Category Archives: Drugs

ACE Inhibitors, But Not ARBs, Marginally Increase Bone Loss in Men

Abstract

Does the use of ACE inhibitors or angiotensin receptor blockers affect bone loss in older men?

In a prospective cohort study of 5,995 older American men (MrOS), users of angiotensin-converting enzyme (ACE) inhibitors had a small but significant increase in bone loss at the hip over 4 years after adjustment for confounders. Use of angiotensin II AT1 receptor blockers (ARB) was not significantly associated with bone loss.
Experimental evidence suggests that angiotensin II promotes bone loss by its effects on osteoblasts. It is therefore plausible that ACE inhibitor and ARB may reduce rates of bone loss. The objective of this study is to examine the independent effects of ACE inhibitor and ARB on bone loss in older men.
Out of 5,995 American men (87.2%) aged ≥65 years, 5,229 were followed up for an average of 4.6 years in a prospective six-center cohort study-The Osteoporotic Fractures in Men Study (MrOS). Bone mineral densities (BMD) at total hip, femoral neck, and trochanter were measured by Hologic densitometer (QDR 4500) at baseline and year 4.
Out of 3,494 eligible subjects with complete data, 1,166 and 433 subjects reported use of ACE inhibitors and ARBs, respectively. When compared with nonusers, continuous use of ACE inhibitors was associated with a small (0.004 g/cm(2)) but significant increase in the average rate of BMD loss at total hip and trochanter over 4 years after adjustment for confounders. Use of ARB was not significantly associated with bone loss.
Use of ACE inhibitors but not ARB may marginally increase bone loss in older men.

Kwok T, Leung J, Zhang YF, Bauer D…
Osteoporos Int Aug 2012
PMID: 22080379

 

ACE Inhibitor Moexipril Doesn’t Harm Bones in Ovariectomized Rats

Abstract

Impact of antihypertensive therapy on postmenopausal osteoporosis: effects of the angiotensin converting enzyme inhibitor moexipril, 17beta-estradiol and their combination on the ovariectomy-induced cancellous bone loss in young rats.

No data are available on whether angiotensin converting enzyme (ACE) inhibition affects the skeleton, though this might be of clinical relevance when antihypertensive therapy is initiated, particularly in hypertensive women after menopause who typically suffer from a concomitant rapid onset of osteoporosis. In the present study we investigated the effects of the new ACE inhibitor moexipril, 17beta-estradiol and their combination on the bone turnover in ovariectomized Sprague-Dawley rats, an established animal model for studying human postmenopausal osteoporosis.
We studied 119 12-week-old virgin female Sprague-Dawley rats. Seven rats were killed on day 0 as basal controls. The remaining rats were divided into sham-ovariectomy or ovariectomy groups. Vehicle, moexipril at 10 mg/kg per day alone (orally), 17beta-estradiol at 10 mu g/kg per day alone (subcutaneously) or both were administered to both groups immediately after the operation for 14 (short-term effects) or 56 (long-term effects) days. A stereology computer program was used for measurements. Static histomorphometric measurements, using a stereology computer program, were taken on double-fluorescent labeled undecalcified proximal tibial metaphyseal (cancellous bone site) and tibial shaft (cortical bone site) sections.
Ovariectomy induced dramatically cancellous bone loss due to increased bone turnover, with resorption exceeding formation. Moexipril had no effect on the cancellous bone site in either ovariectomized or sham-operated rats. 17beta-Estradiol treatment added extra cancellous bone in the sham-operated rats and prevented cancellous bone loss in the ovariectomized rats by inhibiting bone resorption. The combination of moexipril and 17beta-estradiol gave similar results to those of 17beta-estradiol alone. Comparable results were observed in the cortical bone site.
The results of this study show that ACE inhibition by moexipril has no effect on the skeleton when given alone and that it does not hamper the osteoprotective effects of 17beta-estradiol. These findings are relevant for the use of antihypertensive therapy in postmenopausal women treated or not with hormone replacement therapy.

Stimpel M, Jee WS, Ma Y, Yamamoto N…
J. Hypertens. Dec 1995
PMID: 8903666

Onobrychis Ebenoides Has SERM-Like Activity in Ovariectomized Rats

Abstract

Protective effect of plant extract from Onobrychis ebenoides on ovariectomy-induced bone loss in rats.

Certain plant extracts have been the object of recent studies due to their mild estrogenic action and their possible potential role in osteoporosis prevention and/or treatment. The present study was undertaken to investigate the possible protective effect of the aqueous solution of the plant Onobrychis ebenoides, with proven in vitro mild estrogenic action, on bone mass loss of the ovariectomized (Ovx) rat experimental model of osteoporosis.
Forty intact female mature (10-month-old) Wistar rats were separated into three groups: Ovx, Ovx plus plant extract (Ph) and sham-operated (control). Ph administration in the drinking water at a dose of 300 mg/kg body weight/day commenced immediately after Ovx. Bone mineral density (BMD) values, percentage change from the baseline measurement and histomorphometry of the tibia, as well as body and uterine weight, were examined and compared between groups.
Comparison of BMD absolute values of the whole tibia of Ovx + Ph and Ovx animals at both 3 and 6 months post-Ovx were highly significant (p < 0.0005), showing a protective effect on treated animals. The extract did not appear to have such a beneficial effect on BMD of the proximal tibia of the treated animals compared to the Ovx animals after 3 months; however, a significant protective effect was observed at 6 months post-Ovx in treated animals compared to the Ovx (p = 0.015). When the % changes from baseline measurement of the whole tibia of Ovx + Ph and controls were compared, there was no significant difference at 3 or 6 months, demonstrating a highly protective effect; the respective comparisons of proximal tibia % changes did not display such protection. Body and uterine weight comparisons showed no significant difference between Ovx and treated rats, whereas, the level of significance for each group compared to controls was p < 0.0005.
The Ph studied showed a highly significant protective effect on BMD of the whole tibia of Ovx rats after 3 and 6 months of treatment, compared to the non-treated animals. Its effect on the proximal tibia was less pronounced, but also statistically significant compared to non-treated rats after 6 months. The lack of significant effect on body and uterine weight is in favor of its selective estrogen receptor modulator-like activity, and merits further studies.

Dontas I, Halabalaki M, Moutsatsou P, Mitakou S…
Maturitas Jan 2006
PMID: 15979258

Oral Calcitonin Phase 3 Trail

Abstract

A phase 3 trial of the efficacy and safety of oral recombinant calcitonin: the Oral Calcitonin in Postmenopausal Osteoporosis (ORACAL) trial.

The Oral Calcitonin in Postmenopausal Osteoporosis (ORACAL) study was a randomized, double-blind, double-dummy, active- and placebo-controlled, multiple-dose, phase 3 study to assess the efficacy and safety of oral recombinant calcitonin for treatment of postmenopausal osteoporosis. A total of 565 women age 46 to 86 (mean 66.5) years were randomized (4:3:2) to receive oral recombinant salmon calcitonin (rsCT) tablets (0.2  mg/d) plus placebo nasal spray, synthetic salmon calcitonin (ssCT) nasal spray (200 IU/d) plus placebo tablets, or placebo (placebo tablets plus placebo nasal spray), respectively for 48 weeks. All women received calcium (≥1000  mg/d) and vitamin D (800 IU/d). Women randomized to oral rsCT had a mean ± SD percent increase from baseline in lumbar spine bone mineral density (BMD) (1.5% ± 3.2%) that was greater than those randomized to ssCT nasal spray (0.78% ± 2.9%) or placebo (0.5% ± 3.2%). Lumbar spine BMD change in those receiving nasal calcitonin did not differ from placebo. Oral rsCT treatment also resulted in greater improvements in trochanteric and total proximal femur BMD than ssCT nasal spray. Reductions in bone resorption markers with oral rsCT were greater than those observed in ssCT nasal spray or placebo recipients. Approximately 80% of subjects in each treatment group experienced an adverse event, the majority of which were mild or moderate in intensity. Gastrointestinal system adverse events were reported by nearly one-half of women in all treatment groups and were the principal reason for premature withdrawals. Less than 10% of women experienced a serious adverse event and no deaths occurred. Overall, oral rsCT was superior to nasal ssCT and placebo for increasing BMD and reducing bone turnover. Oral rsCT was safe and as well tolerated as ssCT nasal spray or placebo. Oral calcitonin may provide an additional treatment alternative for women with postmenopausal osteoporosis.

Binkley N, Bolognese M, Sidorowicz-Bialynicka A, Vally T…
J. Bone Miner. Res. Aug 2012
PMID: 22437792

From Tarsa Therapeutics’ web site:

Tarsa Therapeutics in conjunction with Unigene Laboratories has developed a once-daily oral tablet version of calcitonin. This proprietary technology prevents the degradation of calcitonin in the gastrointestinal system and assists its transit across the cells lining the intestine and into the bloodstream.

Review: Oral Calcitonin 2012

Abstract

Oral calcitonin.

Calcitonin is a hormone secreted by the C-cells of the thyroid gland in response to elevations of the plasma calcium level. It reduces bone resorption by inhibiting mature active osteoclasts and increases renal calcium excretion. It is used in the management of postmenopausal osteoporosis, Paget’s disease of bone, and malignancy-associated hypercalcemia. Synthetic and recombinant calcitonin preparations are available; both have similar pharmacokinetic and pharmacodynamic profiles. As calcitonin is a peptide, the traditional method of administration has been parenteral or intranasal. This hinders its clinical use: adherence with therapy is notoriously low, and withdrawal from clinical trials has been problematic. An oral formulation would be more attractive, practical, and convenient to patients. In addition to its effect on active osteoclasts and renal tubules, calcitonin has an analgesic action, possibly mediated through β-endorphins and the central modulation of pain perception. It also exerts a protective action on cartilage and may be useful in the management of osteoarthritis and possibly rheumatoid arthritis. Oral formulations of calcitonin have been developed using different techniques. The most studied involves drug-delivery carriers such as Eligen(®) 8-(N-2hydroxy-5-chloro-benzoyl)-amino-caprylic acid (5-CNAC) (Emisphere Technologies, Cedar Knolls, NJ). Several factors affect the bioavailability and efficacy of orally administered calcitonin, including amount of water used to take the tablet, time of day the tablet is taken, and proximity to intake of a meal. Preliminary results looked promising. Unfortunately, in two Phase III studies, oral calcitonin (0.8 mg with 200 mg 5-CNAC, once a day for postmenopausal osteoporosis and twice a day for osteoarthritis) failed to meet key end points, and in December 2011, Novartis Pharma AG announced that it would not pursue further clinical development of oral calcitonin for postmenopausal osteoporosis or osteoarthritis. A unique feature of calcitonin is that it is able to uncouple bone turnover, reducing bone resorption without affecting bone formation and therefore increasing bone mass and improving bone quality. This effect, however, may be dose-dependent, with higher doses inhibiting both resorption and formation. Because so many factors affect the pharmacokinetics and pharmacodynamics of calcitonin, especially orally administered calcitonin, much work remains to be done to explore the full pharmacologic spectrum and potential of calcitonin and determine the optimum dose and timing of administration, as well as water and food intake.

Hamdy RC, Daley DN
Int J Womens Health 2012
PMID: 23071417 | Free Full Text

Another successful way of formulating oral calcitonin is by using an acid-resistant enteric coating that prevents dissolution in the stomach and adding citric acid to the tablet core to inhibit intestinal proteases and enhance paracellular transport across the intestinal mucosa. This formulation also has been tested in Phase III studies.

Nasal Calcitonin No Benefit After Hip Replacement

Abstract

Salmon calcitonin (Miacalcic ns 200 IU) in prevention of bone loss after hip replacement.

Loosening of a hip prosthesis after total arthroplasty is related to periprosthetic bone loss. Calcitonin has been used in the treatment of bone loss in osteoporosis and prevention of fractures. The main purposes of the study were firstly to evaluate the effect of calcitonin on periprosthetic bone after total hip arthroplasty, secondly investigate possible loosening of the prosthesis and thirdly examine further clinical outcome.
60 patients who underwent total hip arthroplasty using cemented Exeter prosthesis were randomized in the treatment group (salmon calcitonin 200 IU nasal spray daily + calcium 500 mg) and the placebo group (inactive nasal spray + calcium 500 mg) for six months. Bone mineral density (BMD) was measured from different locations at the time of discharge and after six and 12 months. Dynamic histomorphometry on bone biopsies taken from femoral collum was performed. Serum bone-specific alkaline phosphatase (BAP), serum osteocalcine (OC) and cross-linked N-telopeptides (NTX) were measured after one week, one month, three months and 12 months. Clinical manifestations and the incidence of fractures and loosening of the prosthesis were followed up to eight years.
Statistically there was not significant difference in bone histomorphometry between the groups. In both groups there was a significant BMD decrease in periprosthetic bone. However, the difference between the groups was not statistically significant. In the biochemical analysis NTX increased more in the Miacalcic group than in the placebo group (p = 0.013). There were no significant differences between the groups in serum BAP or OC even though the changes within the groups were statistically significant. No loosening of the prosthesis was seen during the follow-up and there was no need for revision of any reason. Four fractures were recorded in three patients. One patient sustained a periprosthetic fracture. All the patients with fractures were allocated in the placebo group.
Nasal salmon calcitonin 200 IU on a daily basis does not promote any additional value on calcium substitution to prevent bone loss after hip replacement. The durability of the Exeter prosthesis was good.

Arnala IO
Scand J Surg 2012
PMID: 23238499 | Free Full Text

Review: Data do Not Support Use of Nitroglycerin

Abstract

Nitroglycerin ointment for the prevention of postmenopausal osteoporosis.

To determine whether clinical trial data support the use of nitroglycerin for prevention of postmenopausal osteoporosis.
A literature search using MEDLINE (1966-September 2011) and EMBASE (1973-September 2011) was conducted using the search terms nitroglycerin, bone mineral density, fracture, and osteoporosis. References of identified articles were reviewed for additional citations.
All English-language articles related to the use of nitroglycerin ointment in postmenopausal women were reviewed.
Four observational studies reported significant improvements in bone mineral density of postmenopausal women with the use of nitrates. One pilot study and 2 prospective, randomized, placebo-controlled clinical trials reported conflicting results regarding the efficacy of nitroglycerin ointment.
Clinical data do not support use of nitroglycerin for this indication; its potential is limited at this time by inconclusive efficacy and a high incidence of headache. Further well-designed clinical trials demonstrating efficacy and safety of nitroglycerin ointment for prevention of postmenopausal osteoporosis are needed before this medication can be recommended for routine use.

Beckett RD, Sheehan AH
Ann Pharmacother Dec 2011
PMID: 22009995

Nitroglycerin Modestly Increases Bone Density and Decreased Resorption in Postmenopausal Women

Abstract

Effect of nitroglycerin ointment on bone density and strength in postmenopausal women: a randomized trial.

Nitroglycerin stimulates bone formation and inhibits bone resorption, is inexpensive, and is widely available. Its effects on bone density, bone structure, and bone strength are unknown. To determine if nitroglycerin increases lumbar spine bone mineral density (BMD) and to evaluate changes in hip BMD, bone geometry, and density at the radius and tibia, and markers of bone turnover.

A single-center, double-blind, placebo-controlled randomized trial conducted in Toronto, Ontario, Canada, for 24 months starting in November 2005 and completed in March 2010, of 243 postmenopausal women with lumbar spine T scores of between 0 and -2.0 who completed a 1-week run-in period taking nitroglycerin ointment. Intervention Nitroglycerin ointment (15 mg/d) or placebo applied at bedtime for 24 months.
Areal BMD at the lumbar spine, femoral neck, and total hip. Secondary outcomes included indices of bone geometry and strength at the distal radius and tibia, and biomarkers of bone formation (bone-specific alkaline phosphatase) and bone resorption (urine N -telopeptide).
At 2 years, women randomized to the nitroglycerin group had significant increases in areal BMD at the lumbar spine (from 1.05 to 1.14 g/cm(2) vs placebo from 1.06 to 1.08 g/cm(2); percentage change, 6.7%; 95% confidence interval [CI], 5.2%-8.2%; P < .001); total hip (from 0.92 to 0.97 g/cm(2) vs placebo from 0.93 to 0.92 g/cm(2); 6.2%; 95% CI, 5.6%-7.0%; P < .001); and femoral neck (from 0.88 to 0.93 g/cm(2) vs placebo from 0.87 to 0.86 g/cm(2); 7.0%; 95% CI, 5.5%-8.5%; P < .001). At 2 years, nitroglycerin also increased volumetric trabecular BMD (11.9% and 8.5%), cortical thickness (13.9% and 24.6%), periosteal circumference (7.4% and 2.9%), polar section modulus (10.7% and 9.8%), and polar moment of inertia (7.3% and 14.5%) at the radius and tibia, respectively (all P < .001); and increased bone-specific alkaline phosphatase by 34.8% and decreased urine N -telopeptide by 54.0% (P < .001). Incidence of serious adverse events did not differ between nitroglycerin (5 [4.2%]) and placebo (5 [4.3%]) groups. Among those women who continued treatment for 24 months, headaches were reported by 40 (35%) in nitroglycerin and 6 (5.4%) in placebo groups during the first month, decreasing substantially after 12 months.
Among postmenopausal women, nitroglycerin ointment modestly increased BMD and decreased bone resorption.

Jamal SA, Hamilton CJ, Eastell R, Cummings SR
JAMA Feb 2011
PMID: 21343579

There is a published comment on this study: Nitroglycerin needs more study.

Nitroglycerin Needs More Study

Is nitroglycerin a novel and inexpensive treatment for osteoporosis?

Khosla S
JAMA Feb 2011
PMID: 21343584 | Free Full Text

Despite the differences in the results of the study by Jamal et al2 compared with the largely negative study by Wimalawansa et al,11 the findings reported by Jamal et al2 should set the stage for an adequately powered, larger study using nitroglycerin ointment with fracture as an outcome. If such a study demonstrates efficacy for reducing fractures, clinicians would have a novel and inexpensive therapy for osteoporosis. The findings of the current study also should prompt development of additional nitric oxide donors with greater skeletal efficacy and a better adverse effect profile, particularly with regard to headaches.

Nitroglycerin Reverses Bone Loss in Ovariectomized Rats

Abstract

Restoration of ovariectomy-induced osteopenia by nitroglycerin.

Nitric oxide (NO) is known to inhibit osteoclastic bone resorption. Previously, we demonstrated that the NO donor nitroglycerin (NG) prevented ovariectomy (OVX)-induced bone loss. The current study shows that NG restores ovariectomy-induced osteopenia. Twenty-four female Sprague-Dawley rats, 36 weeks of age, underwent OVX, and a further six rats were sham-operated. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometric (DXA) scanning prior to OVX, at 6 weeks postsurgery, and at 6 weeks posttreatment. OVX rats were then assigned to four groups and treated with either (1) vehicle, (2) 17-beta-estradiol, (3) NG (0.2 mg/kg/day), or (4) a combination of estrogen and NG (n = 6/group). During the first 6-week post-OVX period, there was a significant decrease in the BMD in all ovariectomized (OVXed) rats (-11.0%, P < 0.001). There were no significant changes in BMD during the entire 12-week period in sham-operated rats. During the second 6-week period (after developing bone loss), there was no further significant loss of BMD in OVXed controls. BMD loss and loss of femur weight produced by OVXed were restored by treatment with estrogen, NG, or the two agents together during the second 6-week period (P < 0.01). The effects of estrogen and NG together, however, were not additive. The BMD of rats treated with NG alone, at 12 weeks, was similar to that of animals treated with estrogen alone or with estrogen and NG, and was comparable to that of sham-operated rats. The increased urinary excretion of deoxypyridinolines caused by OVX was negated by estrogen, NG, and estrogen together with NG (P < 0.01). In contrast to estrogen, NG did not decrease the post-OVX-induced increase of serum osteocalcin levels, suggesting that NG may also have a positive effect on bone formation. In summary, the results suggest that the NO donor, NG, reverses the OVX-induced bone loss in rats, and these effects are likely due to decreased bone resorption and, perhaps, increased bone formation.

Wimalawansa SJ
Calcif. Tissue Int. Jan 2000
PMID: 10602846