Treatment with beta-blockers, ACE inhibitors, and calcium-channel blockers is associated with a reduced fracture risk: a nationwide case–control study

Systemic Factors Affecting Prognosis of Dental Implants

Clinicians who place and restore implants are always concerned about the success and longevity of the same. There are several local and systemic factors that affect osseointegration and the health of the peri-implant tissues. In this study, we review the systemic factors that can affect implant survival, osseointegration, and long-term success. The study highlights the importance of delineating, and taking into consideration these systemic factors from the planning phase to the restorative phase of dental implants. A thorough medical history, including prescription and over-the-counter medications, is vital, as there may be numerous factors that could directly or indirectly influence the prognosis of dental implants.

Evaluation of antihypertensive drug-induced changes in mandibular bone using fractal analysis

OBJECTIVE

The aim was to evaluate changes in trabecular and cortical mandibular bone caused by antihypertensive (AHT) drugs through fractal analysis.

STUDY DESIGN

This retrospective study included 230 patients who were taking AHT medication and had no conditions affecting bone metabolism other than hypertension. A control group of 230 healthy, sex-matched individuals was also included. Patients were divided into subgroups according to AHT drugs: thiazide diuretics (TDs), beta-blockers (BBs), angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and a combination of drugs. The fractal dimension (FD) was calculated bilaterally in 5 regions of interest (ROI 1 - ROI 5) including 4 trabecular regions and 1 cortical region using Image J software.

RESULTS

Mean FD values were significantly higher in all ROIs for the study group compared to the control group (P < .001). FDs were significantlty higher for BB, ACEI, ARB, CCB, and combined subgroups compared to controls in ROIs 1, 2, and 4; for ACEI and CCB subgroups compared to controls in ROI 3; and for TD, BB, ACEI, ARB, CCB, and combined subgroups compared to controls in ROI 5 (P < .001).

CONCLUSIONS

AHTs may increase FD values of the trabecular and cortical structures. Assessment of the effects of AHT drugs is essential for predicting the prognosis for bone healing after tooth extraction, osseointegration after implant surgery, or other surgical procedures.

Hypertension in an ageing population: Diagnosis, mechanisms, collateral health risks, treatments, and clinical challenges

Ageing population is considerably increasing worldwide, which is considered to reflect an improved quality of life. However, longevity in the human lifespan has increased the burden of late-life illnesses including cancer, neurodegeneration, and cardiovascular dysfunction. Of these, hypertension is the most common condition with huge health risks, with an increased prevalence among the elderly. In this review, we outline the current guidelines for defining hypertension and examine the detailed mechanisms underlying the relationship between hypertension and ageing-related outcomes, including sodium sensitivity, arterial stiffness, endothelial dysfunction, isolated systolic hypertension, white coat effect, and orthostatic hypertension. As hypertension-related collateral health risk increases among the elderly, the available management strategies are necessary to overcome the clinical treatment challenges faced among elderly population. To improve longevity and reduce adverse health effects, potential approaches producing crucial information into new era of medicine should be considered in the prevention and treatment of hypertension among elderly population. This review provides an overview of mechanisms underlying hypertension and its related collateral health risk in elderly population, along with multiple approaches and management strategies to improve the clinical challenges among elderly population.

Renin-angiotensin system inhibitors positively impact on multiple aging regulatory pathways: Could they be used to protect against human aging?

The renin-angiotensin system (RAS)-a classical blood pressure regulator-largely contributes to healthy organ development and function. Besides, RAS activation promotes age-related changes and age-associated diseases, which are attenuated/abolished by RAS-blockade in several mammalian species. RAS-blockers also increase rodent lifespan. In previous work, we discussed how RAS-blockade downregulates mTOR and growth hormone/IGF-1 signaling, and stimulates AMPK activity (together with klotho, sirtuin, and vitamin D-receptor upregulation), and proposed that at least some of RAS-blockade's aging benefits are mediated through regulation of these intermediaries and their signaling to mitochondria. Here, we included RAS-blockade's impact on other aging regulatory pathways, that is, TGF-ß, NF-kB, PI3K, MAPK, PKC, Notch, and Wnt, all of which affect mitochondria. No direct evidence is available on RAS/RAS-blockade-aging regulatory pathway-mitochondria interactions. However, existing results allow to conjecture that RAS-blockers neutralize mitochondrial dysfunction by acting on the discussed pathways. The reviewed evidence led us to propose that the foundation is laid for conducting clinical trials aimed at testing whether angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB)-even at subclinical doses-offer the possibility to live longer and in better health. As ACEi and ARB are low cost and well-tolerated anti-hypertension therapies in use for over 35 years, investigating their administration to attenuate/prevent aging effects seems simple to implement.

Alamandine attenuates ovariectomy-induced osteoporosis by promoting osteogenic differentiation via AMPK/eNOS axis

BACKGROUND

Alamandine is a newly characterized peptide of renin angiotensin system. Our study aims to investigate the osteo-preservative effects of alamandine, explore underlying mechanism and bring a potential preventive strategy for postmenopausal osteoporosis in the future.

METHODS

An ovariectomy (OVX)-induced rat osteoporosis model was established for in vivo experiments. Micro-computed tomography and three-point bending test were used to evaluate bone strength. Histological femur slices were processed for immunohistochemistry (IHC). Bone turnover markers and nitric oxide (NO) concentrations in serum were determined with enzyme-linked immunosorbent assay (ELISA). The mouse embryo osteoblast precursor (MC3T3-E1) cells were used for in vitro experiments. The cell viability was analysed with a Cell Counting Kit‑8. We performed Alizarin Red S staining and alkaline phosphatase (ALP) activity assay to observe the differentiation status of osteoblasts. Western blotting was adopted to detect the expression of osteogenesis related proteins and AMP-activated protein kinase/endothelial nitric oxide synthase (AMPK/eNOS) in osteoblasts. DAF-FM diacetate was used for semi-quantitation of intracellular NO.

RESULTS

In OVX rats, alamandine alleviated osteoporosis and maintained bone strength. The IHC showed alamandine increased osteocalcin and collagen type I α1 (COL1A1) expression. The ELISA revealed alamandine decreased bone turnover markers and restored NO level in serum. In MC3T3-E1 cells, alamandine promoted osteogenic differentiation. Western blotting demonstrated that alamandine upregulated the expression of osteopontin, Runt-related transcription factor 2 and COL1A1. The intracellular NO was also raised by alamandine. Additionally, the activation of AMPK/eNOS axis mediated the effects of alamandine on MC3T3-E1 cells and bone tissue. PD123319 and dorsomorphin could repress the regulating effect of alamandine on bone metabolism.

CONCLUSION

Alamandine attenuates ovariectomy-induced osteoporosis by promoting osteogenic differentiation via AMPK/eNOS axis.

Advanced Progress of the Relationship Between Antihypertensive Drugs and Bone Metabolism

Hypertension and osteoporosis are common comorbidities among elderly individuals. Drug therapy has been widely used in clinical practice as the preferred antihypertensive treatment. Therefore, antihypertensive drugs have become some of the most commonly prescribed drugs in healthcare settings. However, antihypertensive drugs have different effects on bone metabolism. The results of animal and clinical studies on the effects of antihypertensive drugs on osteoporosis or fracture risk are controversial and have aroused widespread concern among clinicians. Recent studies found that angiotensin receptor blockers, selective β-adrenergic receptor blockers, and thiazide diuretics might improve bone trabecular number and bone mineral density by stimulating osteoblast differentiation, reducing osteoclast generation, and other mechanism. Furthermore, nonselective β-adrenergic receptor blockers and dihydropyridine calcium channel blockers were found to have no significant relationship with bone mineral density or bone strength, and α-adrenergic receptor blockers and loop diuretics might increase fracture risk by decreasing bone mineral density. This article aimed to review previous animal experiments, clinical studies, and meta-analyses focusing on the effects of different antihypertensive drugs on bone metabolism, and to provide a new approach for the prevention and treatment of osteoporosis.

Brown Tumour in Chronic Kidney Disease: Revisiting an Old Disease with a New Perspective

Osteitis fibrosa cystica (OFC) and Brown Tumours are two related but distinct types of bone lesions that result from the overactivity of osteoclasts and are most often associated with chronic kidney disease (CKD). Despite their potential consequences, these conditions are poorly understood because of their rare prevalence and variability in their clinical manifestation. Canonically, OFC and Brown Tumours are caused by secondary hyperparathyroidism in CKD. Recent literature showed that multiple factors, such as hyperactivation of the renin-angiotensin-aldosterone system and chronic inflammation, may also contribute to the occurrence of these diseases through osteoclast activation. Moreover, hotspot KRAS mutations were identified in these lesions, placing them in the spectrum of RAS-MAPK-driven neoplasms, which were until recently thought to be reactive lesions. Some risk factors contributed to the occurrence of OFC and Brown Tumours, such as age, gender, comorbidities, and certain medications. The diagnosis of OFC and Brown Tumours includes clinical symptoms involving chronic bone pain and laboratory findings of hyperparathyroidism. In radiological imaging, the X-ray and Computed tomography (CT) scan could show lytic or multi-lobular cystic alterations. Histologically, both lesions are characterized by clustered osteoclasts in a fibrotic hemorrhagic background. Based on the latest understanding of the mechanism of OFC, this review elaborates on the manifestation, diagnosis, and available therapies that can be leveraged to prevent the occurrence of OFC and Brown Tumours.

Association between clinical use of nifedipine and the risk of osteoporosis: a nationwide retrospective cohort study

Nifedipine is one of the common calcium channel blockers (CCBs) for hypertension that induce peroxisome-proliferator-activated receptor γ coactivator 1-α, which is envisioned as a potential therapeutic target in bone disease. The findings of this retrospective cohort study suggest that patients who receive nifedipine may have a potential protective effect on osteoporosis in comparison to other CCBs.

INTRODUCTION

Nifedipine was one L-type dihydropyridine calcium channel blocker (CCB) that can improve bone loss. However, epidemiological studies on the association between the use of nifedipine and osteoporosis risk are limited. Thus, this study aimed to evaluate the association between the clinical use of nifedipine and the risk of osteoporosis.

METHODS

This retrospective cohort was conducted using the National Health Insurance Research Database of Taiwan from 2000 to 2013. The study includes 1225 patients receiving nifedipine (the exposed cohort) and 4900 patients receiving other CCBs (the comparison cohort). The primary outcome was the diagnosis of osteoporosis. The hazard ratios (HRs) and 95% confidence intervals (CIs) were used to assess the association between the use of nifedipine and the risk of osteoporosis.

RESULTS

Patients receiving nifedipine treatment had a reduced risk of osteoporosis as compared with those undergoing other CCB treatments (adjusted HR, 0.44; 95% CI, 0.37-0.53). Moreover, this inverse association is evident in both sexes and various age groups.

CONCLUSIONS

This population-based cohort study demonstrated that nifedipine may have potential protective effect on osteoporosis compared with other CCBs. The clinical implications of the present study need further investigation.

Association of antihypertensive drugs with fracture and bone mineral density: A comprehensive drug-target Mendelian randomization study

Background

Observational studies have investigated the associations between antihypertensive drugs and fracture risk as well as bone mineral density (BMD), but yielding controversial results.

Methods

In this study, a comprehensive drug-target Mendelian randomization (MR) analysis was conducted to systematically examine the associations between genetic proxies for eight common antihypertensive drugs and three bone health-related traits (fracture, total body BMD [TB-BMD], and estimated heel BMD [eBMD]). The main analysis used the inverse-variance weighted (IVW) method to estimate the causal effect. Multiple MR methods were also employed to test the robustness of the results.

Results

The genetic proxies for angiotensin receptor blockers (ARBs) were associated with a reduced risk of fracture (odds ratio [OR] = 0.67, 95% confidence interval [CI]: 0.54 to 0.84; P = 4.42 × 10-4; P-adjusted = 0.004), higher TB-BMD (β = 0.36, 95% CI: 0.11 to 0.61; P = 0.005; P-adjusted = 0.022), and higher eBMD (β = 0.30, 95% CI: 0.21 to 0.38; P = 3.59 × 10-12; P-adjusted = 6.55 × 10-11). Meanwhile, genetic proxies for calcium channel blockers (CCBs) were associated with an increased risk of fracture (OR = 1.07, 95% CI: 1.03 to 1.12; P = 0.002; P-adjusted = 0.013). Genetic proxies for potassium sparing diuretics (PSDs) showed negative associations with TB-BMD (β = -0.61, 95% CI: -0.88 to -0.33; P = 1.55 × 10-5; P-adjusted = 1.86 × 10-4). Genetic proxies for thiazide diuretics had positive associations with eBMD (β = 0.11, 95% CI: 0.03 to 0.18; P = 0.006; P-adjusted = 0.022). No significant heterogeneity or pleiotropy was identified. The results were consistent across different MR methods.

Conclusions

These findings suggest that genetic proxies for ARBs and thiazide diuretics may have a protective effect on bone health, while genetic proxies for CCBs and PSDs may have a negative effect.

Fracture Risk and Use of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers

Medications used to treat hypertension may affect fracture risk. This study investigated fracture risk for users of angiotensin converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB). Participants (899 men, median age 70.3 yr (59.9-79.1), range 50.0-96.6 yr; 574 women, median age 65.5 yr (58.1-75.4), range 50.1-94.6 yr) were from the Geelong Osteoporosis Study. Medication use was self-reported and incident fractures were ascertained using radiological reports. Bone mineral density (BMD) was measured at the femoral neck. Participants were divided into four groups: (1) non-users without hypertension, (2) non-users with hypertension, (3) ACEI users and (4) ARB users. Dosage was calculated using the defined daily dose (DDD) criteria. Participants were followed from date of visit to first fracture, death or 31 December 2016, whichever occurred first. Cox proportional hazards models were used for analyses. At least one incident fracture was sustained by 156 men and 135 women over a median(IQR) of 11.5(6.2-13.2) and 10.9(6.3-11.6) years of follow-up, respectively. In unadjusted analyses, compared to non-users without hypertension, men in all three other groups had a higher risk of fracture (Hazard Ratio (HR, 95%CI) 1.54, 1.00-2.37; 1.90, 1.18-3.05; 2.15, 1.26-3.66), for non-users with hypertension, ACEI and ARB users, respectively). Following adjustment for age, prior fracture and BMD, these associations became non-significant. A dose effect for ARB use was observed; men using lower doses had a higher risk of fracture than non-users without hypertension, in both unadjusted (2.66, 1.34-5.29) and adjusted (2.03, 1.01-4.08) analyses, but this association was not observed at higher doses. For women, unadjusted analyses showed a higher risk for ACEI users compared to non-users without hypertension (1.74, 1.07-2.83). This was explained after adjustment for age, alcohol consumption, prior fracture and BMD (1.28, 0.74-2.22). No other differences were observed. In men, lower dose (0 < DDD ≤ 1) ARB use was associated with an increased risk of fracture. ACEI or ARB use was not associated with increased risk of incident fracture in women. These findings may be important for antihypertensive treatment decisions in individuals with a high risk of fracture.

Antihypertensive Drugs and Risk of Bone Fractures

Antihypertensive drugs are among the most documented regimens worldwide with an overall survival and cardioprotective benefit. However, there is evidence that they cause symptoms of orthostatic hypotension (i.e., dizziness and syncope) placing patients at risk for falls and fall-related injuries such as bone fractures. Moreover, it seems that they might impact bone metabolism and architecture impairing bone health. The aim of this review was to summarize the accumulative literature exploring any potential association between several antihypertensive medications including diuretics, renin-angiotensin-aldosterone system inhibitors, beta-blockers and calcium channel blockers and the risk of fractures.

Elevated blood pressure, antihypertensive medications and bone health in the population: revisiting old hypotheses and exploring future research directions

Blood pressure and bone metabolism appear to share commonalities in their physiologic regulation. Specific antihypertensive drug classes may also influence bone mineral density. However, current evidence from existing observational studies and randomised trials is insufficient to establish causal associations for blood pressure and use of blood pressure-lowering drugs with bone health outcomes, particularly with the risks of osteoporosis and fractures. The availability and access to relevant large-scale biomedical data sources as well as developments in study designs and analytical approaches provide opportunities to examine the nature of the association between blood pressure and bone health more reliably and in greater detail than has ever been possible. It is unlikely that a single source of data or study design can provide a definitive answer. However, with appropriate considerations of the strengths and limitations of the different data sources and analytical techniques, we should be able to advance our understanding of the role of raised blood pressure and its drug treatment on the risks of low bone mineral density and fractures. As elevated blood pressure is highly prevalent and blood pressure-lowering drugs are widely prescribed, even small effects of these exposures on bone health outcomes could be important at a population level.

Association between bone measures and use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers

Angiotensin-converting enzyme inhibitor use in women was associated with lower femoral neck and lumbar spine bone mineral density as well as trabecular bone score compared to non-users. No differences were identified for men or for those who used ARB medications.

PURPOSE

Many individuals at high fracture risk use medications such as angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) that could affect bone; thus, this study aimed to investigate whether there are any differences in bone mineral density (BMD) and trabecular bone score (TBS) between ACEI users, ARB users, and non-users.

METHODS

Participants (685 men, 573 women) were from the Geelong Osteoporosis Study. Current medication use was self-reported. BMD at the femoral neck (FNBMD) and lumbar spine (LSBMD) were measured using DXA. TBS was calculated using TBS iNsight software. Linear regression models were used to investigate associations between ACEI or ARB use and bone measures, adjusting for other potential confounders. Due to interaction terms, data were stratified by age.

RESULTS

There were 88 (12.8%) men and 41 (7.2%) women taking an ACEI medication, and 71 (10.4%) men and 76 (13.3%) women taking an ARB medication. Compared to non-users, ACEI use was associated with lower FNBMD (- 7.2%), LSBMD (- 12.2%), and TBS (- 9.0%) for women aged < 65 years. Lower TBS was also observed for women aged ≥ 65 years (- 17.3%). No differences were identified for ARB use.

CONCLUSIONS

Women who used an ACEI medication had lower values for FNBMD, LSBMD and TBS compared to non-users. No differences were identified for men or for those who used ARB medications.

Effect of Multimorbidity on Fragility Fractures in Community-Dwelling Older Adults: Shimane CoHRE Study

Fragility fractures (FFxs), which are a common musculoskeletal injury in older adults, is associated with an increased frequency of falls. Both FFxs and falls may result from drugs, habits, and co-occurring diseases. We aimed to evaluate the effects of various diseases on the risk of FFx. This retrospective study included 1420 individuals aged ≥60 years. We evaluated the history of clinical FFx and diseases using a detailed questionnaire and a health examination. The risk of comorbidities was assessed using the Age-Adjusted Charlson Comorbidity (AAC) Index. We performed binary logistic regression analysis to determine the risk of FFx and falls after adjusting for covariates. In elderly men, the incidence of FFx positively correlated with rheumatoid arthritis and parent's hip fracture. For elderly women, the incidence of FFx positively correlated with rheumatoid arthritis and antihypertensive drugs but was inversely associated with dyslipidemia and antilipidemic drugs. The FFX risk of older adults with an AAC Index ≥6 was higher than those with an AAC Index of 1-3. In addition, the AAC Index and falls were independently and strongly associated with a higher risk of FFx. Taken together, multimorbidity increases the risk of clinical FFx independent of falls in the community-dwelling elderly population.

Increased Risk of Nonunion and Charcot Arthropathy After Ankle Fracture in People With Diabetes

The aim of this study was to evaluate the frequency of complications after an ankle fracture in patients with and without diabetes and to evaluate risk factors for nonunion. We conducted a retrospective study of 439 patients with ankle fractures (31.7% had diabetes) and followed them for 1 year or until the fracture healed. The fracture severity and determination of nonunion and Charcot arthropathy were determined from independent evaluation of radiographs by 2 members of the research team. Nonunion was defined as a fracture that did not heal within 6 months of the fracture. The majority of patients were women (67% in each group). The risk of complications was significantly higher in patients with diabetes compared with those without diabetes. The odds ratio (OR) and 95% confidence interval (CI) for nonunion was 6.5 (3.4 to 12.8); for Charcot arthropathy, 7.6 (2.3 to 21.0); for wounds, 1.8 (1.1 to 2.9); for infection, 2.8 (1.4 to 5.7); and for amputation, 6.6 (0.98 to 80.0). In the logistical regression analysis, 6 factors were associated with fracture nonunion: dialysis (7.7; 1.7 to 35.2), diabetes (3.3; 1.5 to 7.4), fracture severity (bi- and trimalleolar fractures) (4.9; 1.4 to 18.0), beta blockers (2.5; 1.1 to 5.4), steroids (3.1; 1.2 to 7.7), and infection (3.7; 1.2 to 11.3). The results of the study demonstrate the increased risk of complications after an ankle fracture among patients with diabetes, dialysis, or open fractures and those using steroids and beta blockers. Further work is needed to identify areas for risk reduction.

Mechanisms Supporting the Use of Beta-Blockers for the Management of Breast Cancer Bone Metastasis

Simple Summary

Bone represents the most common site of metastasis for breast cancer and the establishment and growth of metastatic cancer cells within the skeleton significantly reduces the quality of life of patients and their survival. The interplay between sympathetic nerves and bone cells, and its influence on the process of breast cancer bone metastasis is increasingly being recognized. Several mechanisms, all dependent on β-adrenergic receptor signaling in stromal bone cells, were shown to promote the establishment of disseminated cancer cells into the skeleton. This review provides a summary of these mechanisms in support of the therapeutic potential of β-blockers for the early management of breast cancer metastasis.

Abstract

The skeleton is heavily innervated by sympathetic nerves and represents a common site for breast cancer metastases, the latter being the main cause of morbidity and mortality in breast cancer patients. Progression and recurrence of breast cancer, as well as decreased overall survival in breast cancer patients, are associated with chronic stress, a condition known to stimulate sympathetic nerve outflow. Preclinical studies have demonstrated that sympathetic stimulation of β-adrenergic receptors in osteoblasts increases bone vascular density, adhesion of metastatic cancer cells to blood vessels, and their colonization of the bone microenvironment, whereas β-blockade prevented these events in mice with high endogenous sympathetic activity. These findings in preclinical models, along with clinical data from breast cancer patients receiving β-blockers, support the pathophysiological role of excess sympathetic nervous system activity in the formation of bone metastases, and the potential of commonly used, safe, and low-cost β-blockers as adjuvant therapy to improve the prognosis of bone metastases.

Impact of renin-angiotensin system inhibitors and beta-blockers on dental implant stability

BACKGROUND

Current experimental research suggests antihypertensive medication reduces the failure risk of dental implants due to enhanced bone remodeling. However, evidence from clinical studies evaluating the impact of antihypertensive medication on implant stability is lacking.

METHODS

We retrospectively analyzed 377 implants in 196 patients (46 implants inserted in antihypertensive drug users (AH) and 331 implants in non-users (NAH)) for implant stability measured by radiofrequency analysis, and we determined the implant stability quotient (ISQ). AH subgroups were stratified by the use of beta-blockers, renin-angiotensin system (RAS) inhibitors, and both of the aforementioned. The impact of antihypertensive medication on ISQ values at implant insertion (primary stability) and implant exposure (secondary stability) was analyzed by a linear regression model with a regression coefficient and its 95% confidence interval (95% CI), adjusted for potential confounders.

RESULTS

Time between implant insertion and implant exposure was 117.1 ± 56.6 days. ISQ values at insertion were 71.8 ± 8.7 for NAH and 74.1 ± 5.6 for AH, respectively. ISQ at exposure was 73.7 ± 8.1 for NAH and 75.7 ± 5.9 for AH. Regression analysis revealed that none of the AH subgroups were significantly related to ISQ at implant insertion. However, renin-angiotensin system inhibitors (RAS) were significantly associated with higher ISQ values at exposure (reg. coeff. 3.59, 95% CI 0.46-6.71 (p=0.025)).

CONCLUSIONS

Outcome of the present study indicates enhanced bone remodeling and osseointegration following dental implant insertion in patients taking RAS inhibitors than in non-users. Future randomized prospective studies must confirm these indicative results.

Association between metabolic syndrome and bone mineral density among menopausal Saudi women: Case-control study

Background: Metabolic syndrome (MetS) and osteoporosis are two of the world's major healthcare issues. There are several studies which explored the association between MetS and bone mineral density (BMD), but all of them are cross-sectional. These studies cover all populations, including expatriated, which did not determine the actual problem among Saudi women. This is the first case-control study that determines the causal relationship between MetS and BMD. The objective of this study is to determine the relationship between metabolic syndrome and bone mass density among Saudi menopausal women in Eastern Province - Saudi Arabia.

Methods: It’s a case-control study and 380 menopausal Saudi women were selected through simple random sampling. They were divided into 190 cases with osteoporosis and 190 without osteoporosis. Bone Mineral Density (BMD) at the total hip was determined using dual-energy X-ray absorptiometry (DEXA). T score was calculated. The association between the risk factors of MetS and bone mineral density was determined by binary logistic regression analysis using SPSS (statistical package of social science) software.

Results: Among women, the prevalence of MetS was substantially higher in those with osteoporosis. The Mets is positively correlated with bone mineral density. (r=0.08, p=0.051). The occurrence of MetS was associated with increased osteoporosis among Saudi women (B=0.004; p=0.005) after adjustment of confounders. The existence of obesity was significantly associated with increased odds of Bone marrow density among women (OR 2.56; 95 % CI, 2.22-3.44; p=0.030) after adjustment of confounders.

Conclusion: The incidence of MetS was associated with osteoporosis in Saudi women.

Type I Angiotensin II Receptor Blockade Reduces Uremia-Induced Deterioration of Bone Material Properties

Chronic kidney disease (CKD) is associated with a high incidence of fractures. However, the pathophysiology of this disease is not fully understood, and limited therapeutic interventions are available. This study aimed to determine the impact of type 1 angiotensin II receptor blockade (AT-1RB) on preventing CKD-related fragility fractures and elucidate its pharmacological mechanisms. AT-1RB use was associated with a lower risk of hospitalization due to fractures in 3276 patients undergoing maintenance hemodialysis. In nephrectomized rats, administration of olmesartan suppressed osteocyte apoptosis, skeletal pentosidine accumulation, and apatite disorientation, and partially inhibited the progression of the bone elastic mechanical properties, while the bone mass was unchanged. Olmesartan suppressed angiotensin II-dependent oxidation stress and apoptosis in primary cultured osteocytes in vitro. In conclusion, angiotensin II-dependent intraskeletal oxidation stress deteriorated the bone elastic mechanical properties by promoting osteocyte apoptosis and pentosidine accumulation. Thus, AT-1RB contributes to the underlying pathogenesis of abnormal bone quality in the setting of CKD, possibly by oxidative stress. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Metabolic Syndrome In Saudi Women With Low Bone Mineral Density

Background ― Metabolic syndrome (MetS) is the world's major public health problem. Objectives ― Assessment of metabolic syndrome impact on bone mineral density (BMD) among Saudi menopausal women in Eastern Province – Saudi Arabia. Material and Methods ― It’s a case control study and 380 menopausal Saudi women were selected through stratified random sampling; they are divided into 190 cases with osteoporosis and 190 without osteoporosis. BMD at the total hip were determined using dual-energy X-ray absorptiometry (DEXA). The T score was calculated, the relationship between the risk factors of MetS and bone mineral density were analyzed by statistical methods. Results ― Prevalence of MetS was substantially higher among osteoprotic women. The MetS is significantly correlated with bone mineral density (r=0.08, P=0.05). The occurrence of MetS was associated with increased osteoporosis among Saudi women (B=0.004; 0.05) after adjustment of confounders. The presence of obesity (component of MetS) was significantly associated with increased odds of Bone marrow density among women (OR 2.56, 95% CI, 2.22–3.44, P=0.030) after adjustment of confounders. Conclusion ― MetS was significantly associated with an osteoporosis in Saudi women.

Antihypertensive drug classes and the risk of hip fracture: results from the Swedish primary care cardiovascular database

OBJECTIVE

Hypertension and fractures related to osteoporosis are major public health problems that often coexist. This study examined the associations between exposure to different antihypertensive drug classes and the risk of hip fracture in hypertensive patients.

METHOD

We included 59 246 individuals, 50 years and older, diagnosed with hypertension during 2001-2008 in the Swedish Primary Care Cardiovascular Database. Patients were followed from 1 January 2006 (or the date of diagnosis of hypertension) until they had their first hip fracture, died, or reached the end of the study on 31 December 2012. Cox proportional hazards models were used to calculate the risk of hip fracture across types of antihypertensive medications, adjusted for age, sex, comorbidity, medications, and socioeconomic factors.

RESULTS

In total, 2593 hip fractures occurred. Compared to nonusers, current use of bendroflumethiazide or hydrochlorothiazide was associated with a reduced risk of hip fracture (hazard ratio 0.86; 95% CI 0.75-0.98 and hazard ratio 0.84; 95% CI 0.74-0.96, respectively), as was use of fixed drug combinations containing a thiazide (hazard ratio 0.69; 95% CI 0.57-0.83). Current use of loop diuretics was associated with an increased risk of hip fracture (hazard ratio 1.23; 95% CI 1.11-1.35). No significant associations were found between the risk of hip fracture and current exposure to beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone-receptor blockers or calcium channel blockers.

CONCLUSION

In this large observational study of hypertensive patients, the risk of hip fracture differed across users of different antihypertensive drugs, results that could have practical implications when choosing antihypertensive drug therapy.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Osteocalcin and measures of adiposity: a systematic review and meta-analysis of observational studies

Osteocalcin, the osteoblast-derived protein, has been shown to be modulated in patients with problematic glucose metabolism. Our systematic review and meta-analysis found that in humans, higher blood osteocalcin level is associated with lower body indices of fat.

PURPOSE/INTRODUCTION

Osteocalcin (OC) was found to be inversely correlated with measures of glucose and energy metabolism, with some groups suggesting the undercarboxylated form (ucOC) to be metabolically active, although the link is not clear, especially in humans. Given obesity is a major risk factor for metabolic disorders, we aimed to assess the correlation between OC and two measures of body weight: body mass index (BMI) and percentage body fat (%BF).

METHODS

MEDLINE and EMBASE were searched to identify observational studies in adult populations that reported the crude correlation coefficients (r) between OC and BMI and %BF. Pool r were obtained using random-effects models.

RESULTS

Fifty-one publications were included in this analysis. Both total OC (TOC) (pooled r = - 0.151, 95% CI - 0.17, - 0.130; I² = 52%) and ucOC (pooled r = - 0.060, 95% CI - 0.103, - 0.016; I² = 54%) were inversely correlated with BMI. The pooled r between TOC and BMI in Caucasian-and-other-regions (r = - 0.187) were stronger than those in Asian populations (r = - 0.126; intra-group p = 0.002; R² = 0.21). The mean/median BMI of the reported cohort was the major contributor to between-study heterogeneity in correlation between TOC/ucOC and BMI (R² = 0.28 and 0.77, respectively). Both TOC and ucOC were also inversely correlated with %BF (TOC: pooled r = - 0.185, 95% CI - 0.257 to - 0.112; ucOC: pooled r = - 0.181, 95% CI - 0.258 to - 0.101).

CONCLUSION

Higher OC and ucOC were correlated with lower BMI and %BF. The inverse correlations between TOC/ucOC and BMI appear to be affected by ethnicity and obesity status.

The association between renin angiotensin aldosterone system blockers and future osteoporotic fractures in a hypertensive population - A population-based cohort study in Taiwan

Some cohort studies showed the possibility of renin-angiotensin-aldosterone system (RAAS) blockade in preventing future osteoporotic fractures. The study aimed to evaluate the association between angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and future osteoporotic fracture in a hypertensive population. We queried the Taiwan Longitudinal Health Insurance Database between 2001 and 2012. We used propensity score matching and the total cohort was made up of 57,470 participants (28,735 matched-pairs using or not using RAAS blockers). The mean follow-up period was 6 years. The number of incident fractures was 3757. Hazard ratios (HRs) [95% confidence interval (CI)] of ACEIs and ARBs use with incident fractures were calculated. The incidence of future osteoporotic fracture was significantly lower in the ACEI and ARB user groups but not in the group using an ACEI plus ARB concomitantly, when compared with RAAS blocker nonusers. Comparing ACEI users with RAAS blocker non-users and ARB users with RAAS blocker non-users, the HRs for composite fractures were 0.70 (0.62-0.79) and 0.58 (0.51-0.65), respectively. Sensitivity analysis confirmed a lower incidence of future osteoporotic fracture in patients taking an ACEI for >55 cumulative defined daily doses (cDDDs) and those who received an ARB for >90 cDDDs. These results suggested a lower incidence of future osteoporotic fracture in a hypertensive population who were using an ACEI or ARB compared with RAAS blocker nonusers but not in the group taking an ACEI and ARB concomitantly.

ACE-inhibitors: a preventive measure for bone flap resorption after autologous cranioplasty?

OBJECTIVE

Decompressive craniectomy (DC) is an established treatment for refractory intracranial hypertension. It is usually followed by autologous cranioplasty (AC), the reinsertion of a patient's explanted bone flap. A frequent long-term complication of AC is bone flap resorption (BFR), which results in disfigurement as well as loss of the protective covering of the brain. This study investigates risk factors for BFR after AC, including medical conditions and antihypertensive drug therapies, with a focus on angiotensin-converting enzyme inhibitors (ACEIs), which have been associated with a beneficial effect on bone healing and bone preservation in orthopedic, osteoporosis, and endocrinology research.

METHODS

In this single-center, retrospective study 183 consecutive cases were evaluated for bone flap resorption after AC. Information on patient demographics, medical conditions, antihypertensive therapy, and BFR-defined as an indication for revision surgery established by a neurosurgeon based on clinical or radiographic assessments-was collected. A Kaplan-Meier analysis of time from AC to diagnosis of BFR was performed, and factors associated with BFR were investigated using the log-rank test and Cox regression.

RESULTS

A total of 158 patients were considered eligible for inclusion in the data analysis. The median follow-up time for this group was 2.2 years (95% CI 1.9-2.5 years). BFR occurred in 47 patients (29.7%), with a median time to event of 3.7 years (95% CI 3.3-4.1 years). An ACEI prescription was recorded in 57 cases (36.1%). Univariate Kaplan-Meier analysis and the log-rank test revealed that ACEI therapy (2-year event free probability [EFP] 83.8% ± 6.1% standard error vs 63.9% ± 5.6%, p = 0.02) and ventriculoperitoneal (VP) shunt treatment (2-year EFP 86.9% ± 7.1% vs 66% ± 5.0%, p = 0.024) were associated with a lower probability of BFR. Multiple Cox regression analysis showed ACEI therapy (HR 0.29, p = 0.012), VP shunt treatment (HR 0.278, p = 0.009), and male sex (HR 0.500, p = 0.040) to be associated with a lower risk for BFR, whereas bone fragmentation (HR 1.92, p = 0.031) was associated with a higher risk for BFR.

CONCLUSIONS

Hypertensive patients treated with ACEIs demonstrate a lower rate of BFR than patients treated with other hypertensive medications and nonhypertensive patients. Our results are in line with previous reports on the positive influence of ACEIs on bone healing and preservation. Further analysis of the association between ACEI treatment and BFR development is needed and will be evaluated in a multicenter prospective trial.

Association of Receiving Multiple, Concurrent Fracture-Associated Drugs With Hip Fracture Risk

IMPORTANCE

Many prescription drugs increase fracture risk, which raises concern for patients receiving 2 or more such drugs concurrently. Logic suggests that risk will increase with each additional drug, but the risk of taking multiple fracture-associated drugs (FADs) is unknown.

OBJECTIVE

To estimate hip fracture risk associated with concurrent exposure to multiple FADs.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a 20% random sample of Medicare fee-for-service administrative data for age-eligible Medicare beneficiaries from 2004 to 2014. Sex-stratified Cox regression models estimated hip fracture risk associated with current receipt of 1, 2, or 3 or more of 21 FADs and, separately, risk associated with each FAD and 2-way FAD combination vs no FADs. Models included sociodemographic characteristics, comorbidities, and use of non-FAD medications. Analyses began in November 2018 and were completed April 2019.

EXPOSURE

Receipt of prescription FADs.

MAIN OUTCOMES AND MEASURES

Hip fracture hospitalization.

RESULTS

A total of 11.3 million person-years were observed, reflecting 2 646 255 individuals (mean [SD] age, 77.2 [7.3] years, 1 615 613 [61.1%] women, 2 136 585 [80.7%] white, and 219 579 [8.3%] black). Overall, 2 827 284 person-years (25.1%) involved receipt of 1 FAD; 1 322 296 (11.7%), 2 FADs; and 954 506 (8.5%), 3 or more FADs. In fully adjusted, sex-stratified models, an increase in hip fracture risk among women was associated with the receipt of 1, 2, or 3 or more FADs (1 FAD: hazard ratio [HR], 2.04; 95% CI, 1.99-2.11; P < .001; 2 FADs: HR, 2.86; 95% CI, 2.77-2.95; P < .001; ≥3 FADs: HR, 4.50; 95% CI, 4.36-4.65; P < .001). Relative risks for men were slightly higher (1 FAD: HR, 2.23; 95% CI, 2.11-2.36; P < .001; 2 FADs: HR, 3.40; 95% CI, 3.20-3.61; P < .001; ≥3 FADs: HR, 5.18; 95% CI, 4.87-5.52; P < .001). Among women, 2 individual FADs were associated with HRs greater than 3.00; 80 pairs of FADs exceeded this threshold. Common, risky pairs among women included sedative hypnotics plus opioids (HR, 4.90; 95% CI, 3.98-6.02; P < .001), serotonin reuptake inhibitors plus benzodiazepines (HR, 4.50; 95% CI, 3.76-5.38; P < .001), and proton pump inhibitors plus opioids (HR, 4.00; 95% CI, 3.56-4.49; P < .001). Receipt of 1, 2, or 3 or more non-FADs was associated with a small, significant reduction in fracture risk compared with receipt of no non-FADs among women (1 non-FAD: HR, 0.93; 95% CI, 0.90-0.96; P < .001; 2 non-FADs: HR, 0.84; 95% CI, 0.81-0.87; P < .001; ≥3 non-FADs: HR, 0.74; 95% CI, 0.72-0.77; P < .001).

CONCLUSIONS AND RELEVANCE

Among older adults, FADs are commonly used and commonly combined. In this cohort study, the addition of a second and third FAD was associated with a steep increase in fracture risk. Many risky pairs of FADs included potentially avoidable drugs (eg, sedatives and opioids). If confirmed, these findings suggest that fracture risk could be reduced through tighter adherence to long-established prescribing guidelines and recommendations.

The renin-angiotensin aldosterone system and osteoporosis: findings from the Women's Health Initiative

New users of RAAS inhibitors, including ACE inhibitors and ARBs, have a small increased risk for fracture in the first 3 years of use, with a reduced risk of fracture with longer duration of use.

INTRODUCTION

Pharmacological inhibitors of the renin-angiotensin aldosterone system (RAAS) are used to treat hypertension. However, the relationship of these medications to osteoporosis is inconsistent, and no study has included simultaneous measurements of both incident fractures and bone mineral density (BMD).

METHODS

The association of RAAS inhibitor use (n = 131,793) with incident fractures in new users of these medications in women in the Women's Health Initiative over a minimum median follow-up of 6.5 years was assessed by Cox proportional hazard models. The association of incident fractures by a cumulative duration of use of these medications (< 3 years.) and (> 3 years.) was also estimated. Subgroup analysis of fracture risk by RAAS inhibitor use confined to women with hypertension was also performed (n = 33,820). The association of RAAS inhibitor use with changes in BMD of the hip was estimated by linear regression in 8940 women with dual energy X-ray absorptiometry measurements.

RESULTS

There was no significant association between RAAS inhibitor use and all fractures in the final adjusted multivariable models including hip BMD (HR 0.86 (0.59, 1.24)). However, among users of RAAS inhibitors, including ACE inhibitors and angiotensin receptor blockers (ARBs), hazard ratios for all incident fracture sites in final multivariable models including hip BMD showed dramatic differences by duration of use, with short duration of use (3 years or less) associated with a marked increased risk for fracture (HR 3.28 (1.66, 6.48)) to (HR 6.23 (3.11, 12.46)) and use for more than 3 years associated with a reduced fracture risk (HR 0.40 (0.24, 0.68) to (HR 0.44 (0.20, 0.97)) . Findings were similar in the subgroup of women with a history of hypertension. There was no significant change in BMD of the hip by RAAS inhibitor use.

CONCLUSIONS

In postmenopausal women, use of RAAS inhibitors, including ACE inhibitors and ARBs, is associated with an increased risk for fracture among new users of these medications in the first 3 years of use. However, long-term use (> 3 years) is associated with a reduced risk. Consideration for fracture risk may be part of the decision-making process for initiation of these medications for other disease states.

Effects of telmisartan and losartan treatments on bone turnover markers in patients with newly diagnosed stage I hypertension

INTRODUCTION

Telmisartan is an angiotensin-II receptor type-1 blocker and a partial agonist for peroxisome proliferator-activated receptor-γ. The aim of this study was to determine the potential effects of telmisartan on bone metabolism and turnover markers.

METHODS

Forty-two patients with newly diagnosed stage I hypertension who were prescribed telmisartan 80 mg/day or losartan 100 mg/day were included. Serum levels of calcium, phosphorus, 25-hydroxy vitamin D, bone-specific alkaline phosphatase, osteocalcin, interleukin 6 and 24-hour urinary N-terminal telopeptide were measured at the beginning and after 12 weeks of treatment.

RESULTS

When treatment arms were evaluated together, significantly increased 25-hydroxy vitamin D levels (p=0.01), and decreased parathormone (PTH) (p<0.001), bone-specific alkaline phosphatase (p=0.01), osteocalcin (p=0.045), urinary N-terminal telopeptide (p<0.001) and interleukin 6 levels (p=0.006) were observed. After eliminating the 25-hydroxy vitamin D effect, significant changes were not observed at any of the parameters. None of the levels of parameters were different between groups.

CONCLUSIONS

Neither telmisartan, despite its partial peroxisome proliferator-activated receptor-γ agonistic effect, nor losartan treatment had significant effects on bone turnover markers in newly diagnosed stage I hypertensive patients.

The skeletal renin-angiotensin system: A potential therapeutic target for the treatment of osteoarticular diseases

The classical renin-angiotensin system (RAS) is known to be a key regulator of blood pressure as well as fluid and electrolyte homeostasis. Additionally, it is now evident that components of the RAS are produced and act locally in many tissues, including liver, kidney, heart, lung, eye, bone, reproductive organ, adipose, and adrenal tissue, and these components are collectively known as tissue RAS. Recently, several studies have shown that local bone RAS is directly involved in bone metabolism, and activation of skeletal RAS plays an important role in bone diseases, such as osteoporosis, arthritis, and deterioration as well as in fracture healing. Based on the identification of RAS components in bone, we examined a new therapeutic approach to attenuate bone diseases through RAS inhibitors: renin inhibitor, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. In this paper, we provide a systematic review of the skeletal RAS in the pathophysiology of bone diseases and the beneficial effect of RAS inhibitors on bone tissue.

Atherosclerosis and Osteoporosis. Common Targets for the Effects of Cardiovascular and Anti-osteoporotic Drugs (Part I). The Effect of Cardiovascular Drugs on Bone Strength

Daily use of antihypertensive and lipid-lowering drugs in clinical practice dictates the need for knowledge of their pleiotropic effects. The article presents the results of studies of the effect of cardiovascular drugs, such as statins, beta-blockers, ACE inhibitors, diuretics, calcium antagonists and nitrates on bone mineral density and fractures associated with osteoporosis. The mechanisms of action of drugs on bone mass, markers of bone metabolism, the frequency of fractures in osteoporosis are discussed. Most studies show that the use of cardiac drugs along with a positive effect on the vascular wall, slow bone resorption and increase bone mass. Knowledge of the additional effect on bone metabolism of drugs used in cardiovascular diseases allows to choose an adequate therapy and improve the prognosis of both diseases.

Does common prescription medication affect the rate of orthodontic tooth movement? A systematic review

Background

As the taking of any medication may theoretically affect the complex pathways responsible for periodontal tissue homeostasis and the events leading to orthodontic tooth movement, it is considered important for the orthodontist to be able to identify prospective patients' history and patterns of pharmaceutical consumption.

Objective

To systematically investigate and appraise the quality of the available evidence regarding the effect of commonly prescribed medications on the rate of orthodontic tooth movement.

Search methods

Search without restrictions in eight databases and hand searching until June 2017.

Selection criteria

Controlled studies investigating the effect of commonly prescribed medications with emphasis on the rate of orthodontic tooth movement.

Data collection and analysis

Following study retrieval and selection, relevant data was extracted and the risk of bias was assessed using the SYRCLE's Risk of Bias Tool.

Results

Twenty-seven animal studies, involving various pharmacologic and orthodontic interventions, were finally identified. Most studies were assessed to be at unclear or high risk of bias. The rate of orthodontic tooth movement was shown to increase after the administration of diazepam, Vitamin C and pantoprazole, while simvastatin, atorvastatin, calcium compounds, strontium ranelate, propranolol, losartan, famotidine, cetirizine, and metformin decreased the rate of orthodontic tooth movement. No interference with the rate of orthodontic tooth movement was reported for phenytoin, phenobarbital and zinc compounds, whereas, inconsistent or conflicting effects were noted after the administration of L-thyroxine, lithium compounds, fluoxetine and insulin. The quality of the available evidence was considered at best as low.

Conclusions

Commonly prescribed medications may exhibit variable effects on the rate of orthodontic tooth movement. Although the quality of evidence was considered at best as low, raising reservations about the strength of the relevant recommendations, the clinician should be capable of identifying patients taking medications and should take into consideration the possible implications related to the proposed treatment.

Registration

PROSPERO (CRD42015029130).

Effects of Leptin on the Skeleton

Leptin originates in adipocytes, including those in bone marrow, and circulates in concentrations 20 to 90 times higher than those in the cerebrospinal fluid. It has direct anabolic effects on osteoblasts and chondrocytes, but it also influences bone indirectly, via the hypothalamus and sympathetic nervous system, via changes in body weight, and via effects on the production of other hormones (e.g., pituitary). Leptin's role in bone physiology is determined by the balance of these conflicting effects. Reflecting this inconsistency, the leptin-deficient mouse has reduced length and bone mineral content of long bones but increased vertebral trabecular bone. A consistent bone phenotype in human leptin deficiency has not been established. Systemic leptin administration in animals and humans usually exerts a positive effect on bone mass, and leptin administration into the cerebral ventricles usually normalizes the bone phenotype in leptin-deficient mice. Reflecting the role of the sympathetic nervous system in mediating the central catabolic effects of leptin on the skeleton, β-adrenergic agonists and antagonists have major effects on bone in mice, but this is not consistently seen in humans. The balance of the central and peripheral effects of leptin on bone remains an area of substantial controversy and might vary between species and according to other factors such as body weight, baseline circulating leptin levels, and the presence of specific pathologies. In humans, leptin is likely to contribute to the positive relationship observed between adiposity and bone density, which allows the skeleton to respond appropriately to changes in soft tissue mass.

Cardiovascular autonomic neuropathy and bone metabolism in Type 1 diabetes

AIM

To investigate the association between cardiovascular autonomic neuropathy and bone metabolism in people with Type 1 diabetes.

METHODS

We assessed cardiovascular autonomic neuropathy in 329 people with Type 1 diabetes according to heart rate response to deep breathing, to standing and to the Valsalva manoeuvre, and 2-min resting heart rate. More than one pathological non-resting test was defined as cardiovascular autonomic neuropathy. Bone mineral density of the femoral neck (BMDfn) was assessed by dual energy X-ray absorptiometry. Serum parathyroid hormone levels and other bone markers were measured.

RESULTS

The mean (sd) age of the participants was 55.6 (9.4) years, 52% were men, and the mean (sd) diabetes duration was 40 (8.9) years, HbA_1c 62 (9) mmol/mol and estimated GFR 78 (26) ml/min/1.73m² . In all, 36% had cardiovascular autonomic neuropathy. Participants with cardiovascular autonomic neuropathy had 4.2% (95% CI -8.0 to -0.2; P=0.038) lower BMDfn and 33.6% (95% CI 14.3 to 53.8; P=0.0002) higher parathyroid hormone levels compared with participants without cardiovascular autonomic neuropathy in adjusted models. Higher resting heart rate remained associated with higher parathyroid hormone level and lower BMDfn after additional adjustment for eGFR (P<0.0001 and P = 0.042, respectively).

CONCLUSIONS

The presence of cardiovascular autonomic neuropathy was associated with reduced BMDfn and increased levels of parathyroid hormone. Kidney function may either confound or mediate these findings. Cardiovascular autonomic neuropathy could be associated with increased risk of osteoporosis in Type 1 diabetes. Whether cardiovascular autonomic neuropathy directly affects bone metabolism detrimentally or if this association is mediated via decreased kidney function should be investigated further.

The Time Point-Specific Effect of Beta-Adrenergic Blockade in Attenuating High Fat Diet-Induced Obesity and Bone Loss

We aimed to clarify the key factor determining the effect of beta blocker attenuating high fat diet- induced obesity and bone loss. Six-week-old C57BL/6 male mice were assigned to groups reflecting different relative onset of obesity and beta blocker administration, different diet (control vs. high fat), and treatment (vehicle vs. beta blocker: propranolol). Mice in Group 1 were fed a control diet (CON) or high fat diet (HIGH) with vehicle or propranolol for 12 weeks. Mice in Group 2 were fed a CON or HIGH without pharmaceutical treatment for the first 12 weeks, followed by another 12 weeks of treatment with vehicle or propranolol. Mice in Group 3 were fed a CON without pharmaceutical treatment for the first 12 weeks, followed by stratification into diet-based subgroups and another 12 weeks of treatment with vehicle or propranolol. Propranolol attenuated the HIGH-induced increase in body weight/fat mass in Group 1 mice and in Group 3 mice, but not in Group 2 mice. Propranolol mitigated HIGH-induced reduction in femoral trabecular bone mineral density and bone architecture deterioration in Group 1 mice but not in Group 2 mice. HIGH feeding in Group 3 did not compromise skeletal integrity. Taken together, propranolol attenuates HIGH-induced body weight increases while weight gain is in progress but not once obesity has already been established. HIGH feeding during the growth period results in compromised bone mass/architecture; which can be attenuated by propranolol administration during the growth period, but not by propranolol administration after obesity has already been established.

Effects of Amlodipine on Bone Metabolism in Orchidectomised Spontaneously Hypertensive Rats

Spontaneously hypertensive rats (SHR) represent a model of essential hypertension. We studied the effect of amlodipine (AML) on bone markers, bone mineral density (BMD), and biomechanical properties of osteopenic bone induced by orchidectomy in male SHR. Rats were allocated to 3 groups and were sacrificed after 12 weeks: sham-operated control; orchidectomised control; and orchidectomised receiving a diet supplemented with AML. Indicators of bone turnover were assessed in bone homogenate, BMD was measured by dual energy X-ray absorptiometry, and the femurs were subjected to biomechanical testing. Long-term AML administration does not have a negative impact on bone metabolism and density in male SHR.

The Impact of Antihypertensive Medications on Bone Mineral Density and Fracture Risk

PURPOSE OF REVIEW

This review summarizes the impact of thiazide diuretics on fracture risk in older hypertensive individuals.

RECENT FINDINGS

We performed a post hoc evaluation of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, a randomized, prospective, double blind hypertension study comparing a thiazide-like diuretic, a calcium channel blocker (CCB), and an angiotensin converting enzyme inhibitor (ACEi). We examined the risk of hip and pelvic fractures during the in-trial period (n = 22,180 participants; mean 4.9-year follow-up) and during the post-trial period using national data bases (n = 16,622 participants) (mean total follow-up 7.8 years). During the trial, participants randomized to the thiazide diuretic versus the CCB or the ACEi had a lower risk of fracture on adjusted analyses (HR 0.79 [95% CI, 0.63, 0.98], p = 0.04). Risk of fracture was significantly lower in participants randomized to the diuretic as compared to those randomized to the ACEi (HR 0.75 [95% CI, 0.58, 0.98]; p = 0.04), but not significantly different compared to the CCB (HR 0.87 [95% CI, 0.71, 1.09]; p = 0.17). Over the entire trial and post-trial period of follow-up, the cumulative incidence of fractures was non-significantly lower in participants assigned to the diuretic vs assignment to the ACEi or the CCB (HR 0.87 [0.74-1.03], p = 0.10) and versus each medication separately. These findings establish a benefit for thiazide diuretic treatment for the prevention of fractures versus other commonly used antihypertensive medications using prospective, randomized data. The effects of the thiazide diuretic on bone appear to be long lasting.

P2Y12 Receptor Antagonist, Clopidogrel, Does Not Contribute to Risk of Osteoporotic Fractures in Stroke Patients

Background: Stroke is a leading cause of mortality and morbidity. It is associated with excessive bone loss and risk of fracture in stroke patients is high. The P2Y12R antagonist and platelet inhibitor, clopidogrel, is widely used for secondary prevention after a stroke. However, recent studies have shown that clopidogrel has negative effects on bone and that long-term clopidogrel use is associated with increased fracture risk. The purpose of the current study was therefore to investigate the association of clopidogrel treatment with risk of fractures in stroke and TIA patients.

Methods: The study was a cohort study including all subjects who were prescribed clopidogrel between 1996 and 2008 in Denmark (n = 77,503). Age- and gender matched controls (n = 232,510) were randomly selected from the background population. The study end-points were occurrence of stroke or TIA and occurrence of fracture. Clopidogrel use was primary exposure.

Results: Ischemic stroke increased risk of fracture by 50% while haemorrhagic stroke and TIA increased the risk by 30%. However, after adjusting for multiple confounders only patients with ischemic stroke and haemorrhagic stroke had increased fracture risk. Clopidogrel use was not associated with increased fracture risk in subjects with ischaemic stroke or TIA. In contrast, after adjusting for multiple confounders clopidogrel treatment was associated with a 10–35% reduced risk of fracture.

Conclusion: Patients with stroke have increased risk of osteoporotic fractures, but clopidogrel treatment does not increase fracture risk. In contrast, patients less adherent to the treatment have lower risk of fractures than non-users and patients with high adherence. However, based on the increased risk in stroke patients, clinicians should consider evaluation of bone status of these patients.

Association between renin-angiotensin-aldosterone system blockade and future osteoporotic fracture risk in hypertensive population: A population-based cohort study in Taiwan

Tissue renin-angiotensin-aldosterone system (RAAS) activation in sites of osteoporosis had been demonstrated in animal studies; however, the possibility of RAAS blockade to prevent future osteoporotic fracture had rarely been verified in clinical studies. We Used the Taiwan Longitudinal Health insurance database 2000 to 2008, the cohort study comprised patients age over 40 with a recorded new diagnosis of hypertension between January 1, 2000 to December 31, 2008, in addition, patients who had diagnosis of osteoporosis before the date of cohort enter were excluded. After the definite diagnosis of hypertension, each patient was followed until osteoporotic fracture happened or the end of 2008. The occurrence of osteoporotic fracture was evaluated in patients who either were or without taking RAAS blockade agents. Cox proportional hazard regressions were used to evaluate the osteoporotic fracture incidence after adjusting for known confounding factors. In total, 57,132 hypertensive patients comprised the study cohort. Our study results showed that the incidence of osteoporosis fracture in the whole cohort was significantly higher in the RAAS blockade non-user group than the user group. This phenomenon was observed in both sex and all age categories. Sensitivity analysis further showed the concordant lower osteoporosis fracture risk in patients with various RAAS blockers usage durations; the risk of osteoporosis fracture was the lowest in those drug use >365 days when compared with the non-user cohort. In conclusion, our study result demonstrated the lower future osteoporotic fracture risk in hypertensive subjects who received long term RAAS blocker treatment.

Long-term use of angiotensin-converting enzyme inhibitors protects against bone loss in African-American elderly men

Greater bone mineral density was observed after treating hypertension using angiotensin-converting enzyme inhibitor (ACEi). We report decreased rate of bone loss in hypertensive black men using ACEi for 9 years. There may be a gender- and race-specific effect of ACEi in the prevention of age-associated bone loss.

PURPOSE

There is evidence of bone mass preservation in patients receiving ACEis, commonly used to treat hypertension. However, limitations of previous studies include being cross-sectional or only including a short-term follow-up of patients using ACEi and including patients with diabetes, which affects bone metabolism. None of the previous studies described effects of ACEi stratified by race. The objective of this study was to investigate differences in changes in bone mineral density (BMD) in older adults who suffer from hypertension and had reported ACEi use during each study visit for at least 9 years during the study, stratified by gender and race.

METHODS

We used data from the Dynamics of Health, Aging and Body Composition (HABC) study, which enrolled 3075 community-dwelling older white and black individuals. We compared changes in femoral neck, total hip, and whole-body BMD after either no use of ACEi (n = 580) or long-term use (at least 9 years) of ACEi (n = 239) in HABC participants with hypertension and no known diagnosis of diabetes mellitus.

RESULTS

Overall, BMD values significantly decreased for all subgroups over time. In the stratified multivariate analysis, long-term use of ACEi was associated with a reduced rate of decline for all three BMD measures among black men, but no significant effect was observed in the other subgroups.

CONCLUSION

Our findings show a gender- and race-specific effect of ACEi in the prevention of age-associated bone loss that warrants further evaluation.

Initiation of antihypertensive monotherapy and incident fractures among Medicare beneficiaries

BACKGROUND

Research suggests antihypertensive medications are associated with fractures in older adults, however results are inconsistent and few have examined how the association varies over time. We sought to examine the association between antihypertensive class and incident non-vertebral fractures among older adults initiating monotherapy according to time since initiation.

METHODS

We used a new-user cohort design to identify Medicare beneficiaries (≥ 65 years of age) initiating antihypertensive monotherapy during 2008-2011 using a 20% random sample of Fee-For-Service Medicare beneficiaries enrolled in parts A (inpatient services), B (outpatient services), and D (prescription medication) coverage. Starting the day after the initial antihypertensive prescription, we followed beneficiaries for incident non-vertebral fractures. We used multinomial logistic regression models to estimate propensity scores for initiating each antihypertensive drug class. Using these propensity scores, we weighted beneficiaries to achieve the same baseline covariate distribution as beneficiaries initiating with angiotensin-converting enzyme inhibitors. Lastly, we used weighted Cox proportional hazard models to estimate hazard ratios (HRs) of having an incident fractures according to antihypertensive class and time since initiation.

RESULTS

During 2008-2011, 122,629 Medicare beneficiaries initiated antihypertensive monotherapy (mean age 75, 61% women, 86% White). Fracture rates varied according to days since initiation and antihypertensive class. Beneficiaries initiating with thiazides had the highest fracture rate in the first 14 days following initiation (438 per 10,000 person-years, 95% confidence interval (CI): 294-628; HR: 1.40, 0.78-2.52). However, beneficiaries initiating with calcium channel blockers had the highest fracture rate during the 15-365 days after initiation (435 per 10,000 person-years, 95% CI: 404-468; HR: 1.11, 1.00-1.24). Beneficiaries initiating with angiotensin-receptor blockers had the lowest fracture rates during the initial 14 days (333 per 10,000 person-years, 190-546, HR: 0.92, 0.49-1.75) and during 15-365 days after initiation (321 per 10,000 person-years, 287-358, HR: 0.96, 0.84-1.09).

CONCLUSION

The association between antihypertensives and fractures varied according to class and time since initiation. Results suggest that when deciding upon antihypertensive therapy, clinicians may want to consider possible fracture risks when choosing between antihypertensive drug classes.

Renin-angiotensin system inhibitors and risk of fractures: a prospective cohort study and meta-analysis of published observational cohort studies

The renin-angiotensin system (RAS) represents an important target of antihypertensive medications. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB), which are widely-used RAS inhibiting drugs, have been suggested to have beneficial effects on bone tissue. We aimed to assess the associations of use of ACEIs and/or ARBs with the risk of fractures using a population-based prospective cohort and a meta-analysis of published prospective cohort studies. Information on antihypertensive medication use (including both ACEIs and ARBs) were assessed in 1743 men and women of the Kuopio Ischemic Heart Disease prospective cohort study. Hazard ratios (HRs) [95% confidence intervals (CI)] of ACEIs or ARBs use with incident fractures were calculated. A total of 203 composite (hip, humeral, and wrist) fractures occurred during a median follow-up of 14.8 years. In multivariate adjusted analysis, the HR for composite fractures comparing users of ACEIs or ARBs with non-users was 1.00 (0.59-1.69). The corresponding adjusted HR for hip fractures comparing users versus non-users of ACEIs or ARBs was 0.89 (0.32-2.47). Including the current study, a total of 11 observational cohort studies involving 3526,319 participants and >323,355 fractures were included in a meta-analysis. Comparing ACEI users with non-users and ARB users with non-users, the HRs for composite fractures were 1.09 (0.89-1.33) and 0.87 (0.76-1.01) respectively. The corresponding HRs for hip fractures were 0.91 (0.86-0.95) and 0.80 (0.75-0.85) respectively. Use of RAS inhibitors was not associated with long-term risk of composite fractures in both primary and pooled analyses. Pooled evidence however suggests a beneficial effect of RAS blockers on hip fracture risk.

Angiotensin (1-7) ameliorates the structural and biochemical alterations of ovariectomy-induced osteoporosis in rats via activation of ACE-2/Mas receptor axis

The local and systemic renin angiotensin system (RAS) influences the skeletal system micro-structure and metabolism. Studies suggested angiotensin 1-7 (Ang(1-7)) as the beneficial RAS molecule via Mas receptor activation. This study examines the function of Ang(1-7) in bone micro-architecture and metabolism in an ovariectomized (OVX) rodent model of osteoporosis. OVX rats showed structural and bone metabolic degeneration in parallel with suppressed expressions of the angiotensin converting enzyme-2 (ACE-2)/Ang(1-7)/Mas components. The infusion of Ang(1-7) markedly alleviated the altered bone metabolism and significantly enhanced both trabecular (metaphyseal) and cortical (metaphyseal-diaphyseal) morphometry. Urinary and bones minerals were also improved in OVX rats by Ang(1-7). The infusion of the heptapeptide enhanced ACE-2/Mas receptor expressions, while down-regulated AngII, ACE, and AngII type-1 receptor (AT1R) in OVX animals. Moreover, Ang(1-7) markedly improved osteoprotegerin (OPG) and lowered receptor activator NF-κB ligand (RANKL) expressions. The defensive properties of Ang(1-7) on bone metabolism, structure and minerals were considerably eradicated after blockage of Mas receptor with A-779. Ang(1-7)-induced up-regulated ACE-2/Ang(1-7)/Mas cascade and OPG expressions were abolished and the expressions of ACE/AngII/AT1R and RANKL were provoked by A-779. These findings shows for the first time the novel valuable therapeutic role of Ang(1-7) on bone health and metabolism through the ACE-2/Mas cascade.

Effects of 1,25-dihydroxyvitamin D3 on the local bone renin-angiotensin system in a murine model of glucocorticoid-induced osteoporosis

Active vitamin D is closely related to the circulating renin-angiotensin system (RAS) in experimental animal models and humans; however, corresponding local bone data remain limited. The present study examined whether 1,25-dihydroxyvitamin D₃ supplementation altered local bone RAS elements in a murine model of glucocorticoid-induced osteoporosis (GIOP). A total of 36 8-week-old mice were randomized into three equal-sized groups: The sham, GIOP and 1,25-dihydroxyvitamin D₃ treatment groups. After 12 weeks, the cancellous bone microstructure of the third lumbar vertebra and left femur from the mice from each group were examined using micro-computed tomography. To access the impact of glucocorticoid use, the effect of 1,25-dihydroxyvitamin D₃ on cancellous bone microstructure, the expression of bone turnover markers, circulation and expression of the main RAS components was assessed. Results demonstrated that bone volume fraction, trabecular number and trabecular thickness of the treatment and sham groups were significantly higher than the GIOP group (P<0.05). Furthermore, the structure model index, trabecular separation and bone surface to bone volume ratio of the sham and treatment groups were significantly reduced compared with the GIOP group (P<0.05). All assessed parameters exhibited no significant differences between the treatment and sham groups. mRNA expression levels of local bone angiotensin type 1 and 2 receptors and receptor activator of nuclear factor-κB ligand were significantly lower in the treatment group than in the GIOP group (P<0.05); however, there were no significant differences in circulating protein levels between the groups (P>0.05). In conclusion, 1,25-dihydroxyvitamin D₃ may modulate bone metabolism by downregulating the local bone RAS in mice with GIOP.

Differential response of bone and kidney to ACEI in db/db mice: A potential effect of captopril on accelerating bone loss

The components of renin-angiotensin system (RAS) are expressed in the kidney and bone. Kidney disease and bone injury are common complications associated with diabetes. This study aimed to investigate the effects of an angiotensin-converting enzyme inhibitor, captopril, on the kidney and bone of db/db mice. The db/db mice were orally administered by gavage with captopril for 8weeks with db/+ mice as the non-diabetic control. Serum and urine biochemistries were determined by standard colorimetric methods or ELISA. Histological measurements were performed on the kidney by periodic acid-schiff staining and on the tibial proximal metaphysis by safranin O and masson-trichrome staining. Trabecular bone mass and bone quality were analyzed by microcomputed tomography. Quantitative polymerase chain reaction and immunoblotting were applied for molecular analysis on mRNA and protein expression. Captopril significantly improved albuminuria and glomerulosclerosis in db/db mice, and these effects might be attributed to the down-regulation of angiotensin II expression and the expression of its down-stream profibrotic factors in the kidney, like connective tissue growth factor and vascular endothelial growth factor. Urinary excretion of calcium and phosphorus markedly increased in db/db mice in response to captopril. Treatment with captopril induced a decrease in bone mineral density and deterioration of trabecular bone at proximal metaphysis of tibia in db/db mice, as shown in the histological and reconstructed 3-dimensional images. Even though captopril effectively reversed the diabetes-induced changes in calcium-binding protein 28-k and vitamin D receptor expression in the kidney as well as the expression of RAS components and bradykinin receptor-2 in bone tissue, treatment with captopril increased the osteoclast-covered bone surface, reduced the osteoblast-covered bone surface, down-regulated the expression of type 1 collagen and transcription factor runt-related transcription factor 2 (markers for osteoblastic functions), and up-regulated the expression of carbonic anhydrase II (marker for bone resorption). Captopril exerted therapeutic effects on renal injuries associated with type 2 diabetes but worsened the deteriorations of trabecular bone in db/db mice; the latter of which was at least in part due to the stimulation of osteoclastogenesis and the suppression of osteogenesis by captopril.