Position Statement on the Use of Bone Turnover Markers for Osteoporosis Treatment

Super-high levels of serum intact-parathyroid hormone and bone turnover markers descended with recuperating allograft function and a short-term high-dose methylprednisolone during preoperative period of renal transplantation: a retrospective cohort study

Background

Secondary hyperparathyroidism is an important factor of chronic kidney disease-mineral and bone disorder (CKD-MBD), which frequently results in maintenance dialysis patients having super-high levels of serum intact-parathyroid hormone (iPTH) and bone turnover markers (BTMs). This study aimed to investigate the immediate changes of iPTH and BTMs levels after renal transplantation during the perioperative period, and to explore the allograft function rapid recovery and the effect of high-dose glucocorticoids on serum iPTH and BTMs.

Methods

Between April 2018 and August 2021, a total of 346 Chinese kidney transplantation (KT) recipients (median age, 34.0 years; 236 males and 110 females; median dialysis duration, 12 months) were enrolled in this retrospective cohort study. The included patients had been undergoing maintenance dialysis for at least three months before transplant, and all of them accepted short-term high-dose methylprednisolone (MP) to prevent allograft rejection in the perioperative period. Allograft functions were evaluated and divided into different groups accorded to the CKD staging on the postoperative fifth day. Serum beta C-terminal crosslinking telopeptide of type I collagen (β-CTX), type 1N-terminal propeptide (P1NP), osteocalcin (OC), and iPTH were measured from fasting morning blood samples before surgery and on the postoperative fifth day with an electro-chemiluminescence immunoassay analyzer (2012; Roche Diagnostics).

Results

Among the participants, the graft functions were in CKD-II (n=134), CKD-III (n=137), CKD-IV (n=24), and CKD-V (n=51) after the postoperative fifth day. The changes of P1NP level [-95.8 (-84.0 to -2.4) ng/mL] and the OC level [-88.0 (-96.9 to -42.9) ng/mL] were significantly greater than those of the β-CTX level [-62.3 (-73.6 to 0) pg/mL] and the iPTH level [-57.6 (-15.6 to 11.9) pg/mL] (P<0.001). In the CKD-V group, the changes of β-CTX level [-0.7 (-43.15 to 0) pg/mL (+15.7%, P=0.61)] and the iPTH level [-8.69 (226.73 to 17.79) pg/mL (-22.8%), P=0.36] were less than those of the CKD-II group (P<0.001). β-CTX, P1NP, and OC levels related with iPTH (r=0.413, 0.459, 0.482, respectively, P<0.001), and iPTH level with estimated glomerular filtration rate (eGFR; r=-0.474, P<0.001).

Conclusions

The super-high levels of BTMs and iPTH rapidly descended with recuperating allograft function during the short-term, indicating that improvement of current dialysis equipment to achieve clean up iPTH could more favorably decrease BMTs and improve CKD-MBD. Osteogenesis markers P1NP and OC still decreased and were not affected in CKD-V group, indicating that high-dose glucocorticoids might strongly inhibit osteoblast activity.

Effects of Glucagon-Like Peptide-1 Receptor Agonist on Bone Mineral Density and Bone Turnover Markers: A Meta-Analysis

AIMS

Glucagon-like peptide-1 receptor agonist (GLP-1RA) may promote bone formation, but conversely, they could also weaken bones due to the reduction in mechanical load associated with weight loss. However, the clinical effects in humans have not been clearly demonstrated. This meta-analysis aimed to evaluate whether GLP-1RAs affect BMD and bone turnover markers.

MATERIAL AND METHODS

PubMed, Embase, and Scopus were searched on June 13, 2024. The eligibility criteria were: (1) human studies, (2) receiving a GLP-1RA for more than 4 weeks, (3) an untreated control group or a placebo group, (4) reporting of at least one BMD or bone turnover marker, and (5) an RCT design. The risk of bias was assessed using the Cochrane risk of bias 2 tool. Fixed- or random-effects meta-analysis was performed according to heterogeneity.

RESULTS

Seven studies were included in the meta-analysis. GLP-1RAs did not significantly change BMD in the femoral neck (mean difference [MD], 0.01 g/cm2; 95% CI, -0.01-0.04 g/cm2), in the total hip (MD, -0.01 g/cm2; 95% CI, -0.02-0.01 g/cm2), and in the lumbar spine (MD, 0 g/cm2; 95% CI, -0.02-0.02 g/cm2). C-terminal telopeptide of type 1 collagen (CTX), a bone resorption marker, significantly increased after GLP-1RA treatment (MD, 0.04 μg/L; 95% CI, 0.01-0.07 μg/L). GLP-1RAs did not significantly change bone formation markers such as procollagen type 1 N-terminal propeptide, bone-specific alkaline phosphatase, osteocalcin.

CONCLUSIONS

GLP-1RA did not affect BMD and bone formation markers. However, GLP-1RAs led to a significant increase in CTX.

The Use of Bone-Turnover Markers in Asia-Pacific Populations

Bone-turnover marker (BTM) measurements in the blood or urine reflect the bone-remodeling rate and may be useful for studying and clinically managing metabolic bone diseases. Substantial evidence supporting the diagnostic use of BTMs has accumulated in recent years, together with the publication of several guidelines. Most clinical trials and observational and reference-interval studies have been performed in the Northern Hemisphere and have mainly involved Caucasian populations. This review focuses on the available data for populations from the Asia-Pacific region and offers guidance for using BTMs as diagnostic biomarkers in these populations. The procollagen I N-terminal propeptide and β-isomerized C-terminal telopeptide of type-I collagen (measured in plasma) are reference BTMs used for investigating osteoporosis in clinical settings. Premenopausal reference intervals (established for use with Asia-Pacific populations) and reference change values and treatment targets (used to monitor osteoporosis treatment) help guide the management of osteoporosis. Measuring BTMs that are not affected by renal failure, such as the bone-specific isoenzyme alkaline phosphatase and tartrate-resistant acid phosphatase 5b, may be advantageous for patients with advanced chronic kidney disease. Further studies of the use of BTMs in individuals with metabolic bone disease, coupled with the harmonization of commercial assays to provide equivalent results, will further enhance their clinical applications.

Osteoporosis: Investigations and Monitoring

Background

Osteoporosis is characterized by microarchitectural disruption of the bone, decrease in bone mineral density, and increased skeletal fragility and risk of fracture. Osteoporosis occurs due to the decoupling of bone formation and bone resorption, with a significant increase in resorption. This review article focuses on the role of laboratory investigations in the diagnosis and monitoring of treatment in patients with osteoporosis.

Methods

This review article collected literature from various databases using keywords such as 'Laboratory investigations', 'Osteoporosis', 'Diagnosis', 'Monitoring', and 'Bone turnover markers'.

Results and Discussion

Laboratory investigations, including serum calcium, alkaline phosphatase, vitamin D, and parathormone, are commonly performed tests to exclude secondary causes of osteoporosis and monitor the response to therapy. The biochemical markers of bone turnover are newly emerged tests for monitoring individual patients with osteoporosis. These markers are classified as bone formation and resorption markers, measurable in both serum and urine. The use of these markers is limited by biological and analytical variability. The International Federation of Clinical Chemistry and Laboratory Medicine and the International Osteoporosis Foundation recommend serum procollagen type 1 amino-terminal propeptide as the bone formation marker and β-form of C-terminal cross-linked telopeptide of type I collagen (β-CTx-1/β-CrossLaps) as the marker of choice, using standardized procedures. However, in specific cases, such as patients with chronic renal disease, CTx-1 is replaced by the resorption marker tartrate-resistant acid phosphatase 5b, as its levels are not affected by renal excretion.

Conclusion

Bone turnover markers have emerged as tools for the assessment of osteoporosis, using standardized procedures, and are useful in monitoring therapy and treatment compliance.

Metabolomics insights into the effects of pre-pregnancy lead exposure on bone metabolism in pregnant rats

Today's women of childbearing age with a history of high lead (Pb) exposure in childhood have large Pb body burdens, which increases Pb release during pregnancy by promoting bone Pb mobilisation. The purpose of this study was to investigate the metabolic mechanisms underlying bone Pb mobilisation and explore the bone metabolism-related pathways during pregnancy. Drinking water containing 0.05% sodium acetate or Pb acetate was provided to weaned female rats for 4 weeks followed by a 4-week washout period, and then rats were co-caged with healthy males of the same age until pregnancy. Blood and bone tissues of the female rats were collected at gestational day (GD) 3 (early pregnancy), GD 10 (middle pregnancy), and GD 17 (late pregnancy), respectively. Pb and calcium concentrations, biomarkers for bone turnover, bone microstructure, serum metabolomics, and metabolic indicators were intensively analyzed. The results demonstrated that pre-pregnancy Pb exposure elevated blood lead levels (BLLs) at GD17, accompanied by a negative correlation between BLLs and trabecular bone Pb levels. Meanwhile, Pb-exposed rats had low bone mass and aberrant bone architecture with a larger number of mature osteoclasts (OCs) compared to the control group. Moreover, the metabolomics uncovered that Pb exposure caused mitochondrial dysfunction, such as enhanced oxidative stress and inflammatory response, and suppressed energy metabolism. Additionally, the levels of ROS, MDA, IL-1β, and IL-18 involved in redox and inflammatory pathways of bone tissues were significantly increased in the Pb-exposed group, while antioxidant SOD and energy metabolism-related indicators including ATP levels, Na+-K+-ATPase, and Ca2+-Mg2+-ATPase activities were significantly decreased. In conclusion, pre-pregnancy Pb exposure promotes bone Pb mobilisation and affects bone microstructure in the third trimester of pregnancy, which may be attributed to OC activation and mitochondrial dysfunction.

Effectiveness and Usefulness of Bone Turnover Marker in Osteoporosis Patients: A Multicenter Study in Korea

BACKGROUND

This study aimed to investigate real-world data of C-terminal telopeptide (CTX), propeptide of type I collagen (P1NP), and osteocalcin through present multicenter clinical study, and retrospectively analyze the usefulness of bone turnover markers (BTMs) in Koreans.

METHODS

The study focused on pre- and post-menopausal patients diagnosed with osteoporosis and excluded patients without certain test results or with test intervals of over 1 year. The demographic data and 3 BTMs (CTX, P1NP, and osteocalcin) were collected. The patients were classified by demographic characteristics and the BTM concentrations were analyzed by the group.

RESULTS

Among women with no history of fractures, the levels of P1NP (N=2,100) were 43.544±36.902, CTX (N=1,855) were 0.373 ±0.927, and osteocalcin (N=219) were 10.81 ±20.631. Among men with no history of fractures, the levels of P1NP (N=221) were 48.498±52.892, CTX (N=201) were 0.370±0.351, and osteocalcin (N=15) were 7.868 ±10.674. Treatment with teriparatide increased the P1NP levels after 3 months in both men and women, with a 50% increase observed in women. Similarly, treatment with denosumab decreased the CTX levels after 3 months in both men and women, with a reduction of 50% observed in women.

CONCLUSIONS

The results of this study can contribute to the accurate assessment of bone replacement status in Koreans. We also provide the P1NP level in the Korean population for future comparative studies with other populations.

Effects of Bazedoxifene/Vitamin D Combination Therapy on Serum Vitamin D Levels and Bone Turnover Markers in Postmenopausal Women with Osteopenia: A Randomized Controlled Trial

BACKGROUND

This study aimed to evaluate the effectiveness of bazedoxifene/vitamin D combination therapy in preventing osteoporosis in postmenopausal women with osteopenia.

METHODS

This was an open-label, multicenter randomized-controlled, phase 4 clinical trial. Women between ages of 55 and 70 years in 9 medical tertiary centers in Korea were enrolled and assigned into 2 groups: an experiment group and a control group. The experimental group received bazedoxifene 20 mg/vitamin D 800 IU tablets for 6 months, and the control group received calcium 100 mg/vitamin D 1,000 IU tablets for 6 months.

RESULTS

A total of 142 patients (70 in the experimental group and 72 in the control group) were included. The least-square mean±standard error of change in propeptide of type I collagen after 3 months was -6.87±2.56% in the experimental group and 1.22±2.54% in the control group. After 6 months, it was -21.07±2.75% in the experimental group and 1.26±2.71% in the control group. The difference between the 2 groups was -22.33% (p<0.01). The change of C-terminal telopeptide was -12.55±4.05% in the experimental group and 11.02±4.03% in the control group after 3 months. It was -22.0±3.95% and 10.20±3.89, respectively, after 6 months. The difference between the 2 groups was -32.21% (p<0.01) after 6 months. There was no significant difference in adverse events between the 2 groups.

CONCLUSIONS

The osteoporosis preventive effect and safety of administering bazedoxifene/vitamin D combination pill were confirmed in postmenopausal women who needed osteoporosis prevention.

Predisposing factors for a second fragile hip fracture in a population of 1130 patients with hip fractures, treated at Oulu University Hospital in 2013-2016: a retrospective study

OBJECTIVE

The life-time risk of a second fragile hip fracture is 8.4%, but the risk factors that predispose to a second hip fracture remain unresolved. This study aimed to define risk factors that predisposed patients to a second hip fracture.

METHODS

For this retrospective study, we retrieved clinical data on 1130 patients with fragile hip fractures (67.2% female, mean age: 79.3 years) that underwent surgery at the Oulu University Hospital in 2013-2016. These data included the fracture risk assessment score (measured with the FRAX tool), the bone-mass T-score, laboratory values, ambulatory capacity, and the time of death.

RESULTS

In this population, 12.4% of patients sustained a second hip fracture. The predisposing factors for a second hip fracture were: female (p = 0.016), a high FRAX score (p = 0.020), and low physical capacity (p < 0.001). The vitamin D level recommended for treating osteoporosis (i.e., vitamin D > 75 nmol/l) was observed in only 24% of patients, and 42% of patients had ionized calcium levels below the reference range. According to the level of the cross-linked carboxy-terminal telopeptide of type I collagen (ICTP), 37% of patients did not have high bone turnover. We found a positive correlation between age and ICTP (p = 0.001). The risk of death was higher after the second hip fracture (p = 0.005), but we found no difference in age between patients with first and second hip fractures (p = 0.11).

CONCLUSION

After a hip fracture, a second hip fracture is a well-known risk. Nevertheless, we found that only one-third of patients with a second hip fracture had used anti-osteoporosis medication at any time previously. These findings suggested that second hip fractures were most likely to occur in patients with osteopenic T-score values, in women more often than men, and in patients with high FRAX scores and low ambulatory capacity.

Forearm bone mineral density as a predictor of reduction loss in distal radius fractures treated with cast immobilization

Objective

Many potential predictors have been identified and proposed for predicting late reduction loss in distal radius fractures. However, no report exists on whether the bone mineral density (BMD) of the forearm correlates with the loss of reduction in distal radius fractures. This study aimed to investigate whether forearm BMD can be used as a predictor of reduction loss in distal radius fractures treated with cast immobilization.

Methods

Ninety patients with distal radius fractures were divided into two groups according to the maintenance or loss of reduction evaluated from radiographs taken at least 6 weeks after their injury. Lumbar and forearm BMD (total and metaphysis) T-scores were measured and compared between the maintenance of reduction (MOR) group and the loss of reduction (LOR) group. Additionally, serologic markers (C-terminal telopeptide, osteocalcin, vitamin D) and radiologic risk factors (intra-articular fracture, ulnar fracture, dorsal comminuted fracture, volar hook) were evaluated and a logistic multiple regression analysis was performed to know the main risk factors of reduction loss.

Results

Reduction loss was observed in 38 patients (42.2%). The total and metaphyseal BMD of the forearm was less in the LOR group than in the MOR group. However, the difference was not statistically significant [−2.9 vs. −2.5 for total (p = 0.18), −2.3 vs. −2.0 for metaphysis (p = 0.17)]. Multiple logistic regression analysis showed initial dorsal comminution (p = 0.008) and ulnar variance (p = 0.01) were the main risk factors for reduction loss.

Conclusions

Forearm BMD was not a valuable prognostic factor for reduction loss in distal radius fractures. Initial dorsal comminution and ulnar variance rather than forearm BMD should be considered preferentially when predicting which patients are at high risk of reduction loss in distal radius fractures.

Intra-Individual Changes in Total Procollagen-Type 1 N-terminal Propeptide in a Korean Adult Population

We aimed to investigate intra-individual changes in total procollagen-type 1 N-terminal pro-peptide (P1NP), a biochemical marker of bone turnover, to understand patient populations and test utilization in a Korean adult population while considering different definitions of least significant changes by sex, age, and medical institution type. Overall, 31,501 P1NP tests were performed on 24,644 Korean adults (3389 men and 21,255 women) with a median age of 68.9 years (interquartile range, IQR, 61.2–77.2) for osteoporosis evaluation. Among these, 1331 (5.4%) patients (127 men and 1204 women) underwent ≥3 follow-up P1NP measurements. The median follow-up period was 12.5 months (IQR, 11.7–15.9). Among 1331 patients, 64.4% experienced a decrease in P1NP and 35.6% experienced an increase in P1NP during follow-up. Among these, the proportion of patients who experienced serum P1NP changes ≥14.4% from baseline was 92.3%, and the proportion of patients who achieved ≤40 ng/mL (a median level of premenopausal Korean women) during follow-up was 31.8%. The overall proportion of patients that experienced a serum P1NP change exceeding the least significant change during follow-up was not significantly different by the type of medical institution.

Association between bone turnover markers and the risk of imminent recurrent osteoporotic fracture

The association between bone turnover markers (BTMs) and the risk of imminent recurrent osteoporotic fracture (ROF) in the elderly remains unclear. The present study thus aimed to explore BTMs in relation to imminent ROF in the elderly with an index OF. For this purpose, data from a prospective cohort study were used for analysis. Elderly patients hospitalized due to an index OF were included and followed-up. The BTMs included bone resorption marker (C-terminal telopeptide of type I collagen) and the bone formation markers, procollagen type I N propeptide, osteocalcin (OC) and total alkaline phosphatase. The outcome was the time to the first ROF following their index fracture. Cox regression analysis was used to assess the association between BTMs and ROF. Model discrimination was calculated to explore whether the BTMs had potential to improve fracture risk prediction. There were 169 eligible patients included in the analysis (median age, 72 years; 87.6% females). During a median follow-up period of 10.5 months, there were seven ROFs (4.1%) observed. Serum OC levels were found to be significantly associated with the risk of ROF [hazard ratio, 0.13; 95% confidence interval (CI) 0.018-0.90; P=0.039] for per-SD increase in OC from multivariable analysis. After incorporating OC into the model, a C-index of 0.83 (95% CI, 0.70-0.96; P<0.001) was observed, which outperformed the model with bone mineral density alone (improvement for C-index, 0.29; 95% CI, 0.028-0.55). On the whole, the present study demonstrates a significant association between serum OC and the decreased risk of imminent ROF in the elderly with index fractures. However, further high-quality evidence is required to further clarify and validate the BTMs in relation to the imminent risk of ROFs among the elderly.

Denosumab-induced hypocalcemia in a patient with hyperthyroidism: a case report

Denosumab is a humanized monoclonal antibody targeting the receptor activator of nuclear factor kappa-B ligand (RANKL). Denosumab is an effective treatment for osteoporosis but can cause hypocalcemia. We present a case of denosumab-induced hypocalcemia in a patient with hyperthyroidism with a high bone turnover state. A 48-year-old postmenopausal woman was diagnosed with hyperthyroidism and osteoporosis and received antithyroid drugs (propylthiouracil 200 mg/day) and denosumab. After 2 months of taking medication, the patient complained of numbness and tingling in the hands and feet and was diagnosed with hypocalcemia (calcium, 5.8 mg/dL; ionized calcium, 0.83 mmol/L). Alfacalcidol (0.5 μg/day) and calcium carbonate (3000 mg/day) were prescribed. Subsequently, the patient's symptoms improved, and her serum calcium level normalized. The risk of denosumab-induced hypocalcemia may be increased in patients with diseases related to high bone turnover, such as hyperthyroidism; therefore, caution is needed.

Associations between bone turnover markers and bone mineral density in older adults

OBJECTIVE

To examine the associations between bone turnover markers (BTMs) and bone mineral density (BMD) in older adults aged 60-85 years.

METHODS

A total of 1124 men (mean age, 69.1 years) and 1203 women (mean age, 70.7 years) from the National Health and Nutrition Examination Survey 1999-2002 were included in this cross-sectional analysis. Independent variables were serum bone-specific alkaline phosphatase (sBAP) and urinary N-telopeptide (uNTx), which are biomarkers of bone formation and resorption, respectively. Outcome variable was lumbar BMD. The associations of sBAP and uNTx levels with lumbar BMD was examined using multivariable linear regression models.

RESULTS

sBAP was negatively associated with lumbar BMD in each multivariable linear regression model, and this negative association was stable in both men and women men (men: β = -0.0028, 95% CI: -0.0046 to -0.0010; women: β = -0.0039, 95% CI: -0.0054 to -0.0023). On the other hand, uNTx was negatively associated with lumbar BMD after adjustment of relevant covariables (β = -0.0328, 95% CI: -0.0523 to -0.0133). However, in the subgroup analysis stratified by gender, this negative association remained only in older women (β = -0.0491, 95% CI: -0.0751 to -0.0231).

CONCLUSION

Our study suggested that elevated sBAP and uNTX levels correlated with decreased lumbar BMD, especially in older women. This finding indicated that maintaining BTMs at low levels may be beneficial to bone health for older adults.

Real-world bone turnover marker use: impact on treatment decisions and fracture

The use of bone turnover marker (BTM) testing for patients with osteoporosis in the USA has not been well characterized. This retrospective US-based real-world data study found BTM testing has some association with treatment decision-making and lower fracture risk in patients with presumed osteoporosis, supporting its use in clinical practice.

INTRODUCTION

The purpose of this study was to characterize bone turnover marker (BTM) testing patterns and estimate their clinical utility in treatment decision-making and fragility fracture risk in patients with osteoporosis using a retrospective claims database.

METHODS

Data from patients aged ≥ 50 years with newly diagnosed osteoporosis enrolled in the Truven MarketScan^® Commercial Claims and Encounters and Medicare Supplemental and Co-ordination of Benefits databases from January 2008 to June 2018 were included. Osteoporosis was ascertained by explicit claims, fragility fracture events associated with osteoporosis, or prescribed anti-resorptive or anabolic therapy. BTM-tested patients were 1:1 propensity score matched to those untested following diagnosis. Generalized estimating equation models were performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for testing versus no testing on both treatment decision-making and fragility fracture.

RESULTS

Of the 457,829 patients with osteoporosis, 6075 were identified with ≥ 1 BTM test following diagnosis; of these patients, 1345 had a unique treatment decision made ≤ 30 days from BTM testing. The percentage of patients receiving BTM tests increased significantly each year (average annual % change: + 8.1%; 95% CI: 5.6-9.0; p = 0.01). Patients tested were significantly more likely to have a treatment decision (OR: 1.14; 95% CI: 1.13-1.15), and testing was associated with lower odds of fracture versus those untested (OR: 0.87; 95% CI: 0.85-0.88).

CONCLUSION

In this large, heterogeneous population of patients with presumed osteoporosis, BTM testing was associated with treatment decision-making, likely leading to fragility fracture reduction following use.

Exploring the Relationship of Bone Turnover Markers and Bone Mineral Density in Community-Dwelling Postmenopausal Women

Aims

To explore the relationships of procollagen type 1 N-terminal propeptide (P1NP) and β cross-linked C-telopeptide of type 1 collagen (β-CTX) with bone mineral density (BMD) in postmenopausal women.

Methods

All postmenopausal women were selected from a community-based case-control study. The anteroposterior L1-L4 and left proximal femur BMD were measured. P1NP and β-CTX were also collected and tested. The main correlation analysis was applied to explore the relationships of BMD, P1NP, and β-CTX.

Results

The total 1055 postmenopausal women were enrolled. The BMD at all sites kept a decrease continually with age (P < 0.01). In addition, the level of β-CTX increased significantly from 45 to 50 years old and remained at a high level in the later stage, while the level of P1NP changed little or even decreased with age. Logistic regression model showed that β-CTX has better ability to predict BMD than P1NP, as demonstrated by an area under the curve (AUC) of 0.63.

Conclusion

P1NP and β-CTX are important markers to monitor bone metabolism. This trial is registered with ChiCTR-SOC-17013090. The date of registration is Oct. 23, 2017.

Safety and efficacy of Wharton's jelly-derived mesenchymal stem cells with teriparatide for osteoporotic vertebral fractures: A phase I/IIa study

Osteoporotic vertebral compression fractures (OVCFs) are serious health problems. We conducted a randomized, open-label, phase I/IIa study to determine the feasibility, safety, and effectiveness of Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) and teriparatide (parathyroid hormone 1-34) in OVCFs. Twenty subjects with recent OVCFs were randomized to teriparatide (20 μg/day, daily subcutaneous injection for 6 months) treatment alone or combined treatment of WJ-MSCs (intramedullary [4 × 107 cells] injection and intravenous [2 × 108 cells] injection after 1 week) and teriparatide (20 μg/day, daily subcutaneous injection for 6 months). Fourteen subjects (teriparatide alone, n = 7; combined treatment, n = 7) completed follow-up assessment (visual analog scale [VAS], Oswestry Disability Index [ODI], Short Form-36 [SF-36], bone mineral density [BMD], bone turnover measured by osteocalcin and C-terminal telopeptide of type 1 collagen, dual-energy x-ray absorptiometry [DXA], computed tomography [CT]). Our results show that (a) combined treatment with WJ-MSCs and teriparatide is feasible and tolerable for the patients with OVCFs; (b) the mean VAS, ODI, and SF-36 scores significantly improved in the combined treatment group; (c) the level of bone turnover markers were not significantly different between the two groups; (d) BMD T-scores of spine and hip by DXA increased in both control and experimental groups without a statistical difference; and (e) baseline spine CT images and follow-up CT images at 6 and 12 months showed better microarchitecture in the combined treatment group. Our results indicate that combined treatment of WJ-MSCs and teriparatide is feasible and tolerable and has a clinical benefit for fracture healing by promoting bone architecture. Clinical trial registration: https://nedrug.mfds.go.kr/, MFDS: 201600282-30937.

Romosozumab in Postmenopausal Korean Women with Osteoporosis: A Randomized, Double-Blind, Placebo-Controlled Efficacy and Safety Study

BACKGROUND

This phase 3 study evaluated the efficacy and safety of 6-month treatment with romosozumab in Korean postmenopausal women with osteoporosis.

METHODS

Sixty-seven postmenopausal women with osteoporosis (bone mineral density [BMD] T-scores ≤-2.5 at the lumbar spine, total hip, or femoral neck) were randomized (1:1) to receive monthly subcutaneous injections of romosozumab (210 mg; n=34) or placebo (n=33) for 6 months.

RESULTS

At month 6, the difference in the least square (LS) mean percent change from baseline in lumbar spine BMD (primary efficacy endpoint) between the romosozumab (9.5%) and placebo (-0.1%) groups was significant (9.6%; 95% confidence interval, 7.6 to 11.5; P&lt;0.001). The difference in the LS mean percent change from baseline was also significant for total hip and femoral neck BMD (secondary efficacy endpoints). After treatment with romosozumab, the percent change from baseline in procollagen type 1 N-terminal propeptide transiently increased at months 1 and 3, while that in C-terminal telopeptide of type 1 collagen showed a sustained decrease. No events of cancer, hypocalcemia, injection site reaction, positively adjudicated atypical femoral fracture or osteonecrosis of the jaw, or positively adjudicated serious cardiovascular adverse events were observed. At month 9, 17.6% and 2.9% of patients in the romosozumab group developed binding and neutralizing antibodies, respectively.

CONCLUSION

Treatment with romosozumab for 6 months was well tolerated and significantly increased lumbar spine, total hip, and femoral neck BMD compared with placebo in Korean postmenopausal women with osteoporosis (ClinicalTrials.gov identifier NCT02791516).

Reference Intervals for Bone Turnover Markers in Korean Healthy Women

Background

Adequate suppression of bone turnover rate is important to decrease fracture risk without mineralization defect due to oversuppression. This study was performed to determine reference intervals (RIs) for 2 bone turnover markers, serum C-terminal telopeptide of type I collagen (CTX) and osteocalcin, in Korean women.

Methods

A total of 461 Korean women (287 premenopausal and 174 postmenopausal) without any disease or drug history affecting bone metabolism was included. Serum CTX and osteocalcin were measured after overnight fasting. Bone mineral density (BMD) was measured at the 1st to 4th lumbar vertebra using dual energy X-ray absorptiometry. Subjects with normal spinal BMD (T-score ≥-1.0) were included in this study.

Results

After stable concentrations were maintained, both CTX and osteocalcin were abruptly increased in 50 to 59 years, and then decreased with increasing age. Median levels and interquartile range of serum CTX and osteocalcin in all subjects were 0.322 (0.212-0.461) ng/mL and 15.68 (11.38-19.91) ng/mL. RIs for serum CTX and osteocalcin in all subjects were 0.115 to 0.861 ng/mL and 6.46 to 36.76 ng/mL. Those were higher in postmenopausal women (CTX, 0.124-1.020 ng/mL, osteocalcin, 5.42-41.57 ng/mL) than in premenopausal women (CTX, 0.101-0.632 ng/mL, osteocalcin, 6.73-24.27 ng/mL). If we use target reference levels as lower half of premenopausal 30 to 45 years in patients with antiresorptive drugs, those were 0.101 to 0.251 ng/mL and 6.40 to 13.36 ng/mL.

Conclusions

We established RIs for serum CTX and osteocalcin in healthy Korean women with normal lumbar spine BMD. Premenopausal RIs for serum CTX and osteocalcin would be useful to monitor patients with low bone mass using osteoporosis drugs.