, newer forms of oestrogen replacement have a future role for the treatment of osteoporosis, because of potential cardiovascular benefits. In the longer term, agents that directly increase bone formation and density may become available, and have a greater role in the treatment of patients with more established osteoporosis.

The Use of Backscattered Electron Imaging and Transmission Electron Microscopy to Assess Bone Architecture and Mineral Loci: Effect of Intermittent Slow-Release Sodium Fluoride Therapy

Backscattered electron imaging (BEI) and transmission electron microscopy (TEM) were used to examine the effects of treatment with intermittent slow-release sodium fluoride (SRNaF) and continuous calcium citrate on bone architecture and crystallinity. Examination was performed in nondecalcified biopsies obtained from patients following up to four years of therapy (placebo or SRNaF) and compared to pretreatment biopsies from each patient, as well as to bone from young, normal subjects. BEI images disclosed increased areas of recent bone formation following fluoride administration. There was no evidence of a mineralization defect in any biopsy and both cortical and trabecular architecture remained normal. TEM analysis demonstrated intrafibrillar platelike crystals and extrafibrillar needlelike crystals for both the pre- and post-treatment biopsies as well as for the bone from young normal subjects. There was no evidence of increased crystal size or of an increase in extrafibrillar mineral deposition. These observations suggest that intermittent SRNaF and continuous calcium therapy exerts an anabolic action on the skeleton not accompanied by a mineralization defect or an alteration of bone mineral deposition. The use of BEI and TEM holds promise for the study of the pathophysiology and treatment of metabolic bone diseases.

Metabolic bone disease in gastrointestinal, hepatobiliary, and pancreatic disorders and total parenteral nutrition.

Privational vitamin D deficiency is assumed to be uncommon in the developed countries because of the routine fortification of foods with vitamin D. Malabsorption of vitamin D and calcium (especially in an environment of reduced sun exposure) therefore accounts for the majority of cases of metabolic bone disease seen in patients with various gastrointestinal disorders in the United States. Yet recognition of this often asymptomatic bone disease is unsatisfactory and frequently delayed for months or even years. This results in severe irreversible bone loss, putting patients at increased fracture risk for the remainders of their lives. As evident from the small number of published reports, it is obvious that little attention is given to understanding the pathogenesis and prevention of bone disease in patients with various gastrointestinal disorders. This review will summarize recent advances in the pathogenesis, prevention, and treatment of metabolic bone disease in patients with these disorders. We propose methods for identifying bone loss in such patients so that appropriate preventive measures can be instituted to avoid significant morbidity.

Drugs used in the treatment of metabolic bone disease. Clinical pharmacology and therapeutic use.

Osteoporosis is the most important metabolic bone disease and places an increasing burden on the healthcare system. The condition can be prevented by the early introduction of hormone replacement therapy. The role of bisphosphonates in achieving the same result is being actively explored. The attraction of preventing bone loss is that it preserves the micro-architecture of bone, and therefore its mechanical integrity. The great problem of treating the established condition is that substantial bone loss is accompanied by architectural disintegration. Replacing lost bone may not necessarily restore mechanical integrity and protect against fractures. The management of Paget's disease has been quite revolutionised by the introduction of the bisphosphonates. The condition is a result of a primary increase in osteoclastic bone resorption which can be corrected by bisphosphonates, with considerable symptomatic improvement. The increasing potency and safety margin of the newer agents has meant that the threshold for treatment has fallen. There is now potential for long term control of bone turnover with the hope of preventing late complications. Hypercalcaemia of malignancy is usually the result of both increased bone destruction and decreased urinary calcium excretion. These two components of hypercalcaemia demand different approaches to management. The general availability of an ever-expanding range of increasingly potent bisphosphonates has resulted in a dramatic improvement in the treatment of increased bone resorption associated with malignancy. Many types of tumour, either directly or indirectly, compromise the ability of the kidney to eliminate a calcium load derived from increased bone destruction. Calcitonin is the only agent which is currently available to counter this process.

Bisphosphonates in the treatment of metabolic bone diseases.

Bisphosphonates (BP) are pyrophosphate analogs, P-C-P with various carbon side-chains. The phosphate groups are responsible for the low gastrointestinal absorption (about 1%), limited penetration into cells, adsorption to bone mineral and rapid excretion in the urine. Based on the C side-chains, BPs can inhibit osteoclastic bone resorption with potencies which differ by as much as 10,000-fold among compounds. The most potent inhibitors are aminobisphosphonates. Studies of the amino-BP alendronate show preferential uptake at sites of bone resorption where they block osteoclastic activity by inhibiting ruffled border formation. BPs are the treatment of choice for hypercalcaemia of malignancy, where a single infusion with a potent BP will normalize serum calcium in 80% of the patients. Paget's disease also shows an excellent long-term response to BPs. In addition, BPs are being studied for the treatment of osteoporosis and other bone disorders which could be helped by inhibition of bone resorption.

Effects of ipriflavone on bone remodeling in primary hyperparathyroidism

The aim of this study was to evaluate the effects of ipriflavone treatment on bone remodeling in primary hyperparathyroidism. Nine patients, 6 females and 3 males (mean +/- SD age 56 +/- 12.5 years) were treated with 1200 mg/day of ipriflavone by oral administration divided in 3 daily doses. All patients were treated for 21 days; in 5 patients treatment was prolonged to 42 days. In all patients the main serum and urinary parameters of bone remodeling were evaluated. The results suggest that ipriflavone affects bone remodeling by inhibiting bone resorption without affecting bone formation. Ipriflavone is, therefore, indicated in the treatment of metabolic bone diseases characterized by a high bone turnover.

Biologic effect of 1,24(R)(OH)2D3 versus 1,25(OH)2D3 administration in chronic renal failure

1,24(R)(OH)2D3 is a synthetic analogue of 1,25(OH)2D3 which binds to the same receptors as the physiologic metabolite with a lower affinity. The aim of the present study was to compare the activity of 1,24(R)(OH)2D3 and 1,25(OH)2D3 on several target organs in patients with chronic renal failure. Treatment with 1,24(R)(OH)2D3 at doses of either 1 or 2 μg daily was carried out in two groups of 9 patients, with serum creatinine of 4.61 ± 1.59 and 4.66 ± 1.46 mg/dl, respectively. Doses of 1,25(OH)2D3 were 0.5 and 1 μg daily and were administered to 9 and 13 patients, serum creatinine of 4.52 ± 1.67 and 4.3 ± 1.16 mg/dl, respectively. Treatment periods were of 2 weeks. Administration of 1,25(OH)2D3, 1 μg, induced significant increments of intestinal calcium absorption (ICA), ionized calcium, osteocalcin, serum creatinine, urine Ca/GFR, and a decrease in iPTH. 1,25(OH)2D3, 0.5 μg, induced a significant increase in ICA and osteocalcin and a decrease in iPTH. Similarly 1,24(OH)2D3, 2 μg daily, significantly stimulated ICA and raised serum levels of osteocalcin and creatinine while lowering serum iPTH. In addition, 1,24(R)(OH)2D3 administration induced a significant fall of serum 1,25(OH)2D3. Following 1 μg, only osteocalcin increased. Therefore, the dose of 2 μg of 1,24(R)(OH)2D3 has biologic activity similar to 0.5 μg 1,25(OH)2D3 (4:1). However the activity ratio on osteocalcin production appears to be 2:1. In addition, 1,24(R)(OH)2D3 is able to inhibit renal tubular 1α-hydroxylase. In conclusion 1,24(R)(OH)2D3 may prove to be useful in the treatment of metabolic bone disease.

Bone-derived proteins

The diagnosis and treatment of metabolic bone disease has been limited by a lack of understanding of bone cell physiology and of suitable markers for various bone cell functions in different diseases. The identification of noncollagenous proteins and their measurement in serum has added to our knowledge. At this stage, of all the bone-derived proteins, bone Gla protein (BGP) is apparently the most useful, but it is best used in conjunction with other tests. The diagnostic usefulness of other noncollagenous proteins, procollagen, and local factors still remains to be documented.

Serum and urinary markers of bone remodeling: assessment of bone turnover.

It appears that at present, serum BGP is the one bone protein that has the most promise for assisting in the diagnosis and management of high turnover metabolic bone disease states. If further studies confirm its usefulness in osteoporosis as a predictor of rapid bone loss without the need for bone biopsy, this serum marker will then not only allow early detection but also an appropriate choice of therapy in osteoporosis, i.e. the use of specific inhibitors of high turnover states such as estrogen, calcitonin, or bisphosphonates. In addition, it may also permit more accurate follow-up of patients suffering from diseases such as primary hyperparathyroidism after surgery. In low turnover osteoporosis, it may also serve a useful function to observe whether the osteoblast can be stimulated to enhance bone formation with therapies such as fluoride, anabolic steroids, PTH, etc. As yet, additional measurements, such as bone histomorphometry and other bone mineral markers, are required for definitive diagnosis. Hopefully, the availability of specific well-characterized antibodies against BGP may define its role more accurately. Recently, several other new bone proteins have been identified but at present they have very limited clinical application. Future studies into the structure-function relationship of these bone proteins may identify those markers which will be most relevant to the diagnosis and treatment of metabolic bone disease.

High-performance liquid chromatography of vitamin D and its application to endocrinology.

The newest arrival among the steroid hormones is 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3], which is derived from the vitamin D molecule. Although vitamin D has been known since 1919–1922 (McCollum, 1922; Mellanby, 1919), an appreciation that it is a precursor of a steroid hormone did not exist until the discovery that the vitamin D molecule must be altered metabolically in the liver and kidney before function (DeLuca, 1972, 1974). This led to a delineation of the vitamin D endocrine system based in the kidney which gave new understanding of metabolic bone diseases as well as provided new tools for diagnosis and treatment. This exciting development has led to a great deal of effort in the measurement of the vitamin D compounds, not only for nutritional studies but more importantly for clinical investigation of disease in preparation for treatment. Since the vitamin D hormone and some of its important anlogs are currently used for treatment of metabolic bone disease, a large number of analogs have now been prepared, some of which will find their way into human as well as agricultural use. Thus, analysis of the metabolites derived from vitamin D and their analogs has become an exceedingly important field. This chapter is devoted to those measurements and their meaning.KeywordsTotal Lipid ExtractionHypophosphatemic RicketsMicroparticulate SilicaRadioactive VitaminHigh Plasma VitaminThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Inhibitory effect of inositol phosphates on parathyroid hormone-induced bone resorption in organ cultures.

This study investigates the ability of phytic acid, its inositol phosphate derivatives (inositol penta-, tetra-, tri-, di-, and monophosphate), and inorganic phosphate to inhibit parathyroid hormone (PTH)-induced resorption of fetal rat long bones in organ culture. Pregnant rats injected with 45Ca on the 18th day of gestation were killed the next day and their fetuses removed. Half of each pair of dissected long bones was incubated in a chemically defined control medium, while the contralateral half was incubated in medium containing PTH or PTH plus the phosphate compound to be tested. 45Ca released into the medium was indicative of the amount of bone resorption. All phosphate compounds tested inhibited resorption. The inositol phosphates should be studied further to assess their suitability as therapeutic agents for treatment of metabolic bone diseases involving increased turnover.

A program package for quantitative analysis of histologic structure and remodeling dynamics of bone

Quantitative bone histology has become an increasingly valuable tool for the management and diagnosis of metabolic bone disease. A new computer-assisted method for quantitative analysis of bone histology which combines the advantages of discriminatory input by the investigator with a significant reduction of evaluation time is presented. These programs allow the analysis of a sufficient number of subjects from different populations for the establishment of normative data, and are useful in the diagnosis and documentation of the treatment of metabolic bone disease.

VITAMIN D METABOLISM

During the past decade, an explosion of information has become available on the metabolism and function of vitamin D which is of great importance to clinicians in the treatment of metabolic bone disease. We have learned that vitamin D is the precursor of at least one hormone and that this hormone carries out functions in calcium and phosphorus metabolism bringing about mineralization of bone on one hand, and the prevention of hypocalcaemic tetany on the other. It may also function in the prevention of such degenerative bone diseases as osteoporosis. An important analogue of this hormone, 1alpha-hydroxyvitamin D3 has been prepared and is used successfully in the treatment of a variety of clinical conditions. This presentation will summarize these findings and their possible implications in these metabolic bone diseases.