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Siddiq MAB, Liu X, Fedorova T, Bracken K, Virk S, Venkatesha V, Farivar A, Oo WM, Linklater J, Hill DC, Hunter DJ. Efficacy and safety of pentosan polysulfate sodium in people with symptomatic knee osteoarthritis and dyslipidaemia: protocol of the MaRVeL trial. BMJ Open 2024; 14:e083046. [PMID: 38777590 PMCID: PMC11116866 DOI: 10.1136/bmjopen-2023-083046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/03/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Knee osteoarthritis (OA) is the most prevalent arthritis type and a leading cause of chronic mobility disability. While pain medications provide only symptomatic pain relief; growing evidence suggests pentosan polysulfate sodium (PPS) is chondroprotective and could have anti-inflammatory effects in knee OA. This study aims to explore the efficacy and safety of oral PPS in symptomatic knee OA with dyslipidaemia. METHODS AND ANALYSIS MaRVeL is a phase II, single-centre, parallel, superiority trial which will be conducted at Royal North Shore Hospital, Sydney, Australia. 92 participants (46 per arm) aged 40 and over with painful knee OA and mild to moderate structural change on X-ray (Kellgren and Lawrence grade 2 or 3) will be recruited from the community and randomly allocated to receive two cycles of either oral PPS or placebo for 5 weeks starting at baseline and week 11. Primary outcome will be the 16-week change in overall average knee pain severity measured using an 11-point Numeric Rating Scale. Main secondary outcomes include change in knee pain, patient global assessment, physical function, quality of life and other structural changes. A biostatistician blinded to allocation groups will perform the statistical analysis according to the intention-to-treat principle. ETHICS AND DISSEMINATION The protocol has been approved by the NSLHD Human Research Ethics Committee (HREC) (2021/ETH00315). All participants will provide written informed consent online. Study results will be disseminated through conferences, social media and academic publications. TRIAL REGISTRATION NUMBERS Australian New Zealand Clinical Trial Registry (ACTRN12621000654853); U1111-1265-3750.
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Affiliation(s)
- Md Abu Bakar Siddiq
- Department of Rheumatology, Royal North Shore Hospital, Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Xiaoqian Liu
- Department of Rheumatology, Royal North Shore Hospital, Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Tatyana Fedorova
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Karen Bracken
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
- Musculoskeletal Health, Arabanoo Precinct, Kolling Institute, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sonika Virk
- Department of Rheumatology, Royal North Shore Hospital, Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Venkatesha Venkatesha
- Rheumatology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Abdolhay Farivar
- Department of Rheumatology, Royal North Shore Hospital, Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Win Min Oo
- Rheumatology, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
- University of Medicine, Mandalay, Mandalay, Myanmar
| | - James Linklater
- Castlereagh Imaging, St Leonard, NSW, St Leonard, New South Wales, Australia
| | | | - David J Hunter
- Department of Rheumatology, Royal North Shore Hospital, Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
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Bratkovic D, Gravance C, Ketteridge D, Krishnan R, Navuru D, Sheehan M, Skerrett D, Imperiale M. Open-label, single-center, clinical study evaluating the safety, tolerability and clinical effects of pentosan polysulfate sodium in subjects with mucopolysaccharidosis I. J Inherit Metab Dis 2024; 47:355-365. [PMID: 38467596 DOI: 10.1002/jimd.12715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 03/13/2024]
Abstract
Lysosomal enzyme deficiency in mucopolysaccharidosis (MPS) I results in glycosaminoglycan (GAG) accumulation leading to pain and limited physical function. Disease-modifying treatments for MPS I, enzyme replacement, and hematopoietic stem cell therapy (HSCT), do not completely resolve MPS I symptoms, particularly skeletal manifestations. The GAG reduction, anti-inflammatory, analgesic, and tissue remodeling properties of pentosan polysulfate sodium (PPS) may provide disease-modifying treatment for musculoskeletal symptoms and joint inflammation in MPS I following ERT and/or HSCT. The safety and efficacy of PPS were evaluated in four subjects with MPS I aged 14-19 years, previously treated with ERT and/or HSCT. Subjects received doses of 0.75 mg/kg or 1.5 mg/kg PPS via subcutaneous injections weekly for 12 weeks, then every 2 weeks for up to 72 weeks. PPS was well tolerated at both doses with no serious adverse events. MPS I GAG fragment (UA-HNAc [1S]) levels decreased at 73 weeks. Cartilage degradation biomarkers serum C-telopeptide of crosslinked collagen (CTX) type I (CTX-I) and type II (CTX-II) and urine CTX-II decreased in all subjects through 73 weeks. PROMIS scores for pain interference, pain behavior, and fatigue decreased in all subjects through 73 weeks. Physical function, measured by walking distance and dominant hand function, improved at 49 and 73 weeks. Decreased GAG fragments and cartilage degradation biomarkers, and positive PROMIS outcomes support continued study of PPS as a potential disease-modifying treatment for MPS I with improved pain and function outcomes.
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Affiliation(s)
- Drago Bratkovic
- Metabolic Unit, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Curtis Gravance
- Paradigm Biopharmaceuticals Ltd., North Adelaide, Victoria, Australia
| | - David Ketteridge
- Metabolic Unit, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Ravi Krishnan
- Paradigm Biopharmaceuticals Ltd., North Adelaide, Victoria, Australia
| | - Divya Navuru
- Paradigm Biopharmaceuticals Ltd., North Adelaide, Victoria, Australia
| | - Michael Sheehan
- Paradigm Biopharmaceuticals Ltd., North Adelaide, Victoria, Australia
| | - Donna Skerrett
- Paradigm Biopharmaceuticals Ltd., North Adelaide, Victoria, Australia
| | - Michael Imperiale
- Paradigm Biopharmaceuticals Ltd., North Adelaide, Victoria, Australia
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Cheng C, Tang S, Cui S, Yang T, Li L, Zhai M, Wei F, Ding G. Nerve growth factor promote osteogenic differentiation of dental pulp stem cells through MEK/ERK signalling pathways. J Cell Mol Med 2024; 28:e18143. [PMID: 38333908 PMCID: PMC10853700 DOI: 10.1111/jcmm.18143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/14/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024] Open
Abstract
Nerve growth factor (NGF) and its receptor, tropomyosin receptor kinase A (TrkA), are known to play important roles in the immune and nervous system. However, the effects of NGF on the osteogenic differentiation of dental pulp stem cells (DPSCs) remain unclear. This study aimed to investigate the role of NGF on the osteogenic differentiation of DPSCs in vitro and the underlying mechanisms. DPSCs were cultured in osteogenic differentiation medium containing NGF (50 ng/mL) for 7 days. Then osteogenic-related genes and protein markers were analysed using qRT-PCR and Western blot, respectively. Furthermore, addition of NGF inhibitor and small interfering RNA (siRNA) transfection experiments were used to elucidate the molecular signalling pathway responsible for the process. NGF increased osteogenic differentiation of DPSCs significantly compared with DPSCs cultured in an osteogenic-inducing medium. The NGF inhibitor Ro 08-2750 (10 μM) and siRNA-mediated gene silencing of NGF receptor, TrkA and ERK signalling pathways inhibitor U0126 (10 μM) suppressed osteogenic-related genes and protein markers on DPSCs. Furthermore, our data revealed that NGF-upregulated osteogenic differentiation of DPSCs may be associated with the activation of MEK/ERK signalling pathways via TrkA. Collectively, NGF was capable of promoting osteogenic differentiation of DPSCs through MEK/ERK signalling pathways, which may enhance the DPSCs-mediated bone tissue regeneration.
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Affiliation(s)
- Chen Cheng
- School of StomatologyShandong Second Medical UniversityWeifangChina
- Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of MedicineShandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral DiseasesChina
- Department of StomatologyHeze Municipal HospitalChina
| | - Shuai Tang
- School of StomatologyShandong Second Medical UniversityWeifangChina
- Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of MedicineShandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral DiseasesChina
| | - Shuyue Cui
- School of StomatologyShandong Second Medical UniversityWeifangChina
- Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of MedicineShandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral DiseasesChina
| | - Tong Yang
- School of StomatologyShandong Second Medical UniversityWeifangChina
| | - Lan Li
- Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of MedicineShandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral DiseasesChina
| | - Mingrui Zhai
- Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of MedicineShandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral DiseasesChina
| | - Fulan Wei
- Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of MedicineShandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral DiseasesChina
| | - Gang Ding
- School of StomatologyShandong Second Medical UniversityWeifangChina
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Ohnishi T, Homan K, Fukushima A, Ukeba D, Iwasaki N, Sudo H. A Review: Methodologies to Promote the Differentiation of Mesenchymal Stem Cells for the Regeneration of Intervertebral Disc Cells Following Intervertebral Disc Degeneration. Cells 2023; 12:2161. [PMID: 37681893 PMCID: PMC10486900 DOI: 10.3390/cells12172161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/24/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023] Open
Abstract
Intervertebral disc (IVD) degeneration (IDD), a highly prevalent pathological condition worldwide, is widely associated with back pain. Treatments available compensate for the impaired function of the degenerated IVD but typically have incomplete resolutions because of their adverse complications. Therefore, fundamental regenerative treatments need exploration. Mesenchymal stem cell (MSC) therapy has been recognized as a mainstream research objective by the World Health Organization and was consequently studied by various research groups. Implanted MSCs exert anti-inflammatory, anti-apoptotic, and anti-pyroptotic effects and promote extracellular component production, as well as differentiation into IVD cells themselves. Hence, the ultimate goal of MSC therapy is to recover IVD cells and consequently regenerate the extracellular matrix of degenerated IVDs. Notably, in addition to MSC implantation, healthy nucleus pulposus (NP) cells (NPCs) have been implanted to regenerate NP, which is currently undergoing clinical trials. NPC-derived exosomes have been investigated for their ability to differentiate MSCs from NPC-like phenotypes. A stable and economical source of IVD cells may include allogeneic MSCs from the cell bank for differentiation into IVD cells. Therefore, multiple alternative therapeutic options should be considered if a refined protocol for the differentiation of MSCs into IVD cells is established. In this study, we comprehensively reviewed the molecules, scaffolds, and environmental factors that facilitate the differentiation of MSCs into IVD cells for regenerative therapies for IDD.
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Affiliation(s)
- Takashi Ohnishi
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan; (T.O.); (K.H.); (A.F.); (N.I.)
| | - Kentaro Homan
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan; (T.O.); (K.H.); (A.F.); (N.I.)
| | - Akira Fukushima
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan; (T.O.); (K.H.); (A.F.); (N.I.)
| | - Daisuke Ukeba
- Department of Orthopedic Surgery, Hokkaido University Hospital, Sapporo 060-8648, Japan;
| | - Norimasa Iwasaki
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan; (T.O.); (K.H.); (A.F.); (N.I.)
| | - Hideki Sudo
- Department of Advanced Medicine for Spine and Spinal Cord Disorders, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan
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Wee NKY, Novak S, Ghosh D, Root SH, Dickerson IM, Kalajzic I. Inhibition of CGRP signaling impairs fracture healing in mice. J Orthop Res 2023; 41:1228-1239. [PMID: 36281531 PMCID: PMC10123175 DOI: 10.1002/jor.25474] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/06/2022] [Accepted: 10/18/2022] [Indexed: 02/04/2023]
Abstract
Calcitonin gene-related peptide (CGRP) is a neuropeptide produced by sensory nerves and functions as a pain sensor. It acts by binding to the calcitonin-like receptor (CLR, protein; Calcrl, gene). CGRP inhibition has been recently introduced as therapeutic treatment of migraine-associated pain. Previous studies have shown that CGRP stimulates bone formation. The aim of our study is to determine whether the inhibition of CGRP signaling negatively impacted fracture healing. Using α-smooth muscle actin (αSMA) Cre animals crossed with Ai9 reporter mice, we showed that CGRP-expressing nerves are near αSMA + cells in the periosteum. In vitro experiments revealed that periosteal cells express Calcrl and receptor activity modifying protein 1; and CGRP stimulation increased periosteal cell proliferation. Using a tamoxifen-inducible model αSMACre/CLRfl/fl , we targeted the deletion of CLR to periosteal progenitor cells and examined fracture healing. Microcomputed tomography of fractured femurs showed a reduction in bone mass in αSMACre+/CLRfl/fl female mice relative to controls and callus volume in males. Pharmacological CGRP-CLR inhibition was achieved by subcutaneous delivery of customized pellets with small molecule inhibitor olcegepant (BIBN-4096) at a dose of 10 μg/day. BIBN-4096-treated C57BL/6J mice had a higher latency toward thermal nociception than placebo-treated mice, indicating impaired sensory function through CGRP inhibition. CGRP inhibition also resulted in reduced callus volume, bone mass, and bone strength compared to placebo controls. These results indicate that inhibiting CGRP by deleting CLR or by using BIBN-4096, contributes to delayed bone healing.
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Affiliation(s)
- Natalie KY Wee
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
- Bone Cell Biology and Disease Unit, St Vincent’s Institute of Medical Research, Fitzroy, VIC 3065, Australia
| | - Sanja Novak
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Debolina Ghosh
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Sierra H Root
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Ian M Dickerson
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Ivo Kalajzic
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
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Smith MM, Melrose J. Pentosan Polysulfate Affords Pleotropic Protection to Multiple Cells and Tissues. Pharmaceuticals (Basel) 2023; 16:437. [PMID: 36986536 PMCID: PMC10132487 DOI: 10.3390/ph16030437] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/18/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
Pentosan polysulfate (PPS), a small semi-synthetic highly sulfated heparan sulfate (HS)-like molecule, shares many of the interactive properties of HS. The aim of this review was to outline the potential of PPS as an interventional therapeutic protective agent in physiological processes affecting pathological tissues. PPS is a multifunctional molecule with diverse therapeutic actions against many disease processes. PPS has been used for decades in the treatment of interstitial cystitis and painful bowel disease, it has tissue-protective properties as a protease inhibitor in cartilage, tendon and IVD, and it has been used as a cell-directive component in bioscaffolds in tissue engineering applications. PPS regulates complement activation, coagulation, fibrinolysis and thrombocytopenia, and it promotes the synthesis of hyaluronan. Nerve growth factor production in osteocytes is inhibited by PPS, reducing bone pain in osteoarthritis and rheumatoid arthritis (OA/RA). PPS also removes fatty compounds from lipid-engorged subchondral blood vessels in OA/RA cartilage, reducing joint pain. PPS regulates cytokine and inflammatory mediator production and is also an anti-tumor agent that promotes the proliferation and differentiation of mesenchymal stem cells and the development of progenitor cell lineages that have proven to be useful in strategies designed to effect repair of the degenerate intervertebral disc (IVD) and OA cartilage. PPS stimulates proteoglycan synthesis by chondrocytes in the presence or absence of interleukin (IL)-1, and stimulates hyaluronan production by synoviocytes. PPS is thus a multifunctional tissue-protective molecule of potential therapeutic application for a diverse range of disease processes.
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Affiliation(s)
- Margaret M. Smith
- Raymond Purves Laboratory, Institute of Bone and Joint Research, Kolling Institute of Medical Research, Faculty of Health and Science, University of Sydney at Royal North Shore Hospital, St. Leonards, NSW 2065, Australia;
| | - James Melrose
- Raymond Purves Laboratory, Institute of Bone and Joint Research, Kolling Institute of Medical Research, Faculty of Health and Science, University of Sydney at Royal North Shore Hospital, St. Leonards, NSW 2065, Australia;
- Graduate Schools of Biomedical Engineering, University of NSW, Sydney, NSW 2052, Australia
- Sydney Medical School, Northern Campus, Royal North Shore Hospital, St. Leonards, NSW 2065, Australia
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Kim H, Seo J, Lee Y, Park K, Perry TA, Arden NK, Mobasheri A, Choi H. The current state of the osteoarthritis drug development pipeline: a comprehensive narrative review of the present challenges and future opportunities. Ther Adv Musculoskelet Dis 2022; 14:1759720X221085952. [PMID: 36504595 PMCID: PMC9732806 DOI: 10.1177/1759720x221085952] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/18/2022] [Indexed: 12/12/2022] Open
Abstract
In this narrative review article, we critically assess the current state of the osteoarthritis (OA) drug development pipeline. We discuss the current state-of-the-art in relation to the development and evaluation of candidate disease-modifying OA drugs (DMOADs) and the limitations associated with the tools and methodologies that are used to assess outcomes in OA clinical trials. We focus on the definition of DMOADs, highlight the need for an updated definition in the form of a consensus statement from all the major stakeholders, including academia, industry, regulatory agencies, and patient organizations, and provide a summary of the results of recent clinical trials of novel DMOAD candidates. We propose that DMOADs should be more appropriately targeted and investigated according to the emerging clinical phenotypes and molecular endotypes of OA. Based on the findings from recent clinical trials, we propose key topics and directions for the development of future DMOADs.
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Affiliation(s)
- Heungdeok Kim
- Institute of Bio Innovation Research, Kolon
Life Science, Inc., Seoul, South Korea
| | - Jinwon Seo
- Institute of Bio Innovation Research, Kolon
Life Science, Inc., Seoul, South Korea
| | - Yunsin Lee
- Institute of Bio Innovation Research, Kolon
Life Science, Inc., Seoul, South Korea
| | - Kiwon Park
- Institute of Bio Innovation Research, Kolon
Life Science, Inc., Seoul, South Korea
| | - Thomas A. Perry
- Centre for Osteoarthritis Pathogenesis Versus
Arthritis, Kennedy Institute of Rheumatology, University of Oxford, Oxford,
UK
| | - Nigel K. Arden
- Versus Arthritis Centre for Sport, Exercise and
Osteoarthritis, University of Oxford, Oxford, UK,Botnar Research Centre, Nuffield Orthopaedic
Centre, Oxford, UK
| | - Ali Mobasheri
- Research Unit of Medical Imaging, Physics and
Technology, Faculty of Medicine, University of Oulu, Oulu, Finland,Department of Regenerative Medicine, State
Research Institute Center for Innovative Medicine, Vilnius, Lithuania,Department of Orthopedics and Department of
Rheumatology and Clinical Immunology, University Medical Center Utrecht,
Utrecht, The Netherlands,Department of Joint Surgery, The First
Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China,World Health Organization Collaborating Center
for Public Health Aspects of Musculoskeletal Health and Aging, Université de
Liège, Liège, Belgium
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Mechanisms of bone pain: Progress in research from bench to bedside. Bone Res 2022; 10:44. [PMID: 35668080 PMCID: PMC9170780 DOI: 10.1038/s41413-022-00217-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 12/27/2022] Open
Abstract
AbstractThe field of research on pain originating from various bone diseases is expanding rapidly, with new mechanisms and targets asserting both peripheral and central sites of action. The scope of research is broadening from bone biology to neuroscience, neuroendocrinology, and immunology. In particular, the roles of primary sensory neurons and non-neuronal cells in the peripheral tissues as important targets for bone pain treatment are under extensive investigation in both pre-clinical and clinical settings. An understanding of the peripheral mechanisms underlying pain conditions associated with various bone diseases will aid in the appropriate application and development of optimal strategies for not only managing bone pain symptoms but also improving bone repairing and remodeling, which potentially cures the underlying etiology for long-term functional recovery. In this review, we focus on advances in important preclinical studies of significant bone pain conditions in the past 5 years that indicated new peripheral neuronal and non-neuronal mechanisms, novel targets for potential clinical interventions, and future directions of research.
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Muratovic D, Findlay DM, Quarrington RD, Cao X, Solomon LB, Atkins GJ, Kuliwaba JS. Elevated levels of active Transforming Growth Factor β1 in the subchondral bone relate spatially to cartilage loss and impaired bone quality in human knee osteoarthritis. Osteoarthritis Cartilage 2022; 30:896-907. [PMID: 35331858 DOI: 10.1016/j.joca.2022.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The association between the spatially distributed level of active TGFβ1 in human subchondral bone, and the characteristic structural and cellular parameters of human knee OA, was assessed. DESIGN Paired subchondral bone samples from 35 OA arthroplasty patients, (15 men and 20 women, aged 69 ± 9 years) were obtained from beneath macroscopically present (CA+) or denuded cartilage (CA-) to determine the concentration of active TGFβ1 (ELISA) and its relationship to bone quality (synchrotron micro-CT), cellularity, and vascularization (histology). RESULTS Bone samples beneath (CA-) regions had significantly increased concentrations of active TGFβ1 protein (mean difference: 26.4; 95% CI: [3.2, 49.7]), when compared to bone in CA + regions. Trabecular Bone below (CA-) regions had increased bone volume (median difference: 4.3; 96.49% CI: [-1.7, 17.8]), increased trabecular number (1.5 [0.006, 2.6], decreased trabecular separation (-0.05 [-0.1,-0.005]), and increased bone mineral density (394.5 [65.7, 723.3]) comparing to (CA+) regions. Further, (CA-) bone regions showed increased osteocyte density (0.012 [0.006, 0.018]), with larger osteocyte lacunae (39.8 [7.8, 71.7]) that were less spherical (-0.02 [-0.04, -0.003]), and increased bone matrix vascularity (12.4 [0.3, 24.5]) compared to (CA+). In addition, increased levels of active TGFβ1 related to increased bone volume (0.04 [-0.11, 0.9]), while increased OARSI grade associated with lacunar volume (-44.1 [-71.1, -17.2]), and orientation (2.7 [0.8, 4.6]). CONCLUSION Increased concentration of active TGFβ1 in the subchondral bone of human knee OA associates spatially with impaired bone quality and disease severity, suggesting that TGFβ1 is a potential therapeutic target to prevent or reduce human OA disease progression.
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Affiliation(s)
- D Muratovic
- Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, South Australia 5000, Australia.
| | - D M Findlay
- Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, South Australia 5000, Australia.
| | - R D Quarrington
- Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, South Australia 5000, Australia.
| | - X Cao
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - L B Solomon
- Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, South Australia 5000, Australia; Orthopaedic and Trauma Service, The Royal Adelaide Hospital and the Central Adelaide Local Health Network, Adelaide, South Australia 5000, Australia.
| | - G J Atkins
- Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, South Australia 5000, Australia.
| | - J S Kuliwaba
- Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, South Australia 5000, Australia.
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Zhou F, Han X, Wang L, Zhang W, Cui J, He Z, Xie K, Jiang X, Du J, Ai S, Sun Q, Wu H, Yu Z, Yan M. Associations of osteoclastogenesis and nerve growth in subchondral bone marrow lesions with clinical symptoms in knee osteoarthritis. J Orthop Translat 2022; 32:69-76. [PMID: 34934628 PMCID: PMC8645426 DOI: 10.1016/j.jot.2021.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022] Open
Abstract
Background/objective Subchondral bone marrow lesions (BMLs) are common magnetic resonance imaging (MRI) features in joints affected by osteoarthritis (OA), however, their clinical impacts and mechanisms remain controversial. Thus, we aimed to investigate subchondral BMLs in knee OA patients who underwent total knee arthroplasty (TKA), then evaluate the associations of osteoclastogenesis and nerve growth in subchondral BMLs with clinical symptoms. Methods Total 70 patients with primary symptomatic knee OA were involved, then separated into three groups based on MRI (without BMLs group, n = 14; BMLs without cyst group, n = 37; BMLs with cyst group, n = 19). Volume of BMLs and cyst-like lesions was calculated via the OsiriX system. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire was used to assess clinical symptoms. Histology and immunohistochemistry were deployed to assess subchondral osteoclastogenesis and nerve distribution. Pearson's correlation coefficient was used to evaluate the associations between volume of BMLs and joint symptoms, and to assess the associations of osteoclastogenesis and nerve growth in subchondral BMLs with joint symptoms. Results In BMLs combined with cyst group, patients exhibited increased osteoclastogenesis and nerve distribution in subchondral bone, as shown by increased expression of tartrate resistant acid phosphatase (TRAP) and protein gene product 9.5 (PGP9.5). Volume of subchondral cyst-like component was associated with joint pain (p < 0.05). Subchondral osteoclastogenesis and nerve distribution were positively associated with joint pain in BMLs with cyst group (p < 0.05). Conclusion The subchondral cyst-like lesion was an independent factor for inducing pain in OA patients; osteoclastogenesis and nerve growth in subchondral cyst-like lesions could account for this joint pain. The translational potential of this article Our results indicated that the increased osteoclastogenesis and nerve growth in subchondral cyst-like lesions could account for the pain of OA joints. These findings may provide valuable basis for the treatment of OA.
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Pentosan polysulfate sodium prevents functional decline in chikungunya infected mice by modulating growth factor signalling and lymphocyte activation. PLoS One 2021; 16:e0255125. [PMID: 34492036 PMCID: PMC8423248 DOI: 10.1371/journal.pone.0255125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/09/2021] [Indexed: 11/19/2022] Open
Abstract
Chikungunya virus (CHIKV) is an arthropod-borne virus that causes large outbreaks world-wide leaving millions of people with severe and debilitating arthritis. Interestingly, clinical presentation of CHIKV arthritides have many overlapping features with rheumatoid arthritis including cellular and cytokine pathways that lead to disease development and progression. Currently, there are no specific treatments or vaccines available to treat CHIKV infections therefore advocating the need for the development of novel therapeutic strategies to treat CHIKV rheumatic disease. Herein, we provide an in-depth analysis of an efficacious new treatment for CHIKV arthritis with a semi-synthetic sulphated polysaccharide, Pentosan Polysulfate Sodium (PPS). Mice treated with PPS showed significant functional improvement as measured by grip strength and a reduction in hind limb foot swelling. Histological analysis of the affected joint showed local inflammation was reduced as seen by a decreased number of infiltrating immune cells. Additionally, joint cartilage was protected as demonstrated by increased proteoglycan staining. Using a multiplex-immunoassay system, we also showed that at peak disease, PPS treatment led to a systemic reduction of the chemokines CXCL1, CCL2 (MCP-1), CCL7 (MCP-3) and CCL12 (MCP-5) which may be associated with the reduction in cellular infiltrates. Further characterisation of the local effect of PPS in its action to reduce joint and muscle inflammation was performed using NanoString™ technology. Results showed that PPS altered the local expression of key functional genes characterised for their involvement in growth factor signalling and lymphocyte activation. Overall, this study shows that PPS is a promising treatment for alphaviral arthritis by reducing inflammation and protecting joint integrity.
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12
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Yang X, Mou D, Yu Q, Zhang J, Xiong Y, Zhang Z, Xing S. Nerve growth factor promotes osteogenic differentiation of MC3T3-E1 cells via BMP-2/Smads pathway. Ann Anat 2021; 239:151819. [PMID: 34391912 DOI: 10.1016/j.aanat.2021.151819] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/16/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Exogenous nerve growth factor (NGF) can induce osteogenic precursor cell differentiation and promote fracture healing. However, the molecular mechanism by which NGF induces osteogenesis is not well understood. BMP-2 has good osteogenic efficacy and is one of the most osteogenic-inducing growth factors known. Therefore, this study aimed to determine whether NGF induces osteogenic differentiation of mouse embryonic osteogenic precursor cell line MC3T3-E1 by BMP-2 and search further mechanisms of NGF on BMP-2. METHODS MC3T3-E1 cells were treated with NGF at a concentration gradient for indicated times, after which the cell viability was measured by CCK-8 kit. Osteogenic differentiation was detected with quantification of alkaline phosphatase (ALP) activity also visualized with ALP staining. The transcription and expression of relevant genes were detected by qPCR and western blotting, respectively. NGF's effect on BMP2 was studied with qPCR and luciferase reporter assay. The phosphorylation of Smads was probed with specific antibodies by western blotting, and the location of Smads was observed through immunofluorescence. RESULTS We found that NGF promoted proliferation and osteogenic differentiation of MC3T3-E1, increased the expression level of BMP-2, as well as the phosphorylation and nuclear translocation of Smad1/5/8. However, neutralization of BMP-2 with si-BMP-2 or BMP-2 signal inhibitors reversed NGF induced phosphorylation and nuclear translocation of Smad1/5/8, as well as the expression of Runx2, type I collagen, osteocalcin and osteopontin. In addition, si-BMP-2 abrogated NGF-induced ALP activity. CONCLUSION NGF induced osteogenic differentiation of MC3T3-E1 cells through BMP-2/Smads pathway and induction of Runx2. Our study would provide a theoretical basis for clinical treatment of fractures using NGF.
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Affiliation(s)
- Xuming Yang
- Orthopedics Department, Yan'an Hospital Affiliated to Kunming Medical University, Kunming 650035, Yunnan Province, China.
| | - Donggang Mou
- Orthopedics Department, Yan'an Hospital Affiliated to Kunming Medical University, Kunming 650035, Yunnan Province, China
| | - Qunying Yu
- Maternity Department, The Second Affiliated Hospital of Kunming Medical University, Kunming 650051, Yunnan Province, China
| | - Jimei Zhang
- Department of Gastroenterology, Yan'an Hospital Affiliated to Kunming Medical University, Kunming 650065, Yunnan Province, China
| | - Ying Xiong
- Orthopedics Department, Yan'an Hospital Affiliated to Kunming Medical University, Kunming 650035, Yunnan Province, China
| | - Zhimin Zhang
- Orthopedics Department, Yanshan County Hospital of Traditional Chinese Medicine, Wenshan Zhuang and Miao Autonomous Prefecture 663100, Yunnan Province, China
| | - Shan Xing
- Orthopedics Department, The Second People's Hospital of Yanshan County, Wenshan Zhuang and Miao Autonomous Prefecture 663101, Yunnan Province, China
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Targeting Nerve Growth Factor for Pain Management in Osteoarthritis-Clinical Efficacy and Safety. Rheum Dis Clin North Am 2021; 47:181-195. [PMID: 33781489 DOI: 10.1016/j.rdc.2020.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Nerve growth factor (NGF) is a neurotrophin that mediates pain sensitization in pathologic states, including osteoarthritis. In clinical trials, antibodies to NGF reduce pain and improve physical function due to osteoarthritis of the knee or hip and have a long duration of action. Rapidly progressive osteoarthritis is a dose-dependent adverse event with these agents, and additional joint safety signals, such as subchondral insufficiency fractures and increased rates of total joint replacement, are reported. The effects on pain and potential mechanisms behind these joint events both are of considerable importance in the consideration of future use of anti-NGF therapies for osteoarthritis.
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14
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Stapledon CJM, Stamenkov R, Cappai R, Clark JM, Bourke A, Bogdan Solomon L, Atkins GJ. Relationships between the Bone Expression of Alzheimer's Disease-Related Genes, Bone Remodelling Genes and Cortical Bone Structure in Neck of Femur Fracture. Calcif Tissue Int 2021; 108:610-621. [PMID: 33398413 DOI: 10.1007/s00223-020-00796-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 12/12/2020] [Indexed: 01/18/2023]
Abstract
Neck of femur (NOF) fracture is a prevalent fracture type amongst the ageing and osteoporotic populations, commonly requiring total hip replacement (THR) surgery. Increased fracture risk has also been associated with Alzheimer's disease (AD) in the aged. Here, we sought to identify possible relationships between the pathologies of osteoporosis and dementia by analysing bone expression of neurotropic or dementia-related genes in patients undergoing THR surgery for NOF fracture. Femoral bone samples from 66 NOF patients were examined for expression of the neurotropic genes amyloid precursor protein (APP), APP-like protein-2 (APLP2), Beta-Secretase Cleaving Enzyme-1 (BACE1) and nerve growth factor (NGF). Relationships were examined between the expression of these and of bone regulatory genes, systemic factors and bone structural parameters ascertained from plain radiographs. We found strong relative levels of expression and positive correlations between APP, APLP2, BACE1 and NGF levels in NOF bone. Significant correlations were found between APP, APLP2, BACE1 mRNA levels and bone remodelling genes TRAP, RANKL, and the RANKL:OPG mRNA ratio, indicative of potential functional relationships at the time of fracture. Analysis of the whole cohort, as well as non-dementia (n = 53) and dementia (n = 13) subgroups, revealed structural relationships between APP and APLP2 mRNA expression and lateral femoral cortical thickness. These findings suggest that osteoporosis and AD may share common molecular pathways of disease progression, perhaps explaining the common risk factors associated with these diseases. The observation of a potential pathologic role for AD-related genes in bone may also provide alternative treatment strategies for osteoporosis and fracture prevention.
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Affiliation(s)
- Catherine J M Stapledon
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Roumen Stamenkov
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Roberto Cappai
- Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, VIC, Australia
| | - Jillian M Clark
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- South Australian Spinal Cord Injury Research Centre, Hampstead Rehabilitation Centre, Lightsview, SA, Australia
| | - Alice Bourke
- Department of Gerontology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - L Bogdan Solomon
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Gerald J Atkins
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA, Australia.
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Krishnan R, Duiker M, Rudd PA, Skerrett D, Pollard JGD, Siddel C, Rifat R, Ng JHK, Georgius P, Hererro LJ, Griffin P. Pentosan polysulfate sodium for Ross River virus-induced arthralgia: a phase 2a, randomized, double-blind, placebo-controlled study. BMC Musculoskelet Disord 2021; 22:271. [PMID: 33711991 PMCID: PMC7955617 DOI: 10.1186/s12891-021-04123-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background Alphaviruses, such as Ross River (RRV) and chikungunya virus (CHIKV), cause significant global morbidity, with outbreaks of crippling joint inflammation and pain, leaving patients incapacitated for months to years. With no available vaccine or specific therapeutic for any alphaviral disease, and a growing economic and public health burden, there is a serious need for the development of specific therapies. Methods This study evaluated the safety and efficacy of pentosan polysulfate sodium (PPS) in subjects with RRV-induced arthralgia in a double-blind, placebo-controlled trial. Twenty subjects were randomized 2:1 to subcutaneous PPS (2 mg/kg) or placebo (sodium chloride 0.9%) twice weekly for 6 weeks. Safety evaluation included physical examination, concomitant medications, and laboratory findings. Efficacy assessments included change from baseline in joint function (hand grip strength and RAPID3) and quality of life (SF-36) at Days 15, 29, 39 and 81 after treatment initiation. Inflammatory and cartilage degradation biomarkers were exploratory endpoints. Results PPS was well tolerated, with a similar proportion of subjects reporting at least one treatment-emergent adverse event (TEAE) in the treatment and placebo groups. Injection site reactions were the most common TEAE and occurred more frequently in the PPS group. Dominant hand grip strength and SF-36 scores improved with PPS at all time points assessed, with hand grip strength improvement of 6.99 kg (p = 0.0189) higher than placebo at Day 15. PPS showed significant improvements versus placebo in adjusted mean relative change from baseline for RAPID3 Pain (p = 0.0197) and Total (p = 0.0101) scores at Day 15. At the conclusion of the study overall joint symptoms, assessed by RAPID3, showed near remission in 61.5% of PPS subjects versus 14.3% of placebo subjects. Additionally, PPS treatment improved COMP, CTX-II, CCL1, CXCL12, CXCL16 and CCL17 biomarker levels versus placebo. Conclusions Overall, the improvements in strength and joint symptoms warrant further evaluation of PPS as a specific treatment for RRV-induced and other forms of arthritis. Trial registration This trial is registered at the Australian New Zealand Clinical Trials Registry #ACTRN12617000893303. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04123-w.
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Affiliation(s)
- Ravi Krishnan
- Paradigm Biopharmaceuticals Ltd., Melbourne, Victoria, Australia
| | - Melanie Duiker
- Paradigm Biopharmaceuticals Ltd., Melbourne, Victoria, Australia
| | - Penny A Rudd
- Institute for Glycomics, Griffith University, Southport, Queensland, Australia
| | - Donna Skerrett
- Paradigm Biopharmaceuticals Ltd., Melbourne, Victoria, Australia
| | | | | | - Rifat Rifat
- Rich River Health Group, Echuca, Victoria, Australia
| | - Jennifer H K Ng
- Clinical Trials Unit (Griffith Health), Griffith University, Gold Coast, Australia and Gold Coast University, Gold Coast, Queensland, Australia
| | - Peter Georgius
- Sunshine Coast Clinical Research, Gold Coast, Queensland, Australia
| | - Lara J Hererro
- Institute for Glycomics, Griffith University, Southport, Queensland, Australia
| | - Paul Griffin
- Department of Medicine and Infectious Diseases, Mater Misericordiae Ltd., Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia.
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Abstract
Osteoarthritis (OA) is one of the most debilitating diseases and is associated with a high personal and socioeconomic burden. So far, there is no therapy available that effectively arrests structural deterioration of cartilage and bone or is able to successfully reverse any of the existing structural defects. Efforts to identify more tailored treatment options led to the development of strategies that enabled the classification of patient subgroups from the pool of heterogeneous phenotypes that display distinct common characteristics. To this end, the classification differentiates the structural endotypes into cartilage and bone subtypes, which are predominantly driven by structure-related degenerative events. In addition, further classifications have highlighted individuals with an increased inflammatory contribution (inflammatory phenotype) and pain-driven phenotypes as well as senescence and metabolic syndrome phenotypes. Most probably, it will not be possible to classify individuals by a single definite subtype, but it might help to identify groups of patients with a predominant pathology that would more likely benefit from a specific drug or cell-based therapy. Current clinical trials addressed mainly regeneration/repair of cartilage and bone defects or targeted pro-inflammatory mediators by intra-articular injections of drugs and antibodies. Pain was treated mostly by antagonizing nerve growth factor (NGF) activity and its receptor tropomyosin-related kinase A (TrkA). Therapies targeting metabolic disorders such as diabetes mellitus and senescence/aging-related pathologies are not specifically addressing OA. However, none of these therapies has been proven to modify disease progression significantly or successfully prevent final joint replacement in the advanced disease stage. Within this review, we discuss the recent advances in phenotype-specific treatment options and evaluate their applicability for use in personalized OA therapy.
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Affiliation(s)
- Susanne Grässel
- Department of Orthopedic Surgery, Exp. Orthopedics, ZMB/Biopark 1, Am Biopark 9, University of Regensburg, Regensburg, 93053, Germany
| | - Dominique Muschter
- Department of Orthopedic Surgery, Exp. Orthopedics, ZMB/Biopark 1, Am Biopark 9, University of Regensburg, Regensburg, 93053, Germany
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