Current Molecular Pharmacology - Volume 5, Issue 2, 2012

Intermittent parathyroid hormone (iPTH) is the only FDA-approved therapy for bone loss due to conditions such as osteoporosis that increases bone formation by osteoblasts; all other therapies approved for osteoporosis block bone resorption by osteoclasts. The anabolic effects of iPTH are likely due to a combination of multiple mechanisms, including induction of immediate-early genes, increased expression and/or activity of essential osteoblast transcription factors, and downregulation of anti-osteogenic proteins, such as sclerostin. In contrast, continuous administration of PTH induces bone loss primarily due to up-regulation of RANKL expression and inhibition of osteoprotegerin expression.

This review focuses on the mechanisms by which PTH stimulates both osteoblast and osteoclast function, emphasizing the critical role that IGF-I plays in these processes. After reviewing the current literature on the skeletal actions of PTH and the modulation of IGF action on bone by the different IGF-binding proteins, the review then examines studies from mouse models in which IGF-I or its receptor have been selectively deleted in different cells of the skeletal system, in particular osteoprogenitors, mature osteoblasts, and osteoclasts. Mice in which IGF-I production has been deleted from all cells are deficient in both bone formation and bone resorption with few osteoblasts or osteoclasts in bone in vivo, reduced osteoblast colony forming units, and an inability of either the osteoblasts or osteoclast precursors to support osteoclastogenesis in vitro. Mice in which the IGF-I receptor is specifically deleted in mature osteoblasts have a mineralization defect in vivo, and bone marrow stromal cells from these mice fail to mineralize in vitro. Mice in which the IGF-I receptor is deleted in osteoprogenitor cells have a marked reduction in osteoblast proliferation and differentiation leading to osteopenia. Finally mice lacking the IGF-I receptor in their osteoclasts have increased bone and decreased osteoclast formation. PTH fails to stimulate bone formation in the mice lacking IGF-I or its receptor in osteoblasts or enhance the signaling between osteoblasts and osteoclasts through RANKL/RANK and Ephrin B2/Eph B4, emphasizing the role IGF-I signaling plays in cell-communication per se and as stimulated by PTH.

The insulin-like growth factors (IGFs) are the most abundant growth factors stored in bone and produced by osteoblasts. IGF-I is an important regulator of osteoblast function and required for optimal bone development and maintenance. IGF-I can act in an endocrine, paracrine or autocrine manner and is regulated by a family of six IGF binding proteins (IGFBPs). The IGFBPs are often found bound to IGF-I in the circulation or complexed with IGF-I in osteoblasts. IGFBP-3 and -5 are known stimulators of IGF-I actions, whereas IGFBP-1, -2, -4 and -6 are known inhibitors of IGF-I action in bone. Once IGF-I binds to its receptor (type 1 IGF receptor) it initiates a complex signaling pathway including the phosphoinositol 3-kinase (PI3-K)/3-PI-dependent kinase (PDK)-1/Akt pathway and the Ras/Raf/mitogen-activated protein (MAP) kinase pathway which stimulate cell function and/or survival. Based on the critical role for IGF-I in osteoblasts, it is a logical candidate for anabolic therapy. However, systemic administration of IGF-I is not cell specific and a limited number of long term experiments have been completed to date. Several recent findings indicate that many of the IGFBPs and specific proteins in the IGF-I signaling pathways are also potent anabolic factors in regulating osteoblast function. This review will focus on the role of these factors in mediating IGF-I action in osteoblasts and how they may serve as potential targets to stimulate osteoblast function and bone formation.

Bone morphogenetic proteins (BMPs) were discovered in 1965 as potent inducers of ectopic bone formation when implanted subcutaneously. BMP2, BMP4, BMP6, and BMP7 are osteoinductive, and BMP2 and BMP7 are currently approved for clinical applications such as bone fracture healing and spine surgery. Although BMPs’ role in bone formation is well known, the current clinical data supporting their effectiveness are not robust, possibly in part because BMPs affect bone resorption as well. BMPs can reduce bone mass by inducing osteoclastogenesis via the RANKL-OPG pathway, which is a critical regulator of osteoclasts by osteoblasts. BMPs have both bone anabolic and catabolic effects by affecting multiple cell types in bone such as mesenchymal cells, chondrocytes, osteoblasts, osteoclasts, and endothelial cells. We recently generated an osteoblast-targeted deletion of BMP signaling using a Cre-loxP strategy and found that BMP signaling in osteoblasts can inhibit Wnt signaling through the Wnt inhibitors DKK1 and SOST. Loss-of-function of either DKK1 or SOST, which are downstream targets of BMPs, causes a high bone mass phenotype in humans and mice, suggesting an importance of DKK1 and SOST for bone mass regulation. There are many bone anabolic effectors that control bone mass such as BMPs, PTH, and Wnt inhibitors. This article will focus on BMPs’ effects on bone anabolism and propose a potential network of the bone mass mediators BMPs, PTH, and SOST. We believe it is important to understand this network to guide the clinical application of bone anabolic agents.

Normal bone homeostasis is the result of a cross-talk between the anabolic axis (osteoblast differentiation) and catabolic axis (osteoclast remodeling). A disruption of this tightly regulated relationship leads to imbalanced bone turnover which ultimately results in diseases of the skeleton. Given that the majority of disease states are characterized by an inadequate renewal of osteoblasts, and the canonical wingless (Wnt) pathway is critical for their differentiation from progenitors, this represents an intriguing target for bone therapy. This mini-review focuses on the different options available for pharmaceutical enhancement of osteogenic differentiation through targeting the various proteins involved in Wnt signaling.

Prostaglandin E2 is known to be a potent metabolite in bone biology. Its effects are mediated via four receptor subtypes with different properties, effects and mechanisms of action. The EP2 and EP4 receptors have been extensively investigated as bone anabolic therapy targets in the literature. The aim of this review was to analyse the available evidence supporting the use of selective agonists for those receptors for anabolic bone application purposes. Although several studies report on the presence of the EP2 receptor in several cell types, efforts to directly confirm the presence of this receptor in human bone cells have not been successful. The EP4 receptor however has been identified in human bone cells and its significant role in bone biology has been demonstrated with the use of selective agonists, antagonists and transgenic small animals. The use of selective EP4 agonists reversed established osteoporotic changes, enhanced the boneimplant interface strength and was shown to have a synergistic effect when used with other bone cell targeting pharmacological agents such as BMP-2 and bisphosphonates. Further elucidation of the side-effect profile of prostanoid and non-prostanoid agonists is required for these agents to proceed towards clinical applications.

With a rise in the aging population, the global osteoporosis market represents a major unmet need and one of the greatest challenges for the pharmaceutical companies. Currently bisphosphonates constitute the mainstay antiosteoporotic treatment. They inhibit osteoclast-dependent bone resorption, and substantially reduce the risk of vertebral and non-vertebral fractures. However, bisphosphonates are only marginally effective in subjects with significant loss of bone mineral density. Furthermore, safety concerns have recently been raised due to an increased risk of low-energy fractures associated with long-term bisphosphonate treatment; hence the need for new osteoanabolic drugs. Transient fluctuations in plasma parathyroid hormone (PTH) are a well-established bone anabolic stimulus and efforts have aimed at identifying new medical therapies that can reduce the risk of vertebral and non-vertebral fractures and increase bone mineral density through modifications of circulating PTH. Two approaches have recently emerged in the search for new bone anabolics: a) administration of exogenous PTH, and b) administration of compounds, which evoke transient release of endogenous PTH, namely calcilytics. This review will focus on the potential use of PTH modifying agents as the new osteoanabolics.

Osteoporosis is a major public health problem for adults above 55 years of age, which leads to an increase in bone fragility. Last decade has witnessed remarkable advances in molecular biology and genetics that led to detailed understanding of the bone remodeling cycle and new therapeutic targets for its treatment have emerged. Thus, besides classical approach (vitamin D and calcium administration, bisphosphonates, oestrogen, raloxifene), new therapeutic agents such as parathyroid hormone (PTH) compounds, anti-RANKL antibodies and strontium ranelate are or will be increasingly used in the treatment of osteoporosis. In this review, we have presented the importance and therapeutic potential of strontium ranelate as a dual agent in the current treatment of osteoporosis.

Current antiresorptive therapies not only prevent bone loss by decreasing osteoclastic bone resorption but also inhibit bone formation. Dual anabolic antiresorptive agents may be required to cure severe osteoporosis by preventing further bone loss and increasing bone mass to normal levels. Recent studies have demonstrated that activin signaling plays a crucial role in the skeleton. Activins, like other TGF-β superfamily members, transduce their signals through type I and II receptor serine/threonine kinases. The binding of activins to activin type IIA (ActRIIA) or type IIB (ActRIIB) receptors induces the recruitment and phosphorylation of an activin type I receptor (ALK4 and/or ALK7), which then phosphorylates the Smad2 and Smad3 intracellular signaling proteins. Activin signaling is down-regulated by inhibins, follistatin and other proteins, which antagonize activin signaling by a variety of mechanisms. A soluble chimeric protein composed of the extracellular domain of ActRIIA fused to IgG-Fc binds to circulating ligands such as activin A and prevents signaling through the endogenous receptor. In cynomolgus monkeys, the ActRIIA soluble receptor increases bone volume by decreasing bone resorption and increasing bone formation, leading to enhanced mechanical strength and bone quality. In addition, a single dose of the soluble ActRIIA-Fc fusion protein increased serum BSALP and PINP and decreased serum CTX and TRACP 5b in postmenopausal women. These data provide evidence of a dual anabolic antiresorptive effect of the soluble ActRIIA-Fc fusion protein in the skeleton. Therefore, targeting activin receptor signaling may be useful for therapeutic intervention in osteoporosis.

From a nutritional point of view, several factors are involved in ensuring optimal bone health. The most documented of these are calcium and vitamin D. However, it is now well acknowledged that some phytochemicals, also known as phytonutrients, which are plant-based compounds that are present in our daily diet, can positively regulate a number of physiological functions in mammalian systems involved in chronic diseases such as osteoporosis. Indeed, emerging data in animal models of postmenopausal osteoporosis has shown that exposure to some of these naturally plant-derived compounds (e.g. flavonoids) positively influences bone metabolism through preserved bone mineral density. In vitro experiments with bone cells have reported cellular and molecular mechanisms of phytonutrients involved in bone metabolism. Indeed, phytonutrients and especially polyphenols can act on both osteoblasts and osteoclasts to modulate bone metabolism, a balance between both cell type activities being required for bone health maintenance. To date, most studies investigating the effects of polyphenols on osteoblast cells have reported involvement of complex networks of anabolic signalling pathways such as BMPs or estrogen receptor mediated pathways. This review will report on the interaction between phytochemicals and bone metabolism in cell or animal models with a particular focus on the molecular mechanisms involved in the bone anabolic response.

Chronically-elevated plasma lipid concentrations, particularly when combined with high glucose, elicit a plethora of effects that cause the progressive deterioration of insulin sensitivity and ultimately cellular malfunction or death. This review addresses how metabolic abnormalities in white adipose tissue leading to excessive lipid or abnormal adipokine release can be modified by PPARγ activation. It also discusses the etiology of cardiac lipotoxicity and oxidative stress, in relation to imbalanced lipid delivery and clearance and how PPARα activation can be used to correct some of these effects.

Cardiometabolic syndrome is a mixture of interrelated risk factors predisposing individuals to elevated risk of atherosclerotic cardiovascular disease and type 2 diabetes mellitus. Nuclear receptors, specifically peroxisome proliferator-activated receptors (PPARs), were identified to play a pivotal role in the regulation of metabolic homeostasis. However, with rosiglitazone currently under intense scrutiny great concerns have arisen regarding the safety of the thiazolidinedione PPAR-γ agonist family as a whole. This review discusses the current concern with PPAR-γ agonists by exploring if PPARs can still be considered worth pursuing as a viable target for cardiovascular diseases. We examine current research focusing on identifying ligands that are dual and pan-PPAR agonists, selective PPAR-γ modulators, PPAR-β/δ agonists and that are of natural origin.

Peroxisome proliferator-activated receptor (PPAR)γ, a nuclear hormone receptor, is activated by its agonists including anti-diabetic thiazolidinediones, and has recently been reported to exert beneficial effects in the vasculature independently of its anti-diabetic effects. We here discuss our recent findings on the beneficial pleiotropic effects of PPARγ agonists. PPARγ agonists have been shown to lower blood pressure in both animals and humans, which may possibly be mediated via the PPARγ agonist-mediated inhibition of the renin-angiotensin-aldosterone system (RAAS) including the suppression of angiotensin (Ang) II type 1 receptor expression/Ang II-mediated signaling pathways and Ang II-induced adrenal aldosterone synthesis/secretion. PPARγ agonists also inhibited the progression of atherosclerosis in both animals and humans. PPARγ agonist-mediated inhibition of the RAAS and the thromboxane A2 system as well as endothelial protection may possibly be involved in the inhibitory effects on blood pressure and atherosclerosis. Furthermore, PPARγ agonists were demonstrated to have reno-protective effects, especially in reducing proteinuria in diabetic nephropathy in both animals and humans. The reno-protective effects of PPARγ agonists were also observed in non-diabetic renal dysfunctions. The effects may possibly be mediated via the PPARγ agonist-mediated blood pressure lowering, endothelial protection, and vasodilation of the glomerular efferent arterioles.. Additionally, anti-neoplastic effects of PPARγ agonists have recently received much attention. PPARγ agonists, may therefore, be useful and effective against lifestyle-related diseases.

PPAR agonists represent a heterogeneous group of compounds that have been used in the treatment of cardiovascular and metabolic diseases for over thirty years. While the primary indications for PPAR agonist therapy focus on hyperlipidemia and diabetes, there is a growing body of pre-clinical data that suggests they may be beneficial in the treatment of heart failure; a disease marked by abnormal myocardial metabolism, fibrosis and insulin insensitivity. PPAR agonist treatment in numerous animal models of systolic heart failure have demonstrated improvement in cardiac function with decreased fibrosis, improved contractility and endothelial function. However, considerable controversy exists on the cardiac safety profile of PPAR agonists, particularly concern for inducing lipotoxicty and precipitating or worsening heart failure. In addition during pre-clinical testing, many compounds have been associated with increased death and adverse cardiovascular outcomes casting a pall over their future use for treating disorders of myocardial function. This article will review cardiac pathways involved in PPAR activation and their potential regulation of maladaptive pathways involved in heart failure and highlight molecular mechanisms that may contribute to adverse events and raise safety concerns. Specific attention will be focused on PPAR alpha and gamma, subtypes for which commercially available PPAR agonists are currently available.

PPARγ-modulators, a class of anti-diabetic drugs as represented by thiazolidinediones (TZD), have been associated with cardiovascular risks in type-2 diabetes in humans but a similar liability has not been demonstrated in preclinical models. This gap between clinical and preclinical observations may reflect the lack of a translational model for cardiac safety assessment because preclinical efficacy for glycemic control for PPARγ-modulators is routinely conducted in animals with diabetic background while drug safety study is performed in young and health animals with little risk of heart failure, in contrast to the complex pathophysiological conditions of patients subjected to the treatment of TZDs. Therefore, some key steps are important to address this translational gap. First, it is essential to use an appropriate translational model that mimics most of human pathophysiology for the assessment of cardiovascular safety for TZDs. Second, it calls for the discovery of a translational biomarker (most likely a collection of biomarkers due to multiple risk factors contributed to the complex disease) to be able to sensitively detect the disease progression and in response to therapy. Specific examples are provided in this review for the use of a rodent model of myocardial infarction-induced heart failure to address the cardiac safety concern in response to chronic treatment of rosiglitazone. Multiple biomarkers, including physiological, biochemical, pharmacogenomic and imaging biomarkers, were applied to assess the cardiovascular risk in this heart failure model. The data and strategic approach are discussed from translational medicine perspectives.

Peroxisome proliferator-activated receptor (PPAR) is involved in the pathology of numerous diseases including obesity, diabetes, and atherosclerosis, because of its role in decreasing insulin resistance and inflammation. Type 2 diabetes mellitus and obesity are the most frequent endocrine-metabolic diseases and their pathogenic basis are characterized by insulin resistance and insulin secretion defects that can be demonstrated through several alterations in carbohydrates, lipids, and protein metabolism. For that reason a class of compounds, called thiazolidinediones, has been developed for the management of type 2 diabetes mellitus. Thiazolidinediones are PPAR-γ agonists regulating the expression of several genes involved in the regulation of glucose, lipid and protein metabolism, enhancing the action of insulin in insulin-sensitive tissue by increasing glucose uptake in skeletal muscle and adipose tissue, and decreasing hepatic glucose production. Pioglitazone is the only available PPAR-γ agonist for the treatment of type 2 diabetes after rosiglitazone withdrawal from several countries. This review discusses the safety and effectiveness of pioglitazone in the clinical practice for the treatment of type 2 diabetes mellitus.

Peroxisome Proliferator-Activated Receptor γ (PPARγ), originally described as a transcription factor for genes of carbohydrate and lipid metabolism, has been more recently studied in the context of cardiovascular pathophysiology. Here, we review the available data on PPARγ ligands as modulator of vascular tone. PPARγ ligands include: thiazolidinediones (used in the treatment of type 2 diabetes mellitus), glitazars (bind and activate both PPARγ and PPARα), and other experimental drugs (still in development) that exploit the chemistry of thiazolidinediones as a scaffold for PPARγ-independent pharmacological properties. In this review, we examine both short (mostly from in vitro data)- and long (mostly from in vivo data)-term effects of PPARγ ligands that extend from PPARγ-independent vascular effects to PPARγ-dependent gene expression. Because endothelium is a master regulator of vascular tone, we have attempted to differentiate between endothelium-dependent and endothelium-independent effects of PPARγ ligands. Based on available data, we conclude that PPARγ ligands appear to influence vascular tone in different experimental paradigms, most often in terms of vasodilatation (potentially increasing blood flow to some tissues). These effects on vascular tone, although potentially beneficial, must be weighed against specific cardiovascular warnings that may apply to some drugs, such as rosiglitazone.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common of the monogenic disorders and is characterized by bilateral renal cysts; cysts in other organs including liver, pancreas, spleen, testis and ovary; vascular abnormalities including intracranial aneurysms and subarachnoid hemorrhage; and cardiac disorders such as left ventricular hypertrophy (LVH), mitral valve regurgitation, mitral valve prolapse and aortic regurgitation. Autosomal recessive polycystic kidney disease (ARPKD) is an early-onset multisystem disorder characterized by polycysts divided from the renal collecting ducts, congenital hepatic fibrosis, and ductal plate malformation complicated by pulmonary hyperplasia and systemic hypertension. In these polycystic kidney diseases (PKD), progressive enlargement of the cysts results from the aberrant proliferation of tubule epithelial cells and trans-epithelial fluid secretion leading to extensive nephron loss and interstitial fibrosis. Peroxisome proliferator-activated receptor-γ (PPAR-γ), a member of the liganddependent nuclear receptor superfamily, is expressed in a variety of tissues, including kidneys and liver, and plays important roles in cell proliferation, fibrosis, and inflammation. PPAR-γ agonists ameliorate polycystic kidney, polycystic liver and cardiac defects through β-catenin, c-Myc, CFTR, MCP-1, S6, ERK, and TGF-β signaling pathways in animal models of PKD. In this review, we describe the possible therapeutic value of PPAR-γ agonists in the treatment of renal and hepatic manifestations, and cardiac defects in progressive PKD.