Quantitative analysis of efficacy and associated factors of calcium intake on bone mineral density in postmenopausal women

Current status and challenges of model-informed drug discovery and development in China

In the past decade, biopharmaceutical research and development in China has been notably boosted by government policies, regulatory initiatives and increasing investments in life sciences. With regulatory agency acting as a strong driver, model-informed drug development (MIDD) is transitioning rapidly from an academic pursuit to a critical component of innovative drug discovery and development within the country. In this article, we provided a cross-sectional summary on the current status of MIDD implementations across early and late-stage drug development in China, illustrated by case examples. We also shared insights into regulatory policy development and decision-making. Various modeling and simulation approaches were presented across a range of applications. Furthermore, the challenges and opportunities of MIDD in China were discussed and compared with other regions where these practices have a more established history. Through this analysis, we highlighted the potential of MIDD to enhance drug development efficiency and effectiveness in China's evolving pharmaceutical landscape.

Joint longitudinal model-based meta-analysis of FEV1 and exacerbation rate in randomized COPD trials

Model-based meta-analysis (MBMA) is an approach that integrates relevant summary level data from heterogeneously designed randomized controlled trials (RCTs). This study not only evaluated the predictability of a published MBMA for forced expiratory volume in one second (FEV₁) and its link to annual exacerbation rate in patients with chronic obstructive pulmonary disease (COPD) but also included data from new RCTs. A comparative effectiveness analysis across all drugs was also performed. Aggregated level data were collected from RCTs published between July 2013 and November 2020 (n = 132 references comprising 156 studies) and combined with data used in the legacy MBMA (published RCTs up to July 2013 - n = 142). The augmented data (n = 298) were used to evaluate the predictive performance of the published MBMA using goodness-of-fit plots for assessment. Furthermore, the model was extended including drugs that were not available before July 2013, estimating a new set of parameters. The legacy MBMA model predicted the post-2013 FEV₁ data well, and new estimated parameters were similar to those of drugs in the same class. However, the exacerbation model overpredicted the post-2013 mean annual exacerbation rate data. Inclusion of year when the study started on the pre-treatment placebo rate improved the model predictive performance perhaps explaining potential improvements in the disease management over time. The addition of new data to the legacy COPD MBMA enabled a more robust model with increased predictability performance for both endpoints FEV₁ and mean annual exacerbation rate.

How do carbohydrate quality indices influence on bone mass density in postmenopausal women? A case-control study

BACKGROUND

Carbohydrates are the primary energy source in Asian countries, including Iran. An emerging method can be used to measure the quality of carbohydrates, including the carbohydrate quality index (CQI), which includes a variety of components. Low-carbohydrate diet score (LCDS) has been proposed as a new method of scoring micronutrient intake that could provide a reasonable explanation for the link between diet and the risk of chronic diseases.

OBJECTIVE

This study aimed to investigate the relationship between CQI, LCDS, glycemic index (GI), glycemic load (GL), insulin load (IL), and insulin index (II) with bone mass density (BMD) in postmenopausal women.

METHOD

In this case-control study, 131 postmenopausal women with osteoporosis/osteopenia and 131 healthy postmenopausal women aged 45-65 participated. The dual-energy X-ray absorptiometry (DEXA) method measured the BMD of the lumbar vertebrae and femoral neck. A validated semi-quantitative food frequency questionnaire was used to assess dietary intake. Logistic regression were used to evaluate the relation between GI, GL, II, IL, CQI, and LCDS with BMD.

RESULTS

Diets with higher GI increased the risk of osteopenia and osteoporosis, but LCDS and CQI decreased the risk of osteopenia and osteoporosis.

CONCLUSION

These findings suggest that a higher intake of fruits and vegetables and receiving various dietary vitamins, minerals, and antioxidant compounds may be a useful way to prevent osteopenia in Iranian women.

Applications of Model-Based Meta-Analysis in Drug Development

Model-based meta-analysis (MBMA) is a quantitative approach that leverages published summary data along with internal data and can be applied to inform key drug development decisions, including the benefit-risk assessment of a treatment under investigation. These risk-benefit assessments may involve determining an optimal dose compared against historic external comparators of a particular disease indication. MBMA can provide a flexible framework for interpreting aggregated data from historic reference studies and therefore should be a standard tool for the model-informed drug development (MIDD) framework.In addition to pairwise and network meta-analyses, MBMA provides further contributions in the quantitative approaches with its ability to incorporate longitudinal data and the pharmacologic concept of dose-response relationship, as well as to combine individual- and summary-level data and routinely incorporate covariates in the analysis.A common application of MBMA is the selection of optimal dose and dosing regimen of the internal investigational molecule to evaluate external benchmarking and to support comparator selection. Two case studies provided examples in applications of MBMA in biologics (durvalumab + tremelimumab for safety) and small molecule (fenebrutinib for efficacy) to support drug development decision-making in two different but well-studied disease areas, i.e., oncology and rheumatoid arthritis, respectively.Important to the future directions of MBMA include additional recognition and engagement from drug development stakeholders for the MBMA approach, stronger collaboration between pharmacometrics and statistics, expanded data access, and the use of machine learning for database building. Timely, cost-effective, and successful application of MBMA should be part of providing an integrated view of MIDD.

Quantitative Comparison of the Clinical Efficacy of 6 Classes Drugs for IgA Nephropathy: A Model-Based Meta-Analysis of Drugs for Clinical Treatments

Introduction

There is a wide variety of drugs for the clinical treatment of immunoglobulin A (IgA) nephropathy; however, previous studies have failed to clarify the quantitative differences in the efficacy of various drugs. In this study, we aimed to quantitatively compare the clinical efficacy of 6 classes of drugs with different pharmacological mechanisms for the treatment of IgA nephropathy and to identify relevant influencing factors.

Methods

Clinical trials of drugs for the treatment of IgA nephropathy were obtained from public databases. The change in daily urinary protein excretion from baseline was used as the efficacy index, and the time–effect model was established using a model-based meta-analysis method. Based on the final model, the typical efficacy was simulated, and the differences in efficacy were compared.

Results

A total of 40 studies with 2288 subjects were included in this study. The results showed that the time–effect relationship of the placebo and 6 classes of drugs was consistent with the E_max model. The placebo reduced urinary protein excretion by up to 0.44 g/day, and it took more than 27 months to reach half of its maximum effect. The onset of the 6 classes of drugs were the same; they all reached half of their maximum effect after 5.59 months. More importantly, we found a significant influence of urinary protein baseline on drug efficacy, as indicated by an increase of 0.63 g/day in the theoretical maximum effect of drugs for every 1 g/day increase in urinary protein baseline. After correcting for the urinary protein baseline, the order of efficacy of the 6 classes of drugs was as follows: corticosteroids > immunosuppressants > other drugs > renin–angiotensin system blockers > antiplatelet agents > N-3 fatty acids.

Conclusion

This study provides the first comprehensive quantitative analysis of the differences in the efficacy of 6 classes of drugs with different pharmacological mechanisms for treating IgA nephropathy. The results of this study provide an important reference for the rational clinical use of drugs for IgA nephropathy, and also provide a reliable efficacy standard for the development of new drugs for IgA nephropathy.

Nutrition, Physical Activity, and Dietary Supplementation to Prevent Bone Mineral Density Loss: A Food Pyramid

Bone is a nutritionally modulated tissue. Given this background, aim of this review is to evaluate the latest data regarding ideal dietary approach in order to reduce bone mineral density loss and to construct a food pyramid that allows osteopenia/osteoporosis patients to easily figure out what to eat. The pyramid shows that carbohydrates should be consumed every day (3 portions of whole grains), together with fruits and vegetables (5 portions; orange-colored fruits and vegetables and green leafy vegetables are to be preferred), light yogurt (125 mL), skim milk (200 mL,) extra virgin olive oil (almost 20 mg/day), and calcium water (almost 1 l/day); weekly portions should include fish (4 portions), white meat (3 portions), legumes (2 portions), eggs (2 portions), cheeses (2 portions), and red or processed meats (once/week). At the top of the pyramid, there are two pennants: one green means that osteopenia/osteoporosis subjects need some personalized supplementation (if daily requirements cannot be satisfied through diet, calcium, vitamin D, boron, omega 3, and isoflavones supplementation could be an effective strategy with a great benefit/cost ratio), and one red means that there are some foods that are banned (salt, sugar, inorganic phosphate additives). Finally, three to four times per week of 30-40 min of aerobic and resistance exercises must be performed.

Metabolomics and physiological analysis of the effect of calcium supplements on reducing bone loss in ovariectomized rats by increasing estradiol levels

BACKGROUND

Data from the 2010-2012 Chinese National Nutrition and Health Survey showed that the vast majority of postmenopausal women in China had dual deficiencies in calcium and estrogen.

OBJECTIVE

This study aimed to clarify whether calcium supplementation alleviated bone loss caused by calcium restriction combined with estrogen deficiency in rats.

METHODS

Forty-eight female rats aged 9 weeks were assigned to 4 groups and fed a low-calcium diet: sham-operated (SHAM-LC), ovariectomized (OVX-LC), and ovariectomized rats treated with 750 mg/kg (OVX-LC-M) or 2800 mg/kg CaCO3 (OVX-LC-H). CaCO3 or distilled water was administered orally for 13 weeks. Bone mineral density (BMD) and histomorphometry of the femur, serum biochemical parameters, and serum metabolites were analyzed.

RESULTS

The OVX-LC rats showed a significant increase in body weight and serum levels of lipid markers, a significant decrease in serum estradiol, calcium, phosphorus, and 25(OH)D levels, and deterioration of the femur. At 750 mg/kg and 2800 mg/kg, CaCO3 reduced the deterioration of trabecular bone and increased the trabecular area percentage (Tb.Ar %) and BMD of the femur. Serum estradiol levels increased in a dose-dependent manner after CaCO3 supplementation (p < 0.01). The administration of 2800 mg/kg CaCO3 decreased serum triglyceride and high-density lipoprotein levels (p < 0.05) and decreased the levels of the bone turnover markers osteocalcin, N-telopeptide of type I collagen and β-crosslaps. The results of the metabolomics analysis showed that the glycerophospholipid metabolism pathway was closely related to calcium supplementation, and more DG (44:6 n3), LysoPC (22:2) and PE (P-34:3) and less Cer (d43:0) and PE-NMe2 (46:3) were produced.

CONCLUSIONS

The results clearly indicated that calcium supplementation was beneficial for decreasing bone loss in OVX-LC rats. The present study is the first to show that calcium supplementation increased the estradiol content in OVX-LC rats, and the effect of calcium on bone loss may be partially attributed to the increase in the estrogen level that subsequently induced the changes in metabolite levels, eventually increasing the bone mineral density to a relatively higher level to reduce bone deterioration.

Quantitative efficacy of L-carnitine supplementation on glycemic control in type 2 diabetes mellitus patients

OBJECTIVES

This study aimed to explore the quantitative efficacy of L-carnitine supplementation on glycemic control in type 2 diabetes mellitus patients using model-based meta-analysis (MBMA).

METHODS

Literatures were retrieved from the public database and data from these trials were extracted. The quantitative efficacy of L-carnitine on fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) in type 2 diabetes mellitus patients were evaluated by maximal effect (E_max) models with nonlinear mixed effects modeling (NONMEM).

RESULTS

In the model of FPG, E_max and _treatment duration to reach half of the maximal effects (ET₅₀) were -9.8% and 36.1 weeks, respectively. In the model of HbA1c, E_max and ET₅₀ were -19.6% and 106 weeks, respectively. In addition, the durations for achieving 25%, 50%, 75%, 80%, and 90% E_max of L-carnitine on FPG were 13, 36.1, 118, 160, and 390 weeks, respectively. The durations for achieving 25%, 50%, 75%, 80%, and 90% E_max of L-carnitine on HbA1c were 38, 106, 334, 449, and 1058 weeks, respectively.

CONCLUSIONS

It was the first time to provide valuable quantitative information for efficacy of L-carnitine supplementation on glycemic control in type 2 diabetes mellitus patients.

Analysis of Time Course and Dose Effect From Metformin on Body Mass Index in Children and Adolescents

The purpose of this study was to analyze the time course and dose effect from metformin on body mass index (BMI) in children and adolescents by model-based meta-analysis (MBMA). Searching randomized controlled trial (RCT) studies of metformin on BMI in children and adolescents. The change rates of BMI from baseline values were used as indicator of evaluating metformin efficacy. A total of 18 RCT studies, 1,228 children and adolescents, were included for analysis, including patients with obesity, patients with type 1 diabetes mellitus, patients with nonalcoholic fatty liver, and patients with precocity. In order to achieve better effect of metformin on BMI in children and adolescents, the present study recommended that for patients with obesity, 1,000 mg/day metformin was required for at least 15.2 weeks and 60.8 weeks to achieve the plateau of metformin effect; for patients with type 1 diabetes mellitus, 1,000 mg/day metformin was required for at least 25.2 weeks and 100.8 weeks to achieve the plateau of metformin effect; for patients with nonalcoholic fatty liver, 1,000 mg/day metformin was required for at least 6.57 weeks and 26.28 weeks to achieve the plateau of metformin effect; for patients with precocity, 425 mg/day metformin was required for at least 12.4 weeks and 49.6 weeks to achieve the plateau of metformin effect. It was the first time to analyze the time course and dose effect from metformin on BMI and to recommend dosage and duration of treatment for metformin in children and adolescents with different disease types.

Effects of metformin on body weight in polycystic ovary syndrome patients: model-based meta-analysis

OBJECTIVES

The present study aimed to investigate the effects of metformin on body weight in polycystic ovary syndrome (PCOS) patients by model-based meta-analysis (MBMA).

METHODS

Randomized controlled trial (RCT) studies of metformin in treatment of PCOS patients were collected and efficacy indicators were the body mass index (BMI) change rates from baseline.

RESULTS

28 RCT studies, 1631 PCOS patients were included for analysis. Model of metformin monotherapy, and model of metformin combination therapy were established, respectively. After deducting control group effects, the E_max of metformin on BMI were -5.88% and -11.8% in metformin monotherapy and metformin combination therapy, respectively. In order to play better curative effects, for metformin monotherapy, 1000 mg/day metformin needs for at least 25.5 weeks; For metformin combination therapy, 1000 mg/day metformin needs for at least 58.6 weeks.

CONCLUSION

It was the first time to quantify the effects of metformin on body weight and recommend dose and duration for metformin monotherapy and metformin combination therapy in PCOS patients.

Time course and dose effect of metformin on weight in patients with different disease states

OBJECTIVES

The present study was to quantitate and compare the efficacy of metformin on weight in different disease states using model-based meta-analysis (MBMA).

METHODS

Randomized controlled trials (RCT) of metformin effects on weight in different disease states were collected by searching the public databases. The change rate of weight from baseline was selected as the efficacy indicator.

RESULTS

A total 21 RCTs containing 1885 patients including patients with type 2 diabetes mellitus, patients with antipsychotic induced weight gain, patients with obesity, were included into the present study. After deducting placebo effect, the maximal effect (E_max) of metformin on weight in patients with type 2 diabetes mellitus, patients with antipsychotic induced weight gain, patients with obesity were -6.86%, -8.82%, and -4.14%, respectively. The treatment duration to reach half of the maximal effect (ET₅₀) were 107, 45.5, and 15.1 weeks, respectively. Within the metformin dose range from 21 RCTs, no significant dose-response relationship was observed. However, the time-course relationship is obvious for efficacy of metformin on weight.

CONCLUSIONS

The present study firstly provided quantitative information for metformin effects on weight in different disease states, including patients with type 2 diabetes mellitus, patients with antipsychotic induced weight gain, patients with obesity.

Analysis of time course and dose effect of tacrolimus on proteinuria in lupus nephritis patients

WHAT IS KNOWN AND OBJECTIVES

Tacrolimus is used to treat patients with lupus nephritis; however, its time course and dose effect on proteinuria in lupus nephritis patients remain unknown. The purpose of this study was to determine the time course and dose effect of tacrolimus on proteinuria in lupus nephritis patients via model-based meta-analysis (MBMA).

METHODS

PubMed, Web of Science, Cochrane Library and ClinicalTrials.gov databases were systematically searched for information on the efficacy of tacrolimus against proteinuria in lupus nephritis patients. Useful data were extracted to build a model for the population studied using a non-linear mixed-effect model (NONMEM). This model was applied to simulate time course of tacrolimus on proteinuria using Monte Carlo simulations.

RESULTS

Ten clinical studies that recruited 222 patients with lupus nephritis were included. Based on various diagnostic plots, we found that the established model described the observed data reasonably well. In addition, the typical E_max and ET₅₀ of tacrolimus for 24-hour proteinuria in lupus nephritis patients were -5.88 g and 0.37 months, respectively. The baseline value of 24-hour proteinuria affected E_max . No significant dose-response relationship was observed in the range of tacrolimus concentration used in the present study (3-10 ng/mL), indicating that the effect of tacrolimus on proteinuria depends on effective concentration range and not the dose. However, the time course relationship was obvious; the efficacy of tacrolimus increased over time, reaching a plateau (80% E_max ) at approximately 1.48 months from the beginning of treatment.

WHAT IS NEW AND CONCLUSION

When the concentration range of tacrolimus is maintained at 3-10 ng/mL, at least 1.48 months of treatment is required to achieve a better outcome with regard to proteinuria in lupus nephritis patients.

Calcium intake from different food sources in Italian women without and with non-previously diagnosed osteoporosis

An adequate calcium and vitamin D intake may play a role in preventing osteoporosis, but the contribution of the different food sources of calcium with regards to the risk of osteoporosis been barely explored. This observational study evaluated the calcium intake through a food frequency questionnaire in 126 adult women with not previously diagnosed osteoporosis undergoing Dual-energy X-ray Absorptiometry (DXA) to screen for osteoporosis, and to correlate the calcium intake with parameters of bone density, measured by DXA. Total daily calcium intake and daily intake from food were similar among women found to have osteoporosis, osteopenia or normal condition. The main food source was milk and dairy products, while calcium supplementation was consumed by only 14% of subjects, irrespectively from osteoporosis conditions. DXA parameters were not significantly correlated with total daily calcium intake and calcium from food. The present study highlighted no qualitative and quantitative differences in the consumption of food groups contributing to calcium intakes in women with and without osteoporosis.

Association between Dietary Calcium Intake and Bone Mineral Density in Older Adults

Calcium is a requisite nutrient in maintaining bone health. High calcium intake has been recommended for osteoporosis prevention. However, the relationship of dietary calcium intake with bone mineral density (BMD) in the elderly remained controversial. We aimd to evaluate the association between them in older adults. Using data from the Nutrition and Health Examination Survey (NHANES, 2001-2006), we conducted multivariate logistic regression analyses to explore the association of dietary calcium intake with lumbar BMD in older adults. Subgroup analyses were also performed. We included 2904 older adults aged ≥ 60 (43.63% men) for analysis. Higher dietary calcium intake was associated with greater lumbar BMD after adjusting for other covariates. In the subgroup analysis stratified by sex, this positive association existed in women, but not in men. In conclusion, for older adults aged ≥ 60, higher dietary calcium intake is associated with a higher lumbar BMD in women, but not in men.

Pharmacological interventions for the treatment of insomnia: quantitative comparison of drug efficacy

PURPOSE

Although different forms of pharmacological intervention are often prescribed for insomnia disorder, the comparative efficacies among various drugs remain unclear. We therefore conducted this study to quantitatively compare the efficacy of various pharmacotherapies for insomnia by modeling.

METHODS

We searched PubMed, EMBASE and Cochrane Library databases for randomized placebo-controlled trials of insomnia medications that were conducted within a designated time period (from the inception dates to May 16, 2019). Pharmacodynamic models were established to describe the time course of changes from baseline in selected sleep parameters. Sleep quality and dropout rates were also compared by a single-arm meta-analysis.

RESULTS

In sum, 43 studies covering 44 trials (14,535 patients) were included in the analysis. The drugs evaluated included flurazepam, quazepam, temazepam, triazolam, eszopiclone, zaleplon, zolpidem, extended-release zolpidem, suvorexant, ramelteon and doxepin. The established models revealed eszopiclone had the highest efficacy in terms of sleep latency (SL), total sleep time (TST), and sleep quality, and was also associated with the lowest dropout rates. The effect of suvorexant on the parameter 'wake after sleep onset' (WASO) was significantly higher than that of the other drugs analyzed.

CONCLUSIONS

Each drug has its own characteristics in the treatment of insomnia, and this needs to be taken into consideration to meet individual clinical needs. These results serve as a quantitative supplement for clinical practice by reflecting the difference in efficacy of various drugs in the treatment of insomnia.

Quantitative analysis of the placebo response in pharmacotherapy of insomnia and its application in clinical trials

Study Objectives

This study aimed to develop a robust placebo response model for the pharmacotherapy for insomnia to guide drug development and clinical practice.

Methods

PubMed, EMBASE, and Cochrane Library databases were systematically searched for randomized placebo-controlled trials of medications for insomnia dating from the inception dates of the databases to April 18, 2018. Three placebo response models were established to describe the time–course of sleep parameters measured by objective (polysomnography or actigraphy) or subjective methods (sleep diary or questionnaires). The established models were applied to simulate placebo response distribution under different conditions using Monte Carlo simulations.

Results

Fifty-four studies involving 6,416 subjects were included. Placebo response increased over time and reached a plateau at approximately 8 weeks from start of therapy. Established models described the observed data reasonably well based on various diagnostic plots. Baseline sleep parameters affected the placebo response. There were significant positive correlations with placebo response and the severity of sleep latency, wake after sleep onset, and total sleep time at baseline. In addition, placebo response, assessed by subjective and objective methods, was consistent after correcting the baseline levels.

Conclusions

The established placebo response models can serve as a tool to predict placebo response at different baseline levels, which can provide valuable reference for clinical trial design, decision-making in drug development, and clinical practice.

Low bone mass is associated with carotid calcification plaque in Chinese postmenopausal women: the Chongqing osteoporosis study

Background: The aim of this study was to examine the relationship between low bone mass and the risk of carotid calcification plaques in Chinese postmenopausal women.Methods: We conducted a 5 years prospective study. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA) scanning. Carotid computed tomography angiography (CTA) was conducted using a 64-multidetector row scanner to assess carotid arterial plaque at baseline and during follow-up. Cox proportional hazards analysis was used to evaluate the association of BMD and risk of carotid calcification plaques.Results: Four hundred and eighty-eight women sustained prospective carotid plaques during the follow-up. Women with carotid calcification plaques had low BMD than those with carotid non-calcification plaques. After adjustment for potential confounders, BMD, age, years since menopause, levels of plasma osteoprotegerin and adiponectin, hypertension, diabetes mellitus and hyperlipidemia were independently associated with increased risk of carotid calcification plaques. For carotid calcification plaques, a significant inverse correlation was indicated between BMD and the plaques, and a significant positive correlation was indicated between bone loss and plaques.Conclusions: This study suggested that lower BMD and increased loss rate of BMD were associated with a higher risk of carotid calcification plaques in Chinese postmenopausal women.

Vitamin C reverses bone loss in an osteopenic rat model of osteoporosis

Fruits and vegetables are rich in vitamin C with antioxidant properties which are known to influence bone quality. This study evaluated whether vitamin C (1000 mg/L) added to drinking water reverses the bone loss in ovariectomized rats. Ninety-day-old female Sprague-Dawley rats were randomly assigned to either sham (n = 14) or ovariecotmized groups (n = 28). Sixty days after ovariectomy, the treatments were sham, ovariectomy (OVX), OVX + vitamin C (22 mg oral intake daily) for 60 days. Urine was collected for deoxypyridinoline (DPD) evaluation, rats were sacrificed, and antioxidant capacity, osteopontin, alkaline phosphatase (ALP), and bone specific tartrate resistant acid phosphatase (TRAP) were evaluated in the plasma. Right femur and 5th lumbar were evaluated for bone density, strength, ash, Ca, and Mg concentrations. Antioxidant capacity, ALP activity, osteopontin decreased (p-value < 0.05), while TRAP and urinary DPD increased (p-value < 0.05) with ovariectomy. In contrast, vitamin C increased (p-value < 0.05) antioxidant capacity, ALP activity, osteopontin concentration and reduced (p-value < 0.05) TRAP and urinary DPD excretion, respectively. Ovariectomy reduced (p-value < 0.05) bone quality, bone ash, Ca and Mg concentrations. Vitamin C increased (p-value < 0.05) femoral density without affecting (p-value > 0.1) femoral strength, ash, or Ca, and Mg concentrations, while it increased (p-value < 0.05) the 5th lumbar density, ash, and Ca and Mg concentrations. In conclusion, vitamin C increased bone quality and antioxidant capacity in ovariectomized rats.