Combination therapy of anabolic agents and bisphosphonates on bone mineral density in patients with osteoporosis: a meta-analysis of randomised controlled trials

Insights into the Mechanism of Osteoporosis and the Available Treatment Options

Osteoporosis, one of the most prevalent bone illnesses, majorly affects postmenopausal women and men over 50 years of age. Osteoporosis is associated with an increased susceptibility to fragility fractures and can result in persistent pain and significant impairment in affected individuals. The primary method for diagnosing osteoporosis involves the assessment of bone mineral density (BMD) through the utilisation of dual energy x-ray absorptiometry (DEXA). The integration of a fracture risk assessment algorithm with bone mineral density (BMD) has led to significant progress in the diagnosis of osteoporosis. Given that osteoporosis is a chronic condition and multiple factors play an important role in maintaining bone mass, comprehending its underlying mechanism is crucial for developing more effective pharmaceutical interventions for the disease. The effective management of osteoporosis involves the utilisation of appropriate pharmacological agents in conjunction with suitable dietary interventions and lifestyle modifications. This review provides a comprehensive understanding of the types of osteoporosis and elucidates the currently available pharmacological treatment options and their related mechanism of action and usage.

Osteoporosis: Review of Etiology, Mechanisms, and Approach to Management in the Aging Population

Osteoporosis is the most common metabolic bone disease. With special respect to the aging population, it is very common, not only due to changes in lifestyle and diet but as a result of the aging process there is low-grade inflammation and immune system activation that directly affects bone strength and quality. This article provides a review of the incidence, etiology, and approach to screening and management of osteoporosis in the aging population. A thorough screening of lifestyle, environmental, and clinical conditions will be reviewed which identifies appropriate candidates for screening and treatment.

Comparison of Bisphosphonates Versus Teriparatide in Therapy of the Glucocorticoid-Induced Osteoporosis (GIOP): A Meta-Analysis of Randomized Controlled Trials

Osteoporosis (OP) is characterized as decreased bone mineral density (BMD) and increased risk of bone fracture. Secondary OP resulting from excess endogenous or exogenous glucocorticoid is defined as glucocorticoid-induced osteoporosis (GIOP). Current therapeutic strategies for GIOP are similar to menopausal osteoporosis, including calcium and vitamin D supplementation, bisphosphonates, and parathyroid hormone (PTH) analogues (teriparatide). Previously, several published meta-analyses compared anti-osteoporotic agents for the menopausal or aging-dependent OP. However, the physiopathologic bone metabolism of GIOP is different. In this study, we investigated the efficacy of BMD enhancement, bone fracture rate and safety of bisphosphonates versus teriparatide in the therapy of GIOP. We searched databases including PubMed, Embase, and the Cochrane Library until Jan 2023, and selected ten random clinical trials (RCT)s that compared the efficacy and/or safety of bisphosphonate versus teriparatide for GIOP patients. Teriparatide therapy increased lumber spinal BMD by 3.96% (95% CI 3.01-4.9%, p<0.00001), 1.23% (95% CI 0.36-2.1%, p=0.006) at total hip, and 1.45% (95% CI 0.31-2.58%, p=0.01) at femoral neck, respectively, compared to bisphosphonates at 18-month therapy for GIOP. Teriparatide also reduced bone fracture especially in vertebral bone (p=0.0001, RR 6.27, 95% CI 2.44-16.07), and increased bone formation and resorption marker levels. There was no difference in the incidence of adverse effects in bisphosphonate and teriparatide groups. Teriparatide showed better performance over bisphosphonate in BMD enhancement, bone fracture reduction, and bone remodeling improvement, without increasing the incidence of adverse effects.

The clinician's guide to prevention and treatment of osteoporosis

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

CYT387, a JAK-Specific Inhibitor Impedes Osteoclast Activity and Oophorectomy-Induced Osteoporosis via Modulating RANKL and ROS Signaling Pathways

Osteoclasts are of hematopoietic lineage and have the ability to degrade mineralized bone tissues. Abnormalities in osteoclastic activity under certain pathological conditions are common in bone diseases such as osteoporosis, osteosclerosis, and arthritis. Although many kinds of drugs are currently used to treat osteoporosis, they have obvious adverse reactions and limitations. CYT387 is a new small-molecule Janus kinase (JAK) inhibitor involved in hematopoiesis, immune modulation, fertility, lactation, and embryonic development. However, it has remained unclear whether CYT387 functionally impacts osteoclast formation. Our study demonstrated through osteoclast formation assay in vitro, that the use of CYT387 is a potential drug candidate for treating osteoclast-associated bone disease. The effects of CYT387 on osteoclast formation, bone resorption, NFATc1 activation, and especially intracellular ROS levels were investigated in vitro. Further, we examined the preclinical prospects of CYT387 using an oophorectomy (OVX) mouse model of osteoporosis with its anti-osteoclast activity in vivo. On the whole, this study shows that CYT387 holds promise for treating osteoclast-related bone illnesses including osteoporosis.

Therapeutic Treatments for Osteoporosis-Which Combination of Pills Is the Best among the Bad?

Osteoporosis is a chronical, systemic skeletal disorder characterized by an increase in bone resorption, which leads to reduced bone density. The reduction in bone mineral density and therefore low bone mass results in an increased risk of fractures. Osteoporosis is caused by an imbalance in the normally strictly regulated bone homeostasis. This imbalance is caused by overactive bone-resorbing osteoclasts, while bone-synthesizing osteoblasts do not compensate for this. In this review, the mechanism is presented, underlined by in vitro and animal models to investigate this imbalance as well as the current status of clinical trials. Furthermore, new therapeutic strategies for osteoporosis are presented, such as anabolic treatments and catabolic treatments and treatments using biomaterials and biomolecules. Another focus is on new combination therapies with multiple drugs which are currently considered more beneficial for the treatment of osteoporosis than monotherapies. Taken together, this review starts with an overview and ends with the newest approaches for osteoporosis therapies and a future perspective not presented so far.

Effect of Nerve Training Technology on Apoptosis of Cartilage and Osteoblasts and Expression of Aggrecan Protein in Osteoporotic Arthritis

Arthritis and osteoporosis are two common disorders in the world, especially for the elder, but the current treatments have limited efficacy. Herein, we aimed to determine whether the novel technique, neurological training can alleviate osteoporosis complicated with arthritis in rat model. Thirty rats were assigned into normal group, model group, and treatment group (treated with forsythin and neurological training) (n = 10) followed by assessment of chondrocytes and osteoblasts using Mankin score, apoptosis by TUNEL and flow cytometry, and IL-1β, TNF-α, and Aggrecan levels. Apoptotic chondrocytes of treatment group (27.43±1.34) was lower than model group (p < 0.05), whereas amount of osteoblast was increased upon forsythin and neurological training, with lower Mankin’s score (6.38±0.76). Besides, the content of IL-1β and TNF-α of treatment group was significantly lower but Aggrecan mRNA and protein expression was significantly higher. In conclusion, neurological training could protect and alleviate osteoporosis complicated with arthritis.

Efficacy and Safety of Postmenopausal Osteoporosis Treatments: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Although a range of pharmacological interventions is available, it remains uncertain which treatment for osteoporosis is more effective. This network meta-analysis study aimed to compare different drug efficacy and safety in randomized controlled trials (RCTs) for the treatment of postmenopausal osteoporosis. PubMed, EMBASE, MEDLINE, Clinicaltrial.gov, Cochrane library, Google scholar were searched up to 31 October 2020. Randomized placebo-controlled trials that reported measures of bone mineral density (BMD) percentage change and/or numbers of adverse events of postmenopausal osteoporosis patients were included. Network meta-analysis was conducted using frequentist approach. Ninety-four RCTs comprising 15,776 postmenopausal osteoporosis females were included in the network meta-analysis. Compared with placebo, most interventions showed increase in BMD change. According to surfaces under the cumulative ranking curves (SUCRAs), strontium ranelate, fluoride, and hormone replacement therapy were most effective in increasing total hip, lumbar spine, and distal radius BMD, respectively. Parathyroid hormone (PTH) was most effective in preventing new hip fracture. When taking into account all anatomic sites, bisphosphonate (BP), monoclonal antibody (mAb), and fluoride have a balanced efficacy in increasing BMD at all sites. Considering both the effectiveness of increasing BMD and preventing hip fracture, mAb, BP, and PTH are more favorable among all interventions. The treatment effects of different medications on BMD percentage change are anatomic site-dependent. After weighing anti-osteoporosis treatment efficacy against risk of complications, BP and mAb are the more favorable interventions to increase BMD at all sites and reduce the risks of hip fracture and death.

Absorption and transport of a Mytilus edulis-derived peptide with the function of preventing osteoporosis

The YPRKDETGAERT peptide (PME-1) identified from the Mytilus edulis proteins has been shown to promote the proliferation and differentiation of osteoblasts and it has good bone-forming activity in vitro. Further, PME-1 has been shown to prevent osteoporosis in vivo. PME-1 can be absorbed through the gastrointestinal tract, and the passing rate in monolayer Caco-2 cells was 6.57%. PME-1 can also enter the blood circulation and the concentration of PME-1 in serum reached the maximum, 61.06 ± 26.32 ng mL-1, 20 min after feeding. The multifunctional in vivo imager was used to further determine the distribution of the 5-FITC-(Acp)-YPRKDETGAERT peptide (PME-1-FITC) 2 h after feeding the peptide, and the result confirmed the above results and showed that a part of PME-1-FITC can affect bone in vivo. Therefore, PME-1 not only was easily absorbed in the gastrointestinal tract, but also has the potential beneficial effect on preventing osteoporosis.

Development of selective bispecific Wnt mimetics for bone loss and repair

The Wnt signaling pathway is intricately connected with bone mass regulation in humans and rodent models. We designed an antibody-based platform that generates potent and selective Wnt mimetics. Using this platform, we engineer bi-specific Wnt mimetics that target Frizzled and low-density lipoprotein receptor-related proteins and evaluate their effects on bone accrual in murine models. These synthetic Wnt agonists induce rapid and robust bone building effects, and correct bone mass deficiency and bone defects in various disease models, including osteoporosis, aging, and long bone fracture. Furthermore, when these Wnt agonists are combined with antiresorptive bisphosphonates or anti-sclerostin antibody therapies, additional bone accrual/maintenance effects are observed compared to monotherapy, which could benefit individuals with severe and/or acute bone-building deficiencies. Our data support the continued development of Wnt mimetics for the treatment of diseases of low bone mineral density, including osteoporosis.

Acupuncture therapy for tennis elbow: A protocol for systematic review and meta-analysis

BACKGROUND

Acupuncture is widely used for analgesia in China and western countries. Lateral epicondylitis (LE) is a common disease, which influences the quality of life for many patients. The clinical practice indicates that acupuncture has a therapeutic effect on the LE; however, whether acupuncture is superior to sham acupuncture and some conventional therapy methods has been controversial. Hence, we will provide a protocol to explore the effectiveness and safety for acupuncture for LE.

METHODS

We will search only the randomized controlled trials (RCTs) literatures of acupuncture for LE from the following seven databases, including PubMed, Cochrane Central Register of Controlled Trials (The Cochrane Library), Excerpta Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Data, and Chinese Scientific Journals Database (VIP). The Visual Analogue Scale (VAS) will be considered as the primary outcome and the secondary outcome will include effective rate and function recovery. Adverse events incidence caused by acupuncture will also be discussed, such as dizziness, nausea, vomiting, and weariness. The searching strategy, inclusion and exclusion criteria were made according to the principle of evidence-based medicine. The quality was evaluated by Cochrane Handbook for Systematic Reviews of Interventions (V5.1). All analyses will be conducted by Review Manager Software (V5.3).

RESULT

The results of this review will be submitted to a recognized journal for publication.

CONCLUSION

This proposed meta-analysis will assess the efficacy and safety of acupuncture therapy for LE.

Combination Therapy of PTH and Antiresorptive Drugs on Osteoporosis: A Review of Treatment Alternatives

Antiresorptive drugs have been widely used for osteoporosis. Intermittent parathyroid hormone (PTH), an anabolic agent, increases osteoblast production rate and inhibits apoptosis of osteoblasts, thus increasing skeletal mass besides improving bone microarchitecture and strength. Combination therapy for osteoporosis produced great interests and controversies. Therefore, we performed a systematic literature search from PubMed, EMBASE, Scopus, Web of Science, CINDHL, and the Cochrane Database of Systematic Reviews using the search terms PTH or teriparatide combined with bisphosphonate, alendronate, ibandronate, risedronate, raloxifene, denosumab, and zoledronic acid with the limit osteoporosis. At last, 36 related articles were included for further analysis. Findings from previous studies revealed that combination therapy in different conditions of naive or previous bisphosphonate treatment might have different outcomes. The use of combination therapy, however, may be an alternative option among osteoporotic patients with a history of bisphosphonate use. Combined teriparatide with denosumab appear to show the most substantial and clinically relevant skeletal benefits to osteoporotic patients. Additional research is necessary to define optimal methods of developing sequential and/or cyclical combinations of PTH and antiresorptive agents.

Pharmacological Management of Postmenopausal Osteoporosis: a Level I Evidence Based - Expert Opinion

Objectives: Postmenopausal osteoporosis carries a high risk of fractures, which decrease quality of life and are associated with high morbidity, mortality, and economic burden. The best pharmacological treatment options to manage and prevent osteoporotic fractures remain still unclear. The present study investigated the efficacy and safety of the most commonly employed drugs in the management of postmenopausal osteoporosis. Methods: Only RCTs comparing different drugs for the management of postmenopausal osteoporosis were included. Data from 76 RCTs (205,011 patients) were collected. The mean follow-up was 27.6 ± 14.9 months. Results: Denosumab reported the lowest rate of non-vertebral fractures (LOR -1.57), Romosozumab the lowest rate of vertebral fractures (LOR 1.99), and Ibandronate the lowest rate of hip fractures (LOR0.18). Serious adverse events resulted in the lowest in the Raloxifene group (LOR 3.11), while those leading to study discontinuation were lowest in the Romosozumab cohort (LOR 2.65). Conclusions: Denosumab resulted in most effective, particularly in reducing the occurrence of non-vertebral fractures. Romosozumab and Ibandronate resulted best to prevent, respectively, vertebral fractures and hip fractures. Adverse events leading to study discontinuation were less frequent in the Romosozumab and Denosumab groups, while Raloxifene and Alendronate showed a lower incidence of serious adverse events overall. Level of evidence: I, Bayesian network meta-analysis of RCTs.

Safety and efficacy of teriparatide treatment for severe osteoporosis in patients with Duchenne muscular dystrophy

Osteoporosis is a major concern in patients with Duchenne muscular dystrophy. In this novel study of teriparatide treatment in 6 patients with severe osteoporosis, bone health (fractures, vertebral morphometry, and DXA) remained stable, with no adverse events. These findings will help inform future osteoporosis research in this challenging population.

INTRODUCTION

Despite standard therapy with vitamin D and bisphosphonates (BP), many patients with Duchenne muscular dystrophy (DMD) continue to sustain fragility fractures due to long-term glucocorticoid treatment and limited mobility. We aimed to evaluate the safety and efficacy of teriparatide for the treatment of severe osteoporosis in adolescent and young adult patients with DMD.

METHODS

We prospectively treated 6 patients with DMD who had severe osteoporosis with teriparatide 20 mcg subcutaneously daily for 1-2 years. Inclusion criteria were long-term glucocorticoid therapy, and severe osteoporosis despite treatment with BP, or intolerance to BP. We examined long bone and vertebral fracture outcomes, including vertebral morphometry measures, bone mineral density and content, bone formation markers, safety indices, and adverse events.

RESULTS

The mean age at teriparatide start was 17.9 years (range 13.9-22.1 years). All 6 patients were on daily glucocorticoids (mean ± SD; duration 10.9 ± 2.5 years) and 5 were non-ambulatory. Five patients had been treated with BP for 7.9 ± 4.2 years. All had vertebral and a history of long bone fragility fractures at baseline. Vertebral heights and Genant fracture grading remained stable. Long bone fracture rate appeared to decrease (from 0.84/year to 0.09/year); one patient sustained a long bone fracture at 6 months of treatment. Trajectories for change in bone mineral density and content were not different post- vs. pre-teriparatide. Procollagen type 1 amino-terminal propeptide (P1NP) increased, while laboratory safety indices remained stable and non-concerning. No adverse events were observed.

CONCLUSION

In six patients with DMD treated with teriparatide for severe osteoporosis, we observed stable bone health and modest increases in P1NP, without safety concerns. Further studies are needed to better understand teriparatide efficacy for treatment of osteoporosis in patients with DMD.

Long noncoding RNA HCG18 inhibits the differentiation of human bone marrow-derived mesenchymal stem cells in osteoporosis by targeting miR-30a-5p/NOTCH1 axis

Background

Recent studies have demonstrated that long non-coding RNAs (LncRNAs) can influence bone cell differentiation and formation. However, it is unclear whether lncRNA HCG18 is involved in osteoporosis (OP). This study was conducted to investigate the regulation of HCG18 in osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs).

Methods

BMSCs were isolated and cultured from mouse pathological models and osteoporosis patients. RT-qPCR was performed to detect the expression of HCG18 and miR-30a-5p in BMSCs. The interaction between HCG18 and miR-30a-5p was analyzed by dual luciferase assay and RNA pulldown assay. The interaction between miR-30a-5p and NOTCH1 3′-UTR was analyzed by dual luciferase assay. RT-qPCR and Western blotting were used to detect the expression of osteogenic genes Runx2, OCN and OPN. Hindlimb-unloaded (HU) mice model was established, and HCG18 was knocked down on bone-formation surfaces by using lentivirus mediated shRNA transfection.

Results

The expression of HCG18 was increased in BMSCs of OP patients, while the expression of miR-30a-5p was decreased. The expression of HCG18 and miR-30a-5p was negatively correlated in BMSCs. During the differentiation from BMSCs to osteoblasts, the expression of HCG18 was significantly downregulated, and the expression of miR-30a-5p was significantly upregulated. Overexpression of HCG18 was able to reverse the osteogenic-induced upregulation of miR-30a-5p expression, and knockdown of HCG18 further promoted the expression of miR-30a-5p. In addition, miR-30a-5p partially abolished the effect of HCG18 on osteogenic differentiation of BMSCs. NOTCH1 was a target protein of miR-30a-5p, and upregulation of NOTCH1 reversed the effect of miR-30a-5p on osteogenic differentiation of BMSCs. Furthermore, this study found that lentivirus mediated HCG18 knockdown on the bone-formation surfaces of hindlimb-unloaded (HU) mice partially alleviated unloading-induced bone loss

Conclusions

HCG18 inhibited osteogenic differentiation of BMSCs induced by OP via the miR-30a-5p/NOTCH1 axis. HCG18 can be identified as a regulator of osteogenic differentiation of BMSCs.

The efficacy of teriparatide on lumbar spine bone mineral density, vertebral fracture incidence and pain in post-menopausal osteoporotic patients: A systematic review and meta-analysis

Objective

Teriparatide has been increasingly utilized in the management of osteoporosis. The efficacy of low and high dose teriparatide on lumbar spine bone mineral density, vertebral fracture incidence and pain is unknown. We sought to determine the efficacy of teriparatide on these patient-important outcomes using a systematic review and meta-analysis.

Methods

A systematic search of electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL) was performed to identify randomized controlled trials (RCTs) that evaluate teriparatide to any comparator for the treatment of osteoporosis in postmenopausal women. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria were used by two independent reviewers to assess the strength and quality of evidence.

Results

A total of 20 studies (n = 6024) were included in this review, with 2855 patients receiving teriparatide and 3169 patients receiving placebo or control treatment. A teriparatide dose of 20 μg/day increased lumbar spine bone mineral density (BMD) (standardized mean difference (SMD) 0.34 standard deviation (SD) units higher (95% CI 0.19–0.48 SDs higher) in comparison to placebo. Relative to anti-resorptive agents, 20 μg/day of teriparatide had a range from 0.14 SD units to 0.96 SD units higher (95% CI, 0.08 SDs lower to 0.36 SDs higher, CI, 0.33–1.59 SDs higher, respectively). 20 μg/day teriparatide had a significant effect on pain severity to placebo or control (SMD 0.80, 95% CI, 1.16–0.43 SDs lower) and also decreased the incidence of vertebral fractures compared to placebo (relative risk 0.31, 95% CI 0.21 to 0.46). Arthralgia and extremity pain incidence were also calculated; there were 15 and 8 fewer events per 1000 patients with the use of 20 μg/day of teriparatide compared to placebo or control, respectively.

Conclusion

High quality evidence supports the utilization of teriparatide 20 μg/day dose to significantly improve lumbar spine BMD and decrease incidence of vertebral fractures and pain severity relative to all comparators. 40 μg/day dose of teriparatide demonstrated significantly better results with prolonged treatment. This data is valuable for clinicians involved in the care of this growing demographic of patients. Further investigation on the safety and efficacy of teriparatide in higher doses for the long-term treatment of osteoporosis in postmenopausal women should be conducted through high-quality clinical trials.

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Teriparatide (20 μg/day) significantly improves lumbar spine bone mineral density.

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Teriparatide (20 μg/day) reduces vertebral fracture incidence and pain.

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Increased teriparatide dose (40 μg/day) may have even greater clinical efficacy.

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Further investigation on safety profiles for longer-term treatment is warranted.

A survey of the feasibility of developing osteoporosis clinical trials in Duchenne muscular dystrophy: Survey of the opinion of young people with Duchenne muscular dystrophy, families and clinicians

BACKGROUND/AIMS

Given the extent of osteoporosis in people with Duchenne muscular dystrophy treated with glucocorticoids and the limited evidence of bone-protective therapies, clinical trials are needed. We conducted surveys to obtain the opinion of young people with Duchenne muscular dystrophy, parents/guardians and neuromuscular clinicians on the feasibility of osteoporosis clinical trials in this population.

METHODS

Online surveys were sent to three groups: (a) people with a confirmed diagnosis of Duchenne muscular dystrophy (≥14 years), (b) parents and guardians and (c) neuromuscular clinicians in the UK NorthStar Clinical Network. Surveys (a) and (b) were distributed via the UK Duchenne muscular dystrophy Registry.

RESULTS

Survey respondents included 52 people with Duchenne muscular dystrophy with a median age of 17 years (range: 14, 40) and 183 parents/guardians. Fourteen out of 23 (61%) NorthStar centres responded. Of the 52 people with Duchenne muscular dystrophy, 13 (25%) were very concerned about their bone health and 21 (40%) were slightly concerned. Of the 183 parents/guardians, 75 (41%) were very concerned about their son's bone health and 90 (49%) were slightly concerned. Fractures and quality of life were the top two main outcome measures identified by people with Duchenne muscular dystrophy. Fractures and bone density were the top two main outcome measures identified by parents/guardians and neuromuscular clinicians. Thirty percent of people with Duchenne muscular dystrophy and 40% of parents/guardians would not take part if an osteoporosis trial involved a placebo that was administered parenterally. Only 2 of the 14 NorthStar centres (14%) would enrol people with Duchenne muscular dystrophy if a parenteral placebo was used in an osteoporosis trial in Duchenne muscular dystrophy.

CONCLUSION

There is great awareness of bone health and the need for bone-protective trials among people with Duchenne muscular dystrophy and their carers. However, a proportion of people with Duchenne muscular dystrophy and parents are reluctant to participate in a placebo-controlled osteoporosis trial that included a parenteral therapy. A larger proportion of health care experts are unwilling to enrol their patients in such a trial. Our finding is relevant for the design of bone-protective studies in Duchenne muscular dystrophy.

Bisphosphonate drug holidays: One size does not fit all

Bisphosphonates have been safely used to treat osteoporosis, effectively reducing fracture risk after 3 to 5 years of treatment. Recent concerns about long-term safety coupled with posttreatment fracture risk reduction have increased support for drug holidays. The decision to start low-risk patients on drug holidays must be based on current fracture risk assessment.

Combination therapy in the Col1a2G610C mouse model of Osteogenesis Imperfecta reveals an additive effect of enhancing LRP5 signaling and inhibiting TGFβ signaling on trabecular bone but not on cortical bone

Enhancing LRP5 signaling and inhibiting TGFβ signaling have each been reported to increase bone mass and improve bone strength in wild-type mice. Monotherapy targeting LRP5 signaling, or TGFβ signaling, also improved bone properties in mouse models of Osteogenesis Imperfecta (OI). We investigated whether additive or synergistic increases in bone properties would be attained if enhanced LRP5 signaling was combined with TGFβ inhibition. We crossed an Lrp5 high bone mass (HBM) allele (Lrp5^A214V) into the Col1a2^G610C/+ mouse model of OI. At 6-weeks-of-age we began treating mice with an antibody that inhibits TGFβ1, β2, and β3 (mAb 1D11), or with an isotype-matched control antibody (mAb 13C4). At 12-weeks-old, we observed that combining enhanced LRP5 signaling with inhibited TGFβ signaling produced an additive effect on femoral and vertebral trabecular bone volumes, but not on cortical bone volumes. Although enhanced LRP5 signaling increased femur strength in a 3-point bending assay in Col1a2^G610C/+ mice, femur strength did not improve further with TGFβ inhibition. Neither enhanced LRP5 signaling nor TGFβ inhibition, alone or in combination, improved femur 3-point-bending post-yield displacement in Col1a2^G610C/+ mice. These pre-clinical studies indicate combination therapies that target LRP5 and TGFβ signaling should increase trabecular bone mass in patients with OI more than targeting either signaling pathway alone. Whether additive increases in trabecular bone mass will occur in, and clinically benefit, patients with OI needs to be determined.

Rapamycin could increase the effects of melatonin against age-dependent bone loss

Previous studies have demonstrated the beneficial effect of melatonin (MEL) on bone tissue and bone metabolism. Rapamycin (RAP) promotes osteoblast proliferation and inhibits osteoclast proliferation, and positively affects bone regeneration; however, reports about effects of RAP on bone loss for aged female rats with MEL administration are limited. This study investigated the impact of treatment with RAP on bone loss for aged female rats with MEL administration. Female Sprague-Dawley rats weighing approximately 520 g were randomly divided into 3 groups of 10: group CON, group MEL and group MEL + RAP and received saline, MEL, RAP plus MEL treatment until death at 12 weeks, respectively. The results of maintaining bone mass and bone strength with RAP plus MEL administration were evaluated by histology, microcomputerized tomography (Micro-CT), gene expression analysis and biomechanical testing. Results from this study indicated that MEL + RAP had stronger effects on the prevention and treatment of osteoporosis than MEL administration. Administration of MEL + RAP produced the strongest effects on bone parameters and strength for distal femurs and regulation of OPG/RANKL signalling pathway-related gene expression. These results seemed to indicate that RAP could increase the effects of MEL on age-dependent bone loss.

Synergistic Application of Platelet-Rich Fibrin and 1% Alendronate in Periodontal Bone Regeneration: A Meta-Analysis

Periodontal bone regeneration relies on coupled and cooperative bone formation and resorption. Accordingly a novel strategy on concurrent use of platelet-rich fibrin (PRF) (anabolic agent) and 1% alendronate (ALN) (anticatabolic agent) was proposed recently in regenerative periodontal treatment. It was supposed to enhance bone formation and reduce bone resorption simultaneously. However, there is a lack of evidence-based studies to answer whether this concurrent application was superior to single application until now. Besides, concerns on ALN lead to some reservation on this synergistic way. ALN may impair new bone formation and necrotize jaws. Thus, in order to compare the clinical efficacy between PRF plus 1%ALN and PRF alone on periodontal bone regeneration, we performed present systematic review and meta-analysis. Because it is the prerequisite for measuring the combined efficacy of PRF plus 1%ALN, firstly we evaluated the effectiveness of 1%ALN. Our data indicated that adjunctive 1%ALN was effective in promoting periodontal bone repair. Further, PRF plus 1%ALN showed a greater capacity for periodontal regeneration than PRF alone with statistical significance. The findings of this study revealed the promising prospects on synergistic application of bone anabolic agents (PRF) and antiresorption medications (1%ALN) in regenerative periodontal treatment.

Is Teriparatide Beneficial to Spinal Fusion Surgery in the Older Patient?: A Narrative Review

Since FDA approval in 2002, teriparatide has gained popularity as an anabolic therapy for the treatment of osteoporosis. Animal studies have suggested a role for teriparatide in spine surgery. Several recent studies have demonstrated adjunctive use of teriparatide in osteoporotic patients undergoing spine fusions improves fusion rates, decreases time to union, and decreases osteoporosis-related complications such as proximal junctional kyphosis. On the basis of the available literature, we outline an algorithm for the use of teriparatide in spine surgery.

Osteoanabolic and dual action drugs

Teriparatide (TPTD) and abaloparatide (ABL) are the only osteoanabolic drugs available, at this time, for treatment of osteoporosis. TPTD is a 34-amino acid fragment that is identical in its primary sequence to the 34 amino acids of full-length human parathyroid hormone [hPTH(1-84)]. ABL is identical to parathyroid hormone-related peptide (PTHrP) through the first 22 residues with significantly different amino acids inserted thereafter, between residues 22 and 34. The osteoanabolic actions of PTH are due directly to its effects on cells of the osteoblast lineage and indirectly by stimulating IGF-I synthesis and suppressing sclerostin and associated enhancement of Wnt signalling. Both TPTD and ABL are ligands that bind to and activate the PTH receptor type 1 (PTHR1) receptor but they appear to do so differently: ABL favours the transient, more anabolic configuration of the receptor. Both TPTD and ABL reduce the risk of vertebral fractures and non-vertebral fractures. Both drugs are administered for a maximum of 24 months, and should be followed by an antiresorptive agent to maintain gains in bone mineral density (BMD). Romosozumab, a monoclonal antibody that binds to and inhibits sclerostin, appears to have dual actions by stimulating bone formation and reducing bone resorption. In the pivotal clinical trial, romosozumab, administered as a 210 mg monthly subcutaneous dose, significantly reduced new vertebral fractures and in a subsequent study reduced both vertebral and non-vertebral fractures.

Acupuncture for primary osteoporosis: A network meta-analysis of randomized controlled trials protocol

BACKGROUND

A large number of randomized controlled trials (RCTs) have shown that acupuncture (ACU) has certain advantages over pharmacotherapies in the treatment of primary osteoporosis (POP). However, due to the diversity of ACU treatments, its relative effectiveness have not yet been studied and explained. Therefore, based on the network meta-analysis (NMA), this study will compare the differences in the efficacy of multiacupuncture in the treatment of POP, to provide a reference for clinical treatment.

METHODS

We will search PubMed, MEDLINE, Embase, the Cochrane Library, China National Knowledge Infrastructure (CHKD-CNKI), WANFANG database (Chinese Medicine Premier), Chinese Biomedical Literature database (CBM), and VIP for relevant RCTs of ACU treatments for POP, from their inceptions to January 2019. STATA 15.0 and GEMTC software will be used to perform a NMA. The evidence will be evaluated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the type 1 error rate will be assessed by trial sequential analysis (TSA).

RESULTS

The results of this review will be submitted to a recognized journal for publication.

CONCLUSION

This proposed systematic review will evaluate the different advantages of various types of ACU in the treatment of POP.

REGISTRATION

PROSPERO (registration number CRD42019122724).

Role of Bisphosphonate Therapy in Patients with Osteopenia: A Systemic Review

By contrast to clinical trials exploring osteoporosis, clinical trials specifically designed for the osteopenic population are limited. Thus, less clinical data are available regarding treatment benefits and cost-effectiveness of treating a patient population with a bone mass density in the osteopenic range (T-score between -1 and -2.5). In this article, we aimed to highlight this high-risk population with a low bone mass density (BMD) susceptible to high fracture risk by reviewing different national and international guidelines for treating osteopenia. The cost-effectiveness of the therapy for the above-mentioned patient population is also discussed. By reviewing different clinical trials, we have specifically highlighted the role of bisphosphonate therapy for fracture risk reduction and increment in bone mineral density (BMD) in patients with osteopenia.

Denosumab compared to bisphosphonates to treat postmenopausal osteoporosis: a meta-analysis

BACKGROUND

The standard treatment for osteoporosis was controversial. Denosumab and bisphosphonates were two most common drugs. The purpose of this study was to compare the efficacy and safety of denosumab with bisphosphonates to treat osteoporosis.

METHODS

Published literatures, only including randomized controlled trials (RCTs), were searched in the following electronic databases: PubMed, Embase, Web of Science, Cochrane Library, and Google database from inception to April 20 2018. Studies that compared denosumab with bisphosphonates to treat osteoporosis were included. Random-effect model was used for meta-analysis due to the unavoidable clinical heterogeneity. We used the risk of fracture as the primary outcome. Stata 12.0 was used for meta-analysis.

RESULTS

Eleven studies involving 5446 patients (denosumab = 2873, bisphosphonates = 2573) were included in the present meta-analysis. There was no significant difference between the risk of fracture (risk ratio (RR), 1.13; 95% confidence interval (CI), 0.82-1.55; P = 0.466), adverse events (AEs) (RR 1.00; 95% CI 0.96-1.04; P = 0.957) and withdrawn due to AEs (RR 0.68; 95% CI 0.34-137; P = 0.280). Denosumab compared with bisphosphonates significantly increased change in total hip, femoral neck, lumbar spine, and one-third radius bone mineral density (BMD) for postmenopausal osteoporosis patients (P < 0.05).

CONCLUSIONS

Our meta-analysis suggested that denosumab but not bisphosphonates significantly increased change in total hip, femoral neck, lumbar spine, and one-third radius BMD for postmenopausal osteoporosis patients. Current evidence suggested no benefit of denosumab for reducing risk of fracture than bisphosphonates. More long-term follow-up RCTs are needed to identify the potential complications of denosumab.