Drugs used in the treatment of metabolic bone disease. Clinical pharmacology and therapeutic use

Challenges in the management of hypercalcemia in pregnancy - Case report of two cases

Hypercalcemia in pregnancy is rare and can pose a great diagnostic challenge due to its asymptomatic presentation. It is associated with maternal complications such as urolithiasis, pancreatitis, renal insufficiency and preeclampsia, fetal complications such as growth restriction and intrauterine fetal demise, and neonatal complications such as neonatal hypocalcemia, tetany and hypoparathyroidism. Prompt diagnosis and treatment of the underlying cause of hypercalcemia is important. Two cases of hypercalcemia in pregnancy were encountered over 12 months. Both presented asymptomatically in the first trimester and were associated with hyperparathyroidism and hypertensive disease in current and previous gestations. Genetic testing ruled out familial hypocalciuric hypercalcemia, and both women required surgical management in the second trimester for control of hypercalcemia. The literature on the diagnosis and management of hypercalcemia in pregnancy is reviewed, and the challenges and pitfalls are discussed. Hypercalcemia in pregnancy requires a high index of suspicion for early diagnosis, and young women with unexplained hypertension in early pregnancy should be investigated for secondary causes, including hypercalcemia and primary hyperparathyroidism. Management of hypercalcemia secondary to primary hyperparathyroidism requires multidisciplinary team management, and surgery should be considered if the patient has not responded to conservative measures, ideally in the second trimester.

Calcium Chelidonate: Semi-Synthesis, Crystallography, and Osteoinductive Activity In Vitro and In Vivo

Calcium chelidonate [Ca(ChA)(H₂O)₃]_n was obtained by semi-synthesis using natural chelidonic acid. The structure of the molecular complex was determined by X-ray diffraction analysis. The asymmetric unit of [Ca(ChA)(H₂O)₃]_n includes chelidonic acid coordinated through three oxygen atoms, and three water ligands. The oxygen atoms of acid and oxygen atoms of water from each asymmetric unit are also coordinated to the calcium of another one, forming an infinite linear complex. Calcium geometry is close to the trigonal dodecahedron (D2d). The intra-complex hydrogen bonds additionally stabilize the linear species, which are parallel to the axis. In turn the linear species are packed into the 3D structure through mutual intercomplex hydrogen bonds. The osteogenic activity of the semi-synthetic CaChA was studied in vitro on 21-day hAMMSC culture and in vivo in mice using ectopic (subcutaneous) implantation of CaP-coated Ti plates saturated in vitro with syngeneic bone marrow. The enhanced extracellular matrix ECM mineralization in vitro and ectopic bone tissue formation in situ occurred while a water solution of calcium chelidonate at a dose of 10 mg/kg was used. The test substance promotes human adipose-derived multipotent mesenchymal stromal/stem cells (hAMMSCs), as well as mouse MSCs to differentiate into osteoblasts in vitro and in vivo, respectively. Calcium chelidonate is non-toxic and can stimulate osteoinductive processes.

Complexities surrounding the diagnosis and management of hypercalcaemia in pregnancy

SUMMARY

Hypercalcaemia in pregnancy is uncommon, with associated adverse obstetric and perinatal outcomes for both the mother and the fetus. Determination of causality is central to its management. Diagnostic imaging techniques are limited during pregnancy and the diagnosis is made more complex by physiological changes in calcium and vitamin D homeostasis in pregnancy. Further, therapeutic options are limited due to safety considerations for the pregnant woman and the developing foetus. Three cases of hypercalcaemia in pregnancy will be presented, highlighting the distinct aetiologies and management strategies for hypercalcaemia in pregnancy and the importance of early measurement of serum calcium in pregnancy screening.

LEARNING POINTS

There are complex physiological changes in calcium balance in pregnancy, including increased calcium intestinal absorption and renal excretion. Hypercalcaemia in pregnancy is uncommon but has important potential maternal and foetal complications, making a compelling argument for routine antenatal, calcium screening. Identifying the cause of hypercalcaemia in pregnancy can be challenging due to the complex placental interplay in biochemical test interpretation and due to safety constraints restricting imaging and surgery. Acute medical management of hypercalcaemia must be considered in the context of both maternal and foetal well-being, along with gestational age and specific consideration for the safety of the developing fetus in late gestation.

New PCNT candidate missense variant in a patient with oral and maxillofacial osteodysplasia: a case report

Background

Osteodysplasia of the oral and maxillofacial bone is generally accompanied by systemic bone abnormalities (such as short stature, joint contracture) or other systemic abnormalities (such as renal, dermatological, cardiovascular, optic, or hearing disorders). However, it does not always present this way. Recent reports have suggested that genome-wide sequencing is an effective method for identifying rare or new disorders. Here, we performed whole-exome sequencing (WES) in a patient with a unique form of acquired, local osteodysplasia of the oral and maxillofacial region.

Case presentation

A 46-year-old woman presented to our hospital with the complaint of gradually moving mandibular teeth (for 6 months), changing facial appearance, and acquired osteolysis of the oral and maxillofacial bones, showing mandibular hypoplasia without family history. Upon skeletal examination, there were no abnormal findings outside of the oral and maxillofacial area; the patient had a height of 157 cm and bone mineral density (according to dual energy x-ray absorptiometry) of 90%. Results of blood and urine tests, including evaluation of bone metabolism markers and neurological and cardiovascular examinations, were normal. We performed WES of genomic DNA extracted from the blood of this patient and her mother, who did not have the disease, as a negative control. We identified 83 new missense variants in the patient, not detected in her mother, including a candidate single nucleotide variant in exon 14 of PCNT (pericentrin). Critical homozygous or compound heterozygous variants in PCNT are a known cause of microcephalic osteodysplastic primordial dwarfism type II accompanied by mandibular hypoplasia, which is similar to the maxillofacial phenotype in this patient.

Conclusions

Protein simulations performed using Polymorphism Phenotyping v2 and Combined Annotation Dependent Depletion software indicated that this missense variant is likely to disrupt the PCNT protein structure. These results suggest that this is a new form of osteolysis related to this PCNT variant.

Hypercalcemic crisis in third trimenon: evaluating the optimal treatment strategy

Hypercalcemia due to primary hyperparathyroidism during pregnancy is a rare condition and associated with increased morbidity and mortality for the mother and the unborn child. Whereas parathyroidectomy is favored during the second trimester, no clear recommendations exist for its management during the third trimenon. We here report the case of a 26-year-old woman in the 29th week of her first pregnancy, who was admitted to our clinic with hypertension, intra-uterine growth retardation and polyhydramnios. Severe hypercalcemia due to primary hyperparathyroidism was diagnosed (total calcium 3.34 mmol/l; PTH 216 pg/ml), but no enlarged parathyroid gland could be localized by ultrasound. Treatment with calcitonin and cinacalcet could not control hypercalcemia. Therefore explorative surgery was performed and a single parathyroid adenoma was resected, resulting in normalization of serum calcium levels. The surgical procedure was tolerated well by the mother and fetus. Hypercalcemia-induced hypertension and polyhydramnios ameliorated before C-section was performed two weeks later and unrelated to the intervention. This case report underlines the importance of early diagnosis and treatment of primary hyperparathyroidism during pregnancy. If diagnosed in the third trimenon, an interdisciplinary approach is crucial. If medical treatment fails to sufficiently control hypercalcemia, surgical parathyroid exploration should be considered even in cases of unsuccessful localization of adenomatous parathyroid glands.

Hypercalcemia in pregnancy - a multifaceted challenge: case reports and literature review

Hypercalcemia in pregnancy is an uncommon event that can cause major maternal morbidity and/or fetal or neonatal morbidity and mortality. Management is a challenge for the clinicians, especially as regards to investigations in pregnancy, surgery, and the use of cinacalcet and bisphosphonates. We present three case reports and discuss management.

Incorporation of salmon calcitonin-loaded poly(lactide-co-glycolide) (PLGA) microspheres into calcium phosphate bone cement and the biocompatibility evaluation in vitro

Slow tissue ingrowth is the major drawback for the use of calcium phosphate cements; to address the issue, salmon calcitonin–loaded biodegradable poly(lactide- co-glycolide) microspheres were incorporated into calcium phosphate cement in this study. The effects of poly(lactide- co-glycolide) weight ratio on the mechanical strength, self-setting properties, and salmon calcitonin release ability of calcium phosphate cement were systematically investigated. The in vitro degradation behavior and the cumulative mass loss (%) of the composite during incubation in phosphate-buffered saline were studied. The release of salmon calcitonin was sustained for at least 35 days, and the release rate can be tailored by adjusting the ratio of PLGA. The scanning electron microscopic images of the composites after incubation for 48 days indicated that the poly(lactide- co-glycolide) degraded completely and formed a porous structure in the calcium phosphate cement. An in vitro cell culture of the calcium phosphate cement/salmon calcitonin–poly(lactide- co-glycolide) cement provided more biocompatible than calcium phosphate cement. This composite possesses the basic performance for clinical needs, and it has potential use for treating osteoporosis and accelerating bone repair.

Large molecule bioanalysis using Q-TOF without predigestion and its data processing challenges

Background: Recent developments in LC–MS have turned it into a viable and valid alternative to ligand-binding assays. Large molecule bioanalysis by LC–MS is generally performed by tryptic digestion, purification and detection of one or more small signature peptides. High-resolution MS instruments offer quantification of intact small proteins or peptides and are able to increase the selectivity, while maintaining sensitivity. Results: Unlike multiple reaction monitoring assays, several factors affecting data processing were presented and the optimal parameters to consider during quantification method building were also demonstrated. MUC5AC-13 (MW 1709.8 Da), human hepcidin/LEAP-1 (MW 2797.4 Da), porcine calcitonin (MW 3604 Da) and chicken lysozyme (MW 14.3 kDa) were selected as model compounds and the possibility of intact peptide and small protein quantification, without tryptic digestion, was demonstrated. Conclusion: Selectivity and sensitivity were improved using different scan modes, such as TOF-MS and TOF-MS/MS.

Construction of a recombinant eukaryotic expression plasmid containing human calcitonin gene and its expression in NIH3T3 cells

AIM

To construct a recombinant eukaryotic expression plasmid containing human calcitonin (hCT) gene and express the gene in murine fibroblast NIH3T3 cells.

MATERIALS AND METHODS

A murine Igkappa-chain leader sequence and hCT gene were synthesized and cloned into pCDNA3.0 to form the pCDNA3.0-Igkappa-hCT eukaryotic expression vector, which was transfected into NIH3T3 cells. The mRNA and protein expressions and secretion of hCT were detected. Primarily cultured osteoclasts were incubated with the supernatant of pCDNA3.0-Igk-hCT-transfected NIH3T3 cells, and their numbers were counted and morphology observed.

RESULTS

The expression and secretion of hCT were successfully detected in pCDNA3.0-Igk-hCT-transfected NIH3T3 cells. The number of osteoclasts was decreased and the cells became crumpled when they were incubated with the supernatant of pCDNA3.0-Igk-hCT-transfected NIH3T3 cells.

CONCLUSION

A recombinant eukaryotic expression vector containing hCT gene was successfully constructed and expressed in NIH3T3 cells. The secreted recombinant hCT inhibited the growth and morphology of osteoclasts.

Enhanced intestinal absorption of salmon calcitonin (sCT) from proliposomes containing bile salts

PURPOSE

The feasibility of using proliposomes containing salmon calcitonin (sCT) and absorption enhancing agents, as an oral delivery system, to improve the intestinal absorption of sCT was explored using rats and Caco-2 cell systems.

METHODS

Seventeen surfactants were examined for their effects with reference to accelerating the permeability of sCT (300 microg/ml) across Caco-2 cell monolayers, and damage to the intestinal epithelial cells, as measured by the change in transepithelial electrical resistance (TEER) across the cell monolayer. Proliposomes containing sCT (0.75%, w/w) and sodium taurodeoxycholate (NaTDC, 2.5%, w/w) (TDC proliposomes) were prepared according to the standard method using sorbitol and phosphatidylcholine as core and wall-forming materials, respectively, administered intra-duodenally to rats, and plasma concentrations of sCT were subsequently determined by LC-MS.

RESULTS

Among the surfactants examined, some bile salts including NaTDC appeared to be the most advantageous when estimated based on the balance between the permeation enhancement (e.g., a 10.8-fold increase in the permeability of sCT for 0.1% NaTDC) and damage to the cells (e.g., a 3.55-fold decrease in the TEER value for 0.1% NaTDC). The administration of TDC proliposomes resulted in a 7.1-fold increase in the bioavailability (i.e., 0.49%) of sCT, when administered duodenally to rats. The size of the reconstituted liposomes in water was significantly smaller (e.g., 23.2 nm, number weighted diameter), and the entrapment efficiency (EE) of sCT in the reconstituted liposomes was 2.8-fold larger (54.9%), for TDC proliposomes, compared to proliposomes prepared without NaTDC (sCT proliposomes).

CONCLUSION

A 7.1-fold increase in the bioavailability of sCT could be achieved from the TDC proliposomes. In addition to the intrinsic activity of the bile salt to fluidize the membrane, the simultaneous delivery of sCT and NaTDC to the site of absorption in the intestine via proliposomes and the subsequent formation of lipophilic ion-pair complexes between sCT and NaTDC at the site might have been contributing factors in this outstanding absorption enhancement.

pH-sensitive microsphere delivery increases oral bioavailability of calcitonin

Oral calcitonin (CT) administration is aimed in the treatment of calcemia in order to circumvent the required regular injections. CT containing microspheres (MS) were designed for colonic delivery by applying a pH-sensitive polymer Eudragit P-4135F for a double emulsion [water/oil/water (w/o/w)] microsphere preparation technique. CT was incorporated in the internal aqueous phase and carboxyfluorescein was encapsulated similarly to allow the characterization of the MS dissolution behavior. Eudragit P-4135F was found to keep the leakage of CT and carboxyfluorescein in vitro at pH 6.8 below 20% within 4 h while at pH 7.4, a fast release was observed for both, dye and peptide. Plasma levels of carboxyfluorescein after oral MS administration proved a sustained release in a rat model, where Cmax of carboxyfluorescein solution was found at around 60 min while for MS formulations it was detected after 4 h. At a dose of 20 microg CT/kg, no significant calcemic effects were found by MS formulations. However, increasing the dose to 100 microg CT/kg resulted in a distinct calcemia and revealed the sustained release properties of the MS. The relative pharmacological effect became most intense after 8-12 h based on the selective pH-dependent delivery. MS showed a fourfold increase of the area above the curve of calcium blood level compared to levels reached after CT solution. The coencapsulation of chitosan in the MS as absorption enhancer did not show any additional effect. The MS formulations proved their applicability as a promising device for pH-dependent colonic CT delivery and might be useful for other peptides.

A tolerability andpharmacokinetic study of a newinjectable formulation of disodium clodronate in healthyfemale volunteers

Disodium clodronate (dichloromethylene bisphosphonic acid, disodium salt; CAS 22560-50-5) is a bisphosphonate that has demonstrated efficacy in patients with a variety of diseases of enhanced bone resorption. Intramuscular clodronate can determine pain at the injection site, it is therefore particularly useful to co-administer a local anaesthetic with clodronate to reduce pain at the injection site. The tolerability and pharmacokinetic of a new formulation of 100 mg disodium clodronate containing 1% lidocaine (test formulation, Chiesi Farmaceutici S.p.A) were investigated in comparison to the same formulation without the local anaesthetic (Clody) and a marketed formulation containing 1% benzyl alcohol (Clasteon). Thirty healthy female volunteers were treated according to a single dose, double-blind, randomised, three-way cross-over design. The local tolerability was investigated by assessing reddening and hardening at the injection site, and plasma CPK levels. Pain intensity was investigated on the VAS (visual analogue scale) and on the VRS (verbal rating score). Urinary clodronic acid concentrations were determined using a validated specific GC/MS/NCI assay. The statistical analysis on pain assessment showed a significant reduction of pain intensity immediately and up to 2 hours after administration of the new formulation compared to the marketed ones. CPK levels and occurrence of hardening at the injection site did not show statistically significant differences between formulations. No local redness was reported. Clodronate urinary excretion during the 48 h collection interval was not statistically different among the formulations and the 95% confidence intervals were inside the bioequivalence acceptance region, demonstrating comparable bioavailability. It was concluded that the investigated new formulation of 100 mg disodium clodronate was better tolerated than the reference marketed formulations.

Biodegradable nanoparticles containing protein‐fatty acid complexes for oral delivery of salmon calcitonin

Biodegradable nanoparticles containing salmon calcitonin (sCT) were formulated using protein-fatty acid complexes, and their in vitro transport against a Caco-2 cell monolayer and the extent of in vivo oral uptake were assessed. Positively charged sCT was hydrophobically ion paired to form physical complexes with fatty acid, phospholipid, and surfactant. Among the complexes, sodium oleate was used to form sCT-oleate complexes, which were characterized and formulated into biodegradable poly(lactic-co-glycolic acid) (PLGA) nanoparticles. Endocytosis of sCT nanoparticles by Caco-2 cells was studied by flow cytometry. Transcytosis of sCT across the Caco-2 monolayer was also quantitated by an ELISA method. The sCT nanoparticles were orally administered to Sprague-Dawley rats, and serum sCT was monitored. Biodegradable polymeric nanoparticles containing a loading amount of sCT as high as 2.7% (w/w) were prepared based on the complexation of sCT with sodium oleate. A greater amount of sCT nanoparticles could be delivered into Caco-2 cells compared with free sCT, and sCT could also be transported from the apical side to the basolateral side of the Caco-2 monolayer. In vivo experiments using a rat animal model showed the possibility of oral uptake of sCT. This study showed that physical complexation of sCT with amphiphilic molecules enabled the formation of sCT-loaded PLGA nanoparticles at a high loading efficiency and that sCT-PLGA nanoparticles were transported across the Caco-2 cell monolayer and were readily taken up in vivo following oral admistration.

Reversible lipidization for the oral delivery of salmon calcitonin

Salmon calcitonin (sCT), a 32-amino-acid polypeptide, was lipidized by using a reversible aqueous lipidization (REAL) technology. When injected subcutaneously into mice, the AUC of REAL-sCT was four times greater than that of sCT and a similar pattern of reduction in plasma calcium level was observed. The therapeutic effect of REAL-sCT was evaluated in ovariectomized (OVX) rats. The development of osteoporosis in OVX rats was determined by measuring the urinary level of deoxypyridinoline (DPD), a biochemical marker of bone resorption. It was found that the DPD levels were significantly reduced in rats that were orally administered a dose of 50 microg/kg/day of REAL-sCT. No reduction in urinary DPD levels could be detected in OVX rats treated similarly with unmodified sCT. In addition, significant levels of sCT were detected in rat plasma up to 12 h after oral administration of REAL-sCT at 500 microg/kg, while the plasma concentration of sCT was undetectable at 1 h after oral administration with the same dose of sCT. The AUC of oral REAL-sCT was at least 19 times higher than that of sCT. Our results indicate that reversibly lipidized polypeptides exhibit not only improved pharmacokinetic and pharmacodynamic behaviors, but also an enhanced oral bioavailability.

Estimation of Bioavailability of Salmon Calcitonin from the Hypocalcemic Effect in Rats (I): Pharmacokinetic-Pharmacodynamic Modeling Based on the Endogenous Ca Regulatory System

The hypocalcemic effect of salmon calcitonin (sCT) after intravenous administration was explained on the basis of an integrated pharmacokinetic-pharmacodynamic (PK-PD) model with the endogenous Ca regulatory system in the rat. The pharmacokinetics of sCT described by a conventional two-compartment model showed the extremely rapid elimination of sCT from plasma (MRT; 6.86 min). The hypocalcemic effect of sCT reached a peak from 0.5 to 1.5 hrs after administration, and the peak time tended to prolong with increasing doses. This delay in pharmacological effect of sCT against plasma concentration may be a result of a summation of multiple actions of the endogenous Ca regulatory system including feedback control. The plasma Ca regulation system in the rat was investigated by i.v. bolus administration of calcium gluconate and/or endogenous (rat) calcitonin (rCT). Since non-linearity in the relationship between Ca and rCT concentrations in plasma was observed, we assumed that rCT was secreted in accordance with the plasma Ca level via an exponential function. The pharmacokinetics of rCT was represented as a linear one-compartment model. To link the rCT level with plasma Ca level, an additional effect compartment was required to explain the delay in onset and decline of the pharmacological effect. This Ca regulation model explained the observed Ca and rCT profiles in plasma after administration of Ca and/or rCT. The plasma Ca levels after administration of sCT could be well described by the present integrated model. This suggested the potential for prediction of plasma sCT concentration only from the hypocalcemic effect after extravascular administration of sCT, using this PK-PD model.

Preparation and evaluation of proliposomes containing salmon calcitonin

Salmon calcitonin (sCT)-containing proliposomes were prepared by penetrating a methanol-chloroformic solution of sCT and phosphatidylcholine (PC) into microporous sorbitol particles, followed by vacuum evaporation of the solvent. As a result, sCT proliposomes with free-flowing flowability were obtained. On contact with water, the proliposomes were rapidly converted into a liposomal dispersion, in which a certain amount of sCT was entrapped by the liposomes. The apparent permeability of sCT across Caco-2 cell monolayers was increased as the result of incorporating sCT into the proliposomes, suggesting that the pharmacokinetics of sCT would be modified through the administration of proliposomes. This is the first study that reports the successful loading of sCT, a protein drug, in proliposomes. The development of various dosage forms of sCT, especially solid dosage forms, appears be feasible using proliposomes.

Simple liquid chromatography-electrospray ionization mass spectrometry method for the routine determination of salmon calcitonin in serum

A simple liquid chromatography-electrospray ionization mass spectrometry (LC-ESI-MS) method was developed for the quantification of salmon calcitonin (sCT) in serum. Serum samples from rats and dogs were deproteinized and freeze-dried. The residue was then reconstituted with 57% acetonitrile in water containing 0.1% trifluoroacetic acid and 0.005% benzalkonium chloride. A 20-microl aliquot of the reconstituted solution was injected onto a polymer based RP-C18 column, The outlet was connected to an ion-trap mass spectrometer equipped with an ESI source, and spectra were recorded in a positive-ion, selected-ion monitoring mode. The limit of quantification of the method was 10 ng/ml. Biexponential curves were observed for the temporal serum concentration of sCT following intravenous administration of sCT to rats (100 microg/kg) and dogs (250 microg/kg), resulting in reasonable pharmacokinetic parameters. The present method appears applicable to routine analysis of serum sCT in pharmacokinetic studies with good selectivity, accuracy and precision.

Bioavailability and biological efficacy of a new oral formulation of salmon calcitonin in healthy volunteers

Salmon calcitonin (SCT) is a well-tolerated peptide drug with a wide therapeutic margin and is administered parenterally for long-term treatments of bone diseases. Its clinical usefulness would be enhanced by the development of an orally active formulation. In this randomized crossover double-blinded phase I trial, controlled by both a placebo and a parenteral verum, we have tested a new oral formulation of SCT associated with a caprylic acid derivative as carrier. Eight healthy volunteers received single doses of 400, 800, and 1200 microg of SCT orally, a placebo, and a 10-microg (50 IU) SCT intravenous infusion. SCT was reliably absorbed from the oral formulation, with an absolute bioavailability of 0.5-1.4%, depending on the dose. It induced a marked, dose-dependent drop in blood and urine C-terminal telopeptide of type I collagen (CTX), a sensitive and specific bone resorption marker, with the effects of 1200 microg exceeding those of 10 microg intravenously. It also decreased blood calcium and phosphate, and increased the circulating levels of parathyroid hormone (PTH) and, transiently, the urinary excretion of calcium. It was well-tolerated, with some subjects presenting mild and transient nausea, abdominal cramps, diarrheic stools, and headaches. This study shows that oral delivery of SCT is feasible with reproducible absorption and systemic biological efficacy. Such an oral formulation could facilitate the use of SCT in the treatment of osteoporosis and other bone diseases.

Oral multiple w/o/w emulsion formulation of a peptide salmon calcitonin: in vitro-in vivo evaluation

BACKGROUND

Salmon calcitonin (sCT) is a polypeptide hormone consisting of 32 amino acid residues (MW approx. 3400 Da), which can be used successfully for the treatment of osteoporosis, Paget's disease and hypercalcaemia. Only nasal and parenteral preparations of sCT are currently available, and as injections are poorly accepted by patients, nonparenteral preparations for oral, rectal and nasal administration are highly desirable. However, oral sCT is poorly bioavailable, being susceptible to enzymatic degradation in the gastrointestinal tract.

OBJECTIVES

To design a formulation of sCT suitable for oral use.

METHOD

A water/oil/water (w/o/w) type multiple emulsion formulation was designed for oral application of sCT. sCT was placed in the inner water phase, and a protease inhibitor, aprotinin, was included in the outer water phase of this system to investigate the influence of protease inhibitors in the presence of sCT. The effectiveness of the formulation was evaluated in vitro by placing emulsion samples in a dialysis medium and in vivo by using a rat model.

RESULTS

Incorporating sCT in the inner aqueous phase of a w/o/w emulsion appears to protect the peptide from enzymatic degradation. sCT was further protected by incorporating the protease inhibitor, aprotinin, in the outer aqueous phase.

CONCLUSION

w/o/w emulsion formulations appear to be promising carrier systems for peptide-protein drugs.

Oral delivery of salmon calcitonin

Calcitonin plays a crucial role in both calcium homeostasis and bone remodeling. Establishing an oral delivery system for CT is of great importance since CT is currently administered only parenterally or nasally. Poor absorption and rapid proteolytic degradation have impeded the clinical development of an orally administered sCT drug product. Potential approaches to enhance sCT absorption include the use of formulation additives in the drug product to transiently modulate the intestinal environment or targeting specific intestinal regions that may have favorable peptide delivery properties (e.g., low residual volume, high absorptive surface area or reduced enzymatic activity). Potential approaches to limit the activity of intestinal enzymes include adjusting the pH of the intestinal contents to the pH minima of specific enzymes or maintaining high local drug concentrations in order to saturate enzyme systems. In this review, pharmacokinetic studies elucidating the rate-limiting steps for achieving adequate sCT oral bioavailability are detailed. Further, several approaches for enhancing the oral absorption of sCT are presented. Specific emphasis is placed on regio-specific targeting (e.g., intestinal regional differences in dilution and spreading, etc.) and modulation of the intestinal environment (e.g., changing pH, etc.). The approaches are evaluated in in vitro and in vivo models. Finally, this paper closes with a brief section of concluding remarks.

Evaluation of a novel, natural oligosaccharide gum as a sustained-release and mucoadhesive component of calcitonin buccal tablets

The objective of this study was to evaluate the gum from Hakea gibbosa (hakea) as a sustained-release and mucoadhesive component in buccal tablets for a model peptide, namely, salmon calcitonin. Flat-faced core tablets containing either 12 or 32 mg of hakea and 40 microg (200 IU) of salmon calcitonin (sCT) per tablet were formulated using a direct compression technique and were coated with Cutina on all but one face. The in vitro release profiles were sigmoidal in nature and according to a mathematical model indicated super Case II transport as the primary mechanism of release. The resulting plasma sCT and calcium concentrations were determined following both intravenous administration and buccal application of mucoadhesive tablets in rabbits. Following intravenous administration, the mean values determined for t(1/2) (alpha), t(1/2) (beta), V(d), and CL for sCT were 0.76 +/- 0.06 min, 67 +/- 18 min, 1484 +/- 454 mL/kg, and 19 +/- 2 mL/min.kg, respectively. Following the application of the mucoadhesive buccal tablets which contained 40 microg of sCT and either 12 or 32 mg of hakea, the calculated apparent bioavailability (F) and clearance (CL) were 37 +/- 6% and 19 +/- 3.3 mL/min.kg and 16 +/- 8% and 18 +/- 0.4 mL/min. kg, respectively. Serum calcium concentrations indicated that biologically active sCT was delivered across the rabbit buccal mucosa. The strength of mucoadhesion of the tablets was also quantitated in terms of the force of detachment as a function of time. The force of detachment for the mucoadhesive buccal tablets containing either 12 or 32 mg of hakea and 40 microg of sCT increased from 4.47 +/- 0.68 to 8.41 +/- 1.0 N and 8.23 +/- 1.62 to 14.98 +/- 1.63 N, respectively, from 5 to 90 min following application to excised rabbit intestinal mucosa. These results demonstrate that the novel, natural gum from Hakea gibbosa may be used to sustain the release of sCT from a unidirectional-release buccal tablet. The mechanism of in vitro release is likely to involve peptide diffusion/polymer dissolution. The mucoadhesive strength, as measured by the force of detachment, can be modulated by altering the amount of hakea in the tablet. The mucoadhesive buccal tablets described in this paper represent an improved transbuccal delivery system for therapeutic polypeptides.

Factors associated with self-rated health in patients with Paget's disease of bone

Multiple studies show that poor self-rated health (SRH) increases the risk of mortality up to 5-fold when compared to excellent SRH. This powerful association remains even with objective health status and risk factors controlled. However, few studies have examined the determinants of SRH, especially as they relate to specific chronic diseases. Here we identify personal characteristics and disease-related attributes that are strongly associated with SRH in a sample of patients with Paget's disease of bone to determine whether any factors can be modified. Two thousand people randomly selected from the Paget Foundation mailing list received a survey asking for information on demographics, general health and functioning, and the impact of Paget's disease. Nine hundred and fifty-eight PD patients returned the completed survey and answered the question, "How would you rate your overall health?" Answers ranged from excellent (1) to poor (5). Ordinary least squares regression was used, with SRH as the dependent variable, to identify those variables significantly associated with SRH. The overall regression model was significant (p = 0.0001; R2 = 0.44). Age (p = 0. 005), satisfaction with family help (p = 0.0001), number of comorbid conditions (p = 0.0001), functional limitations (p = 0.0003), disease impact (p = 0.0002), health compared to 5 years ago (p = 0. 0001), and depressive symptoms (p = 0.012) were significant predictors. Of these, satisfaction with family help, functional limitations, disease impact, and depressive symptoms are potentially modifiable with appropriate interventions. Future longitudinal studies should examine the effectiveness of such interventions in improving SRH.

Biopharmaceutical approaches for developing and assessing oral peptide delivery strategies and systems: in vitro permeability and in vivo oral absorption of salmon calcitonin (sCT)

PURPOSE

To evaluate a biopharmaceutical approach for selecting formulation additives and establishing the performance specifications of an oral peptide delivery system using sCT as a model peptide.

METHODS

The effect of formulation additives on sCT effective permeability and transepithelial electrical resistance (TEER) was evaluated in side-by-side diffusion chambers using rat intestinal segments. Baseline regional oral absorption of sCT was evaluated in an Intestinal and Vascular Access Port (IVAP) dog model by administration directly into the duodenum, ileum, and colon by means of surgically implanted, chronic catheters. The effect of varying the input rate and volume of the administered solution on the extent of sCT absorption was also evaluated. Citric acid (CA) was utilized in all studies to cause a transient reduction in local pH. In vitro samples and plasma samples were analyzed by radioimmunoassay (RIA). Two oral delivery systems were prepared based on the results of the in vitro and IVAP studies, and evaluated in normal dogs.

RESULTS

Maximal permeability enhancement of sCT was observed using taurodeoxycholate (TDC) or lauroyl carnitine (LC) in vitro. Ileal absorption of sCT was higher than in other regions of the intestine. Low volume and bolus input of solution formulations was selected as the optimal condition for the IVAP studies since larger volumes or slower input rates resulted in significantly lower sCT bioavailability (BA). Much lower BA of sCT was observed when CA was not used in the formulation. The absolute oral bioavailability (mean+/-SD) in dogs for the control (sCT + CA) and two proprietary sCT delivery systems was 0.30%+/-0.05%, 1.10+/-0.18%, and 1.31+/-0.56%, respectively.

CONCLUSIONS

These studies demonstrate the utility of in vitro evaluation and controlled in vivo studies for developing oral peptide delivery strategies. Formulation additives were selected, the optimal intestinal region for delivery identified, and the optimal release kinetics of additives and actives from the delivery system were characterized. These methods were successfully used for devising delivery strategies and fabricating and evaluating oral sCT delivery systems in animals. Based on these studies, sCT delivery systems have been fabricated and tested in humans with favorable results.

Bisphosphonates in bone diseases

Bisphosphonates are a class of drugs which are strongly attracted to the bone where they influence the calcium metabolism, mainly by inhibition of the osteoclast-mediated bone resorption. This property makes these compounds suited for the treatment of several diseases of the bone. In Paget's disease, several bisphosphonates can reduce bone pain and decrease the bone turnover 60-70%. Cyclical oral etidronate and daily oral alendronate both proved to reduce the vertebral fracture rate for postmenopausal osteoporotic woman, while most investigated bisphosphonates can increase spinal bone mass in osteoporosis. Bisphosphonates can help lowering serum calcium and reverse skeletal complications in malignancy mediated bone diseases. Oral and intravenous administration of therapeutic doses is relatively safe. In general, gastrointestinal disturbances are described most often and the oldest, least potent, bisphosphonate etidronate can induce osteomalacia. The various characteristics of bisphosphonates: physicochemical, biological, therapeutic and toxicological, vary greatly depending on the structure of the individual bisphosphonate. Even small changes in the structure can lead to enormous differences in potency. Overall, this class of drugs offers several prospects for the future.

Skeletal response to clodronate in prostate cancer with bone metastases

Bone metastases, together with generalized bone resorption, represent the main complication in patients with advanced prostate cancer, and palliative treatments are required to delay the progression of the metastases and improve the quality of life of these patients. For this reason, the bisphosphonate clodronate was administered to 18 patients (clodronate group) from a total of 30, all of whom were receiving complete androgenic blockade; the remaining 12 formed the control group. Transiliac bone biopsies were taken at the beginning of the study and 6 months later to determine the effect of the bisphosphonate on the skeleton. The results were assessed by bone histomorphometry and showed, although without statistical significance between the groups, an antiresorptive effect of the clodronate expressed as the eroded surface/bone surface and as the osteoclast number/bone surface. However, the bone volume also decreased after 6 months of treatment. Similarly, osteoid formation decreased as indicated by the osteoid surface and by the osteoid volume, probably due to the effect of the drug on the osteoblasts. The mineralization rate was apparently slightly retarded in the clodronate group, although to a lesser degree than in the control group. The results confirm the antiresorptive effect of clodronate and its detrimental effect on osteoblast activity.

Changes in bone mineral density in patients with Paget's disease treated with risedronate

OBJECTIVES

To study changes in bone mineral density (BMD) in patients with Paget's disease of bone treated with risedronate.

METHODS

Whole body dual energy x ray absorptiometry (DXA) scans were carried out on 20 patients with Paget's disease treated with oral risedronate. DXA scanning was carried out at baseline and 11 months. Whole body bone mineral content (BMC) was measured. In addition, regions of interest were drawn around the skull, individual lumbar vertebrae, hemipelvis, femora, and tibiae to obtain BMD for these sites. An uncoupling index was also calculated as the area under the curve for serum alkaline phosphatase (ALP) divided by the area under the curve for hydroxyproline excretion (HYPRO) for the period of treatment.

RESULTS

Median whole body BMC increased from 3057 g to 3156 g (p < 0.001) resulting from an increase in pagetic and non-pagetic BMD. From the analysis of regions of interest it was found that pagetic trabecular bone showed the largest increase in BMD. The pretreatment HYPRO and the uncoupling index were significantly related to the change in BMD for all pagetic sites for a patient (r = 0.65, p < 0.01 and r = 0.57, p < 0.05 respectively).

CONCLUSION

Bisphosphonate treatment of Paget's disease results in an increase in BMD of pagetic bone without redistribution of mineral from non-pagetic bone. The remodelling space and extent of uncoupling are significantly related to increases in BMD at pagetic sites.

Can alendronate help my osteoporosis?

Bone is an active tissue, undergoing continuous remodeling to renew and replace the skeleton. Remodeling involves resorption (breakdown) followed by formation.

Calcitonin versus etidronate for the treatment of postmenopausal osteoporosis: a meta-analysis of published clinical trials

This review examines the evidence on the efficacy of calcitonin and etidronate in the prevention of osteoporosis and osteoporotic fractures. MEDLINE was searched for clinical trials calcitonin or etidronate and reviews of the treatment of postmenopausal osteoporosis. The reference sections of the papers retrieved were again searched for trials on the treatments of interest. Two people independently collected data from the trials that met the inclusion criteria of the study. Weighted means in the change in bone mineral density (BMD) and differences in vertebral fracture rates were computed for calcitonin and etidronate separately. The existence of publication bias was investigated by funnel plots of effect size against sample size. Eighteen clinical trials and calcitonin and six with etidronate were included in the meta-analysis. The pooled change in vertebral BMD at the end of the studies was 1.97 (95% CI 1.77 to 2.17) with calcitonin and 3.20 (95% CI 2.92 to 3.48) with etidronate. Pooled change in proximal femur BMD was 0.32 (95% CI -0.27 to 0.91) with calcitonin and 2.42 (95% CI 2.16 to 2.68) with etidronate. The aggregated number of vertebral fractures prevented by the treatment was 59.2 per 1000 patient-years (95% CI 55.1 to 63.3) for calcitonin and 28.3 (95% CI 26.2 to 30.4) for etidronate. With the available evidence we cannot establish the superiority of either of the two drugs for the treatment of postmenopausal osteoporosis. The clinical trials are particularly lacking in data on hip fracture, the most important consequence of osteoporosis. In this situation consideration of the relative costs of the drugs is prominent.

Paget's disease of bone and quality of life

Little is known about how Paget's disease of bone affects quality of life. To better understand the relative impact of factors on quality of life, we mailed a brief survey to 2000 people randomly selected from the Paget's Foundation mailing list. The sample was geographically stratified to examine the effects of specialist availability. Nine hundred and fifty-eight persons responded to the questionnaire (53% response rate after adjustment for death, incorrect addresses, and nondeliverable mailings). The sample had equal proportions of males and females, with a mean age of 74 years (SD = 9.0). Most (97%) were white, with high levels of education (mean 13 years; SD 3.7) and income (60% earned more than $20,000 annually). They reported pagetic bone in the skull (34%), spine (35%), pelvis (49%), and leg (48%). The most frequently mentioned complications were hearing loss (37%) and bowed limbs (31%). Comorbidity included arthritis (64%), hypertension (32%), and heart problems (28%). Nearly half (47%) reported feelings of depression, and 42% said that their health was fair or poor. Only 21% reported that quality of life was very good or excellent. In multiple partial F-test regression analyses, variables were divided into four domains (social, psychological, care, and biomedical). The psychological domain explained 19% of the variance beyond that explained by all other variables; the social domain explained 3%, the biomedical domain explained 3% and the care domain explained 1%. The importance of the psychological aspects of Paget's disease suggests that treatment protocols should include psychological intervention to improve quality of life.

Paget's disease of bone: diagnosis and management

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Osteoporosis: the need for comprehensive treatment guidelines

Osteoporosis is a debilitating disease that results in nearly 1.3 million fractures per year in the United States. The cost of treating these fractures has been estimated to be as high as $10 billion per year. These costs are expected to more than double during the next 50 years unless comprehensive programs of prevention and treatment are initiated. Both pharmacologic and nonpharmacologic interventions (eg, diet and exercise) have been shown to have a significant impact on the incidence of osteoporosis, depending on the time of their application. Unfortunately, osteoporosis is often not diagnosed until after fractures have occurred, when it may be too late for treatment to have a major impact. To be most effective, therapy should be started early, before serious bone loss has occurred. Because of its efficacy and relatively low acquisition cost, long-term hormone replacement therapy (HRT) is considered first-line pharmacologic therapy for the prevention of osteoporosis. However, for various reasons, less than 25% of US women who might benefit from HRT are receiving it. Aside from HRT, the only other products approved by the US Food and Drug Administration for the treatment of osteoporosis are salmon calcitonin and alendronate. Several other agents are under development, including sustained-release fluoride and other products in the bisphosphonate class. The development and adoption of early detection programs and treatment guidelines are crucial to help ease the economic burden of osteoporosis. These guidelines should incorporate preventive measures such as diet and exercise, risk assessment through proper screening programs, and the appropriate use of pharmaceutical products. The purpose of this paper is to discuss relevant economic issues associated with osteoporosis and discuss the need for a management algorithm that could be used to more efficiently prevent and treat this disease. We conclude that further modeling is needed to determine which programs and treatments are most cost-effective within each at-risk subgroup. As clinicians better understand the need for preventive care and the advantages of the various pharmacologic therapies, patients with osteoporosis will receive higher-quality and more efficient medical care.

Vitamin D3 analogs and salmon calcitonin partially reverse the development of renal osteodystrophy in rats

We have previously established an uremic rat model which is suitable for investigating the effect of various treatment modalities on the progression of renal osteodystrophy [1]. Four months subsequent to 5/6 nephrectomy, animals were treated three times a week for 3 months with either vehicle, 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], 1,25(OH)2D3 + 24,25-dihydroxyvitamin D3 [24,25(OH)2D3], 1,25(OH)2D3 + calcitonin (CT), or 1,25(OH)2D3 + 24,25(OH)2D3 + CT. At termination of the study, clinical chemistry, chemical composition, and mechanical properties of femurs, calvarial parathyroid hormone (PTH)-elicited adenylate cyclase (AC), and phospholipase C (PL-C) activities, femoral cross-sectional area, and bone histomorphometry were analyzed. The main findings were that 1,25(OH)2D3 +/- 24,25(OH)2D3 treatment enhanced elasticity as well as time to fracture at the femoral metaphysis. CT potentiated the increase in elasticity obtained by 1,25(OH)2D3 +/- 24,25(OH)2D3 treatment. Only 24,25(OH)2D3 administration rectified the supernormal PTH-stimulated uremic bone AC, and only 1,25(OH)2D3 medication normalized the diminished CT-elicited AC. The obliterated uremic bone PTH-sensitive PL-C was fully normalized by all drug regimens. Femoral shaft inner zone diameter was enhanced by uremia, however, all drug treatments normalized it. Ditto effect was registered with either drug treatment on the subnormal outer and inner zone widths. Histomorphometrical analyses showed that 1,25(OH)2D3 administration reduced both eroded and osteoid surfaces. Most prominently, adjuvant 24,25(OH)2D3 or CT administration potentiated the beneficial effect of 1,25(OH)2D3 on fibrosis and osteomalacia. We assert that vitamin D3 treatment markedly reverses the development of renal osteodystrophy, and CT potentiates the effect of vitamin D3.

Utility of pharmacodynamic measures for assessing the oral bioavailability of peptides. 1. Administration of recombinant salmon calcitonin in rats

Salmon calcitonin (sCT) is a therapeutic peptide used in the treatment of Paget's Disease, postmenopausal osteoporosis, and hypercalcemia due to malignancy. In this study, recombinant sCT (rsCT) was administered intravenously (iv), subcutaneously (sc), and intraduodenally (id.) in rats to evaluate pharmacodynamic (PD) response as a measure of rsCT bioavailability (F) and to test the feasibility of delivering rsCT orally. rsCT pharmacokinetics were linear throughout the range of iv and sc doses studied. Following sc administration, F ranged from 11.2% to 23.1% and was linear. The absorption of rsCT after id. administration was low (0.022%); however, a significant lowering of serum calcium concentrations was observed. Serum calcium lowering was nonlinear and saturable after sc administration with the minimum dose required for maximum calcium lowering (Dmin/max) equal to 10.2 ng and a maximal response of 426.8 mg min/dL. Using Dmin/max as the reference dose, absolute Fs were recalculated using PD response after id. administration of 1 and 2 mg of rsCT and were 0.040% and 0.029%, respectively. Substantial overestimates of F were obtained when the reference dose was not properly selected. While the absorption of rsCT was low, the significant lowering of serum calcium levels suggests that oral delivery of sCT is feasible. The results of these studies also suggest that PD response is useful in assessing the oral bioavailability of peptides; however, when PD response is saturable, as is the case for rsCT, the reference dose should be carefully selected in order to avoid overestimates of F.

Hypercalcemia of malignancy in the palliative care patient: a treatment strategy

Hypercalcemia of malignancy is most commonly due to the effects of parathyroid hormone-related peptide, which acts as a humoral factor to cause generalized osteoclast-mediated bone resorption and reabsorption of calcium by the kidney tubule, and may also act as a local resorptive factor adjacent to bone metastases. Local resorptive mechanisms are less common causes of malignant hypercalcemia than previously believed. Treatment begins with intravenous fluid rehydration, followed by a furosemide diuresis and the bisphosphonate pamidronate, 60-90 mg, intravenously. Gallium nitrate is an efficacious but inconvenient alternative to pamidronate. Calcitonin combined with pamidronate is a reasonable initial therapy for severe hypercalcemia to hasten normalization of the serum calcium. Steroids should be reserved for hypercalcemia due to tumor production of 1,25 dihydroxyvitamin D, or for steroid-responsive malignancies. Oral or parenteral bisphosphonates can be used to maintain normocalcemia. In addition to improving the morbidity of acute hypercalcemia, bisphosphonate therapy has been shown to reduce bone pain and pathological fractures in patients with bone metastases, and calcitonin also has a potent analgesic effect in these patients. Treatment for hypercalcemia should therefore be considered in the majority of patients in the palliative care setting.