Strontium ranelate: a novel treatment for postmenopausal osteoporosis: a review of safety and efficacy

Injectable Hydrogel Technologies for Bone Disease Treatment

Injectable hydrogels represent a highly promising approach for localized drug delivery systems (DDSs) in the management of bone-related conditions such as osteoporosis, osteonecrosis, osteoarthritis, osteomyelitis, and osteosarcoma. Their appeal lies in their biocompatibility, adjustable mechanical properties, and capacity to respond to external stimuli, including pH, temperature, light, redox potential, ionic strength, and enzymatic activity. These features enable enhanced targeted delivery of bioactive agents. This mini-review evaluates the synthesis of injectable hydrogels as well as recent advancements for treating a range of bone disorders, focusing on their mechanisms as localized and sustained DDSs for delivering drugs, nanoparticles, growth factors, and cells (e.g., stem cells). Moreover, it highlights their clinical studies for bone disease treatment. Additionally, it emphasizes the potential synergy between injectable hydrogels and hydrogel-based point-of-care technologies, which are anticipated to play a pivotal role in the future of bone disease therapies. Injectable hydrogels have the potential to transform bone disease treatment by facilitating precise, sustained, and minimally invasive therapeutic delivery. Nevertheless, significant challenges, including long-term biocompatibility, scalability, reproducibility, and precise regulation of drug release kinetics, must be addressed to unlock their clinical potential fully. Addressing these challenges will not only advance bone disease therapy but also open new avenues in regenerative medicine and personalized healthcare.

Strontium-containing mineralized phospholipid coatings improve osseointegration in osteoporotic rats

Surface treatments play an important role in enhancing the osseointegration of Titanium (Ti) and its alloys. This study introduces a method employing biomimetic hydroxyapatite (Hap) deposition guided by molecularly organized phospholipids, affixed to the metal implant surface. Using the Langmuir-Blodgett technique, phospholipids were deposited onto Ti-screws by using CaCl2 or CaCl2/SrCl2 aqueous solution in the subphase of a Langmuir trough in the target proportion (i.e. 10 and 90 mol% of Sr2+ in relation of Ca2+) followed by immersion in phosphate buffer and in supersaturated simulated body fluid. Coating composition and morphology were evaluated using infrared spectroscopy and scanning electron microscopy, respectively, while contact angle measurements assessed coating wettability and surface energy. Randomized screws were then implanted into the tibias of healthy and osteoporotic female rats (G1: Control-Machined, G2: Hap, G3: HapSr10, G4: HapSr90). Osseointegration, assessed 60 days post-implantation, included reverse torque, fluorochrome area, bone tissue-screw contact area, and linear extent of bone-screw contact. Results, grouped by surface treatment (Machined, Hap, HapSr10, HapSr90), revealed that the deposition of Hap, HapSr10, and HapSr90 resulted in thin and rough coatings composed of hydroxyapatite (Hap) on the screw surface with nanoscale pores. The coatings resulted in increased wettability and surface energy of Ti surfaces. The minerals are chemically similar to natural bone apatite as revealed by FTIR analysis. In vivo analyses indicated higher torque values for strontium-containing surfaces in the osteoporotic group (p = 0.02) and, in the control group superior torque for screw removal on the Hap surface (p = 0.023). Hydroxyapatite-treated surfaces enhance morphology, composition, and reactivity, promoting screw osseointegration in healthy and osteoporotic female rats. The incorporation of strontium into the mineral phase has been proposed to not only stimulate osteoblast activity but also reduce osteoclastic resorption, which may explain the improved outcomes observed here in experimental osteoporotic conditions.

Insights into the Mechanism of Osteoporosis and the Available Treatment Options

Osteoporosis, one of the most prevalent bone illnesses, majorly affects postmenopausal women and men over 50 years of age. Osteoporosis is associated with an increased susceptibility to fragility fractures and can result in persistent pain and significant impairment in affected individuals. The primary method for diagnosing osteoporosis involves the assessment of bone mineral density (BMD) through the utilisation of dual energy x-ray absorptiometry (DEXA). The integration of a fracture risk assessment algorithm with bone mineral density (BMD) has led to significant progress in the diagnosis of osteoporosis. Given that osteoporosis is a chronic condition and multiple factors play an important role in maintaining bone mass, comprehending its underlying mechanism is crucial for developing more effective pharmaceutical interventions for the disease. The effective management of osteoporosis involves the utilisation of appropriate pharmacological agents in conjunction with suitable dietary interventions and lifestyle modifications. This review provides a comprehensive understanding of the types of osteoporosis and elucidates the currently available pharmacological treatment options and their related mechanism of action and usage.

In Vitro Evaluation of Ag- and Sr-Doped Hydroxyapatite Coatings for Medical Applications

Osseointegration plays the most important role in the success of an implant. One of the applications of hydroxyapatite (HAp) is as a coating for metallic implants due to its bioactive nature, which improves osteoconduction. The purpose of this research was to assess the in vitro behavior of HAp undoped and doped with Ag and/or Sr obtained by galvanostatic pulsed electrochemical deposition. The coatings were investigated in terms of chemical bonds, contact angle and surface free energy, electrochemical behavior, in vitro biomineralization in acellular media (SBF and PBS), and biocompatibility with preosteoblasts cells (MC3T3-E1 cell line). The obtained results highlighted the beneficial impact of Ag and/or Sr on the HAp. The FTIR spectra confirmed the presence of hydroxyapatite within all coatings, while in terms of wettability, the contact angle and surface free energy investigations showed that all surfaces were hydrophilic. The in vitro behavior of MC3T3-E1 indicated that the presence of Sr in the HAp coatings as a unique doping agent or in combination with Ag elicited improved cytocompatibility in terms of cell proliferation and osteogenic differentiation. Therefore, the composite HAp-based coatings showed promising potential for bone regeneration applications.

Strontium Functionalization of Biomaterials for Bone Tissue Engineering Purposes: A Biological Point of View

Strontium (Sr) is a trace element taken with nutrition and found in bone in close connection to native hydroxyapatite. Sr is involved in a dual mechanism of coupling the stimulation of bone formation with the inhibition of bone resorption, as reported in the literature. Interest in studying Sr has increased in the last decades due to the development of strontium ranelate (SrRan), an orally active agent acting as an anti-osteoporosis drug. However, the use of SrRan was subjected to some limitations starting from 2014 due to its negative side effects on the cardiac safety of patients. In this scenario, an interesting perspective for the administration of Sr is the introduction of Sr ions in biomaterials for bone tissue engineering (BTE) applications. This strategy has attracted attention thanks to its positive effects on bone formation, alongside the reduction of osteoclast activity, proven by in vitro and in vivo studies. The purpose of this review is to go through the classes of biomaterials most commonly used in BTE and functionalized with Sr, i.e., calcium phosphate ceramics, bioactive glasses, metal-based materials, and polymers. The works discussed in this review were selected as representative for each type of the above-mentioned categories, and the biological evaluation in vitro and/or in vivo was the main criterion for selection. The encouraging results collected from the in vitro and in vivo biological evaluations are outlined to highlight the potential applications of materials’ functionalization with Sr as an osteopromoting dopant in BTE.

In vitro cellular testing of strontium/calcium substituted phosphate glass discs and microspheres shows potential for bone regeneration

Phosphate-based glasses (PBGs) are ideal materials for regenerative medicine strategies because their composition, degradation rates, and ion release profiles can easily be controlled. Strontium has previously been found to simultaneously affect bone resorption and deposition. Therefore, by combining the inherent properties of resorbable PBG and therapeutic activity of strontium, these glasses could be used as a delivery device of therapeutic factors for the treatment of orthopaedic diseases such as osteoporosis. This study shows the cytocompatibility and osteogenic potential of PBGs where CaO is gradually replaced by SrO in the near invert glass system 40P2 O5 ·(16-x)CaO·20Na2 O·24MgO·xSrO (x = 0, 4, 8, 12, and 16 mol%). Direct seeding of MG63 cells onto glass discs showed no significant difference in cell metabolic activity and DNA amount measurement across the different formulations studied. Cell attachment and spreading was confirmed via scanning electron microscopy (SEM) imaging at Days 3 and 14. Alkaline phosphatase (ALP) activity was similarly maintained across the glass compositions. Follow-on studies explored the effect of each glass composition in microsphere conformation (size: 63-125 μm) on human mesenchymal stem cells (hMSCs) in 3D cultures, and analysis of cell metabolic activity and ALP activity showed no significant differences at Day 14 over the compositional range investigated, in line with the observations from MG63 cell culture studies. Environmental SEM and live cell imaging at Day 14 of hMSCs seeded on the microspheres showed cell attachment and colonisation of the microsphere surfaces, confirming these formulations as promising candidates for regenerative medicine strategies addressing compromised musculoskeletal/orthopaedic diseases.

Bibliographic review on the state of the art of strontium and zinc based regenerative therapies. Recent developments and clinical applications

This review brings up to date the state of the art of strontium and zinc based regenerative therapies, both having a promoting effect on tissue formation and a role inhibiting resorption in musculoskeletal disorders.

Strontium-releasing fluorapatite glass-ceramic scaffolds: Structural characterization and in vivo performance

There is increasing interest in biodegradable ceramic scaffolds for bone tissue engineering capable of in situ delivery of ionic species favoring bone formation. Strontium has been shown to be osteogenic, but strontium-containing drugs such as strontium ranelate, used in Europe for the treatment of osteoporosis, are now restricted due to clinical evidence of systemic effects. By doping fluorapatite-based glasses with strontium, we developed ceramic scaffolds with fully interconnected macroporosity and cell size similar to that of cancellous bone, that are also capable of releasing strontium. The crystallization behavior, investigated by XRD and SEM, revealed the formation of akermanite and fluorapatite at the surface of strontium-free glass-ceramic scaffolds, and strontium-substituted fluorapatite at the surface of the strontium-doped scaffolds. At 8 weeks after implantation in a rat calvarial critical size defect, scaffolds doped with the highest amount of strontium led to the highest mineral apposition rate. A significantly higher amount of newly-formed bone was found with the strontium-free glass-ceramic scaffold, and possibly linked to the presence of akermanite at the scaffold surface. We demonstrate by energy dispersive XRF analyses of skull sections that strontium was present in newly formed bone with the strontium-doped scaffolds, while a significant amount of fluorine was incorporated in newly formed bone, regardless of composition or crystallization state.

Hair for a long-term biological indicator tissue for assessing the strontium nutritional status of men and women

Strontium (Sr) is a trace element that closely resembles calcium metabolism. At the present time there is no available long-term biological indicator tissue for assessing the human Sr nutritional status. Here we have presented a novel concept on how to assess the Sr nutritional status by studying the frequency distribution properties of hair Sr (^SrH) concentration. In this prospective, observational, cross-sectional, and exploratory epidemiological study, we analyzed ^SrH in 311 apparently healthy adult Croatians (123 men, 188 women). Hair strontium was analyzed by the ICP-MS. The natural frequency distribution of ^SrH followed the Power law, so that the data were analyzed by fitting the logistic bioassay sigmoid curve (ogive) of median derivatives. Women tend to accumulate three and a half time more ^SrH than men (median men 867ngg^-1 vs. median women 3120ngg^-1). The normal (adequate) linear physiological response range of the sigmoid curve was 351-3489ngg^-1 for men and 846-8457ngg^-1 for women. Values below that linear range are considered to indicate deficient Sr nutritional status, whereas values above that linear range indicate excessive strontium exposure. Hair, as a long-term, and whole blood as a short-term biological indicator tissues were not commensurable entities. Similarly, ^SrH accumulation was not age dependent in either men or women. Hair strontium is a reliable long-term biological indicator tissue for assessing the strontium nutritional status.

Controlled release of strontium through neutralization reaction within a methoxy(polyethylene glycol)-polyester hydrogel

BACKGROUND

The aim of this study was to develop a minimally invasive hydrogel system that can release strontium ions, an element that has been shown to increase osteoblast proliferation and prohibit bone resorption, in a controlled manner.

METHODS

SrCO3 was selected as the salt of choice due to potential acid neutralization reaction between SrCO3 and degradation by-products of methoxy(polyethylene glycol)-co-poly(lactic-co-glycolic acid) (mPEG-PLGA): namely, lactic acid and glycolic acid. SrCO3 was incorporated into mPEG-PLGA hydrogel, and the system was assessed for gelation properties, drug release and biocompatibility.

RESULTS

SrCO3 incorporation at hydrogel to SrCO3 ratios of 5:1, 3:1 and 1:1 (wt%) did not compromise the thermosensitivity of mPEG-PLGA hydrogels. Furthermore, incorporation of SrCO3 at 1:1 ratio prevented copolymer self-catalysis and decreased hydrogel weight loss from 85% to 61% in vitro after 30 days. During the 30-day time frame, zero-order strontium release was observed and was correlated to hydrogel degradation and acidity. The addition of SrCO3 also improved in vivo hydrogel biocompatibility, due to moderation of acidic microenvironment and amelioration of inflammatory response.

CONCLUSIONS

These results showed that the described system is suitable for the extended release of strontium and exhibits potential for localized treatment for osteoporosis or as a bone void filler.

[Suitability of strontium ranelate in a health care management area after drug surveillance alerts]

OBJECTIVE

To analyse the impact of a strategy on the suitability of strontium ranelate, and its level of acceptance, after issuing recommendations based on drug surveillance alerts issued by the Spanish Medicines and Medical Devices Agency.

DESIGN

A prospective interventional study conducted from April 2012 to November 2014.

SETTING

South Seville Health Management Area.

PARTICIPANTS

Patients currently prescribed with strontium ranelate.

INTERVENTIONS

The study consisted of four phases linked to the issue of drug surveillance alerts on strontium ranelate by the Spanish Medicines and Medical Devices Agency, listed by patients and suitability recommendations.

MAIN MEASUREMENTS

Suitability of strontium ranelate treatment and the level of acceptance by physicians.

RESULTS

There was a reduction of 87.9% in prescriptions from the beginning of the study, with 182 patients included, until the review of the suitability of the drug began. The prescribing of strontium ranelate was unsuitable in 16 out of the 22 patients remaining; 11 of which were due not meeting the treatment criteria, 3 for not having had previous treatments with other drugs for the prevention of fractures, and 2 due to contraindications. The level of acceptance of the recommendations was 87.5%, leading to the stopping of strontium ranelate in 10 patients, and the changing to alendronate or alendronate/cholecalciferol in another four patients.

CONCLUSIONS

The number of patients prescribed strontium ranelate has decreased considerably. The interventions directed at reviewing the suitability of this treatment, based on the drug surveillance alerts, have been effective.

Monitoring bone strontium intake in osteoporotic females self-supplementing with strontium citrate with a novel in-vivo X-ray fluorescence based diagnostic tool

Ten female volunteers were recruited as part of the Ryerson and McMaster University Strontium (Sr) in Bone Research Study to have their bone Sr levels measured as they self-supplemented with Sr supplements of their choice. Of the ten volunteers, nine were suffering from osteopenia and/or osteoporosis. Non-invasive bone Sr measurements were performed using an in vivo x-ray fluorescence (IVXRF) I-125 based system. Thirty minute measurements were taken at the finger and ankle, representing primarily cortical and trabecular bone, respectively. For analysis, the 14.2keV Sr K-alpha peak normalized to the Coherent peak at 35.5keV was used. Baseline readings, representing natural bone Sr levels were acquired since all volunteers had no previous intake of Sr based supplements or medications. Once Sr supplements were started, a 24h reading was taken, followed by frequent measurements ranging from weekly, biweekly to monthly. The longest volunteer participation was 1535days. The mean baseline Sr signal observed for the group was 0.42±0.13 and 0.39±0.07 for the finger and ankle, respectively. After 24h, the mean Sr signal rose to 1.43±1.12 and 1.17±0.51, for the finger and ankle, respectively, representing a statistically significant increase (p=0.0043 & p=0.000613). Bone Sr levels continued to increase throughout the length of the study. However the Sr signal varied widely between the individuals such that after three years, the highest Sr signal observed was 28.15±0.86 for the finger and 26.47±1.22 for the ankle in one volunteer compared to 3.15±0.15 and 4.46±0.36, for the finger and ankle, respectively in another. Furthermore, while it was previously reported by our group, that finger bone Sr levels may plateau within two years, these results suggest otherwise, indicating that bone Sr levels will continue to rise at both bone sites even after 4years of Sr intake.

Osteodystrophy in chronic liver diseases

Osteoporosis and osteomalacia are, to date, among the most common metabolic diseases in the world. Lately, an association between metabolic bone diseases and chronic liver disease has been increasingly reported, inducing many authors to create a new nosographic entity known as 'hepatic osteodystrophy.' The importance of such a condition is further increased by the morbidity of these two diseases, which greatly reduce the quality of life because of frequent fractures, especially vertebral and femoral neck ones. For this reason, early identification of high-risk patients should be routinely performed by measuring bone mass density. The explanation for the association between bone diseases and chronic liver disease is still uncertain, and involves many factors: from hypogonadism to use of corticosteroid drugs, from genetic factors to interferon therapy. To date, few studies have been conducted, and all with a small number of patients to establish definitive conclusions about the possible treatment, but some evidence is beginning to emerge about the safety and efficacy of bisphosphonates.

Accumulation of bone strontium measured by in vivo XRF in rats supplemented with strontium citrate and strontium ranelate

Strontium ranelate is an approved pharmacotherapy for osteoporosis in Europe and Australia, but not in Canada or the United States. Strontium citrate, an alternative strontium salt, however, is available for purchase over-the-counter as a nutritional supplement. The effects of strontium citrate on bone are largely unknown. The study's objectives were 1) to quantify bone strontium accumulation in female Sprague Dawley rats administered strontium citrate (N=7) and compare these levels to rats administered strontium ranelate (N=6) and vehicle (N=6) over 8 weeks, and 2) to verify an in vivo X-ray fluorescence spectroscopy (XRF) system for measurement of bone strontium in the rat. Daily doses of strontium citrate and strontium ranelate were determined with the intention to achieve equivalent amounts of elemental strontium. However, post-hoc analyses of each strontium compound conducted using energy dispersive spectrometry microanalysis revealed a higher elemental strontium concentration in strontium citrate than strontium ranelate. Bone strontium levels were measured at baseline and 8 weeks follow-up using a unique in vivo XRF technique previously used in humans. XRF measurements were validated against ex vivo measurements of bone strontium using inductively coupled plasma mass spectrometry. Weight gain in rats in all three groups was equivalent over the study duration. A two-way ANOVA was conducted to compare bone strontium levels amongst the three groups. Bone strontium levels in rats administered strontium citrate were significantly greater (p<0.05) than rats administered strontium ranelate and vehicle. ANCOVA analyses were performed with Sr dose as a covariate to account for differences in strontium dosing. The ANCOVA revealed differences in bone strontium levels between the strontium groups were not significant, but that bone strontium levels were still very significantly greater than vehicle.

Weak effect of strontium on early implant fixation in rat tibia

Strontium ranelate increases bone mass and is used in the treatment of osteoporosis. Its effects in metaphyseal bone repair are largely unknown. We inserted a stainless steel and a PMMA screw into each tibia of male Sprague-Dawley rats. The animals were fed with ordinary feed (n=20) or with addition of strontium ranelate (800 mg/kg/day; n=10). As a positive control, half of the animals on control feed received alendronate subcutaneously. The pullout force of the stainless steel screws was measured after 4 or 8 weeks, and µCT was used to assess bone formation around the PMMA screws. No significant effects of strontium treatment on pullout force were observed, but animals treated with bisphosphonate showed a doubled pullout force. Strontium improved the micro architecture of the cancellous bone below the primary spongiosa at the growth plate, but no significant effects were found around the implants. Strontium is known to improve bone density, but it appears that this effect is weak in conjunction with metaphyseal bone repair and early implant fixation.

The co-effect of Cordyceps sinensis and strontium on osteoporosis in ovariectomized osteopenic rats

The co-effect of Cordyceps sinensi (CS; caterpillar fungus) and strontium on ovariectomized osteopenic rats was studied in this paper. After the rats were treated orally with CS, strontium (SR), and CS rich in strontium (CSS), respectively, the urine calcium, plasma calcium, plasma phosphorus, bone mineral content, mechanical testing, and the mass of uterus, thymus, and body were examined. Both CSS and SR have a positive effect on mechanical strength and mineral content of ovariectomized osteopenic rats. However, femoral neck strength in the CSS-treated group was higher than those in the SR-treated groups. CSS and SR significantly decreased urinary calcium excretion and plasma total calcium and inorganic phosphate concentrations. On the contrary, CS and CSS significantly increased weights of atrophic uteri and weights of body and also decreased the thymus mass in animals, whereas SR did not exhibit any such effects. Our experiments have demonstrated that CSS possess a preferable effect against the decrease of bone strength and bone mineral mass caused by osteoporosis. It was caused by the co-effect of CS and strontium. The mechanism of it includes decreases bone resorption, increases bone formation, increases in body weight, and enhances 17β-estradiol-producing as well as enhancing the immune functions in animals. The data provide an important proof of concept that CSS might be a new potential therapy for the management of postmenopausal osteoporosis in humans.

Effects of strontium in modified biomaterials

Strontium (Sr) plays a special role in bone remodelling, being associated with both the stimulation of bone formation and a reduction in bone resorption. Thus, the modification of biomaterials by partial or full substitution by Sr is expected to increase both bioactivity and biocompatibility. However, such effects have to be studied individually. Although no phase transition was found in Sr-substituted hydroxyapatite (Sr-HA), Sr-containing calcium silicate (Sr-CS) or Sr-containing borosilicate (Sr-BS), their biological performance was substantially affected by changes in the physico-chemical properties and Sr content of the materials. Three distinct outcomes were found for the presence of Sr: (1) increased HA solubility; (2) no significant effect on the degradation rate of CS; (3) apparent inhibition of the otherwise rapid degradation of BS. In each case the released Sr affected osteoblast proliferation and alkaline phosphatase activity, with clear evidence that an optimum Sr dose exists. Such chemical and biological variations must be disentangled for the behaviour to be properly understood and materials design to be advanced.

Strontium fructose 1,6-diphosphate alleviates early diabetic testopathy by suppressing abnormal testicular matrix metalloproteinase system in streptozocin-treated rats

Objectives

Male hypogonadism is frequently associated with testopathy in patients with type 2 diabetes and in middle-aged males. We hypothesized that abnormal matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) in testis have large roles to play in male hypogonadism. It has been found in diabetic rats that a novel compound, strontium fructose 1,6-diphosphate (FDP-Sr), with extra high energy supply, could reverse male hypogonadism by normalizing MMP-9 and TIMPs in the testis. We investigated whether FDP-Sr could be promising in treating diabetic testopathy.

Methods

Adult male Sprague-Dawley rats were administered a single dose of streptozocin (65 mg/kg, i.p.) to induce diabetes. The diabetic rats were treated with FDP-Sr in three doses or testosterone propionate in the final four weeks during the eight-week study.

Key findings

Serum testosterone, activity of marker enzymes, and mRNA of MMPs and TIMPs and protein of MMP-9 in the testis were detected. After eight weeks, the activity of acid phosphatase, lactate dehydrogenase, succinate dehydrogenase and γ-glutamyl transpeptidase in testis were significantly decreased (P &lt; 0.01), accompanied by down-regulated mRNA and activity of MMP-2 and MMP-9 (P &lt; 0.01) and upregulated mRNA of TIMP-1 and TIMP-2. Downregulated MMP-9 protein and degenerative changes in histology were predominant in diabetic testis.

Conclusions

FDP-Sr or testosterone propionate significantly normalized expression and activity of the MMPs–TIMPs system to attenuate changes in serum testosterone, marker enzymes and histology in testis. Effects of FDP-S-r were dose-dependent and comparable with those of testosterone propionate. By supplying extra energy, FDP-Sr could be promising in treating diabetic testopathy by normalizing abnormal MMP-9 and its endogenous inhibitors in testes.