HMG CoA reductase inhibitors and the skeleton: a comprehensive review

Recent studies suggest that the mevalonate pathway plays an important role in skeletal metabolism. HMG CoA reductase inhibitors ("statins"), which inhibit a key enzyme in the mevalonate pathway, are widely used for the treatment of hyperlipidemia. In vitro and animal studies demonstrate that statins stimulate the production of BMP-2, a potent regulator of osteoblast differentiation and activity, suggesting that statins may have an anabolic effect on bone. Statin use in most, but not all observational studies is associated with a reduced risk of fracture, particularly hip fracture, even after adjustment for the confounding effects of age, weight and other medication use. This beneficial effect has not been observed in clinical trials designed to assess cardiovascular endpoints. The effects of statins on bone mass and bone turnover are controversial, but increased bone mass and reduced bone turnover have been observed in controlled studies. Further studies of the skeletal effects of statins are needed, particularly their effects on surrogate markers such as bone mass, bone turnover, and microarchitecture, to determine the optimal formulation, dosing and route of administration. Clinical trials with fracture endpoints are needed before statins can be recommended as therapeutic agents for osteoporosis.