Stemming bone loss by suppressing apoptosis

Forecasting the critical role of intermittent therapies for the control of bone resorption

BACKGROUND

Osteoporosis is a chronic metabolic disease characterized by an imbalance of bone resorption and formation, leading to bone fragility and increased susceptibility to fracture. Parathyroid hormone is approved therapy for the treatment of osteoporosis.

METHODS

The intermittent therapy of parathyroid hormone requires accurate administration. Meta-analysis is conducted to draw a clear picture of the impact of intermittent therapy and dose rates relative to time, on the osteoporotic patients. A novel mathematical model is presented in this article synchronised with the parametric values, depicted from meta-analysis.

FINDINGS

Results obtained from the mathematical model are in close agreement with the results obtained from the clinical trials. The model can be used to forecast the drug potency and dosage rates, to control the vicious cycle of osteoporosis.

INTERPRETATIONS

The intermittent administration of parathyroid hormone, rather than the continuous administration, is more effective, furthermore it is also concluded that a mathematical model, linked with the extensive literature of clinical trials, using meta-analysis can help in drug administration and future clinical studies of drug development.

Isorhamnetin inhibits IL‑1β‑induced expression of inflammatory mediators in human chondrocytes

Isorhamnetin (ISH) is a flavonoid primarily obtained from the fruit of Hippophae rhamnoides L., which possesses anti‑inflammatory properties. However, the effect of ISH on the expression of inflammatory mediators in response to interleukin (IL)‑1β stimulation has not been elucidated. The present study investigated the effects of ISH on the expression of inflammatory mediators in human chondrocytes, induced by IL‑1β. The results of the present study demonstrated that pretreatment with ISH inhibited the expression of stromelysin‑1 and collagenase 3 in chondrocytes, induced by IL‑1β. Pretreatment with ISH inhibited the IL‑1β‑stimulated synthesis of NO and prostaglandin E2 induced by IL‑1β, in addition to the expression of inducible nitric oxide synthase and prostaglandin G/H synthase 2 in chondrocytes. Additionally, ISH inhibited the expression of nuclear factor (NF)‑κB and transcription factor p65, and the degradation of NF‑κB inhibitor α induced by IL‑1β in chondrocytes. In conclusion, the results of the present study indicated that ISH exhibited anti‑inflammatory and chondroprotective effects in IL‑1β‑stimulated chondrocytes. The results of the present study suggest that ISH may be a potential agent in the future treatment of osteoarthritis.

Anabolic agents and bone quality

BACKGROUND

The definition of bone quality is evolving particularly from the perspective of anabolic agents that can enhance not only bone mineral density but also bone microarchitecture, composition, morphology, amount of microdamage, and remodeling dynamics.

QUESTIONS/PURPOSES

This review summarizes the molecular pathways and physiologic effects of current and potential anabolic drugs.

METHODS

From a MEDLINE search (1996-2010), articles were identified by the search terms "bone quality" (1851 articles), "anabolic agent" (5044 articles), "PTH or parathyroid hormone" (32,229 articles), "strontium" or "strontium ranelate" (283 articles), "prostaglandin" (77,539 articles), and "statin" or "statins" (14,233 articles). The search strategy included combining each with the phrase "bone quality." Another more limited search aimed at finding more novel potential agents.

RESULTS

Parathyroid hormone is the only US Food and Drug Administration-approved bone anabolic agent in the United States and has been the most extensively studied in in vitro animal and human trials. Strontium ranelate is approved in Europe but has not undergone Food and Drug Administration trials in the United States. All the studies on prostaglandin agonists have used in vivo animal models and there are no human trials examining prostaglandin agonist effects. The advantages of statins include the long-established advantages and safety profile, but they are limited by their bioavailability in bone. Other potential pathways include proline-rich tyrosine kinase 2 (PYK2) and sclerostin (SOST) inhibition, among others.

CONCLUSIONS

The ongoing research to enhance the anabolic potential of current agents, identify new agents, and develop better delivery systems will greatly enhance the management of bone quality-related injuries and diseases in the future.

Vascular endothelial growth factor regulates osteoblast survival - evidence for an autocrine feedback mechanism

BACKGROUND

Apoptosis of osteoblasts and osteoclasts regulates bone homeostasis. Skeletal injury in humans results in 'angiogenic' responses primarily mediated by vascular endothelial growth factor(VEGF), a protein essential for bone repair in animal models. Osteoblasts release VEGF in response to a number of stimuli and express receptors for VEGF in a differentiation dependent manner. This study investigates the putative role of VEGF in regulating the lifespan of primary human osteoblasts(PHOB) in vitro.

METHODS

PHOB were examined for VEGF receptors. Cultures were supplemented with VEGF(0-50 ng/mL), a neutralising antibody to VEGF, mAB VEGF(0.3 ug/mL) and Placental Growth Factor (PlGF), an Flt-1 receptor-specific VEGF ligand(0-100 ng/mL) to examine their effects on mineralised nodule assay, alkaline phosphatase assay and apoptosis.. The role of the VEGF specific antiapoptotic gene target BCl2 in apoptosis was determined.

RESULTS

PHOB expressed functional VEGF receptors. VEGF 10 and 25 ng/mL increased nodule formation 2.3- and 3.16-fold and alkaline phosphatase release 2.6 and 4.1-fold respectively while 0.3 ug/mL of mAB VEGF resulted in approx 40% reductions in both. PlGF 50 ng/mL had greater effects on alkaline phosphatase release (103% increase) than on nodule formation (57% increase). 10 ng/mL of VEGF inhibited spontaneous and pathological apoptosis by 83.6% and 71% respectively, while PlGF had no significant effect. Pretreatment with mAB VEGF, in the absence of exogenous VEGF resulted in a significant increase in apoptosis (14 vs 3%). VEGF 10 ng/mL increased BCl2 expression 4 fold while mAB VEGF decreased it by over 50%.

CONCLUSION

VEGF is a potent regulator of osteoblast life-span in vitro. This autocrine feedback regulates survival of these cells, mediated via a non flt-1 receptor mechanism and expression of BCl2 antiapoptotic gene.

DXA in vivo BMD methodology: an erroneous and misleading research and clinical gauge of bone mineral status, bone fragility, and bone remodelling

The seemingly unqualified reliance and near-universal dependence upon in vivo dual-energy X-ray absorptiometric (DXA) methodology to provide accurate, quantitative, and meaningful in vivo (in situ cadaveric) bone mineral areal density ("BMD") determinations are proven to be unwarranted and misplaced. The underlying systematics of sizable, inherently unavoidable and un-correctable inaccuracies in the DXA output values of in vivo "BMD" are shown to be quantitatively consistent with being the root cause of unreliable, misdirected, and misinterpreted aspects of consensual knowledge of bone fragility, osteoporotic diagnostics/prognostics, and remodelling therapies. The "BMD" label that DXA ascribes to the output values of in vivo (in situ cadaveric) bone densitometry scans is shown to be a misnomer and an erroneous and invalid measure of bone mineral material. The DXA-derived "BMD" value does not correctly represent the areal density of bone mineral material, as it is contaminated by sizable, unavoidable, inextricable, independent soft tissue contributions. Due to intra- and extra-osseous soft tissue X-ray absorptiometric effects, it is unknown (and unknowable) exactly what DXA in vivo "BMD" is a measure of in any given case, or what proportion of the "BMD" value represents the actual bone mineral material areal density present in the DXA scan region of interest (ROI) of any predominantly trabecular bone-site (e.g., lumbar vertebrae, proximal femora). This inherent fundamental defect in DXA in vivo bone mineral areal density methodology adversely compromises both the validity and reliability of patient-specific diagnostic/prognostic evaluations, cross sectional and prospective studies, and DXA-based interpretations of bone quality and bone fragility. It further undermines the WHO characterizations (and definitions) of 'normal', 'osteopenic', and 'osteoporotic' classifications. It is also seen to make equivocal the qualitative and quantitative epidemiological estimates of the proportion of the population that is, or is deemed to become, osteoporotic. The present quantitative exposition shows DXA-measured in vivo "BMD" methodology to be an intrinsically flawed and misleading indicator of bone mineral status and an erroneous gauge of relative fracture risk.

Effects of transient PTH on early proliferation, apoptosis, and subsequent differentiation of osteoblast in primary osteoblast cultures

In primary calvarial osteoblast cultures derived from transgenic mice expressing green fluorescent protein (GFP) under the control of 3.6-kb Col1a1 promoter, the emergence of GFP signal marks the transition of multipotential osteoprogenitors into preosteoblasts. Early transient treatment (days 1-7) of these cultures with parathyroid hormone (PTH) has an anabolic effect that is not associated with an increase in total DNA content or cell number in day 21 cultures. In the present study, the effect of early PTH treatment on cell proliferation and apoptosis was examined in greater detail in GFP(+) and GFP(-) cells using flow cytometry. In preconfluent cultures, PTH significantly reduced the proportion of cells in S phase but increased those in G(0)/G(1) and G(2)+M phases in both GFP(+) and GFP(-) subpopulations. PTH decreased apoptosis only in GFP(-) but not GFP(+) cells, indicating an increased survival of GFP(-) cells. In contrast, PTH did not change the amounts of cell proliferation and apoptosis seen in either compartment after these cultures reached confluence. To further assess the effect of early PTH treatment on osteogenic differentiation, secondary cultures of sorted GFP(+) or GFP(-) cells were obtained from day 7 primary cultures that had been treated for 1 wk with PTH. This treatment resulted in larger areas of GFP expression accompanied by increased xylenol orange/von Kossa staining in the secondary cultures of GFP fractions. Early transient PTH treatment appears to enhance the commitment of progenitor cells to an osteogenic fate and results in a higher proportion of cells that achieve full osteoblast differentiation.

Intermittent parathyroid hormone therapy to increase bone formation

Clinical data suggested that parathyroid hormone (PTH) might be effective in improving bone mass in patients with osteoporosis, providing its resorptive effects, which are particularly marked at cortical sites, were kept under control. We reviewed the evidence that intermittent PTH therapy is a valid treatment option whose predominant effect is bone anabolism. In cell culture studies, PTH affected both bone formation and bone resorption, suggesting that the net result of PTH therapy may be either bone gain or bone loss depending on the dosage, mode of administration, bone site, and animal species. Histological studies established that intermittent PTH therapy was associated with an increase in trabecular bone and, importantly, with improvements in trabecular and cortical microarchitectural parameters that have not been reported with antiresorptive drugs. This anabolic effect of intermittent PTH therapy translates into increased biomechanical strength, despite the increase in endocortical porosity seen in humans and nonhuman primates. The biochemical response profile to intermittent PTH therapy in clinical trials indicated a phase of isolated anabolism followed by an overall increase in bone remodeling that predominantly affected bone formation, the result being a large increase in spinal bone mineral density as early as the first treatment year. Thus, intermittent PTH therapy exerts predominantly anabolic effects on bone.

Drugs used to treat osteoporosis: the critical need for a uniform nomenclature based on their action on bone remodeling

There continues to be uncertainty about the classification of available drugs for treating osteoporosis. We find that grouping them into anti-catabolic and anabolic classes based on the mechanisms of their action on bone remodeling and fracture reduction removes ambiguities and provides a relatively straightforward classification. The recent introduction of teriparatide into clinical practice initiated the era of anabolic therapy for osteoporosis, but it is still unclear how to define an anabolic drug. All drugs that increase bone mass do so by affecting bone remodeling. When their mechanisms of action on bone remodeling and on fracture reduction are considered, we find that anti-osteoporotic drugs fall naturally into either anti-catabolic or anabolic classes. Anti-catabolic drugs increase bone strength and reduce fractures mainly by decreasing the number of bone multicellular units (BMUs). This reduces perforative resorption and preserves skeletal microarchitecture (by preventing further structural damage to trabecular bone and increased porosity in cortical bone induced by high bone remodeling). Reduction in bone remodeling by anti-catabolic drugs may increase bone mass moderately during the interval in which previously initiated BMUs are completing mineralization. Some anti-catabolic drugs may also enhance the formation phase of the remodeling cycle, but their major action is to reduce overall bone turnover (i.e., the number of BMUs in bone). In contrast, anabolic drugs increase bone strength and reduce fractures by substantially increasing bone mass as a result of an overall increase in the number of BMUs combined with a positive BMU balance (the magnitude of the formation phase is greater than that of the resorption phase). Some anabolic drugs also induce renewed modeling, increase periosteal apposition and repair of trabecular microstructure. We hope that this classification will serve as a starting point for continued discussion on the important issue of nomenclature.

Comparison of the action of transient and continuous PTH on primary osteoblast cultures expressing differentiation stage-specific GFP

Primary calvarial osteoblast cultures derived from type I collagen promoter-GFP reporter transgenic mice were used to examine progression of the osteoblast lineage. This system was validated by assessing the effect of PTH on osteoblast growth in real time. The anabolic effect of PTH seemed to be the result of enhanced osteoblast differentiation rather than expansion of a progenitor population.

INTRODUCTION

Activation of green fluorescent protein (GFP) marker genes driven by Col1a1 promoter fragments has been associated with the level of osteoblast differentiation. GFP-marked cultures provide an approach to continuously monitor the level of osteoblast differentiation in real time without the termination of cultures.

MATERIALS AND METHODS

Neonatal calvarial cells transgenic for pOBCol2.3GFP and pOBCol3.6GFP were used to establish calvarial osteoblast cultures. Parathyroid hormone (PTH) was added either continuous (days 1-21) or transient (days 1-7) to examine its diverse effect on osteoblast differentiation in cultures for 21 days. Three fluorescent markers were used: (1) pOBCol3.6GFP, which is activated in preosteoblastic cells; (2) pOBCol2.3GFP, which is restricted to differentiated osteoblasts; and (3) xylenol orange (XO), which stains the mineralized nodules. Progression of osteoblast differentiation indicated by fluorescent markers was documented throughout the entire period of culture. Recorded fluorescent images were analyzed in the patterns of expression and quantitated in the area of expression.

RESULTS

Continuous PTH blocked osteoblast differentiation, which was evident by the attenuation of pOBCol3.6GFP and an absence of pOBCol2.3GFP. In contrast, transient PTH inhibited the initial osteoblast differentiation but ultimately resulted in a culture with more mineralized nodules and enhanced osteoblast differentiation expressing strong levels of pOBCol3.6GFP and pOBCol2.3GFP. Quantitative analysis showed that transient PTH first decreased then later increased areas of GFP expression and XO staining, which correlated with results of Northern blot and alkaline phosphatase activity. Transient PTH caused a decrease in DNA content during the treatment and after the removal of PTH.

CONCLUSION

GFP-marked cultures combined with fluorescent image analysis have the advantage to assess the effect of PTH on osteoblast differentiation in real time. Results suggest that the anabolic effect of transient PTH is caused by an enhancement in osteoblast differentiation rather than an increase in the population of progenitor cells.

Parathyroid Hormone Rapidly Stimulates Hyaluronan Synthesis by Periosteal Osteoblasts in the Tibial Diaphysis of the Growing Rat

Short term treatment (3-24 h) with parathyroid hormone (PTH) stimulated the synthesis and accumulation of hyaluronan (HyA) in explant cultures of tibial diaphyses from young rats. PTH increased the overall HyA content of periosteum 5-fold, with the basal cambium layer exhibiting the greatest enhancement ( approximately 8-fold). PTH increased the HyA content of cortical bone by 2-fold while not affecting the HyA content of bone marrow. PTH treatment greatly enhanced HyA staining throughout all layers of the periosteum, although its most dramatic effect occurred in the basal cambium layer. Here, unlike in the control tissue sections, nearly all cambium-lining osteoblasts stained intensely positive for HyA. PTH treatment enhanced the HyA staining of osteocytes in cortical bone tissue sections to the extent that the lacunocanalicular system became visualized. Three significant findings were revealed in this study. First, mature periosteal osteoblasts, under natural conditions, do not contain much HyA in their surrounding extracellular matrix but dramatically enhance their matrix HyA content when treated with PTH. Second, pre-osteocytes and osteocytes contain more HyA in their natural matrix than mature lining osteoblasts, and they appear to have functional PTH receptors because they responded to PTH treatment with an enhancement of HyA content. Finally, it was observed that the lining cells along the endosteal surface of the diaphysis did not stain strongly positive for HyA either naturally or when exposed to PTH treatment. This indicates that periosteal and endosteal osteoblastic cell populations exhibit metabolic differences in their extracellular matrix responses to PTH.

Intracellular zinc fluxes associated with apoptosis in growth plate chondrocytes

Matrix vesicles released by epiphyseal growth plate chondrocytes are known to contain a significant quantity of labile Zn(2+). Zonal analysis of chicken metatarsal bones showed that the resting/proliferative region of the growth plate contained high levels of Zn(2+) with significantly lower levels in the hypertrophic cartilage suggesting a loss of cellular Zn(2+) as the chondrocytes mature. Intracellular labile Zn(2+) was measured in primary cultures of growth plate chondrocytes by assay with the fluorescent Zn-chelator toluenesulfonamidoquinoline (TSQ) and imaged by multi-photon laser scanning microscopy (MPLSM) with the TSQ derivative zinquin. Short-term exposure to Zn(2+), both in the presence and absence of pyrithione resulted in significant increases in cytosolic Zn(2+). Treatment with the membrane-permeant Zn(2+) chelator TPEN rapidly reduced the levels of labile Zn(2+) and triggered apoptosis. Cytosolic Zn(2+) levels were significantly reduced following 24-h incubations with known inducers of chondrocyte apoptosis. The loss of intracellular Zn(2+) was accompanied by a significant reduction in the cytosolic metal-binding protein metallothionein. Examination of Zn(2+)-treated cells with MPLSM showed uniformly higher zinquin fluorescence. Treatment of Zn(2+)-loaded cells with TPEN quenched zinquin fluorescence confirming that the observed fluorescence in chondrocytes is due to the presence of intracellular Zn(2+). A dose-dependent increase in zinquin fluorescence was observed in cells treated with a range of Zn(2+) concentrations. Short-term treatment of cultured chondrocytes with apoptosis-inducing chemicals resulted in transient increases in intracellular labile Zn(2+). These results indicate that Zn(2+) is mobilized from intracellular binding sites in the early stages of chondrocyte apoptosis and is subsequently lost from the cells. The early mobilization of Zn(2+) provides a mechanism for its movement to matrix vesicles and the extracellular matrix.

Bone growth stimulators. New tools for treating bone loss and mending fractures

In the new millennium, humans will be traveling to Mars and eventually beyond with skeletons that respond to microgravity by self-destructing. Meanwhile in Earth's aging populations growing numbers of men and many more women are suffering from crippling bone loss. During the first decade after menopause all women suffer an accelerating loss of bone, which in some of them is severe enough to result in "spontaneous" crushing of vertebrae and fracturing of hips by ordinary body movements. This is osteoporosis, which all too often requires prolonged and expensive care, the physical and mental stress of which may even kill the patient. Osteoporosis in postmenopausal women is caused by the loss of estrogen. The slower development of osteoporosis in aging men is also due at least in part to a loss of the estrogen made in ever smaller amounts in bone cells from the declining level of circulating testosterone and is needed for bone maintenance as it is in women. The loss of estrogen increases the generation, longevity, and activity of bone-resorbing osteoclasts. The destructive osteoclast surge can be blocked by estrogens and selective estrogen receptor modulators (SERMs) as well as antiosteoclast agents such as bisphosphonates and calcitonin. But these agents stimulate only a limited amount of bone growth as the unaffected osteoblasts fill in the holes that were dug by the now suppressed osteoclasts. They do not stimulate osteoblasts to make bone--they are antiresorptives not bone anabolic agents. (However, certain estrogen analogs and bisphosphates may stimulate bone growth to some extent by lengthening osteoblast working lives.) To grow new bone and restore bone strength lost in space and on Earth we must know what controls bone growth and destruction. Here we discuss the newest bone controllers and how they might operate. These include leptin from adipocytes and osteoblasts and the statins that are widely used to reduce blood cholesterol and cardiovascular damage. But the main focus of this article is necessarily the currently most promising of the anabolic agents, the potent parathyroid hormone (PTH) and certain of its 31- to 38-aminoacid fragments, which are either in or about to be in clinical trial or in the case of Lilly's Forteo [hPTH-(1-34)] tentatively approved by the Food and Drug Administration for treating osteoporosis and mending fractures.

The parathyroid hormone, its fragments and analogues--potent bone-builders for treating osteoporosis

As populations age a rising number of men and women, but especially women during the first decade after menopause, become victims of a severe, accelerated loss of bone with crippling fractures known as osteoporosis. This often results in costly, prolonged hospitalisation and perhaps indirectly, death. Osteoporosis in women is caused by the menopausal oestrogen decline, which removes several key restraints on the generation, longevity and activity of bone-resorbing osteoclasts. Although there are many antiresorptive drugs on or coming onto the market (calcitonin, bisphosphonates, oestrogen and SERMS) that can slow or stop further bone loss, there are none that can restore lost bone mechanical strength by directly stimulating osteoblast activity and bone growth. However, there is a family of potent bone-building peptides, namely the 84 amino acid parathyroid hormone (PTH). Its 31 to 38 amino acid N-terminal fragments are currently in or about to enter clinical trials. We can predict that these peptides will be effective therapeutics for osteoporosis especially when supplemented with bisphosphonates or SERMs to protect the new bone from osteoclasts. These peptides should also accelerate the healing of fractures in persons of all ages and restore lost bone mass and mechanical strength to astronauts following their return to earth after long voyages in space.

Birth and death of bone cells: basic regulatory mechanisms and implications for the pathogenesis and treatment of osteoporosis

The adult skeleton regenerates by temporary cellular structures that comprise teams of juxtaposed osteoclasts and osteoblasts and replace periodically old bone with new. A considerable body of evidence accumulated during the last decade has shown that the rate of genesis of these two highly specialized cell types, as well as the prevalence of their apoptosis, is essential for the maintenance of bone homeostasis; and that common metabolic bone disorders such as osteoporosis result largely from a derangement in the birth or death of these cells. The purpose of this article is 3-fold: 1) to review the role and the molecular mechanism of action of regulatory molecules, such as cytokines and hormones, in osteoclast and osteoblast birth and apoptosis; 2) to review the evidence for the contribution of changes in bone cell birth or death to the pathogenesis of the most common forms of osteoporosis; and 3) to highlight the implications of bone cell birth and death for a better understanding of the mechanism of action and efficacy of present and future pharmacotherapeutic agents for osteoporosis.