Experimental basis for the clinical use of diphosphonates in Paget's disease of bone

Amino acid phosphatase activity of alkaline phosphatase. A possible role of protein phosphatase

Alkaline phosphatase (ALP) hydrolyzed phosvitin and amino acid phosphates demonstrating nonisotropy at different pH. Orthovanadate, a protein phosphatase inhibitor, more specifically inhibited the serine and tyrosine phosphatase activities of ALP than that of threonine phosphatase at concentrations > 0.1 mM or 0.01 mM, respectively. Calyculin A and okadaic acid at increased concentrations increased ALP amino acid phosphatase activity. Bisphosphonates, such as disodium-1-hydroxy-1-aminopropylidine-1,1-diphosphonate (APD) and ethane-1-hydroxy-1,1-diphosphonate (HEBP), at increased concentrations, inhibited ALP amino acid phosphatase activity. These results suggest that ALP may function as a protein phosphatase. In terms of protein kinase inhibitors, N-[2-(methylamino)ethyl]-5-isoquinolinesulfonamide, N-(6-aminoheyxl)-5-chloro-1-naphthalenesulfomide hydrochloride and 4',5,7-trihydroxyisoflavone had little effect on ALP amino acid phosphatase activity. Staurosporine slightly enhanced ALP serine and threonine phosphatase activities at a concentration of 0.1 mM. These results suggest that protein phosphatase activity does not depend on the protein kinase activity of ALP, since duality between the former and the latter is not supported. ALP may function less as a protein kinase than as a protein phosphatase. The coupling mechanism of phosphate dynamics may be regulated indirectly.

Alendronate modulates osteogenesis of human osteoblastic cells in vitro

The bisphosphonates, which are carbon-substituted pyrophosphates, have been studied extensively both in vivo and in vitro to elucidate their effects on bone tissues and cells. However, because these agents were shown to have a potent inhibitory effect on bone resorption, the majority of studies have focused on only this aspect of bone metabolism. There appears to be less information regarding the direct effect of bisphosphonates on bone formation, so thus we undertook experiments to investigate the effects of bisphosphonates, especially alendronate, on the mineralization and matrix protein synthesis of human osteoblastic cells in vitro. The data show that the bisphosphonates, alendronate, etidronate and pamidronate, suppressed 1,25-dihydroxycholecalciferol (1,25(OH)2D3)-stimulated mineralization of human osteoblastic cells at high concentrations, while relatively lower concentrations of alendronate and etidronate potentiated mineralization of the cells in the presence of 1,25(OH)2D3. The potentiation of mineralization with alendronate was accompanied by increased synthesis of bone matrix proteins, osteocalcin and collagen, and the mRNA of pro alpha(I) collagen. These findings show that in addition to their well-known effects on bone resorption, bisphosphonates have significant and direct effects on osteogenesis in osteoblasts in vitro. The actual mechanism remains to be further investigated.

Bone demineralization induced by cementless alumina-coated femoral stems

The biologic compatibility of ceramic materials has been widely demonstrated, and alumina (Al2O3) has been used extensively in clinical applications for nearly 20 years. The authors examined the behavior of bone tissue adjacent to the alumina coating in eight cementless hip prosthetic stems that appeared radiologically stable and were explanted because of pain. Histologic evaluation demonstrated the presence of a consistent layer of decalcified bone tissue in continuity with and parallel to the prosthetic interface. Based on laboratory findings, the authors attribute this demineralization phenomenon to a high local concentration of aluminum ions with metabolic bone disease, which is histologically comparable to the osteomalacic osteodystrophy described in dialysis patients. These findings must be carefully considered given the potential long-term implications for alumina-coated implants.

Corticosteroid induced osteoporosis in severe menstrual asthma. Steroid sparing drugs may be useful

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Effects of bisphosphonates and inorganic pyrophosphate on osteogenesis in vitro

The bisphosphonates, which are chemically related to pyrophosphate, have been studied extensively both in vivo and in vitro to elucidate their effects on bone tissues and cells. However, because these agents have important effects on bone resorption, the majority of investigations have focused on this area. Few studies regarding direct bisphosphonate effects on bone formation have been carried out in the past and, thus, we chose to use the chick periosteal osteogenesis (CPO) in vitro model system to test the direct effects of pyrophosphate and the bisphosphonates ethane-1-hydroxy-1,1-diphosphate (HEBP) and disodium-1-hydroxy-1-amino-propylidine (APD) on various parameters of osteogenesis in vitro. The data show that the bisphosphonate HEBP inhibits bone mineralization reversibly while APD, at low doses, may actually enhance mineralization of bone. Similarly, pyrophosphate (PPi) will prevent mineralization in CPO cultures. However, CPO cultures can circumvent PPi-mediated blockage of mineralization with longer-term, continuous (10-day) incubation, whereas this does not occur if cultures are incubated continuously with bisphosphonates. Both drugs appear to be able to reverse beta-glycerophosphate-induced changes in alkaline phosphatase activity, but do not appear on their own to regulate the activity of this enzyme. The findings show that in addition to their well-known effects on resorption, bisphosphonates have significant and direct effects on mineralization in bone-forming cultures. Their direct effects on osteoblastic activity and differentiation remain to be determined.

The pharmacokinetics and distribution of pamidronate for a range of doses in the mouse

The pharmacokinetics of the bisphosphonate drug pamidronate (APD, 3-amino-1-hydroxypropylidene-1,1-bisphosphonate) have been investigated in the mouse by using 14C-APD and following the tissue concentrations for up to 90 days postdose. The accumulation of APD in bone was the highest of all tissues and was linear with increasing dose up to the maximum dose employed (30 mg/kg), which is indicative of the uptake process being a simple chemical phenomenon. Despite the known effects of APD on bone turnover rates and osteoclast activity, the dose appeared to have no significant influence on the biological half-life of APD in bone which was found to be 90-140 days. A high dose of APD (5 mg/kg) appeared to prolong its uptake phase by bone, however, a net movement of APD from the soft tissues is the likely explanation for this finding. The concentrations of APD in the soft tissues investigated (liver, spleen, kidney, lung, and muscle) declined in a biphasic manner, initially in parallel with the fall in the plasma concentration and followed by a gradual fall in APD's concentration in the soft tissues due to renal elimination and a redistribution favoring the calcified tissues. The liver and spleen contained higher concentrations of APD relative to the other soft tissues. The 0-24 hour renal excretion of APD was found to fall with increasing dose above 2.5 mg/kg; this may be due to either nephrotoxicity or increased uptake by soft tissues. For doses over 20 mg/kg, there was some evidence of nephrotoxicity. The data from these studies have been used to formulate a simple physiological model for APD disposition.

Effects of ethane-1-hydroxy-1, 1-diphosphonate on cell differentiation, and proteoglycan and calcium metabolism, in the proximal tibia of young rats

The effects of ethane-1-hydroxy-1, 1-diphosphonate(EHDP) on cell differentiation, and on the metabolism of proteoglycan and calcium in the epiphyseal plate and metaphysis of rats were investigated through histology and autoradiograms of [35S]-sulfate, 45Ca, and [3H]-thymidine. Suppression of bone resorption in the metaphysis due to low dose EHDP administration was associated with a proliferation of osteoclasts with an increased number of nuclei. High dose EHDP induced enlargement of the hypertrophic zone of the epiphyseal plate and suppression of calcification of the cartilage matrix. This change had a significant association not only with the suppression of chondroitin sulfate synthesis and the degradation in the cartilage matrix, but also with the suppression of growth and differentiation of chondrocytes. Calcification was also inhibited in the metaphysis, and growth and differentiation from undifferentiated mesenchymal cells to osteoblasts, osteocytes, and osteoclasts were also suppressed by high dose EHDP.

Paget's disease of bone

Paget's disease is a relatively common bone disease. This review aims to present reasonable treatment recommendations with enough background to understand them. To accomplish this end, some aspects of basic bone cell biology, biochemistry, and pathology are presented, as are speculations about possible causes of this disease. Treatment of Paget's disease will be considered in three sections. The first two sections will review treatment with calcitonin and diphosphonates, respectively. These sections briefly will consider the mechanism of action of the drugs, review in detail clinical studies of drug effectiveness, and summarize the advantages and disadvantages of each drug. The third section details specific treatment recommendations for each of the six clinical settings in which treatment of Paget's disease is justified.

Treatment of calcinosis universalis with low-dose warfarin

Patients with calcinosis universalis secondary to dermatomyositis or systemic sclerosis have increased levels of the calcium-binding amino acid, gamma-carboxyglutamic acid. The enzyme that effects gamma carboxylation of glutamic acid is warfarin-sensitive. Four patients with calcinosis universalis were treated with 1 mg per day of warfarin for 18 months in a non-blind initial study. Two patients had both decreased gamma-carboxyglutamic acid urinary concentration and decreased extra-skeletal uptake on technetium 99m-diphosphonate whole-body nuclear scanning. In a subsequent double-blind placebo study, two thirds of the patients receiving 1 mg per day of warfarin had decreases in extra-skeletal nuclear tracer uptake after 18 months, compared with none of the four patients receiving placebo. No patient had a change in clinical assessment, bleeding complication, or baseline normal prothrombin time. This low-dose warfarin regimen appears to have no demonstrable adverse effects, and these results suggest a beneficial effect on the progression of calcinosis in these rheumatic diseases.

Distribution of [14C]clodronate (dichloromethylene bisphosphonate) disodium in mice

The distribution of 14C-labeled clodronate (dichloromethylene bisphosphonate), a new bisphosphonate for the treatment of osteolytic bone metastases and hypercalcemia, was studied in mice by whole-body autoradiography and by measuring the 14C activities in various tissues [14C]Clodronate was administered into the tail vein, and its distribution was followed from 5 min to 90 days after the injection. The drug disappeared promptly from the plasma and accumulated intensively in the bone and moderately in the spleen. In both tissues, relatively high radioactivities were measured as late as 90 days after the [14C]clodronate administration. Small amounts of 14C activity were also detected in the liver for 90 days. The results agree well with the previous observations that bisphosphonates deposit rapidly in the bone. Our findings indicate further that clodronate accumulates in the bone and the spleen for several months.

Efficacy of aminohydroxypropylidene diphosphonate in the treatment of malignancy-associated hypercalcaemia

Two patients with symptomatic malignancy-associated hypercalcaemia were treated with intravenously-administered aminohydroxypropylidene diphosphonate (APD). Both patients demonstrated dramatic falls in serum calcium concentration, and in urinary calcium and hydroxyproline excretion that were consistent with a reduction in the rate of bone resorption. Normocalcaemia occurred by day 5 and persisted for approximately three weeks after treatment. No significant side-effects were encountered. It was concluded that APD is a promising new agent in the management of hypercalcaemia that is associated with malignant disease and warrants further investigation.

Effects of four bisphosphonates on bone resorption, lysosomal enzyme release, protein synthesis and mitotic activities in mouse calvarial bones in vitro

The effects of 3-amino-1-hydroxy-propylidene-1,1-bisphosphonate (AHPrBP), 1-hydroxyethylidene-1,1-bisphosphonate (HEBP), dichloromethylenebisphosphonate (Cl2MBP) and azacycloheptylidene-2,2-bisphosphonate (AHBP) on bone were examined in organ culture using newborn mice calvaria. AHPrBP, HEBP and Cl2MBP caused a dose-dependent inhibition of PTH-stimulated (10 nmol/l) release of 45Ca from the calvaria, at and above a concentration of 3 mumol/l, whereas AHBP only caused a slight inhibition, at and above 100 mumol/l. AHPrBP inhibited PTH-stimulated release of 3H from bones prelabelled with [3H]-proline. AHPrBP (30 mumol/l) diminished the stimulatory effect of 1 alpha(OH)vitamin D3 (10 nmol/l), prostaglandin E2 (0.1 mumol/l) and renal tumor conditioned media on 45Ca release. AHPrBP and Cl2MBP, at and above 3 mumol/l, decreased PTH-stimulated mobilization of Ca2+ and Pi and in parallel the release of beta-glucuronidase without affecting the release of lactate dehydrogenase. The inhibitory effect of AHPrBP (30 mumol/l) on PTH-induced 45Ca release was irreversible. The inhibition by AHPrBP (30 mumol/l) on spontaneous and PTH-stimulated release of 45Ca can be seen first after 24 h of culture. Similarly the inhibitory effect by HEBP (30 mumol/l) and Cl2MBP (30 mumol/l) was delayed and could be observed after 36 and 24 h of culture, respectively. PTH-stimulated release of Ca2+, Pi, beta-glucuronidase and beta-N-acetylglucosaminidase was reduced by AHPrBP first after 24 h of culture. AHPrBP, HEBP and Cl2MBP, at concentrations which are inhibitory on bone resorption, do not affect protein synthesis and mitotic activities in mouse calvaria. These data show that AHPrBP, HEBP and Cl2MBP inhibit bone resorption in vitro and in parallel decrease lysosomal enzyme release by a mechanism, which is not related to cytotoxicity. In addition, the delayed inhibitory effect on bone resorption and lysosomal enzyme release by all the compounds suggest that bisphosphonates inhibit bone resorption indirectly and not by a direct effect on existing osteoclasts. The delayed inhibition by bisphosphonates on bone resorption may be due to decreased recruitment of new osteoclasts as a consequence of an inhibitory action on mononuclear osteoclast precursor cells.

Osteolytic bone metastases in breast carcinoma pathogenesis, morbidity and bisphosphonate treatment

In this review different aspects of osteolytic bone metastasis of breast carcinoma including morbidity, pathogenesis, accompanying hypercalcaemia and treatment, are discussed. Bone metastases occur in many patients with breast cancer (percentages of up to 85% have been reported); although patients seldom die of bone metastases morbidity is pronounced. Literature data point out that humoral factors, such as prostaglandins and the recently described growth factors are of importance beside cell interactions between monocytes, lymphocytes, osteoclasts and tumour cells. Nowadays, no significance is attributed to parathyroid hormone (PTH) overproduction in this respect. The differential diagnosis between primary hyperparathyroidism and tumour-induced hypercalcaemia is not always easy biochemically; combinations of both do occur less frequently than has been assumed in the past. A new and promising line of investigations involves the growth factors, which can increase osteolytic bone resorption and may bind to epidermal growth factor (EGF) or PTH receptors, thus inducing some of the biological effects of PTH (including hypercalcaemia). Until recently it was exceedingly difficult to treat tumour-induced hypercalcaemia (TIH) (the acute condition). Since the availability of the bisphosphonates dichloromethylidene bisphosphonate (Cl2MDP) and 3-amino-1-hydroxypropylidene-1, l-bisphosphonate (APD) this treatment has become very simple. Preliminary results, derived from the literature, point out that bisphosphonate treatment might also be effective in providing long-term control.

Effects of 1-hydroxyethylidene-1,1 bisphosphonate and (chloro-4 phenyl) thiomethylene bisphosphonic acid (SR 41319) on the mononuclear cell factor-mediated release of neutral proteinases by articular chondrocytes and synovial cells

Articular chondrocytes and synovial cells were stimulated to produce collagenase, neutral casein and proteoglycan-degrading proteinases by conditioned medium from human peripheral blood mononuclear cells. Collagenase, neutral casein and proteoglycan-degrading proteinase secretion was inhibited by SR 41319, a new bisphosphonate, in a concentration-dependent manner. Complete inhibition was achieved at about 0.3 mM. EHDP exhibited the same general profile but was about 10-fold less active and never completely inhibited the enzyme secretion. When added before MCF, SR 41319 had a protective effect against subsequent activation of the cells by MCF. SR 41319 also inhibited the increase of enzyme secretion by cells previously stimulated with MCF. The results suggest that the ability of SR 41319 to inhibit the MCF-mediated secretion of neutral enzymes involved in cartilage destruction could be valuable in the management of connective tissue damage in rheumatoid arthritis.

Long-term follow-up of therapy with intermittent etidronate disodium in Paget's disease of bone

A long-term trial of etidronate disodium therapy in 93 patients with Paget's disease of bone yielded generally favorable results. Treatment or retreatment was initiated for symptomatic Paget's disease with elevated serum alkaline phosphatase and urinary hydroxyproline values. Improvement occurred in 60 percent of patients even in the presence of secondary osteoarthritis. There appeared to be three types of responses: (1) Patients with prolonged clinical and chemical improvement after a single course of therapy (40 percent); these patients tended to have less active disease on the basis of initial alkaline phosphatase and hydroxyproline values, with suppression to normal in 76 percent of patients after etidronate disodium therapy. (2) Patients with response to retreatment (45 percent); these patients had modest disease on the basis of alkaline phosphatase and hydroxyproline values and required retreatment less often than once a year. (3) Patients with response to retreatment but eventual development of resistance to etidronate disodium (15 percent); these patients had the most severe disease clinically and on the basis of alkaline phosphatase and hydroxyproline values. In this last group, resistance to etidronate disodium (5 mg/kg per day) was common and early, and patients received etidronate disodium more often than one course per year; alkaline phosphatase response was transient, often of less than three months' duration.

The bisphosphonates HEBP and AHPrBP but not AHBP inhibit mineral mobilization and lysosomal enzyme release from mouse calvarial bones in tissue culture

The effect of 3 bisphosphonates, 1-hydroxyethylidene-1, 1-bisphosphonate (HEBP), 3-amino-1-hydroxy-propylidene-1, 1-bisphosphonate (AHPrBP) and azacycloheptylidene-2, 2-bisphosphonate (AHBP), on the release of minerals (40Ca, 45Ca, Pi) and enzymes from cultured mouse calvaria was investigated in an organ culture system. HEBP and AHPrBP reduced PTH-stimulated mobilization of calcium and inorganic phosphate without affecting the release of lactate dehydrogenase. In contrast, no significant effect by AHBP on mineral mobilization and lysosomal enzyme release could be registered. In parallel with inhibited mineral mobilization, HEBP and AHPrBP inhibited the release of the lysosomal enzyme beta-glucuronidase. A possible cellular mechanism of action of bisphosphonates is discussed in the light of these data.

Focal osteomalacia due to low-dose diphosphonate therapy in Paget's disease

Transiliac bone biopsies carried out on 13 patients with Paget's disease to evaluate the effects of low-dose diphosphonate (disodium etidronate) therapy showed focal osteomalacia in the 9 patients in whom post-therapy specimens were taken through pagetic bone. Active bone resorption persisted in 5 of these. A mineralisation defect not amounting to osteomalacia--ie, osteoid of increased thickness but of normal extent--was present in the 4 specimens taken through non-pagetic bone. Although 9 patients experienced symptomatic improvement, 2 suffered fissure fractures in affected lower limbs. In Paget's disease, the combination of osteomalacia and continuing active resorption within a lytic lesion may increase the risk of fracture in a weight-bearing bone. It is suggested that although disodium etidronate often provides effective pain relief it should be administered with caution until the optimum dose and duration of therapy are further evaluated.

The origin of osteoclasts: evidence, clinical implications and investigative challenges of an extra-skeletal source

Recent evidence for an extraskeletal origin of osteoclasts and the historical record of the genesis of osteoclasts are examined critically. Reviews of the structure, function and development of osteoclasts from mononuclear precursors, the local regulation of bone resorption and the coupling of bone formation to preceding resorption are presented as a background for discussing the clinical implications for management of osteolytic bone diseases. The roles of osteoclasts and macrophages as phagocytes are compared and contrasted, and recent evidence for macrophage heterogeneity resulting from site-specific monoblastic precursors is reviewed. The implications of these recent developments in macrophage biology are extrapolated to osteoclasts and the existence of site-specific, extraskeletal osteoclast precursors is proposed. Finally, the investigative challenges inherent in these perspectives are discussed.

Effect of dichloromethylene diphosphonate on fluoride balance in healthy men

Healthy men with a daily intake of 0.37 mg fluoride were given dichloromethylene diphosphonate (Cl2MDP) or a placebo during a period of ambulation followed by bed rest. In both groups, serum ionic fluoride was unchanged, and fluoride balances were negative, but Cl2MDP significantly reduced loss of fluoride in the treated groups.

Effects of dichloromethylene diphosphonate in women with breast carcinoma metastatic to the skeleton

Ten women with skeletal metastases from breast carcinoma received dichloromethylene diphosphonate (Cl2MDP), an inhibitor of osteoclast function, in a placebo-controlled, double-blind, crossover study. Eight of these patients had either hypercalcemia or hypercalciuria, and all 10 had elevated urinary hydroxyproline levels as evidence of active skeletal disease. Eight patients had moderate to severe bone pain. After eight weeks of oral dichloromethylene diphosphonate treatment (3,200 mg per day), either preceded by or followed by an eight-week placebo period, seven of eight patients with hypercalciuria had significant reductions in urinary calcium levels, and nine of 10 had reductions in urinary hydroxyproline levels (significant in eight) when the dichloromethylene diphosphonate treatment periods were compared with prestudy or placebo periods. Additionally, seven of eight subjects had decreased pain with dichloromethylene diphosphonate. There were no adverse effects other than transient diarrhea in some patients. We conclude that oral dichloromethylene diphosphonate can significantly inhibit osteoclast-mediated bone destruction in patients with bone metastases from breast cancer.

Effect of dichloromethylene diphosphonate (Cl2MDP) on immune function in breast cancer patients with bone metastases

Immune function was studied in normocalcemic breast cancer patients with bone metastases treated with either dichloromethylene diphosphonate (Cl2MDP) or placebo. The results showed no significant difference between the two patient groups. This suggests that Cl2MDP does not markedly impair the host's defense mechanisms, and in this respect can be safely used in the treatment of patients with resorptive bone disease.