Extraskeletal benefits and risks of calcium, vitamin D and anti-osteoporosis medications

A systematic review examining the effect of vitamin D supplementation on functional outcomes post-stroke

OBJECTIVE

The objective of this systematic review was to explore the effect of vitamin D supplementation on functional outcomes (motor function, mobility, activities of daily living and stroke impairment) among individuals post-stroke (PROSPERO CRD42022296462).

DATA SOURCES

MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for all articles published up to March 5, 2023.

METHODS

Only interventional studies assessing vitamin D supplementation compared to placebo or usual care in adult stroke patients were selected. After duplicate removal, 2912 studies were screened by two independent reviewers. A total of 43 studies underwent full text review; 10 studies met inclusion criteria (8 randomized controlled trials and 2 non-randomized studies of intervention). Data were extracted by two independent reviewers using Covidence software. Motor function (Brunnstrom Recovery Stage, Berg Balance Score), mobility (Functional Ambulation Category), activities of daily living (Barthel Index, Functional Independence Measure) and stroke impairment (modified Rankin Scale, National Institutes for Health Stroke Severity, Scandinavian Stroke Severity) were the outcome measures of interest reported in the included studies.

RESULTS

In total, 691 patients were studied for which 11 of 13 outcome measures showed improvement with vitamin D supplementation.

CONCLUSIONS

The majority of studies showed a statistical improvement in motor function, mobility, and stroke impairment with vitamin D supplementation; however, the evidence did not support an improvement in activities of daily living with treatment. Despite this, there may not be clinical significance. Strong, methodologically sound, randomized controlled trials are required to verify these findings.

The pathogenesis of post-stroke osteoporosis and the role oxidative stress plays in its development

Cardiovascular disease and osteoporotic fractures (OF) are the main diseases affecting the health of middle-aged and elderly people. With the gradual increase of population aging in China and even the world, the incidence of the two and the prevalence of high-risk groups are also showing a continuous upward trend. The relationship between the two, especially the impact of cardiovascular disease on the risk and prognosis of OF, has attracted more and more attention. Therefore, it is of great significance to fully understand the pathogenesis of cardiovascular and cerebrovascular diseases and the resulting osteoporosis and to provide targeted interventions to prevent the occurrence of diseases and fractures. This article reviews the relationship between one of the Cardiovascular disease-stroke and related therapeutic drugs and the risk of OF, and the role of oxidative stress in its pathophysiological mechanism by reviewing relevant domestic and foreign literature in recent years, in order to gain a more comprehensive understanding of the association between stroke and OF, and then provide a basis and reference for screening high-risk groups of fractures and reducing the burden on the health system caused by the disease.

Infections and Autoimmunity-The Immune System and Vitamin D: A Systematic Review

Both 25-autoimmunity and(25(OH)D: calcifediol) and its active form, 1,25-dihydroxyvitamin D (1,25(OH)2D: calcitriol), play critical roles in protecting humans from invasive pathogens, reducing risks of autoimmunity, and maintaining health. Conversely, low 25(OH)D status increases susceptibility to infections and developing autoimmunity. This systematic review examines vitamin D's mechanisms and effects on enhancing innate and acquired immunity against microbes and preventing autoimmunity. The study evaluated the quality of evidence regarding biology, physiology, and aspects of human health on vitamin D related to infections and autoimmunity in peer-reviewed journal articles published in English. The search and analyses followed PRISMA guidelines. Data strongly suggested that maintaining serum 25(OH)D concentrations of more than 50 ng/mL is associated with significant risk reduction from viral and bacterial infections, sepsis, and autoimmunity. Most adequately powered, well-designed, randomized controlled trials with sufficient duration supported substantial benefits of vitamin D. Virtually all studies that failed to conclude benefits or were ambiguous had major study design errors. Treatment of vitamin D deficiency costs less than 0.01% of the cost of investigation of worsening comorbidities associated with hypovitaminosis D. Despite cost-benefits, the prevalence of vitamin D deficiency remains high worldwide. This was clear among those who died from COVID-19 in 2020/21-most had severe vitamin D deficiency. Yet, the lack of direction from health agencies and insurance companies on using vitamin D as an adjunct therapy is astonishing. Data confirmed that keeping an individual's serum 25(OH)D concentrations above 50 ng/mL (125 nmol/L) (and above 40 ng/mL in the population) reduces risks from community outbreaks, sepsis, and autoimmune disorders. Maintaining such concentrations in 97.5% of people is achievable through daily safe sun exposure (except in countries far from the equator during winter) or taking between 5000 and 8000 IU vitamin D supplements daily (average dose, for non-obese adults, ~70 to 90 IU/kg body weight). Those with gastrointestinal malabsorption, obesity, or on medications that increase the catabolism of vitamin D and a few other specific disorders require much higher intake. This systematic review evaluates non-classical actions of vitamin D, with particular emphasis on infection and autoimmunity related to the immune system.

Dietary calcium intake in Brazilian preschoolers and schoolchhildren: review of the literature

Objective:

The objective of this study was to map and synthesize evidence on the adequacy of dietary calcium intake and dairy products in Brazilian preschoolers and schoolchildren.

Data source:

Evidence searches were performed in the MEDLINE (via PubMed) and Latin American and Caribbean Health Sciences Literature (LILACS; via BVS) databases, with no restriction on date or language of publication. Experimental or observational studies that evaluated healthy Brazilian children between 2 and 12 incomplete years old were included.

Data synthesis:

A total of 18 studies were included. Seven of 11 studies of 11 studies (63.6%) identified mean values of dietary calcium intake below the age recommendation, especially in schoolchildren, with the progression of the age group. Among preschoolers, studies with direct weighing of food showed higher mean values of dietary calcium ingested compared to those with dietary recall. Children attending public daycare centers on a part-time basis tended to have inadequate calcium intake. The consumption of milk and dairy products was lower among older children, especially schoolchildren.

Conclusions:

Inadequate dietary calcium intake seems to be prevalent in Brazil during childhood, especially among schoolchildren. Therefore, the evaluation of milk and dairy products intake must be considered in order to desgn appropriate corrective actions.

The Rationale for Using Neridronate in Musculoskeletal Disorders: From Metabolic Bone Diseases to Musculoskeletal Pain

Neridronate or ((6-amino-1-hydroxy-1-phosphonohexyl) phosphonic acid) is an amino-bisphosphonate (BP) synthetized in Italy in 1986. Bisphosphonates are molecules with a P-C-P bond in their structure that allows strong and selectively binding to hydroxyapatite (HAP) as well as osteoclasts inhibition through different mechanisms of action. Neridronate was initially used to treat Paget disease of the bone, demonstrating effectiveness in reducing bone turnover markers as well as pain. The interesting molecular properties of neridronate foster its wide use in several other conditions, such as osteogenesis imperfecta, and osteoporosis. Thanks to the unique safety and efficacy profile, neridronate has been used in secondary osteoporosis due to genetic, rheumatic, and oncological diseases, including in pediatric patients. In the last decade, this drug has also been studied in chronic musculoskeletal pain conditions, such as algodystrophy, demonstrating effectiveness in improving extraskeletal outcomes. This review highlights historical and clinical insights about the use of neridronate for metabolic bone disorders and musculoskeletal pain conditions.

Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I

The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.

An AI-based prediction model for drug-drug interactions in osteoporosis and Paget's diseases from SMILES

Referring to common skeletal-related diseases, osteoporosis and Paget's are two of the most frequently found diseases in the elderly. Nowadays, the combination of multiple drugs is the optimal therapy to decelerate osteoporosis and Paget's pathologic process, which contains various underlying adverse effects due to drug-drug interactions (DDIs). Artificial intelligence (AI) has the potential to evaluate the interaction, pharmacodynamics, and possible side effects between drugs. In this research, we created an AI-based machine-learning model to predict the outcomes of interactions between drugs used for osteoporosis and Paget's treatment, furthermore, to mitigate cost and time in implementing the best combination of medications in clinical practice. Our dataset was collected from the DrugBank database, and we then extracted a variety of chemical features from the simplified molecular-input line-entry system (SMILES) of defined drug pairs that interact with each other. Finally, machine-learning algorithms have been implemented to learn the extracted features. Our stack ensemble model from Random Forest and XGBoost reached an average accuracy of 74% in predicting DDIs. It was superior to individual models and previous methods in most measurement metrics. This study showed the potential of AI models in predicting DDIs of Osteoporosis-Paget's disease in particular, and other diseases in general.

Long-term effect of full-body pulsed electromagnetic field and exercise protocol in the treatment of men with osteopenia or osteoporosis: A randomized placebo-controlled trial

Background: Osteoporosis is the most prevalent metabolic disease affecting bones. Objective: To investigate the long-term effect of pulsed electromagnetic field (PEMF) combined with exercise protocol on bone mineral density (BMD) and bone markers in men with osteopenia or osteoporosis. Methods: Ninety-five males with osteopenia or osteoporosis (mean age, 51.26 ± 2.41 years; mean height, 176 ± 2.02 cm; mean weight, 83.08 ± 2.60 kg; mean body–mass index (BMI), 26.08 ± 1.09 kg/m ²) participated in the study, and they were randomly assigned to one of three groups: Group 1 received a full-body PEMF and exercise protocol (PEMF +EX), Group 2 received a placebo full-body PEMF and exercise protocol (PPEMF +EX), and Group 3 received a full-body PEMF alone (PEMF). PEMF was applied for the whole body using a full-body mat three times per week for 12 weeks, with an exercise protocol that includes flexibility, aerobic exercise, strengthening, weight-bearing, and balance exercises followed by whole-body vibration (WBV) training. Outcome measures include BMD of total hip and lumbar spine and bone markers [serum osteocalcin (s-OC), Serum amino-terminal cross-linking telopeptide of type I collagen (s-NTX), Serum carboxy-terminal cross-linking telopeptide of type I collagen (s-CTX), Parathyroid hormones (PTH), Bone-specific Alkaline Phosphatase (BSAP), and 25-hydroxy vitamin D (Vit D)]. Results: The BMD of total hip and lumbar spine was significantly increased post-treatment in all groups, and more so in Group 1 and Group 2 than Group 3. There was a significant difference in bone markers in all groups, more so in Group 1 and Group 2 than in Group 3. Conclusion: PEMF combined with exercise protocol exerts a potent role for treating OP, is more effective than exercise and PEMF alone for increasing BMD and enhancing bone formation, and suppresses bone-resorption markers after 12-weeks of treatment with the impact lasting up to 6 months.

Exercise vs Conventional Treatment for Treatment of Primary Osteoporosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

Physical exercise has obvious effects on bone loss, pain relief, and improvement of bone metabolism indexes in patients with osteoporosis, but currently lacks sufficient evidence. The aim of this systematic review and meta‐analysis was to synthesize and present the best available evidence on the effectiveness and safety of exercises in the treatment of primary osteoporosis.

Methods

Publications pertaining to the effectiveness of exercise on bone mineral density (BMD), visual analog scores (VAS), and biochemical markers of bone metabolism in primary osteoporosis (POP) from PubMed, Cochrane Library, Embase, VIP, CNKI, and Wanfang Database were retrieved from their inception to April 2020.

Results

A total of 20 studies with 1824 participants were included. The results of the meta‐analysis revealed that exercise therapy for lumbar spine and femoral neck BMD is statistically different from conventional therapy (lumbar spine BMD: SMD = 0.78, 95%CI: 0.46, 1.10, P < 0.00001, I² = 85%; femoral neck BMD (SMD = 0.80, 95%CI: 0.34, 1.27, P = 0.0007, I² = 88%), exercise therapy can significantly increase the lumbar spine BMD of patients with OP, especially in lumbar spine2‐4 BMD (SMD = 0.47; 95%CI: 0.20, 0.75; P = 0.0008; I² = 69%). Compared with conventional treatment, kinesitherapy also has significant differences in alleviating the pain of POP patients (SMD = −1.39, 95%CI: −2.47,−0.31, P = 0.01, I² = 97%). Compared with conventional therapy, kinesitherapy has no significant difference in improving biochemical markers of bone metabolism such as bone glaprotein (BGP) (SMD = 2.59, 95%CI:0.90, 4.28, P = 0.003, I² = 98%), N‐terminal pro peptide of type I procollagen (PINP) (SMD = 0.77, 95%CI: −0.44 to 1.98, P = 0.21, I² = 95%), serum phosphorus (SMD = 0.04, 95%CI: −0.13, 0.22, P = 0.61, I² = 30%), alkaline phosphatase (ALP) (SMD = −0.08, 95%CI: −0.44, 0.27, P = 0.64, I² = 76%), and serum calcium (SMD = 0.12, 95%CI: −0.18, 0.43, P = 0.42, I² = 63%) in POP patients.

Conclusions

Kinesitherapy significantly improved lumbar spine and femoral neck BMD, and relieve the pain of patients in the current low‐quality evidence. Additional high‐quality evidence is required to confirm the effect of exercise therapy on the biochemical markers of bone metabolism in POP patients.

Promising application of Pulsed Electromagnetic Fields (PEMFs) in musculoskeletal disorders

Increasing evidence suggests that an exogenous electromagnetic field might be involved in many biologic processes which are of great importance for therapeutic interventions. Pulsed electromagnetic fields (PEMFs) are known to be a noninvasive, safe and effective therapy agent without apparent side effects. Numerous studies have shown that PEMFs possess the potential to become a stand-alone or adjunctive treatment modality for treating musculoskeletal disorders. However, several issues remain unresolved. Prior to their widely clinical application, further researches from well-designed, high-quality studies are still required to standardize the treatment parameters and derive the optimal protocol for health-care decision making. In this review, we aim to provide current evidence on the mechanism of action, clinical applications, and controversies of PEMFs in musculoskeletal disorders.

Calcium Intake from Food and Supplemental Sources Decreased in the Canadian Population from 2004 to 2015

BACKGROUND

In light of the publications (2008-2014) linking calcium intake, mainly from supplements, to the elevated risk of cardiovascular events, there is a need to determine if there have been any changes in usual intakes of calcium among Canadians.

OBJECTIVE

We aimed to examine changes in dietary and total usual intake of calcium among Canadians aged ≥1 y over the period 2004-2015.

METHODS

We used nutrition data from 2 nationally representative surveys conducted in 2004 and 2015 (CCHS 2004 Cycle 2.2 and CCHS-Nutrition 2015). This study included all the Canadians across 10 provinces, and the analyses were performed across different age/sex groups. We used the National Cancer Institute (NCI) method to estimate the usual intake of calcium and the prevalence of calcium inadequacy. Multiple logistic regression was performed to assess the relation between supplement uses and sociodemographic variables.

RESULTS

From 2004 to 2015, the usual intake of calcium from food sources significantly decreased in calcium supplement nonusers (from 872 ± 18.2 mg/d to 754 ± 18.0 mg/d), but not in calcium supplement users. The contribution of calcium from the Milk and alternatives food group significantly decreased by 7.5% and 6.1% in calcium supplement users and nonusers, respectively. The prevalence of calcium supplement use significantly decreased from 2004 to 2015 in the Canadian population, from 27.5% to 22.0%. During this time, the percentage contribution of calcium from supplemental sources significantly decreased among Canadians, especially women. The prevalence of calcium inadequacy increased from 58.0% to 68.0% in supplement nonusers; however, among users of calcium supplements, the prevalence of calcium inadequacy remained at ∼31%.

CONCLUSIONS

Calcium intake from both food and supplemental sources decreased in the Canadian population over an 11-y period, which must be addressed by policy-makers in their efforts to decrease the high prevalence of calcium inadequacy.

Drug treatment strategies for osteoporosis in stroke patients

INTRODUCTION

Osteoporosis and subsequent fractures are well-recognized complications of stroke. However, drug treatment strategies for osteoporosis after stroke have been rarely discussed in the current guidelines for the management of stroke or osteoporosis.

AREAS COVERED

The authors review the epidemiology, characteristics, pathophysiology, and risk prediction of post-stroke osteoporosis and fractures. Then they provide an overview of existing evidence regarding drug treatment strategies for osteoporosis in stroke patients. They also review the effects on bone mineral density (BMD) and fractures for those drugs commonly used in stroke patients.

EXPERT OPINION

Currently, there is scarce evidence. A small randomized control trial suggested that a single use of 4 mg of intravenous zoledronate within 5 weeks of stroke onset was beneficial for preserving BMD, while simultaneous use of calcium and vitamin D supplements may be effective in preventing hypocalcemia. Further studies are needed to address several important issues of post-stroke osteoporosis, including who (the eligibility for treatment), when (the best timing of treatment), what (which drug), and how long (the best duration of treatment). On the other hand, physicians should bear in mind that drugs commonly used for stroke, such as statins or warfarin, may have beneficial or adverse effects on BMD and fracture risks.

Bisphosphonate's Effect on Tongue Mucosa: An Experimental Electron Microscopy Study

BACKGROUND AND OBJECTIVES

Bisphosphonates (BPs) are selective inhibitors of osteoclasts, used for the treatment of bone disorders. The objective of this study is to investigate the possible effects of BPs on the tongue's mucosa.

MATERIALS AND METHODS

Specimens of the tongue of 20 female 12-month old Wistar rats were taken. Ten were used as control group, while in the remaining alendronate (Fosamax, Merck) was administered per os from 13 weeks. Observation of the harvested samples was made by Transmission Electron Microscopy (TEM).

RESULTS

In the experimental group, focal alterations were observed to various extent in all specimens. The basement membrane was intact. Furthermore, an increase at the intercellular space was observed, predominantly at the middle layer, and the desmosomes were disorganized. In the lamina propria focal edema was observed.

CONCLUSIONS

Investigation on the effect of BPs on the tongue's mucosa through TEM hasn't been documented in the past. According to our results, BPs seem to cause mild mucosal lesions on the tongue.

Evidence of patient beliefs, values, and preferences is not provided in osteoporosis clinical practice guidelines

We examined how patient beliefs, values, and preferences (BVPs) were included and conceptualized in international osteoporosis guidelines. The majority of guidelines did not mention BVPs. When mentioned, BVPs were conceptualized as preference for one medication over another. A broader conceptualization and inclusion of BVPs should be incorporated in osteoporosis guidelines.

INTRODUCTION

Our objectives were to determine (1) the extent to which osteoporosis guidelines reflected patients' beliefs, values, and preferences (BVPs); (2) how BVPs were conceptualized; and (3) the methods used to elicit BVPs in the references cited by the guidelines.

METHODS

We conducted a document analysis of English-language international osteoporosis guidelines based on the International Osteoporosis Foundation website. We examined each guideline and extracted all instances of statements pertaining to BVPs. The statements were reviewed by two independent researchers. Discrepancies in data extraction were resolved by the first author. We developed categories based on five common elements that represented the BVP statements.

RESULTS

Twenty-seven of 70 (39%) guidelines included 95 statements about patient BVPs. Of the 95 statements, 32 statements (14 guidelines) were classified under BVP related to the choice of pharmacotherapy or general treatment, 10 (7 guidelines) under BVP related to adherence to pharmacotherapy or treatment in general, 5 (5 guidelines) under BVP related to financial costs and benefits, 43 (19 guidelines) under other BVP mentioned but not supported by a reference to a primary study or systematic review, and 5 (3 guidelines) under other BVP mentioned and supported by at least one reference to a primary study or systematic review. Twenty-nine references were cited to reflect the BVPs mentioned, including an editorial and quantitative studies.

CONCLUSIONS

Twenty-seven (39%) of the guidelines included mention of patients' BVPs. In 19 guidelines, the importance of BVPs was mentioned but these statements were not supported by references to a primary study or systematic review. BVPs were most often (14 guidelines) conceptualized as preference for one medication over another. We suggest that qualitative data be included as evidence of BVPs in guidelines.

Supplemental calcium intake in the aging individual: implications on skeletal and cardiovascular health

Adequate calcium intake during childhood is necessary to achieve optimal peak bone mass and this has the potential by increasing bone reserves, to modulate the rate of age-associated bone loss. However, data regarding the efficacy of calcium obtained either through the diet or in the form of medicinal supplementation, for prevention of bone loss and osteoporotic fractures in the elderly is conflicting. Calcium alone is unlikely to be of benefit for this purpose though the co-administration of calcium and vitamin D may have modest fracture risk benefits. Supplemental calcium with or without vitamin D has recently come into the spotlight after the publication of the findings from a controversial randomized controlled trial that associated calcium supplementation with an increased risk of myocardial infarction. Since then, multiple studies have explored this potential link. The data remains conflicting and the potential mechanistic link if any exists, remains elusive. This review examines the relationship between supplemental calcium intake and skeletal and cardiovascular health in the aging individual through an appraisal of studies done on the subject in the last three decades. It also briefly details some of the studies evaluating fractional absorption of calcium in the elderly and the rationale behind the current recommended dietary allowances of calcium.

Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.

Anemarrhena asphodeloides Bunge ameliorates osteoporosis by suppressing osteoclastogenesis

Anemarrhena asphodeloides Bunge has been traditionally used in Korean medicine for its antipyretic, diuretic, sedative, and antitussive effects. In the present study, the effects of an ethanol extract of A. asphodeloides Bunge (AAB) on osteoporosis and its underlying mechanisms on bone remodeling were investigated. Osteoporosis was induced in ICR strain mice by ovariectomy. The mice were divided into four groups: sham, ovariectomized, 17β‑estradiol and 100 mg/kg AAB. The treatment was continued for 4 weeks. Bone mineral density (BMD) and bone mineral content (BMC) were measured using dual‑energy X‑ray absorptiometry. In addition, Raw 264.7 cells were treated in the presence of 0.1, 1 and 10 µg/ml AAB with 100 ng/ml receptor activator of nuclear factor κΒ ligand (RANKL) to induce osteoclast formation and stained with tartrate resistant acid phosphatase. In addition, levels of osteoclast‑related factors were analyzed to investigate the signaling cascades in osteoclasts. The results demonstrated that AAB treatment reversed the decreases of both BMD and BMC in osteoporotic femurs. Additionally, the formation of osteoclasts was significantly suppressed by the AAB treatment in RANKL‑stimulated Raw 264.7 cells. Compared with cells treated with RANKL alone, the AAB‑treated osteoclasts had significantly decreased tumor necrosis factor‑α and interleukin‑6. The protein levels of c‑fos were also decreased in the AAB‑treated osteoclasts. Furthermore, the RANKL‑induced nuclear translocation of nuclear factor‑κB was attenuated in osteoclasts by the AAB treatment compared with cells treated with RANKL alone. Finally, AAB treatment downregulated the phosphorylation of mitogen‑activated protein kinases. The present results demonstrated that AAB exhibited ameliorative effects on osteoporosis by inhibiting osteoclastogenesis, and suggested that AAB may be a potential candidate for the treatment of osteoporosis.

Effect of Strontium Ranelate on the Muscle and Vertebrae of Ovariectomized Rats

Osteoporosis is often accompanied by sarcopenia. The effect of strontium ranelate (SR) on muscle tissue has not been investigated sufficiently. In this study, the effect of different SR treatments on muscle was studied. Additionally, the lumbar vertebrae were analyzed. Three-month-old female rats were divided into five groups (n = 12): Group 1: untreated (NON-OVX); Group 2: ovariectomized and left untreated (OVX); Group 3: SR after OVX until the study ended (13 weeks, SR prophylaxis and therapy = pr+th); Group 4: OVX and SR for 8 weeks (SR prophylaxis = pr); Group 5: SR for 5 weeks from the 8 week after OVX (SR therapy = SR th). SR was applied in food (630 mg/kg body weight). The size of muscle fibers, capillary density, metabolic enzymes, and mRNA expression were assessed in soleus, gastrocnemius, and longissimus muscles. The vertebral bodies underwent micro-CT, biomechanical, and ashing analyses. In general, SR did not alter the muscle histological parameters. The changes in fiber size and capillary ratio were related to the body weight. Myostatin mRNA was decreased in Sr pr+th; protein expression was not changed. SR th led to increase in mRNA expression of vascular endothelial growth factor (Vegf-B). In lumbar spine, SR pr+th enhanced biomechanical properties, bone mineral density, trabecular area, density, and thickness and cortical density. The reduced calcium/phosphate ratio in the SR pr+th group indicates the replacement of calcium by strontium ions. SR has no adverse effects on muscle tissue and it shows a favorable time-dependent effect on vertebrae. A functional analysis of muscles could verify these findings.

Vitamin D and Age-Related Macular Degeneration

In recent years, the relationship between vitamin D and health has received growing attention from the scientific and medical communities. Vitamin D deficiencies have been repeatedly associated with various acute and chronic diseases, including age-related macular degeneration (AMD). Its active metabolite, 1α,25-dihydoxy vitamin D, acts as a modulator of cell proliferation, differentiation and apoptosis, and cumulative data from experimental and observational studies suggest that relatively a lower vitamin D status could be a potential risk factor for the development of early and/or late AMD. Herein, we made a narrative review of the mechanisms linking a potential role of vitamin D with the current concepts of AMD pathophysiology.

Advanced glycation end products and strontium ranelate promote osteogenic differentiation of vascular smooth muscle cells in vitro: Preventive role of vitamin D

Advanced glycation end products (AGE) have been demonstrated to induce the osteogenic trans-differentiation of vascular smooth muscle cells (VSMC). Strontium ranelate (SR) is an anti-osteoporotic agent that has both anti-catabolic and anabolic actions on bone tissue. However, in the last years SR has been associated with an increase of cardiovascular risk. We hypothesize that SR can increase the osteoblastic trans-differentiation of VSMC and the induction of extracellular calcifications, an effect that could be potentiated in the presence of AGE and inhibited by simultaneous administration of vitamin D. The present results of our in vitro experiments demonstrate that AGE and SR alone or in combination, stimulate L-type calcium channels, causing an increase in reactive oxygen species and activation of both ERK and NFkB, with the final effect of promoting the osteogenic shift of VSMC. Importantly, these in vitro effects of AGE and/or SR can be prevented by co-incubation with vitamin D.

Parathyroid hormone and vitamin D are associated with the risk of metabolic obesity in a middle-aged and older Korean population with preserved renal function: A cross-sectional study

BACKGROUND

In general, obesity is a major contributor to metabolic syndrome (MetS) and is associated with insulin resistance (IR). Metabolically obese but normal weight (MONW) individuals present metabolic abnormalities and features of MetS despite having a normal range of body mass index (BMI). In recent years, different subtypes of obesity have been introduced, including metabolically healthy obese (MHO) and metabolically obese obese (MOO). Also, it has been reported that vitamin D and parathyroid hormone (PTH) are possibly linked with MetS.

METHODS AND FINDINGS

In this study, we aimed to evaluate the association between serum 25(OH)D, serum PTH, and the risk of metabolic obesity in four subtypes using nationally representative survey data for a Korean population conducted between 2008 and 2010. Of the 29,235 Korean participants, 18,997 subjects aged under 50 years were excluded. Participants with diabetes (n = 1,520), renal insufficiency (glomerular filtration rate [GFR] < 45 ml/min/1.73 m2, chronic kidney disease [CKD] stage 3b, 4, and 5 according to KDOQI classification [1]) (n = 49), history of treatment for osteoporosis (n = 455), insufficient data (n = 1,613), and fasting time less than 8 hours prior to blood collection (n = 771) were excluded for analysis. Ultimately, 5,830 adults (2,582 men and 3,248 women) were eligible for the present study. And, subtypes of obesity were divided into four types: Metabolically healthy normal weight (MHNW), Metabolically healthy obese (MHO), Metabolically obese but normal weight (MONW), and Metabolically obese obese (MOO). Female subjects with metabolic obesity were more likely to have higher levels of PTH and Male subjects with metabolic health were more likely to have higher serum 25(OH)D levels.

CONCLUSION

We concluded that a positive association between serum PTH concentration and metabolic obesity among female subjects and an inverse relationship between serum 25(OH)D levels and the risk of metabolic obesity were found among male subjects. Further prospective studies are necessary to explore the biological mechanisms underlying these sex-specific findings.

Calcium intake: good for the bones but bad for the heart? An analysis of clinical studies

The proper dietary calcium intake and calcium supplementation, when indicated, are important factors in the acquisition of peak bone mass during youth and in the prevention of fractures in old age. In addition to its deposition in bone, calcium confers an increase in its resistance and exhibits important activities in different enzymatic pathways in the body (e.g., neural, hormonal, muscle-related and blood clotting pathways). Thus, calcium supplementation can directly or indirectly affect important functions in the body, such as the control of blood pressure, plasma glucose, body weight, lipid profile and endothelial function. Since one publication reported increased cardiovascular risk due to calcium supplementation, many researchers have studied whether this risk actually exists; the results are conflicting, and the involved mechanisms are uncertain. However, studies that have evaluated the influence of the consumption of foods rich in calcium have reported no increase in the cardiovascular risk, which suggests that nutritional intake should be prioritized as a method for supplementation and that the use of calcium supplements should be reserved for patients who truly need supplementation and are unable to achieve the recommended daily nutritional intake of calcium.

Impact and risk factors of post-stroke bone fracture

Bone fracture occurs in stroke patients at different times during the recovery phase, prolonging recovery time and increasing medical costs. In this review, we discuss the potential risk factors for post-stroke bone fracture and preventive methods. Most post-stroke bone fractures occur in the lower extremities, indicating fragile bones are a risk factor. Motor changes, including posture, mobility, and balance post-stroke contribute to bone loss and thus increase risk of bone fracture. Bone mineral density is a useful indicator for bone resorption, useful to identify patients at risk of post-stroke bone fracture. Calcium supplementation was previously regarded as a useful treatment during physical rehabilitation. However, recent data suggests calcium supplementation has a negative impact on atherosclerotic conditions. Vitamin D intake may prevent osteoporosis and fractures in patients with stroke. Although drugs such as teriparatide show some benefits in preventing osteoporosis, additional clinical trials are needed to determine the most effective conditions for post-stroke applications.

Ostericum koreanum Reduces LPS-Induced Bone Loss Through Inhibition of Osteoclastogenesis

The roots of Ostericum koreanum (OK) Maximowicz have traditionally been used to produce an herbal medicine reported to possess anti-inflammatory, anti-oxidant, antimicrobial, and antitumor activities; however, its effect on bone metabolism has not yet been reported. The present study examined the effects of OK extract on lipopolysaccharide (LPS)-induced bone loss in mice by investigating bone structure and the levels of the receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) in serum and bone marrow fluid (BMF). The effects of OK extract on osteoclastogenesis were also investigated in mouse bone marrow macrophages by examining the formation of tartrate-resistant acid phosphatase (TRAP)-positive cells, the actin ring, and bone resorption activity. OK reduced LPS-induced bone destruction in vivo via a decrease in the RANKL/OPG ratio. Furthermore, it suppressed the formation of TRAP-positive cells and the actin ring, and reduced the bone-resorbing activity of mature osteoclasts. OK also significantly down-regulated the expression of various osteoclast-specific genes. However, it did not affect osteoblast differentiation, or the expression of genes involved in this process. These results demonstrated that OK prevented LPS-induced bone loss by decreasing the RANKL/OPG ratio in serum and BMF, and inhibited osteoclast differentiation and function, suggesting that OK represents a potential therapeutic drug for the treatment of osteoclast-associated bone diseases.

The impact of preadmission oral bisphosphonate use on 30-day mortality following stroke: a population-based cohort study of 100,043 patients

Purpose

Bisphosphonate use has been associated with increased risk of fatal stroke. We examined the association between preadmission use of oral bisphosphonates and 30-day mortality following hospitalization for stroke.

Patients and methods

We conducted a nationwide population-based cohort study using medical databases and identified all patients in Denmark with a first-time hospitalization for stroke between 1 July 2004 and 31 December 2012 (N=100,043). Cox regression was used to compute adjusted hazard ratios as a measure of 30-day mortality rate ratios (MRRs) associated with bisphosphonate current use (prescription filled within 90 days prior to the stroke) or recent use (prescription filled in the 90–180 days prior to the stroke). Current use was further classified as new or long-term use.

Results

We found 51,982 patients with acute ischemic stroke (AIS), 11,779 with intracerebral hemorrhage (ICH), 4,528 with subarachnoid hemorrhage (SAH), and 31,754 with unspecified stroke. Absolute 30-day mortality risks were increased among current vs nonusers of bisphosphonates for AIS (11.9% vs 8.5%), ICH (43.2% vs 34.5%), SAH (40.3% vs 23.2%), and unspecified strokes (18.8% vs 14.0%). However, in adjusted analyses, current bisphosphonate use did not increase 30-day mortality from AIS (MRR, 0.87; 95% confidence interval [CI]: 0.75, 1.01); ICH (MRR, 1.05; 95% CI: 0.90, 1.23); SAH (MRR, 1.15; 95% CI: 0.83, 1.61); or unspecified stroke (MRR, 0.94; 95% CI: 0.81, 1.09). Likewise, no association with mortality was found for recent use. Adjusted analyses by type of bisphosphonate showed increased mortality following stroke among new users of etidronate (MRR, 1.40; 95% CI: 1.01, 1.93) and reduced mortality after AIS among current users of alendronate (MRR, 0.87; 95% CI: 0.74, 1.02).

Conclusion

We found no overall evidence that preadmission bisphosphonate use increases 30-day mortality following stroke.

Associations between calcium and vitamin D supplement use as well as their serum concentrations and subclinical cardiovascular disease phenotypes

BACKGROUND

Supplementation of calcium (Ca) and vitamin D for the prevention of osteoporosis is frequently found in Western countries. Recent re-analyses of clinical trials observed a higher risk of myocardial infarction and stroke in subjects taking Ca (+vitamin D) supplements, although the underlying mechanisms are not clear.

OBJECTIVE

Thus, we analyzed the associations between Ca and vitamin D supplementation as well as serum concentrations of Ca and 25-hydroxyvitamin D (25(OH)D) and subclinical cardiovascular disease (CVD) phenotypes, namely intima-media thickness, ankle-brachial-index (ABI), intermittent claudication, and atrial fibrillation (AF).

DESIGN

Data of 1601 participants aged 50-81 years of the population-based cross-sectional Cooperative Health Research in the Region of Augsburg (KORA) F4 study in Germany were analyzed. Logistic and linear regression models were used to estimate odds ratios (OR) (95% confidence intervals (CI)) and β-estimates (p-values), respectively.

RESULTS

Regular Ca supplementation showed a significant positive association with the presence of AF after multivariable adjustment (OR = 3.89; 95% CI 1.28-11.81). Higher serum 25(OH)D concentrations were independently associated with a lower prevalence of asymptomatic peripheral arterial disease as assessed by ABI measurements (β = 0.007; p = 0.01). No other significant associations between supplementation or serum concentrations of Ca or vitamin D and CVD phenotypes were identified.

CONCLUSIONS

Although based on few cases the finding of a significant higher prevalence of AF in Ca supplement users hints at one possible mechanism that may contribute to an increased risk of myocardial infarction and stroke. The observed association between serum 25(OH)D and ABI supports results from other studies.

Strontium ranelate inhibits titanium-particle-induced osteolysis by restraining inflammatory osteoclastogenesis in vivo

Wear-particle-induced osteolysis is considered to be the main reason for revision after arthroplasty. Although the exact mechanism remains unclear, inflammatory osteoclastogenesis plays an important role in this process. Strontium ranelate (SR) was found to have a therapeutic effect on osteoporosis in postmenopausal women. Based on prior studies, the present authors hypothesized that SR prevents wear-particle-induced osteolysis through restraining inflammatory osteoclastogenesis. The present study used 80 male C57BL/J6 mice to test this hypothesis in a murine osteolysis model. All experimental animals were randomly divided into four groups: a control group; a SR group; a titanium group; and a titanium+SR group. Once titanium particles had been implanted in mice, the mice were administered SR (900 mg kg(-1) day(-1)) by gavage for 14 days. After 14 days, the calvaria were collected for micro-computed tomography (μCT), histological and molecular analysis. The results of μCT and histomorphometric analysis demonstrated that SR markedly inhibited bone resorption and the generation of tartrate-resistant acid-phosphatase-positive cells in vivo, compared with titanium-stimulated calvaria. Reverse transcription polymerase chain reaction and ELISAs showed that SR stimulated the mRNA and protein expression of osteoprotegerin, and inhibited gene and protein expression of receptor activators of nuclear factor-kappa B ligand in titanium-particle-charged calvaria. In addition, SR obviously reduced the secretion of tumor necrosis factor-α and interleukin-1β in the calvaria of the titanium group. It was concluded that SR inhibits titanium-induced osteolysis by restraining inflammatory osteoclastogenesis, and that it could be developed as a new drug to prevent and treat aseptic loosening.

A review of lifestyle, smoking and other modifiable risk factors for osteoporotic fractures

Although many strong risk factors for osteoporosis-such as family history, fracture history and age-are not modifiable, a number of important risk factors are potential targets for intervention. Thus, simple, non-pharmacological intervention in patients at increased risk of osteoporotic fractures could include reduction of excessive alcohol intake, smoking cessation, adequate nutrition, patient education, daily physical activity and a careful review of medications that could increase the risk of falls and fractures. There remains, however, an unmet need for high-quality intervention studies in most of these areas.

National health programs in the field of endocrinology and metabolism - Miles to go

The endocrine and metabolic diseases of childhood obesity, diabetes mellitus, hypertension, iodine deficiency disorders, vitamin D deficiency, and osteoporosis are major public health problems. Different programs including National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke address these problems although some are yet to be addressed. National surveys have shown high prevalence of these disorders and their risk factors. Most of the programs aim at awareness raising, lifestyle modification, (primary prevention) and screening (secondary prevention) for the disease conditions as these are proven to be cost-effective compared to late diagnosis and treatment of various complications. Urgent concerted full scale implementation of these programs with good coordination under the umbrella of National Rural Health Mission is the need of the moment. The referral system needs strengthening as are the secondary and tertiary levels of health care. Due attention is to be given for implementation of these programs in the urban areas, as the prevalence of these conditions is almost equal or even higher among urban poor people where primary and secondary prevention measures are scarcely available and treatment costs are sky-high.

Pediatric nephrolithiasis and the link to bone metabolism

PURPOSE OF REVIEW

To review the recent publications describing the link between pediatric nephrolithiasis and bone metabolism.

RECENT FINDINGS

Nephrolithiasis incidence is increasing in children and is associated with low bone mineral density (BMD). Affected children are conceptually at risk for fractures and osteoporosis. In addition to abnormal calcium metabolism, inflammation, genetic makeup and dietary habits are being recognized as important factors in the pathophysiology of nephrolithiasis and low bone density. Findings from retrospective reviews suggest that low BMD in children may be improved with citrate or thiazide treatment.

SUMMARY

The healthcare burden from low BMD with subsequent osteoporosis and fracture risk is immense with potential far-reaching effects in patient quality of life and healthcare expense. Bone mass is acquired in the pediatric age range, thus it is important to identify and treat at-risk children. Retrospective reviews in pediatric patients indicate that citrate or thiazide diuretic treatment may improve BMD. We now understand that a relationship exists between nephrolithiasis and low BMD. To improve healthcare for our current patients as well as protect their future health it is important to identify low BMD and initiate strategies to improve BMD in 'at-risk' children.

Vitamin D and the cardiovascular system: an overview of the recent literature

Since the discovery that the enzyme catalyzing the synthesis of the most active natural vitamin D metabolite(calcitriol) and the vitamin D-specific receptor (VDR)were expressed in a wide range of tissues and organs, not only involved in the mineral metabolism (MM), there has been increasing interest on the putative ‘non classical’ roles of vitamin D metabolites, particularly on their possible effects on the cardiovascular (CV) system. These hypothetical CV effects of vitamin D gained particular interesting the nephrology field, given the high prevalence of CV disease in patients affected by either acute or chronic kidney diseases. However, notwithstanding a huge amount of experimental data suggesting a possible protective role of vitamin D on the CV system, the conclusions of two recent meta-analyses from the Cochrane group and a recent statement from the Institute of Medicine, based on a complete revision of the available data, concluded that there is no clear evidence for a role of vitamin D other than that strictly associated with bone health. However, a continuous and increasing flow of new studies still continues to add information on this topic. In the present review, we have tried to critically address the data added on this topicin the last 2 years, considering separately the experimental,observational, and intervention studies that have appeared in PubMed in the last 2 years, discussing the data providing proof, pro or contra, the involvement of vitamin D in CV disease, both in the absence or presence of kidney function impairment.

Osteoporosis in postmenopausal women: considerations in prevention and treatment: (women's health series)

Osteoporosis, the most common human bone disease, affects 8 million American women and has significant morbidity and mortality. Screening is important in older women and younger postmenopausal women with additional risk factors for osteoporosis/fracture. Preventive measures include avoiding smoking, excessive alcohol/caffeine intake, and falls in addition to maintaining adequate calcium/vitamin D intake and exercise. Estrogen/hormone therapy may be considered in some patients. Various medications have proven efficacy in treating postmenopausal osteoporosis; however, potential adverse effects such as hypocalcemia, worsening of renal impairment, and osteonecrosis of the jaw must be considered. The optimal duration of therapy requires further investigation.

Methanol Extract of Euchelus asper Prevents Bone Resorption in Ovariectomised Mice Model

Marine molluscs are widely distributed throughout the world and many bioactive compounds exhibiting antiviral, antitumor, antileukemic, and antibacterial activity have been reported worldwide. The present study was designed to investigate the beneficial effect of methanol extract of Euchelus asper (EAME) on estrogen deficiency induced osteoporosis in ovariectomised mice model. Forty-two female Swiss albino mice were randomly assigned into Sham operated (Sham) group and six ovariectomised (OVX) subgroups such as OVX with vehicle (OVX); OVX with estradiol (2 mg/kg/day); OVX with EAME of graded doses (25, 50, 100, and 200 mg/kg/day). Bone turnover markers like serum alkaline phosphatase (ALP), serum acid phosphatase (ACP), serum calcium, and histological investigations of tibia and uterus were analysed. Metaphyseal DNA content of the femur bone was also studied. Antiosteoclastogenic activity of EAME was examined. Administration of EAME was able to reduce the increased bone turnover markers in the ovariectomised mice. Histomorphometric analysis revealed an increase in bone trabeculation and restoration of trabecular separation by EAME treatment. Metaphyseal DNA content of the femur of the OVX mice was increased by EAME administration. EAME also showed a potent antiosteoclastogenic behaviour. Thus, the present study reveals that EAME was able to successfully reduce the estrogen deficiency induced bone loss.

Poststroke hip fracture: prevalence, clinical characteristics, mineral-bone metabolism, outcomes, and gaps in prevention

Objective. To assess the prevalence, clinical and laboratory characteristics, and short-term outcomes of poststroke hip fracture (HF). Methods. A cross-sectional study of 761 consecutive patients aged ≥60 years (82.3 ± 8.8 years; 75% females) with osteoporotic HF. Results. The prevalence of poststroke HF was 13.1% occurring on average 2.4 years after the stroke. The poststroke group compared to the rest of the cohort had a higher proportion of women, subjects with dementia, history of TIA, hypertension, coronary artery disease, secondary hyperparathyroidism, higher serum vitamin B12 levels (>350 pmol/L), walking aid users, and living in residential care facilities. The majority of poststroke HF patients had vitamin D insufficiency (68%) and excess bone resorption (90%). This group had a 3-fold higher incidence of postoperative myocardial injury and need for institutionalisation. In multivariate analysis, independent indicators of poststroke HF were female sex (OR 3.6), history of TIA (OR 5.2), dementia (OR 4.1), hypertension (OR 3.2), use of walking aid (OR 2.5), and higher vitamin B12 level (OR 2.3). Only 15% of poststroke patients received antiosteoporotic therapy prior to HF. Conclusions. Approximately one in seven HFs occurs in older stroke survivors and are associated with poorer outcomes. Early implementation of fracture prevention strategies is needed.

New reference values for calcium

The nutrition societies of Germany, Austria and Switzerland are the joint editors of the 'reference values for nutrient intake'. They have revised the reference values for the intake of calcium and published them in June 2013. The reference values for the calcium intake for infants are derived from the calcium content of breast milk. For infants from 4 to <12 months of age, the calcium intake from solid foods is included in addition to the calcium intake from breast milk. Thus, the reference values for infants are estimated values; they are 220 mg/day for infants to <4 months and 330 mg/day for infants from 4 to <12 months of age. As a parameter for determining the calcium requirement in children and adolescents, calcium retention is taken into account. The average requirement is calculated by the factorial method. A balanced calcium metabolism is calculated based upon calcium balance studies and used as a parameter for the determination of the calcium requirement in adults. On the basis of the average requirement, recommended calcium intake levels for children, adolescents and adults are derived. Depending on age, the recommended calcium intake ranges between 600 mg/day for children aged 1 to <4 years and 1,200 mg/day for adolescents aged 13 to <19 years; for adults, it is 1,000 mg/day.

Quality of life in sarcopenia and frailty

The reduced muscle mass and impaired muscle performance that define sarcopenia in older individuals are associated with increased risk of physical limitation and a variety of chronic diseases. They may also contribute to clinical frailty. A gradual erosion of quality of life (QoL) has been evidenced in these individuals, although much of this research has been done using generic QoL instruments, particularly the SF-36, which may not be ideal in older populations with significant comorbidities. This review and report of an expert meeting presents the current definitions of these geriatric syndromes (sarcopenia and frailty). It then briefly summarizes QoL concepts and specificities in older populations and examines the relevant domains of QoL and what is known concerning QoL decline with these conditions. It calls for a clearer definition of the construct of disability, argues that a disease-specific QoL instrument for sarcopenia/frailty would be an asset for future research, and discusses whether there are available and validated components that could be used to this end and whether the psychometric properties of these instruments are sufficiently tested. It calls also for an approach using utility weighting to provide some cost estimates and suggests that a time trade-off study could be appropriate.

2013 Up-date of the consensus statement of the Spanish Menopause Society on postmenopausal osteoporosis

Postmenopausal osteoporosis is a major female health problem that increases morbidity, mortality and healthcare system costs. Considering that gynecologists are the primary health practitioners involved in the treatment of women with osteoporosis in our country, a panel of experts from the Spanish Menopause Society met to establish a set of criteria and procedures for the diagnosis and treatment of this disease based on the best available evidence and according to the model proposed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to elaborate clinical practice guidelines and to classify the quality of the evidence and the strength of the recommendations. These recommendations should be a reference to gynecologist and other health professionals involved in the treatment of postmenopausal women.

Safety concerns with the long-term management of osteoporosis

INTRODUCTION

Postmenopausal osteoporosis is a chronic disease that exerts a significant burden on both individuals and the community. Hence, there is a requirement for long-term treatment to be associated with a positive benefit-risk balance.

AREAS COVERED

In this descriptive review, the long-term safety of calcitonin, selective estrogen receptor modulators (SERMs), bisphosphonates, denosumab and strontium ranelate was reviewed based on randomized controlled trials of 3 years or longer supplemented by extension study data and data from large, observational studies.

EXPERT OPINION

Rare adverse events become apparent with all currently available treatments for osteoporosis with long-term therapy. Due to the rarity of these adverse events and to the worldwide burden of osteoporosis, the benefit-risk balance remains in favor of the beneficial effects of treatment on an outcome rather than the probability of an adverse effect. No single antiosteoporosis agent is appropriate for all patients. Treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations.

Potential antiosteoporotic agents from plants: a comprehensive review

Osteoporosis is a major health hazard and is a disease of old age; it is a silent epidemic affecting more than 200 million people worldwide in recent years. Based on a large number of chemical and pharmacological research many plants and their compounds have been shown to possess antiosteoporosis activity. This paper reviews the medicinal plants displaying antiosteoporosis properties including their origin, active constituents, and pharmacological data. The plants reported here are the ones which are commonly used in traditional medical systems and have demonstrated clinical effectiveness against osteoporosis. Although many plants have the potential to prevent and treat osteoporosis, so far, only a fraction of these plants have been thoroughly investigated for their physiological and pharmacological properties including their mechanism of action. An attempt should be made to highlight plant species with possible antiosteoporosis properties and they should be investigated further to help with future drug development for treating this disease.

Heart failure as a risk factor for osteoporosis and fractures

Although heart failure (HF) and osteoporosis are common diseases, particularly in elderly populations, patients with HF have an increased risk for osteoporosis. The relationship of HF with osteoporosis is modified by gender and the severity of HF. In addition, shared risk factors, medication use, and common pathogenic mechanisms affect both HF and osteoporosis. Shared risk factors for these 2 conditions include advanced age, hypovitaminosis D, renal disease, and diabetes mellitus. Medications used to treat HF, including spironolactone, thiazide diuretics, nitric oxide donors, and aspirin, may protect against osteoporosis. In contrast, loop diuretics may make osteoporosis worse. HF and osteoporosis appear to share common pathogenic mechanisms, including activation of the renin-angiotensin-aldosterone system, increased parathyroid hormone levels, and/or oxidative/nitrosative stress. HF is a major risk factor for mortality following fractures. Thus, in HF patients, it is important to carefully assess osteoporosis and take measures to reduce the risk of osteoporotic fractures.

Aromatase inhibitors-induced bone loss in early breast cancer

Women with breast cancer have an increased prevalence and incidence of fractures. This increased risk of fracture has become most evident following the use of aromatase inhibitors (AIs) as standard adjuvant therapy. AI-induced bone loss occurs at more than twice the rate of physiologic postmenopausal bone loss. Moreover, peripheral quantitative computed tomography data indicate that effects of AIs on bone strength and on cortical bone have been substantially underestimated by dual-energy X-ray absorptiometry. All AIs have been associated with an increased fracture risk. The incidence of fractures is at least 33-43% higher in AI-treated patients than in tamoxifen-treated patients, and this increase in fracture risk is maintained at least for the duration of AI therapy. Over the last few years, clinical trials have established the effectiveness of bisphosphonates and denosumab to preserve and even increase bone mineral density (BMD) during adjuvant AIs. Most data have been obtained with zoledronic acid administered twice a year, which effectively maintains or increases BMD in women receiving AIs. In addition, zoledronic acid has been shown to delay disease recurrence and maybe prolong survival in women with hormone-responsive tumors, thereby providing an adjuvant antitumor benefit besides preserving BMD. It is likely that a combined fracture risk assessment will more accurately identify women with breast cancer who require bone protective therapy. The FRAX tool probably underestimates the net increase in fracture risk due to AI therapy. Recent guidelines for the prevention of AI-induced bone loss have adequately considered the presence of several established clinical risk factors for fractures, in addition to BMD, when selecting patients to be treated with inhibitors of bone resorption.

Extract of Magnoliae Flos inhibits ovariectomy-induced osteoporosis by blocking osteoclastogenesis and reducing osteoclast-mediated bone resorption

Bone homeostasis is maintained by a balance between bone resorption by osteoclasts and bone formation by osteoblasts. Osteoporosis occurs when osteoclast activity surpasses osteoblast activity. Pro-inflammatory cytokines stimulate osteoclast differentiation and activity by increasing production of macrophage-colony stimulating factor and receptor activator of nuclear factor-κB ligand (RANKL). In this study, we investigated whether Magnoliae Flos (MF), one of the most commonly used Chinese medicinal herbs for managing rhinitis, sinusitis and headache, could effectively inhibit osteoporosis. In ovariectomized (OVX) mice compared to sham mice, the body weight increased and serum levels of alkaline phosphatase (ALP), tartrate resistant acid phosphatase 5b, calcium, and osteocalcin were significantly elevated. However, orally administrated MF extract substantially inhibited the increased body weight and serum levels of bone turnover markers, without any evidence of tissue toxicity. MF extract treatment significantly reversed the morphometric parameters of ovariectomy-induced bone loss, including trabecular bone volume, thickness, number, separation, and bone density, to almost the same levels of the sham mice. Furthermore, MF extract reduced the RANKL-mediated osteoclast differentiation and bone resorption by inhibiting the activities of matrix metalloproteinases (MMPs) and cathepsin K in mouse bone marrow macrophages. MF extract appeared to increase ALP activity in murine osteoblastic cells. Taken together, MF extract may be a beneficial supplement for the blockade of osteoporosis progression, particularly for the management of postmenopausal osteoporosis.