Bone and Mineral, 19 (Suppl.) (1992) S57-S62 0169-6009/92/$05.00 0 1992 Elsevier Sciexe Publishers B.V. All rights reserved.
s57
BAM 00489 This paper was presented at a satellite symposium at the XIth International Conference on Calcium Regulating Hormones, held April 2429, 1992, Florence, Italy.
Effect of ipriflavone on bone mass in elderly osteoporotic women
M. Passer?‘, M. Biondi’, D. Costi”, L. Bufalinob, G.N. Castiglioneb, C. Di PeppeC and G. Abate’ ‘Internal Medicine Institute, University of Parma, Parma. Italy, bClinical Rescarch Dept., Chiesi Farmaceutki. Parma, Italy and ‘Geriatrics Dept., University of Chieti, Chieti, ltaly
Summary A study in elderly osteoporotic women was performed to assess the effect of one year treatment with ipriflavone (IP) on bone mass and bone biomarkers. Twenty-eight women aged over 65, with diagnosis of osteoporosis and X-ray evidence of at least one vertebral fracture, were treated with IP tablets (600 mg/ day) or placebo (PL), according to a randomized, double-blind, parallel-group design. One g/day calcium supplementation was given to all patients. After 12 months a significant increase (+ 6%, PcO.05) of bone mineral density (BMD) at the distal radius (DPA) was obtained in the IP-group. Serum osteocalcin (BGP) and urinary HO-proline/creatinine (HOP/Cr) values were reduced in the same group. BMD values did not change (-0.3%) in the placebo group. One woman of the PL-group was withdrawn from treatment because of worsening of pain, due to new vertebral crushes. Side effects (mainly gastrointestinal) arose in 8 IP- and in 5 PL-treated women. The compliance to the oral administration was good.
Key words: Osteoporosis; Elderly patients; lpriflavone
Introduction
It has been stated that most fractures in the elderly are due to low bone mass [l]. They occur spontaneously or with minimal traumas and are more frequent in women than in men. The sites involved are generally hip, vertebrae and distal forearm, in which the cancellous bone is predominant. These types of fractures are designated as age-related fractures [2]and in older patients the effect of ageing itself appears determinant [3,4]. Correspondence to: Prof. Mario Passeri, Istituto di Clinica Medica dell’llniversita’ di Parma, Ospedale Maggiore, 43 100 Parma, Italy.
S58
A number of events have been proposed as pathogenetic factors of bone mass loss in the elderly. Reduced mobility and outdoor activity may lead to scarce sun exposure, and therefore to vitamin D activation deficiency. At the same time both the renal synthesis of the active metabolite and the gut response to 1,25(OH)zDs decrease.The resulting reduction of the intestinal absorption of calcium stimulates the secretion of parathyroid hormone with secondary hyperparathyroidism and consequent bone loss. As a consequence of the increase of elderly people, which is estimated to reach 1200 million in the world in the next 40 years [5], the problem of the enormous social and economic cost ofosteoporosis has to be taken into consideration. For this reason, a series of therapeutic approaches have been suggested. Adequate dietary intake of calcium and vitamin D, physical activity and pharmacological therapy represent the possibilities for the management of involutional osteoporosis, with the aim of arresting bone mass reduction. Calcitonins, anabolic steroids, bisphosphonates and fluorides have been used in the treatment of established osteoporosis with variable results [6-g]. Recently, ipriflavone (IP), a synthetic derivative of natural occurring flavonoids, has been reported to exert interesting effects on bone. In vitro, IP inhibits the release of calcium from rat fetal bones in culture [IO]. Similarly, in vivo, IP reduces bone resorption induced by transplantation of parathyroid glands on the parietal bone of rats [ 11,121,by ovariectomy [ 131,by corticosteroids [ 141and by immobilization [ 151.Beside these inhibitory effects on bone resorption, IP has also been shown to influence the process of bone formation. Sziklai et al. demonstrated that IP stimulates the synthesis of collagen in samples of human otosclerotic auditory ossicles in culture [!6]. More recently, Benvenuti et al. evidenced a stimulatory effect of IP and its main metabolites on growth and function of a subclone of an osteoblast-likecell lineagein culture [ 171. Several non controlled [l&-22] and controlled [23-251 clinical studies have shown the efficacy of IP treatment in preventing loss of bone mass and in increasing bone mineral content in patients with established postmenopausal osteoporosis. The aim of the present study was to investigate the effect of IP in a group of elderly subjects affected by involutional osteoporosis,
Materials and Methods
Twenty-eight female outpatients aged 65 to 85 were enrolled. Prese&.ceof at least one vertebral fracture evidenced by X-ray examination, bone mineral density @MD) at the distal radius ~2 SD compared to the average value of women at maturity, and informed consent were the criteria for eligibility. Women affected by pathologies andfor treated with drugs interfering with bone metabolism, women with severe cardiac, renal or hepatic impairment and psycotic, immobilized or not self-sufficient women were excluded. Patients were randomly assigned to receive at meals one 200 mg tablet of IP tid, or one placebo (PL) tablet tid, according to a double-blind, parallel-group design.
s59
An oral calcium supplementation (1 g of calcium carbonate and gluconate/day) was assigned to all the patients. X-ray examination of the spine, and bone mass measurement at the forearm (10th distal radius) were performed at basal time and repeated after 12 months. For the BMD measurements a dual-photon absorptiometer (Osteoden P NIM, Verona, Italy), which employs 12’1and 241Amas radioactive sources, with a precision of 0.9% in vitro and 1.5% in vivo, was used, Blood samples were taken and 24-h urine collection performed at the same times in order to measure serum calcium, phosphate, alkaline phosphatase boneisoenzyme (ALP-iso), PTH (C terminal) and osteocalcin (BGP) levels, and urinary hydroxyproline (HOP) concentrations. Plasma 25(OH) vitamin D3 levels were measured at basal time. Serum calcium was evaluated with an atomic spectrophotometer. Serum phosphate was measured by the Anorganisches Phosphat kit (Merck, Darmstadt, Germany). Serum ALP-is0 was measured according to the procedure described by Rosalki and Foo [26], where the isoenzyme was precipitated using wheat-germ lectin. Serum BGP was evaluated by a commercially available RIA kit, (Incstar, Minnesota, USA). PTH was measured by PTH C-terminal RIA kit (Incstar, Minnesota, USA). The 24-h urine HOP was assessed by the Hypronosticon kit (Organon, Boxtel, the Netherlands). Serum 25(OH) vitamin Ds levels were determined using the 25OH-D RIA Kit (Nichols Institute Diagnostics, San Juan Capistrano, CA, USA). Urinary creatinine measurement, blood chemistry and haematology and urinalysis were also performed, using the standard laboratory procedures. Blood pressure, heart rate and development of adverse reactions were monitored every 6 months. Statistical analysis
The Wilcoxon signed rank-test was used for the evaluation of the within-treatment differences; the Wilcoxon two-sample test was used for the comparison of the basal values, and for the evaluation of the between-treatment differences.
Results
The characteristics of the patients are summarized in Table 1. The two groups were homogeneous regarding age, height, weight and distance from menopause. 25(OH) vitamin D3 levels were within the limits of the normal range for the same season (mean + SD: 47+25 ng/ml). One or more vertebral crushes were evidenced by the baseline X-ray examination in all patients; flattening or wedging of the thoracic and lumbar vertebrae were also present in most of the patients. The final X-ray examination did not show notable modifications in all but one patient, who was withdrawn from the treatment for the development of back pain due to new fractures in two thoracic
Table I Patients’ description
IP (Ir= 14) PL (fi= 14)
Age W meanf SE
Height (cm) meanf SE
Weight (kg) mean+ SE
Yrs from menopause meanf SE
69 f 0.65 69 f 0.84
IS6 f 1.20 154 f 1.67
63 f: 1.90 59 f 1.70
21 f 1.4s 20 + 1.49
Wilcoxon t-sample test betweentreatments:not significant.
vertebrae, At the opening of the code, the patient was seen to have taken the placebo. A positive effect on hone mass was shown after 12 months in the IP-treated group, in which a 6.094 (PcO.05) increase of the BMD of the forearm was obtained, while a -0.3% variation was evidenced in the PL-treated group (Table 2). The values of biochemical markers of bone metabolism are reported in Table 3. n&ant (PcO.01) increase of serum calcium levels in the PL-treated group was observed. Serum BGP and urinary HOP (expressed as HOP/creatinine ratio) were reduced, although not significantly, in the IP-treated group. Blood chemistry and haematology as well as urinalysis and clinical examinations failed to show any notable modification. Eight patients of the IP-treated group and five of the PL-group complained of side effects in the early period of the study. Gastric discomfort and diarrhea were the most common symptoms; skin rashes appeared in one subject of each group. All the symptoms disappeared spontaneously without interrupting the treatment. The oral administration seemed to play a positive role in patient compliance.
Due to the progressive ageing of the population, the annual number of osteoporosis-related fractures is expected to rise dramatically in the next decades. A delay in loss of bone mass or an increase in bone mass ~‘_;uldcontribute to a considerable reduction in the number of expected hip fractures [27]. For dhis Table 2 Bone Mineral Density (BMD) of the 10th distal radius at the baseline, and after 12 months of treatment with IP or PL Treatment
IP PL
BMD: mg/cm’ (mean & SE) Baseline
12 Months
% Differ.
pu
225.5* 15.4 237.2&14.5
239.0+ 14.7 236.Sk 14.1
+ 6.0 - 0.3
< 0.05 NS
a Wilcoxon signed rank test within treatment.
_
S61
Table 3 Biochemical markers of bone-metabolism in two groups of elderly osteoporotic women before and after 12 months of treatment with IP or PL (mean f SE) Iprillavone
Placebo
baseline
12 months
baseline
12 months
Serum Calcium (mg/ 100 ml)
9.OkO.l
9.4f0.4
9.1 k0.l
Phosphate (mg/lOO ml)
3.8kO.2
3.9rto.3
3.6kO.2
3.8kO.2
ALP-is0 (U/100 ml) BGP (ng/ml)
85.0& 12.0 6.9kO.9
94.3 f 22.9 6.0f0.5
79.0+ 14.0
94.5 19.5
PTH-ter.C (ng/ml)
44.lk5.1
48.0 f 3.0
56.3 II: 6.4
50.0 + 7. I
Creatinine (mg/lOO ml)
0.92 f 0.03
1.03f0.13
0.88 + 0.06
0.90 f 0.04
22.1 f I.8
19.5f2.3
21.5& 1.7
2l.O& 1.3
6.5+0.7
9.7*+0.1
6.8 + 0.6
urir,L# HGP/Cr (mglg)
Wilcoxon signed rank test : *P
s57
BAM 00489 This paper was presented at a satellite symposium at the XIth International Conference on Calcium Regulating Hormones, held April 2429, 1992, Florence, Italy.
Effect of ipriflavone on bone mass in elderly osteoporotic women
M. Passer?‘, M. Biondi’, D. Costi”, L. Bufalinob, G.N. Castiglioneb, C. Di PeppeC and G. Abate’ ‘Internal Medicine Institute, University of Parma, Parma. Italy, bClinical Rescarch Dept., Chiesi Farmaceutki. Parma, Italy and ‘Geriatrics Dept., University of Chieti, Chieti, ltaly
Summary A study in elderly osteoporotic women was performed to assess the effect of one year treatment with ipriflavone (IP) on bone mass and bone biomarkers. Twenty-eight women aged over 65, with diagnosis of osteoporosis and X-ray evidence of at least one vertebral fracture, were treated with IP tablets (600 mg/ day) or placebo (PL), according to a randomized, double-blind, parallel-group design. One g/day calcium supplementation was given to all patients. After 12 months a significant increase (+ 6%, PcO.05) of bone mineral density (BMD) at the distal radius (DPA) was obtained in the IP-group. Serum osteocalcin (BGP) and urinary HO-proline/creatinine (HOP/Cr) values were reduced in the same group. BMD values did not change (-0.3%) in the placebo group. One woman of the PL-group was withdrawn from treatment because of worsening of pain, due to new vertebral crushes. Side effects (mainly gastrointestinal) arose in 8 IP- and in 5 PL-treated women. The compliance to the oral administration was good.
Key words: Osteoporosis; Elderly patients; lpriflavone
Introduction
It has been stated that most fractures in the elderly are due to low bone mass [l]. They occur spontaneously or with minimal traumas and are more frequent in women than in men. The sites involved are generally hip, vertebrae and distal forearm, in which the cancellous bone is predominant. These types of fractures are designated as age-related fractures [2]and in older patients the effect of ageing itself appears determinant [3,4]. Correspondence to: Prof. Mario Passeri, Istituto di Clinica Medica dell’llniversita’ di Parma, Ospedale Maggiore, 43 100 Parma, Italy.
S58
A number of events have been proposed as pathogenetic factors of bone mass loss in the elderly. Reduced mobility and outdoor activity may lead to scarce sun exposure, and therefore to vitamin D activation deficiency. At the same time both the renal synthesis of the active metabolite and the gut response to 1,25(OH)zDs decrease.The resulting reduction of the intestinal absorption of calcium stimulates the secretion of parathyroid hormone with secondary hyperparathyroidism and consequent bone loss. As a consequence of the increase of elderly people, which is estimated to reach 1200 million in the world in the next 40 years [5], the problem of the enormous social and economic cost ofosteoporosis has to be taken into consideration. For this reason, a series of therapeutic approaches have been suggested. Adequate dietary intake of calcium and vitamin D, physical activity and pharmacological therapy represent the possibilities for the management of involutional osteoporosis, with the aim of arresting bone mass reduction. Calcitonins, anabolic steroids, bisphosphonates and fluorides have been used in the treatment of established osteoporosis with variable results [6-g]. Recently, ipriflavone (IP), a synthetic derivative of natural occurring flavonoids, has been reported to exert interesting effects on bone. In vitro, IP inhibits the release of calcium from rat fetal bones in culture [IO]. Similarly, in vivo, IP reduces bone resorption induced by transplantation of parathyroid glands on the parietal bone of rats [ 11,121,by ovariectomy [ 131,by corticosteroids [ 141and by immobilization [ 151.Beside these inhibitory effects on bone resorption, IP has also been shown to influence the process of bone formation. Sziklai et al. demonstrated that IP stimulates the synthesis of collagen in samples of human otosclerotic auditory ossicles in culture [!6]. More recently, Benvenuti et al. evidenced a stimulatory effect of IP and its main metabolites on growth and function of a subclone of an osteoblast-likecell lineagein culture [ 171. Several non controlled [l&-22] and controlled [23-251 clinical studies have shown the efficacy of IP treatment in preventing loss of bone mass and in increasing bone mineral content in patients with established postmenopausal osteoporosis. The aim of the present study was to investigate the effect of IP in a group of elderly subjects affected by involutional osteoporosis,
Materials and Methods
Twenty-eight female outpatients aged 65 to 85 were enrolled. Prese&.ceof at least one vertebral fracture evidenced by X-ray examination, bone mineral density @MD) at the distal radius ~2 SD compared to the average value of women at maturity, and informed consent were the criteria for eligibility. Women affected by pathologies andfor treated with drugs interfering with bone metabolism, women with severe cardiac, renal or hepatic impairment and psycotic, immobilized or not self-sufficient women were excluded. Patients were randomly assigned to receive at meals one 200 mg tablet of IP tid, or one placebo (PL) tablet tid, according to a double-blind, parallel-group design.
s59
An oral calcium supplementation (1 g of calcium carbonate and gluconate/day) was assigned to all the patients. X-ray examination of the spine, and bone mass measurement at the forearm (10th distal radius) were performed at basal time and repeated after 12 months. For the BMD measurements a dual-photon absorptiometer (Osteoden P NIM, Verona, Italy), which employs 12’1and 241Amas radioactive sources, with a precision of 0.9% in vitro and 1.5% in vivo, was used, Blood samples were taken and 24-h urine collection performed at the same times in order to measure serum calcium, phosphate, alkaline phosphatase boneisoenzyme (ALP-iso), PTH (C terminal) and osteocalcin (BGP) levels, and urinary hydroxyproline (HOP) concentrations. Plasma 25(OH) vitamin D3 levels were measured at basal time. Serum calcium was evaluated with an atomic spectrophotometer. Serum phosphate was measured by the Anorganisches Phosphat kit (Merck, Darmstadt, Germany). Serum ALP-is0 was measured according to the procedure described by Rosalki and Foo [26], where the isoenzyme was precipitated using wheat-germ lectin. Serum BGP was evaluated by a commercially available RIA kit, (Incstar, Minnesota, USA). PTH was measured by PTH C-terminal RIA kit (Incstar, Minnesota, USA). The 24-h urine HOP was assessed by the Hypronosticon kit (Organon, Boxtel, the Netherlands). Serum 25(OH) vitamin Ds levels were determined using the 25OH-D RIA Kit (Nichols Institute Diagnostics, San Juan Capistrano, CA, USA). Urinary creatinine measurement, blood chemistry and haematology and urinalysis were also performed, using the standard laboratory procedures. Blood pressure, heart rate and development of adverse reactions were monitored every 6 months. Statistical analysis
The Wilcoxon signed rank-test was used for the evaluation of the within-treatment differences; the Wilcoxon two-sample test was used for the comparison of the basal values, and for the evaluation of the between-treatment differences.
Results
The characteristics of the patients are summarized in Table 1. The two groups were homogeneous regarding age, height, weight and distance from menopause. 25(OH) vitamin D3 levels were within the limits of the normal range for the same season (mean + SD: 47+25 ng/ml). One or more vertebral crushes were evidenced by the baseline X-ray examination in all patients; flattening or wedging of the thoracic and lumbar vertebrae were also present in most of the patients. The final X-ray examination did not show notable modifications in all but one patient, who was withdrawn from the treatment for the development of back pain due to new fractures in two thoracic
Table I Patients’ description
IP (Ir= 14) PL (fi= 14)
Age W meanf SE
Height (cm) meanf SE
Weight (kg) mean+ SE
Yrs from menopause meanf SE
69 f 0.65 69 f 0.84
IS6 f 1.20 154 f 1.67
63 f: 1.90 59 f 1.70
21 f 1.4s 20 + 1.49
Wilcoxon t-sample test betweentreatments:not significant.
vertebrae, At the opening of the code, the patient was seen to have taken the placebo. A positive effect on hone mass was shown after 12 months in the IP-treated group, in which a 6.094 (PcO.05) increase of the BMD of the forearm was obtained, while a -0.3% variation was evidenced in the PL-treated group (Table 2). The values of biochemical markers of bone metabolism are reported in Table 3. n&ant (PcO.01) increase of serum calcium levels in the PL-treated group was observed. Serum BGP and urinary HOP (expressed as HOP/creatinine ratio) were reduced, although not significantly, in the IP-treated group. Blood chemistry and haematology as well as urinalysis and clinical examinations failed to show any notable modification. Eight patients of the IP-treated group and five of the PL-group complained of side effects in the early period of the study. Gastric discomfort and diarrhea were the most common symptoms; skin rashes appeared in one subject of each group. All the symptoms disappeared spontaneously without interrupting the treatment. The oral administration seemed to play a positive role in patient compliance.
Due to the progressive ageing of the population, the annual number of osteoporosis-related fractures is expected to rise dramatically in the next decades. A delay in loss of bone mass or an increase in bone mass ~‘_;uldcontribute to a considerable reduction in the number of expected hip fractures [27]. For dhis Table 2 Bone Mineral Density (BMD) of the 10th distal radius at the baseline, and after 12 months of treatment with IP or PL Treatment
IP PL
BMD: mg/cm’ (mean & SE) Baseline
12 Months
% Differ.
pu
225.5* 15.4 237.2&14.5
239.0+ 14.7 236.Sk 14.1
+ 6.0 - 0.3
< 0.05 NS
a Wilcoxon signed rank test within treatment.
_
S61
Table 3 Biochemical markers of bone-metabolism in two groups of elderly osteoporotic women before and after 12 months of treatment with IP or PL (mean f SE) Iprillavone
Placebo
baseline
12 months
baseline
12 months
Serum Calcium (mg/ 100 ml)
9.OkO.l
9.4f0.4
9.1 k0.l
Phosphate (mg/lOO ml)
3.8kO.2
3.9rto.3
3.6kO.2
3.8kO.2
ALP-is0 (U/100 ml) BGP (ng/ml)
85.0& 12.0 6.9kO.9
94.3 f 22.9 6.0f0.5
79.0+ 14.0
94.5 19.5
PTH-ter.C (ng/ml)
44.lk5.1
48.0 f 3.0
56.3 II: 6.4
50.0 + 7. I
Creatinine (mg/lOO ml)
0.92 f 0.03
1.03f0.13
0.88 + 0.06
0.90 f 0.04
22.1 f I.8
19.5f2.3
21.5& 1.7
2l.O& 1.3
6.5+0.7
9.7*+0.1
6.8 + 0.6
urir,L# HGP/Cr (mglg)
Wilcoxon signed rank test : *P
