Non-adherence to anti-osteoporotic medications in Taiwan: physician specialty makes a difference

Cost-Effectiveness of Osteoporosis Opportunistic Screening Using Computed Tomography in China

OBJECTIVES

Underutilization and insufficient availability of dual-energy X-ray absorptiometry (DXA) in diagnosing osteoporosis in China could be changed by adopting unindicated quantitative computed tomography. We aimed to assess the cost-effectiveness of quantitative computed tomography (QCT) as a screening tool for osteoporosis in China.

METHODS

A Markov microsimulation model was developed to assess the long-term costs and quality-adjusted life-years (QALYs) saved associated with 2 examinations as opportunistic screening for osteoporosis in a general population without prior histories of fracture. The diagnostic performance of both examinations was incorporated into the model. In lifetime modeling, opportunistically screened people may face the risk of experiencing hip, vertebral, and wrist fractures depending on their osteoporosis, age, and sex. Model parameters were informed by published literature.

RESULTS

The base-case result showed that QCT was associated with higher costs ($6054 vs $5883) and higher benefits (10.081 vs 10.071 QALYs) in comparison with DXA, making QCT a cost-effective option for opportunistic screening (incremental cost-effectiveness ratio of US $16 430/QALY). Screening with QCT led to fewer fractures over the lifetime simulation: for every 10 000 people screened, 129 fractures (32 hip, 78 vertebral, and 19 wrist fractures) could be avoided because of the early initiation of antiosteoporotic treatment.

CONCLUSIONS

Using QCT to screen people for osteoporosis is more cost-effective than standard practice in China, where access to DXA is minimal. This finding could support opportunistic osteoporosis screening using QCT in other countries with similar status.

Preparation, characterization, and osteogenic activity mechanism of casein phosphopeptide-calcium chelate

Casein phosphopeptides (CPPs) are good at calcium-binding and intestinal calcium absorption, but there are few studies on the osteogenic activity of CPPs. In this study, the preparation of casein phosphopeptide calcium chelate (CPP-Ca) was optimized on the basis of previous studies, and its peptide-calcium chelating activity was characterized. Subsequently, the effects of CPP-Ca on the proliferation, differentiation, and mineralization of MC3T3-E1 cells were studied, and the differentiation mechanism of CPP-Ca on MC3T3-E1 cells was further elucidated by RNA sequencing (RNA-seq). The results showed that the calcium chelation rate of CPPs was 23.37%, and the calcium content of CPP-Ca reached 2.64 × 10⁵ mg/kg. The test results of Ultraviolet–Visible absorption spectroscopy (UV) and Fourier transform infrared spectroscopy (FTIR) indicated that carboxyl oxygen and amino nitrogen atoms of CPPs might be chelated with calcium during the chelation. Compared with the control group, the proliferation of MC3T3-E1 cells treated with 250 μg/mL of CPP-Ca increased by 21.65%, 26.43%, and 28.43% at 24, 48, and 72 h, respectively, and the alkaline phosphatase (ALP) activity and mineralized calcium nodules of MC3T3-E1 cells were notably increased by 55% and 72%. RNA-seq results showed that 321 differentially expressed genes (DEGs) were found in MC3T3-E1 cells treated with CPP-Ca, including 121 upregulated and 200 downregulated genes. Gene ontology (GO) revealed that the DEGs mainly played important roles in the regulation of cellular components. The enrichment of the Kyoto Encyclopedia of Genes and Genomes Database (KEGG) pathway indicated that the AMPK, PI3K-Akt, MAPK, and Wnt signaling pathways were involved in the differentiation of MC3T3-E1 cells. The results of a quantitative real-time PCR (qRT-PCR) showed that compared with the blank control group, the mRNA expressions of Apolipoprotein D (APOD), Osteoglycin (OGN), and Insulin-like growth factor (IGF1) were significantly increased by 2.6, 2.0 and 3.0 times, respectively, while the mRNA levels of NOTUM, WIF1, and LRP4 notably decreased to 2.3, 2.1, and 4.2 times, respectively, which were consistent both in GO functional and KEGG enrichment pathway analysis. This study provided a theoretical basis for CPP-Ca as a nutritional additive in the treatment and prevention of osteoporosis.

Factors Associated With Adherence to Osteoporosis Medications Among Male Veterans

Risk factors for nonadherence to osteoporosis medication have been well described for cohorts of women with osteoporosis, but little is known about predictors or mediators of nonadherence in men. We conducted a secondary analysis of a national cohort of male veterans to explore factors associated with nonadherence to osteoporosis medications. We included veterans with a prescription for an oral bisphosphonate or calcitonin between 2000 and 2010. We identified demographic, comorbid, and fracture-related risk factors by their International Classification of Diseases-9 (ICD-9) and Current Procedural Terminology (CPT) codes and used multivariable logistic regression to evaluate their association with adherence. Adherence was measured by medication possession ratio (MPR) over 5 years, starting at the time of their first prescription during the study period and censoring at death or end of study period. Of 135,306 men identified with at least one prescription for an osteoporosis medication during the study period, 90,406 (67%) were nonadherent (MPR < 0.80). The median duration of therapy was 3.2 years (interquartile range [IQR] = 1.7-5.0). In the fully adjusted model, the odds of adherence were lower in those aged <65 years (odds ratio [OR] = 0.87; 95% confidence interval [CI] 0.84-0.89), with no copay (OR = 0.78; 95% CI 0.76-0.80), dementia (OR = 0.87; 95% CI 0.83-0.91), anxiety/depression (OR = 0.92; 95% CI 0.90-0.95), tobacco use (OR = 0.91; 95% CI 0.89-0.94), alcohol abuse (OR = 0.91; 95% CI 0.89-0.94), rheumatoid arthritis (OR = 0.92; 95% CI 0.87-0.97), and on androgen deprivation therapy (OR = 0.89; 95% CI 0.83-0.95). The odds of adherence were higher in whites (OR = 1.14; 95% CI 1.11-1.17), with a prior screening colonoscopy (OR = 1.12; 95% CI 1.09-1.14), on alendronate versus other agents (OR = 1.61; 95% CI 1.55-1.67), with a dual-energy X-ray absorptiometry (DXA) (OR = 1.14; 95% CI 1.12-1.17), on glucocorticoids (OR = 1.08; 95% CI 1.02-1.14), and with recent fracture (OR = 1.07; 95% CI 1.04-1.10). In conclusion, adherence to oral bisphosphonates/calcitonin is poor, with particular subgroups at greatest risk. These findings may help tailor approaches for supporting adherence in men prescribed osteoporosis medications. © 2021 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Persistence and adherence to parenteral osteoporosis therapies: a systematic review

Osteoporosis is a chronic disease of low bone mass and fragility. Treatment is frequently compromised by suboptimal medication compliance causing increased morbidity. This review investigates adherence and persistence to parenteral osteoporosis therapies. Findings reveal parenteral medications requiring reduced dosing frequency have higher compliance than oral therapies. This systematic review examines real-world adherence to parenteral osteoporosis therapies. We searched PubMed, Medline, and EMBASE databases for English language observational studies that examined patient adherence and/or persistence to parenteral osteoporosis treatments (teriparatide sc, ibandronate iv, zoledronic acid iv, and denosumab sc) in adults with osteoporosis published up to September 2018. Studies with only self-reported adherence or persistence data and those with less than 20 patients were excluded. Quality assessment of included studies was completed using the Newcastle-Ottawa quality assessment scale (NOS). We identified 40 eligible studies. Teriparatide was examined in 29 studies, with persistence rates of 10-87% (median 55%) at 1 year and 10-69% (median 29.5%) at 2 years, and adherence rates of 21-89% (median 53%) at 1 year and 37-68% (median 40%) at 2 years. Ten studies of zoledronic acid reported persistence rates of 34-73% (median 42%) for second dose and 20-54% (median 35.8%) for third dose. Ten studies of ibandronate adherence reported and 2-year persistence rates of 31-58% (median 47.5%) in 1 year and 13-35% (median 25%) at 2 years, and adherence rates of 21-72% (median 47.3%) and 15-58% (median 36.5%) respectively. Denosumab was reported in 19 studies, with second (1 year) and fourth (2 year) dose persistence rates of 61-100% (median 81%) and 36-99% (median 45.5%). There is substantial heterogeneity in reports of persistence and adherence rates with parenteral osteoporosis therapies. Most of the published data are from short-term studies and evaluations of long-term adherence and persistence with parenteral therapies for osteoporosis are needed.

Cell Proliferation Stimulation Ability and Osteogenic Activity of Low Molecular Weight Peptides Derived from Bovine Gelatin Hydrolysates

It has been recognized that collagen peptides of MW 878 Da (CP1) promote osteoblast proliferation and mineralization. The objective of this study is to identify the peptides responsible for proliferation of osteoblast growth, enhancement of ALP (alkaline phosphatase) activity in osteoblasts and promotion of osteoblast mineralization. To this end, the CP1 were fractioned by a series of chromatography procedures, and 51 peptides from the fraction possessing the most powerful cell proliferation ability were identified by LC-MS-MS. The peptides, GPAGPSGPAGK and GPPGSPGPR, were validated on a simultaneous basis as possessing enhanced bioactivity-inducing properties. In particular, the ALP activity of the cells treated with these two peptides was almost twice that of the control cells. Hydrogen bonds were formed, and the hydrophobic interactions with the EGFR (epidermal growth factor receptor) might be responsible for the osteoblast proliferation activity. On this basis, the two peptides might be potential lead compounds against osteoporosis and osteoarthritis.

A national study on long-term osteoporosis therapy and risk of recurrent fractures in patients with hip fracture

OBJECTIVE

The study aimed to evaluate the impact of osteoporosis (OP) medication persistence on subsequent fractures and all-cause mortality in patients with hip fracture.

METHODS

In this retrospective cohort study, we included patients aged ≥ 40 years with fragility hip fracture from the Taiwan's National Health Insurance Research Database. OP medication persistence was categorized as yes (≥ 12 months) or no (< 12 months). A multivariate Cox proportional hazard model was used to evaluate the association between OP medication persistence and recurrent fractures (including hip, vertebral, and upper and lower limb fractures) and all-cause mortality.

RESULTS

A total of 946 patients were included in the study (86.5 % of them aged ≥ 65 years) and 210 patients persistently received OP medications. Persistent OP medication use was associated with lower fracture risk (adjusted hazard ratio [aHR] = 0.64; 95 % CI = 0.41-0.99; P = .043) in the follow-up period. The strongest predictors for all-cause mortality were age ≥ 80 years (HR = 5.68, 95 % CI = 1.36-23.64, P = .017), male sex (HR = 1.55; 95 % CI = 1.18-2.03; P = .002), and Charlson Comorbidity Index ≥ 3 (aHR = 1.56; 95 % CI = 1.07-2.27; P = .022). Kaplan-Meier curves showed a lower cumulative incidence of recurrent fractures in the persistent group than that in the non-persistent group (P = .028).

CONCLUSION

Persistent OP medication use was associated with a lower risk of recurrent fractures but not with mortality in patients with hip fracture.

A systematic review of factors affecting medication adherence among patients with osteoporosis

The aim of this review was to identify factors that influence patients' adherence to anti-osteoporotic therapy. Factors identified that were associated with poorer medication adherence included polypharmacy, older age, and misconceptions about osteoporosis. Physicians need to be aware of these factors so as to optimize therapeutic outcomes for patients.

INTRODUCTION

To identify factors that influence patients' adherence to anti-osteoporotic therapy.

METHODS

A systematic review of literature was performed for articles published up till January 2018 using PubMed®, PsychINFO®, Embase®, and CINAHL®. Peer-reviewed articles which examined factors associated with anti-osteoporotic medication adherence were included. Classes of anti-osteoporotic therapy included bisphosphonates, parathyroid hormone-related analogue, denosumab, selective estrogen receptor modulators, estrogen/progestin therapy, calcitonin, and strontium ranelate. Meta-analyses, case reports/series, and other systematic reviews were excluded. Identified factors were classified using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains).

RESULTS

Of 2404 articles reviewed, 124 relevant articles were identified. The prevalence of medication adherence ranged from 12.9 to 95.4%. Twenty-four factors with 139 sub-factors were identified. Bisphosphonates were the most well-studied class of medication (n = 59, 48%). Condition-related factors that were associated with poorer medication adherence included polypharmacy, and history of falls was associated with higher medication adherence. Patient-related factors which were associated with poorer medication adherence included older age and misconceptions about osteoporosis while therapy-related factors included higher dosing frequency and medication side effects. Health system-based factors associated with poorer medication adherence included care under different medical specialties and lack of patient education. Socio-economic-related factors associated with poorer medication adherence included current smoker and lack of medical insurance coverage.

CONCLUSION

This review identified factors associated with poor medication adherence among osteoporotic patients. To optimize therapeutic outcomes for patients, clinicians need to be aware of the complexity of factors affecting medication adherence.

Effect of Collagen Hydrolysates from Silver Carp Skin (Hypophthalmichthys molitrix) on Osteoporosis in Chronologically Aged Mice: Increasing Bone Remodeling

Osteoporosis is a common skeletal disorder in humans and gelatin hydrolysates from mammals have been reported to improve osteoporosis. In this study, 13-month-old mice were used to evaluate the effects of collagen hydrolysates (CHs) from silver carp skin on osteoporosis. No significant differences were observed in mice body weight, spleen or thymus indices after daily intake of antioxidant collagen hydrolysates (ACH; 200 mg/kg body weight (bw) (LACH), 400 mg/kg bw (MACH), 800 mg/kg bw (HACH)), collagenase hydrolyzed collagen hydrolysates (CCH) or proline (400 mg/kg body weight) for eight weeks, respectively. ACH tended to improve bone mineral density, increase bone hydroxyproline content, enhance alkaline phosphatase (ALP) level and reduce tartrate-resistant acid phosphatase 5b (TRAP-5b) activity in serum, with significant differences observed between the MACH and model groups (p < 0.05). ACH exerted a better effect on osteoporosis than CCH at the identical dose, whereas proline had no significant effect on repairing osteoporosis compared to the model group. Western blotting results demonstrated that CHs mainly increased bone remodeling by stimulating the transforming growth factor β1 (TGF-β1)/Smad signaling pathway and improving the interaction between collagen and α2β1 integrin. The results indicated that CHs from fish could be applied to alleviate osteoporosis or treat bone loss.

Improving drug adherence in osteoporosis: an update on more recent studies

Similar to other chronic diseases such as diabetes and hypertension, osteoporosis has struggled with suboptimal medication adherence, resulting in an increased risk of fractures and all-cause mortality. The goal of this narrative review was to summarize interventions to improve medication adherence in osteoporosis. Because past reviews of this topic covered published literature through 2013, we conducted our literature search to include the period between January 2012 and November 2017. We identified 10 studies evaluating healthcare system and patient interventions aimed at improving osteoporosis treatment adherence, including three fracture liaison service (FLS) programs, one pharmacist-delivered counseling program, and six patient-directed interventions consisting of three coaching or counseling programs and three interventions using reminder prompts. Four out of the six patient-directed interventions did not lead to significant improvements in outcomes, suggesting that patient-directed interventions may have limited success in this setting. The healthcare system interventions that evaluated FLS programs and pharmacist-directed tailored counseling were effective at improving medication adherence; however, the studies were not randomized, they were costly, resource intensive and effective in countries with more centralized healthcare, possibly limiting their generalizability. In conclusion, while healthcare system interventions such as FLS, and pharmacist-delivered counseling appeared to be successful in improving osteoporosis medication adherence in some settings, behavioral interventions including patient counseling and reminder prompts for medication utilization were not, perhaps due to patient perceptions regarding osteoporosis consequences and need for treatment. Thus, these patient attributes may define patients 'at high risk' for poor adherence and developing intervention approaches to enhance patient knowledge and understanding of osteoporosis and its consequences may improve the perception of the need for treatment, optimize osteoporosis care and thereby improve overall outcomes of patients with osteoporosis. We hope that the knowledge gained through our review will help inform the design of further programs aimed at optimizing osteoporosis care.

Limonene promotes osteoblast differentiation and 2-deoxy-d-glucose uptake through p38MAPK and Akt signaling pathways in C2C12 skeletal muscle cells

BACKGROUND

Limonene is a cyclic monoterpene (CTL) found in citrus fruits and many plant kingdoms. It has attracted attention as potential molecule due to its diverse biological activities. However, molecular mechanism involved in the osteogenic induction of CTL in C2C12 skeletal muscle cells remain unclear.

PURPOSE

Skeletal development maintains the bone homeostasis through bone remodeling process. It coordinated between the osteoblast and osteoblast process. Osteoporosis is one of the most common bone diseases caused by a systemic reduction in bone mass. Recent osteoporosis treatment is based on the use of anti-resorptive and bone forming drugs. However, long term use of these drugs is associated with serious side effects and strategies on the discovery of lead compounds from natural products for osteoblast differentiation are urgently needed. Therefore, we planned to find out the role of CTL on osteoblast differentiation and glucose uptake in C2C12 cells and its effect on signaling pathways.

METHODS

Cell proliferation, alkaline phosphatase (ALP) activity, calcium deposition, genes, and proteins associated with osteoblast activation and glucose utilization were analysed.

RESULTS

CTL did not affect the cell viability. CTL significantly increased ALP activity, calcium depositions and the expression of osteogenic specific genes such as Myogenin, Myogenic differentiation 1 (MyoD), ALP, Run-related transcription factor 2(RUNX2), osteocalcin (OCN). In addition, CTL induced the mRNA expression of bone morphogenetic proteins (BMP-2 BMP-4 BMP-6 BMP-7 BMP-9). CTL treatment enhanced 2-Deoxy-d-glucose (2DG) uptake. Moreover, CTL stimulated the activation of p38 mitogen activated protein kinase (p38MAPK), Protein kinase B (Akt), Extracellular signal related kinase (ERKs) by increasing phosphorylation. CTL treatment abolished p38 inhibitor (SB203580) mediated inhibition of osteoblast differentiation, but no effect was noted by ERKs specific inhibitor (PD98059).

CONCLUSION

These results suggest that limonene induces osteoblast differentiation and glucose uptake through activating p38MAPK and Akt signaling pathways, confirming the molecular basis of the osteoblast differentiation by limonene in C2C12 skeletal muscle cells.

The Growth Proliferation, Apoptotic Prevention, and Differentiation Induction of the Gelatin Hydrolysates from Three Sources to Human Fetal Osteoblasts (hFOB 1.19 Cells)

Gelatins from the skin of bovine, porcine, and tilapia were hydrolyzed to three degrees of hydrolysis (DH) by alcalase, neutrase, and papain, respectively. These hydrolysates at 0.02⁻0.1 g/L promoted the growth of human fetal osteoblasts by 101.4⁻135.7%, while higher DH or using papain and tilapia gelatins resulted in higher proliferation. The hydrolysates from porcine and tilapia gelatins at 0.05 g/L prevented induced apoptosis (decreasing total apoptotic proportions from 28.4% or 35.2% to 10.3⁻17.5% or 16.0⁻23.6%), and had differentiation induction (increasing alkaline phosphatase activity by 126.9⁻246.7% in early differentiation stage, or enhancing osteocalcin production by 4.1⁻22.5% in later differentiation stage). These hydrolysates had a similar amino acid profile; however, tilapia gelatin hydrolysates by papain with DH 15.4% mostly displayed higher activity than others. Tilapia gelatin hydrolysate could up-regulate β-catenin, Wnt 3a, Wnt 10b, cyclin D1, and c-Myc expression at mRNA levels by 1.11⁻3.60 folds, but down-regulate GSK 3β expression by 0.98 fold. Of note, β-catenin in total cellular and nuclear protein was up-regulated by 1.14⁻1.16 folds but unchanged in cytoplasmic protein, Wnt 10b, cyclin D1, and c-Myc expression were up-regulated by 1.27⁻1.95 folds, whilst GSK 3β expression was down-regulated by 0.87 fold. Activation of Wnt/β-catenin pathway is suggested to mediate cell proliferation and differentiation.

Association between teriparatide treatment persistence and adherence, and fracture incidence in Taiwan: analysis using the National Health Insurance Research Database

Medication persistence and adherence are critical for osteoporosis outcomes. Using the Taiwan National Health Insurance Research Database, we found that persistence and adherence to teriparatide were low in Taiwanese patients with osteoporosis and that greater persistence and adherence were associated with a lower incidence of hip and other nonvertebral fractures.

INTRODUCTION

The purpose of this study was to determine the persistence and adherence to teriparatide treatment in Taiwanese patients with osteoporosis, and to examine the association between persistence and adherence to teriparatide with fracture risks.

METHODS

Medical and pharmacy claims for 4,692 patients with vertebral or hip fractures and teriparatide prescriptions between 2005 and 2008 were identified (Taiwan National Health Insurance Research Database). Persistence was the time from the start of treatment to the first 90-day gap between two teriparatide prescriptions. Adherence was the number of teriparatide pens (each pen is used over 1 month) prescribed over 24 months. Association of persistence and adherence to teriparatide with fracture incidence was assessed using adjusted Cox proportional hazards models.

RESULTS

The proportion of patients persisting with teriparatide for >6 months and >12 months was 44.6 and 24.9 %, respectively. Over 24 months, 53.6 % of patients were adherent for >6 months and 33.9 % were adherent for >12 months. Patients persisting for >12 months had a significantly lower incidence of hip (adjusted hazard ratio [HR], 0.61 [95 % confidence interval (CI), 0.40-0.93], P = 0.0229) and nonvertebral fracture (HR, 0.79 [95 % CI, 0.63-0.99], P = 0.0462) compared with those who persisted for ≤12 months. Patients adherent for >12 months had a lower incidence of hip (HR, 0.66 [95 % CI, 0.46-0.96], P = 0.0286) and nonvertebral fracture (HR, 0.81 [95 % CI, 0.66-0.99], P = 0.0377) compared with those adherent for ≤12 months.

CONCLUSIONS

Persistence and adherence to teriparatide over 24 months were low in Taiwanese patients with osteoporosis; greater adherence and persistence were associated with a lower incidence of nonvertebral fractures.

Osteoblastogenic activity of ark shell protein hydrolysates with low molecular weight in mouse mesenchymal stem cells

Ark shell protein promotes bone formation through regulating osteoblast differentiation.

Dropping the Ball and Falling Off the Care Wagon. Factors Correlating With Nonadherence to Secondary Fracture Prevention Programs

Health care systems and hospitals in several countries have implemented Fracture Liaison Services (FLSs). Success rates of FLSs with regard to osteoporosis assessment and treatment, fracture reduction, and adherence to osteoporosis medications have been reported by several groups including ours. A significant drop-out rate among patients in these programs may occur. This has not been evaluated before. We explored the factors correlating with nonadherence among a multiethnic population of patients in the FLS at our institution, the largest tertiary teaching hospital in South East Asia. Our secondary objective was to explore whether patients who defaulted follow-up visits continued to be compliant with medications. A retrospective analysis of our FLS's computerized database was performed. Of 938 patients followed up more than 2 years, 237 defaulted at various time points. A significant percentage of patients who dropped out of the program opined that it was because the follow-up visits were too time consuming. Non-Chinese patients were more likely than Chinese (adjusted hazard ratio [aHR] = 1.98, 1.33-2.94), patients with primary school education and below were more likely than those with secondary school and above education (aHR = 1.65, 1.11-2.45) and those with nonvertebral and/or multiple fractures were more likely than those with spine fractures (aHR = 1.38, 1.06-1.81) to be nonadherent. A fraction of patients who defaulted continued to fill osteoporosis medication prescriptions. Median medication possession ratio among the patients who defaulted was 12.3% (interquartile range: 4.1%-36.7%) at 2 years. Persistence ranged from 15.1% to 20.8% and from 1.9% to 7.5% at 1 and 2 years, respectively after defaulting from the program. Our study, which to the best of our knowledge is the first of its kind, provides insight into the factors correlating with nonadherence to FLSs. Knowledge of the challenges faced by patients may be of help to health care providers interested in developing FLSs.

Medical specialty-related adherence to anti-osteoporotic regimens in fragility hip fracture patients

There is poor adherence in the management of osteoporotic fractures. We designed a study to investigate adherence to osteoporotic regimens among osteoporotic hip fracture patients and to analyze the risk factors associated with poor compliance. This retrospective chart-review study was carried out using a database of osteoporotic hip fracture patients at a medical center in Taiwan for the period 2001-2007. Adherence was assessed using compliance and persistence. Compliance was calculated by the medication possession ratio (MPR) and persistence by the time from treatment initiation to discontinuation. The MPR and corresponding risk factors for poor compliance (MPR < 80 %) were evaluated for year 1. The year 2 results were analyzed only for those subjects with good compliance (MPR ≥ 80 %) at the end of year 1. There were 366 osteoporotic hip fracture patients (323 women, 43 men) with a mean age of 73.9 ± 7.6 years. Of these, 53.8 % had good compliance for year 1 and 68.5 % for year 2. During 2 years of follow-up, the overall persistence ratio was 33.1 %. The risk factor associated with poor compliance in the first year was index prescription by orthopedists [odds ratio (OR) 1.69, 95 % confidence interval (CI) 1.10-2.59]. Subjects with hypertension (OR 0.69, 95 % CI 0.46-0.99) had good compliance. Index prescription by orthopedists (OR 2.44, 95 % CI 1.31-4.51) was the sole risk factor for poor compliance in year 2. In conclusion, although adherence to osteoporotic regimens was sub-optimal in hip fracture patients, the majority of patients' decreased adherence occurred within the first year. Medical specialties showed different adherences in both year 1 and year 2.

Fucoidan promotes osteoblast differentiation via JNK- and ERK-dependent BMP2-Smad 1/5/8 signaling in human mesenchymal stem cells

Fucoidan has attracted attention as a potential drug because of its biological activities, which include osteogenesis. However, the molecular mechanisms involved in the osteogenic activity of fucoidan in human alveolar bone marrow-derived mesenchymal stem cells (hABM-MSCs) remain largely unknown. We investigated the action of fucoidan on osteoblast differentiation in hABM-MSCs and its impact on signaling pathways. Its effect on proliferation was determined using the crystal violet staining assay. Osteoblast differentiation was evaluated based on alkaline phosphatase (ALP) activity and the mRNA expression of multiple osteoblast markers. Calcium accumulation was determined by Alizarin red S staining. We found that fucoidan induced hABM-MSC proliferation. It also significantly increased ALP activity, calcium accumulation and the expression of osteoblast-specific genes, such as ALP, runt-related transcription factor 2, type I collagen-α 1 and osteocalcin. Moreover, fucoidan induced the expression of bone morphogenetic protein 2 (BMP2) and stimulated the activation of extracellular signal-related kinase (ERK), c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase by increasing phosphorylation. However, the effect of fucoidan on osteogenic differentiation was inhibited by specific inhibitors of ERK (PD98059) and JNK (SP600125) but not p38 (SB203580). Fucoidan enhanced BMP2 expression and Smad 1/5/8, ERK and JNK phosphorylation. Moreover, the effect of fucoidan on osteoblast differentiation was diminished by BMP2 knockdown. These results indicate that fucoidan induces osteoblast differentiation through BMP2-Smad 1/5/8 signaling by activating ERK and JNK, elucidating the molecular basis of the osteogenic effects of fucoidan in hABM-MSCs.