DOI: 10.1542/peds.

2006-2023H
2007;119;S150 Pediatrics
R. Graham G. Russell
Bisphosphonates: Mode of Action and Pharmacology

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SUPPLEMENT ARTICLE
Bisphosphonates: Mode of Action and Pharmacology
R. GrahamG. Russell, MD, PhD
Botnar Research Centre and Oxford University Institute of Musculoskeletal Sciences, Oxford, United Kingdom
The author has indicated he has no nancial relationships relevant to this article to disclose.
ABSTRACT
The profound effects of the bisphosphonates on calcium metabolism were discov-
ered over 30 years ago, and they are now well established as the major drugs used
for the treatment of bone diseases associated with excessive resorption. Their
principal uses are for Paget disease of bone, myeloma, bone metastases, and
osteoporosis in adults, but there has been increasing and successful application in
pediatric bone diseases, notably osteogenesis imperfecta. Bisphosphonates are
structural analogues of inorganic pyrophosphate but are resistant to enzymatic and
chemical breakdown. Bisphosphonates inhibit bone resorption by selective ad-
sorption to mineral surfaces and subsequent internalization by bone-resorbing
osteoclasts where they interfere with various biochemical processes. The simpler,
nonnitrogen-containing bisphosphonates (eg, clodronate and etidronate) can be
metabolically incorporated into nonhydrolysable analogues of adenosine triphos-
phate (ATP) that may inhibit ATP-dependent intracellular enzymes. In contrast,
the more potent, nitrogen-containing bisphosphonates (eg, pamidronate, alendro-
nate, risedronate, ibandronate, and zoledronate) inhibit a key enzyme, farnesyl
pyrophosphate synthase, in the mevalonate pathway, thereby preventing the
biosynthesis of isoprenoid compounds that are essential for the posttranslational
modication of small guanosine triphosphate (GTP)-binding proteins (which are
also GTPases) such as Rab, Rho, and Rac. The inhibition of protein prenylation and
the disruption of the function of these key regulatory proteins explains the loss of
osteoclast activity. The recently elucidated crystal structure of farnesyl diphosphate
reveals how bisphosphonates bind to and inhibit at the active site via their critical
nitrogen atoms. Although bisphosphonates are now established as an important
class of drugs for the treatment of many bone diseases, there is new knowledge
about how they work and the subtle but potentially important differences that
exist between individual bisphosphonates. Understanding these may help to ex-
plain differences in potency, onset and duration of action, and clinical
effectiveness.
www.pediatrics.org/cgi/doi/10.1542/
peds.2006-2023H
doi:10.1542/peds.2006-2023H
Key Words
bone resorption, osteoclasts,
bisphosphonates, osteoporosis
Abbreviations
PPiinorganic pyrophosphate
ATPadenosine triphosphate
FPPfarnesyl diphosphate
GGPPgeranylgeranyl diphosphate
FPPSfarnesyl pyrophosphate synthase
Accepted for publication Oct 5, 2006
Address correspondence to R. Graham G.
Russell, MD, PhD, Botnar Research Centre,
Nufeld Department of Orthopaedic Surgery,
University of Oxford, Headington, Oxford OX3
7LD, United Kingdom. E-mail: graham.russell@
ndos.ox.ac.uk
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275); published in the public
domain by the American Academy of
Pediatrics
S150 RUSSELL
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T
HE DISCOVERY AND development of the bisphospho-
nates as a major class of drugs for the treatment of
bone diseases was recently reviewed
1
and represents a
fascinating story that has its origins in studies of biolog-
ical calcication processes. There are many books and
review articles available that describe the chemistry,
pharmacology, and clinical applications of bisphospho-
nates.
25
It had been known since the 1930s that trace
amounts of polyphosphates were capable of acting as
water softeners by inhibiting the crystallization of cal-
cium salts, such as calcium carbonate,
6
and in the 1960s
Fleisch et al
7,8
showed that inorganic pyrophosphate, a
naturally occurring polyphosphate and a known byprod-
uct of many biosynthetic reactions in the body, was
present in serum and urine and could prevent calcica-
tion by binding to newly forming crystals of hydroxyap-
atite. It was proposed that inorganic pyrophosphate (PPi)
might be the bodys own natural water softener that
normally prevents calcication of soft tissues and regu-
lates bone mineralization. It subsequently became clear
that calcication disorders might be linked to distur-
bances in PPi metabolism. The rst example was an
inherited disorder, hypophosphatasia, in which lack of
alkaline phosphatase is associated with mineralization
defects of the skeleton and elevated PPi levels,
9
indicat-
ing that alkaline phosphatase is probably the key extra-
cellular enzyme responsible for hydrolyzing pyrophos-
phate.
Attempts to exploit these concepts by using pyro-
phosphate and polyphosphates to inhibit ectopic calci-
cation in blood vessels, skin, and kidneys in laboratory
animals were successful only when the compounds were
injected.
10
Orally administered pyrophosphate and
polyphosphates were inactive because of their hydrolysis
in the gastrointestinal tract. During the search for more
stable analogues of pyrophosphate that might also have
the antimineralization properties of pyrophosphate but
would be resistant to hydrolysis, several different chem-
ical classes were studied. The bisphosphonates (at that
time called diphosphonates), characterized by P-C-P mo-
tifs, were among these classes.
1113
Like pyrophosphate, bisphosphonates had high afn-
ity for bone mineral
14
and were found to prevent calci-
cation both in vitro and in vivo but, unlike pyrophos-
phate, were also able to prevent experimentally induced
pathologic calcication when given orally to rats in
vivo.
15
This property of being active by mouth was key to
their future use in humans.
In these early studies bisphosphonates were shown
not only to prevent the experimentally induced calci-
cation of many soft tissues, including skin, kidneys, and
blood vessels in vivo but, with some of the compounds
(eg, etidronate), to also inhibit mineralization of ectopic
bone as well of normal calcied tissues such as bone and
cartilage.
16
Bisphosphonates seem to prevent calcica-
tion by physicochemical mechanisms that produce direct
impairment of the calcication process by acting as crys-
tal poisons after adsorption to mineral surfaces rather
than by effects on the deposition of matrix.
Perhaps the most important step toward the future
use of bisphosphonates occurred when we found that
bisphosphonates, as we had already shown for PPi,
17
also
had the novel property of being able to inhibit the dis-
solution of hydroxyapatite crystals.
18
This nding led to
studies to determine if they might also inhibit bone
resorption, which they did in many different experimen-
tal models.
19,20
In growing intact rats, the bisphospho-
nates block the removal of both bone and cartilage, thus
retarding the modeling of the metaphysis, which be-
comes club-shaped and radiologically denser than nor-
mal. This effect is the basis of the Schenk model
21
and is
a phenomenon of interest in pediatrics because it is also
observed in children who are treated with high doses of
bisphosphonates.
The bisphosphonates are also effective in preventing
bone destruction in a number of animal models of hu-
man disease, such as immobilization osteoporosis,
22
and
the prevention of bone loss associated with ovariectomy.
If not given in excess, bisphosphonates do not impair
bone growth and can maintain or improve the biome-
chanical properties of bone in both normal animals and
experimental models of osteoporosis.
23
In general, there is a good correlation between po-
tency and structure-activity relationships in vitro and in
vivo.
24
In the presence of bisphosphonates, isolated os-
teoclasts form fewer and smaller erosion cavities on var-
ious mineralized matrices in vitro.
25
PHARMACOLOGY ANDCELLULAR ACTIONS
Etidronate was the rst bisphosphonate to be used in
humans for brodysplasia ossicans progressiva and
Paget disease.
26
Once the potential clinical value of
bisphosphonates had been appreciated, research efforts
were devoted to the development of compounds with a
more powerful antiresorptive activity but without a cor-
responding ability to inhibit mineralization. With com-
pounds such as etidronate there was only a 10- to 100-
fold difference between doses that inhibit mineralization
compared with doses that reduce bone resorption. En-
hancing this window was readily achieved, and many
hundreds of bisphosphonates have been synthesized;
more than a dozen have been used in humans. With the
development of bisphosphonates that were more potent
inhibitors of bone resorption, these dose differences wid-
ened to several orders of magnitude, which meant that
inhibition of skeletal mineralization observed with etidr-
onate ceased to be a major clinical concern. The grada-
tion of potency evaluated in the animal models corre-
sponded quite well with that found in humans, although
the differences in potency are much smaller in humans.
Bisphosphonates accumulate in bone, so it is impor-
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tant to know what happens during long-term adminis-
tration. From a clinical point of view, it is reassuring that
the inhibition of bone resorption reaches a new steady-
state level rather than becoming progressively lower,
even when the compounds are given continuously.
27
The level of suppression depends on the administered
dose and has also been observed in humans.
28
There
seems to be no progression of the antiresorptive effect
with time, which suggests that the bisphosphonate bur-
ied in the bone is inactive for at least as long as it remains
buried there. This also means that within the therapeu-
tic-dosage range, there is little risk of a continuous and
progressive decrease in bone turnover in the long run
that might lead to an increase in bone fragility. An
additional important pharmacologic property of bisphos-
phonates is that the total dose administered is a major
determinant of their effects. This has been well studied
for ibandronate
29
and zoledronate.
30
In both cases the
same inhibition of bone resorption has been docu-
mented regardless of whether the bisphosphonate was
given in small frequent (eg, daily) doses compared with
larger doses given less frequently. This was the basis for
the development of intermittent-dosing regimens in hu-
mans.
The pronounced selectivity of bisphosphonates for
bone rather than other tissues is the basis for their value
in clinical practice. Their preferential uptake by and
adsorption to mineral surfaces in bone bring them into
close contact with osteoclasts. During bone resorption,
bisphosphonates are probably internalized by endocyto-
sis along with other products of resorption. Many studies
have shown that bisphosphonates can affect osteoclast-
mediated bone resorption in a variety of ways, including
effects on osteoclast recruitment, differentiation, and re-
sorptive activity, and may induce apoptosis.
Because mature, multinucleated osteoclasts are
formed by the fusion of mononuclear precursors of he-
matopoietic origin, bisphosphonates could also inhibit
bone resorption by preventing osteoclast formation, in
addition to affecting mature osteoclasts. In vitro,
bisphosphonates can inhibit dose-dependently the for-
mation of osteoclast-like cells in long-term cultures of
human bone marrow.
31
In organ culture, also, some
bisphosphonates can inhibit the generation of mature
osteoclasts, possibly by preventing the fusion of oste-
oclast precursors.
32,33
It is likely that bisphosphonates are selectively inter-
nalized by osteoclasts rather than other cell types be-
cause of their accumulation in bone and the endocytic
activity of osteoclasts. During the process of bone resorp-
tion, the subcellular space beneath the osteoclast is acid-
ied by the action of vacuolar-type proton pumps in the
rufed border of the osteoclast membrane.
34
The acidic
pH of this microenvironment causes dissolution of the
hydroxyapatite bone mineral, whereas the breakdown
of the extracellular bone matrix is brought about by the
action of proteolytic enzymes, including cathepsin K.
Because bisphosphonates adsorb to bone mineral, espe-
cially at sites of bone resorption where the mineral is
most exposed,
35,36
osteoclasts are the cell type in bone
most likely to be exposed to the highest concentrations
of free, nonmineral-bound bisphosphonate as a result
of the release of the bisphosphonate from bone mineral
in the low-pH environment beneath osteoclasts. It has
been estimated that pharmacologic doses of alendronate
that inhibit bone resorption in vivo could give rise to
local concentrations as high as 1 mM alendronate in the
resorption space beneath an osteoclast, which is much
higher than the concentrations of bisphosphonates re-
quired to affect osteoclast morphology and cause oste-
oclast apoptosis in vitro.
37
In contrast to their ability to induce apoptosis in os-
teoclasts, which contributes to the inhibition of resorp-
tive activity, some experimental studies suggest that
bisphosphonates may protect osteocytes and osteoblasts
from apoptosis induced by glucocorticoids.
38
Recent ev-
idence suggests that the inhibition of osteocyte apoptosis
by bisphosphonates is mediated through the opening of
connexion 43 hemichannels and activation of extracel-
lular signal-regulated kinases.
39
The possibility that
bisphosphonates used clinically may get access to osteo-
cytes differentially depending on their mineral-binding
afnities and inherent structural properties needs to be
studied.
STRUCTURE-ACTIVITY RELATIONSHIPS ANDMECHANISMOF
ACTION
The features of the bisphosphonate molecule necessary
for biological activity were well dened in the early
studies. The P-C-P moiety is responsible for the strong
afnity of the bisphosphonates for binding to hydroxy-
apatite and allows for a number of variations in structure
on the basis of substitution in the R
1
and R
2
positions on
the carbon atom (Fig 1). The ability of the bisphospho-
nates to bind to hydroxyapatite crystals and to prevent
both crystal growth and dissolution was enhanced when
the R
1
side chain (attached to the geminal carbon atom
of the P-C-P group) was a hydroxyl group (as in eti-
dronate) rather than a halogen atom such as chlorine (as
in clodronate). The presence of a hydroxyl group at the
R
1
position increases the afnity for calcium (and, thus,
bone mineral) because of the ability of bisphosphonates
to chelate calcium ions by tridentate rather than biden-
tate binding.
40
The ability of bisphosphonates to inhibit bone resorp-
tion in vitro and in vivo also requires the P-C-P struc-
ture. Monophosphonates (eg, pentane monophospho-
nate) or P-C-C-P or P-N-P compounds are ineffective as
inhibitors of bone resorption. Furthermore, the antire-
sorptive effect cannot be accounted for simply by adsorp-
tion of bisphosphonates to bone mineral and prevention
of hydroxyapatite dissolution. It became clear that
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bisphosphonates must inhibit bone resorption by cellular
effects on osteoclasts rather than simply by physico-
chemical mechanisms.
After the successful clinical use of clodronate and
etidronate in the 1970s and 1980s, more potent antire-
sorptive bisphosphonates, which had different R
2
side
chains but in which R
1
was unaltered, were studied. In
particular, bisphosphonates containing a basic primary
amino-nitrogen atom in an alkyl chain (as in pamidr-
onate and alendronate) were found to be 10- to 100-fold
more potent than etidronate and clodronate. Then, in
the 1980s, there was a phase in which synthesis of novel
compounds took place specically to determine their
possible effects on calcium metabolism, with the result
that compounds highly effective as inhibitors of bone
resorption were identied and studied.
These compounds, especially those that contain a ter-
tiary amino-nitrogen (such as ibandronate
41
and olpad-
ronate
42
), were even more potent at inhibiting bone
resorption. Among this generation of compounds that
were synthesized to optimize their antiresorptive effects,
the most potent antiresorptive bisphosphonates were
those containing a nitrogen atom within a heterocyclic
ring (as in risedronate
43
and zoledronate
44
), which are up
to 10 000-fold more potent than etidronate in some
experimental systems (Fig 2).
The analysis of structure-activity relationships al-
lowed the spatial features of the active pharmacophore
to be dened in considerable detail even before the
molecular mechanism of action was fully elucidated. For
maximal potency, the nitrogen atom in the R
2
side chain
must be a critical distance away from the P-C-P group
and in a specic spatial conguration.
45
This principle
was used successfully for predicting the features required
in the chemical design of new and more active com-
pounds.
Although the structure of the R
2
side chain is the
major determinant of antiresorptive potency, both phos-
phonate groups are also required for the drugs to be
pharmacologically active.
FIGURE 1
The generic structure of pyrophosphate compared with bisphos-
phonates and their functional domains.
FIGURE 2
Structures of the bisphosphonates used in clinical studies classi-
ed according to their biochemical mode of action.
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In summary, studies of the relationships between
bisphosphonate structure and antiresorptive potency
suggested that the ability of bisphosphonates to inhibit
bone resorption depend on 2 separate properties of the
bisphosphonate molecule. The 2 phosphonate groups,
together with a hydroxyl group at the R
1
position,
46
impart high afnity for bone mineral and act as a bone
hook, which allows rapid and efcient targeting of
bisphosphonates to bone mineral surfaces. Once local-
ized within bone, the structure and three-dimensional
conformation of the R
2
side chain (as well as the phos-
phonate groups in the molecule) determine the biolog-
ical activity of the molecule and inuence the ability of
the drugs to interact with specic molecular targets. Our
understanding of what these molecular targets might be
has become much clearer as a result of recent work.
Over the years there have been many efforts to
explain how bisphosphonates work on cells, especially
via inhibitory effects on enzymes (eg, by direct or in-
direct inhibition of the osteoclast proton-pumping
H

ATPase,
47,48
phosphatases, or lysosomal enzymes
49,50
).
Because osteoclasts are highly endocytic, bisphospho-
nate present in the resorption space is likely to be inter-
nalized by endocytosis and thereby affect osteoclasts di-
rectly.
25
The uptake of bisphosphonates by osteoclasts in
vivo has been conrmed by using radiolabeled
51
and
uorescently labeled alendronate, which was internal-
ized into intracellular vacuoles. After cellular uptake, a
characteristic morphologic feature of bisphosphonate-
treated osteoclasts is the lack of a rufed border, the
region of invaginated plasma membrane facing the re-
sorption cavity. Bisphosphonates also disrupt the cy-
toskeleton of the osteoclast.
52
Early explanations for
these effects invoked the inhibition of protein kinases or
phosphatases that regulate cytoskeletal structure, such
as protein tyrosine phosphatases.
5356
However, a more
likely mechanism by which the cytoskeleton may be
affected involves loss of function of small GTPases such
as Rho and Rac.
Since the early 1990s there has been a systematic
effort by our group and others to elucidate the molecular
mechanisms of action of bisphosphonates,
5,57,58
and we
have proposed that bisphosphonates can be classied
into at least 2 major groups with different modes of
action (Fig 3). The rst group comprises the nonnitro-
gen-containing bisphosphonates that perhaps most
closely resemble pyrophosphate, such as clodronate and
etidronate, and these can be metabolically incorporated
into nonhydrolyzable analogues of adenosine triphos-
phate (ATP) by reversing the reactions of aminoacyl
transfer RNA synthetases.
59
The resulting metabolites
contain the P-C-P moiety in place of the ,-phosphate
groups of ATP, thus resulting in nonhydrolyzable
(AppCp) nucleotides.
6063
It is likely that intracellular
accumulation of these metabolites within osteoclasts in-
hibits their function and may cause osteoclast cell death.
The AppCp-type metabolites of bisphosphonates are cy-
totoxic when internalized and cause similar changes in
morphology to those observed in clodronate-treated
cells, possibly by interference with mitochondrial ATP
translocases.
64
Overall, this group of bisphosphonates,
therefore, seem to act as prodrugs, being converted to
active metabolites after intracellular uptake by oste-
oclasts in vivo.
In contrast, the second group contains the more po-
tent, nitrogen-containing bisphosphonates such as alen-
dronate, risedronate, and zoledronate. Members of this
group interfere with other metabolic reactions, notably
in the mevalonate biosynthetic pathway, and affect cel-
lular activity and cell survival by interfering with protein
prenylation and, therefore, the signaling functions of
key regulatory proteins. These mechanisms have been
reviewed in detail elsewhere.
1
The mevalonate pathway
is a biosynthetic route responsible for the production of
cholesterol, other sterols, and isoprenoid lipids such as
isopentenyl diphosphate (also known as isopentenyl py-
rophosphate), as well as farnesyl diphosphate (FPP) and
geranylgeranyl diphosphate (GGPP). FPP and GGPP are
required for the posttranslational modication (prenyla-
tion) of small GTPases such as Ras, Rab, Rho, and Rac,
which are prenylated at a cysteine residue in character-
istic C-terminal motifs.
65
Small GTPases are important
signaling proteins that regulate a variety of cell processes
important for osteoclast function, including cell mor-
phology, cytoskeletal arrangement, membrane rufing,
trafcking of vesicles, and apoptosis.
6669
Prenylation is
FIGURE 3
Two distinct molecular mechanisms of action of bisphospho-
nates (BPs) that both inhibit osteoclasts (see text for details). GTP
indicates guanosine triphosphate.
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required for the correct function of these proteins be-
cause the lipid prenyl group serves to anchor the pro-
teins in cell membranes and may also participate in
protein-protein interactions.
70
Many observations point to the importance of the
mevalonate pathway for osteoclast function and
strengthen the proposal that the nitrogen-containing
bisphosphonates inhibit osteoclastic bone resorption
predominantly by inhibition of this pathway. These
bisphosphonates inhibit the synthesis of mevalonate me-
tabolites including FPP and GGPP, and thereby impair
the prenylation of proteins,
71
and cause alteration of
function of small GTPases. There is a strong structure-
activity relationship such that changes to the structure of
the nitrogen-containing R
2
side chain or to the phospho-
nate groups, which alter antiresorptive potency, also
inuence the ability to inhibit protein prenylation to a
corresponding degree.
72
An important verication of the
critical importance of this pathway has come from show-
ing that the addition of intermediates of the mevalonate
pathway (such as FPP and GGPP) could overcome
bisphosphonate-induced apoptosis and other events in
many cell systems. Another prediction was that if inhi-
bition of the mevalonate pathway could account for the
antiresorptive effects of bisphosphonates, then the statin
drugs should also inhibit bone resorption. Statins are
inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A
(HMG-CoA) reductase, one of the rst steps in the me-
valonate pathway. They proved to be even more potent
than bisphosphonates at inhibiting osteoclast formation
and bone resorption in vitro,
73,74
an effect that could also
be overcome by the addition of geranylgeraniol (which
can be used for protein geranylgeranylation) but not
farnesol (which is used for protein farnesylation). Hence,
it seems that although nitrogen-containing bisphospho-
nates can prevent both farnesylation and geranylgera-
nylation of proteins (probably by inhibiting enzymes
required for synthesis of FPP and GGPP), loss of gera-
nylgeranylated proteins in osteoclasts is of greater con-
sequence than loss of farnesylated proteins. This is con-
sistent with the known role of geranylgeranylated
proteins such as Rho, Rac, and Rab in processes that are
fundamental to osteoclast formation and function (eg,
cytoskeletal rearrangement, membrane rufing, and ve-
sicular trafcking
75
), and further work has conrmed
this, particularly the importance of Rab proteins.
The comparison between bisphosphonates and statins
is interesting. The statins are widely used as cholesterol-
lowering drugs (they are able to lower cholesterol bio-
synthesis by inhibiting 3-hydroxy-3-methylglutaryl co-
enzyme A reductase). Despite several studies, there is no
substantial evidence that statins have effects on bone
when used clinically, perhaps because they are selec-
tively taken up by the liver rather than bone, which is
the converse of the case for bisphosphonates. Therefore,
this is an excellent example of how drug specicity is
achieved by highly selective tissue targeting.
The exact enzymes of the mevalonate pathway that
are inhibited by individual bisphosphonates have been
partially elucidated. Several enzymes of the pathway use
isoprenoid diphosphates as a substrate (isopentenyl py-
rophosphate isomerase, FPP synthase, GGPP synthase,
squalene synthase) and, thus, are likely to have similar
substrate-binding sites. Thus, if nitrogen-containing
bisphosphonates act as substrate analogues of an isopre-
noid diphosphate, it is possible that these bisphospho-
nates will inhibit more than 1 of the enzymes of the
mevalonate pathway. Early studies revealed that incad-
ronate and ibandronate, but not other bisphosphonates,
are inhibitors of squalene synthase, an enzyme in the
mevalonate pathway that is required for cholesterol bio-
synthesis.
76,77
Inhibition of squalene synthase, however,
would not lead to inhibition of protein prenylation.
However, it is now clear that farnesyl pyrophosphate
synthase (FPPS) is a major site of action of the nitrogen-
containing bisphosphonates (N-bisphosphonates).
78
FPPS catalyzes the successive condensation of isopente-
nyl pyrophosphate with dimethylallyl pyrophosphate
and geranyl pyrophosphate. There is a strong relation-
ship among individual bisphosphonates between inhibi-
tion of bone resorption and inhibition of FPPS, with the
most potent bisphosphonates having IC
50
values (con-
centration that inhibits response by 50%) in the nano-
molar range.
79
Modeling studies have provided a molec-
ular rationale for bisphosphonate binding to FPPS.
80
Our
recent studies using protein crystallography, enzyme ki-
netics, and isothermal titration calorimetry led to the
rst published high-resolution radiograph structures of
the human enzyme in complexes with risedronate and
zoledronate.
81
These agents bind to the dimethylallyl/
geranyl pyrophosphate ligand pocket and induce a con-
formational change. The interactions of the N-bisphos-
phonate cyclic nitrogen with Thr201 and Lys200 suggest
that these inhibitors achieve potency by positioning their
nitrogen in a proposed carbocation
82
binding site. This
explains how the nitrogen moiety is so important to the
potency of these bisphosphonates. Kinetic analyses re-
veal that inhibition is competitive with geranyl pyro-
phosphate and is of a slow, tight-binding character,
which indicates that isomerization of an initial enzyme-
inhibitor complex occurs after binding of the N-bisphos-
phonate.
Taken together, these observations clearly indicate
that bisphosphonates can be grouped into 2 classes:
those that can be metabolized into nonhydrolyzable an-
alogues of ATP (the least potent bisphosphonates) and
those that are not metabolized but can inhibit protein
prenylation (the potent, nitrogen-containing bisphos-
phonates). The identication of 2 such classes may help
to explain some of the other pharmacologic differences
between the 2 classes.
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CLINICAL APPLICATIONS OF BISPHOSPHONATES
After it was shown that bisphosphonates inhibited ex-
perimentally induced calcication and bone resorption,
their potential application to clinical disorders was obvi-
ous, but it took many years for them to become well
established.
The earliest clinical applications of bisphosphonates
included use of etidronate as an inhibitor of calcication
in brodysplasia ossicans progressiva (formerly known
as myositis ossicans) and in patients who had under-
gone total hip replacement surgery to prevent subse-
quent heterotopic ossication and improve mobility.
83
One of the other early clinical uses of bisphospho-
nates was as agents for bone imaging, bone scanning,
for which they still remain outstandingly useful for de-
tecting bone metastases and other bone lesions. The
application of pyrophosphate and simple bisphospho-
nates as bone-scanning agents depends on their strong
afnity for bone mineral, particularly at sites of in-
creased bone turnover, and their ability to be linked to a
-emitting technetium isotope.
84,85
The most impressive clinical application of bisphos-
phonates has been as inhibitors of bone resorption, es-
pecially for diseases in which no effective treatment
existed previously. Thus, bisphosphonates became the
treatment of choice for a variety of bone diseases in
which excessive osteoclast activity is an important
pathologic feature, including Paget disease of bone, met-
astatic and osteolytic bone disease, and hypercalcemia of
malignancy, as well as osteoporosis.
The clinical pharmacology of bisphosphonates is char-
acterized by low intestinal absorption (1%4%) but
highly selective localization and retention in bone. Sig-
nicant adverse effects of bisphosphonates are mini-
mal.
8688
Although there are more similarities than dif-
ferences between individual compounds and each
bisphosphonate is potentially capable of treating any of
the disorders of bone resorption in which they are used,
in practice different compounds have come to be favored
for the treatment of different diseases. There are cur-
rently at least 10 bisphosphonates (etidronate, clodr-
onate, tiludronate, pamidronate, alendronate, risedr-
onate, zoledronate, and ibandronate and, to a limited
extent, olpadronate and neridronate) that have been
registered for various clinical applications in various
countries. To a major extent, the diseases in which they
are used reects the history of their clinical development
and the degree of commercial interest in and sponsor-
ship of the relevant clinical trials.
Paget disease was the rst clinical disorder in which a
dose-dependent inhibition of bone resorption could be
demonstrated by using bisphosphonates in humans.
89,90
Bisphosphonates have become the most important drugs
used in the treatment of Paget disease.
91
For many years
pamidronate given by intravenous infusion was used
extensively,
92
but the newer and more potent bisphos-
phonates can produce even more profound suppression
of disease activity than was possible with the bisphos-
phonates available in previous years.
93,94
The latest ad-
vance is with zoledronate,
95
which, when given as a
single 5-mg infusion, produced a greater and longer-
lasting suppression of excess bone turnover than even
oral risedronate given at 30 mg/day over 2 months,
hitherto one of the most effective treatments.
In terms of commercial success, the use of bisphos-
phonates in oncology has been preeminent. Many can-
cers in humans are associated with hypercalcemia
(raised blood calcium) and/or increased bone destruc-
tion. Bisphosphonates are remarkably effective in the
treatment of bone problems associated with malignan-
cy
96
and are now the drugs of choice.
9799
Clinical trials
that investigate the benet of bisphosphonate therapy
use a composite end point dened as a skeletal-related or
bone event, which typically includes pathologic fracture,
spinal cord compression, radiation or surgery to bone,
and hypercalcemia of malignancy. Bisphosphonates sig-
nicantly reduce the incidence of these events in my-
eloma
100
and in patients with breast cancer metasta-
ses
101,102
and in metastatic prostate cancer,
103
lung cancer,
renal cell carcinoma, and other solid tumors. The goals
of treatment for bone metastases are also to prevent
disease-related skeletal complications, palliate pain, and
maintain quality of life. Zoledronate,
104
pamidronate,
clodronate, and ibandronate
105,106
have demonstrated ef-
cacy compared with placebo.
There is the important possibility that the survival of
patients may be prolonged
107109
in some groups of pa-
tients. Recently, osteonecrosis of the jaw
110
was identi-
ed as a potential complication of high-dose bisphospho-
nate therapy in malignant diseases.
The other area of outstanding commercial success
with bisphosphonates has been in the therapy of osteo-
porosis, which is a major public health problem.
111,112
Up
until the 1990s, there were few treatments for osteopo-
rosis. As a drug class the bisphosphonates have emerged
in the past few years as the leading effective treatments
for postmenopausal and other forms of osteoporosis.
Etidronate was the rst of these,
113115
followed by alen-
dronate
116118
and then risedronate.
119,120
All have been
approved as therapies in many countries and can in-
crease bone mass and reduce fracture rates at the spine
by 30% to 50% and at other sites in postmenopausal
women.
121
The reduction in fractures may be related not
only to the increase in bone mass arising from the inhi-
bition of bone resorption and reduced activation fre-
quency of bone-remodeling units but also to enhanced
osteon mineralization.
122
These bisphosphonates also
prevent bone loss associated with glucocorticosteroid ad-
ministration.
123,124
Among the newer bisphosphonates, ibandronate
125
was introduced recently as a once-monthly tablet. In
addition to formulations to be taken by mouth weekly or
S156 RUSSELL
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monthly, new routes of administration are being stud-
ied, especially periodic (eg, 3 monthly) injections with
ibandronate and once-yearly treatment with zoledr-
onate.
126
This has the attraction of delivering a dened
dose without the variability associated with oral admin-
istration as well as avoiding potential gastrointestinal
intolerance. If these approaches are accompanied by
greater compliance and convenience, they are likely to
become popular methods of treatment.
Other clinical issues under consideration with
bisphosphonates include the choice of therapeutic regi-
men (eg, the use of intermittent dosing rather than
continuous, intravenous versus oral therapy), the opti-
mal duration of therapy, the combination with other
drugs such as teriparatide, and their extended use in
related indications (eg, glucocorticosteroid-associated
osteoporosis, male osteoporosis, childhood osteopenic
disorders, arthritis, and other disorders). Therefore,
there is much that needs to be done to improve the way
in which existing drugs can be used and to introduce
new ones.
In pediatrics, pamidronate has proved remarkably ef-
fective in increasing bone in children with the inherited
brittle-bone disorder, osteogenesis imperfecta.
127,128
SOME CURRENT ISSUES WITHBISPHOSPHONATES: BONE
ARCHITECTURE, STRUCTURE, ANDSTRENGTH, ANDONBONE
HEALING ANDFRACTURE REPAIR
Many experimental and clinical studies show that
bisphosphonates conserve bone architecture and
strength.
129133
However, there have been concerns about
whether the use of prolonged high doses of bisphospho-
nates may impair bone turnover to such an extent that
bone strength is impaired. High doses in animals are
associated with increased microdamage
134,135
and even
fractures.
136
It has been suggested that bisphosphonates
might prevent naturally occurring microscopic cracks in
bone from healing. There have been isolated reports of
adynamic bone associated with bisphosphonate usage,
137
but long-term use of the bisphosphonates in the therapy
of osteoporosis seems to be safe.
138
Case reports of in-
duction of osteopetrosis-like lesions in children who
were treated with excessive doses of pamidronate have
been published.
139
A question often asked is whether bisphosphonates
inhibit fracture repair. By reducing bone turnover one
might expect bisphosphonates to interfere with fracture
healing. However, a recent long-term study in a beagle
dog model that simulated fracture repair has demon-
strated that ibandronate treatment did not adversely
affect normal bone healing.
140
Studies of repair processes
after creating drill-hole defects in dogs also showed no
impairment with ibandronate.
141
Several other recent studies raised the intriguing pos-
sibility that bisphosphonates may enhance fracture re-
pair and related processes.
142
In studies of the osseointe-
gration of metal implants in ovariectomized rats,
treatment with ibandronate resulted in improved os-
seointegration rather than impairment of the healing
process.
143
Potential applications of bisphosphonates in
orthopedics include protection against loosening of pros-
theses,
144
better integration of biomaterials and implants,
improved healing in distraction osteogenesis,
145
and con-
serving bone architecture after osteonecrosis
146,147
and in
Perthes disease.
148
There are potentially important differences between
clinically useful bisphosphonates regarding their po-
tency and duration of action. Efcacy is closely related to
afnity for bone mineral and ability to inhibit FPP syn-
thase. Recent studies showing that there are marked
differences among bisphosphonates in binding to hy-
droxyapatite
149
may explain the variations in retention
and persistence of effect that have been observed in
animal and clinical studies. In the case of zoledronic acid,
in particular, the remarkable magnitude of effect and
prolonged duration of action can be explained in part by
these new observations. In explaining the long duration
of action, it has been proposed that there is continual
FIGURE 4
Bisphosphonate (BP) uptake and detachment from bone surfac-
es: effect of binding afnity on recirculation of bisphosphonate
on and off bone surfaces. The differences in mineral-binding af-
nity may affect distribution into different bone compartments
and persistence of drug action at bone surfaces. (Adapted from
Nancollas GH, Tang R, Phipps RJ, et al. Bone. 2006;38:617627.)
PEDIATRICS Volume 119, Supplement 2, March 2007 S157
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recycling of bisphosphonate off and back onto the bone
surface. This notion is supported by observations that
bisphosphonates can be found in plasma and urine
many months after dosing (Fig 4).
There are numerous examples of bisphosphonates
having effects on cells and tissues outside the skeleton.
The effects on osteoclast precursors, tumor cells, macro-
phages, and ,-T cells are examples and in all cases are
probably explained by sufcient bisphosphonates enter-
ing cells to inhibit the mevalonate pathway. A well-
recognized adverse effect of the nitrogen-containing
bisphosphonates is that they cause an acute-phase re-
sponse in vivo,
150,151
which can lead to induction of fever
and u-like symptoms in patients. These effects are
transient and occur predominantly on rst exposure to
the drug, especially with intravenous administration.
The mechanism has been attributed to release of proin-
ammatory cytokines, and the mechanism has been fur-
ther unraveled by showing that it involves selective re-
ceptor-mediated activation of ,-T cells, leading to their
proliferation and activation.
152
The bisphosphonate ef-
fect involves the mevalonate pathway in vitro and can
be overcome by using statins.
153
Another interesting aspect of these nonskeletal effects
are the observations made on protozoan parasites, the
growth of which can be inhibited by bisphosphonates
acting on FPPS.
154,155
In the future, other clinical indications ripe for future
study include the prevention of bone loss and erosions in
rheumatoid arthritis, possible applications in other joint
diseases, the reduction of bone loss associated with peri-
odontal disease, and loosening of joint prostheses.
The recent elucidation of the likely mode of action of
bisphosphonates within cells opens up the possibility of
exploiting the subtle and potentially important differ-
ences between the classes of bisphosphonates and indi-
vidual compounds.
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DOI: 10.1542/peds.2006-2023H
2007;119;S150 Pediatrics
R. Graham G. Russell
Bisphosphonates: Mode of Action and Pharmacology

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