Therapeutic Prospects of HMG-CoA Reductase Inhibitors, Atorvastatin and Rosuvastatin, in Osteoporotic Patients

Osteoporosis is a major public health problem, particularly among postmenopausal women, and is characterized by reduced bone mineral density (BMD) and deterioration of bone microarchitecture, leading to an increased risk of fragility fractures. Hyperlipidemia frequently coexists with osteoporosis in this population because both conditions share several risk factors, including aging and menopause. Experimental studies and retrospective clinical studies have suggested that statins may exert favorable effects on bone metabolism by enhancing osteoblast activity, suppressing osteoclast-mediated bone resorption, and promoting bone formation. These findings raise the possibility that statins may provide additional skeletal benefits when administered in combination with standard anti-osteoporotic therapy.

The present prospective interventional study was designed to evaluate the effect of adjunctive statin therapy on bone health in postmenopausal women with osteoporosis. In addition to assessing the overall effect of statins, the study aimed to compare the skeletal effects of two statins with different physicochemical properties: atorvastatin, a lipophilic statin, and rosuvastatin, a hydrophilic statin. The study also investigated whether combining statins with standard osteoporosis therapy provides greater improvement in bone mineral density and bone turnover markers than standard osteoporosis therapy alone. Furthermore, the study evaluated the relationship between changes in lipid profile parameters and improvements in bone mineral density in order to determine whether lipid lowering is associated with skeletal response.

The study protocol was reviewed and approved by the Ethics Committee of the College of Medicine, University of Kufa, and the required administrative and regulatory approvals were obtained from the Iraqi Ministry of Health through the Najaf Health Directorate before study initiation. All participants were informed about study objectives, procedures, potential benefits and possible risks before study initiation. All therapeutic interventions were performed in accordance with current clinical practice guidelines. Statin therapy was prescribed only for participants with a guideline-based clinical indication for treatment (ASCVD risk ≥5%), and no participant received statin therapy solely for research purposes.

Participants were allocated into three study groups according to their estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk and clinical indication for statin therapy. Women with an ASCVD risk of less than 5%, who had no guideline-based indication for statin treatment, received standard osteoporosis therapy consisting of alendronate, calcium, and vitamin D. Women with an ASCVD risk of 5% or greater, for whom statin therapy was clinically indicated according to current treatment guidelines, received standard osteoporosis therapy plus statin treatment. Participants in this category were randomly assigned to receive either atorvastatin or rosuvastatin in addition to alendronate, calcium, and vitamin D.

Eligible participants were postmenopausal women diagnosed with osteoporosis, defined by a lumbar spine T-score of -2.5 or lower on dual-energy X-ray absorptiometry (DXA). Before treatment initiation, all participants underwent baseline clinical assessment, DXA measurement of bone mineral density, and blood sample collection. Laboratory investigations included lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides), serum calcium, vitamin D, osteocalcin, bone-specific alkaline phosphatase (BALP), C-terminal telopeptide of type I collagen (CTX-1), and bone sialoprotein (BSP).

Participants were followed for six months, during which treatment adherence was monitored. At the end of the follow-up period, DXA measurements and laboratory investigations were repeated using the same assessment methods. Changes in bone mineral density, bone turnover markers, calcium, vitamin D, and lipid profile were compared within each treatment group and between groups. The primary objective was to determine whether the addition of statin therapy to standard osteoporosis treatment resulted in greater improvement in bone mineral density than standard therapy alone. Secondary objectives included comparing the skeletal effects of lipophilic and hydrophilic statins and evaluating the association between improvements in lipid profile and changes in bone mineral density and biochemical markers of bone turnover.

Inclusion criteria

• patients aged ≥ 55 diagnosed with primary age-related osteoporosis according to European guidance osteoporosis, T-score ≤-2.5, and did not receive any treatment for osteoporosis previously or statins.

Exclusion criteria

• patients who had been taking antiresorptive, bone forming or statins, patients who were taking any medications that can affect osteoporosis. Patients who had medical issues that could be a secondary cause for osteoporosis. and patients who were allergic to alendronate or statins were excluded from the study.