Bone safety with risedronate: histomorphometric studies at different dose levels and exposure.

UNLABELLED: This report describes bone safety and histomorphometric data across different dose levels and dosing frequencies of risedronate. Normal bone structure and histomorphometric data were observed, with ongoing bone remodeling and mineralization regardless of dose. These data are reassuring and do not suggest compromised bone remodeling during treatment with established risedronate regimens. INTRODUCTION: The efficacy and bone safety of risedronate 5 mg daily were established in pivotal phase III randomized, placebo-controlled clinical studies. Histomorphometric analysis of paired biopsies demonstrated bone safety as reflected by presence of fluorescent tetracycline double-labels in all evaluable biopsies. This report describes bone safety and histomorphometric data across studies of various dose regimens of risedronate. METHODS: Bridging studies, with bone mineral density as the primary endpoint, demonstrated non-inferiority of risedronate 35 mg and 50 mg once a week, risedronate 150 mg once a month, and a risedronate 75-mg dose on two consecutive days a month versus risedronate 5 mg daily. The low oral bioavailability and known dosing limitations due to food interactions of bisphosphonates have led to development of an oral delayed-release dose form of risedronate 35 mg to be taken weekly, before or after breakfast. Bone biopsies were collected at 24 months in studies involving these risedronate dosing regimens; bone safety and histomorphometric data were evaluated. RESULTS: Qualitative bone histology showed normal mineralization of newly formed bone without evidence of pathological findings, such as osteomalacia, bone marrow dyscrasia, or bone marrow fibrosis. Importantly, ongoing bone remodeling, based on fluorochrome labeling, was observed in all patients regardless of dose and exposure. Key histomorphometric variables were comparable to those observed with the risedronate 5 mg daily dose and were within the range seen in healthy pre- and post-menopausal women. CONCLUSIONS: Overall, the results are reassuring with respect to bone safety and histomorphometric data, and do not suggest oversuppression of bone remodeling during treatment with these established risedronate regimens.

Rolipram, a phosphodiesterase 4 inhibitor, prevented cancellous and cortical bone loss by inhibiting endosteal bone resorption and maintaining the elevated periosteal bone formation in adult ovariectomized rats.

Cyclic AMP (cAMP) is a continually produced nucleotide inactivated by hydrolysis to 5'AMP via phosphodiesterase (PDE) enzymes. Rolipram is a selective PDE4 inhibitor reported to have anti-inflammatory effects and used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). The current study was designed to determine whether Rolipram could prevent and restore bone loss in ovariectomized (OVX) rats. Six-month-old Sprague Dawley rats underwent either sham-operated or bilateral ovariectomy, and were left untreated for 60 days to develop osteopenia. Then they were treated with vehicle, 6 mg/kg PGE(2), 3 microg/kg Alendronate or 0.1-1.0 mg/kg Rolipram for 60 days. At sacrifice, the right tibiae were processed for quantitative bone histomorphometric measurements. The right femurs were measured by dual energy A-ray absorptiometry and the 5th lumbar vertebrae were subjected to micro-computed tomography to access bone mass and architecture changes. Our results indicated that OVX induced negative bone balance in all five bone sites we tested, with bone resorption exceeding bone formation. Rolipram at 0.1-0.6 mg/kg dose levels prevented while at 1 mg/kg restored ovariectomy-induced cancellous and cortical bone loss in the tibia, femur and lumbar vertebra. Dynamic bone histomorphometry suggested that these beneficial effects were achieved by partially maintaining the elevated bone formation at the trabecular bone surface and increasing bone formation at the periosteal bone surface of the cortex. Furthermore, it reduced bone turnover at the trabecular and the endocortical bone surfaces. The prevention of further bone loss effects were comparable to those of an anti-resorption agent (Alendronate) but were not as great as those of an anabolic agent (PGE(2)). In addition, Rolipram treatment increased body and muscle weights compared to the vehicle-treated OVX rats. In conclusion, our study in an osteopenic rat model suggested that a selective PDE4 inhibitor may be used for the treatment of established osteoporosis.

Simvastatin did not prevent nor restore ovariectomy-induced bone loss in adult rats.

Current published results on whether statins have beneficial effects on bone metabolism have been conflicting so far. In order to further investigate if statins were promising candidates for the treatment for osteoporosis, we conducted a study in which rats were ovariectomized (OVX) at 6 months of age, allowed to lose bone for 60 days and followed by oral administration of simvastatin at the dose levels of 0.3-10 mg/kg/d for 60 days. PGE2 (6 mg/kg) was used as a positive control. Study endpoints included bone histomorphometry on the proximal tibial metaphysis (PTM) and the tibial diaphysis (TX), dual-energy X-ray absorptiometry on the right femur and micro computed tomography (ICT) on the 5th lumbar vertebra (LV). After 120 days of OVX, cancellous bone lost by 80% in the PTM and 18% in the LV accompanied by increased bone formation and resorption. Simvastatin at all dose levels did not affect bone volume, bone formation rate and bone erosion surface when compared to 120 day ovariectomized animals at all bone sites studied. By contrast, PGE2 restored cancellous and cortical bone area to sham control levels. In conclusion, this study demonstrated that unlike PGE2, oral administration of simvastatin did not have effects on cancellous or cortical bone formation and resorption; and consequently was not able to prevent further bone loss or restore bone mass in the osteopenic, OVX rats.

Synthesis and biological evaluation of prostaglandin-F alkylphosphinic acid derivatives as bone anabolic agents for the treatment of osteoporosis.

A series of novel C(1) alkylphosphinic acid analogues of the prostaglandin-F family have been evaluated at the eight human prostaglandin receptors for potential use in the treatment of osteoporosis. Using molecular modeling as a tool for structure-based drug design, we have discovered that the phosphinic acid moiety (P(O)(OH)R) behaves as an isostere for the C(1) carboxylic acid in the human prostaglandin FP binding assay in vitro and possesses enhanced hFP receptor selectivity when compared to the parent carboxylic acid. When evaluated in vivo, the methyl phosphinic acid analogue (4b) produced a bone anabolic response in rats, returning bone mineral volume (BMV) [corrected], to intact levels in the distal femur in the ovariectomized rat (OVX) model. These results suggest that prostaglandins of this class may be useful agents in the treatment of diseases associated with bone loss.

Three-dimensional microimaging (MRmicroI and microCT), finite element modeling, and rapid prototyping provide unique insights into bone architecture in osteoporosis.

With the proportion of elderly people increasing in many countries, osteoporosis has become a growing public health problem, with rising medical, social, and economic consequences. It is well recognized that a combination of low bone mass and the deterioration of the trabecular architecture underlies osteoporotic fractures. A comprehensive understanding of the relationships between bone mass, the three-dimensional (3D) architecture of bone and bone function is fundamental to the study of new and existing therapies for osteoporosis. Detailed analysis of 3D trabecular architecture, using high-resolution digital imaging techniques such as magnetic resonance microimaging (MRmicroI), micro-computed tomography (microCT), and direct image analysis, has become feasible only recently. Rapid prototyping technology is used to replicate the complex trabecular architecture on a macroscopic scale for visual or biomechanical analysis. Further, a complete set of 3D image data provides a basis for finite element modeling (FEM) to predict mechanical properties. The goal of this paper is to describe how we can integrate three-dimensional microimaging and image analysis techniques for quantitation of trabecular bone architecture, FEM for virtual biomechanics, and rapid prototyping for enhanced visualization. The integration of these techniques provide us with an unique ability to investigate the role of bone architecture in osteoporotic fractures and to support the development of new therapies.

Bone anabolic therapy with selective prostaglandin analogs.

Prostaglandin E(2) has been shown to increase bone mass in animals and humans but it also has considerable dose limiting systemic side effects. The molecular description of multiple seven transmembrane domain G protein coupled prostanoid receptors offered the opportunity to probe the skeletal effects of specific receptors using selective agonists. Bone effects have been reported with many of the prostanoid receptors, with most interest focused on the anabolic effects of EP2, EP4, and FP receptors. Current data suggests activity at the EP2 receptor stimulates formation, activity at the EP4 receptor stimulates resorption (and possibly formation), and activity at the FP receptor produces new trabeculae. However, caution must be exercised in extending the effects of prostanoids in isolated systems to systemic skeletal effects, since tissue level effects are the cumulative result of bone formation and bone resorption. Furthermore, species differences in receptor sequence and density confound extrapolation of effects from one model to another model. While these molecular targets increase our insight into how the skeleton can be affected pharmacologically, they still do not answer questions about the role of naturally occurring prostaglandins in skeletal health. This manuscript will review some of the recent advances in knowledge of the bone anabolic effects of selective prostanoid ligands.

Effect of prostaglandin and bisphosphonate on cancellous bone volume and structure in the ovariectomized rat studied by quantitative three-dimensional nuclear magnetic resonance microscopy.

The purpose of this work was to evaluate the potential of nuclear magnetic resonance microscopy (NMRM) in conjunction with a processing technique to monitor the effect of preventive agents in an ovariectomized (OVX) rat. Twenty-five female Sprague-Dawley rats were OVX at 6 months of age (except for the intact control group), allowed to lose bone for 60 days, and then treated for 60 days. During treatment, animals were administered vehicle, prostaglandin E2 (PGE2; 6 mg/kg), or alendronate (3 microg/kg) subcutaneously once a day. Subsequently, tibiae were harvested and the marrow removed. NMRM was carried out at 9.4 T, with the specimens immersed in 1.2 mM diethylenetriaminepentaacetic acid-gadolinium salt (Gd-DTPA) aqueous solution. A three-dimensional (3D) partial flip-angle pulse sequence was used, providing a 1283 array of (46 microm)3 isotropic voxels. Fifty of the 128 axial images in the 3D data set comprising approximately 2.4 mm volume distal to the growth plate were processed from each specimen using a probability-based method for determining bone volume fraction (BVF), tubularity, contiguity, as well as the mean trabecular plate thickness and separation. PGE2 and alendronate altered BVF consistently at all tibial regions. The effect of alendronate was to keep BVF about midway between intact and OVX, whereas PGE2 returned BVF to intact levels. The other parameters showed similar responses to treatment. The strongest discriminator was trabecular BVF, which could obviously differentiate the groups. The study establishes NMRM as a nondestructive histomorphometric method for the quantitative evaluation of drug response in a rat ovariectomy model.

Parathyroid hormone enhances fracture healing. A preliminary report.

This investigation tested the hypothesis that daily parenterally administered parathyroid hormone (1-34) improves fracture healing. Twenty, 3-month-old, male Sprague Dawley rats weighing approximately 400 g each, underwent the production of closed, unilateral mid-diaphyseal femoral fractures. Animals were divided into two groups of 10; the animals received either a daily subcutaneous injection of delivery vehicle (0.9% saline) or 80 micrograms/kg parathyroid hormone. On Day 21 after fracture the animals were euthanized, the femurs were removed and subjected to biomechanical testing, bone densitometry (dual energy x-ray absorptiometry, peripheral quantitative computed tomography), and histologic examination. Treatment with parathyroid hormone resulted in statistically significant increases in callus area and strength. Histologic examination of the calluses showed an increase in the amount of new bone formed. No differences were observed in the weights of the animals or the sizes of the bones. Values obtained using dual energy x-ray absorptiometry and peripheral quantitative computed tomography indicate an increase in density in the parathyroid hormone treated fractures consistent with the histologic appearance and the findings of increased strength, although these bone density changes did not achieve statistical significance. These results suggest that parenterally administered parathyroid hormone (1-34) may enhance or accelerate normal fracture healing and support the concept that this hormone be tested clinically as a systemic treatment for fractures that are slow to heal.

Changes in bone mineral density and bone-specific alkaline phosphatase in ovariectomized ewes.

An animal model of human osteoporosis which adequately meets many of the criteria needed to test new therapeutic agents is currently unavailable. The old ewe may serve this purpose, as changes in bone remodeling occur within 3 months, and a difference in bone mass has been indicated 6 months after ovariectomy. In the current study, we have measured longitudinal changes in bone mass and bone-specific alkaline phosphatase (BSAP) for six months in 7-9 year old ovariectomized (OVX) ewes. Thirty ewes were divided into three groups: sham-treated (n = 9), OVX (n = 12) and OVX with estrogen implants (OVXE, n = 9). Bone mineral density (BMD) was determined at 0, 3 and 6 months in the vertebrae (L4-L6/L5-L7), calcaneus (CAL) and distal radius (DR) using dual-energy X-ray absorptiometry (DEXA). Bone-Specific Alkaline Phosphatase (Tandem-R Ostase; Hybritech) was determined at monthly intervals. Body weight did not significantly change in any group during treatment compared to sham, although a trend of increasing body weight at 3 and 6 months was apparent in both OVX groups. Luteinizing hormone increased in all OVX ewes as a function of time as expected, demonstrating successful ovariectomies. Uterine weight was significantly increased (p < 0.01) in the OVXE animals compared to Sham and OVX groups. BMD did not change significantly during the 6-month treatment period in the CAL or DR. BMD in the vertebrae (L4-L6/L5-L7) was significantly lower in the OVX group compared to sham (p < 0.08).(ABSTRACT TRUNCATED AT 250 WORDS)

Histomorphometric analysis of iliac crest bone biopsies in placebo-treated versus fluoride-treated subjects.

In a 4-year controlled, prospective trial, histomorphometric analysis was used to compare the tissue-level skeletal effects of fluoride therapy in 43 postmenopausal women (75 mg NaF/day) with those of 35 matching placebo subjects; all subjects received 1500 mg/day elemental calcium supplement. In addition to an initial, baseline biopsy, a second biopsy was obtained after 6, 18, 30 or 48 months. Measurements were made on a third biopsy obtained from 8 subjects following at least 72 months of fluoride therapy. The change in cancellous bone volume or trabecular thickness in fluoride-treated subjects was not different from a change in placebo-treated subjects. However, paired analysis in the fluoride-treated subjects indicated that bone volume was increased between the first and second biopsies (p < 0.005). Both osteoid length and width were significantly increased in fluoride compared with placebo subjects; however, only the osteoid surface increased linearly (r = 0.63, p < 0.001). The mineral apposition rate and relative tetracycline-covered bone surface were not different between fluoride and placebo treatment, although they were decreased in both groups in the second biopsy. The tetracycline-covered bone surface returned to normal in the third biopsy. Definitive evidence for osteomalacia is a prolonged mineralization lag time, which following fluoride treatment was found to be increased 9-fold in the second biopsy and 4-fold in the third biopsy. Further evidence for osteomalacia was increased osteoid thickness by 6 months, evidence of focal areas of interstitial mineralization defects, and broad tetracycline labels of low fluorescence intensity. In the third biopsies, osteoclastic resorption was observed beneath osteoid seams. Fluoride therapy increased the cortical width compared with placebo treatment (p < 0.02), and increased the osteoid surface in Haversian canals, but did not change the osteoid width, resorption surface or cortical porosity. After an initial rise, serum fluoride levels remained constant, and the urine values fell slightly. The bone fluoride concentration rose throughout the treatment period, and was correlated with the change in osteoid-covered bone surface (r = 0.56, p < 0.001). Although we found definitive evidence for osteomalacia, the cause of the osteomalacia was not determined in this study. On the other hand, the presence of bone resorption beneath unmineralized osteoid and of osteocyte halos is suggestive of hyperparathyroidism. Thus, it is possible that the strong stimulus for bone formation brought about by fluoride therapy resulted in relative calcium deficiency.

Effect of sodium fluoride on bone density in chickens.

In addition to increasing bone volume, fluoride has been demonstrated to increase ash weight and mineral density. To determine whether newly formed or older bone is most affected by fluoride treatment, bone from chickens receiving fluoridated water was fractionated into lower density (recently formed) and higher density (more mature) specific gravity fractions. Fluoride was administered to the chickens for different lengths of time (4 or 13 weeks) or at varying doses for a 4-week period (0, 4.2, 16.8 mmol/liter drinking water). Fluoride treatment caused a shift in the mineral density profile, showing an increased proportion of mineral distribution in the more mature, higher density fractions. To determine whether this density gradient shift was due to increased maturation rate of bone or decreased resorption and mineralization rates, [3H]proline and 45Ca were injected 5 days and 24 hours prior to sacrifice, respectively. The distributions of both 3H or 45Ca, as percentages of total counts incorporated, were shifted by fluoride treatment into more mature, higher density fractions. Expressing the number of counts as a percent of the bone in each fraction (total hydroxyproline or Ca) revealed an increased incorporation of both 3H and 45Ca into the higher specific gravity fractions 2.0-2.2. These results suggest that fluoride treatment increases bone maturation and the rate of secondary mineralization in the cortical bone. Such changes in the quality of more mature, well-mineralized bone, in humans as well as animals, may have a significant influence on brittleness and strength.

A new method for measuring cancellous bone erosion depth: application to the cellular mechanisms of bone loss in postmenopausal osteoporosis.

We have devised a new method for measurement of final depth of erosion in cancellous bone with an intra-individual precision of 4.3% and applied it to determine the mechanism of continuing reduction in trabecular thickness after menopause. Mean erosion depth (SD) was 40.8 (2.0) microns in 10 healthy postmenopausal women and 41.4 (2.1) microns in 10 age-matched patients with postmenopausal osteoporosis; the difference was not statistically significant. In contrast, wall thickness, using a method based on density differences between new and old bone, was 39.5 (2.0) microns in the normal subjects and 35.3 (2.0) microns in the patients with osteoporosis (p less than 0.0001). The balance per remodeling cycle (delta BMU) was -1.34 (2.49) microns in the normal subjects and -6.11 (1.95) microns in the patients with osteoporosis. This difference was also highly significant (p less than 0.001). Indirect estimations of erosion depth and delta BMU, based on the fall in trabecular thickness from an assumed premenopausal value of 147 microns and the number of remodeling cycles accumulated since menopause, agreed closely with the measured values. Erosion depth measured by the Eriksen method also showed no significant difference between the two groups, but because the values were substantially higher delta BMU was improbably high in both groups, did not differ significantly between groups, and was inconsistent with the observed difference in trabecular thickness.(ABSTRACT TRUNCATED AT 250 WORDS)

Growth factor-induced proliferation of osteoblasts measured by bromodeoxyuridine immunocytochemistry.

Immuno-localization of BUdr was used to identify DNA synthesis in vitro in chicken embryonic bone cells stained positively or negatively for alkaline phosphatase activity. The results were similar to, but more sensitive than, our standard bioassay which assesses 3H-thymidine incorporation into DNA by liquid scintillation counting, and more rapid than autoradiographic localization of 3H-thymidine. SGF/IGF-II and bFGF stimulated cellular proliferation equally in ALP(+) and ALP(-) cells. In contrast, IGF-I and TGF-beta stimulate proliferation more in the ALP(-) than ALP(+) cells. The greatest increase in DNA replication of ALP(-) cells occurred following incubation with SGF/IGF-II or TGF-beta, and in the ALP(+) cells with SGF/IGF-II or bFGF. TGF-beta stimulated cellular proliferation at the lowest dose (1 ng/ml). The differential effect of the growth factors on each population of cells indicates that all these bone-matrix derived growth factors may play different roles in the local regulation of skeletal metabolism.

The effect of prolonged fluoride therapy for osteoporosis: bone composition and histology.

To examine the long-term effects of fluoride therapy in osteoporosis, we obtained iliac crest biopsies from 11 osteoporotic patients 6 to 12 years after they had started fluoride therapy. Although basal biopsies were not obtained, nine subjects had been biopsied 4 years prior to the second biopsy. In addition, 4 subjects had stopped fluoride therapy prior to the second biopsy. Biopsy samples were divided and analyzed: (a) histomorphometrically for bone formation and mineralization; and (b) for mineral content. Parameters of bone formation were increased in the first biopsy of all patients; they remained elevated in the second biopsy of subjects still receiving fluoride, but decreased to normal values in subjects who stopped fluoride therapy. Parameters of mineralization (i.e., osteoid width and osteocytic osteoid) were elevated in the first biopsy, but had decreased in the second biopsy whether fluoride was stopped or not. There was no woven bone in these biopsies. Bone mineral content, whether measured as density or by summation of the individual ions (% mineral), was higher than normal in all subjects, whether or not they were still receiving fluoride. These results suggest that prolonged fluoride therapy of osteoporosis continues to stimulate bone formation, but does not cause a progressive mineralization defect. Mineral content is acutely increased following fluoride therapy, and persists after therapy is discontinued.

Chick osteoblasts contain fluoride-sensitive acid phosphatase activity.

We used histological and biochemical methods to determine the cellular origin of bone matrix fluoride-sensitive acid phosphatase in chicken bone. Embryonic chicken calvariae were embedded in plastic and sections stained for acid phosphatase at various concentrations of substrate and fluoride. Acid phosphatase activity was observed in osteoblasts and osteoclasts but not in fibroblasts. Striking inhibition of osteoblastic acid phosphatase occurred at 100 microM fluoride, a concentration that had no apparent effect on osteoclastic acid phosphatase. Inhibition of osteoblastic and osteoclastic acid phosphatase by fluoride was also examined using extracts of embryonic chicken calvarial cells, mouse osteoblasts (MC3T3-El cell line), and purified chick osteoclasts, respectively. Fluoride is a partial competitive inhibitor of both chicken and mouse osteoblastic acid phosphatases, with apparent inhibition constants of 10-100 microM. These concentrations of fluoride correspond to those that increase bone formation in vitro and in vivo. In contrast, the apparent inhibition constant for fluoride of osteoclastic acid phosphatase was much higher (i.e., 0.5 mM). In summary, this study demonstrates that chicken osteoblasts contain an acid phosphatase that is sensitive to inhibition by low concentrations (i.e., microM) of fluoride.

Fluoride therapy for osteoporosis: characterization of the skeletal response by serial measurements of serum alkaline phosphatase activity.

Optimum use of fluoride therapy for osteoporosis requires a sensitive and convenient index of the skeletal response to fluoride. Since previous studies had shown that serum alkaline phosphatase activity (SALP) was increased in response to fluoride therapy, we examined serial measurements of SALP in 53 osteoporotics treated with 66 to 110 mg of sodium fluoride (NaF) for 12 to 91 months. SALP was increased in 87% of the subjects during therapy with fluoride. The increase in SALP was thought to reflect the osteogenic action of fluoride based on the findings that SALP correlated with both trabecular bone area (r = .81, P less than .001) and osteoid length (r = .67, P less than .01) in iliac crest biopsies, predicted increased bone density on spinal radiographs in response to fluoride therapy with an 87% accuracy, and predicted decreased back pain in response to fluoride with a 91% accuracy. In addition, the SALP response to fluoride was seen earlier than other therapeutic responses as indicated by the findings that the tau 1/2 for the SALP response (ie, time for 1/2 of the patients to show a significant response) was significantly less (1.2 +/- 0.3 yr) than that for the pain response (1.6 +/- 0.3 yr, P less than .05) or that for the radiographic response (3.7 +/- 0.5 yr, P less than .001). Although most patients responded to fluoride with an increase in SALP, evaluation of the kinetics of the SALP response to fluoride revealed marked interpatient variation.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of a rapidly responding animal model for fluoride-stimulated bone formation.

Sodium fluoride (NaF) is the single most effective agent for increasing bone volume in the osteoporotic skeleton. However, the mechanism of fluoride-stimulated bone formation is not known, and investigation has been hampered by the lack of a suitable animal model. Young chicks show a rapid skeletal response to NaF that resembles the human skeletal response. This occurs at serum fluoride concentrations comparable to those obtained in humans. Fourteen-day-old chicks treated with NaF (4.2 mM NaF in the drinking water) for 2 weeks showed increases in bone-forming surface in the tibial metaphysis (130% of untreated controls, P less than 0.002), with no change in the number of osteoblasts per length of forming surface (104% of control). The NaF dose dependence of the change in bone-forming surface was biphasic, being optimal at 23 microM fluoride. Linear correlations were observed between dietary NaF and serum fluoride (r = 0.996, P less than 0.001), and serum fluoride and bone fluoride concentrations (r = 0.98, P less than 0.001). Correlations were also observed between the amount of alkaline phosphatase activity in the tibia and the serum fluoride concentration (r = 0.88, P less than 0.03), the serum fluoride concentration and the tibial ash weight (r = 0.93, P less than 0.01), and the bone fluoride concentration and tibial ash weight (r = 0.95, P less than 0.01). Preliminary studies of the time dependence of the skeletal fluoride response in young chicks revealed no difference between 2 weeks and 4 weeks of treatment (bone-forming surface increased to 124% and 139% of controls in separate studies, P less than 0.01 for each).(ABSTRACT TRUNCATED AT 250 WORDS)