Vitamin K2(Menaquinone-7)Prevents DOI: 10.1530/EJE-16-0498 Clinical Study Osteocalcin Isamatrixprotein Producedbythe ±

Home , Vitamin K2

European Journal of Endocrinology 10.1530/EJE-16-0498 osteoblasts inanundercarboxylated form.Vitamin Kis rapid bonelossduringandafter menopause( Postmenopausal womenare especiallyatriskduetothe leading tomorbidity, mortalityandhealth costs( fractures is a major health problem in the western world, Osteoporosis and the consequent increased risk of Introduction trabeculae. ThissuggeststhatvitaminMK-7preservestrabecularbonestructureatthetibia. deterioration oftrabecularstructure,withalosstrabeculaeandgreatermeanthicknesstheremaining Conclusion HRpQCT-derived parametersatthe radiusorinBMDatanysite. (+4.0 and trabecularthicknesswasunchangedintheMK-7group(+0.2 trabecular spacingwasunchangedintheMK-7group(+1.2 tibia wasunchangedintheMK-7-group(−0.1 (−6.4 (−13.5;1.2)%)after3 months( Results them weresupplementedwithcalciumandvitaminD. tomography (HRpQCT)andbiochemicalboneturnovermarkersin148postmenopausalwomenwithosteopenia. Allof X-ray absorptiometry(DXA),bonemicroarchitecturemeasuredbyhigh-resolutionperipheralquantitativecomputed Methods Design (ucOC), andbonemassquality. quality hasneverbeeninvestigated.We investigatedtheeffect ofvitaminMK-7onundercarboxylatedosteocalcin Objective Abstract Department ofEndocrinologyandInternalMedicine,AarhusUniversityHospital,C,Denmark Bente Lomholt Langdahl Sofie Hertz Rønn, Torben Harsløf, SteenBønløkke Pedersen postmenopausal women microarchitecture atthetibiain age-related deteriorationoftrabecularbone Vitamin K2(menaquinone-7)prevents DOI: 10.1530/EJE-16-0498 www.eje-online.orgwww.eje-online.org Clinical Study Osteocalcin isamatrixprotein producedbythe ±

: We conductedarandomised,placebo-controlled,double-blindedclinical trial. : ucOCdecreasedintheMK-7group(−65.6(59.1;71.0)%)(median(CI))comparedwithplacebo 2.2%) (between-groupchangesforall: : We investigatedtheeffect ofMK-7375 : ClinicalstudiessuggestthatvitaminK2protectsagainstbonelossandfractures;however, itseffect onbone : Thechangesinbonemicroarchitecturetheplacebogroupareconsistentwithage-related

0.01). HRpQCTafter12 monthsdemonstratedthattrabecularnumberin Printed inGreatBritain 3 ± P , .% (mean 1.9%)

4 < ).

0.05). Therewerenosignificantdifferences betweenthegroupsin µg for12 monthsonbonemineraldensity(BMD)measuredbydual 1 , 2 ). ± ±

8.0%) andincreasedintheplacebogroup(+4.5 K2 (menaquinones),mainly synthesisedbybacteria.The K1 (phylloquinone),synthesised byplants,andvitamin promote mineralisationofbone ( osteocalcin. Carboxylatedosteocalcin(cOC)isbelieved to availability ofvitaminKcontrolsthecarboxylation of a cofactorinthecarboxylationofosteocalcin,and bone structure MK-7 preservestrabecular

s Published byBioscientifica Ltd. . d and . ) anddecreasedintheplacebogroup(−3.5 Vitamin Kexists in several natural forms; vitamin ±

1.7%) andincreasedintheplacebogroup

Downloaded fromBioscientifica.com at09/30/202102:07:47AM (2016) Endocrinology European Journal of [email protected] Email to SHRønn should beaddressed Correspondence 5 175 ). 175 : 6 175

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–549 via freeaccess European Journal of Endocrinology www.eje-online.org D antagonists, orvitaminDinsufficiency (s-25-OHvitamin metabolism, intakeofvitamin Ksupplementsorvitamin smoking, diseases,oruseof medication whichaffectbone or lumbarspine≤−1,but andosteopenia(T-score ofhip between 60and80 years, yearspastthelastmenstrualperiod, age as atleast2 Inclusion criteriawerepostmenopausalstatusdefined We included148healthypostmenopausal women. Participants andrecruitment Methods quantitative computedtomography(HRpQCT). bone structure evaluated by high-resolution peripheral biochemical markers,arealBMDmeasuredbyDXAand evaluated theeffectonboneturnovermeasuredby placebo asanadd-ontocalciumandvitaminD osteopenia wererandomisedtoMK-7(375 controlled trialinwhichpostmenopausalwomenwith bone structurehasneverbeeninvestigated. equivocal; furthermore,theeffectofvitaminMK-7on Thus, dataontheeffectofvitaminKaresofarsomewhat combination withcalciumandvitaminDonBMD( and thethirdstudyfoundapositiveeffectofMK-7in ( found BMDatthefemoralnecktobepreserved One studyshowednoeffectonBMD( bone metabolisminCaucasianpostmenopausalwomen. Only threestudieshaveinvestigatedtheeffectofMK-7on suggest thatMK-4maypreventfractures( an effectonbone mineral density (BMD) but some studies Japanese populations.Ingeneraltheyhavefailedtoshow studies investigating the effects of MKshave used MK-4in ( vitamin K1inCaucasianpopulations,andallbutone K on bone phenotypes. Five studies have investigated of clinicalstudieshaveinvestigatedtheeffectsvitamin of hipfractureinoldermenandwomen( women ( between serumucOCand the riskofhipfracture in elderly approximately 3 days( has oneofthelongesthalf-livesmenaquinones rich inMK-7,isamajorcontributortovitaminK.MK-7 vitamin K,whereasinJapan,fermentedsoybeans,Natto, In thewesterndiet,vitaminK1ismajorcontributorto based ontheisoprenoidsidechain,denominatedMK-n. menaquinones aredividedintomorethan10subtypes 9 ) found no effectonBMD( Clinical Study < We thereforeconductedarandomisedplacebo- Epidemiological studieshavefoundassociations 50 nmol/L). Women withvitaminDinsufficiency 7 ) andbetweenlowintakeofvitaminK1risk 6 ). > −2.5). Exclusioncriteriawere 10 , S HRønnandothers 11 , 12 18 , 13 ), anotherstudy 14 ). Mostofthe 8 , ). Anumber 15 µg/day) or , 16 , 17 20 19 ). ). ), bone mass,structureandturnover. endpoint Theprimary blinded, clinicaltrialinvestigatingtheeffectofMK-7on The study was a randomised, placebo-controlled, double- Design excluded ( illness andthreeduetolackoftimeparticipate,orwere based ontabletcountsateach visit. calcium andvitaminD), compliancewasestimated at atime(100tabletsofMK-7/placebo, and180tabletsof Study medicationwasprovidedfor3 months 12 months. participants wereseenforstudy visitsafter1,3,6,9and blinded tostudydrugallocation.Afterrandomisationthe each group). The study investigators and participants were University Hospital,inblocksof10participants(five in randomisation wasdonebythepharmacyatAarhus and suppliedbyOrklaHealth(Ishøj,Denmark).The two dailytablets.Thestudymedicationwasproduced of calcium(800 daily. Also,alltheparticipantsreceivedsupplementation menaquinone-7 (MK-7)orsimilarplacebo,takenonce The studymedicationwasonetabletcontaining375 Study medication Clinical Practice(GCP). the DeclarationofHelsinkillandguidelinesonGood initialised. We conductedthestudyinaccordancewith Clinicaltrials.gov (NCT01922804)beforerecruitmentwas the DanishDataProtectionAgency, andregisteredat was approvedbytheRegionalEthicsCommitteeand Internal Medicine,AarhusUniversityHospital.Thestudy Osteoporosis Clinic,DepartmentofEndocrinologyand study wasasingle-centrewhichtookplaceatthe The bone strengthandturnovermarkersat1 year. bone mineraldensity(aBMD),microarchitecture, endpointswerechangesinareal months;secondary 3 was changeins-undercarboxylated osteocalcinafter group). Six womeneither dropped out ( of thestudy(71inMK-7groupand71placebo hundred and forty-twowomen completed the first year eligible andprovidedwritteninformedconsent.One women bymailandofthese242replied148were Clinic fromAugust2013toMay2014.We invited455 previously examinedforosteoporosisattheOsteoporosis one woman. monthsandgothrough re-screening.Thisappliedto 3 had theoptionofreceivingvitaminD,38 bone structure MK-7 preservestrabecular We recruitedstudyparticipantsamongwomen n

= 2), bothduetoillness. mg) andvitaminD(38 Downloaded fromBioscientifica.com at09/30/202102:07:47AM 175 µg), containedin n :6

= 4), one due to µg daily, for 542 µg via freeaccess European Journal of Endocrinology analysis asdescribedpreviously ( microarchitecture andconductedfiniteelement analyses usingsoftwarefrom Scanco.We analysed microarchitecture andperformedfiniteelement We performedthe 3Danalysesofbonedensityand with thereproducibilityreportedbyothers( 0.2% intibiaand0.8%radius.Thisisagreement Coefficient ofvariationrepositioningwasforvBMD for 10participantsattibiaand8radius. by repeatedscansafterrepositioningandevaluation by SHRønn.We calculatedthecoefficientof variation a rescanifnecessary. Analyses wereperformedsolely checked imagequalityaftereachscan,andconducted giving a9 At bothsitesweobtained110cross-sectionalslices, from theendplateofradiusandtibiarespectively. define theregiontoscan,whichwas9.5and22.5 the limbinacarboncast,andusedscoutviewto right side,theleftwaspreferred( Iftherehadbeenapreviousfractureatthe12 months. radius andthedistalrighttibiaatbaselineafter Medical, Switzerland).We examinedthedistalright finite elementanalysisbyHRpQCT(XtremeCT, Scanco We investigatedbonemicroarchitecture andperformed Tomography (HRpQCT) High-Resolution peripheralQuantitativeComputed one patient. spine, it was not possible to perform DXA of the spine in as the baseline scan. Due to metal implants in the lumbar by DXAwithin2 months ofrandomisation,thiswasused throughout the study. If a participant had been examined 12 months. We used the same scanner for each individual hip. We performedDXAatscreeningandafter3,6 hip wasnoteligibleforevaluation,weevaluated the right 1% atthelumbarspineand2%totalhip.Ifleft USA). Thecoefficientofvariation(CV)repositioningis and lefthip(HologicDiscovery, HologicInc,Waltham, MA, We evaluatedaBMDbyDXAofthelumbarspine(L1–L4) Dual X-rayabsorptiometry(DXA) 12 months. performed physicalexaminationatbaselineandafter at baseline,andmonths3,612.Furthermore,we mounted stadiometerwiththeparticipantslightlyclothed We measuredstandingheightandweightonawall- General measurements Clinical Study mm long3Drepresentationofthebone.We S HRønnandothers n 23 10). Weimmobilised =10). , 24 , 25 ). 21 , mm 22 ). ). (P1NP) andbone-specificalkalinephosphatase(BAP) osteocalcin (ucOC),procollagen1N-terminalpropeptide midfragment osteocalcin(OC),undercarboxylated same dayatthehospitalclinicallaboratory. 6 months,the screening visit, and every and analysed the werecollectedat samples forroutinesafetybiochemistry stored serumandplasmaat−80°Cuntilanalysis.Blood 0000 All blood sampleswere collected between 0730 and Blood samplingandbiochemistry placebo group. radius could not be performed in one participant in the (3 ineachgroup),andfiniteelementanalysisofthe placebo), radiuscouldnotbeanalysedin6participants be analysed in two participants (both allocated to each group,assumingachange inucOCof29%,amean determined bypowercalculations tobe51participantsin daily ( serum levelsofucOCafter treatment with180 short-term studieshavedemonstrated decreaseof29%in months. Previous undercarboxylated osteocalcin after 3 included inthestatisticalanalyses. and fiveparticipantswithearlyterminationwere not We conductedthestatisticalanalysesasper protocol Statistical analysis each visit. Information about adverse events was obtained at Safety and interassayCVof10%intherange4.5–45.9 (Immunodiagnostic Systems, Tyne and Wear, UK), with BAP usingachemiluminometricmethodoniSYS with carboxylated osteocalcin was 5%. We analysed with aninterassayCV We analyseducOCusinganELISAkit(Takara Bio) 19–92 CVs of2.9–3.0%,3.7%and5.1–5.8%intheranges reader (RocheDiagnostics,Lewes,UK)withinterassay using a chemiluminometric method on a Cobas 6000 E telopeptide (CTx).We analysedOC,P1NPandCTX and asboneresorptionmarkerwemeasuredC-terminal bone structure MK-7 preservestrabecular As bone formation markers we measuredN-terminal Due totechnicaldifficulties,tibiacouldnot The primary endpointwas change in The primary h afteranovernightfast.Aftercentrifugation,we µg/L, 30–205 26 ). Theminimumnumber of participantswas µg/L and0.26–0.59 Downloaded fromBioscientifica.com at09/30/202102:07:47AM < 6.7% andcross-reactivity 175 www.eje-online.org µg/L respectively. :6 µg MK-7 µg/L. 543 via freeaccess

European Journal of Endocrinology www.eje-online.org or medianandconfidenceinterval. significance was0.05.Resultsarereportedasmean turnover ontreatmentoutcomebyANCOVA. Levelof We investigated the potential effect of baseline bone in s-ucOCandchangestrabecularmicrostructure. performed toinvestigatethecorrelationsbetweenchanges using Bonferronicorrection.Pearson’s correlationwas time point of measurements byaposteriorianalysis models, weanalyseddifferencesbetweengroupsateach case ofasignificantbetween-groupdifferencebymixed for bone turnover markers. In from 0, 6 and 12 months comprised datafrom0,3,6and12 months forBMDand serial changesusingmixedmodels.Theseanalyses were analysedusingChi-squaretests.We investigated treatment groupsusingunpaired monthsbetweenthetwo changes frombaselineto12 distribution. We comparedbaselinecharacteristicsand which waslogarithmictransformedtoachievenormal Data werenormallydistributedexceptforucOC, normality usingQQplotsforthetwogroupsseparately. 75 participantsineachgroup. ( group with a mean level of ucOC of 1.71 a levelofsignificance5%,and54participantsineach level ofucOC2.25 Estimated ultimatefailureload radius(N) Estimated ultimatefailureload tibia(N) Trabecular spacingradius(mm) Trabecular thicknessradius(mm) Trabecular numbersradius(permm) Trabecular spacingtibia(mm) Trabecular thicknesstibia(mm) Trabecular numberstibia(permm) vBMD tibia(g/cm aBMD totalspine(g/cm aBMD hiptotal(g/cm S-ucOC (ng/mL)* S-OC (µg/L) S-BAP (µg/L) S-CTX (ng/mL) S-P1NP (µg/L) S-25-OH-vitamin D(nmol/L) Smoking (previous/never) Low-energy fracture(yes/no) Family historyofosteoporosis(yes/no) BMI (kg/m a Years sincemenopause(years) Age (years) Characteristics Table 1 Results areshownasmean 27 Clinical Study ). To compensatefordrop-outsweaimedatincluding We usedSTATA forstatisticalanalysis.We checked Baseline characteristicsfortheMK-7andplacebogroups. 2 ) 3 ) 2 ) 2 ± ± )

. 1.16 d . exceptfor*thatisshownasmedian andCI.Significant ng/mL, apowerof80%,and S HRønnandothers t -test. Binomialdata ± 0.92ng/mL ±

s . d 0.239 0.873 0.782 6.6 (5.2;8.5) MK-7 2810 8219 0.06 0.07 26.4 15.6 0.40 55.5 23.7 17.5 67.9 .

0.5 1.8 0.5 1.7 88 23/48 11/60 37/34 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ( events orseriousadverse( no differencesbetweenthegroupsregardingadverse participant weremorethan80%compliant.There placebo groupsrespectively( for BAP, OCorucOC. ( MK-7 groupand0.46 ( the MK-7groupand63.0 imbalance ass-P1NPwas55.5 bone turnovermarkers,however, therewasaslight D status,BMDandbonestructure( composition, previous fractures, smoking status, vitamin respect toage,yearssincemenopause,measuresofbody At baselinethe two groups were wellmatched with Baseline characteristics,complianceandtolerability Results rmbsln o1 monthsarepresentedin from baselineto12 Changes inbonemicroarchitecture andgeometry Effect ofMK-7onbonemicroarchitecture not shown). a n bone structure MK-7 preservestrabecular 474 946 0.1 0.01 0.4 0.1 0.01 0.3 0.046 0.060 0.070 8.6 4.0 0.14 17.1 19 3.5 6.6 4.6 P P =71)

= = 0.03). There were no differences between the groups 0.02) and similarly s-CTX was 0.40 Compliance was97.2%and97.8%intheMK-7 P -values areshowninboldface. Placebo 6.0 (4.8;7.5) 0.238 0.871 0.779 ±0.066 2849 8384 0.06 0.07 28.1 17.0 0.46 63.0 24.2 16.9 67.0 0.6 1.7 0.5 1.7 ± 86 29/42 10/61 35/36

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European Journal of Endocrinology for all). ( which wassignificantlydifferentbetweengroups increased intheplacebogroupby4.0 in theMK-7group–+0.7 groups ( ( significantly intheplacebogroupby4.5 MK-7 group–+1.2 In addition,trabecularspacingwasunchangedinthe BMD orfailureloadatthetibiaradius( between thetwogroupsinchangesanymeasureof parameters ( between the two groups in changes in the structural thickness. * trabecular numbers, spacingandtrabecular 12 months. (A)Tibia. (B)Radius.Mean (%)change Changes inmicroarchitectureby HRpQCTfrombaselineto Figure 1 were significantlydifferentbetweenthegroups( ( whereas itdecreasedsignificantlyby−3.5 unchanged in theMK-7 group – −0.6 2 Tables P P P Clinical Study =0.02).

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bone turnover Effect ofMK-7onbiochemicalmarkers 6 months, s-OC had decreased by 23 differed significantlybetweenthegroups( and −7.2(−15.9;2.0)%intheplacebogroup( changes were −70.3 (−63.8; −75.6) % in the MK-7 group % intheplacebogroup( (−77.0; −66.6)%intheMK-7groupand−8.0(−15.3;−0.1) ( with nochangesintheplacebogroup(−6.4(−13.5;1.2)%) 71.0) %(median(95%CI))intheMK-7groupcompared ( between theMK-7groupandplacebo( Changes ins-ucOCovertimedifferedsignificantly Finite element

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European Journal of Endocrinology www.eje-online.org with placebo. from baselineafter6and12 months. * (F) S-C-terminaltelopeptide(CTX). Mean(%)change (BSAP). (E)S-Procollagen1,N-terminal propeptide(P1NP). (ucOC/OC-ratio). (D)S-bone-specific alkalinephosphatase s-undercarboxylated osteocalcintos-total osteocalcin (ucOC).(B)S-total(OC).(C)Ratio Changes inboneturnovermarkers.(A)S-undercarboxylated Figure 2 −4.2% (−12.4;4.8)intheplacebogroup( −62.9% (−69.3; −55.1) in the MK-7 group compared with 4.0) intheplacebogroup( −55.9) %intheMK-7groupcomparedwith−3.2%(−10.0; theratiohaddecreasedby−63.3%(−69.5; After 6 months and s-OCdifferedsignificantlybetweenthegroups( in theplacebogroup( were −18.8 placebo group ( group comparedwithnochange(−4.3 Clinical Study In addition, the changes in the ratio between s-ucOC In addition,thechangesinratiobetweens-ucOC ±

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European Journal of Endocrinology to anincreaseinthemean trabecularthicknessofthe In addition, loss of the thinnest trabeculae would lead trabecular numbersandincreased trabecularseparation. of trabeculae,whichwould explainthedecreasein a deteriorationoftrabecular bonestructure,withaloss in 31postmenopausalwomen( comparable changesalsousingHRpQCTafter12 months reported inpostmenopausalwomen.Kawalilak in agreementwiththeage-relatedchangespreviously group comparedwiththeMK-7-treatedwomenare intheplacebo increase intrabecularthicknessobserved trabecular numbers,increaseinspacingand despite nosignificanteffectsonBMD.Thereduction in maintained microarchitecture intrabecularbonetibia, OC bymorethan60%,increasedBAP5%,and osteocalcin bymorethan70%,reducedtheratioucOC/ monthsreducedserumlevelsofundercarboxylated 12 375 clinical trial,wefoundthattreatmentwithvitaminMK-7 In this randomised, placebo-controlled, double-blinded Discussion the MK-7andplacebogrouprespectively( lumbar spineBMDwere−0.8 placebo grouprespectively( BMD were−0.1 group respectively ( −0.3 P points were included in the analysis ( no differencesinBMDchanges,whenatallthetime differ between groups ( weresmallanddidnot Changes inaBMDafter12 months Effect ofMK-7onbonemassanddensity not shown). allocation ontrabecularbonemicroarchitecture (data s-P1NP ands-CTXdidnotaffecttheeffectoftreatment for s-P1NPand s-P1NP ors-CTXovertimebetweenthegroups( differences betweenthetwogroups( group (21.0 MK-7 group(17.8 ( 12 months compared withtheplacebogroup(−1.3

= Clinical Study 0.76 forfemoralneckand µg daily, in addition to calcium and vitamin D, for t1 monthschangesintotalhipBMD were At 12 Mixed modelsanalysisshowednodifferencein ±

2.1% and−0.5 ± P

67) ( 16.7%) = 0.02). S-25-OH-vitaminDincreasedinthe P ±

3.2% and−0.1 ± 0.54 fors-CTX).Furthermore,baseline 06) ( 20.6%) P Fig. 3 ±

P =

< 1.8% intheMK-7andplacebo 0.42), changes in femoral neck

0.01) after 12 months, withno 0.01) after12 months, ). Mixed models analysis showed ). Mixed models analysis showed P P

< P ± 0.53 fortotalspine). 28

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3.7% and−0.1 ± S HRønnandothers 0.94), andchangesin ). Thefindingsrepresent

3.3% intheMK-7and P P =0.31).

= 0.58 for total hip, 0.58 for total hip, P ± =0.23). 27) after 12.7%) et al. ± .% in 3.3% P found =0.86 demonstrated byCheung tibia. Thisdifferencebetweenthetwositeshasalsobeen radius whichmakesiteasiertodetectdifferencesatthe the variationofmeasurementsbonestructurein measurements performedatthetibiaissmallerthan an arm in the HRpQCT scanner the variation of the because itistechnicallyeasiertopositionalegthan weightbaring bone,whereasradiusisnot.Furthermore, of the treatment with MK-7 at the radius. The tibia is a trabecular structure. We found no significant effects with vitaminMK-7counteractsthisprocess,andpreserves remaining trabeculae.Ourdatasuggestthattreatment merely a consequence of a decreased s-OC; however, cell ( been describedbeforeinresponsetoMK-7treatment S-OC alsodecreasedalthoughtoalesserextent.Thishas indicating anincreasedcarboxylationofosteocalcin. a decreaseins-ucOCresponsetoMK-7treatment oe.Atr3 years,theMK-7-treatedwomenhada women. After3 MK-7-treated womencompared withtheplacebo-treated BMD butBMCatthe not provided( VitaminMK-7 orplacebofor3 years. Dandcalcium were after 1 year( of vitaminDandcalciumfoundnoeffectonBMD MK-7 orplaceboin334womenwithoutsupplementation women. Emaus MK-7 onbonemetabolisminpostmenopausalCaucasian compared withplacebo( significant increaseinBAPtheMK-7-treatedgroup found aborderline In accordancewiththat,Emauset al. significant increaseinBAPtheMK-7-treatedwomen. formation andresorptionmarkers,apartfromasmallbut changes ins-CTXors-P1NPwithtreatment. does notaffectboneturnover;accordinglywefoundno response to MK-7. In addition, changes in mineralisation oftrabecularstructurein may explainthepreservation this decreaseins-ucOCpromotesmineralisationwhich part independent of the change in s-OC. We speculate that significantly showsthatthechangeins-ucOCisatleast matrix. Moreover, thefactthats-ucOC/s-OCalsodecreases and therebyachangeindistributionfromserumtobone is morelikelytobeexplainedbyincreasedcarboxylation accumulates inbonematrix( affinity forcalciumandhydroxyapatite,consequently studies showthatcarboxylatedosteocalcinhasgreater bone structure MK-7 preservestrabecular 18 ). One could speculate that the decrease in s-ucOC is ). Onecouldspeculatethatthedecreaseins-ucOCis Our studylikemanyotherstudies( Knapen Three otherstudieshaveinvestigatedtheeffectof We foundnoeffectofMK-7ontheotherbone 18 t al et 19 ). t al et .Atr1 year, noeffect wasfoundon ). After1 . randomised244womento180 . investigatedtheeffectof360 lumbar spine Downloaded fromBioscientifica.com at09/30/202102:07:47AM 18 et al ). 30 . ( ). Thus, the decrease in s-OC ). Thus,thedecreaseins-OC 29 ). decreasedlessinthe 175 www.eje-online.org 18 :6 , 19 , 20 ) shows ) shows 547 µg µg via freeaccess European Journal of Endocrinology www.eje-online.org the mechanismsbywhich MK-7affectsbone We donothave bonebiopsiestofurtherinvestigate not affectedbybaselineserum levelsofP1NPorCTX. on bone turnover. Furthermore, treatment response was MK-7 doesnotseemtobe mediatedthroughaneffect outcome betweenthetwogroups;however, theeffectof group. Thispotentiallycouldhaveaffectedthedifferent turnover markersatbaselinewerehigherintheplacebo 12 months. Despiterandomisation,twooutoffourbone months,andnotachangeinBMDafter ucOC after3 Thestudywaspoweredtoshowa decreasein of 1 year. Limitations ofthestudyincludeshortfollow-uptime the microarchitectural changesinboneusingHRpQCT. Lastly, thisisthefirststudyofvitaminMK-7 toinvestigate loss andfracturesinpatientswithosteopenia( participants, whichismainstayinthepreventionofbone Moreover, calciumandvitaminDwereprovidedtoall absorption andthebiologicaleffectofvitaminMK-7. Furthermore, s-ucOCdecreased,confirmingintake, strengths includethestudydesignandahighcompliance. ethnicity includingpharmacogenomicsandlifestyle. in thetwogroupsmayalsobeexplainedbydifferences studies). Thismakesitpossiblethatthedifferenteffects for whomnoeffectwasshown,wereCaucasian(9of11 while the majority of the non-osteoporosis individuals, however, wereofJapanese ethnicity (9of10studies), BMD decline.Themajorityoftheosteoporosispatients, with osteoporosis,thetreatmentspreventvertebral MK-4 andMK-7studiesonlyitwasshownthatinpatients with vitaminDandcalciumdoesnotalterthis. 375 adifferenceinBMD,evenwithhighdosesof360– observe to yearistooshort These findingswouldsuggestthat1 between groupsinallMK-7studiesincludingthisstudy. in BMD after 1 year were small and there was no difference inability toinvestigatetheisolatedeffectofMK-7,changes in thatstudyisnotclear. however, the analysis after1 year; was improvedintheMK-7andK1groupsa ( receive anyintervention counselling. Acontrolgroupof39womendidnot received calcium800 women received100 were treatedwith100 the effectsofvitaminK1andMK-7.Twenty-four women the placebogroup.Finally, Kanellakis smaller declineinBMDatthe Clinical Study µg MK-7; our results suggest that supplementation µg MK-7;ourresultssuggestthatsupplementation This studyhasstrengthsandlimitations.The In a recent meta-analysis by Huang Disregarding thestudybyKanellakis µg vitaminK1,boththesegroups mg, vitaminD10 µg MK-7andasecondgroupof26 20 ). BMDatthelumbarspine femoral neck S HRønnandothers isolated et al t al et µg, andlifestyle comparedwith t al et effectofMK-7 . ( . investigated 16 . due to its . duetoits ) including combined 31 , 32 ). ).

perceived asprejudicingtheimpartialityofresearchreported. The authorsdeclarethatthereisnoconflictofinterestcouldbe Declaration ofinterest with calciumandvitaminDonbone. investigate thelong-termeffectofMK-7incombination are neededtoinvestigatetheimplicationsofthis,and trabecularbonestructure.Longer-termstudies preserved in s-BAP. HRpQCTanalysesdemonstratedthatMK-7 increased carboxylationofosteocalcinandanincrease markers. We foundadecreaseins-ucOC,indicatingan bone mass,microarchitecture andboneturnover younger women,men,childrenornon-Caucasians. only. Finally, ourresultsmaynotberepresentativefor that vitaminK2hasaneffectonosteoporosispatients osteopenia, andthemeta-analysisbyHuong microarchitecture. Moreover, ourparticipantshad References conducting thestudy. The authorsthankthestaff attheOsteoporosisClinicfortheirhelpwith Acknowledgements Foundation. MEA ResearchFoundationandtheCentralDenmarkRegion Osteoporoseforeningen, The Family Hede Nielsens Foundation, the study wassupportedbytheAaseandEjnarDanielsensFoundation, supplied vitaminMK-7,placebotablets,calciumandD.The This workwasfinanciallysupportedbyOrklaHealth,whoalso Funding bone structure MK-7 preservestrabecular 6 5 4 3 2 1 Vermeer C. Vitamin supplements: comparisonof K-containingdietary Nutrition jbmr.5650091218) ofBoneandMineralResearchJournal proximal femurmeasuredbydual-energyX-rayabsorptiometry. and postmenopausalchangesinbonemineraldensityofthe jbmr.2002.17.11.2061) Bone andMineralResearch women: theDanishosteoporosispreventionstudy. berepeatedinhealthyperi-andpostmenopausal densitometry Vestergaard P, Tofteng CL &PorsNielsen S.Whenshould s11657-013-0126-3) burden? A healtheconomicanalysisofosteoporoticfractures:whocarriesthe Age andAgeing National analysisofcomedications,comorbidityandsurvival. mortality inmencomparedwithwomenfollowingahipfracture. Schurgers LJ, Teunissen KJ, Hamulyak K,Knapen MH,Vik H & Booth SL. RolesforvitaminKbeyond coagulation. Ravn P, Hetland ML,Overgaard K &Christiansen C.Premenopausal Abrahamsen B, Nissen N,Hermann AP, Hansen B,Barenholdt O, Hansen L, Mathiesen AS,Vestergaard P, Ehlers LH&Petersen KD. Kannegaard PN, vanderMark S,Eiken P&Abrahamsen B.Excess In conclusion,weinvestigatedtheeffectofMK-7on 2009 Archives ofOsteoporosis 2010 29 89–110. 39 203–209. 2002 (doi:10.1146/annurev-nutr-080508-141217) Downloaded fromBioscientifica.com at09/30/202102:07:47AM 2013 17 (doi:10.1093/ageing/afp221) 2061–2067. 1994 8 126-013-0126-3. 9 1975–1980. 175 (doi:10.1359/ :6 Annual Reviewof Journal of Journal et al (doi:10.1002/ (doi:10.1007/ . suggests

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Accepted 13September2016 Revised versionreceived31August2016 Received 9June2016 32 31 24 23 22 21 30 29 28 27 26 25 20 bone structure MK-7 preservestrabecular Bischoff-Ferrari HA, Willett WC, Orav EJ,Lips P, Meunier PJ, Abrahamsen B, Masud T, Avenell A, Anderson F, Meyer HE,Cooper C, Hansen S, Brixen K&Gravholt CH.Compromisedtrabecular Burghardt AJ, Link TM&Majumdar S.High-resolutioncomputed Boutroy S, Bouxsein ML,Munoz F&Delmas PD.Invivoassessment Hansen S, Hauge EM,BeckJensen JE&Brixen K.Differingeffectsof Koshihara Y &Hoshi K.Vitamin K2enhancesosteocalcin Cheung AM, Majumdar S,Brixen K,Chapurlat R,Fuerst T, Engelke K, Kawalilak CE, Johnston JD,Olszynski WP&Kontulainen SA. Atalay S, Elci A,Kayadibi H,Onder CB&Aka N.Diagnostic Kappa Bioscience O,Norway. KappaBioscienceClinicalStudy Pistoia W, vanRietbergen B,Lochmuller EM,Lill CA,Eckstein F& Kanellakis S, Moschonis G,Tenta R, Schaafsma A,vandenHeuvel EG, NEJMoa1109617) ofMedicine New EnglandJournal analysis ofvitaminDdoserequirementsforfractureprevention. Lyons RA, Flicker L,Wark J, Jackson RD,Cauley JA trials inUSandEurope. pooled analysisof68500patientsfromsevenmajorvitaminDfracture Smith H, LaCroix AZ,Torgerson D, Johansen A (doi:10.1359/jbmr.1997.12.3.431) study usinghigh-resolution-pQCT. tibia bonestrengthinadultswithturnersyndrome:across-sectional microarchitecture andlower finiteelementestimatesofradiusand (doi:10.1007/s11999-010-1766-x) andRelatedResearchClinical Orthopaedics tomography forclinicalimagingofbonemicroarchitecture. and Metabolism quantitative computedtomography. of trabecularbonemicroarchitecture byhigh-resolutionperipheral of BoneandMineralResearch studyusingHR-pQCT.an 18-monthopen-labeledobservational and estimatedstrengthinpostmenopausalwomenwithosteoporosis: PTH 1–34,1–84,andzoledronicacidonbonemicroarchitecture International decrease bonelossinhealthypostmenopausalwomen. in vitro. accumulation intheextracellularmatrixofhumanosteoblasts 1786–1794. bone strength. improvements inbonegeometry, microarchitecture, andestimated odanacatib ontheradiusandtibiaofpostmenopausalwomen: Dardzinski B, Cabal A,Verbruggen N, Ather S International and tibiainpostmenopausalwomenusingHR-pQCT. Characterizing microarchitectural changesatthedistalradius alm.2012.32.1.23) women. phosphatase forosteoporosisinpremenopausalandpostmenopausal utility ofosteocalcin,undercarboxylated osteocalcin,andalkaline 2012. Summary (doi:10.1016/S8756-3282(02)00736-6) quantitative computedtomographyimages. element analysismodelsbasedonthree-dimensionalperipheral Ruegsegger P. Estimationofdistalradiusfailureloadwithmicro-finite Research International (vitamin K(2)):thePostmenopausalHealthStudyII. vitamin D,andphylloquinone(vitaminK(1))ormenaquinone-7 productsenrichedwithcalcium, periodusingdairy intervention bone metabolisminpostmenopausalwomenfollowinga12-month Papaioannou N, Lyritis G &Manios Y. Changesinparametersof 2012 Journal ofBoneandMineralResearchJournal Annals of Laboratory Medicine Annals ofLaboratory (doi:10.1002/jbmr.2194) 2012 2013 2014 27 2005 Journal ofBoneandMineralResearchJournal 1794–1803. 25 90 24 251–262. 2499–2507. 2057–2066. 90 BMJ 6508–6515. 2013 2010 Downloaded fromBioscientifica.com at09/30/202102:07:47AM (doi:10.1002/jbmr.1624) 2012 (doi:10.1007/s00223-012-9571-z) 28 340 (doi:10.1007/s00198-014-2719-0) (doi:10.1007/s00198-013-2325-6) Journal ofBoneandMineral Journal 736–745. (doi:10.1210/jc.2005-1258) Journal ofClinicalEndocrinology Journal 367 2012 b5463. 2011 40–49. 32 1997 175 Bone (doi:10.1136/bmj.b5463) (doi:10.1002/jbmr.1784) et al. 23–30. 469 et al. www.eje-online.org :6 2002 (doi:10.1056/ 12 2014 Effectsof 2179–2193. et al. Patient level Patientlevel 431–438. Calcified Tissue (doi:10.3343/ Osteoporosis 30 Osteoporosis Apooled 29 842–848.

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