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Surowiec RK, Saldivar R, Rai RK, Metzger CE, Jacobson AM, Allen MR, Wallace JM. Ex vivo exposure to calcitonin or raloxifene improves mechanical properties of diseased bone through non-cell mediated mechanisms. Bone 2023; 173:116805. [PMID: 37196853 PMCID: PMC10330631 DOI: 10.1016/j.bone.2023.116805] [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: 03/15/2023] [Revised: 05/01/2023] [Accepted: 05/12/2023] [Indexed: 05/19/2023]
Abstract
Raloxifene (RAL) reduces clinical fracture risk despite modest effects on bone mass and density. This reduction in fracture risk may be due to improved material level-mechanical properties through a non-cell mediated increase in bone hydration. Synthetic salmon calcitonin (CAL) has also demonstrated efficacy in reducing fracture risk with only modest bone mass and density improvements. This study aimed to determine if CAL could modify healthy and diseased bone through cell-independent mechanisms that alter hydration similar to RAL. 26-week-old male C57BL/6 mice induced with chronic kidney disease (CKD) beginning at 16 weeks of age via 0.2 % adenine-laced casein-based (0.9 % P, 0.6 % C) chow, and their non-CKD control littermates (Con), were utilized. Upon sacrifice, right femora were randomly assigned to the following ex vivo experimental groups: RAL (2 μM, n = 10 CKD, n = 10 Con), CAL (100 nM, n = 10 CKD, n = 10 Con), or Vehicle (VEH; n = 9 CKD, n = 9 Con). Bones were incubated in PBS + drug solution at 37 °C for 14 days using an established ex vivo soaking methodology. Cortical geometry (μCT) was used to confirm a CKD bone phenotype, including porosity and cortical thinning, at sacrifice. Femora were assessed for mechanical properties (3-point bending) and bone hydration (via solid state nuclear magnetic resonance spectroscopy with magic angle spinning (ssNMR)). Data were analyzed by two-tailed t-tests (μCT) or 2-way ANOVA for main effects of disease, treatment, and their interaction. Tukey's post hoc analyses followed a significant main effect of treatment to determine the source of the effect. Imaging confirmed a cortical phenotype reflective of CKD, including lower cortical thickness (p < 0.0001) and increased cortical porosity (p = 0.02) compared to Con. In addition, CKD resulted in weaker, less deformable bones. In CKD bones, ex vivo exposure to RAL or CAL improved total work (+120 % and +107 %, respectively; p < 0.05), post-yield work (+143 % and +133 %), total displacement (+197 % and +229 %), total strain (+225 % and +243 %), and toughness (+158 % and +119 %) vs. CKD VEH soaked bones. Ex vivo exposure to RAL or CAL did not impact any mechanical properties in Con bone. Matrix-bound water by ssNMR showed CAL treated bones had significantly higher bound water compared to VEH treated bones in both CKD and Con cohorts (p = 0.001 and p = 0.01, respectively). RAL positively modulated bound water in CKD bone compared to VEH (p = 0.002) but not in Con bone. There were no significant differences between bones soaked with CAL vs. RAL for any outcomes measured. RAL and CAL improve important post-yield properties and toughness in a non-cell mediated manner in CKD bone but not in Con bones. While RAL treated CKD bones had higher matrix-bound water content in line with previous reports, both Con and CKD bones exposed to CAL had higher matrix-bound water. Therapeutic modulation of water, specifically the bound water fraction, represents a novel approach to improving mechanical properties and potentially reducing fracture risk.
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Affiliation(s)
- Rachel K Surowiec
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Rosario Saldivar
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Epidemiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ratan K Rai
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Corinne E Metzger
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Andrea M Jacobson
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.
| | - Matthew R Allen
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA; Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA.
| | - Joseph M Wallace
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.
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Abstract
Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.
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Kaneb A, Berardino K, Hanukaai JS, Rooney K, Kaye AD. Calcitonin (FORTICAL, MIACALCIN) for the treatment of vertebral compression fractures. Orthop Rev (Pavia) 2021; 13:24976. [PMID: 34745472 DOI: 10.52965/001c.24976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/18/2021] [Indexed: 12/28/2022] Open
Abstract
Purpose of Review Osteoporosis is a common condition affecting the musculoskeletal system. It carries with it increased risks of fracture in many areas of the body, leading to reduced quality of life, limited mobility, and other long-term implications such as chronic pain. Vertebral compression fractures are a common development in patients with osteoporosis. Current treatment options focus on reducing pain; preventative methods are somewhat limited and focus on minimizing risk factors for the development of osteoporosis. In this review, we explore the use of calcitonin (FORTICAL, MIACALCIN) to treat vertebral compression fractures (VCFs). Recent Findings Osteoporosis had a prevalence of more than 10% in the United States in 2010. The CDC estimates that nearly 25% of women over age 65 have findings of osteoporosis, which include low spinal bone mass. The condition is highly prevalent and, in an aging U.S. population, quite clinically relevant. Risk factors for development include advanced age, cigarette smoking, medications, reduced physical activity, and low calcium and vitamin D intake. Family history may also play a role. Diagnosis is made based on bone mineral density.Standard therapy for VCFs in osteoporosis includes analgesic medications, such as NSAIDs and biphosphonates, and surgical intervention. NSAIDs address the chronic pain that is a common long-term effect of VCFs. Biphosphonates have recently been used to attempt to halt the progression and provide prevention. Surgical interventions such as balloon kyphoplasty and vertebroplasty are typically reserved for patients who have failed other methods.Calcitonin is a peptide naturally produced by the human body, released from the parathyroid gland. It binds to osteoclasts, inhibiting them from inducing bone resorption. By relatively unknown mechanisms, it also appears to cause endorphin release and mitigate pain. Clinical data has shown safety and efficacy for exogenous calcitonin in reducing bone turnover and reducing VCF-induced pain. Summary Osteoporosis is a common condition that can lead to complications such as vertebral compression fractures. It can significantly impact the quality of life in many elderly Americans. There is currently no singular treatment, but calcitonin has recently been explored as a possible option for minimizing pain and reducing disease progression. Further studies are needed to understand its preventative benefits fully.
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Affiliation(s)
- Alicia Kaneb
- Georgetown University School of Medicine, Washington D.C
| | | | | | - Kelsey Rooney
- Louisiana State University Health Science Center, Shreveport, LA
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Xian Y, Su Y, Liang J, Long F, Feng X, Xiao Y, Lian H, Xu J, Zhao J, Liu Q, Song F. Oroxylin A reduces osteoclast formation and bone resorption via suppressing RANKL-induced ROS and NFATc1 activation. Biochem Pharmacol 2021; 193:114761. [PMID: 34492273 DOI: 10.1016/j.bcp.2021.114761] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 01/15/2023]
Abstract
Excessive bone erosion by osteoclasts is associated with osteoporosis, rheumatoid arthritis, and periprosthetic osteolysis. Targeting osteoclasts may serve as an effective treatment for osteolytic diseases. Although drugs are currently available for the treatment of these diseases, exploring potential anti-osteoclast natural compounds with safe and effective treatment remains needed. Oroxylin A (OA), a natural flavonoid isolated from the root of Scutellaria baicalensis Georgi, has numerous beneficial pharmacological characteristics, including anti-inflammatory and antioxidant activity. However, its effects and mechanisms on osteoclast formation and bone resorption have not yet been clarified. Our research showed that OA attenuated the formation and function of osteoclast induced by RANKL in a time- and concentration-dependent manner without any cytotoxicity. Mechanistically, OA suppressed intracellular reactive oxygen species (ROS) levels through the Nrf2-mediated antioxidant response. Moreover, OA inhibited the activity of NFATc1, the master transcriptional regulator of RANKL-induced osteoclastogenesis. OA exhibited protective effects in mouse models of post-ovariectomy (OVX)- and lipopolysaccharide (LPS)-induced bone loss, in accordance with its in vitro anti-osteoclastogenic effect. Collectively, our findings highlight the potential of OA as a pharmacological agent for the prevention of osteoclast-mediated osteolytic diseases.
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Affiliation(s)
- Yansi Xian
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Collaborative Innovation Center for Biomedicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Yuangang Su
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Jiamin Liang
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Feng Long
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Collaborative Innovation Center for Biomedicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Xiaoliang Feng
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Collaborative Innovation Center for Biomedicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Yu Xiao
- Medical College of Guangxi University, Nanning, Guangxi, China
| | - Haoyu Lian
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Jiake Xu
- School of Biomedical Sciences, the University of Western Australia, Perth, Australia
| | - Jinmin Zhao
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China; Orthopaedic Department, the First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Qian Liu
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China.
| | - Fangming Song
- Guangxi Key Laboratory of Regenerative Medicine, Research Centre for Regenerative Medicine, Guangxi Medical University, Nanning, Guangxi, China; Guangxi Collaborative Innovation Center for Biomedicine, Guangxi Medical University, Nanning, Guangxi, China.
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Roy A, Thulasiraman S, Panneerselvam E, Thulasi Doss G, Selvaraj MN, Ganesh SK, Raja KVB, Kangusamy B. Evaluation of the efficacy of salmon calcitonin nasal spray on bone healing following open reduction and internal fixation of mandibular fractures - A randomized controlled trial. J Craniomaxillofac Surg 2021; 49:1151-1157. [PMID: 34593298 DOI: 10.1016/j.jcms.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/04/2021] [Accepted: 08/28/2021] [Indexed: 01/17/2023] Open
Abstract
The objective of this study was to assess the efficacy of calcitonin spray on bone healing following open reduction internal fixation (ORIF) of mandibular fractures. Fourteen patients were subdivided into a study group and a control group. A standardized surgical protocol for ORIF was followed. Postoperatively, salmon calcitonin nasal spray was administered to only the study group. The outcome parameters assessed were serum osteocalcin, pain, and radiographic bone healing. Serum osteocalcin was assessed pre- and postoperatively. Postoperative pain was documented using a visual analogue scale (VAS) on the 7th, 14th, 23rd, and 30th days. An orthopantomogram was used to score fracture healing at four time intervals, as follows: 1 - absence of callus; 2 - presence of minimal callus; 3 - considerable callus; and 4 - complete fusion of fracture. Pain scores were lower for the study group, with no pain from the fifth day, while the control group produced a mean score for day 5 of 2.43 ± 0.98 (p = 0.001). Mean postoperative serum osteocalcin levels were higher for the study group (67.82 ± 8.89) compared with the control group (57.69 ± 6.22; p = 0.029). Bone healing at 12 weeks postoperatively was level 4 for 28.6% of patients in the study group and level 3 for 71.4%. In comparison, 85.7% in the control group demonstrated level 3 healing, while 14.3% remained at level 2 (p = 0.462). Within the limitations of the study, it can be concluded that intranasal salmon calcitonin spray reduces postoperative pain and facilitates fracture healing, although its economic efficiency is still to be proven.
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Affiliation(s)
- Aritra Roy
- Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai, India
| | - Selvakumar Thulasiraman
- Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai, India
| | - Elavenil Panneerselvam
- Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai, India.
| | - Guruprasad Thulasi Doss
- Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai, India
| | - Mary Nancy Selvaraj
- Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai, India
| | - Sriraam Kasi Ganesh
- Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai, India
| | - Krishnakumar V B Raja
- Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai, India
| | - Boopathi Kangusamy
- Indian Council of Medical Research - National Institute of Epidemiology, Chennai, India
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Zizzari AT, Pliatsika D, Gall FM, Fischer T, Riedl R. New perspectives in oral peptide delivery. Drug Discov Today 2021; 26:1097-1105. [PMID: 33497830 DOI: 10.1016/j.drudis.2021.01.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/29/2020] [Accepted: 01/18/2021] [Indexed: 12/27/2022]
Abstract
Owing to their structural diversity, peptides are a unique source of innovative active ingredients. However, their development has been challenging because of their disadvantageous pharmacokinetic (PK) properties. Over the past decade, many attempts have been made to improve the oral bioavailability of peptide drugs. In this review, we highlight the most recent and promising techniques aimed at the improvement of the oral bioavailability of peptides. The most recent findings will influence future approaches of pharmaceutical companies in the development of new, more efficient, and safer orally delivered peptides.
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Affiliation(s)
- Alessandra T Zizzari
- Center of Organic and Medicinal Chemistry, Institute of Chemistry and Biotechnology, Zurich University of Applied Sciences ZHAW, Einsiedlerstrasse 31, 8820 Wädenswil, Switzerland
| | - Dimanthi Pliatsika
- Center of Organic and Medicinal Chemistry, Institute of Chemistry and Biotechnology, Zurich University of Applied Sciences ZHAW, Einsiedlerstrasse 31, 8820 Wädenswil, Switzerland
| | - Flavio M Gall
- Center of Organic and Medicinal Chemistry, Institute of Chemistry and Biotechnology, Zurich University of Applied Sciences ZHAW, Einsiedlerstrasse 31, 8820 Wädenswil, Switzerland
| | - Thomas Fischer
- Center of Organic and Medicinal Chemistry, Institute of Chemistry and Biotechnology, Zurich University of Applied Sciences ZHAW, Einsiedlerstrasse 31, 8820 Wädenswil, Switzerland
| | - Rainer Riedl
- Center of Organic and Medicinal Chemistry, Institute of Chemistry and Biotechnology, Zurich University of Applied Sciences ZHAW, Einsiedlerstrasse 31, 8820 Wädenswil, Switzerland.
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Hamza A, Șaramet G. ACTUALITIES IN ENDOCRINE PHARMACOLOGY: ADVANCES IN THE DEVELOPMENT OF ORAL FORMULATIONS FOR CALCITONIN AND SEMAGLUTIDE. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:383-387. [PMID: 33363667 DOI: 10.4183/aeb.2020.383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
As the medical utility of injectable therapeutic peptides is expanding, so is the challenge of developing technologies that allow the administration of such molecules via alternative routes, considering that chronic patients requiring treatment with parenteral formulations are less adherent and compliant to the therapeutic regimens. Hence, substantial efforts have been made to develop technologies that allow the oral formulation of peptides. Due to their importance in the field of pharmaceutical technology, we describe the latest advancements made in the development of oral salmon calcitonin and oral semaglutide, in co-formulation with absorption enhancers such as 8-[(5-chloro-2-hydroxybenzoyl) amino] octanoic acid (or 5-CNAC) and N-[8-(2-hydroxybenzoyl) amino] caprylate (or SNAC). Oral semaglutide is considered to be a landmark for oral peptide delivery technology, as it is one of the very few successful examples of peptides that can be administered orally. Unlike semaglutide, oral calcitonin is still not approved by the regulatory authorities because it failed to demonstrate the anticipated effects in phase III clinical trials conducted so far. However, the efforts for obtaining an oral form of calcitonin have significantly contributed to the development of technologies that facilitate the absorption of peptide-structure macromolecules.
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Affiliation(s)
- A Hamza
- "Carol Davila" University of Medicine and Pharmacy - Faculty of Pharmacy, Dept. of Pharmaceutical Technology and Biopharmacy, Bucharest, Romania
| | - G Șaramet
- "Carol Davila" University of Medicine and Pharmacy - Faculty of Pharmacy, Dept. of Pharmaceutical Technology and Biopharmacy, Bucharest, Romania
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Ahmed RY, Elsherbini AM, Elkhier MTA, Soussa EF. A comparison of the early therapeutic effects of allogeneic bone marrow-derived mesenchymal stem cells and calcitonin on the healing of surgically induced mandibular bone defects in osteoporotic rats. Arch Oral Biol 2020; 120:104934. [PMID: 33091660 DOI: 10.1016/j.archoralbio.2020.104934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This study aimed to evaluate and compare the early biological effects of allogeneic bone marrow-derived mesenchymal stem cells (BMSCs) versus salmon calcitonin (SC) on healing of surgically induced mandibular bone defects in osteoporotic rats. METHODS Sixty-one female albino rats were included in this study, four of them were used for BMSCs isolation. The remaining 57 rats were divided into 4 groups. Group I (negative control), 12 rats received a vehicle injection after which a unilateral mandibular defect was created in each rat. Osteoporosis was induced in the remaining 45 rats then rats were randomly allocated into 3 equal groups (15 each). Surgical defects were created as in group I. The defects were left to heal spontaneously in group II; positive control. While in group III each defect was filled with an absorbable hemostatic gelatin sponge loaded by 10 IU of injectable SC and in group IV the sponge was seeded by 0.5 × 106 BMSCs. Rats were euthanized at 1st, 2nd, and 4th week postsurgically. Hematoxylin and eosin, Masson's trichrome, picrosirius, and alizarin red s stains were used, followed by statistical analysis. RESULTS BMSCs-treatment showed marked enhanced bone healing. Moreover, collagen fibers and calcium deposits area percentages were statistically significantly higher when compared to the other groups particularly at 2 and 4 weeks. CONCLUSIONS Local application of bone marrow-derived mesenchymal stem cells and salmon calcitonin may be an effective therapy for treatment of osteoporotic bone defects, with privilege to the stem cells in terms of quantity and quality of regenerated bone.
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Affiliation(s)
- Rana Y Ahmed
- Department of Oral Biology, Faculty of Dentistry, Mansoura University, Mansoura, Egypt
| | - Amira M Elsherbini
- Department of Oral Biology, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
| | - Mazen Th Abou Elkhier
- Department of Oral Biology, Faculty of Dentistry, Mansoura University, Mansoura, Egypt
| | - Essam F Soussa
- Department of Oral Biology, Faculty of Dentistry, Mansoura University, Mansoura, Egypt
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Wang Z, Fu M, Wang Y, Meng Q, Guan Y, Zhang Y. Injectable Carrier for Zero-Order Release of Salmon Calcitonin. ACS Biomater Sci Eng 2019; 6:485-493. [DOI: 10.1021/acsbiomaterials.9b01680] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Zuwei Wang
- Key Laboratory of Functional Polymer Materials and State Key Laboratory of Medicinal Chemical Biology, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Mian Fu
- Key Laboratory of Functional Polymer Materials and State Key Laboratory of Medicinal Chemical Biology, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Yuanpeng Wang
- Key Laboratory of Functional Polymer Materials and State Key Laboratory of Medicinal Chemical Biology, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Qingbin Meng
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, 27 Taiping Road, Beijing 100850, China
| | - Ying Guan
- Key Laboratory of Functional Polymer Materials and State Key Laboratory of Medicinal Chemical Biology, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Yongjun Zhang
- Key Laboratory of Functional Polymer Materials and State Key Laboratory of Medicinal Chemical Biology, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
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Adeyemi WJ, Olayaki LA. Effects of salmon calcitonin and omega – 3 fatty acids on selected biomarkers in experimental diabetic – osteoarthritic rats. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.synres.2018.100045] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Impact of Sodium N-[8-(2-Hydroxybenzoyl)amino]-caprylate on Intestinal Permeability for Notoginsenoside R1 and Salvianolic Acids in Caco-2 Cells Transport and Rat Pharmacokinetics. Molecules 2018; 23:molecules23112990. [PMID: 30453465 PMCID: PMC6278436 DOI: 10.3390/molecules23112990] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 01/13/2023] Open
Abstract
For drugs with high hydrophilicity and poor membrane permeability, absorption enhancers can promote membrane permeability and improve oral bioavailability. Sodium N-[8-(2-hydroxybenzoyl)amino]caprylate (SNAC) is a new kind of absorption enhancer that has good safety. To investigate the absorption enhancement effect of SNAC on non-polar charged and polar charged drugs and establish the absorption enhancement mechanism of SNAC, SNAC was synthesized and characterized. Two representative hydrophilic drugs—notoginsenoside R1 (R1) and salvianolic acids (SAs)—were selected as model drugs. In vitro Caco-2 cells transport and in vivo rat pharmacokinetics studies were conducted to examine the permeation effect of SNAC on R1 and SAs. R1, rosmarinic acid (RA), salvianolic acid B (SA-B) and salvianolic acid B (SA-A) were determined to compare the permeation enhancement of different drugs. The MTT assay results showed that SNAC had no toxicity to Caco-2 cells. The transepithelial electrical resistance (TEER) of Caco-2 cell monolayer displayed that SNAC facilitated passive transport of polar charged SAs through the membrane of epithelial enterocytes. The pharmacokinetics results demonstrated that area under the curve (AUC) of RA, SA-B and SA-A with administration of SAs containing SNAC was 35.27, 8.72 and 9.23 times than administration of SAs. Tmax of RA, SA-B and SA-A were also prolonged. The AUC of R1 with administration of R1 containing SNAC was 2.24-times than administration of R1. SNAC is more effective in promoting absorption of SAs than R1. The study demonstrated that SNAC significantly improved bioavailability of R1 and SAs. What’s more, the effect of SNAC on absorption enhancement of charged drugs was larger than that of non-charged drugs. The current findings not only confirm the usefulness of SNAC for the improved delivery of R1 and SAs but also demonstrate the importance of biopharmaceutics characterization in the dosage form development of drugs.
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Adeyemi WJ, Olayaki LA. Calcitonin and Omega-3 Fatty Acids Exhibit Antagonistic and Non-Additive Effects in Experimental Diabetes. ACTA ACUST UNITED AC 2018; 25:117-123. [PMID: 29449103 DOI: 10.1016/j.pathophys.2018.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 01/26/2023]
Abstract
Because optimising therapy for the management of diabetes mellitus remains challenging, the study investigated the effects of salmon calcitonin (Sct) and/or omega-3 fatty acids (N-3 - eicosapentaenoic acid and docosahexaenoic acid-3:2), compared to metformin, on selected biochemical parameters in male Wistar rats, in an experimental model of diabetes. Forty rats were used for this study. They were divided into eight groups of five rats each, which included: Normal control; Diabetic (D) control; D + N-3; D + low dose Sct (Sct. Lw); D + high dose Sct (Sct. Hi); D + N-3 + Sct.Lw; D + N-3 + Sct.Hi; and D + metformin. Diabetes was induced in overnight fasted rats by the administration of streptozotocin (65 mg/kg b.w., i.p.), 15 min after the administration of nicotinamide (110 mg/kg b.w., i.p.). Nine days later, Sct was administered at 2.5 and 5.0 IU/kg b.w./day (i.m.), while N-3 and metformin were administered at 200 and 180 mg/kg b.w./day (p.o.) respectively, for four weeks. Sct, N-3, and metformin significantly reduced total cholesterol, LDL-C, cortisol, c-telopeptide of type 1 collagen, and collagen type 2 alpha-1. The combined administration of Sct and N-3 had more favorable effects on triglyceride and HDL-C than either monotherapy. Unlike metformin and Sct. Hi, N-3 significantly reduced alkaline phosphatase activity. Moreover, N-3 significantly suppressed the hypocalcaemic, hyperglycaemic, and insulin resistance provoking actions of Sct. Furthermore, N-3 contradicted the hepatic glycogen depletion and inhibition of nitric oxide synthesis brought about by Sct. In conclusion, N-3 demonstrated antagonistic and non-additive actions with Sct. Moreover, the effects of the combined administration of Sct and N-3 were comparable to that of metformin; therefore, they might be considered as therapeutic alternatives in diabetes.
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Affiliation(s)
- Wale Johnson Adeyemi
- Department of Physiology, College of Health Sciences, University of Ilorin, Ilorin, Nigeria.
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Wong CY, Martinez J, Dass CR. Oral delivery of insulin for treatment of diabetes: status quo, challenges and opportunities. J Pharm Pharmacol 2016; 68:1093-108. [DOI: 10.1111/jphp.12607] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 06/10/2016] [Indexed: 12/12/2022]
Abstract
Abstract
Objectives
Diabetes mellitus is characterised by progressive β-cell destruction and loss of function, or loss of ability of tissues to respond to insulin. Daily subcutaneous insulin injection is standard management for people with diabetes, although patient compliance is hard to achieve due to the inconvenience of injections, so other forms of delivery are being tested, including oral administration. This review summarises the developments in oral insulin administration.
Methods
The PubMed database was consulted to compile this review comparing conventional subcutaneous injection of insulin to the desired oral delivery.
Key findings
Oral administration of insulin has potential benefits in reducing pain and chances of skin infection, improving the portal levels of insulin and avoiding side effects such as hyperinsulinemia, weight gain and hypoglycaemia. Although oral delivery of insulin is an ideal administration route for patients with diabetes, several physiological barriers have to be overcome. An expected low oral bioavailability can be attributed to its high molecular weight, susceptibility to enzymatic proteolysis and low diffusion rate across the mucin barrier.
Conclusions
Strategies for increasing the bioavailability of oral insulin include the use of enzyme inhibitors, absorption enhancers, mucoadhesive polymers and chemical modification for endogenous receptor-mediated absorption. These may help significantly increase patient compliance and disease management.
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Affiliation(s)
- Chun Y Wong
- School of Pharmacy, Curtin University, Bentley, Australia
| | - Jorge Martinez
- School of Pharmacy, Curtin University, Bentley, Australia
| | - Crispin R Dass
- School of Pharmacy, Curtin University, Bentley, Australia
- Curtin Biosciences Research Precinct, Bentley, Australia
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14
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Bandeira L, Lewiecki EM, Bilezikian JP. Pharmacodynamics and pharmacokinetics of oral salmon calcitonin in the treatment of osteoporosis. Expert Opin Drug Metab Toxicol 2016; 12:681-9. [DOI: 10.1080/17425255.2016.1175436] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Leonardo Bandeira
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - John P. Bilezikian
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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15
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Moon C, Zhang W, Sundaram N, Yarlagadda S, Reddy VS, Arora K, Helmrath MA, Naren AP. Drug-induced secretory diarrhea: A role for CFTR. Pharmacol Res 2015; 102:107-112. [PMID: 26429773 DOI: 10.1016/j.phrs.2015.08.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 08/31/2015] [Indexed: 12/29/2022]
Abstract
Many medications induce diarrhea as a side effect, which can be a major obstacle to therapeutic efficacy and also a life-threatening condition. Secretory diarrhea can be caused by excessive fluid secretion in the intestine under pathological conditions. The cAMP/cGMP-regulated cystic fibrosis transmembrane conductance regulator (CFTR) is the primary chloride channel at the apical membrane of intestinal epithelial cells and plays a major role in intestinal fluid secretion and homeostasis. CFTR forms macromolecular complexes at discreet microdomains at the plasma membrane, and its chloride channel function is regulated spatiotemporally through protein-protein interactions and cAMP/cGMP-mediated signaling. Drugs that perturb CFTR-containing macromolecular complexes in the intestinal epithelium and upregulate intracellular cAMP and/or cGMP levels can hyperactivate the CFTR channel, causing excessive fluid secretion and secretory diarrhea. Inhibition of CFTR chloride-channel activity may represent a novel approach to the management of drug-induced secretory diarrhea.
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Affiliation(s)
- Changsuk Moon
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Weiqiang Zhang
- Department of Physiology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Nambirajan Sundaram
- Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Sunitha Yarlagadda
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Vadde Sudhakar Reddy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kavisha Arora
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Michael A Helmrath
- Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of General Surgery, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Anjaparavanda P Naren
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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16
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Kyllönen L, D’Este M, Alini M, Eglin D. Local drug delivery for enhancing fracture healing in osteoporotic bone. Acta Biomater 2015; 11:412-34. [PMID: 25218339 DOI: 10.1016/j.actbio.2014.09.006] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/30/2014] [Accepted: 09/04/2014] [Indexed: 01/08/2023]
Abstract
Fragility fractures can cause significant morbidity and mortality in patients with osteoporosis and inflict a considerable medical and socioeconomic burden. Moreover, treatment of an osteoporotic fracture is challenging due to the decreased strength of the surrounding bone and suboptimal healing capacity, predisposing both to fixation failure and non-union. Whereas a systemic osteoporosis treatment acts slowly, local release of osteogenic agents in osteoporotic fracture would act rapidly to increase bone strength and quality, as well as to reduce the bone healing period and prevent development of a problematic non-union. The identification of agents with potential to stimulate bone formation and improve implant fixation strength in osteoporotic bone has raised hope for the fast augmentation of osteoporotic fractures. Stimulation of bone formation by local delivery of growth factors is an approach already in clinical use for the treatment of non-unions, and could be utilized for osteoporotic fractures as well. Small molecules have also gained ground as stable and inexpensive compounds to enhance bone formation and tackle osteoporosis. The aim of this paper is to present the state of the art on local drug delivery in osteoporotic fractures. Advantages, disadvantages and underlying molecular mechanisms of different active species for local bone healing in osteoporotic bone are discussed. This review also identifies promising new candidate molecules and innovative approaches for the local drug delivery in osteoporotic bone.
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Abstract
Biological therapy is a thriving area of research and development, and is well established for chronic forms of rheumatoid arthritis (RA) and ankylosing spondylitis (AS). However, there is no clinically validated biological therapy for osteoarthritis (OA). Chronic forms of OA are increasingly viewed as an inflammatory disease. OA was largely regarded as a “wear and tear disease”. However, the disease is now believed to involve “low grade” inflammation and the growth of blood vessels and nerves from the subchondral bone into articular cartilage. This realization has focused research effort on the development and evaluation of biological therapy that targets proinflammatory mediators, angiogenic factors and cytokines in articular cartilage, subchondral bone and synovium in chronic forms of OA. This review article provides an overview of emerging biological therapy for OA, and discusses recent molecular targets implicated in angiogenesis and neurogenesis and progress with antibody-based therapy, calcitonin, and kartogenin, the small molecule stimulator of chondrogenesis.
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Affiliation(s)
- A Mobasheri
- D-BOARD European Consortium for Biomarker Discovery, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, UK,
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18
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Mero A, Campisi M, Favero M, Barbera C, Secchieri C, Dayer JM, Goldring MB, Goldring SR, Pasut G. A hyaluronic acid-salmon calcitonin conjugate for the local treatment of osteoarthritis: chondro-protective effect in a rabbit model of early OA. J Control Release 2014; 187:30-8. [PMID: 24837189 DOI: 10.1016/j.jconrel.2014.05.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/30/2014] [Accepted: 05/03/2014] [Indexed: 12/29/2022]
Abstract
Osteoarthritis (OA) is characterized by chronic degeneration of joints, involving mainly the articular cartilage and the underlying bone, and severely impairing the quality of life of the patient. Although with limited efficacy, currently available pharmacological treatments for OA aim to control pain and to retard disease progression. Salmon calcitonin (sCT) is a drug which has been shown to have therapeutic effects in experimental arthritis by inhibiting both bone turnover and cartilage degradation and reducing the activities of matrix metalloproteinases (MMP). High molecular weight hyaluronic acid (HA) is used as a lubricant in OA therapy, and, interestingly, HA polymers may normalize the levels of MMP-1, -3 and -13. We demonstrated that sCT rapidly clears from the knee joint of rat animal model, after intra-articular (i.a.) administration, and it induces systemic effects. Here, sCT was conjugated to HA (200kDa) with the aim of prolonging the residence time of the polypeptide in the joint space by reducing its clearance. An aldehyde derivative of HA was used for N-terminal site-selective coupling of sCT. The activity of sCT was preserved, both in vitro and in vivo, after its conjugation and the i.a. injection of HA-sCT did not trigger any systemic effects in rats. The efficacy of HA-sCT treatment was tested in a rabbit OA model and clear chondro-protective effect was proven by macro- and microscopic assessments and histological findings. Our results indicate that HAylation of sCT increases the size of the polypeptide in a stable covalent manner and delays its passage into the blood stream. We conclude that HA conjugation prolongs the anti-catabolic effects of sCT in joint tissues, including the synovial membrane and cartilage.
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Affiliation(s)
- Anna Mero
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Via F. Marzolo 5, 35131 Padova, Italy
| | - Monica Campisi
- Fidia Farmaceutici, Via Ponte della Fabbrica 3/A, 35031 Abano Terme, Italy
| | - Marta Favero
- Rheumatology Unit, University Hospital of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Carlo Barbera
- Fidia Farmaceutici, Via Ponte della Fabbrica 3/A, 35031 Abano Terme, Italy
| | - Cynthia Secchieri
- Fidia Farmaceutici, Via Ponte della Fabbrica 3/A, 35031 Abano Terme, Italy
| | - Jean M Dayer
- Faculty of Medicine, CMU, 1, rue Michel-Servet, CH-1211 Geneva, Switzerland
| | - Mary B Goldring
- Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA; Laboratory for Cartilage Biology, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
| | - Steven R Goldring
- Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA
| | - Gianfranco Pasut
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Via F. Marzolo 5, 35131 Padova, Italy.
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Aksoy D, Solmaz V, Erbas O. Positive effect of calcitonin on the seizures induced by pentylenetetrazole in rats. Epilepsy Res 2014; 108:390-5. [PMID: 24548550 DOI: 10.1016/j.eplepsyres.2014.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 12/27/2013] [Accepted: 01/20/2014] [Indexed: 01/14/2023]
Abstract
There are many difficulties involved with the treatment of epilepsy, and these problems have driven the search for new agents to control epileptic seizures. Calcitonin is a peptide hormone that has been well studied and shown to have a positive effect on neuropathic and chronic pain. The mechanism by which calcitonin affects these pain syndromes is thought to be similar to the effect of antiepileptic drugs, such as pregabalin, gabapentin and carbamazepine. In this study, we aim to investigate the effects of calcitonin on seizures induced by pentylenetetrazole (PTZ) in rats. The rats were divided into four groups. The first group was the control group, and the rats were given no medications. The second group was given saline+PTZ. The third group was given 50IU/kg calcitonin+PTZ, and the fourth group was given 100IU/kg calcitonin+PTZ. EEG traces, Racine's convulsion stages and the time of onset of the first myoclonic jerk were compared between the groups. Between the groups, there were significant differences in the Racine's convulsion stages, the onset of the 'first myoclonic jerk', and the rate of the spikes in the EEG traces. The differences were more pronounced in the 100IU/kg calcitonin-treated group (p<0.001). It has been stated that calcitonin relieves pain via regulating voltage-gated Ca(2+) and/or Na(+) channels. Calcitonin has a positive effect on convulsions in epileptic rats, possibly using the same mechanisms as is used in the treatment of neuropathic and chronic pain.
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Affiliation(s)
- Durdane Aksoy
- Gaziosmanpasa University Faculty of Medicine, Department of Neurology, Tokat, Turkey.
| | - Volkan Solmaz
- Gaziosmanpasa University Faculty of Medicine, Department of Neurology, Tokat, Turkey
| | - Oytun Erbas
- Gaziosmanpasa University Faculty of Medicine, Department of Physiology, Tokat, Turkey
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20
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A posteriori comparison of natural and surgical destabilization models of canine osteoarthritis. BIOMED RESEARCH INTERNATIONAL 2013; 2013:180453. [PMID: 24288664 PMCID: PMC3833019 DOI: 10.1155/2013/180453] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 09/10/2013] [Indexed: 02/07/2023]
Abstract
For many years Canis familiaris, the domestic dog, has drawn particular interest as a model of osteoarthritis (OA). Here, we optimized the dog model of experimental OA induced by cranial cruciate ligament sectioning. The usefulness of noninvasive complementary outcome measures, such as gait analysis for the limb function and magnetic resonance imaging for structural changes, was demonstrated in this model. Relationships were established between the functional impairment and the severity of structural changes including the measurement of cartilage thinning. In the dog model of naturally occurring OA, excellent test-retest reliability was denoted for the measurement of the limb function. A criterion to identify clinically meaningful responders to therapy was determined for privately owned dogs undergoing clinical trials. In addition, the recording of accelerometer-based duration of locomotor activity showed strong and complementary agreement with the biomechanical limb function. The translation potential of these models to the human OA condition is underlined. A preclinical testing protocol which combines the dog model of experimental OA induced by cranial cruciate ligament transection and the Dog model of naturally occurring OA offers the opportunity to further investigate the structural and functional benefits of disease-modifying strategies. Ultimately, a better prediction of outcomes for human clinical trials would be brought.
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21
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Cheng T, Zhang L, Fu X, Wang W, Xu H, Song H, Zhang Y. The potential protective effects of calcitonin involved in coordinating chondrocyte response, extracellular matrix, and subchondral trabecular bone in experimental osteoarthritis. Connect Tissue Res 2013; 54:139-46. [PMID: 23323719 DOI: 10.3109/03008207.2012.760549] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Previous reports indicate a potential role for calcitonin (CT) in the treatment of osteoarthritis (OA). To evaluate this potential therapeutic role, we investigated the effect of CT pretreatment on the activation of mitogen-activated protein kinase (MAPK) signaling and the expression of matrix metalloproteinase-13 (MMP-13) in interleukin-1β (IL-1β)-induced chondrocytes, and further assessed its protective effect in a rat model of anterior cruciate ligament transection (ACLT), using sham-operated and saline-treated controls. Using western blotting in vitro, we found that CT pretreatment inhibited the IL-1β-induced phosphorylation of 38,000-dalton protein (p38) and extracellular regulated protein 1/2 (ERK1/2) and reduced the expression of MMP-13 protein. For the in vivo experiment, 30 male rats were randomly divided into three groups of 10, subjected to bilateral ACLT or sham surgery, and then treated for 12 weeks with subcutaneous injections of CT or normal saline. Histological observations showed that CT treatment reduced the severity of the cartilage lesions stemming from the ACLT surgery and provided a lower Mankin score when compared with that determined for rats in the saline-treated ACLT group. Immunohistochemical staining revealed that CT treatment increased type II collagen expression and decreased MMP-3 and a disintegrin and metalloproteinase with thrombospondin motifs-4 (ADAMTS-4) expression when compared with the saline-treated group. Subchondral bone analysis indicated that CT treatment inhibited the reduction in bone mineral density observed in the saline-treated ACLT group and reduced the ACLT-induced destruction to the subchondral trabecular microstructure. Our data demonstrate that CT induces its protective effects by reducing the chondrocyte response to inflammatory stimuli, cartilage extracellular matrix degradation, and subchondral trabecular microstructure damages brought on by OA.
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Affiliation(s)
- Tan Cheng
- Department of Orthopedic Surgery, Hebei Medical University, Shijiazhuang, China
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