Abstract
Osteoclasts and osteoblasts define skeletal mass, structure and strength through their respective actions in resorbing and forming bone. This remodeling process is orchestrated by the actions of hormones and growth factors, which regulate a cytokine system comprising the receptor activator of nuclear factor κB ligand (RANKL), its receptor RANK and the soluble decoy receptor osteoprotegerin (OPG). Bone resorption depends on RANKL, which determines osteoclast formation, activity and survival. Importantly, cells of the osteoblastic lineage mainly provide RANKL and therefore, are central in the regulation of osteoclast functions. Catabolic effects of RANKL are inhibited by OPG, a TNF receptor family member that binds RANKL, thereby preventing the activation of its receptor RANK, which is expressed by osteoclast precursors. Because this cytokine network is pivotal for the regulation of bone mass in health and diseases, including osteoporosis, rheumatoid arthritis and malignant bone conditions, it has been successfully used for the generation of a targeted therapy to block osteoclast actions. The clinical approval of denosumab, a fully monoclonal antibody against RANKL, provides a novel option to treat bone diseases with a potent, targeted and reversible inhibitor of bone resorption. Although RANKL is also expressed by endothelial cells, T lymphocytes, synovial fibroblasts and various tumor cells, no meaningful clinical extraskeletal effects have been reported after administration of denosumab. This article summarizes the molecular and cellular basis of the RANKL/RANK/OPG system and presents preclinical and clinical studies on the skeletal actions of denosumab.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
The adult skeleton consists of trabecular and cortical bone that is continuously resorbed and formed in a process called bone remodeling. This process regulates calcium homeostasis, keeping extracellular calcium levels within a tightly controlled physiological range and is responsible for the repair of bone microdamage. Bone remodeling is well balanced in young adults. In elderly people, postmenopausal women and patients with inflammatory or malignant bone diseases, bone resorption is commonly enhanced, leading to reduced bone mass, impaired bone quality and skeletal fractures.
The discovery and characterization of the RANKL/RANK/OPG pathway has contributed to a better understanding of bone biology and paved the way for developing novel therapies for bone diseases characterized by excessive osteoclastic activity [1, 2]. The principal regulator of bone resorption is RANKL, a transmembrane protein that is highly expressed by osteoblasts [3], periosteal cells [4] and osteocytes [5]. RANKL binds to its receptor RANK, which is mainly expressed by osteoclasts and preosteoclasts [6], but has also been shown to be expressed by endothelial cells, smooth muscle cells, T and B lymphocytes, dendritic cells and various malignant cells [7–9]. RANKL- and RANK-knockout mice are severely osteopetrotic, display defects in tooth eruption, lack lymph nodes and fail to develop a lactating mammary gland [10–12] (Table 1). After binding to RANK, RANKL stimulates the formation, activity and survival of osteoclasts, resulting in increased bone resorption [13]. Osteoprotegerin (OPG) is a soluble ‘decoy receptor’ that is also expressed by osteoblasts and binds to RANKL with high affinity [14]. Because OPG directly competes with RANK for the binding sites of RANKL, osteoclastogenesis and subsequent bone resorption can be prevented by OPG [15, 16]. During physiological bone remodeling, the ratio of RANKL to OPG is balanced. However, an excess of RANKL is found in estrogen deficiency [17], systemic glucocorticoid exposure [18], active inflammatory process in rheumatoid arthritis [19], skeletal malignancies such as multiple myeloma [20], bone metastases [21] and vascular calcification [22], resulting in exacerbated bone loss. Detailed understanding of the RANKL/RANK pathway and its clinical implications led to the development of potential therapeutic targets. The first compounds to be tested were OPG analogues, such as OPG–Fc fusion proteins [23]. These had several limitations concerning half-life and specificity. Thus, a fully human monoclonal antibody against RANKL was developed. A significantly longer circulating half-life allowed a reduction in dosing frequency. The low potential for immune responses [24] and a higher specificity for RANKL preventing interactions with other TNF ligands [25] were other favorable characteristics of this antibody and led to its approval in 2010 (Fig. 1).
Skeletal actions of denosumab
Animal studies
Several animal studies highlight the essential role of RANKL/RANK/OPG in the regulation of bone remodeling. The suppression of bone remodeling by OPG in healthy rats leads to increased bone volume and density, whereas stimulation of bone remodeling in normal mice or rats by RANKL leads to reduced bone volume [26, 27]. Furthermore, injection of recombinant RANKL affects bone quality parameters such as matrix mineralization, cortical geometry and trabecular microarchitecture [28]. Conversely, RANKL inhibition through OPG–Fc in rats resulted in a profound inhibition in the number of functioning osteoclasts and a progressive increase in bone volume and bone mineral density [29]. Furthermore, 12 months of denosumab treatment in eugonad cynomolgus monkeys was associated with significant increases in cortical and cancellous bone strength [30].
In addition to regulating physiological bone remodeling, the RANKL/RANK/OPG cytokine network has also been found to be dysregulated in several animal models of human disease. Ovariectomy is associated with increased bone turnover and changes in qualitative bone parameters in rodents. An increase in RANKL levels [31] as well as increased [32] or decreased [33] OPG levels has been reported in this setting. In ovariectomized rats, OPG treatment was associated with reductions in osteoclast surfaces while increasing biomechanical strength parameters and bone mineral density at various sites [34, 35].
Preclinical orchiectomy models imitate androgen ablation therapy on bone [36, 37]. Androgens directly suppress the formation and bone-resorbing activity of osteoclasts [38, 39]. OPG expression in osteoblasts can be both upregulated [40] and downregulated [41] by androgens, and an increase of RANKL expression within the bone marrow could be shown in androgen-deficient rats [42]. OPG treatment prevented the deleterious effects of orchiectomy on bone microarchitecture when applied to orchiectomized mice [43]. Androgen replacement therapy can partially reverse the periosteal formation deficit when applied to rats after orchiectomy [44].
The significance of excessive RANKL activity in an inflammatory bone loss setting has been demonstrated by ample preclinical data in rheumatoid arthritis (RA) models. Animal models of RA are characterized by increased RANKL levels in inflamed joints [45] and the serum [46]. A significant rise in the RANKL–OPG ratio that is caused by a T cell-mediated release of RANKL has been shown in a murine model of RA [47] and this ratio further correlates with joint erosions and osteoclast activity [48]. Conversely, RANKL inhibition through OPG treatment suppressed the formation of bone erosions and downregulated the activity of osteoclasts in rodent models of adjuvant arthritis [49, 50], collagen-induced arthritis [50, 51] and TNF-mediated arthritis [52]. Furthermore, OPG also prevented systemic bone loss [53] and provided adequate cartilage preservation in arthritic mice [54].
RANKL/OPG abnormalities have also been implicated in glucocorticoid-induced bone loss. Glucocorticoids exert several direct and indirect adverse effects on bone, primarily through a reduction of osteoblasts and osteocyte activity and lifespan [55]. Evidence exists that OPG and RANKL are involved in the pathogenesis of glucocorticoid-induced bone loss. Glucocorticoids suppress OPG expression in osteoblast cell lines [56] while upregulating RANKL expression [57]. In murine models, glucocorticoids decrease bone mineral density mainly through suppression of bone formation [58, 59], whereas treatment with OPG prevented these changes [60].
Clinical data
Denosumab in osteoporosis
The antiresorptive activity and safety of denosumab were first shown in a phase I trial in postmenopausal women (Table 2). A rapid decrease of the bone resorption marker N-telopeptide by 81 % with denosumab at a dose of 3 mg/kg was demonstrated [61]. Subsequently, a phase II randomized placebo-controlled study was conducted in 412 postmenopausal women with low bone mass. In this study, 60 mg denosumab every 6 months during 1 year increased the lumbar spine bone mineral density (BMD) by 6.7 % [62]. The study was extended to cover a total of 4 years using different treatment protocols. While discontinuation of denosumab led to a decrease of BMD by 6.6 % at the lumbar spine within 12 months and an increase of bone turnover markers above baseline, resuming therapy increased BMD levels. This points towards a reversible action of denosumab on bone, which is in contrast to alendronate treatment where discontinuation resulted in a minor decrease of lumbar spine BMD and unchanged values of bone resorption markers [63–66].
The efficacy of denosumab in the treatment of postmenopausal osteoporosis was determined in the FREEDOM (Fracture Reduction Evaluation of Denosumab in Osteoporosis every 6 months) trial and was summarized in several reviews [67–69]. In this phase 3 study, patients received either subcutaneous injections of 60 mg denosumab twice a year or placebo for 3 years. In patients receiving denosumab, vertebral fractures, hip fractures and non-vertebral fractures were decreased by 68, 40 and 20 %, respectively [70]. Especially those patients with a moderate-to-high fracture risk benefited from denosumab as shown with FRAX analysis, a computer-based algorithm that assesses fracture probability from clinical risk factors [71]. Kidney functions were not affected and the appearance of other side effects was comparable to the placebo group. The DECIDE (The Determining Efficacy: Comparison of Initiating Denosumab versus Alendronate) study compared denosumab to alendronate treatment in postmenopausal women during a period of 12 months and revealed that denosumab was more effective in increasing BMD than alendronate at all skeletal sites measured (total hip, femoral neck, trochanter, lumbar spine and distal radius) [72]. Extension of the FREEDOM trial corroborated the efficacy and safety of denosumab. After two additional years of denosumab treatment, annual fracture incidences were still less than the rates observed in the FREEDOM placebo group, the BMD further increased at the lumbar spine and total hip BMD up to 13.7 and 7 %, respectively and no increase in adverse events were reported [73]. Furthermore, in the DAPS (Denosumab Adherence Preference Satisfaction) study, it was shown that postmenopausal women with osteoporosis who received subcutaneous injections of denosumab showed better adherence, compliance and persistence than women who were treated with alendronate once a week [74].
Denosumab in malignant conditions
Bone metastases are frequent complications especially of human prostate, breast and lung cancer [75], renal cell carcinomas [76] as well as multiple myeloma [77] mostly causing osteolysis and hypercalcemia. The RANKL/RANK/OPG signaling pathway has been implicated in regulating cancer cell migration to bone and progression of bone metastases [78–82]. Myeloma cells have been shown to upregulate RANKL expression [83–85] and to downregulate OPG protein production via sequestration and lysosomal inactivation [86]. In a murine model of bone metastasis, higher levels of RANKL were measured and were found to be inhibited by a recombinant OPG–FC protein [87]. Furthermore, elevated RANKL and RANK expressions have been observed in clear renal cell carcinomas compared with non-neoplastic renal tissue. In vitro experiments revealed that adding recombinant RANKL to clear renal cell carcinomas, Caki-1, increased cell migration, which could be inhibited by the administration of recombinant OPG [88]. Furthermore, stimulation of RANK-positive human breast cancer cells with recombinant RANKL induced actin polymerization, which resembles chemokine receptor signaling in cancer cell lines and increased cell migration. Neutralization of RANKL by OPG in a mouse model of myeloma metastasis resulted in a marked reduction in tumor burden in bones, while bisphosphonate treatment with zoledronic acid did not change the tumor burden of cancer metastasis [89]. In a murine prostate cancer model, OPG treatment resulted in reduction of osteoclast numbers and skeletal tumor burden [90, 91], and applying OPG to mice after injection of prostate cancer cells into the tibia and subcutaneously completely prevented the development of tibial tumors, but had no effect on subcutaneous tumor growth [92]. Another complication of bone metastasis, humoral hypercalcemia, was also shown to be reduced with OPG. In a murine model of hypercalcemia, OPG administration (5 mg/kg) significantly suppressed hypercalcemia compared with high-dose bisphosphonate treatment (pamidronate/zoledronic acid, 5 mg/kg) [93].
Targeting RANKL with a recombinant OPG construct in humans was initially examined on a small cohort of patients with breast cancer and multiple myeloma [23]. Receiving a single dose of denosumab reduced bone resorption up to 84 days compared with pamidronate (90 mg), which exhibited suppressive bone resorption effects for 3–4 weeks.
Beneficial effects of denosumab on BMD and the reduction of vertebral fractures were further demonstrated in two phase 3 trials with either non-metastatic breast cancer patients receiving aromatase inhibitors or non-metastatic prostate cancer patients receiving androgen-deprivation therapy [94, 95].
In a phase III randomized double-blind clinical trial in 1,904 men with bone metastases from castration-resistant prostate cancer, denosumab was compared with zoledronic acid. Denosumab at a dose of 120 mg once a month was found to be superior to placebo or zoledronic acid in preventing tumor-related bone lesions or skeletal-related events (SREs) as measured with the time between first diagnosis of prostate cancer and first-documented event of bone metastasis [96, 97]. These results were reproducible in a double-blind controlled study of 2,049 women with advanced breast cancer randomized to receive either monthly denosumab (120 mg) or zoledronic acid (4 mg) [98], where denosumab was superior in delaying the time to first and subsequent SRE per month by 18 and 23 % respectively. In a phase III randomized double-blind study in 1,779 patients with advanced cancer involving bone metastases or multiple myeloma, denosumab treatment was found to be non-inferior to zoledronic acid treatment regarding the median time of first on study SRE (21 vs. 16 months, respectively) [99].
Extraskeletal actions of denosumab
Denosumab in the treatment of arterial calcification
Osteoporosis and arterial calcification are prevalent diseases in Western society that may coincide. Especially in postmenopausal women, bone loss is associated with the progression of vascular calcification [100], and has been attributed to abnormalities of the RANKL/RANK/OPG pathway [101]. This was first suspected based on the phenotype from OPG−/− mice, where two thirds developed severe osteoporosis as well as marked calcified lesions in the aorta and renal arteries, sites of endogenous OPG expression, 2 months after birth [102]. Transgenic overexpression of OPG in these mice inhibited the development of those calcified lesions, whereas an injection of recombinant OPG to adult OPG−/− mice was not able to rescue arterial calcification, indicating that a lifelong deficiency prevents arterial calcification but OPG administration is not able to fully reverse this process [103]. However, treatment of an atherogenic mouse model with recombinant OPG significantly reduced calcified lesions, implying that OPG inhibits vascular calcification by blocking RANKL [104]. Similarly, RANKL induced calcification of vascular smooth muscle cells in vitro, which was inhibited after coincubation with OPG [8]. The induction of osteogenesis in the vasculature was shown to be dependent on a RANKL-mediated increased expression of bone morphogenic protein-2 and matrix Gla protein, two important regulators of the calcification process [105]. Furthermore, a direct effect of denosumab on RANKL was demonstrated in human RANKL knock-in mice expressing a chimeric murine/human RANKL protein, where denosumab reduced calcium deposition in the aortic wall of glucocorticoid-treated human RANKL knock-in mice [106].
Given this preclinical evidence, it seems reasonable that treating osteoporotic patients with denosumab could also have beneficial effects on arterial calcification. However, thus far, there is no evidence that denosumab reduces arterial calcification in osteoporosis patients. Several phase II studies showed no differences concerning the incidence of vascular disorders compared with placebo or bisphosphonate treatment, respectively [63, 107, 108]. Similarly, in the FREEDOM study, where 7,868 women between 60 and 90 years received either 60-mg denosumab or a placebo for 36 months, no differences regarding cardiovascular events were detected [70].
Denosumab in the treatment of inflammatory conditions
Inflammatory diseases such as rheumatoid arthritis (RA) [109] inflammatory bowel disease (IBD) [110], chronic obstructive pulmonary disease (COPD) [111] or systemic lupus erythematosis [112] are accompanied with systemic and local bone loss. The RANKL/RANK/OPG circuit and its function in the immune system is considered to be responsible for the connection between inflammation and bone destruction [113]. RANKL is expressed by activated CD4+ T cells [47], which activate osteoclasts [47, 114] and further stimulate other RANKL-expressing cells, such as dendritic cells or monocytes/macrophages [115, 116], promoting a catabolic milieu in the bone. In the event of COPD, it was shown that the level of RANKL and the RANKL/OPG ratio in the serum were significantly higher in patients with low BMD probably caused by the systemic inflammation [117]. But although inflammation and bone destruction are accompanied, several studies indicate that the RANKL/RANK/OPG pathway is only responsible for the situation in the bone and has no influence on the inflammatory component. In the case of collagen-induced arthritis in rats, a suitable model for RA, treatment with Fc–OPG prevented joint destruction had no effects on the inflammation [54]. Similarly, systemic OPG treatment of type II collagen-immunized mice overexpressing IL-17, a T cell cytokine that was shown to promote RANKL expression in vitro [118], prevented bone erosion [119]. In addition, in human TNF transgenic mice, which spontaneously develop inflammatory arthritis, OPG treatment increased BMD about 89 %; however, levels of inflammatory cytokines were not affected [120]. Finally, RANKL−/− mice remained sensitive to arthritis following administration of an arthritis-inducing serum [121]. However, although these studies propose no immunomodulatory function of RANKL, studies in IL-2-deficient mice, a model of autoimmunity that exhibits hyperactivation of CD4+ T cells leading to IBD, showed that treatment with Fc–OPG not only increased bone density but also reduced gastrointestinal inflammation. The authors assumed that these diverse results are because of significant differences of the underlying mechanisms involved in T cell-mediated inflammatory colitis, where RANK+ dendritic cells are the major antigen presenting cells and bone disease [122].
In humans, denosumab treatment is limited to RA so far. As is in preclinical studies, denosumab only improved bone parameters without any anti-inflammatory action. In a phase II clinical trial, injections of 180-mg denosumab twice a year to RA patients receiving methotrexate treatment significantly inhibited structural damage [123]. Other investigations showed that not only structural damage was inhibited but also denosumab treatment increased bone mineral density in the cortical bone [124] as well as the hands and wrists [125], but did not affect inflammation.
Immune system and thermoregulation
Apart from a T cell-mediated inflammatory response elicited by RANKL, other potential immune effects exist. For instance, RANKL and RANK-deficient mice completely lack lymph nodes and have a hypoplastic thymus [10, 11, 126], whereas OPG-deficient mice exhibit hypertrophic thyme accompanied with an increased number of mature medullary thymic epithelial cells [127]. Simultaneously, some RANK mutations in humans are associated with hypogammaglobulinemia [128–130], a disorder caused by a lack of B lymphocytes leading to an impaired antibody response to antigens.
Another immune mechanism for RANKL and RANK, which are also expressed in the central nervous system [131, 132], was reported in the context of central fever response in inflammation. In mice and rats, RANKL injections into the lateral ventricle caused severe fever with no effects on osteoclasts and which could be inhibited with OPG [133]. On the contrary, peripheral intraperitoneal injections of RANKL had no impact on body temperature, indicating that only central RANKL/RANK signaling is required for fever response. Furthermore, two children with RANK mutations leading to autosomal-recessive osteopetrosis could not become febrile during pneumonia identifying RANKL/RANK as key thermoregulators.
It further has been suggested that RANKL/RANK also might regulate immunity via the control of epidermal immune response. It was reported that RANKL is inducible on keratinocytes upon UV exposure and induces RANK-expressing Langerhans cells to regulate CD4+ CD25+ regulatory T cells, which show immunosuppressive effects. In line with that study, RANKL expression was strongly induced in psoriatic lesions, whereas in the epidermis of patients with cutaneous lupus erythematosus, an autoimmune disorder triggered by sun exposure, no RANKL expression was detected indicating its involvement in the suppression of autoimmunity [134].
Despite these preclinical findings, extension of the FREEDOM trial and pooled analysis of other clinical trials revealed that the overall susceptibility to infections or autoimmune diseases after denosumab treatment is not different from placebo treatment [70, 135].
Conclusions
Denosumab, a fully human monoclonal antibody to RANKL, displays an effective therapy to reduce fractures in osteoporosis, SREs in patients with bone metastases because of breast and prostate cancer as well as bone erosions in inflammatory disorders such as RA. Although several preclinical studies also indicate extraskeletal functions for the RANKL/RANK/OPG pathway, e.g., in the process of arterial calcification, fever regulation or immunosuppression in the skin, there is no evidence from clinical phase 3 studies to support that RANKL blockade by denosumab interferes with these processes.
References
H. Yasuda, N. Shima, N. Nakagawa, K. Yamaguchi, M. Kinosaki, S. Mochizuki, A. Tomoyasu, K. Yano, M. Goto, A. Murakami, E. Tsuda, T. Morinaga, K. Higashio, N. Udagawa, N. Takahashi, T. Suda, Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclastogenesis-inhibitory factor and is identical to TRANCE/RANKL. Proc. Natl Acad. Sci. USA 95, 3597–3602 (1998)
L.C. Hofbauer, A.E. Heufelder, Clinical review 114: hot topic. The role of receptor activator of nuclear factor-kappaB ligand and osteoprotegerin in the pathogenesis and treatment of metabolic bone diseases. J. Clin. Endocrinol. Metab. 85, 2355–2363 (2000)
P. Collin-Osdoby, Regulation of vascular calcification by osteoclast regulatory factors RANKL and osteoprotegerin. Circ. Res. 95, 1046–1057 (2004)
G. Silvestrini, P. Ballanti, F. Patacchioli, M. Leopizzi, N. Gualtieri, P. Monnazzi, E. Tremante, D. Sardella, E. Bonucci, Detection of osteoprotegerin (OPG) and its ligand (RANKL) mRNA and protein in femur and tibia of the rat. J. Mol. Histol. 36, 59–67 (2005)
T. Nakashima, M. Hayashi, T. Fukunaga, K. Kurata, M. Oh-Hora, J.Q. Feng, L.F. Bonewald, T. Kodama, A. Wutz, E.F. Wagner, J.M. Penninger, H. Takayanagi, Evidence for osteocyte regulation of bone homeostasis through RANKL expression. Nat. Med. 17, 1231–1234 (2011)
H. Hsu, D.L. Lacey, C.R. Dunstan, I. Solovyev, A. Colombero, E. Timms, H.L. Tan, G. Elliott, M.J. Kelley, I. Sarosi, L. Wang, X.Z. Xia, R. Elliott, L. Chiu, T. Black, S. Scully, C. Capparelli, S. Morony, G. Shimamoto, M.B. Bass, W.J. Boyle, Tumor necrosis factor receptor family member RANK mediates osteoclast differentiation and activation induced by osteoprotegerin ligand. Proc. Natl Acad. Sci. USA 96, 3540–3545 (1999)
J.-K. Min, Y.-M. Kim, Y.-M. Kim, E.-C. Kim, Y.S. Gho, I.-J. Kang, S.-Y. Lee, Y.-Y. Kong, Y.-G. Kwon, Vascular endothelial growth factor up-regulates expression of receptor activator of NF-kappa B (RANK) in endothelial cells. Concomitant increase of angiogenic responses to RANK ligand. J. Biol. Chem. 278, 39548–39557 (2003)
S. Panizo, A. Cardus, M. Encinas, E. Parisi, P. Valcheva, S. López-Ongil, B. Coll, E. Fernandez, J.M. Valdivielso, RANKL increases vascular smooth muscle cell calcification through a RANK-BMP4-dependent pathway. Circ. Res. 104, 1041–1048 (2009)
D. Santini, G. Schiavon, B. Vincenzi, L. Gaeta, F. Pantano, A. Russo, C. Ortega, C. Porta, S. Galluzzo, G. Armento, N. La Verde, C. Caroti, I. Treilleux, A. Ruggiero, G. Perrone, R. Addeo, P. Clezardin, A.O. Muda, G. Tonini, Receptor activator of NF-kB (RANK) expression in primary tumors associates with bone metastasis occurrence in breast cancer patients. PLoS ONE 6, e19234 (2011)
W.C. Dougall, M. Glaccum, K. Charrier, K. Rohrbach, K. Brasel, T. De Smedt, E. Daro, J. Smith, M.E. Tometsko, C.R. Maliszewski, A. Armstrong, V. Shen, S. Bain, D. Cosman, D. Anderson, P.J. Morrissey, J.J. Peschon, J. Schuh, RANK is essential for osteoclast and lymph node development. Genes Dev. 13, 2412–2424 (1999)
Y.Y. Kong, H. Yoshida, I. Sarosi, H.L. Tan, E. Timms, C. Capparelli, S. Morony, A.J. Oliveira-dos-Santos, G. Van, A. Itie, W. Khoo, A. Wakeham, C.R. Dunstan, D.L. Lacey, T.W. Mak, W.J. Boyle, J.M. Penninger, OPGL is a key regulator of osteoclastogenesis, lymphocyte development and lymph-node organogenesis. Nature 397, 315–323 (1999)
J.E. Fata, Y.Y. Kong, J. Li, T. Sasaki, J. Irie-Sasaki, R.A. Moorehead, R. Elliott, S. Scully, E.B. Voura, D.L. Lacey, W.J. Boyle, R. Khokha, J.M. Penninger, The osteoclast differentiation factor osteoprotegerin-ligand is essential for mammary gland development. Cell 103, 41–50 (2000)
L.C. Hofbauer, A.E. Heufelder, Role of receptor activator of nuclear factor-kappaB ligand and osteoprotegerin in bone cell biology. J. Mol. Med. 79, 243–253 (2001)
W.S. Simonet, D.L. Lacey, C.R. Dunstan, M. Kelley, M.S. Chang, R. Lüthy, H.Q. Nguyen, S. Wooden, L. Bennett, T. Boone, G. Shimamoto, M. DeRose, R. Elliott, A. Colombero, H.L. Tan, G. Trail, J. Sullivan, E. Davy, N. Bucay, L. Renshaw-Gegg, T.M. Hughes, D. Hill, W. Pattison, P. Campbell, S. Sander, G. Van, J. Tarpley, P. Derby, R. Lee, W.J. Boyle, Osteoprotegerin: a novel secreted protein involved in the regulation of bone density. Cell 89, 309–319 (1997)
T.L. Burgess, Y. Qian, S. Kaufman, B.D. Ring, G. Van, C. Capparelli, M. Kelley, H. Hsu, W.J. Boyle, C.R. Dunstan, S. Hu, D.L. Lacey, The ligand for osteoprotegerin (OPGL) directly activates mature osteoclasts. J. Cell Biol. 145, 527–538 (1999)
D.L. Lacey, H.L. Tan, J. Lu, S. Kaufman, G. Van, W. Qiu, A. Rattan, S. Scully, F. Fletcher, T. Juan, M. Kelley, T.L. Burgess, W.J. Boyle, A.J. Polverino, Osteoprotegerin ligand modulates murine osteoclast survival in vitro and in vivo. Am. J. Pathol. 157, 435–448 (2000)
G. Eghbali-Fatourechi, S. Khosla, A. Sanyal, W.J. Boyle, D.L. Lacey, B.L. Riggs, Role of RANK ligand in mediating increased bone resorption in early postmenopausal women. J. Clin. Invest. 111, 1221–1230 (2003)
C. von Tirpitz, S. Epp, J. Klaus, R. Mason, G. Hawa, N. Brinskelle-Schmal, L.C. Hofbauer, G. Adler, W. Kratzer, M. Reinshagen, Effect of systemic glucocorticoid therapy on bone metabolism and the osteoprotegerin system in patients with active Crohn’s disease. Eur. J. Gastroenterol. 15, 1165–1170 (2003)
H. Mori, R. Kitazawa, S. Mizuki, M. Nose, S. Maeda, S. Kitazawa, RANK ligand, RANK, and OPG expression in type II collagen-induced arthritis mouse. Histochem. Cell Biol. 117, 283–292 (2002)
T. Standal, C. Seidel, Ø. Hjertner, T. Plesner, R.D. Sanderson, A. Waage, M. Borset, A. Sundan, Osteoprotegerin is bound, internalized, and degraded by multiple myeloma cells. Blood 100, 3002–3007 (2002)
T. Michigami, M. Ihara-Watanabe, M. Yamazaki, K. Ozono, Receptor activator of nuclear factor kappaB ligand (RANKL) is a key molecule of osteoclast formation for bone metastasis in a newly developed model of human neuroblastoma. Cancer Res. 61, 1637–1644 (2001)
W. Lieb, P. Gona, M.G. Larson, J.M. Massaro, I. Lipinska, J.F. Keaney, J. Rong, D. Corey, U. Hoffmann, C.S. Fox, R.S. Vasan, E.J. Benjamin, C.J. O’Donnell, S. Kathiresan, Biomarkers of the osteoprotegerin pathway: clinical correlates, subclinical disease, incident cardiovascular disease, and mortality. Arterioscler. Thromb. Vasc. Biol. 30, 1849–1854 (2010)
J.-J. Body, P. Greipp, R.E. Coleman, T. Facon, F. Geurs, J.-P. Fermand, J.-L. Harousseau, A. Lipton, X. Mariette, C.D. Williams, A. Nakanishi, D. Holloway, S.W. Martin, C.R. Dunstan, P.J. Bekker, A phase I study of AMGN-0007, a recombinant osteoprotegerin construct, in patients with multiple myeloma or breast carcinoma related bone metastases. Cancer 97, 887–892 (2003)
L.M. Weiner, Fully human therapeutic monoclonal antibodies. J. Immunother. 29, 1–9 (1997)
P.J. Kostenuik, Osteoprotegerin and RANKL regulate bone resorption, density, geometry and strength. Curr. Opin. Pharmacol. 5, 618–625 (2005)
Y.Y. Yuan, P.J. Kostenuik, M.S. Ominsky, S. Morony, S. Adamu, D.T. Simionescu, D.M. Basalyga, F.J. Asuncion, T.A. Bateman, Skeletal deterioration induced by RANKL infusion: a model for high-turnover bone disease. Osteoporos. Int. 19, 625–635 (2008)
S.A.J. Lloyd, Y.Y. Yuan, P.J. Kostenuik, M.S. Ominsky, A.G. Lau, S. Morony, M. Stolina, F.J. Asuncion, T.A. Bateman, Soluble RANKL induces high bone turnover and decreases bone volume, density, and strength in mice. Calcif. Tissue Int. 82, 361–372 (2008)
S. Kwan Tat, M. Padrines, S. Théoleyre, D. Heymann, Y. Fortun, IL-6, RANKL, TNF-alpha/IL-1: interrelations in bone resorption pathophysiology. Cytokine Growth Factor Rev. 15, 49–60 (2004)
C. Capparelli, S. Morony, K. Warmington, S. Adamu, D. Lacey, C.R. Dunstan, B. Stouch, S. Martin, P.J. Kostenuik, Sustained antiresorptive effects after a single treatment with human recombinant osteoprotegerin (OPG): a pharmacodynamic and pharmacokinetic analysis in rats. J. Bone Miner. Res. 18, 852–858 (2003)
M.S. Ominsky, P.J. Kostenuik, P. Cranmer, S.Y. Smith, J.E. Atkinson, The RANKL inhibitor OPG-Fc increases cortical and trabecular bone mass in young gonad-intact cynomolgus monkeys. Osteoporos. Int. 18, 1073–1082 (2007)
T. Yoneda, N. Ishimaru, R. Arakaki, M. Kobayashi, T. Izawa, K. Moriyama, Y. Hayashi, Estrogen deficiency accelerates murine autoimmune arthritis associated with receptor activator of nuclear factor-kappa B ligand-mediated osteoclastogenesis. Endocrinology 145, 2384–2391 (2004)
T. Miyazaki, T. Matsunaga, S. Miyazaki, S. Hokari, T. Komoda, Changes in receptor activator of nuclear factor-kappaB, and its ligand, osteoprotegerin, bone-type alkaline phosphatase, and tartrate-resistant acid phosphatase in ovariectomized rats. J. Cell. Biochem. 93, 503–512 (2004)
F.-S. Wang, J.-Y. Ko, C.-L. Lin, H.-L. Wu, H.-J. Ke, P.-J. Tai, Knocking down dickkopf-1 alleviates estrogen deficiency induction of bone loss. A histomorphological study in ovariectomized rats. Bone 40, 485–492 (2007)
T. Ikeda, M. Utsuyama, K. Hirokawa, Expression profiles of receptor activator of nuclear factor kappaB ligand, receptor activator of nuclear factor kappaB, and osteoprotegerin messenger RNA in aged and ovariectomized rat bones. J. Bone Miner. Res. 16, 1416–1425 (2001)
M.S. Ominsky, X. Li, F.J. Asuncion, M. Barrero, K.S. Warmington, D. Dwyer, M. Stolina, Z. Geng, M. Grisanti, H.-L. Tan, T. Corbin, J. McCabe, W.S. Simonet, H.Z. Ke, P.J. Kostenuik, RANKL inhibition with osteoprotegerin increases bone strength by improving cortical and trabecular bone architecture in ovariectomized rats. J. Bone Miner. Res. 23, 672–682 (2008)
M. Gunness, E. Orwoll, Early induction of alterations in cancellous and cortical bone histology after orchiectomy in mature rats. J. Bone Miner. Res. 10, 1735–1744 (1995)
R.S. Weinstein, R.L. Jilka, A.M. Parfitt, S.C. Manolagas, The effects of androgen deficiency on murine bone remodeling and bone mineral density are mediated via cells of the osteoblastic lineage. Endocrinology 138, 4013–4021 (1997)
D.M. Huber, A.C. Bendixen, P. Pathrose, S. Srivastava, K.M. Dienger, N.K. Shevde, J.W. Pike, Androgens suppress osteoclast formation induced by RANKL and macrophage-colony stimulating factor. Endocrinology 142, 3800–3808 (2001)
L. Pederson, M. Kremer, J. Judd, D. Pascoe, T.C. Spelsberg, B.L. Riggs, M.J. Oursler, Androgens regulate bone resorption activity of isolated osteoclasts in vitro. Proc. Natl Acad. Sci. USA 96, 505–510 (1999)
Q. Chen, H. Kaji, M. Kanatani, T. Sugimoto, K. Chihara, Testosterone increases osteoprotegerin mRNA expression in mouse osteoblast cells. Horm. Metab. Res. 36, 674–678 (2004)
L.C. Hofbauer, K.C. Hicok, D. Chen, S. Khosla, Regulation of osteoprotegerin production by androgens and anti-androgens in human osteoblastic lineage cells. Eur. J. Endocrinol. 147, 269–273 (2002)
V. Proell, H. Xu, C. Schüler, K. Weber, L.C. Hofbauer, R.G. Erben, Orchiectomy upregulates free soluble RANKL in bone marrow of aged rats. Bone 45, 677–681 (2009)
X. Li, M.S. Ominsky, M. Stolina, K.S. Warmington, Z. Geng, Q.-T. Niu, F.J. Asuncion, H.-L. Tan, M. Grisanti, D. Dwyer, S. Adamu, H.Z. Ke, W.S. Simonet, P.J. Kostenuik, Increased RANK ligand in bone marrow of orchiectomized rats and prevention of their bone loss by the RANK ligand inhibitor osteoprotegerin. Bone 45, 669–676 (2009)
R.T. Turner, G.K. Wakley, K.S. Hannon, Differential effects of androgens on cortical bone histomorphometry in gonadectomized male and female rats. J. Orthop. Res. 8, 612–617 (1990)
E. Romas, O. Bakharevski, D.K. Hards, V. Kartsogiannis, J.M. Quinn, P.F. Ryan, T.J. Martin, M.T. Gillespie, Expression of osteoclast differentiation factor at sites of bone erosion in collagen-induced arthritis. Arthritis Rheum. 43, 821–826 (2000)
M. Stolina, S. Adamu, M. Ominsky, D. Dwyer, F. Asuncion, Z. Geng, S. Middleton, H. Brown, J. Pretorius, G. Schett, B. Bolon, U. Feige, D. Zack, P.J. Kostenuik, RANKL is a marker and mediator of local and systemic bone loss in two rat models of inflammatory arthritis. J. Bone Miner. Res. 20, 1756–1765 (2005)
Y.Y. Kong, U. Feige, I. Sarosi, B. Bolon, A. Tafuri, S. Morony, C. Capparelli, J. Li, R. Elliott, S. McCabe, T. Wong, G. Campagnuolo, E. Moran, E.R. Bogoch, G. Van, L.T. Nguyen, P.S. Ohashi, D.L. Lacey, E. Fish, W.J. Boyle, J.M. Penninger, Activated T cells regulate bone loss and joint destruction in adjuvant arthritis through osteoprotegerin ligand. Nature 402, 304–309 (1999)
M. Stolina, B. Bolon, S. Middleton, D. Dwyer, H. Brown, D. Duryea, L. Zhu, A. Rohner, J. Pretorius, P. Kostenuik, U. Feige, D. Zack, The evolving systemic and local biomarker milieu at different stages of disease progression in rat adjuvant-induced arthritis. J. Clin. Immunol. 29, 158–174 (2009)
B. Bolon, G. Campagnuolo, U. Feige, Duration of bone protection by a single osteoprotegerin injection in rats with adjuvant-induced arthritis. Cell. Mol. Life Sci. 59, 1569–1576 (2002)
M. Stolina, G. Schett, D. Dwyer, S. Vonderfecht, S. Middleton, D. Duryea, E. Pacheco, G. Van, B. Bolon, U. Feige, D. Zack, P. Kostenuik, RANKL inhibition by osteoprotegerin prevents bone loss without affecting local or systemic inflammation parameters in two rat arthritis models: comparison with anti-TNFalpha or anti-IL-1 therapies. Arthritis Res. Ther. 11, R187 (2009)
G. Schett, S. Middleton, B. Bolon, M. Stolina, H. Brown, L. Zhu, J. Pretorius, D.J. Zack, P. Kostenuik, U. Feige, Additive bone-protective effects of anabolic treatment when used in conjunction with RANKL and tumor necrosis factor inhibition in two rat arthritis models. Arthritis Rheum. 52, 1604–1611 (2005)
K. Redlich, B. Görtz, S. Hayer, J. Zwerina, N. Doerr, P. Kostenuik, H. Bergmeister, G. Kollias, G. Steiner, J.S. Smolen, G. Schett, Repair of local bone erosions and reversal of systemic bone loss upon therapy with anti-tumor necrosis factor in combination with osteoprotegerin or parathyroid hormone in tumor necrosis factor-mediated arthritis. Am. J. Pathol. 164, 543–555 (2004)
N. Saidenberg-Kermanac’h, A. Corrado, D. Lemeiter, M.C. deVernejoul, M.C. Boissier, M.E. Cohen-Solal, TNF-alpha antibodies and osteoprotegerin decrease systemic bone loss associated with inflammation through distinct mechanisms in collagen-induced arthritis. Bone 35, 1200–1207 (2004)
E. Romas, N.A. Sims, D.K. Hards, M. Lindsay, J.W.M. Quinn, P.F.J. Ryan, C.R. Dunstan, T.J. Martin, M.T. Gillespie, Osteoprotegerin reduces osteoclast numbers and prevents bone erosion in collagen-induced arthritis. Am. J. Pathol. 161, 1419–1427 (2002)
R.S. Weinstein, Clinical practice. Glucocorticoid-induced bone disease. N. Engl. J. Med. 365, 62–70 (2011)
N.O. Vidal, H. Brändström, K.B. Jonsson, C. Ohlsson, Osteoprotegerin mRNA is expressed in primary human osteoblast-like cells: down-regulation by glucocorticoids. J. Endocrinol. 159, 191–195 (1998)
L.C. Hofbauer, F. Gori, B.L. Riggs, D.L. Lacey, C.R. Dunstan, T.C. Spelsberg, S. Khosla, Stimulation of osteoprotegerin ligand and inhibition of osteoprotegerin production by glucocorticoids in human osteoblastic lineage cells: potential paracrine mechanisms of glucocorticoid-induced osteoporosis. Endocrinology 140, 4382–4389 (1999)
R.S. Weinstein, R.L. Jilka, A.M. Parfitt, S.C. Manolagas, Inhibition of osteoblastogenesis and promotion of apoptosis of osteoblasts and osteocytes by glucocorticoids. Potential mechanisms of their deleterious effects on bone. J. Clin. Invest. 102, 274–282 (1998)
S. Ikeda, Y. Morishita, H. Tsutsumi, M. Ito, A. Shiraishi, S. Arita, S. Akahoshi, K. Narusawa, T. Nakamura, Reductions in bone turnover, mineral, and structure associated with mechanical properties of lumbar vertebra and femur in glucocorticoid-treated growing minipigs. Bone 33, 779–787 (2003)
P. Oelzner, S. Fleissner-Richter, R. Bräuer, G. Hein, G. Wolf, T. Neumann, Combination therapy with dexamethasone and osteoprotegerin protects against arthritis-induced bone alterations in antigen-induced arthritis of the rat. Inflamm. Res. 59, 731–741 (2010)
P.J. Bekker, D.L. Holloway, A.S. Rasmussen, R. Murphy, S.W. Martin, P.T. Leese, G.B. Holmes, C.R. Dunstan, A.M. DePaoli, A single-dose placebo-controlled study of AMG 162, a fully human monoclonal antibody to RANKL, in postmenopausal women. J. Bone Miner. Res. 19, 1059–1066 (2004)
M.R. McClung, E.M. Lewiecki, S.B. Cohen, M.A. Bolognese, G.C. Woodson, A.H. Moffett, M. Peacock, P.D. Miller, S.N. Lederman, C.H. Chesnut, D. Lain, A.J. Kivitz, D.L. Holloway, C. Zhang, M.C. Peterson, P.J. Bekker, Denosumab in postmenopausal women with low bone mineral density. N. Engl. J. Med. 354, 821–831 (2006)
E.M. Lewiecki, P.D. Miller, M.R. McClung, S.B. Cohen, M.A. Bolognese, Y. Liu, A. Wang, S. Siddhanti, L.A. Fitzpatrick, A.M.G. Bone, L. Study, Two-year treatment with denosumab (AMG 162) in a randomized phase 2 study of postmenopausal women with low BMD. J. Bone Miner. Res. 22, 1832–1841 (2007)
P.D. Miller, M.A. Bolognese, E.M. Lewiecki, M.R. McClung, B. Ding, M. Austin, Y. Liu, J. San Martin, Effect of denosumab on bone density and turnover in postmenopausal women with low bone mass after long-term continued, discontinued, and restarting of therapy: a randomized blinded phase 2 clinical trial. Bone 43, 222–229 (2008)
P.D. Miller, R.B. Wagman, M. Peacock, E.M. Lewiecki, M.A. Bolognese, R.L. Weinstein, B. Ding, J. San Martin, M.R. McClung, Effect of denosumab on bone mineral density and biochemical markers of bone turnover: six-year results of a phase 2 clinical trial. J. Clin. Endocrinol. Metab. 96, 394–402 (2011)
S. Boonen, S. Ferrari, P.D. Miller, E.F. Eriksen, P.N. Sambrook, J. Compston, I.R. Reid, D. Vanderschueren, F. Cosman, Postmenopausal osteoporosis treatment with antiresorptives: Effects of discontinuation or long-term continuation on bone turnover and fracture risk-a perspective. J. Bone Miner. Res. 27(5), 963–974 (2012)
G. Mazziotti, J. Bilezikian, E. Canalis, D. Cocchi, A. Giustina, New understanding and treatments for osteoporosis. Endocrine 41(1), 58–69 (2012)
J. Compston, The use of combination therapy in the treatment of postmenopausal osteoporosis. Endocrine 41(1), 11–18 (2012)
T.D. Rachner, S. Khosla, L.C. Hofbauer, Osteoporosis: now and the future. Lancet 377(9773), 1276–1287 (2011)
S.R. Cummings, J. San Martin, M.R. McClung, E.S. Siris, R. Eastell, I.R. Reid, P. Delmas, H.B. Zoog, M. Austin, A. Wang, S. Kutilek, S. Adami, J. Zanchetta, C. Libanati, S. Siddhanti, C. Christiansen, Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N. Engl. J. Med. 361, 756–765 (2009)
E.V. McCloskey, H. Johansson, A. Oden, M. Austin, E. Siris, A. Wang, E.M. Lewiecki, R. Lorenc, C. Libanati, J.A. Kanis, Denosumab reduces the risk of osteoporotic fractures in postmenopausal women, particularly in those with moderate to high fracture risk as assessed with FRAX®. J. Bone Miner. Res. (2012). doi:10.1002/jbmr.1606
J.P. Brown, R.L. Prince, C. Deal, R.R. Recker, D.P. Kiel, L.H. de Gregorio, P. Hadji, L.C. Hofbauer, J.M. Alvaro-Gracia, H. Wang, M. Austin, R.B. Wagman, R. Newmark, C. Libanati, J. San Martin, H.G. Bone, Comparison of the effect of denosumab and alendronate on BMD and biochemical markers of bone turnover in postmenopausal women with low bone mass: a randomized, blinded, phase 3 trial. J. Bone Miner. Res. 24(1), 153–161 (2009)
S. Papapoulos, R. Chapurlat, C. Libanati, M. Brandi, J. Brown, E. Czerwiński, M.A. Krieg, Z. Man, D. Mellström, S. Radominski, J.Y. Reginster, H. Resch, J. Román, C. Roux, E. Vittinghoff, M. Austin, N. Daizadeh, M. Bradley, A. Grauer, S. Cummings, H. Bone, Five years of denosumab exposure in women with postmenopausal osteoporosis: results from the first two years of the FREEDOM extension. J. Bone Miner. Res. 27(3), 694–701 (2011)
N. Freemantle, S. Satram-Hoang, E.-T. Tang, P. Kaur, D. Macarios, S. Siddhanti, J. Borenstein, D.L. Kendler, Final results of the DAPS (denosumab adherence preference satisfaction) study: a 24-month, randomized, crossover comparison with alendronate in postmenopausal women. Osteoporos. Int. 23(1), 317–326 (2012)
R.E. Coleman, Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin. Cancer Res. 12, 6243s–6249s (2006)
J. Zekri, N. Ahmed, R.E. Coleman, B.W. Hancock, The skeletal metastatic complications of renal cell carcinoma. Int. J. Oncol. 19, 379–382 (2001)
Y. Wittrant, S. Théoleyre, C. Chipoy, M. Padrines, F. Blanchard, D. Heymann, F. Rédini, RANKL/RANK/OPG: new therapeutic targets in bone tumours and associated osteolysis. Biochim. Biophys. Acta 1704, 49–57 (2004)
Bendre, M., Gaddy, D., Nicholas, R.W., Suva, L.J.: Breast cancer metastasis to bone: it is not all about PTHrP. Clin. Orthop. Relat. Res. (415 Suppl) S39–45 (2003)
R.J. Thomas, T.A. Guise, J.J. Yin, J. Elliott, N.J. Horwood, T.J. Martin, M.T. Gillespie, Breast cancer cells interact with osteoblasts to support osteoclast formation. Endocrinology 140, 4451–4458 (1999)
J.M. Brown, E. Corey, Z.D. Lee, L.D. True, T.J. Yun, M. Tondravi, R.L. Vessella, Osteoprotegerin and rank ligand expression in prostate cancer. Urology 57, 611–616 (2001)
O. Sezer, U. Heider, I. Zavrski, C.A. Kühne, L.C. Hofbauer, RANK ligand and osteoprotegerin in myeloma bone disease. Blood 101, 2094–2098 (2003)
S. Yaccoby, M.J. Wezeman, A. Henderson, M. Cottler-Fox, Q. Yi, B. Barlogie, J. Epstein, Cancer and the microenvironment: myeloma–osteoclast interactions as a model. Cancer Res. 64, 2016–2023 (2004)
N. Giuliani, R. Bataille, C. Mancini, M. Lazzaretti, S. Barillé, Myeloma cells induce imbalance in the osteoprotegerin/osteoprotegerin ligand system in the human bone marrow environment. Blood 98, 3527–3533 (2001)
R.N. Pearse, E.M. Sordillo, S. Yaccoby, B.R. Wong, D.F. Liau, N. Colman, J. Michaeli, J. Epstein, Y. Choi, Multiple myeloma disrupts the TRANCE/osteoprotegerin cytokine axis to trigger bone destruction and promote tumor progression. Proc. Natl Acad. Sci. USA 98, 11581–11586 (2001)
T. Okada, S. Akikusa, H. Okuno, M. Kodaka, Bone marrow metastatic myeloma cells promote osteoclastogenesis through RANKL on endothelial cells. Clin. Exp. Metastasis 20, 639–646 (2003)
C.M. Shipman, P.I. Croucher, Osteoprotegerin is a soluble decoy receptor for tumor necrosis factor-related apoptosis-inducing ligand/Apo2 ligand and can function as a paracrine survival factor for human myeloma cells. Cancer Res. 63, 912–916 (2003)
J.R. Canon, M. Roudier, R. Bryant, S. Morony, M. Stolina, P.J. Kostenuik, W.C. Dougall, Inhibition of RANKL blocks skeletal tumor progression and improves survival in a mouse model of breast cancer bone metastasis. Clin. Exp. Metastasis 25, 119–129 (2008)
S. Mikami, K. Katsube, M. Oya, M. Ishida, T. Kosaka, R. Mizuno, S. Mochizuki, T. Ikeda, M. Mukai, Y. Okada, Increased RANKL expression is related to tumour migration and metastasis of renal cell carcinomas. J. Pathol. 218(4), 530–539 (2009)
D.H. Jones, T. Nakashima, O.H. Sanchez, I. Kozieradzki, S.V. Komarova, I. Sarosi, S. Morony, E. Rubin, R. Sarao, C.V. Hojilla, V. Komnenovic, Y.-Y. Kong, M. Schreiber, S.J. Dixon, S.M. Sims, R. Khokha, T. Wada, J.M. Penninger, Regulation of cancer cell migration and bone metastasis by RANKL. Nature 440, 692–696 (2006)
H. Yonou, N. Kanomata, M. Goya, T. Kamijo, T. Yokose, T. Hasebe, K. Nagai, T. Hatano, Y. Ogawa, A. Ochiai, Osteoprotegerin/osteoclastogenesis inhibitory factor decreases human prostate cancer burden in human adult bone implanted into nonobese diabetic/severe combined immunodeficient mice. Cancer Res. 63, 2096–2102 (2003)
R.E. Miller, M. Roudier, J. Jones, A. Armstrong, J. Canon, W.C. Dougall, RANK ligand inhibition plus docetaxel improves survival and reduces tumor burden in a murine model of prostate cancer bone metastasis. Mol. Cancer Ther. 7, 2160–2169 (2008)
J. Zhang, J. Dai, Y. Qi, D.L. Lin, P. Smith, C. Strayhorn, A. Mizokami, Z. Fu, J. Westman, E.T. Keller, Osteoprotegerin inhibits prostate cancer-induced osteoclastogenesis and prevents prostate tumor growth in the bone. J. Clin. Invest. 107, 1235–1244 (2001)
S. Morony, K. Warmington, S. Adamu, F. Asuncion, Z. Geng, M. Grisanti, H.L. Tan, C. Capparelli, C. Starnes, B. Weimann, C.R. Dunstan, P.J. Kostenuik, The inhibition of RANKL causes greater suppression of bone resorption and hypercalcemia compared with bisphosphonates in two models of humoral hypercalcemia of malignancy. Endocrinology 146, 3235–3243 (2005)
G.K. Ellis, H.G. Bone, R. Chlebowski, D. Paul, S. Spadafora, J. Smith, M. Fan, S. Jun, Randomized trial of denosumab in patients receiving adjuvant aromatase inhibitors for nonmetastatic breast cancer. J. Clin. Oncol. 26, 4875–4882 (2008)
M.R. Smith, B. Egerdie, N. Hernández Toriz, R. Feldman, T.L.J. Tammela, F. Saad, J. Heracek, M. Szwedowski, C. Ke, A. Kupic, B.Z. Leder, C. Goessl, Denosumab in men receiving androgen-deprivation therapy for prostate cancer. N. Engl. J. Med. 361, 745–755 (2009)
K. Fizazi, M. Carducci, M. Smith, R. Damião, J. Brown, L. Karsh, P. Milecki, N. Shore, M. Rader, H. Wang, Q. Jiang, S. Tadros, R. Dansey, C. Goessl, Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet 377, 813–822 (2011)
M.R. Smith, F. Saad, R. Coleman, N. Shore, K. Fizazi, B. Tombal, K. Miller, P. Sieber, L. Karsh, R. Damião, T.L. Tammela, B. Egerdie, H. Van Poppel, J. Chin, J. Morote, F. Gómez-Veiga, T. Borkowski, Z. Ye, A. Kupic, R. Dansey, C. Goessl, Denosumab and bone-metastasis-free survival in men with castration-resistant prostate cancer: results of a phase 3, randomised, placebo-controlled trial. Lancet 379, 39–46 (2011)
A.T. Stopeck, A. Lipton, J.-J. Body, G.G. Steger, K. Tonkin, R.H. de Boer, M. Lichinitser, Y. Fujiwara, D.A. Yardley, M. Viniegra, M. Fan, Q. Jiang, R. Dansey, S. Jun, A. Braun, Denosumab compared with zoledronic acid for the treatment of bone metastases in patients with advanced breast cancer: a randomized, double-blind study. J. Clin. Oncol. 28, 5132–5139 (2010)
D.H. Henry, L. Costa, F. Goldwasser, V. Hirsh, V. Hungria, J. Prausova, G.V. Scagliotti, H. Sleeboom, A. Spencer, S. Vadhan-Raj, R. von Moos, W. Willenbacher, P.J. Woll, J. Wang, Q. Jiang, S. Jun, R. Dansey, H. Yeh, Randomized, double-blind study of denosumab versus zoledronic acid in the treatment of bone metastases in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma. J. Clin. Oncol. 29, 1125–1132 (2011)
D.P. Kiel, L.I. Kauppila, L.A. Cupples, M.T. Hannan, C.J. O’Donnell, P.W. Wilson, Bone loss and the progression of abdominal aortic calcification over a 25 year period: The Framingham Heart Study, New York. Calcif. Tissue Int. 74(2), 208 (2001)
M. Baud’huin, F. Lamoureux, L. Duplomb, F. Rédini, D. Heymann, RANKL, RANK, osteoprotegerin: key partners of osteoimmunology and vascular diseases. Cell. Mol. Life Sci. 64, 2334–2350 (2007)
N. Bucay, I. Sarosi, C.R. Dunstan, S. Morony, J. Tarpley, C. Capparelli, S. Scully, H.L. Tan, W. Xu, D.L. Lacey, W.J. Boyle, W.S. Simonet, Osteoprotegerin-deficient mice develop early onset osteoporosis and arterial calcification. Genes Dev. 12, 1260–1268 (1998)
H. Min, S. Morony, I. Sarosi, C.R. Dunstan, C. Capparelli, S. Scully, G. Van, S. Kaufman, P.J. Kostenuik, D.L. Lacey, W.J. Boyle, W.S. Simonet, Osteoprotegerin reverses osteoporosis by inhibiting endosteal osteoclasts and prevents vascular calcification by blocking a process resembling osteoclastogenesis. J. Exp. Med. 192, 463–474 (2000)
S. Morony, Y. Tintut, Z. Zhang, R.C. Cattley, G. Van, D. Dwyer, M. Stolina, P.J. Kostenuik, L.L. Demer, Osteoprotegerin inhibits vascular calcification without affecting atherosclerosis in ldlr(−/−) mice. Circulation 117, 411–420 (2008)
M.K. Osako, H. Nakagami, N. Koibuchi, H. Shimizu, F. Nakagami, H. Koriyama, M. Shimamura, T. Miyake, H. Rakugi, R. Morishita, Estrogen inhibits vascular calcification via vascular RANKL system: common mechanism of osteoporosis and vascular calcification. Circ. Res. 107, 466–475 (2010)
S. Helas, C. Goettsch, M. Schoppet, U. Zeitz, U. Hempel, H. Morawietz, P.J. Kostenuik, R.G. Erben, L.C. Hofbauer, Inhibition of receptor activator of NF-kappaB ligand by denosumab attenuates vascular calcium deposition in mice. Am. J. Pathol. 175, 473–478 (2009)
G.G. Teng, N.M. Patkar, K.G. Saag, Denosumab in postmenopausal women with low bone mineral density. Curr. Rheumatol. Rep. 9(1), 48–49 (2007)
A. Lipton, G.G. Steger, J. Figueroa, C. Alvarado, P. Solal-Celigny, J.-J. Body, R. de Boer, R. Berardi, P. Gascon, K.S. Tonkin, R. Coleman, A.H.G. Paterson, M.C. Peterson, M. Fan, A. Kinsey, S. Jun, Randomized active-controlled phase II study of denosumab efficacy and safety in patients with breast cancer-related bone metastases. J. Clin. Oncol. 25, 4431–4437 (2007)
M.J. Green, A.A. Deodhar, Bone changes in early rheumatoid arthritis. Best Pract. Res. Clin. Rheumatol. 15, 105–123 (2001)
G. Kaya, E. Koçak, E. Akbal, A. Taş, S. Köklü, Comparison of the possible risk factors of bone mineral density in subjects with ulcerative colitis and healthy subjects. South. Med. J. 104, 747–751 (2011)
L. Graat-Verboom, F.W. Smeenk, B.E. van den Borne, M.A. Spruit, F.H. Jansen, J.W. van Enschot, E.F. Wouters, Progression of osteoporosis in patients with COPD: a 3-year follow up study. Respir. Med. 106(6), 861–870 (2012)
D. Carmona-Fernandes, M.J. Santos, I.P. Perpétuo, J.E. Fonseca, H. Canhão, Soluble receptor activator of nuclear factor κB ligand/osteoprotegerin ratio is increased in systemic lupus erythematosus patients. Arthritis Res. Ther. 13, R175 (2011)
H. Takayanagi, H. Iizuka, T. Juji, T. Nakagawa, A. Yamamoto, T. Miyazaki, Y. Koshihara, H. Oda, K. Nakamura, S. Tanaka, Involvement of receptor activator of nuclear factor kappaB ligand/osteoclast differentiation factor in osteoclastogenesis from synoviocytes in rheumatoid arthritis. Arthritis Rheum. 43, 259–269 (2000)
Y. Li, G. Toraldo, A. Li, X. Yang, H. Zhang, W.-P. Qian, M.N. Weitzmann, B cells and T cells are critical for the preservation of bone homeostasis and attainment of peak bone mass in vivo. Blood 109, 3839–3848 (2007)
S. Cenci, G. Toraldo, M.N. Weitzmann, C. Roggia, Y. Gao, W.P. Qian, O. Sierra, R. Pacifici, Estrogen deficiency induces bone loss by increasing T cell proliferation and lifespan through IFN-gamma-induced class II transactivator. Proc. Natl Acad. Sci. USA 100, 10405–10410 (2003)
D.M. Anderson, E. Maraskovsky, W.L. Billingsley, W.C. Dougall, M.E. Tometsko, E.R. Roux, M.C. Teepe, R.F. DuBose, D. Cosman, L. Galibert, A homologue of the TNF receptor and its ligand enhance T-cell growth and dendritic-cell function. Nature 390, 175–179 (1997)
P. Bai, Y. Sun, J. Jin, J. Hou, R. Li, Q. Zhang, Y. Wang, Disturbance of the OPG/RANK/RANKL pathway and systemic inflammation in COPD patients with emphysema and osteoporosis. Respir. Res. 12, 157 (2011)
R.L. Van Bezooijen, H.C. Farih-Sips, S.E. Papapoulos, C.W. Löwik, Interleukin-17: a new bone acting cytokine in vitro. J. Bone Miner. Res. 14, 1513–1521 (1999)
E. Lubberts, L. van den Bersselaar, B. Oppers-Walgreen, P. Schwarzenberger, C.J. Coenen-de Roo, J.K. Kolls, L.A. Joosten, W.B. van den Berg, IL-17 promotes bone erosion in murine collagen-induced arthritis through loss of the receptor activator of NF-kappa B ligand/osteoprotegerin balance. J. Immunol. 170(5), 2655–2662 (2003)
G. Schett, K. Redlich, S. Hayer, J. Zwerina, B. Bolon, C. Dunstan, B. Görtz, A. Schulz, H. Bergmeister, G. Kollias, G. Steiner, J.S. Smolen, Osteoprotegerin protects against generalized bone loss in tumor necrosis factor-transgenic mice. Arthritis Rheum. 48, 2042–2051 (2003)
A.R. Pettit, H. Ji, D. von Stechow, R. Müller, S.R. Goldring, Y. Choi, C. Benoist, E.M. Gravallese, TRANCE/RANKL knockout mice are protected from bone erosion in a serum transfer model of arthritis. Am. J. Pathol. 159, 1689–1699 (2001)
A.J. Ashcroft, S.M. Cruickshank, P.I. Croucher, M.J. Perry, S. Rollinson, J.M. Lippitt, J.A. Child, C. Dunstan, P.J. Felsburg, G.J. Morgan, S.R. Carding, Colonic dendritic cells, intestinal inflammation, and T cell-mediated bone destruction are modulated by recombinant osteoprotegerin. Immunity 19, 849–861 (2003)
S.B. Cohen, R.K. Dore, N.E. Lane, P.A. Ory, C.G. Peterfy, J.T. Sharp, D. van der Heijde, L. Zhou, W. Tsuji, R. Newmark, Denosumab treatment effects on structural damage, bone mineral density, and bone turnover in rheumatoid arthritis: a twelve-month, multicenter, randomized, double-blind, placebo-controlled, phase II clinical trial. Arthritis Rheum. 58, 1299–1309 (2008)
J.T. Sharp, W. Tsuji, P. Ory, C. Harper-Barek, H. Wang, R. Newmark, Denosumab prevents metacarpal shaft cortical bone loss in patients with erosive rheumatoid arthritis. Arthritis Care Res. 62, 537–544 (2010)
A. Deodhar, R.K. Dore, D. Mandel, J. Schechtman, W. Shergy, R. Trapp, P.A. Ory, C.G. Peterfy, T. Fuerst, H. Wang, L. Zhou, W. Tsuji, R. Newmark, Denosumab-mediated increase in hand bone mineral density associated with decreased progression of bone erosion in rheumatoid arthritis patients. Arthritis Care Res. 62, 569–574 (2010)
D. Kim, R.E. Mebius, J.D. MacMicking, S. Jung, T. Cupedo, Y. Castellanos, J. Rho, B.R. Wong, R. Josien, N. Kim, P.D. Rennert, Y. Choi, Regulation of peripheral lymph node genesis by the tumor necrosis factor family member trance. J. Exp. Med. 192, 1467–1478 (2000)
Y. Hikosaka, T. Nitta, I. Ohigashi, K. Yano, N. Ishimaru, Y. Hayashi, M. Matsumoto, K. Matsuo, J.M. Penninger, H. Takayanagi, Y. Yokota, H. Yamada, Y. Yoshikai, J.-I. Inoue, T. Akiyama, Y. Takahama, The cytokine RANKL produced by positively selected thymocytes fosters medullary thymic epithelial cells that express autoimmune regulator. Immunity 29, 438–450 (2008)
M.M. Guerrini, C. Sobacchi, B. Cassani, M. Abinun, S.S. Kilic, A. Pangrazio, D. Moratto, E. Mazzolari, J. Clayton-Smith, P. Orchard, F.P. Coxon, M.H. Helfrich, J.C. Crockett, D. Mellis, A. Vellodi, I. Tezcan, L.D. Notarangelo, M.J. Rogers, P. Vezzoni, A. Villa, A. Frattini, Human osteoclast-poor osteopetrosis with hypogammaglobulinemia due to TNFRSF11A (RANK) mutations. Am. J. Hum. Genet. 83, 64–76 (2008)
C. Sobacchi, A. Frattini, M.M. Guerrini, M. Abinun, A. Pangrazio, L. Susani, R. Bredius, G. Mancini, A. Cant, N. Bishop, P. Grabowski, A. Del Fattore, C. Messina, G. Errigo, F.P. Coxon, D.I. Scott, A. Teti, M.J. Rogers, P. Vezzoni, A. Villa, M.H. Helfrich, Osteoclast-poor human osteopetrosis due to mutations in the gene encoding RANKL. Nat. Genet. 39, 960–962 (2007)
J.C. Crockett, D.J. Mellis, D.I. Scott, M.H. Helfrich, New knowledge on critical osteoclast formation and activation pathways from study of rare genetic diseases of osteoclasts: focus on the RANK/RANKL axis. Osteoporos. Int. 22, 1–20 (2011)
N. Nakagawa, M. Kinosaki, K. Yamaguchi, N. Shima, H. Yasuda, K. Yano, T. Morinaga, K. Higashio, RANK is the essential signaling receptor for osteoclast differentiation factor in osteoclastogenesis. Biochem. Biophys. Res. Commun. 253, 395–400 (1998)
V. Kartsogiannis, H. Zhou, N.J. Horwood, R.J. Thomas, D.K. Hards, J.M. Quinn, P. Niforas, K.W. Ng, T.J. Martin, M.T. Gillespie, Localization of RANKL (receptor activator of NF kappa B ligand) mRNA and protein in skeletal and extraskeletal tissues. Bone 25, 525–534 (1999)
R. Hanada, A. Leibbrandt, T. Hanada, S. Kitaoka, T. Furuyashiki, H. Fujihara, J. Trichereau, M. Paolino, F. Qadri, R. Plehm, S. Klaere, V. Komnenovic, H. Mimata, H. Yoshimatsu, N. Takahashi, A. von Haeseler, M. Bader, S.S. Kilic, Y. Ueta, C. Pifl, S. Narumiya, J.M. Penninger, Central control of fever and female body temperature by RANKL/RANK. Nature 462, 505–509 (2009)
K. Loser, A. Mehling, S. Loeser, J. Apelt, A. Kuhn, S. Grabbe, T. Schwarz, J.M. Penninger, S. Beissert, Epidermal RANKL controls regulatory T-cell numbers via activation of dendritic cells. Nat. Med. 12, 1372–1379 (2006)
N.B. Watts, C. Roux, J.F. Modlin, J.P. Brown, A. Daniels, S. Jackson, S. Smith, D.J. Zack, L. Zhou, A. Grauer, S. Ferrari, Infections in postmenopausal women with osteoporosis treated with denosumab or placebo: coincidence or causal association? Osteoporos. Int. 23(1), 327–337 (2012)
Conflict of interest
LCH has received honoraria from Amgen, Merck, Novartis, and Nycomed. KS, ET, MR, TDR and CH have no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Additional information
Kathrin Sinningen and Elena Tsourdi contributed equally for this review.
Rights and permissions
About this article
Cite this article
Sinningen, K., Tsourdi, E., Rauner, M. et al. Skeletal and extraskeletal actions of denosumab. Endocrine 42, 52–62 (2012). https://doi.org/10.1007/s12020-012-9696-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12020-012-9696-x