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Non-Steroidal Anti-Inflammatory Drugs Inhibit Bone Healing: a Review S

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Non-Steroidal Anti-Inflammatory Drugs Inhibit Bone Healing: a Review S Review Article © Schattauer 2010 385 Non-steroidal anti-inflammatory drugs inhibit bone healing: A review S. Barry Washington State University, Department of Veterinary Clinical Sciences, Veterinary Teaching Hospital, Pullman, Wash- ington, USA crine and autocrine activity, have since Keywords stems from prostaglandin inhibition and is been shown to regulate constitutive and in- Non-steroidal anti-inflammatory drugs, likely multifactorial. In human medicine ducible functions throughout the body, in- NSAID, bone healing NSAID are known to prevent heterotopic ossi- cluding bone healing (5–9). The mech- fication, however the clinical importance of anism of NSAID inhibition to bone healing Summary their effects on bone healing remains contro- is unknown, but is likely multifactorial. Re- The ability of non-steroidal anti-inflammatory versial. Although a small handful of reports searchers have suggested that NSAID affect drugs (NSAID) to inhibit bone healing has suggest that NSAID suppress bone healing in normal bone healing in multiple ways, with been established in experimental animal dogs and horses, there is little published infor- emphasis often (but not exclusively) placed models using mice, rats, and rabbits. The mation to direct veterinary practice in do- on processes related to the inflammatory mechanism of action is largely unknown but mestic species. stage. Deciphering the mechanism of NSAID inhibition requires an understanding of Correspondence to: Vet Comp Orthop Traumatol 2010; 23: 385–392 Sabrina Barry, DVM doi:10.3415/VCOT-10-01-0017 fracture healing. Fracture healing presents Washington State University Received: January 31, 2010 an exquisitely orchestrated series of coor- Department of Veterinary Clinical Sciences Accepted: June 23, 2010 dinated molecular and cellular events. Be- Veterinary Teaching Hospital Pre-published on: September 9, 2010 fore the molecular mechanisms of bone PO Box 647060 Pullman, WA 99164–7060 healing were appreciated, careful histologi- USA cal observations characterised the tem- Phone: +1 509 335 0711 poral stages of bone healing (10, 11). Fax: +1 509 335 3330 E-mail: [email protected] Direct (primary) fracture healing is characterised histologically by osteonal ‘cutting cones’ directly crossing the fracture gap, bypassing the intermediate stages of cartilaginous callus and endochondral Introduction directed by subsequent discoveries such as ossification (10–12). This type of healing is cyclooxygenase-2 (COX-2) and the bio- possible only with direct bone contact and The mechanism of action of non-steroidal logical mechanisms of bone healing. Today, rigid stabilisation. Osteonal activity in- anti-inflammatory drugs (NSAID) had NSAID are recognised as being effective in- creases near the injury – this phenomenon only recently been discovered when the hibitors of bone formation in experimental is referred to as ‘regional acceleratory phe- drugs’ ability to inhibit bone healing was models of fracture healing, spinal fusion, nomenon’ (RAP) and probably plays an first documented. In 1976, Ro and others bone ingrowth into implants, mechanically important role in direct fracture healing reported significantly reduced fracture induced bone remodelling, and hetero- (12). The mechanism of RAP is unknown, healing in rats treated with indomethacin topic ossification (3). This review focuses but the phenomenon may be mediated by (1). In the same year, a 64-year-old man on the effects of NSAID on bone healing the same signalling molecules as seen in with an ankle fracture/luxation was pur- after injury. other types of tissue repair (12). posefully treated with indomethacin to Indirect (secondary) fracture healing prevent callus formation in anticipation of can be classified into four histologically ob- surgery (2). The authors noted, “A dis- Mechanism of inhibition servable overlapping phases: inflamma- placed fibular fracture usually heals even tory, chondrogenic, osteogenic, and re- without external immobilisation. In the In 1971 Vane and others discovered that as- modelling (10, 13). The inflammatory present case, however, the fracture did not pirin, indomethacin, and salicylate exert phase is characterised by haematoma unite in spite of external immobilisation their potent antiphlogistic effects by in- formation, local tissue hypoxia, and in- for nine weeks.” hibiting COX, the rate-limiting enzyme in creased local production of inflammatory These initial reports led to a flurry of re- prostaglandin synthesis (4). Prostagland- cytokines and growth factors, including search which was periodically excited and ins, small signalling molecules with para- prostaglandins (6, 14). Mesenchymal stem Vet Comp Orthop Traumatol 6/2010 386 S. Barry: Non-steroidal anti-inflammatory drugs inhibit bone healing cells are recruited from intra- and extra- ing, are most prominent during endochon- wild type and COX-2-/- cell cultures to ap- osseous tissues to differentiate into chon- dral ossification in the osteogenic phase proximately the same degree. The authors drogenic and osteogenic cell types. In the (16). suggested that BMP-2 may be downstream chondrogenic phase, a cartilaginous callus Although the mechanism for NSAID- to prostaglandins during osteoblastogen- bridges the fracture fragments and intram- induced bone healing inhibition is un- esis and bone formation (21). embranous ossification occurs under the known, the predominant theory supposes Subsequent studies have investigated periosteum at the fracture edges. In the os- that NSAID, by inhibiting prostaglandin the relationship between COX-induced teogenic phase, the cartilaginous callus is synthesis, interfere with cell signalling dur- prostaglandin production and bone mor- replaced by woven bone via endochondral ing the inflammatory phase leading to an phogenetic proteins. A selective COX-2 in- ossification in a process reminiscent of uncoordinated healing response. Endogen- hibitor reduced BMP-2 expression in physeal growth. In the remodelling phase, ous prostaglandins E and F increase locally human mesenchymal stem cells; this effect young woven bone is replaced by lamellar in the first seven days after fracture, sug- was reversed with the addition of PGE2, bone to restore mechanical integrity. gesting a signalling function by prostag- suggesting COX-2 derived PGE2 induces The molecular mechanisms of bone landins in the early healing period (6–8). BMP-2 expression (24). Another study healing are complex and are the subjects of Attempts to simplify prostaglandin’s effects showed further support for this relation- current ongoing studies. Local and sys- on bone have been frustrated by the dif- ship, but indicated an opposite pathway in temic regulatory molecules including cyto- ficulty in simulating their naturally occur- that BMP-2 induced COX-2 expression in kines, growth and differentiation factors, ring expression and environment in vitro. cultured murine osteoblasts (25). In the hormones, and extracellular matrix mol- The small, quickly metabolised and locally same study, BMP-2-induced ectopic ossifi- ecules regulate processes such as cellular acting molecules can promote bone resorp- cation was inhibited in COX-2-/- mice, indi- migration, proliferation, differentiation, tion, bone formation, or both depending cating that BMP-2 effects on bone extracellular protein synthesis, and apopto- on the extracellular environment and the formation are in part due to COX-2 acti- sis (15). The most important local mol- intracellular chemical milieu (9). Exogen- vation. Finally, immunohistochemistry de- ecules currently recognised in fracture ous prostaglandin E administration in- tected a simultaneous rise in BMP-7 (also healing can be divided into three cat- creases regional acceleratory phenomenon known as osteogenic protein-1, or OP-1) egories: 1) pro-inflammatory cytokines, in- after rib fractures in dogs, increasing both and COX-2 at fracture calluses in mice. In cluding interleukin-1 (IL-1), interleukin-6 resorption and production in response to the same study, BMP-7-induced ectopic (IL-6), tumour necrosis factor-alpha injury (17, 18). Synthetic prostaglandin re- ossification was inhibited by diclofenac, an (TNF-α), platelet-derived growth factor ceptor agonists have an overall anabolic ef- NSAID (26). (PDGF), and others; 2) transforming fect and enhance bone healing in rats and Inhibition of angiogenesis has also been growth factor-beta superfamily members, dogs in experimental conditions (19, 20). suggested as a mechanism of NSAID effects which include bone morphogenetic pro- Inhibitory effects on mesenchymal stem on bone healing. Cyclooxygenase-2 meta- teins (BMP), transforming growth factor cell differentiation and activity have been bolic products (mainly prostaglandins) are beta isoforms (TGF-β), growth differenti- proposed as a mechanism for NSAID-in- stimulators of angiogenesis, which is essen- ation factors (GDF), activins, inhibins, and duced bone inhibition (21–23). In a no- tial for fracture healing (27, 28). Rofecoxib Müllerian inhibiting substance; and 3) an- table in vivo study involving an NSAID, di- inhibited osteotomy healing in mice fe- giogenic factors, including vascular en- clofenac profoundly reduced the number murs and significantly reduced blood flow dothelial growth factor (VEGF) and angio- of histologically visible osteoblasts at the within the femoral calluses (29). After ana- poietins (15, 16). Although there is con- injury site 10 days after bone drill defects lysing linear regression models, however, siderable overlap,
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