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Kawashima I, Hiraiwa H, Ishizuka S, Oba H, Sakaguchi T, Idota M, Kawai R, Tsukahara T, Imagama S. Displaced tibial and fibular stress fractures in a female elite pole-vaulter with menstrual dysfunction, vitamin D deficiency, and high serum pentosidine. J Orthop Sci 2023; 28:1513-1517. [PMID: 34794859 DOI: 10.1016/j.jos.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/31/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Itaru Kawashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Hideki Hiraiwa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Shinya Ishizuka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takefumi Sakaguchi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masaru Idota
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Ryosuke Kawai
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Takashi Tsukahara
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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Brandt IAG, Jessen MH, Rimestad DE, Højgaard MKF, Vestergaard P. Advanced glycation end products and bone - How do we measure them and how do they correlate with bone mineral density and fractures? A systematic review and evaluation of precision of measures. Bone 2022; 165:116569. [PMID: 36174927 DOI: 10.1016/j.bone.2022.116569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/20/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022]
Abstract
The role of advanced glycation end products (AGEs) in bone fragility especially in diabetic bone disease is increasingly recognized and researched. As skeletal frailty in diabetes does not correlate to bone mineral density (BMD) in the same way as in postmenopausal osteoporosis, BMD may not be a suitable measure of bone quality in persons with diabetes. Abundant research exists upon the effect of AGEs on bone, and though full understanding of the mechanisms of actions does not yet exist, there is little doubt of the clinical relevance. Thus, the measurement of AGEs as well as possible treatment effects on AGEs have become issues of interest. The aim of this report is to summarize results of measurements of AGEs. It consists of a systematic review of the existing literature on AGE measurements in clinical research, an evaluation of the precision of skin autofluorescence (SAF) measurement by AGE Reader® (Diagnoptics), and a short commentary on treatment of osteoporosis in patients with and without diabetes with respects to AGEs. We conclude that various AGE measures correlate well, both fluorescent and non-fluorescent and in different tissues, and that more than one target of measure may be used. However, pentosidine has shown good correlation with both bone measures and fracture risk in existing literature and results on SAF as a surrogate measurement is promising as some corresponding associations with fracture risk and bone measures are reported. As SAF measurements performed with the AGE Reader® display high precision and allow for a totally noninvasive procedure, conducting AGE measurements using this method has great potential and further research of its applicability is encouraged.
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Miyoshi A, Kameda H, Nagai S, Nakamura A, Miya A, Takase T, Atsumi T, Miyoshi H. Beneficial effects of switching to denosumab from bisphosphonates or selective estrogen receptor modulators in postmenopausal women with type 2 diabetes and osteopenia/osteoporosis. J Diabetes Investig 2021; 12:1293-1300. [PMID: 33141482 PMCID: PMC8264394 DOI: 10.1111/jdi.13458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 01/22/2023] Open
Abstract
AIMS/INTRODUCTION Patients with type 2 diabetes mellitus have a higher bone fracture risk than patients without diabetes. Although denosumab (Dmab) is a potent bone resorption inhibitor, its efficacy in patients with type 2 diabetes mellitus has not been elucidated. In this study, we investigated the effects of switching to Dmab from bisphosphonates (BP) or a selective estrogen receptor modulator (SERM) in postmenopausal type 2 diabetes mellitus patients. MATERIALS AND METHODS This was a three medical institutions, prospective, observational study for postmenopausal patients with type 2 diabetes mellitus whose T-score of femoral neck or lumbar spine bone mineral density was under -1.0 standard deviation, even after >6 months of BP or SERM administration. After obtaining consent, participants were treated for osteopenia/osteoporosis by either continuing BP (BP-BP group)/SERM (SERM-SERM group), or by switching to Dmab (BP-Dmab or SERM-Dmab groups). Changes in bone mineral density and bone metabolism marker levels were evaluated after 6 months. RESULTS A total of 48 patients were included in this study, and each group comprised 12 patients. No significant difference existed in baseline characteristics among the groups. The average age and glycated hemoglobin were 71 ± 8 years and 7.2 ± 0.9%, respectively. In the SERM-Dmab group, lumbar spine bone mineral density was significantly increased by 5.0% compared with the SERM-SERM group (P < 0.04). Serum bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase 5b were significantly decreased in the BP-Dmab and SERM-Dmab groups compared with the BP-BP and SERM-SERM groups, respectively. CONCLUSIONS Switching to Dmab from BP or SERM is beneficial to prevent osteoporosis progression in postmenopausal patients with type 2 diabetes mellitus patients.
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Affiliation(s)
- Arina Miyoshi
- Department of Diabetes and EndocrinologySapporo City General HospitalSapporoJapan
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - So Nagai
- Sapporo Medical Center NTT ECSapporoJapan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Aika Miya
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Takahiro Takase
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Hideaki Miyoshi
- Division of Diabetes and ObesityFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
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Ingle DN, Porter ME. Microarchitecture of cetacean vertebral trabecular bone among swimming modes and diving behaviors. J Anat 2021; 238:643-652. [PMID: 33058161 PMCID: PMC7855079 DOI: 10.1111/joa.13329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 01/27/2023] Open
Abstract
Cetaceans (dolphins, whales, and porpoises) are fully aquatic mammals that are supported by water's buoyancy and swim through axial body bending. Swimming is partially mediated by variations in vertebral morphology that creates trade-offs in body flexibility and rigidity between axial regions that either enhance or reduce displacement between adjacent vertebrae. Swimming behavior is linked to foraging ecology, where deep-diving cetaceans glide a greater proportion of the time compared to their shallow-diving counterparts. In this study, we categorized 10 species of cetaceans (Families Delphinidae and Kogiidae) into functional groups determined by swimming patterns (rigid vs. flexible torso) and diving behavior (shallow vs. deep). Here, we quantify vertebral trabecular microarchitecture (a) among functional groups (rigid-torso shallow diver (RS), rigid-torso deep diver (RD), and flexible-torso deep diver (FD)), and (b) among vertebral column regions (posterior thoracic, lumbar, caudal peduncle, and fluke insertion). We microCT scanned vertebral bodies, from which 1-5 volumes of interest were selected to quantify bone volume fraction (BV/TV), specific bone surface (BS/BV), trabecular thickness (TbTh), trabecular number (TbN), trabecular separation (TbSp), and degree of anisotropy (DA). We found that BV/TV was greatest in the rigid-torso shallow-diving functional group, smallest in flexible-torso deep-diving species, and intermediate in the rigid-torso deep-diving group. DA was significantly greater in rigid-torso caudal oscillators than in their flexible-torso counterparts. We found no variation among vertebral regions for any microarchitectural variables. Despite having osteoporotic skeletons, cetacean vertebrae had greater BV/TV, TbTh, and DA than previously documented in terrestrial mammalian bone. Cetacean species are an ideal model to investigate the long-term adaptations, over an animal's lifetime and over evolutionary time, of trabecular bone in non-weight-bearing conditions.
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Affiliation(s)
- Danielle N. Ingle
- Department of Biological SciencesFlorida Atlantic UniversityBoca RatonFLUSA
| | - Marianne E. Porter
- Department of Biological SciencesFlorida Atlantic UniversityBoca RatonFLUSA
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Cabelka CA, Baumann CW, Lindsay A, Norton A, Blixt NC, Le G, Warren GL, Mansky KC, Novotny SA, Lowe DA. Tissue selective effects of bazedoxifene on the musculoskeletal system in female mice. J Endocrinol 2021; 248:181-191. [PMID: 33295882 PMCID: PMC7933086 DOI: 10.1530/joe-20-0391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/08/2020] [Indexed: 11/08/2022]
Abstract
The actions of selective estrogen receptor modulators are tissue dependent. The primary objective of the current study was to determine the tissue selective effects of bazedoxifene (BZA) on the musculoskeletal system of ovariectomized (OVX) female mice, focusing on the strengths of muscle-bone pairs in the lower hindlimb. Treatment with BZA after ovariectomy (OVX+BZA) did not prevent body or fat mass gains (P < 0.05). In vivo plantarflexor muscle isometric torque was not affected by treatment with BZA (P = 0.522). Soleus muscle peak isometric, concentric and eccentric tetanic force production were greater in OVX+BZA mice compared to OVX+E2 mice (P ≤ 0.048) with no effect on maximal isometric specific force (P = 0.228). Tibia from OVX+BZA mice had greater cortical cross-sectional area and moment of inertia than OVX mice treated with placebo (P < 0.001), but there was no impact of BZA treatment on cortical bone mineral density, cortical thickness, tibial bone ultimate load or stiffness (P ≥ 0.086). Overall, these results indicate that BZA may be an estrogen receptor agonist in skeletal muscle, as it has previously been shown in bone, providing minor benefits to the musculoskeletal system.
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Affiliation(s)
- Christine A. Cabelka
- Divisions of Rehabilitation Science and Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota; MMC 388, 420 Delaware St SE, Minneapolis, MN 55455, USA
- Department of Physical Therapy, The College of St. Scholastica; 940 Woodland Ave, Suite 210, Duluth, MN 55812, USA
| | - Cory W. Baumann
- Divisions of Rehabilitation Science and Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota; MMC 388, 420 Delaware St SE, Minneapolis, MN 55455, USA
| | - Angus Lindsay
- Divisions of Rehabilitation Science and Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota; MMC 388, 420 Delaware St SE, Minneapolis, MN 55455, USA
- Department of Biochemistry, Molecular Biology and Biophysics, University of Minnesota; 420 Washington Ave SE, Minneapolis, MN 55455, USA
| | - Andrew Norton
- Department of Developmental and Surgical Sciences, University of Minnesota; School of Dentistry, Room 16-146 Moos Tower, 515 Delaware St. SE, Minneapolis, MN 55455, USA
| | - Nick C. Blixt
- Department of Genetics, Cell Biology and Development, University of Minnesota; 6-160 Jackson Hall, 321 Church St.SE, Minneapolis, MN 55455, USA
| | - Gengyun Le
- Divisions of Rehabilitation Science and Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota; MMC 388, 420 Delaware St SE, Minneapolis, MN 55455, USA
| | - Gordon L. Warren
- Department of Physical Therapy, Georgia State University; P.O. Box 4019, Atlanta, GA 30302, USA
| | - Kim C. Mansky
- Department of Developmental and Surgical Sciences, University of Minnesota; School of Dentistry, Room 16-146 Moos Tower, 515 Delaware St. SE, Minneapolis, MN 55455, USA
| | - Susan A. Novotny
- Divisions of Rehabilitation Science and Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota; MMC 388, 420 Delaware St SE, Minneapolis, MN 55455, USA
- Gillette Children’s Specialty Healthcare, 200 University Avenue East, Saint Paul, MN 55101, USA
| | - Dawn A. Lowe
- Divisions of Rehabilitation Science and Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota; MMC 388, 420 Delaware St SE, Minneapolis, MN 55455, USA
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Kanazawa I, Inaba M, Inoue D, Uenishi K, Saito M, Shiraki M, Suzuki A, Takeuchi Y, Hagino H, Fujiwara S, Sugimoto T. Executive summary of clinical practice guide on fracture risk in lifestyle diseases. J Bone Miner Metab 2020; 38:746-758. [PMID: 32892240 DOI: 10.1007/s00774-020-01149-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/23/2020] [Indexed: 12/16/2022]
Abstract
Accumulating evidence has shown that patients with lifestyle diseases such as type 2 diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease are at increased risk of osteoporotic fracture. Fractures deteriorate quality of life, activities of daily living, and mortality as well as a lifestyle disease. Therefore, preventing fracture is an important issue for those patients. Although the mechanism of the lifestyle diseases-induced bone fragility is still unclear, not only bone mineral density (BMD) reduction but also bone quality deterioration are involved in it. Because fracture predictive ability of BMD and FRAX® is limited, especially for patients with lifestyle diseases, the optimal management strategy should be established. Thus, when the intervention of the lifestyle diseases-induced bone fragility is initiated, the deterioration of bone quality should be taken into account. We here review the association between lifestyle diseases and fracture risk and proposed an algorism of starting anti-osteoporosis drugs for patients with lifestyle diseases.
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Affiliation(s)
- Ippei Kanazawa
- Kanazawa Diabetes and Osteoporosis Clinic, 990-2-1 Enya-cho, Izumo, Shimane, 693-0021, Japan.
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Inoue
- Third Department of Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Kazuhiro Uenishi
- Division of Nutritional Physiology, Kagawa Nutrition University, Saitama, Japan
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Masataka Shiraki
- Research Institute and Practice for Involutional Diseases, Nagano, Japan
| | - Atsushi Suzuki
- Department of Endocrinology and Metabolism, Fujita Health University, Aichi, Japan
| | - Yasuhiro Takeuchi
- Endocrine Center, Toranomon Hospital and Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Hiroshi Hagino
- School of Health Science Faculty of Medicine, Tottori University, Tottori, Japan
| | - Saeko Fujiwara
- Department of Pharmacy, Yasuda Women's University, Hiroshima, Japan
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Yuasa Y, Miyakoshi N, Kasukawa Y, Nagahata I, Akagawa M, Ono Y, Sato C, Tsuchie H, Nozaka K, Nagasawa H, Hongo M, Shimada Y. Effects of bazedoxifene and low-intensity aerobic exercise on bone and fat parameters in ovariectomized rats. J Bone Miner Metab 2020; 38:179-187. [PMID: 31587108 DOI: 10.1007/s00774-019-01045-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/29/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Postmenopausal osteoporosis and dyslipidemia are well-known skeletal and metabolic changes in middle-aged women. We investigated the effects of combined treatments with a selective estrogen receptor modulator (SERM) and exercise on bone and fat parameters in ovariectomized (OVX) rats. MATERIALS AND METHODS Sixteen-week-old female Sprague-Dawley rats underwent bilateral ovariectomy, and rats were randomized to BZA (bazedoxifene at 0.3 mg/kg/day), Exe (treadmill exercise at 12-15 m/min, 60 min/day, 5 days/week), Comb (BZA and Exe), and Cont (control treated with vehicle and no exercise) groups 8 weeks after ovariectomy. After 4 or 8 weeks of treatment, bone mineral density (BMD) of the total femur and lumbar spine and whole-body percentage fat mass were determined by dual-energy X-ray absorptiometry, and mechanical testing of the femoral shaft, and bone and fat histomorphometric analyses of the proximal tibia were performed. RESULTS Treadmill exercise had decreased bone marrow adipocytes from 4 weeks of treatment and whole-body percentage fat mass at 8 weeks. BZA increased BMD at the lumbar spine and decreased the whole-body percentage fat mass from 4 weeks and bone marrow adipocytes at 8 weeks. Combination therapy increased BMD for the lumbar spine and decreased bone marrow adipocytes and whole-body percentage fat mass from 4 weeks. CONCLUSION Combination therapy with BZA and exercise appears effective to improve bone and fat parameters in OVX rats.
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Affiliation(s)
- Yusuke Yuasa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Yuji Kasukawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Itsuki Nagahata
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Manabu Akagawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yuichi Ono
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Chiaki Sato
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Hiroyuki Tsuchie
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Koji Nozaka
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Hiroyuki Nagasawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Michio Hongo
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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Kida Y, Saito M, Shinohara A, Soshi S, Marumo K. Non-invasive skin autofluorescence, blood and urine assays of the advanced glycation end product (AGE) pentosidine as an indirect indicator of AGE content in human bone. BMC Musculoskelet Disord 2019; 20:627. [PMID: 31881872 PMCID: PMC6933723 DOI: 10.1186/s12891-019-3011-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/17/2019] [Indexed: 12/21/2022] Open
Abstract
Background Bone mineral density (BMD) measurements are widely used to assess fracture risk. However, the finding that some fracture patients had high BMD together with the low contribution of drugs to osteoporosis suggests that bone strength factors other than BMD contribute to bone quality. We evaluated the amount of advanced glycation end products (AGEs) by non-invasive assays of serum and urine as well as by skin autofluorescence to measure the levels of a representative AGE, pentosidine, to investigate whether pentosidine can serve as an indirect indicator of AGEs formation in bone collagen. Methods A total of 100 spinal surgery patients without fragility fracture (54 males and 46 females) treated at our hospital were enrolled. The amount of pentosidine in blood, urine, skin and bone (lumbar lamina) samples from these patients was measured. AGE accumulation was assessed by measuring skin autofluorescence. We examined the correlation between pentosidine content in tissues and body fluid, as well as skin AGEs with age, height, body weight, BMI, and estimated glomerular filtration rate (eGFR). Results A significant age-related increase in pentosidine levels in tissues was observed, while there was a significant negative correlation between tissue pentosidine and eGFR. The amount of skin pentosidine was significantly and positively correlated with pentosidine content of the bone in those under 50 years of age. Urine pentosidine also correlated positively with bone pentosidine and skin pentosidine, but only in females. The total amount of AGEs in skin did not correlate with bone pentosidine. Conclusion In this study, the strong correlation between the pentosidine content in each sample and eGFR may indicate that renal dysfunction with advancing age increases oxidative stress and induces AGEs formation in collagen-containing tissues. The correlation of skin pentosidine concentration and eGFR, with AGEs formation in bone collagen suggests that pentosidine would be a useful indirect index of decreased bone quality. Skin AGEs estimated by autofluorescence in clinical situations may not be suitable as an indirect assessment of bone quality. Because urine pentosidine correlated positively with bone pentosidine and skin pentosidine in females, urine pentosidine may be a candidate for an indirect assessment of bone quality.
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Affiliation(s)
- Yoshikuni Kida
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Akira Shinohara
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shigeru Soshi
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Keishi Marumo
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
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Shiraki M, Kashiwabara S, Imai T, Tanaka S, Saito M. The association of urinary pentosidine levels with the prevalence of osteoporotic fractures in postmenopausal women. J Bone Miner Metab 2019; 37:1067-1074. [PMID: 31214839 DOI: 10.1007/s00774-019-01017-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/03/2019] [Indexed: 12/13/2022]
Abstract
To evaluate whether or not the urinary pentosidine level has clinical value in the assessment of the osteoporotic fracture risk, a novel ELISA for pentosidine was used in clinical samples. This study employed a cross-sectional design to analyze a subset of postmenopausal women in the Nagano Cohort Study. A total of 517 urine samples were analyzed using an ELISA system, which can measure urinary pentosidine without hydrolysis. Patients were asked about their history of non-vertebral osteoporotic fracture and the prevalence of vertebral fracture was semi-quantitatively assessed on X-ray films. A 10-year increase in age was related to a 1.09-fold increase in the urinary pentosidine level (95% CI 1.05-1.13, P < 0.001), prevalent fracture (+) was related to a 1.10-fold increase in the urinary pentosidine level (95% CI 1.03-1.18, P = 0.006). Patients with prevalent fracture who had a normal bone mineral density (BMD) showed higher pentosidine levels (median 34.3 pM/mg Cr) than patients with a low BMD without fracture (median 31.4 pM/mg Cr). A multivariable logistic regression analysis revealed that urinary pentosidine was significantly associated with the prevalence of fracture after adjustment for known risk factors for fracture (odds ratio 1.92, 95% CI 1.09-3.37, P = 0.023). The present results indicated a significant association between urinary pentosidine and fracture after adjustment for age and BMD, suggesting that urinary pentosidine may be useful for assessing the fracture risk in postmenopausal women.
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Affiliation(s)
- Masataka Shiraki
- Research Institute and Practice for Involutional Diseases, 1610-1, Meisei, Misato, Azumino, Nagano Prefecture, 399-8101, Japan.
| | | | - Takumi Imai
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuru Saito
- Department of Orthopedic Surger, Jikei University School of Medicine, Tokyo, Japan
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Permuy M, López-Peña M, Muñoz F, González-Cantalapiedra A. Rabbit as model for osteoporosis research. J Bone Miner Metab 2019; 37:573-583. [PMID: 31087186 DOI: 10.1007/s00774-019-01007-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/20/2019] [Indexed: 10/26/2022]
Abstract
Osteoporosis is a major public health problem affecting more than 200 million people worldwide. The use of different animal models, for the study of its pathophysiology and treatments, is important being actually the ovariectomized rat the most widely used; although this model has several problems due its small size, lack of true closure of epiphyseal plate and bone differences with humans. This review is aimed at summarizing the most common methods published for osteoporosis induction in rabbits as model for human disease with their advantages and disadvantages. The paper shows the advantages of the use of this specie compared with the rat. All the techniques seemed to achieve the osteoporotic condition, but the one which obtained the most consistent bone mineral reduction in less time was the combination of surgery and corticoid treatment. The conclusion of the review was that rabbits are promising as a model of osteoporosis research because of their size, haversian remodelling and closure of epiphyseal plate, which solve some of the problems of the rat model. There are different techniques in the literature used to achieve the osteoporotic condition with diverse results, but there is a lack of consensus as to the best one.
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Affiliation(s)
- María Permuy
- Departamento de Anatomía, Producción Animal e Ciencias Clínicas Veterinarias, Universidade De Santiago de Compostela, Campus Universitario s/n, 27002, Lugo, Spain.
| | - Mónica López-Peña
- Departamento de Anatomía, Producción Animal e Ciencias Clínicas Veterinarias, Universidade De Santiago de Compostela, Campus Universitario s/n, 27002, Lugo, Spain
| | - Fernando Muñoz
- Departamento de Anatomía, Producción Animal e Ciencias Clínicas Veterinarias, Universidade De Santiago de Compostela, Campus Universitario s/n, 27002, Lugo, Spain
| | - Antonio González-Cantalapiedra
- Departamento de Anatomía, Producción Animal e Ciencias Clínicas Veterinarias, Universidade De Santiago de Compostela, Campus Universitario s/n, 27002, Lugo, Spain
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Yoshitake S, Mashiba T, Saito M, Fujihara R, Iwata K, Takao-Kawabata R, Yamamoto T. Once-Weekly Teriparatide Treatment Prevents Microdamage Accumulation in the Lumbar Vertebral Trabecular Bone of Ovariectomized Cynomolgus Monkeys. Calcif Tissue Int 2019; 104:402-410. [PMID: 30564860 DOI: 10.1007/s00223-018-0500-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/26/2018] [Indexed: 01/22/2023]
Abstract
The effect of teriparatide treatment on microdamage accumulation has yet to be examined in animal studies. The purpose of this study was to investigate the effect of once-weekly teriparatide treatment on bone microdamage accumulation and the relationship between microdamage parameters and bone mass, architecture, turnover, and collagen cross-linking in the lumbar vertebral trabecular bone of ovariectomized (OVX) cynomolgus monkeys. Female monkeys were divided into four groups (n = 18-20 per group): (1) SHAM group, (2) OVX group, (3) OVX with 1.2 µg/kg once-weekly teriparatide group (LOW group), (4) OVX with 6.0 µg/kg once-weekly teriparatide group (HIGH group). After 18 months, all animals were double-labeled with calcein for histomorphometry. L3 and L7 lumbar vertebrae were harvested and analyzed for differences in histomorphometry, microdamage, and collagen cross-linking. The iliac crest was also analyzed for differences in bone turnover. In the OVX group, cancellous bone mass was reduced and microdamage accumulation was increased as compared with the SHAM control. Once-weekly teriparatide at both doses prevented the decrease in bone mass and increase in microdamage accumulation, and improved the distribution of collagen cross-linkage types. Regression analyses indicated that decreased microdamage accumulation was associated with reduced non-enzymatic cross-link pentosidine rather than increased cancellous bone mass or enzymatic cross-links. These findings suggest that once-weekly teriparatide treatment decreases microdamage accumulation by recovering the balance in collagen cross-links.
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Affiliation(s)
- Shingo Yoshitake
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Tasuku Mashiba
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ryuji Fujihara
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Ken Iwata
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Ryoko Takao-Kawabata
- Pharmaceuticals Research Center, Asahi Kasei Pharma Corporation, 632-1 Mifuku, Izunokuni, Shizuoka, 410-2321, Japan
| | - Tetsuji Yamamoto
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
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Zhu Z, Li J, Ruan G, Wang G, Huang C, Ding C. Investigational drugs for the treatment of osteoarthritis, an update on recent developments. Expert Opin Investig Drugs 2018; 27:881-900. [PMID: 30345826 DOI: 10.1080/13543784.2018.1539075] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Osteoarthritis (OA) is the leading cause of pain, loss of function, and disability among elderly, with the knee the most affected joint. It is a heterogeneous condition characterized by complex and multifactorial etiologies which contribute to the broad variation in symptoms presentation and treatment responses that OA patients present. This poses a challenge for the development of effective treatment on OA. AREAS COVERED This review will discuss recent development of agents for the treatment of OA, updating our previous narrative review published in 2015. They include drugs for controlling local and systemic inflammation, regulating articular cartilage, targeting subchondral bone, and relieving pain. EXPERT OPINION Although new OA drugs such as monoclonal antibodies have shown marked effects and favorable tolerance, current treatment options for OA remain limited. The authors believe there is no miracle drug that can be used for all OA patients'; treatment and disease stage is crucial for the effectiveness of drugs. Therefore, early diagnosis, phenotyping OA patients and precise therapy would expedite the development of investigational drugs targeting at symptoms and disease progression of OA.
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Affiliation(s)
- Zhaohua Zhu
- a Clinical Research Centre, Zhujiang Hospital, Southern Medical University , Guangzhou , China
| | - Jia Li
- a Clinical Research Centre, Zhujiang Hospital, Southern Medical University , Guangzhou , China
| | - Guangfeng Ruan
- a Clinical Research Centre, Zhujiang Hospital, Southern Medical University , Guangzhou , China.,b Department of Rheumatology and Immunology , Arthritis Research Institute, The First Affiliated Hospital of Anhui Medical University , Hefei , China
| | - Guoliang Wang
- c Menzies Institute for Medical Research, University of Tasmania , Hobart , Australia
| | - Cibo Huang
- d Department of Rheumatology & Immunology , Beijing Hospital , Beijing , China
| | - Changhai Ding
- a Clinical Research Centre, Zhujiang Hospital, Southern Medical University , Guangzhou , China.,b Department of Rheumatology and Immunology , Arthritis Research Institute, The First Affiliated Hospital of Anhui Medical University , Hefei , China.,c Menzies Institute for Medical Research, University of Tasmania , Hobart , Australia
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Abstract
PURPOSE OF REVIEW Homocystinuria is a congenital metabolic disorder in which cystathionine β-synthase deficiency results in a prominent increase in homocysteine (serum levels > 100 μM), causing mental retardation, atherosclerotic cerebral infarction, and osteoporosis accompanied by fragility fractures. Encountering a case with excessive homocysteinemia such as that seen in hereditary homocystinuria is unlikely during usual medical examinations. However, in individuals who have vitamin B or folate deficiency, serum homocysteine concentrations are known to increase. These individuals may also have a polymorphism in methylenetetrahydrofolate reductase, MTHFR (C677T: TT type), which regulates homocysteine metabolism. These changes in homocysteine levels may elicit symptoms resembling those of homocystinuria (e.g., Alzheimer's disease, atherosclerosis, osteoporosis). RECENT FINDINGS High serum homocysteine has been shown to have detrimental effects on neural cells, vascular endothelial cells, osteoblasts, and osteoclasts. Homocysteine is also known to increase oxidative stress, disrupt cross-linking of collagen molecules, and increase levels of advanced glycation end products, which results in reduced bone strength through a mechanism that goes beyond low bone density and increased bone resorption. Therefore, high serum homocysteine may be regarded as a factor that can reduce both bone mass and impair bone quality. In this review, we outline the epidemiology and pathophysiology of osteoporosis associated with hyperhomocysteinemia.
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Affiliation(s)
- Mitsuru Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Keishi Marumo
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
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Ishimoto T, Yamada K, Takahashi H, Takahata M, Ito M, Hanawa T, Nakano T. Trabecular health of vertebrae based on anisotropy in trabecular architecture and collagen/apatite micro-arrangement after implantation of intervertebral fusion cages in the sheep spine. Bone 2018; 108:25-33. [PMID: 29241826 DOI: 10.1016/j.bone.2017.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/07/2017] [Accepted: 12/10/2017] [Indexed: 11/22/2022]
Abstract
Healthy trabecular bone shows highly anisotropic trabecular architecture and the preferential orientation of collagen and apatite inside a trabecula, both of which are predominantly directed along the cephalocaudal axis. This makes trabecular bone stiff in the principally loaded direction (cephalocaudal axis). However, changes in these anisotropic trabecular characteristics after the insertion of implant devices remain unclear. We defined the trabecular architectural anisotropy and the preferential orientation of collagen and apatite as parameters of trabecular bone health. In the present study, we analyzed these parameters after the implantation of two types of intervertebral fusion cages, open and closed box-type cages, into sheep spines for 2 and 4months. Alteration and evolution of trabecular health around and inside the cages depended on the cage type and implantation duration. At the boundary region, the values of trabecular architectural anisotropy and apatite orientation for the closed-type cages were similar to those for isotropic conditions. In contrast, significantly larger anisotropy was found for open-type cages, indicating that the open-type cage tended to maintain trabecular anisotropy. Inside the open-type cage, trabecular architectural anisotropy and apatite orientation significantly increased with time after implantation. Assessing trabecular anisotropy might be useful for the evaluation of trabecular health and the validation and refinement of implant designs.
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Affiliation(s)
- Takuya Ishimoto
- Division of Materials and Manufacturing Science, Graduate School of Engineering, Osaka University, 2-1, Yamada-Oka, Suita, Osaka 565-0871, Japan
| | - Katsuhisa Yamada
- Department of Orthopedic Surgery, Graduate School of Medicine, Hokkaido University, North-15, West-7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan
| | - Hiroyuki Takahashi
- Division of Materials and Manufacturing Science, Graduate School of Engineering, Osaka University, 2-1, Yamada-Oka, Suita, Osaka 565-0871, Japan; Teijin Nakashima Medical Co., Ltd., 688-1 Joto-Kitagata, Higashi-ku, Okayama 709-0625, Japan
| | - Masahiko Takahata
- Department of Orthopedic Surgery, Graduate School of Medicine, Hokkaido University, North-15, West-7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan
| | - Manabu Ito
- Department of Spine and Spinal Cord Disorders, National Hospital Organization, Hokkaido Medical Center, 5-7-1-1 Yamanote, Nishi-ku, Sapporo, Hokkaido 063-0005, Japan
| | - Takao Hanawa
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Kanda-surugadai, Chiyoda-ku, Tokyo 101-0062, Japan
| | - Takayoshi Nakano
- Division of Materials and Manufacturing Science, Graduate School of Engineering, Osaka University, 2-1, Yamada-Oka, Suita, Osaka 565-0871, Japan.
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Pelvic fractures after definitive and postoperative radiotherapy for cervical cancer: A retrospective analysis of risk factors. Gynecol Oncol 2017; 147:585-588. [DOI: 10.1016/j.ygyno.2017.09.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/24/2017] [Accepted: 09/30/2017] [Indexed: 11/23/2022]
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Mashiba T, Saito M, Yamagami Y, Tanaka M, Iwata K, Yamamoto T. Effects of suppressed bone remodeling by minodronic acid and alendronate on bone mass, microdamage accumulation, collagen crosslinks and bone mechanical properties in the lumbar vertebra of ovariectomized cynomolgus monkeys. Bone 2017; 97:184-191. [PMID: 28082077 DOI: 10.1016/j.bone.2017.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 12/16/2016] [Accepted: 01/06/2017] [Indexed: 01/22/2023]
Abstract
Collagen crosslinking is an important determinant of the quality of bone material. We have previously shown that suppressed bone turnover by high doses of minodronic acid and alendronate increases compressive strength of vertebra, but also increases microdamage accumulation, in monkey bone. The aim of this study is to examine the effects of these bisphosphonates on collagen crosslinks and intrinsic material properties, in addition to microdamage accumulation, in vertebral cancellous bone in ovariectomized cynomolgus monkeys. Sixty female monkeys aged 9-17years were divided into five groups: sham and ovariectomized groups were treated daily for 17months with lactose vehicle, and the other three groups were given minodronic acid daily at 0.015 or 0.15mg/kg or alendronate daily at 0.5mg/kg orally. After sacrifice, lumbar vertebrae were subjected to histomorphometry, microdamage measurement, analysis of collagen crosslinking and compressive mechanical tests. Minodronic acid caused dose-dependent suppression of increased bone remodeling due to ovariectomy, and low-dose minodronic acid suppressed remodeling same level as alendronate. However, low-dose minodronic acid did not change microdamage accumulation, collagen maturity and the pentosidine level, whereas high-dose minodronic acid and alendronate increased these parameters. Compressive ultimate load was increased following high-dose minodronic acid and alendronate, but no treatment altered the reduction in intrinsic material properties caused by ovariectomy. These findings suggest that deterioration of bone material and formation of pentosidine and microdamage induced by minodronic acid is less than that expected based on the extent of remodeling suppression, in comparison with alendronate, but this was not reflected in any significant change of mechanical properties.
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Affiliation(s)
- Tasuku Mashiba
- Department of Orthopedic Surgery, Kagawa University Faculty of Medicine, Kagawa, Japan.
| | - Mitsuru Saito
- Department of Orthopedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiki Yamagami
- Department of Orthopedic Surgery, Kagawa University Faculty of Medicine, Kagawa, Japan
| | - Makoto Tanaka
- Research Promotion, Ono Pharmaceutical Co., Ltd., Osaka, Japan
| | - Ken Iwata
- Department of Orthopedic Surgery, Kagawa University Faculty of Medicine, Kagawa, Japan
| | - Tetsuji Yamamoto
- Department of Orthopedic Surgery, Kagawa University Faculty of Medicine, Kagawa, Japan
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Pentosidine as a Biomarker for Poor Bone Quality and Elevated Fracture Risk. BIOMARKERS IN BONE DISEASE 2017. [DOI: 10.1007/978-94-007-7693-7_32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Xiao YP, Tian FM, Dai MW, Wang WY, Shao LT, Zhang L. Are estrogen-related drugs new alternatives for the management of osteoarthritis? Arthritis Res Ther 2016; 18:151. [PMID: 27352621 PMCID: PMC4924302 DOI: 10.1186/s13075-016-1045-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Osteoarthritis (OA) is a chronic degenerative disease involving multiple physiopathological mechanisms. The increased prevalence of OA after menopause and the presence of estrogen receptors in joint tissues suggest that estrogen could help prevent development of OA. This review summarizes OA research with a focus on the effects of estrogen and selective estrogen receptor modulators (SERMs). Preclinical studies and clinical trials of estrogen therapy have reported inconsistent results. However, almost all studies assessing SERM treatment have obtained more consistent and favorable effects in OA with a relatively safety and tolerability profiles. At present, some SERMs including raloxifene and bazedoxifene have been approved for the treatment of osteoporosis. In summary, estrogen-related agents may exert both a direct effect on subchondral bone and direct and/or indirect effects upon the surrounding tissues, including the articular cartilage, synovium, and muscle, to name a few. Estrogen and SERMs may be particularly favorable for postmenopausal patients with early-stage OA or osteoporotic OA, a phenotype defined by reduced bone mineral density related to high remodeling in subchondral bone. At present, no single drug exists that can prevent OA progression. Although estrogen-related drugs provide insight into the continued work in the field of OA drug administration, further research is required before SERMs can become therapeutic alternatives for OA treatment.
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Affiliation(s)
- Ya-Ping Xiao
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Road, Tangshan, Hebei Province, China
| | - Fa-Ming Tian
- Medical Research Center, North China University of Science and Technology, Tangshan, China
| | - Mu-Wei Dai
- Department of Orthopedic Surgery, Hebei Medical University, Shijiazhuang, China
| | - Wen-Ya Wang
- Department of Pathology, School of Basic Medical Sciences, North China University of Science and Technology, Tangshan, China
| | - Li-Tao Shao
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Road, Tangshan, Hebei Province, China
| | - Liu Zhang
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Road, Tangshan, Hebei Province, China.
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