Statin use, clinical fracture, and bone density in postmenopausal women: results from the Women's Health Initiative Observational Study

Periostin-targeted SDSSD peptide decorated calcium phosphate nanocomposites incorporation with simvastatin for osteoporosis treatment

The limited options of anabolic drugs restrict their application potential in osteoporosis treatment, despite their theoretical superiority in therapeutic efficacy over antiresorptive drugs. As a prevailing strategy, nano-delivery systems could offer a wider choice of anabolic drugs. In this study, calcium phosphate nanocomposites incorporated with simvastatin (Sim) with periostin-targeting ability were designed and prepared for osteoporosis treatment. Carboxymethyl dextran (CMD) as an anionic and hydrophilic dextran derivative was used to stabilize CaP. In addition, periosteum-targeted peptide (SDSSD) was further grafted on CMD to achieve the bone targeting function. In a one-step coordination assembly strategy, hydrophobic anabolic agent Sim and SDSSD-CMD graft (SDSSD-CMD) were incorporated into the CaP nanoparticles forming SDSSD@CaP/Sim nanocomposites. The resulting SDSSD@CaP/Sim possesses uniform size, great short-term stability and excellent biocompatibility. Moreover, SDSSD@CaP/Sim exhibited a reduced release rate of Sim and showed slow-release behaviour. As anticipated, the nanocomposites exhibited bone bonding capacity in both cellular and animal studies. Besides, SDSSD@CaP/Sim achieved obviously enhanced osteoporosis treatment effect compared to direct injection of Simin vivo. Therefore, our findings highlight the potential of SDSSD-incorporated and CaP-based nanocomposites as a viable strategy to enhance the therapeutic efficacy of anabolic drugs for osteoporosis treatment.

Age- and dose-dependent effect of statin use on the risk of osteoporotic fracture in older adults

Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporosis-related measurement has shown controversial results. In this study, we found an age, dose andduration-dependent osteoprotective effect of statins in general older population.

PURPOSE

Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporotic fractures has shown controversial results.

METHODS

In this study with Korean National Health Insurance Service-Senior cohort database, a total of 365,656 elderly without previous history of osteoporosis and who were started on statin since January 1 2004 were included and observed until December 31 2012. Hazard rations (HR) for major osteoporotic fractures were calculated using the weighted Cox proportional hazards model with inverse-probability of treatment weighting method.

RESULTS

During 6.27 years of follow-up period, 54,959 osteoporotic fractures occurred and the majority of fractures (69.5%) were vertebral fractures. Compared with non-users, statin use was associated with a decreased risk of all outcomes with adjusted HR (95% CI) of 0.77 (0.72-0.83; P < 0.001) for major osteoporotic fractures, 0.49 (0.38-0.62; P < 0.001) for hip fractures, and 0.70 (0.64-0.77; P < 0.001) for vertebral fractures. When outcomes were examined separately by sex, the results were broadly comparable in terms of patterns of risk reduction by statin use. The patients with statin initiated at age ≥ 80 years had the highest risk reduction for most outcomes relative to non-users. Higher cumulative dose of statin was negatively associated with the osteoporotic fracture risk; 0.97 (0.91-1.02) for 30-364 cumulative daily defined dose (cDDD), 0.45 (0.40-0.51) for 365-1,094 cDDD, and 0.22 (0.15-0.33) for ≥ 1,095 cDDD.

CONCLUSIONS

Our results showed that statin use was associated with significant reduction in the risk of osteoporotic fractures in general older population.

Race and Ethnicity and Fracture Prediction Among Younger Postmenopausal Women in the Women's Health Initiative Study

Importance

The best approach to identify younger postmenopausal women for osteoporosis screening is uncertain. The Fracture Risk Assessment Tool (FRAX), which includes self-identified racial and ethnic information, and the Osteoporosis Self-assessment Tool (OST), which does not, are risk assessment tools recommended by US Preventive Services Task Force guidelines to identify candidates for bone mineral density (BMD) testing in this age group.

Objective

To compare the ability of FRAX vs OST to discriminate between younger postmenopausal women who do and do not experience incident fracture during a 10-year follow-up in the 4 racial and ethnic groups specified by FRAX.

Design, Setting, and Participants

This cohort study of Women's Health Initiative participants included 67 169 women (baseline age range, 50-64 years) with 10 years of follow-up for major osteoporotic fracture (MOF; including hip, clinical spine, forearm, and shoulder fracture) at 40 US clinical centers. Data were collected from October 1993 to December 2008 and analyzed between May 11, 2022, and February 23, 2023.

Main Outcomes and Measures

Incident MOF and BMD (in a subset of 4607 women) were assessed. The area under the receiver operating characteristic curve (AUC) for FRAX (without BMD information) and OST was calculated within each racial and ethnic category.

Results

Among the 67 169 participants, mean (SD) age at baseline was 57.8 (4.1) years. A total of 1486 (2.2%) self-identified as Asian, 5927 (8.8%) as Black, 2545 (3.8%) as Hispanic, and 57 211 (85.2%) as White. During follow-up, 5594 women experienced MOF. For discrimination of MOF, AUC values for FRAX were 0.65 (95% CI, 0.58-0.71) for Asian, 0.55 (95% CI, 0.52-0.59) for Black, 0.61 (95% CI, 0.56-0.65) for Hispanic, and 0.59 (95% CI, 0.58-0.59) for White women. The AUC values for OST were 0.62 (95% CI, 0.56-0.69) for Asian, 0.53 (95% CI, 0.50-0.57) for Black, 0.58 (95% CI, 0.54-0.62) for Hispanic, and 0.55 (95% CI, 0.54-0.56) for White women. For discrimination of femoral neck osteoporosis, AUC values were excellent for OST (range, 0.79 [95% CI, 0.65-0.93] to 0.85 [95% CI, 0.74-0.96]), higher for OST than FRAX (range, 0.72 [95% CI, 0.68-0.75] to 0.74 [95% CI, 0.60-0.88]), and similar in each of the 4 racial and ethnic groups.

Conclusions and Relevance

These findings suggest that within each racial and ethnic category, the US FRAX and OST have suboptimal performance in discrimination of MOF in younger postmenopausal women. In contrast, for identifying osteoporosis, OST was excellent. The US version of FRAX should not be routinely used to make screening decisions in younger postmenopausal women. Future investigations should improve existing tools or create new approaches to osteoporosis risk assessment for this age group.

Simvastatin therapy in higher dosages deteriorates bone quality: Consistent evidence from population-wide patient data and interventional mouse studies

BACKGROUND

Combining mouse experiments with big data analysis of the Austrian population, we investigated the association between high-dose statin treatment and bone quality.

METHODS

The bone microarchitecture of the femur and vertebral body L4 was measured in male and ovariectomized female mice on a high-fat diet containing simvastatin (1.2 g/kg). A sex-specific matched big data analysis of Austrian health insurance claims using multiple logistic regression models was conducted (simvastatin 60-80 mg/day vs. controls; males: n = 138,666; females: n = 155,055).

RESULTS

High-dose simvastatin impaired bone quality in male and ovariectomized mice. In the trabecular femur, simvastatin reduced bone volume (µm³: ♂, 213 ± 15 vs. 131 ± 7, p < 0.0001; ♀, 66 ± 7 vs. 44 ± 5, p = 0.02) and trabecular number (1/mm: ♂, 1.88 ± 0.09 vs. 1.27 ± 0.06, p < 0.0001; ♀, 0.60 ± 0.05 vs. 0.43 ± 0.04, p = 0.01). In the cortical femur, bone volume (mm³: ♂, 1.44 ± 0.03 vs. 1.34 ± 0.03, p = 0.009; ♀, 1.33 ± 0.03 vs. 1.12 ± 0.03, p = 0.0002) and cortical thickness were impaired (µm: ♂, 211 ± 4 vs. 189 ± 4, p = 0.0004; ♀, 193 ± 3 vs. 169 ± 3, p < 0.0001). Similar impairments were found in vertebral body L4. Simvastatin-induced changes in weight or glucose metabolism were excluded as mediators of deteriorations in bone quality. Results from mice were supported by a matched cohort analysis showing an association between high-dose simvastatin and increased risk of osteoporosis in patients (♂, OR: 5.91, CI: 3.17-10.99, p < 0.001; ♀, OR: 4.16, CI: 2.92-5.92, p < 0.001).

CONCLUSION

High-dose simvastatin dramatically reduces bone quality in obese male and ovariectomized female mice, suggesting that direct drug action accounts for the association between high dosage and increased risk of osteoporosis as observed in comparable human cohorts. The underlying pathophysiological mechanisms behind this relationship are presently unknown and require further investigation.

Facts and ideas on statins with respect to their lipophilicity: a focus on skeletal muscle cells and bone besides known cardioprotection

Statins are known to block cholesterol synthesis in the liver. They also exhibit non-lipid pleiotropic effects due to the inhibition of protein prenylation, thereby modulating various signaling pathways of cellular homeostasis and integrity. Both lipid control and pleiotropic action of statins are clinically used, mainly for treatment of hypercholesterolemia and primary and secondary prevention of cardiovascular diseases. Because the prescription of statins is increasing and statin therapy is often lifelong, in particular in patients with other risk factors, safety issues being associated with polymorbidity and polypragmasia as well as the persistence with and adherence to statins are specific points of attention of clinicians and clinical pharmacologists. Furthermore, because skeletal myocytes have a cholesterol inhibitory sensitivity greater than hepatocytes, a choice of an appropriate statin based on its lipophilicity and the associated likelihood of its side effects on skeletal muscle cells and bone is warranted in such polymorbid patients. These approaches can effectively modulate the risk: benefit ratio and highlight a need for personalized therapy as much as possible, thereby minimizing risk of discontinuation of therapy and poor compliance.

Advances in Our Understanding of the Mechanism of Action of Drugs (including Traditional Chinese Medicines) for the Intervention and Treatment of Osteoporosis

Osteoporosis (OP) is known as a silent disease in which the loss of bone mass and bone density does not cause obvious symptoms, resulting in insufficient treatment and preventive measures. The losses of bone mass and bone density become more severe over time and an only small percentage of patients are diagnosed when OP-related fractures occur. The high disability and mortality rates of OP-related fractures cause great psychological and physical damage and impose a heavy economic burden on individuals and society. Therefore, early intervention and treatment must be emphasized to achieve the overall goal of reducing the fracture risk. Anti-OP drugs are currently divided into three classes: antiresorptive agents, anabolic agents, and drugs with other mechanisms. In this review, research progress related to common anti-OP drugs in these three classes as well as targeted therapies is summarized to help researchers and clinicians understand their mechanisms of action and to promote pharmacological research and novel drug development.

Low dose hydrophilic statins are the preferred agents for females at risk of osteoporosis

Objectives

The correlation between atherosclerosis and osteoporosis, independent of age, is clear. Multifactorial co-dependence between bone mineral density (BMD) and statin dose has been proposed. It is hypothesised that inhibition of the synthesis of cholesterol will also inhibit the synthesis of sex hormones and Vitamin D, negatively affecting BMD. This study aims to evaluate hydrophilic and non-hydrophilic statins effect on osteoporosis and analyse any possible superiority of one agent over the other within the group.

Methods

We identified 538 caucasian females who had a DEXA scan performed between 2002 and 2016 (age 60-89) in one DEXA center in Mid-West Ireland. A DEXA T-score results were analysed in the current study. Two hundred fifty females were not on statin therapy, and 323 females were on statin therapy. Females on therapy were separated into the atorvastatin group (N = 190), rosuvastatin group (N = 97), and pravastatin group (N = 36), comprising low dose and high dose groups. All anonymised data were analysed with SPSS statistical. To test the hypothesis that lower bone density is associated with high dose statins, an independent sample t-test was performed. The one-way between-groups ANOVA test was used to test the hypothesis that the BMD level depended on the statin's potency.

Results

Statin-naïve females have a statistically higher bone mineral density in the lumbar spine, t (538) = 3.42, p < 0.05 and in hip t (538) = 4.99, p < 0.05 than females on statin therapy. There was a significant difference in patient's age between the group, and no significant correlation was found between the patient's age and type of statin or bone density. In the atorvastatin group statistically, significant results were obtained both for spine and hip bone mineral density, t (188) = -5.61, p < 0.05 and t (188) = -3.62, p < 0.05, respectively. In the rosuvastatin group, statistically, a significant result was noted for bone mineral density of hip t (95) = -3.52, p < 0.05. This demonstrates a dose-dependency between bone mineral density and the dose of the statin. The independent between-group ANOVA yielded a statistically significant effect, F (2, 59) = 6.69, p < 0.05, η2 = 0.21 in the spine. Thus, patients on lipophilic statins had statistically lower BMD than females on hydrophilic statins. Multilinear regression analysis identified that age is not a statistically significant contributor in our analysis; however, the trend of decrease in bone mineral density with women's age is acknowledged by authors.

Conclusions

The study results support the theory that bone mineral density decreases with an increase in a statin dose, and hydrophilic statins, like pravastatin, have a better metabolic profile in the lumbar spine than lipophilic agents.

A Retrospective Study on Statins and Post-stroke Patients: What About Functional Outcome and Follow-Up in a Stroke Rehabilitation Cohort?

Objective: Statins exert pleiotropic effects by influencing several mechanisms, including synaptogenesis, neurogenesis, cerebral flow regulation, and angiogenesis. Results from in vitro and animal models suggest that statins could have beneficial effect on functional recovery and outcome after stroke events. However, results in human studies are still controversial. The aim of our study was to evaluate the role of statin in influencing functional outcome and subsequent clinical follow-up in a large cohort of post-stroke rehabilitation patients.

Methods: This retrospective study consecutively enrolled 413 adult patients with stroke event, admitted to the division of Neurorehabilitation of the IRCCS ICS Maugeri, Veruno (Italy), for an individual rehabilitation program between 2015 and 2017. Follow-up lasted 3–5 years after discharge. Demographic data, etiology, classification, and anatomical site of stroke lesion, functional assessment, use and duration of statin therapy, and death during hospitalization were collected at baseline and on discharge. Clinical data on subsequent follow-up were also evaluated, considering these as variables: stroke recurrence, bone fractures, cardiovascular complications, and death.

Results: In our cohort, 177 patients (42.9%) were prescribed statin therapy, of whom 50 (28.2%) before the stroke event and 127 (71.8%) at the beginning of the rehabilitation process. The use and type of statin therapy as well as the duration of treatment were not associated with recovery and functional outcome, regardless of confounders including sex, age, etiology, and site of stroke lesion, and initial functional level. For what concern post-discharge clinical follow-up, the use of statin therapy was significantly associated with a lower risk of bone fractures (OR = 0.095, CI 95%: 0.012–0.743, p = 0.01) independently from age, sex, initial and final functional level, and comorbidities.

Conclusions: The use of statins does not seem to influence the functional outcome in post-stroke patients. However, they could exert a protective role against bone fractures during post-discharge follow-up, suggesting further evaluation on this topic.

Statin Therapy and the Risk of Osteoporotic Fractures in Patients with Metabolic Syndrome: a Nested Case-Control Study

OBJECTIVE

We aimed to investigate the association between statin use and the risk of major osteoporotic fractures in patients with metabolic syndrome (MetS).

METHODS

A nested case-control study was performed in patients with MetS (≥50 years) who had no history of osteoporotic fracture using the Korean National Health Insurance Service-Health Screening Cohort. This study included 17,041 patients diagnosed with new-onset osteoporotic fractures and controls matched in a 1:1 ratio by age, sex, body mass index, cohort entry date, and follow-up duration. Conditional logistic regression analysis was used to evaluate covariate-adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

During a 4-year follow-up period, the risk of major osteoporotic fractures was significantly reduced by 9% (OR, 0.91; 95% CI, 0.85-0.97) in statin users compared with that in non-users. Among subtypes of major osteoporotic fracture, a risk reduction with statin therapy was significant for vertebral fracture (OR, 0.86; 95% CI, 0.79-0.94) but not for non-vertebral fracture (OR, 0.97; 95% CI, 0.88-1.06). Longer duration (OR, 0.97; 95% CI, 0.96-0.99, per 1-year increase) and higher cumulative dose (OR, 0.97; 95% CI, 0.95-0.99, per 365 defined daily doses) of statins were negatively associated with the risk of major osteoporotic fracture.

CONCLUSION

This study supports the hypothesis that statin therapy has a beneficial effect on major osteoporotic fractures, especially vertebral fractures, in patients with MetS.

Molecular enhancement of fracture healing - Is there a role for Bone Morphogenetic Protein-2, parathyroid hormone, statins, or sclerostin-antibodies?

Enhancement of fracture healing has been a hot topic over the last two decades. This narrative review article is aimed to provide an update on current clinical use and evidence on four clinically available agents in the treatment of fracture healing: bone morphogenetic proteins-2 (BMP-2), parathyroid hormone, statins and sclerostin-antibodies. After first promising results from animal and clinical studies in the early 2000s, BMP-2 was studied mainly in open tibia shaft fractures treated with intramedullary nailing. There are conflicting results from different randomized clinical trials (RCTs) regarding fracture healing time and complications compared to BMP-2 free control treatment in open tibia fractures, as BMP-2 could not show significant differences in patients treated with reamed nails compared to BMP-2 free control treatment with reamed nailing only. Given that fact, its official use was limited in Europe to open tibia shaft fractures treated with unreamed tibial nailing by the European Medical Agency (EMA). Another more recent RCT failed to show equivalence of BMP- 2 together with allograft versus autograft for the treatment of tibia fractures with critical size defects. Recombinant human parathyroid hormone has proven anabolic effects on bone metabolism and is commonly used in treatment of severe osteoporosis. Different animal trials suggested an enhancement effect in fracture healing by PTH. In several clinical trials, PTH seems to have a stimulative effect for lower limb fractures. Statins, commonly used in treatment of dyslipidemia, could also enhance fracture healing in animal trials, especially when they were applied locally at the fracture site. For statins, there is only one RCT that failed to show significant effects for the oral administration of statins in undisplaced distal radius fractures. The role of sclerostin in fracture healing has more and more been understood. Application of sclerostin antibodies has been shown to be beneficial for fracture healing in animal trials. However, no RCTs on the effect of sclerostin antibodies on fracture healing have been performed yet. In conclusion, the "magic bullet" for molecular enhancement of fracture healing has not been identified yet, at least not with its optimal dosage and delivery method.

Serial Bone Density Measurement and Incident Fracture Risk Discrimination in Postmenopausal Women

IMPORTANCE

Repeated bone mineral density (BMD) testing to screen for osteoporosis requires resources. For patient counseling and optimal resource use, it is important for clinicians to know whether repeated BMD measurement (compared with baseline BMD measurement alone) improves the ability to discriminate between postmenopausal women who will and will not experience a fracture.

OBJECTIVE

To assess whether a second BMD measurement approximately 3 years after the initial assessment is associated with improved ability to estimate fracture risk beyond the baseline BMD measurement alone.

DESIGN, SETTING, AND PARTICIPANTS

The Women's Health Initiative is a prospective observational study. Participants in the present cohort study included 7419 women with a mean (SD) follow-up of 12.1 (3.4) years between 1993 and 2010 at 3 US clinical centers. Data analysis was conducted between May 2019 and December 2019.

MAIN OUTCOMES AND MEASURES

Incident major osteoporotic fracture (ie, hip, clinical spine, forearm, or shoulder fracture), hip fracture, baseline BMD, and absolute change in BMD were assessed. The area under the receiver operating characteristic curve (AU-ROC) for baseline BMD, absolute change in BMD, and the combination of baseline BMD and change in BMD were calculated to assess incident fracture risk discrimination during follow-up.

RESULTS

Of 7419 participants, the mean (SD) age at baseline was 66.1 (7.2) years, the mean (SD) body mass index was 28.7 (6.0), and 1720 (23%) were nonwhite individuals. During the study follow-up (mean [SD] 9.0 [3.5] years after the second BMD measurement), 139 women (1.9%) experienced hip fractures, and 732 women (9.9%) experienced major osteoporotic fracture. In discriminating between women who experience hip fractures and those who do not, AU-ROC values were 0.71 (95% CI, 0.67-0.75) for baseline total hip BMD, 0.61 (95% CI, 0.56-0.65) for change in total hip BMD, and 0.73 (95% CI, 0.69-0.77) for the combination of baseline total hip BMD and change in total hip BMD. Femoral neck and lumbar spine BMD values had similar discrimination for hip fracture. For discrimination of major osteoporotic fracture, AU-ROC values were 0.61 (95% CI, 0.59-0.63) for baseline total hip BMD, 0.53 (95% CI, 0.51-0.55) for change in total hip BMD, and 0.61 (95% CI, 0.59-0.63) for the combination of baseline total hip BMD and change in total hip BMD. Femoral neck and lumbar spine BMD values had similar ability to discriminate between women who experienced major osteoporotic fracture and those who did not. Associations between change in bone density and fracture risk did not differ by subgroup, including diabetes, age, race/ethnicity, body mass index, or baseline BMD T score.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a second BMD assessment approximately 3 years after the initial measurement was not associated with improved discrimination between women who did and did not experience subsequent hip fracture or major osteoporotic fracture beyond the baseline BMD value alone and should not routinely be performed.

Corilagin suppresses RANKL-induced osteoclastogenesis and inhibits oestrogen deficiency-induced bone loss via the NF-κB and PI3K/AKT signalling pathways

Over‐activated osteoclastogenesis, which is initiated by inflammation, has been implicated in osteoporosis. Corilagin, a natural compound extracted from various medicinal herbaceous plants, such as Cinnamomum cassia, has antioxidant and anti‐inflammatory activities. We found that Corilagin suppressed osteoclast differentiation in a dose‐dependent manner, significantly decreased osteoclast‐related gene expression and impaired bone resorption by osteoclasts. Moreover, phosphorylation of members of the nuclear factor‐kappaB (NF‐κB) and PI3K/AKT signalling pathways was reduced by Corilagin. In a murine model of osteoporosis, Corilagin inhibited osteoclast functions in vivo and restored oestrogen deficiency‐induced bone loss. In conclusion, our findings suggested that Corilagin inhibited osteoclastogenesis by down‐regulating the NF‐κB and PI3K/AKT signalling pathways, thus showing its potential possibility for the treatment of osteoporosis.

Statin therapy: does sex matter?

OBJECTIVE

Statins are a class of drugs that competitively bind to the active site of HMG-CoA reductase enzyme, thereby inhibiting the initial steps in cholesterol synthesis. Originally approved for use in lowering serum cholesterol, a risk factor for developing atherosclerosis and coronary heart disease, statins have subsequently been noted to have myriad extrahepatic effects, including potential effects on cognition, diabetes, breast cancer, bone, and muscle. This narrative review assesses the current state of the science regarding the risks and benefits of statin therapy in women to identify areas where additional research is needed.

METHODS

Basic and clinical studies were identified by searching PubMed with particular attention to inclusion of female animals, women, randomized controlled trials, and sex-specific analyses.

RESULTS

Statin therapy is generally recommended to reduce the risk of cardiovascular disease. None of the current clinical guidelines, however, offer sex-specific recommendations for women due to lack of understanding of sex differences and underlying mechanisms of disease processes. In addition, conclusions regarding efficacy of treatments do not consider lipid solubility for the drug, dosing, duration of treatment, interactions with estrogen, or comorbidities. Pleiotropic effects of statins are often derived from secondary analysis of studies with cardiovascular events as primary outcomes.

CONCLUSIONS

Many of the trials that have established the efficacy and safety of statins were conducted predominantly or entirely in men, with results extrapolated to women. Additional research is needed to guide clinical recommendations specific to women. : Video Summary:http://links.lww.com/MENO/A462.

The Women's Health Initiative: A Landmark Resource for Skeletal Research Since 1992

The Women's Health Initiative (WHI) is a large longitudinal study designed to investigate strategies for the prevention and control of common chronic diseases in postmenopausal women, including cardiovascular disease, cancer, and osteoporotic fractures. The WHI consisted of three overlapping clinical trials of hormone therapy, diet modification to reduce total dietary fat, and calcium/vitamin D supplementation. Women who were ineligible for the hormone therapy or diet modification trials or not interested were invited to participate in the observational study. Women were recruited into WHI from 1993 to 1998 at 40 US clinical centers. WHI enrolled 26,046 underrepresented minority women and 135,762 white women. Women could participate in each trial if eligible. The final enrollment included 27,347 women in the hormone trial; 48,835 women in the diet modification trial; 36,282 women in the calcium/vitamin D trial, and 93,676 in the observational study. After the main study ended in 2005, women were invited to continue follow-up for exposures and outcomes through two extensions to 2020. Proposals were recently submitted to continue follow-up through 2027. Information was collected on an extensive number of risk factors for fractures at baseline and over the follow-up, including fall and fracture history, weight patterns, comorbidities, diet, reproductive history, medications, anthropometry, and biomarkers. Bone mineral density was measured at three WHI clinical centers (n = 11,020) chosen to maximize race/ethnic diversity. WHI encourages outside investigators to make use of the publicly available WHI data and to access the biobank of specimens (www.whi.org). © 2020 American Society for Bone and Mineral Research.

Medications associated with fracture risk in patients with rheumatoid arthritis

OBJECTIVE

To examine the fracture risk with use of disease-modifying antirheumatic drugs (DMARDs), statins, proton pump inhibitors (PPIs), opioids, non-opioid analgesics and psychotropic medications in a US-wide observational rheumatoid arthritis (RA) cohort.

METHODS

Patients with RA without prior fracture from 2001 through 2017 in FORWARD, a longitudinal observational registry, were assessed for osteoporosis-related site fractures (vertebra, hip, forearm and humerus). DMARD exposure was assessed in four mutually exclusive groups: (1) methotrexate monotherapy-reference, (2) tumour necrosis factor-α inhibitors (TNFi), (3) non-TNFi biologics and (4) others. Non-DMARDs and glucocorticoids were classified as current/ever use and based on treatment duration. Fracture Risk Assessment Tool (FRAX) scores estimating for 10-year major osteoporotic fractures were calculated. Cox proportional hazard models stratified by FRAX were used to adjust for confounders.

RESULTS

During median (IQR) 3.0 (1.5-6.0) years of follow-up in 11 412 patients, 914 fractures were observed. The adjusted models showed a significant fracture risk increase with use of any dose glucocorticoids ≥3 months (HR (95% CI) for <7.5 mg/day 1.26 (1.07 to 1.48) and for ≥7.5 mg/day 1.57 (1.27 to 1.94)), opioids (for weak: 1.37 (1.18 to 1.59); strong: 1.53 (1.24 to 1.88)) and selective serotonin reuptake inhibitors (SSRIs) (1.37 (1.15 to 1.63)). Fracture risk with opioids increased within 1 month of use (1.66 (1.36 to 2.04)) and with SSRIs >3 months of use (1.25 (1.01 to 1.55)). Statins (0.77 (0.62 to 0.96)) and TNFi (0.72 (0.54 to 0.97)) were associated with reduction in vertebral fracture risk only. PPIs and other psychotropic medications were not associated with increased fracture risk.

CONCLUSION

Use of opioids, SSRIs and glucocorticoids were associated with increased risk of any fracture in patients with RA, whereas statins and TNFi were associated with decreased vertebral fractures.

A Comparison of US and Canadian Osteoporosis Screening and Treatment Strategies in Postmenopausal Women

The optimal approach to osteoporosis screening and treatment in postmenopausal women is unclear. We compared (i) the United States Preventive Services Task Force (USPSTF) and Osteoporosis Canada osteoporosis screening strategies; and (ii) the National Osteoporosis Foundation (NOF) and Canadian treatment strategies. We used data from the prospective Women's Health Initiative Observational Study and Clinical Trials of women aged 50 to 79 years at baseline (n = 117,707 followed for self-reported fractures; n = 8134 in bone mineral density [BMD] subset). We determined the yield of the screening and treatment strategies in identifying women who experienced major osteoporotic fractures (MOFs) during a 10-year follow-up. Among women aged 50 to 64 years, 23.1% of women were identified for BMD testing under the USPSTF strategy and 52.3% under the Canadian strategy. For women ≥65 years, 100% were identified for testing under the USPSTF and Canadian strategies, 35% to 74% were identified for treatment under NOF, and 16% to 37% were identified for treatment under CAROC (range among 5-year age subgroups). Among women who experienced MOF during follow-up, the USPSTF strategy identified 6.7% of women 50 to 54 years-old and 49.5% of women 60 to 64 years-old for BMD testing (versus 54.4% and 60.6% for the Canadian strategy, respectively). However, the specificity of the USPSTF strategy was higher than that of the Canadian strategy among women 50 to 64 years-old. Among women who experienced MOF during follow-up, sensitivity for identifying women as treatment candidates was lowest for both strategies in women aged 50 to 64 (NOF 10% to 38%; CAROC 1% to 15%) and maximal in 75-year-old to 79-year-old women (NOF 82.8%; 51.6% CAROC); specificity declined with advancing age and was lower with the NOF compared to the CAROC strategy. Among women aged 50 to 64 years, the screening and treatment strategies examined had low sensitivity for identifying those who subsequently experience MOF; sensitivity was higher among women ≥65 years than among younger women. New screening and treatment algorithms are needed. © 2018 American Society for Bone and Mineral Research.

Atherosclerosis and Osteoporosis. Common Targets for the Effects of Cardiovascular and Anti-osteoporotic Drugs (Part I). The Effect of Cardiovascular Drugs on Bone Strength

Daily use of antihypertensive and lipid-lowering drugs in clinical practice dictates the need for knowledge of their pleiotropic effects. The article presents the results of studies of the effect of cardiovascular drugs, such as statins, beta-blockers, ACE inhibitors, diuretics, calcium antagonists and nitrates on bone mineral density and fractures associated with osteoporosis. The mechanisms of action of drugs on bone mass, markers of bone metabolism, the frequency of fractures in osteoporosis are discussed. Most studies show that the use of cardiac drugs along with a positive effect on the vascular wall, slow bone resorption and increase bone mass. Knowledge of the additional effect on bone metabolism of drugs used in cardiovascular diseases allows to choose an adequate therapy and improve the prognosis of both diseases.

Association Between Cortical Bone Microstructure and Statin Use in Older Women

CONTEXT

Treatment with statins has been associated with increased bone mineral density, but whether this association depends on differences in cortical or trabecular volumetric bone microstructure is unknown.

OBJECTIVE

The aim of this study was to investigate if treatment with statins is associated with bone microstructure and geometry in older women.

DESIGN SETTING AND PARTICIPANTS

Older women were included in a population-based study of 3028 women (mean age ± SD, 77.8 ± 1.6 years) from the greater Gothenburg area in Sweden. Information regarding medical history, medication, and lifestyle factors was obtained from validated questionnaires.

MAIN OUTCOME

Bone geometry and microstructure were measured at the ultradistal and distal (14%) site of radius and tibia using high-resolution peripheral quantitative computed tomography.

RESULTS

The 803 women in the cohort who used statins had higher body weight, worse physical function, and more frequent cardiovascular disease and diabetes than nonusers (P < 0.05). Statin users had lower cortical porosity (radius, 2.2 ± 1.9 vs 2.5 ± 2.0%; tibia, 5.2 ± 2.4 vs 5.4 ± 2.5; P = 0.01), higher cortical bone density (radius, 1008 ± 39.1 vs 1001 ± 38.4 mg/cm3; tibia, 919 ± 42.6 vs 914 ± 41.5; P < 0.01), and greater cortical area (radius, 60.5 ± 9.6 vs 58.6 ± 9.7 mm2; tibia, 150.0 ± 23.6 vs 146.7 ± 23.8; P < 0.01) than nonusers after adjustment for a large number of confounders, including age, weight, smoking, other medications, and prevalent diseases.

CONCLUSIONS

Use of statins was associated with better cortical bone characteristics in older women.

Long-term effect of statins on the risk of new-onset osteoporosis: A nationwide population-based cohort study

Background

Several observational cohort and meta-analytical studies in humans have shown that statin users have a lower risk of fractures or greater bone mineral densities (BMD) than nonusers. However, some studies including randomized clinical trials have the opposite results, particularly in Asian populations.

Objective

This study investigates the impacts of statins on new-onset osteoporosis in Taiwan.

Methods

In a nationwide retrospective population-based cohort study, 45,342 subjects aged between 50–90 years having received statin therapy (statin-users) since January 1 2001, and observed through December 31 2013 were selected from the National Health Insurance Research Database of Taiwan. Likewise, 115,594 patients had no statin therapy (statin-non-users) were included as controls in this study. Multivariable Cox proportional hazards analysis for drug exposures was employed to evaluate the association between statin treatment and new-onset of osteoporosis risk. We also used the long-rank test to evaluate the difference of probability of osteoporosis-free survival.

Results

During the 13-year follow-up period, 16,146 of all enrolled subjects (10.03%) developed osteoporosis, including 3097 statin-users (6.83%) and 13,049 statin-non-users (11.29%). Overall, statin therapy reduced the risk of new-onset osteoporosis by 48% (adjusted hazard ratio [HR] 0.52; 95% CI 0.50 to 0.54). A dose-response relationship between statin treatment and the risk of new-onset osteoporosis was observed. The adjusted hazard ratios for new-onset osteoporosis were 0.84 (95% CI, 0.78 to 0.90), 0.56 (95% CI, 0.52 to 0.60) and 0.23 (95% CI, 0.21 to 0.25) when cumulative defined daily doses (cDDDs) ranged from 28 to 90, 91 to 365, and more than 365, respectively, relative to nonusers. Otherwise, high-potency statins (rosuvastatin and atorvastatin) and moderate-potency statin (simvastatin) seemed to have a potential protective effect for osteoporosis.

Conclusions

In this population-based cohort study, we found that statin use is associated with a decreased risk of osteoporosis in both genders. The osteoprotective effect of statins seemed to be more prominent with a dependency on the cumulative dosage and statin intensity.

High-potency statins but not all statins decrease the risk of new-onset osteoporotic fractures: a nationwide population-based longitudinal cohort study

Background

Statins have been linked to new-onset osteoporotic fractures (NOFs), and different statins may alter the risk for the development of NOFs.

Aim

In this study, we investigated the association between different statins and the development of NOFs.

Patients and methods

This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance, including case patients with NOFs from January 2004 to December 2013 and non-NOF subjects. We estimated the hazard ratios (HRs) of NOFs associated with statin use. Nonuser subjects served as the reference group.

Results

A total of 44,405 patients with NOFs were identified from among 170,533 patients with hyperlipidemia during the study period. The risk of developing NOFs after adjusting for age, sex, comorbidities, and concurrent medication use was lower among users of atorvastatin (HR, 0.77; 95% CI, 0.71-0.84) and rosuvastatin (HR, 0.72; 95% CI, 0.64-0.81) than among simvastatin users. Lovastatin, pravastatin, fluvastatin, and pitavastatin were not associated with the risk of developing NOFs compared with simvastatin users.

Conclusion

This study supports previous reports regarding a beneficial effect of statin use and NOF risk, but not all statins. Patients taking atorvastatin or rosuvastatin were at lower risk of developing NOFs compared with simvastatin users during the 10-year follow-up. Other statins such as pravastatin, fluvastatin, lovastatin, and pitavastatin were not associated with NOFs. This study also highlighted that high-potency statin has a dose-response effect on lower NOF risk.

Genetic Variant in ACVR2B Is Associated with Lean Mass

INTRODUCTION

Low lean mass (LM) is a risk factor for chronic disease, a major cause of disability and diminished quality of life, and is a heritable trait. However, relatively few specific genetic factors have been identified as potentially influencing this trait.

METHODS

In this study, we selected 1493 single-nucleotide polymorphisms (SNP) in 155 candidate genes involved in anabolic, catabolic, growth hormone, and other related pathways and examined their association with LM, assessed by dual-energy x-ray absorptiometry, in a sample of 2760 non-Hispanic and Hispanic white postmenopausal women from the Women's Health Initiative (WHI) Observational Study. We assessed the replication of our top findings in a meta-analysis of 20 genome-wide association studies (n = 38,292) conducted by the Cohorts for Heart and Aging Research in Genomic Epidemiology Consortium Musculoskeletal Working Group.

RESULTS

We identified 32 SNPs that had nominally significant associations with LM in the WHI cohort. In the replication stage, we find that SNP rs2276541 in the activin A receptor, type IIB (ACVR2B), was significantly associated with LM (β = 0.15, P = 2.17 × 10). ACVR2B codes for a receptor for a negative regulator of skeletal muscle, myostatin, and has previously been identified in a candidate gene study as a determinant of skeletal muscle mass.

CONCLUSIONS

Our findings support a previously proposed role of ACVR2B allelic variation as a determinant of muscle mass and extend prior findings in men and women. Additional large-scale studies will be needed to confirm our findings in different populations.

Associations of Parity, Breastfeeding, and Fractures in the Women's Health Observational Study

OBJECTIVE

To examine associations of several aspects of parity and history of lactation with incident hip fractures and clinical fractures and, in a subset of women, with bone mineral density.

METHODS

In this observational study, we analyzed data from 93,676 postmenopausal women participating in the Women's Health Initiative Observational Study and all bone density data from the subset of participants who underwent bone density testing at three clinical centers. At baseline, participants were aged 50-79 years. Using Cox proportional hazards regression analysis, we examined associations of fracture incidence and bone density with several aspects of parity (number of pregnancies, age at first pregnancy lasting 6 months or greater, and number of pregnancies lasting 6 months or greater) and breastfeeding (number of episodes of breastfeeding for at least 1 month, number of children breastfed, age when first breastfed, age when last breastfed, total number of months breastfed).

RESULTS

The mean baseline age (standard deviation) of participants was 64 (±7.4) years (mean follow-up 7.9 years). During follow-up, the incident rate of hip fracture was 1.27%. Ten percent of participants were nulligravid. In fully adjusted models, number of pregnancies, parity, age at first birth, number of children breastfed, age at first breastfeeding, age at last breastfeeding, and total duration of breastfeeding were not statistically significantly associated with hip fracture incidence. There were no consistent associations of parity or lactation characteristics with overall clinical fracture risk or bone density. However, compared with never breastfeeding, a history of breastfeeding for at least 1 month was associated with a decreased risk of hip fracture (yes compared with no, hazard ratio 0.84, 95% confidence interval 0.73-0.98).

CONCLUSION

Patterns of parity and history of lactation were largely unrelated to fracture risk or bone density.

Statin use and hip fractures in U.S. kidney transplant recipients

Background

Basic and translational research supports beneficial effects of statins on bone metabolism. Clinical studies suggest that statin use may reduce the risk of hip fractures in the general population. Whether statin use is associated with hip fracture risk in kidney transplant recipients, a particularly high-risk group for this outcome, is unknown.

Methods

From the U.S. Renal Data System (2007–2011), we identified all hip fracture events recorded in Medicare billing claims of first-time kidney transplant recipients. We then matched all cases to an unlimited number of controls on age (±3 years), sex, race (black vs. non-black), and time since transplant. Cases and controls were required to have >1 year of Medicare Parts A + B + D coverage and be without a recorded history of hip fracture. We ascertained any statin use in the previous year and defined adherent statin use as those who had filled prescriptions for statins to cover >80% of days in that year (proportion of days covered, PDC). We ascertained several potential confounders (demographics, comorbidities, BMI, transplant-related factors) and applied conditional logistic regression with multiple imputation for missing data to estimate odds ratios (OR) and 95% confidence intervals (CI).

Results

We identified 231 hip fracture cases (mean age 51.8 years; 53% female; 11.3% black; 6.9 years from transplant, and 9.9 years from ESRD) and 15,575 matched controls. Any prior statin use was present in 64.1% of cases and 60.3% of controls with 37.2% of cases and 33.9% of controls being found adherent. Unadjusted conditional logistic regression showed an OR of 1.17 (0.89-1.54) for any statin use, and a fully-adjusted OR of 0.89 (0.67-1.19). Compared with statin non-users, the adjusted OR for patients with lesser adherence (PDC ≤80%) and those with greater adherence (PDC >80%) were 0.93 (0.66-1.31) and 0.87 (0.63-1.20), respectively.

Conclusion

Statin use was not associated with hip fracture risk in first-time kidney transplant recipients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0559-9) contains supplementary material, which is available to authorized users.

Exposure to statins is associated to fracture risk reduction in elderly people with cardiovascular disease: evidence from the AIFA-I-GrADE observational project

PURPOSE

Conflicting findings were observed from clinical trials and observational studies evaluating the association between the use of statins and the risk of fracture. A case-control study nested into a cohort of elderly patients on treatment with statins for cardiovascular secondary prevention was performed on this issue.

METHODS

The cohort was formed by 13 875 individuals aged ≥65 years from several Italian health units receiving statins after hospital discharge for cardiovascular outcomes. From this cohort, 964 patients who experienced fracture were identified (i.e., cases). Up to five controls were randomly selected for each case from the underlying cohort. Conditional logistic regression was used to model the risk of fracture associated with adherence to statins, which was measured from the proportion of days covered (PDC) by treatment. A set of sensitivity analyses was performed in order to account for sources of systematic uncertainty.

RESULTS

Compared with patients with low adherence (PDC ≤ 40%), those on intermediate (PDC 41-80%) and high (PDC > 80%) adherence exhibited a risk reduction of 21% (95% confidence interval 6% to 23%) and 25% (7% to 40%). Similar effects were observed among patients younger and older than 80 years, as well as among men, while there was no evidence that adherence to statins affected the risk of fracture among women. Sensitivity analyses revealed that the associations were consistent and robust.

CONCLUSIONS

Use of statins for secondary cardiovascular prevention is associated with fracture risk reduction in elderly people. Further studies are required to better clarify the statin-fracture association in postmenopausal women. Copyright © 2017 John Wiley & Sons, Ltd.

Efficacy of statins for osteoporosis: a systematic review and meta-analysis

Our meta-analysis assessed the efficacy of statins on the risk of fracture, bone mineral density (BMD), and the markers of bone metabolism by collecting data from 33 clinical trials. We found that statin treatment was associated with bone metabolism. And statins seemed to be more effective on male patients with osteoporosis. The efficacy of statins for the treatment of osteoporosis has been controversial in previous studies and meta-analyses. Our meta-analysis was conducted to examine in detail the efficacy of statins on osteoporosis. We searched PubMed, Embase, and the Cochrane Library databases for clinical trials from inception to May 2016. We included studies that described the effect of statins on the risk of fracture, BMD, or bone turnover markers. Moreover, we also conducted subgroup analyses according to the skeleton site, patient gender, and length of follow-up. A total of 33 studies which included 23 observational studies (16 cohort studies and 7 case-control studies) and 10 randomized controlled trials (RCTs) were evaluated. These 33 studies included 314,473 patients in statin group and 1,349,192 patients in control group. Statins decreased the risk of overall fractures (OR = 0.81, 95% CI 0.73-0.89) and hip fractures (OR = 0.75, 95% CI 0.60-0.92). Furthermore, the use of statins was associated with increased BMD at the total hip (standardized mean difference (SMD) = 0.18, 95% CI 0.00-0.36) and lumbar spine (SMD = 0.20, 95% CI 0.07-0.32) and improved the bone formation marker, osteocalcin (OC) (SMD = 0.21, 95% CI 0.00-0.42). However, there was no positive effect on vertebral fractures, upper extremity fractures, BMD at the femoral neck, bone-specific alkaline phosphatase (BALP), and serum C-terminal peptide of type I collagen (S-CTX). Also, compared with male subgroups, the effect on female subgroups was only slightly positive or of no statistical significance. Our meta-analysis indicates that statin treatment may be associated with a decreased risk of overall fractures and hip fractures, an increased BMD at the total hip, BMD at the lumbar spine, and OC. Moreover, our results also show that statin treatment may have a greater effect on male patients than on female patients.

Effects of Statins on Bone Mineral Density and Fracture Risk: A PRISMA-compliant Systematic Review and Meta-Analysis

Although observational studies have identified the protective effect of statins on bone health, the effects remain controversial in randomized controlled trials (RCTs). We conducted a meta-analysis of RCTs to evaluate the effects of statins on bone mineral density (BMD) and fracture risk among adults.We searched electronic databases of Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) and conducted a bibliography review to identify articles published until May, 2015.Studies included in this meta-analysis should be randomized controlled trials conducted in adults, using statins in the intervention group. Information on changes in BMD or odds ratio, relative risk or hazard ratio (HR) for fracture risk with the corresponding 95% confidence interval (CI) was provided.Two investigators independently reviewed the title or abstract, further reviewed the full-texts and extracted information on study characteristics and study outcomes. Net change estimates of BMD and pooled HR of fracture risk comparing the intervention group with the control group were estimated across trials using random-effects models.Of the relevant 334 citations, 7 trials (including 27,900 randomized participants in total) meeting the eligibility criteria were included. Of the 7 trials, 5 were conducted to assess the association of statins use with BMD change and 2 with fracture risk. Compared with the control group, statins use was associated with significant increase in BMD of 0.03 g/cm (95% CI: 0.006, 0.053; I = 99.2%; P < 0.001), but null association with fracture risk, with the pooled HR of 1.00 (95% CI: 0.87, 1.15; I = 0; P = 0.396). Sensitivity analyses revealed that the associations were consistent and robust.The effect of statins use on bone health among subpopulation could not be identified due to limited number of trials.These findings provide evidence that statins could be used to increase BMD other than decreasing fracture risk in participant with dyslipidemia. In addition, further trials with the primary outcome of bone health-related measurements in subpopulation are warranted to ensure the effect of statins use.

Effects of 96 Weeks of Rosuvastatin on Bone, Muscle, and Fat in HIV-Infected Adults on Effective Antiretroviral Therapy

Heightened inflammation and immune activation are associated with lower bone mineral density (BMD) and lean body mass (LBM) among HIV-infected persons. We hypothesized that a reduction in inflammation with rosuvastatin would be associated with improvements in BMD and LBM. HIV-infected participants on stable antiretroviral therapy without statin indication and with heightened immune activation (≥19% CD8(+)CD38(+)HLA-DR(+) T cells) or inflammation (hsCRP ≥2 mg/liter) were randomized to rosuvastatin 10 mg daily or placebo for 96 weeks. Among 72 participants randomized to rosuvastatin and 75 to placebo, there were no significant differences in the relative changes in BMD (p > 0.29) or in fat (p ≥ 0.19). A trend toward increased LBM (p = 0.059) was seen in the rosuvastatin arm without differences in creatinine kinase or self-reported physical activity (p ≥ 0.10). In a multivariable regression model, rosuvastatin was associated with a significant positive effect on LBM after adjusting for age, sex, race, smoking status, and detectable HIV-1 viral load. Higher baseline sCD163 correlated with increases in LBM from weeks 0 to 96 (p = 0.023); greater changes in total and leg lean mass were seen among statin users with higher compared to lower baseline IP-10 levels (LBM 1.8 vs. -0.3%; p = 0.028 and leg lean mass 2.9 vs. -1.7%; p = 0.012). Rosuvastatin is associated with an absence of toxicity on BMD and a potential benefit on LBM over 96 weeks of therapy. The preservation of LBM in the rosuvastatin arm over the 2 years of the study is of major clinical relevance in delaying loss of muscle mass with aging.

Statins and hip fracture risk in men: a population-based case-control study

PURPOSE

To estimate the association between hydroxymethylglutaryl-CoA inhibitor (statin) use and hip fracture.

METHODS

We conducted a population-based case-control study. Cases were 6774 male enrollees in a large managed care organization, aged 45 or more years, with an incident hip fracture from 1997 to 2006. Controls without fracture (n = 6774) were matched to cases on age, race, and medical center. Electronic information on pharmaceutical use was used to identify the dispensing of statins from 1991 forward.

RESULTS

Overall, 1884 (27.8%) cases and 2150 controls (31.7%) used a statin before index date (matched odds ratio [mOR] = 0.81, 95% confidence interval [CI] = 0.74-0.87). Adjustment for comorbidity burden strengthened the magnitude of the overall association (mOR = 0.68, CI = 0.62-0.74). The adjusted association was similar across age groups but was strongest among men aged 80 years or more (mOR = 0.62, CI = 0.54-0.71) and was most pronounced in African Americans (mOR = 0.43, CI = 0.28-0.64). Greater duration of statin use did not alter the odds ratios.

CONCLUSIONS

These data add to the growing evidence of a potential protective effect of statin use on bone health. However, these results need to be replicated in a prospective study that can account for confounding by indication which may explain these findings.

Pleiotropic effects of statins on the treatment of chronic periodontitis--a systematic review

AIM

Statins are inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase and are an important group of hypolipidaemic drugs, widely used in the treatment of hypercholesterolaemia and cardiovascular disease. Some studies have shown that statins are able to modulate inflammation and alveolar bone loss.

METHODS

In order to evaluate whether statins could influence periodontal treatment, improving the clinical and radiographic parameters in chronic periodontitis, a systematic review was conducted in the databases PUBMED and BIREME, searching for articles in English and Portuguese, published between the years 2004 and 2014, using the combined keywords statin, periodontal disease, periodontitis and alveolar bone. Studies regarding the treatment of chronic periodontitis in humans, blind or double-blind, retrospective cohort or randomized controlled trials that used statins topically or systemically were selected.

RESULTS

Statins have important anti-inflammatory and immune effects, reducing levels of C-reactive protein and matrix metalloproteinases and their intermediate products, such as tumour necrosis factor-α, and are also able to inhibit the adhesion and extravasation of leukocytes, which block the co-stimulation of T cells. Statins reduce bone resorption by inhibiting osteoclast formation and lead to increased apoptosis of these cells. The effect of statins on bone formation is related to the increased gene expression of bone morphogenetic protein in osteoblasts.

CONCLUSION

Although we found biological mechanisms and clinical results that show lower alveolar bone loss and reduction of clinical signs of inflammation, further studies are needed to evaluate the clinical applicability of statins in the routine treatment of chronic periodontitis.

Statin therapy and risk of fracture: results from the JUPITER randomized clinical trial

IMPORTANCE

Osteoporosis and cardiovascular disease may share common biological pathways, with inflammation playing a role in the development of both. Although observational studies have suggested that statin use is associated with a lower risk of fractures, randomized trial data addressing this issue are scant.

OBJECTIVE

To determine whether statin therapy reduces the risk of fracture and, in a secondary analysis, whether baseline levels of the inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) are associated with the risk of fracture.

DESIGN, SETTING, AND PARTICIPANTS

The JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) trial was an international, randomized, double-blind, placebo-controlled study enrolling 17,802 men older than 50 years and women older than 60 years with hs-CRP level of at least 2 mg/L. Participants were screened from 2003 to 2006 and observed prospectively for up to 5 years (median follow-up, 1.9 years).

INTERVENTION

Rosuvastatin calcium, 20 mg daily, or placebo.

MAIN OUTCOMES AND MEASURES

Incident fracture was a prespecified secondary end point of JUPITER. Fractures were confirmed by radiographs, computed tomography, bone scan, or other methods. Cox proportional hazards models were used to calculate hazard ratios (HRs) and associated 95% confidence intervals for the risk of fracture according to randomized treatment assignment, as well as increasing tertiles of hs-CRP, controlling for potential confounders.

RESULTS

During the study, 431 incident fractures were reported and confirmed. Among participants allocated to rosuvastatin, 221 fractures were confirmed, compared with 210 among those allocated to placebo, such that the incidence of fracture in the rosuvastatin and placebo groups was 1.20 and 1.14 per 100 person-years, respectively (adjusted HR, 1.06 [95% CI, 0.88-1.28]; P = .53). Overall, increasing baseline hs-CRP level was not associated with an increased risk of fractures (adjusted HR for each unit increase in hs-CRP tertile, 1.06 [95% CI, 0.94-1.20]; P for trend, .34).

CONCLUSIONS AND RELEVANCE

Among men and women with elevated hs-CRP level enrolled in a large trial of rosuvastatin therapy for cardiovascular disease, statin therapy did not reduce the risk of fracture. Higher baseline hs-CRP level was not associated with an increased risk of incident fracture.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00239681.

Effects of randomized rosuvastatin compared with placebo on bone and body composition among HIV-infected adults

BACKGROUND

Statins have a beneficial effect on bone mineral density (BMD) and lean mass in some studies of HIV-uninfected adults; however, this has never been investigated in the setting of HIV infection.

DESIGN

HIV-infected individuals on stable antiretroviral therapy with a low-density lipoprotein cholesterol level of 130 mg/dl or less and evidence of heightened immune activation or inflammation were randomized to rosuvastatin 10 mg daily or placebo for 96 weeks.

METHODS

This was a prespecified interim analysis at 48 weeks. Between-group and within-group differences were compared; multivariable regression models were constructed.

RESULTS

Seventy-two individuals were randomized to statin therapy and 75 to placebo. Modest 48-week relative increases in trochanter BMD [0.9%; 95% confidence interval (95% CI) -0.9 to 0.6] and total hip BMD (0.6%; 95% CI 0.0-1.1) in the statin arm were significantly greater than placebo (P < 0.05). The relationship between statin use and total hip BMD change was robust to adjustment of age, sex, race and smoking status (P = 0.02) and strengthened by inclusion of baseline (P = 0.01) and week 48 change in soluble tumour necrosis factor-α receptor (sTNFR)-1 (P = 0.009). Relative increases in total body, trunk and limb fat were similar between statin and placebo arms (P ≥ 0.58). Although a significant gain in leg lean mass was seen in the statin arm, this was not significantly different compared with placebo (P = 0.36).

CONCLUSION

The improvements seen in total hip BMD after 48 weeks of rosuvastatin therapy support further potential benefits of statin therapy in HIV, beyond a reduction of cardiovascular risk.

Efficacy of Simvastatin in Bone Regeneration After Surgical Removal of Mandibular Third Molars: A Clinical Pilot Study

INTRODUCTION

Simvastatin, a common cholesterol-lowering drug that inhibits hepatic hydroxymethylglutaryl coenzyme A reductase, the rate-limiting enzyme in the mevalonate pathway, increases expression of the BMP-2 gene and thus promotes bone regeneration.

MATERIALS AND METHODS

A study was conducted in mandibular third molar sockets to study the efficacy of the drug by implanting it into sockets (experimental group) and observations were made over 3 months to compare the healing with the (control group).

CONCLUSION

The results showed faster regeneration of the bone in the simvastatin site using the gray level histogram values.

Novel applications of statins for bone regeneration

The use of statins for bone regeneration is a promising and growing area of research. Statins, originally developed to treat high cholesterol, are inhibitors of the enzyme 3-hydroxy-3-methylglutaryl, the rate-limiting enzyme of the mevalonate pathway. Because the mevalonate pathway is responsible for the synthesis of a wide variety of important biochemical molecules, including cholesterol and other isoprenoids, the effects of statins are pleiotropic. In particular, statins can greatly affect the process of bone turnover and regeneration via effects on important cell types, including mesenchymal stem cells, osteoblasts, endothelial cells, and osteoclasts. Statins have also been shown to have anti-inflammatory and antimicrobial properties that may be useful since infection can derail normal bone healing. This review will explore the pleiotropic effects of statins, discuss the current use of statins for bone regeneration, particularly with regard to biomaterials-based controlled delivery, and offer perspectives on the challenges and future directions of this emerging area of bone tissue engineering.

Association of Statins and Risk of Fractures in a Military Health System

Background: Contradictory evidence exists regarding statin use and risk of osteoporotic fractures. Objective: The study objective was to examine the effect of statins on fracture risk in a Military Healthcare System (MHS) with similar access and standard of health care for its beneficiaries. Methods: This is a retrospective study of patients enrolled in an MHS encompassing the period from October 1, 2003, to March 1, 2010. Statin users were defined as those receiving a statin for ≥90 days in Fiscal Year 2005, whereas nonusers were defined as individuals not receiving a statin throughout the study period. A propensity score–matched cohort of statin users and nonusers was created using 42 variables. The outcomes were identified using ICD-9-CM codes in the follow-up period (October 1, 2006, to March 1, 2010). In all, 4 outcomes were examined: all fractures, femoral neck fractures, upper-extremity fractures, and lower-extremity fractures. Results: Of 46 249 patients, 6967 pairs of statin users and nonusers were matched. Statin users had a lower risk of femoral neck fracture in comparison to nonusers (odds ratio = 0.58, 95% CI = 0.36-0.94) but similar risk of all fractures, lower-extremity fractures, and upper-extremity fractures. Conclusions: In this cohort of patients managed in an MHS, statin use was associated with a lower risk of femoral neck fractures, but not all fractures, upper-extremity fractures, or lower-extremity fractures.

Simvastatin local drug delivery in smokers with chronic periodontitis: a randomized controlled clinical trial

BACKGROUND

Simvastatin (SMV) is a specific competitive inhibitor of 3-hydroxy-2-methyl-glutaryl coenzyme A reductase. Statins have recently been shown to promote bone formation. This study was designed to investigate the effectiveness of SMV 1.2% in an indigenously prepared biodegradable controlled release gel as an adjunct to scaling and root planing (SRP) in the treatment of smokers with chronic periodontitis.

METHODS

Forty patients were categorized into two treatment groups: SRP plus SMV 1.2% and SRP plus placebo. Clinical parameters were recorded at baseline and at 3, 6 and 9 months; they included modified sulcus bleeding index (mSBI), probing depth (PD) and clinical attachment level (CAL). At baseline, after 6 months and 9 months, radiologic assessment of intrabony defect (IBD) fill was done using computer-aided software.

RESULTS

Mean probing depth reduction and mean clinical attachment level gain was greater in the SMV group than the placebo group at all visits. Furthermore, significantly greater mean percentage of bone fill was found in the SMV group (32.37 ± 10.23%) compared to the placebo (4.18 ± 5.39%).

CONCLUSIONS

There was a greater decrease in mSBI and PD and more CAL gain with significant IBD fill at sites treated with SRP plus locally delivered SMV in smokers with chronic periodontitis.

Unintended effects of statins from observational studies in the general population: systematic review and meta-analysis

BACKGROUND

Efficacy of statins has been extensively studied, with much less information reported on their unintended effects. Evidence from randomized controlled trials (RCTs) on unintended effects is often insufficient to support hypotheses generated from observational studies. We aimed to systematically assess unintended effects of statins from observational studies in general populations with comparison of the findings where possible with those derived from randomized trials.

METHODS

Medline (1998 to January 2012, week 3) and Embase (1998 to 2012, week 6) were searched using the standard BMJ Cohort studies filter. The search was supplemented with reference lists of all identified studies and contact with experts in the field. We included prospective studies with a sample size larger than 1,000 participants, case control (of any size) and routine health service linkage studies of over at least one year duration. Studies in subgroups of patients or follow-up of patient case series were excluded, as well as hospital-based cohort studies.

RESULTS

Ninety studies were identified, reporting on 48 different unintended effects. Statins were associated with lower risks of dementia and cognitive impairment, venous thrombo-embolism, fractures and pneumonia, but these findings were attenuated in analyses restricted to higher quality studies (respectively: OR 0.74 (95% CI 0.62 to 0.87); OR 0.92 (95% CI 0.81 to 1.03); OR 0.97 (95% CI 0.88 to 1.05); OR 0.92 (95% CI 0.83 to 1.02)); and marked heterogeneity of effects across studies remained. Statin use was not related to any increased risk of depression, common eye diseases, renal disorders or arthritis. There was evidence of an increased risk of myopathy, raised liver enzymes and diabetes (respectively: OR 2.63 (95% CI 1.50 to 4.61); OR 1.54 (95% CI 1.47 to 1.62); OR 1.31 (95% CI 0.99 to 1.73)).

CONCLUSIONS

Our systematic review and meta-analyses indicate that high quality observational data can provide relevant evidence on unintended effects of statins to add to the evidence from RCTs. The absolute excess risk of the observed harmful unintended effects of statins is very small compared to the beneficial effects of statins on major cardiovascular events.

Statins, bone metabolism and treatment of bone catabolic diseases

The discovery that statins had bone anabolic properties initiated many investigations into their use for treatment of bone catabolic diseases, such as osteoporosis. This paper reviews the molecular basis of statin's role in bone metabolism, and animal and human studies on the impact of systemic statins on osteoporosis-induced bone fracture incidence and healing, and on bone density. Limitations of systemic statins are described along with alternative dosing strategies, including local applications and bone-targeting systemic preparations. The principal findings of this review are: (1) traditional oral dosing with statins results in minimal efficacy in the treatment of osteoporosis; (2) local applications of statins show promise in the treatment of accessible bony defects, such as periodontitis; and (3) systemically administered statins which can target bone or inflammation near bone may be the safest and most effective strategy in the treatment of osseous deficiencies.

Statin use and fracture risk: can we quantify the healthy-user effect?

BACKGROUND

Numerous observational studies show that statin use is associated with lower risk of osteoporotic fractures. However, a causal relationship is not supported by data from randomized trials. Unmeasured confounding is implicated as a likely culprit for the controversy because of failure to measure and adjust for patient-level tendencies to engage in healthy behaviors. However, an alternative explanation is selection bias because of the inclusion of prevalent users of statins in the analysis. The relative importance of either bias has not been investigated in a quantitative sensitivity analysis.

METHODS

We conducted a systematic review to summarize the pattern of association between statin use and fracture risk in observational studies. Our objective was to quantify the magnitude of unmeasured confounding and selection bias in a sensitivity analysis.

RESULTS

In 17 published studies, the pooled relative risk for the association between current use of statins and fracture risk was 0.75 (95% confidence interval = 0.66-0.85). Upon adjustment for individual-level use of preventative health services, the pooled relative risk shifted by less than 5% on the log scale. However, a sensitivity analysis for selection bias revealed that moderate levels of bias could eliminate the association between statins and fracture risk.

CONCLUSIONS

It appears that confounding from unmeasured variables cannot explain the protective association between statins and fractures that has been observed in the literature.

Desenvolvimento do germe dentário e do palato em fetos de camundongos sob o efeito da Sinvastatina

INTRODUÇÃO: As estatinas causaram uma revolução na prevenção e no tratamento do colesterol alto, porém é contraindicada no primeiro trimestre da gravidez, pois podem causar má formação no feto, no sistema nervoso central e nos membros. OBJETIVO: Verificar os efeitos da Sinvastatina na formação do palato e no desenvolvimento dos germes dentários dos primeiros molares superiores e inferiores. MATERIAL E MÉTODO: Para o acasalamento, foram utilizados 14 camundongos fêmeas e quatro machos; o dia 'zero' da gestação foi identificado pelo plug vaginal após acasalamento. As fêmeas prenhes foram divididas em Grupos I e III - receberam 10 mg/kg solução salina em três semanas antes do acasalamento e a partir do acasalamento até o 14.º dia de prenhez, respectivamente. Grupos II e IV receberam 10 mg/kg de Sinvastatina, no período de três semanas antes do acasalamento e a partir do acasalamento até o 14.º dia de prenhez, respectivamente. RESULTADO: A análise histológica dos fetos dos Grupos I, II, III e IV mostrou o palato fusionado na linha mediana do processo palatino. Os germes dentários dos primeiros molares dos Grupos II e IV apresentaram um desenvolvimento atrasado quando comparados aos Grupos I e III, porém, todos estavam nas etapas de capuz e campânula. CONCLUSÃO: As análises histológica e estatística mostraram que os fetos apresentaram palato fusionado na linha média de fusão do processo palatino e os germes dentários dos Grupos II e IV mostraram-se com formas indefinidas e contornos irregulares. Este estudo preliminar mostrou que a Sinvastatina pode ocasionar alterações morfológicas nos germes dentários.

New Clues that May Link Osteoporosis to the Circulating Lipid Profile

Bone Mineral Density (BMD) is a gold standard for the diagnosis of osteoporosis and is also important in the assessment of fracture risk. Other risk factors have been identified that together make up fracture risk assessment tools such as FRAX. Another potential factor, circulating lipids, has been suggested because of reports linking statins to fracture risk reduction. We analyzed the lipid profile in a cohort of women diagnosed with postmenopausal osteoporosis based on bone density determination: 610 women with osteoporosis (mean lumbar spine T-score -3.16±0.81, mean yrs. since menopause 15.79±8.9) were grouped according to age at evaluation (< 50 years, 51-60 years, 61-70 years, > 70 years), the presence/absence of a history of a fragility fracture, statin and/or antiresorptive drug use. There was no correlation between BMD and Body Mass Index (BMI: P>0.05, r (2)<0.02). However, when BMD was correlated with both BMI and the lipid profile (Triglycerides, Cholesterol, LDLc, HDLc), significant correlations were found in 5 cohorts: 51-60 years with fractures (n=61, r (2)=0.14, P<0.01), 61-70 years (n=201, r (2)=0.09, P<0.01) with fractures (n=88, r (2)=0.14, P<0.01) or without fractures (n=113, r (2)=0.24, P=0.02) and over 70 years (n=247, r (2)=0.11, P<0.01).

Laxative use and incident falls, fractures and change in bone mineral density in postmenopausal women: results from the Women's Health Initiative

Background

Laxatives are among the most widely used over-the-counter medications in the United States but studies examining their potential hazardous side effects are sparse. Associations between laxative use and risk for fractures and change in bone mineral density [BMD] have not previously been investigated.

Methods

This prospective analysis included 161,808 postmenopausal women (8907 users and 151,497 nonusers of laxatives) enrolled in the WHI Observational Study and Clinical Trials. Women were recruited from October 1, 1993, to December 31, 1998, at 40 clinical centers in the United States and were eligible if they were 50 to 79 years old and were postmenopausal at the time of enrollment. Medication inventories were obtained during in-person interviews at baseline and at the 3-year follow-up visit on everyone. Data on self-reported falls (≥2), fractures (hip and total fractures) were used. BMD was determined at baseline and year 3 at 3 of the 40 clinical centers of the WHI.

Results

Age-adjusted rates of hip fractures and total fractures, but not for falls were similar between laxative users and non-users regardless of duration of laxative use. The multivariate-adjusted hazard ratios for any laxative use were 1.06 (95% confidence interval [CI], 1.03-1.10) for falls, 1.02 (95% CI, 0.85-1.22) for hip fractures and 1.01 (95% CI, 0.96-1.07) for total fractures. The BMD levels did not statistically differ between laxative users and nonusers at any skeletal site after 3-years intake.

Conclusion

These findings support a modest association between laxative use and increase in the risk of falls but not for fractures. Its use did not decrease bone mineral density levels in postmenopausal women. Maintaining physical functioning, and providing adequate treatment of comorbidities that predispose individuals for falls should be considered as first measures to avoid potential negative consequences associated with laxative use.

HMG-CoA reductase inhibitors (statins) and bone mineral density: a meta-analysis

CONTEXT

The association between 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) and bone mineral density (BMD) is controversial because of conflicting findings from previous studies.

OBJECTIVE AND DESIGN

The purpose of the present study was to evaluate the effect of statins on BMD reported in randomized and non-randomized controlled trials. We searched PubMed and Embase, using text, medical subject headings (MeSH) and keywords "bone mineral density" and "statins" or "HMG-CoA reductase inhibitors". Our last PubMed and Embase queries were updated to August 2012. Data on participants, interventions, and outcomes from each study were abstracted independently by two authors.

RESULTS

Five case-control studies, six cohort studies and four randomized controlled trials (RCTs) met the inclusion criteria. Included studies involved 34,877 subjects (3824 in the intervention group and 31,053 in the control group) in 12 different countries with ages ranging from 44 to 66 years. Statins significantly increased BMD at lumbar spine [standardized mean difference (SMD) 0.15, 95% CI 0.09-0.22], total hip (SMD 0.22, 95% CI 0.17-0.27) and femoral neck (SMD 0.19, 95% CI 0.09-0.29). We carried out subgroup analyses on selected populations of the cohorts. Statistically significant increases were also observed in the lumbar spine (SMD 0.12, 95% CI 0.04-0.21), total hip (SMD 0.23, 95% CI 0.17-0.28) and femoral neck BMD (SMD 0.22, 95% CI 0.08-0.36).

CONCLUSION

The results of this study suggest that statins may help improve and maintain BMD at the lumbar spine, hip and femoral neck, especially in Caucasians and Asians. It also provides justification for prospective RCTs to evaluate the possible role of statins in BMD in different ethnic populations, such as Latin American and Africans.