Skeletal effects of thyroid hormone analogues: b-ALP – bone alcalic phosphatase; BMD - bone mineral density; EGP - epiphyseal growth plate; HC – hypertrophic chondrocytes; ns – non significant; PINP - procollagen type I N-terminal propeptide
1. Introduction
Thyroid hormones play a crucial role in the skeletal growth, peak bone mass acquisition and maintenance of bone mass. Abnormalities in hypothalamic–pituitary–thyroid axis in infancy and childhood have been shown to interfere with a normal linear growth and skeletal maturation. Hypothyroidism compromises normal bone formation and results in slowing of linear growth. Thyrotoxicosis leads to growth acceleration, diminution of bone mass and advance in bone age. Studies in animal models have demonstrated the importance of thyroid hormone signaling in the maintenance of bone mass in adulthood. Increased risk of fracture has been demonstrated in both hypothyroidism and hyperthyroidism. The thyroid hormone, 3,5,3’-triiodothyronine (T3), has long been considered to play a primordial role in the skeletal homeostasis. However, recent studies have shown that TSH acts as a direct regulator of bone remodeling, highlighting the importance of integrity of the hypothalamo-pituitary-thyroid axis.
This chapter will review our current understanding regarding the action of thyroid hormones on the bone development and maintenance of bone mass, under normal conditions and as a result of thyroid gland dysfunction. Mechanism of thyroid hormone action will be illustrated in relation to bone with the focus on the genetic regulation and the molecular interactions between thyroid hormones and skeletal cells. Clinical consequences of thyroid dysfunction on the growth and skeletal maturation will be detailed. We will review the published literature regarding BMD in hyperthyroid and hypothyroid patients including patients on medical therapy, as well as the influence of sex and menopause on the maintenance of bone mass. The impact of treatments for thyroid dysfunction on the bone mineral metabolism will be discussed.
2. Role of thyroid hormones in bone growth and metabolism
Thyroid hormones are critical for the skeletal development and the bone maintenance. The thyroid hormone, 3,5,3’-triiodothyronine (T3), is responsible for major actions of thyroid hormones. T3 binds to nuclear receptors that regulate gene transcription via interaction with thyroid hormone response elements of specific genes (Sap et al., 1986; Weinberger et al., 1986; Thompson et al., 1987). Recently, non-genomic actions of T3 and T4 have been described (Cheng et al., 2010). Local tissue availability of T3 seems to be regulated by type 2 and 3 deiodinase (St Germain et al, 2009). The nuclear thyroid hormone receptors (TRs) are derived from the THRA and THRB genes coding for the TRα1 and β1-2 T3-binding isoforms, truncated isoforms ∆α1, ∆α2 and ∆β3, and a TRa2 non-T3-binding isoform of unknown function (Lazar et Chin et al, 1990; Lazar, 1993; Chassande et al, 1997; Williams, 2000; Cheng et al, 2010). Expression of TRα1 and TRβ1 was described in growth plate chondrocytes, osteoblasts, and stromal cells of bone marrow (Williams et al, 1994; Abu et al, 1997; Ballock et al, 1999; Bradley et al, 1992; Bassett et Williams, 2003; Siddiqi et al, 2002). Expression of TRα in the skeleton is higher than that of TRβ (Bookout et al, 2006; O’Shea et al, 2003).
2.1. Thyroid hormone and bone development
Studies on animal models have brought valuable insights into role of TRs in bone development and growth. Mice lacking TRβ or TRα1 did not display abnormalities in skeletal development (Forrest et al, 1996; Wikstrom et al, 1998). On the other hand, genetic disruption of both receptors (TRα1 and TRβ) led to delayed ossification and disorders in development of epiphyseal growth plates (EGPs; Gothe et al, 1999). Pax-8−/− mice, expressing all TR isoforms, but lacking the follicular cells producing T4 and T3 in the thyroid gland, displayed more severe abnormalities in bone development than mice KO for all TRs (TRα0/0, TRβ−/−) (Flamant et al, 2002). The authors concluded that the unliganded TRs (aporeceptors) on thyroid hormone responsive genes have repressor effects during bone development. In support of this, Pax-8−/−TRα0/0, but not Pax-8−/−TRβ−/−, compound mutants presented a partial rescue of the bone phenotype (O’Shea et Williams, 2002; Flamant et al, 2002). Another study was realized employing mice invalidated for TRα. These animals were euthyroid, but displayed a growth delay with abnormal bone development and ossification (Bassett et al 2007a, 2007b; Gauthier et al, 1999, 2001; O’Shea 2003, 2005). Mice lacking all TRα isoforms presented a less severe impairment of bone development than TRα-/- mice, pointing to the role of non-T3 binding TRα isoforms (∆α1 and ∆α2) (Gauthier et al, 2001). On the other hand, mice with nonfunctional TRβ displayed augmentation in circulating thyroid hormone levels associated with dysregulation of hypothalamo-pituitary-thyroid axis. These animals had skeletal signs of hyperthyroidism, increased bone mineral deposition and acceleration of growth-plate maturation, resulting in a short adult body size (Bassett et al, 2007a; O’Shea et al, 2003). These findings suggested an increased skeletal response to T3 via TRα, which was consistent with the hypothesis that elevated circulating thyroid hormone levels in TRβ mutant mice result in an increased skeletal response to T3 via TRα (O’Shea et al, 2006). Recently, GC-1, thyroid hormone analogue targeting preferentially TRβ1 over TRα1, has partially reverted skeletal development and maturation defects in hypothyroid rats (Freitas et al, 2005). This finding is suggestive of TRβ1 involvement in bone growth.
Thyroid hormones regulate bone development also indirectly through the growth hormone (GH) and insulin-like growth factor-I (IGF-I) axis. Previously, it was demonstrated that T4 enhanced the growth promoting effect of GH/IGF-I (Thorngren et Hansson, 1974) and could stimulate longitudinal bone growth in hypophysectomized rats (Thorngren et Hansson, 1973; Ray et al, 1954). T3 was shown to interact with the thyroid hormone receptor - thyroid hormone responsive element complex (TR-TRE) in the GH promoter to regulate GH gene transcription (Glass et al, 1987; Koenig et al, 1987). However, GH without T3 did not promote the maturation (Ballock et Reddi, 1994) and organization (Lewinson et al, 1989) of growth plate chondrocytes and GH replacement could not rescue the impaired ossification in TRα and TRβ-null mice (Kindblom et al, 2001). In TRα1−/−β−/− mice, GH substitution reversed the growth phenotype, but not the defective ossification (Kindblom et al, 2001). On the other hand, inactivation of GH or IGF-I receptors in mice was associated with delayed ossification (Liu et al, 1993; Sjogren et al, 2000).
Overall, the literature data indicate importance of both TRs and GH-IGF-I axis in skeletal development. Other factors, such as the Indian Hedgehog (Ihh), parathyroid hormone-related peptide (PTHrP), fibroblast growth factor receptor and Wnt-β-catenin signaling pathways, are implicated in this process (Barnard et al, 2005; O’Shea et al, 2005; Stevens et al, 2000, 2003; Wang et al, 2007). Further studies are warranted to clarify the exact mechanisms underlying the physiological regulation of bone development.
2.2. Thyroid hormone and bone remodeling
Literature evidence points to the critical importance of thyroid hormones in bone remodeling and maintenance. Adult euthyroid mice invalidated for TRα have reduced osteoclastic bone resorption and increased trabecular bone volume and mineralization (Bassett et al, 2007a, 2007b), indicating a critical role of TRα in T3 action in bone cells. On the other hand, increased osteoclastic bone resorption and severe osteoporosis were demonstrated in adult TRβ mutant mice, suggestive of thyroid hormone excess in TRα-expressing skeletal cells (Bassett et al, 2007a, 2007b; Gauthier et al, 2001; O’Shea et al, 2006).
The bone architecture and strength are maintained by a balanced process of remodeling, which involves recruitment of osteoclast and osteoblasts. T3 can induce differentiation and inhibits proliferation of osteoblastic cells. T3 was shown to promote production of IL-6, IL-8, IGF-I and its binding proteins IGFBP2-4 in bone marrow stromal cells and osteoblasts (Milne et al, 2001; Siddiqi et al, 1998), and to increase the expression of several bone-related genes, including osteocalcin, collagen type I, gelatinase B and collagenase 3 (Gouveia et al 2001; Milne et al 1998; Pereira 1999; Varga et al 1997; Williams et al 1994). T3 is implicated in chondrogenesis, angiogenesis, bone matrix formation and mineralization (Himeno et al, 2002; Makihira et al, 2003; Pereira et al, 1999). In primary cultures of growth plate chondrocytes, T3 inhibits chondrocyte clonal expansion and cell proliferation, induces hypertrophic chondrocyte differentiation and promotes cartilage matrix mineralization (Robson et al, 2000).
Furthermore, T3 is involved in local signaling pathways by stimulating osteoblast responses to IGF1-I, PTH and fibroblast growth factors. T3 is a critical regulator of the Ihh - bone morphogenetic protein (BMP) – PTHrP feedback loop (Stevens et al, 2000). Hypothyroidism is marked by increased PTHrP expression and impaired hypertrophic chondrocyte differentiation (Stevens et al, 2000). In hyperthyroidism, reduced expression of PTHrP associated with augmentation of BMP enhances hypertrophic chondrocyte differentiation (Lassova et al, 2009; Stevens et al, 2000). It has also been shown that T3 regulates terminal differentiation of growth plate chondrocytes in part through controlling cell cycle progression at the G1/S restriction point (Ballock et al, 2000). T3 mediates osteoclastic bone resorption through activation of osteoblasts, which then release receptor activator for NF-κB ligand (RANKL), a member of the TNF cytokine family. RANKL is a ligand for osteoprotegerin, a cytokine that regulates osteoclastic differentiation, and functions as a key factor for osteoclast differentiation and activation by inhibiting osteoclasts apoptosis (Allain et al, 1992; Britto et al, 1994).
Overall, T3 seems to enhance activity of osteoblasts by various mechanisms and signaling loops. Although the effects of thyrotoxicosis in adult bone are characterized by increased bone resorption, it is not known whether T3 acts directly in osteoclasts or whether effects on osteoclasts are secondary to the actions of T3 in osteoblasts.
2.3. Role of TSH on bone
Thyroid stimulating hormone (TSH) is a ligand hormone between hypothalamic-pituitary axis and the thyroid gland. TSH has long been recognized to act on the thyroid gland to control follicle development and thyroid hormone production and secretion. Beyond thyroid, TSH has also been shown to have additional effects on other tissues. TSH can exert a direct effect on bone metabolism independently of the peripheral thyroid hormone (thyroxine, T4, and triiodothyronine, T3) levels. This effect is mediated through the receptor for binding the thyroid-stimulating hormone (TSH-R), which is a pituitary G protein-coupled transmembrane receptor. Its expression has been demonstrated on osteoblast and osteoclast precursors. The TSH-R haploinsufficient mice display osteoporosis and focal osteosclerosis and thyroid hormone replacement did not restore bone mass but corrected growth deficiency in these animals (Abe et al, 2003). It has been suggested that the effects of TSH on the skeleton are independent of thyroid hormone levels.
3. Thyroid hormones and skeletal growth in infancy and adolescence
In prepubertal children, the linear growth is controlled mainly by GH-IGF-I axis, with influence from glucocorticoids and thyroid hormones. Thyroid hormones were shown to play an essential role for normal onset of the childhood component of growth (Heyerdahl, 1997). Role of the GH/IGF-I axis in the regulation of thyroid gland growth has recently been demonstrated (Boas et al, 2009). During pubertal period, sex steroids are important co-regulators of skeletal growth. Age related consequences of thyroid dysfunction on bone development have largely been described. Nevertheless, the exact role of thyroid hormone in the peak bone mass acquisition during childhood and early adulthood is not well understood. The same is for the gender specific action of T3 in the developing skeleton (Gauthier et al, 1999).
Euthyroid status is essential for normal skeletal development and linear growth. Generalized retardation in endochondral and intramembranous ossification associated with alterations in the EGPs, such as reduced thickness, disorganized columns of chondrocytes, and impaired differentiation of hypertrophic chondrocytes, have been reported in hypothyroid status during development (Lewinson et al, 1989; Stevens et al, 2000). The clinical consequences are reduced growth and skeletal abnormalities (Allain & McGregor, 1993). Theodore Kocher was awarded the Nobel Prize in Medicine in 1909 for his description of consequences of thyroidectomy. He showed the impact of hypothyroidism on the child growth (Kocher, 1883). Hypothyroid children present with the growth retardation and disproportionately short limbs in relation to the trunk. Radiographic skeletal examination may reveal, depending on the age and onset of hypothyroidism, a delayed closure of the fontanelles, enlargement of pituitary fossa and epiphyseal dysgenesis. Reilly & Smyth have described in 1937 stippled appearance of epiphyses on X-ray films in hypothyroid children. The pathognomonic nature of these changes was later confirmed by Wilkis (Wilkis, 1941). Epiphyseal dysgenesis has been demonstrated in the ossification centers that normally ossify after the onset of the hypothyroid status. Delayed appearance of ossification centers and delayed bone age are also noted in hypothyroid children. BMD seems to be also affected by a hypothyroid status during childhood. In one cross-sectional study, BMD was reported to be lower in prepubertal children with congenital hypothyroidism than in controls (Demartini et al, 2007).
Treatment with thyroxine results in a period of rapid catch-up growth, although predicted final height based on midparental height calculations may not be achieved, particularly when hypothyroidism is prolonged (Rivkees et al, 1988). The LT4 replacement for 8 years in children with congenital hypothyroidism did not have a negative effect on BMD for the lumbar spine and the femoral site and on biochemical markers of bone turnover (Leger et al, 1997). The results showed normal serum levels of calcium, phosphate, alkaline phosphatase, parathyroid hormone and 25-hydroxyvitamin D and did not demonstrate any relationship between BMD and L-T4 dosage or biochemical markers of bone formation. These findings were confirmed by other studies reporting no alterations of bone mass in adolescents and young adults with congenital hypothyroidism, treated from the neonatal period (Salerno et al, 2004, Demeester-Mirkine et al, 1990).
On the other hand, thyroid hormone excess results in accelerated skeletal maturation, premature closure of the EGPs and subsequent decrease in longitudinal bone growth with a compromised final adult height (Allain & McGregor, 1993; O’Shea et al, 1993; Harvey et al, 2002). In severe cases, hyperthyroidism during early childhood may also cause craniosynostosis due to premature fusion of the sutures of the skull (Segni et al 1999). Low bone density values and high bone resorption rates were demonstrated at diagnosis of hyperthyroidism in children and adolescents (Mora et al, 1999). Successful treatment of hyperthyroidism was shown to increase BMD in children and improve the conditions for the best obtainable peak bone mass (Mora et al, 1999).
Consequences of syndrome of resistance to thyroid hormone (RTH) on the skeletal development have been described in literature. RTH results from dominant negative mutations in the carboxyl terminus of the thyroid hormone receptor β gene. The mutant receptors are transcriptionally impaired and inhibit thyroid hormone receptor action. RTH is characterized by phenotypic variability including skeletal manifestations (Weiss et Refetoff, 2000). Our current understanding is based mainly on the published case reports. Involvement of the skeleton can cause a short stature, advanced or delayed bone age, increased bone turnover, osteoporosis, fractures, craniofacial abnormalities and craniosynostosis. The clinical variability might be secondary to functional properties of mutant proteins and heterogeneity of cofactors mediating action of TR (Kvistad et al, 2004).
4. Effects of thyroid dysfunction on bone turnover in adult bone
4.1. Hypothyroidism
Reduced bone turnover in hypothyroidism impairs bone formation and mineralization (Eriksen et al, 1986). Results of population studies indicate an increased fracture risk in hypothyroid individuals (Ahmed et al, 2006; Vestegaard et al 2002, 2005). The association between subclinical hypothyroidism and decreased BMD with increased fracture risk has also been reported, but has not been confirmed by others (Lee et al, 2006, 2010; Bertoli et al, 2002). Overall, the literature data have so far presented conflicting results. We will review the current literature and discuss changes in the bone metabolism, BMD and fracture risk in adult men and women with overt and subclinical hypothyroidism.
4.1.1. Mineral metabolism in hypothyroidism
Slight perturbations in some parameters of bone and mineral metabolism have been reported in hypothyroid patients. Minor abnormalities of calcium metabolism may exist with slightly elevated serum calcium, PTH and 1,25(OH)2 vitamin D, decreased level of alkaline phosphatase, decreased urinary calcium excretion and glomerular filtration rate. The exchangeable pool of calcium and its rate of turnover may be reduced, reflecting decreased bone formation and resorption. However, these changes seem not to be different, even during the treatment, in hypothyroid patients compared to euthyroid controls (Sabuncu et al, 2001).
4.1.2. Overt hypothyroidism and skeletal changes
Large population based studies identified an increased fracture risk in individuals with hypothyroidism (Vestegaard et al 2000; 2002). The first of these studies (Vestegaard et al, 2000) analyzed 408 patients with primary hypothyroidism and found a temporary increase in fracture risk within the first 2 years after diagnosis, mainly in the age group >50 years, and was limited to the forearms. In the following study (Vestegaard, 2002), 4473 patients with autoimmune hypothyroidism (mean age, 66.1 +/- 17.3) were shown to present a significantly increased fracture risk up to 8 years prior to diagnosis with a peak around the time of diagnosis. The fracture risk was found to return to normal more than 5 years after its diagnosis.
An increased fracture risk in hypothyroid patients is not probably due to modifications of bone density. There are no convincing literature data as to changes in bone architecture during hypothyroidism. Neuromuscular symptoms and impaired muscle energy metabolism could be responsible for bone changes in this population. Hypothyroid patients have been shown to display impaired neuromuscular response to exercise persisting even after restoration of euthyroid status (Caraccio et al, 2005).
4.1.3. Subclinical hypothyroidism and skeletal changes
Subclinical hypothyroidism is a relatively frequent clinical condition, particularly among aged population, characterized by a low-normal free T4 level and a slightly elevated TSH level. The prevalence of subclinical hypothyroidism has been reported between 3.9 and 6.5% (Hollowell et al, 2002; Huber et al, 2002)
In Trosmo study, Grimnes et al. (2008) have demonstrated that, after multivariate adjustment, 25 out of 950 postmenopausal women with serum TSH above the 97.5 percentile had significantly higher BMD at the femoral neck than women with serum TSH in the normal range. However, there was no association between TSH and BMD, and serum TSH as a continuous variable had no effect on BMD.
Bone quality was studied by Nagata et al. using quantitative ultrasound in postmenopausal women with subclinical hypothyroidism. The results demonstrated that calcaneo osteo sono assessment indices of right feet measured by ultrasound bone densitometer decreased according to the increase in TSH concentration. The authors have suggested that hypothyroidism affects bone structure (Nagata et al, 2007).
4.2. Hyperthyroidism
Hyperthyroid patients present with an increased bone turnover and a risk for osteoporosis. The activity of osteoblasts and osteoclasts are increased, the latter predominates favoring resorption, negative balance of calcium, and bone loss (Melsen & Mosekilde, 1977; Mosekilde et al, 1990). Thyrotoxicosis in adults is a recognized cause of high-bone-turnover osteoporosis. Reduced bone mineral density was noted in hyperthyroid patients with an increased susceptibility to fragility fracture (Mosekilde et al, 1990; Vestergaard et al, 2002, 2005).
In both, clinical and subclinical hyperthyroidism, elevation of markers of bone turnover and decreased BMD have been reported (Kumeda et al, 2000; Heemstra et al, 2006; Lee et al, 2006). Previous studies that investigated impact of thyroid dysfunction on BMD and fracture risk did not provide conclusive results. Recently published population studies indicate association of endogenous subclinical hyperthyroidism with an increased fracture risk (Bauer et al, 2001; Jamal et al, 2005; Vadiveloo et al, 2011). Consequences of the hyperthyroid status (overt and subclinical) on bone turnover, BMD and fracture risk will be discussed and compared with the data in healthy population.
4.2.1. Mineral metabolism in hyperthyroidism
Hyperthyroidism is associated with impaired mineral metabolism. Increased serum calcium levels have been reported in up to 27% of hyperthyroid patients (Begic-Karup et al, 2001), but severe and symptomatic hypercalcemia is rare. Concentrations of serum alkaline phosphatase and osteocalcin are also frequently elevated. These findings are reminiscent of those in primary hyperparathyroidism, however, serum parathyroid hormone is mostly low-normal (Iqbal et al, 2003). True primary hyperparathyroidism and thyrotoxicosis may coexist (Beus & Stack, 2004; Wagner et al, 1999). Decreased plasma 25-hydroxycholecalciferol levels observed in hyperthyroidism could participate to the lower intestinal absorption of calcium and osteopenia in these patients (Mohan et al, 2004). Bone resorption markers, urinary pyridinoline and deoxypyridinoline, are increased 7-8 times more than in age and sex matched controls (Kraenzlin et al, 2008). Furthermore, hyperthyroid patients display a greater increase in urinary pyridinoline cross-links than that in serum markers of bone formation (osteocalcin, bone-specific alkaline phosphatase) (Akalin et al, 2002; Kisakol et al, 2003). Altogether, an increased bone turnover in these patients is in favor of osteoclastic bone resorption.
After initiation of anti-thyroid treatment, biochemical markers of bone resorption, such as urinary hydroxyproline, serum pyridinoline, serum deoxypiridinoline cross-links, have been found to fall, with a subsequent rise of the bone formation markers (Mosekilde et al 1990; Siddiqi et al, 1997; Garnero et al, 1994). Elevation of serum PTH has been reported in some patients with severe thyrotoxicosis under anti-thyroid treatment (Pantazi et al, 2000). This rise in PTH was suggested to play a role in inducing some temporal changes in mineral metabolism and participate to the reversal of the catabolic bone status of hyperthyroidism to anabolic. Furthermore, another study found that in hyperthyroidism, despite normal or high IGF-I levels, IGF-I bioactivity is reduced, probably because of high levels of IGF-binding protein-1 (Miell et al, 1993). Treatment of thyrotoxicosis reverses this abnormality. The rise in IGF-I bioactivity may therefore have a positive effect on the bone metabolism.
4.2.2. Overt hyperthyroidism and skeletal changes
Pathological skeletal changes, including osteopenia and osteoporosis, with higher incidence of fracture rates have been reported in hyperthyroid patients. Accordingly, hyperthyroidism was found 2.5-fold more often in postmenopausal women presenting with hip fracture than in controls. Among postmenopausal women, risk of hip fracture was significantly higher in patients with overt untreated hyperthyroidism and a history of past hyperthyroidism (Wejda et al, 1995). These findings were confirmed by a prospective follow-up study realized in 9516 Caucasian women, 65 years of age or older (Cummings et al, 1995). The authors demonstrated a higher risk of hip fracture among women who had previous hyperthyroidism. Another study reported that the prevalence of all types of fractures in patients with a history of thyroid disease was not different from that of control subjects.
However, women with a history of hyperthyroidism or thyroid cancer appeared to have their first fracture earlier than women without thyroid disease (Solomon et al, 1993). Median lumbar BMD in patients with thyrotoxicosis was shown to be 12.6% lower than that of normal individuals before the initiation of treatment (Krolner et al, 1983). Decreased BMD in hyperthyroid patients was demonstrated particularly in areas consisting of cortical bone. The risk of hip fracture increased significantly with age at diagnosis of hyperthyroidism (Campos-Pastor et al, 1993; Udayakmar et al, 2006; Vestergaard et al, 2002, 2005). The etiology of hyperthyroidism is not believed to play a role in the severity of hyperthyroid bone disease (Jodar et al, 1997).
A recent meta-analysis (Vestergaard et al, 2005) evaluated data regarding BMD and fracture risk in 20 (962 patients) and 5 publications, respectively (62 830 patients and controls). The results showed that patients with hyperthyroidism have a significantly decreased BMD. These values were lower in untreated patients compared to those under treatment, particularly for the lumbar spine (-0.83 vs. -0.27 Z-score) and the femoral site (-0.75 vs. -0.15 Z-score). The risk of hip fracture at the moment of diagnosis of hyperthyroidism was 1.6 (95% CI 0.7 to 3.4), and the value of BMD alone was associated with a risk of hip fracture corresponding to 1.2 (95% CI 0.9-1.5).
Decreased bone density in hyperthyroid patients tended to normalize under treatment (Wejda et al, 1995, Jodar et al, 1997). The improvement of BMD was noted even though no other specific anti-osteoporotic measures were introduced. The type of treatment of hyperthyroidism, iodine 131 or anti-thyroid drugs was not shown to alter the fracture risk (Vestergaard et al, 2005).
4.2.3. Subclinical hyperthyroidism and skeletal changes
Subclinical hyperthyroidism is defined as subnormal serum TSH with normal serum free thyroid hormones without signs or symptoms of thyrotoxicosis. Its prevalence in the U.S. population has been reported 0.7% (Hollowell et al, 2002). By definition, such patients should not have any clinical abnormalities associated with thyrotoxicosis (Biondi et al, 2005). However, a reduced bone mass was reported among postmenopausal patients (Bauer et al 2001). These observations could thus have a broader impact on the healthcare systems, as the subclinical hyperthyroidism is more frequent than overt thyrotoxicosis (Hollowell et al, 2002). Improvement of bone mineral density was shown in postmenopausal women with subclinical hyperthyroidism after normalization of their thyroid function (Faber et al, 1998). These data would justify indications of treatment in the older population. However, the risk/benefit ratio needs to be demonstrated by long-term, randomized studies.
On the other hand, the bone mineral density of the lumbar spine, femoral neck and the midshaft of the radius were not significantly decreased in premenopausal women (Foldes et al, 1993). The impact of subclinical hyperthyroidism in men is less known. A recent work suggests that a serum TSH concentration at the lower end of the reference range may be associated with low BMD in men (Kim et al, 2010).
5. Impact of thyroid hormone treatment on bone metabolism
Effects of thyroid replacement therapy or thyroid suppressive therapy on bone mineral density (BMD) are controversial. Results of previous studies are confounded by differences in study design, insufficient prospective data and small numbers of subjects. In the population study by Vestergaard et al (2005), the use of anti-thyroid drugs was associated with a significantly reduced fracture risk, no effect of levothyroxine on fracture risk was observed. No influence of L-thyroxine therapy on BMD was reported in young adults with congenital hypothyroidism (Salerno et al, 2004). Recently published population based case-control study has demonstrated a significantly increased fracture risk in adults over 70 years treated by levothyroxine (Turner et al, 2011). Publications on the association between the thyroid replacement and suppressive treatments and the bone mineral metabolism will be discussed.
5.1. Thyroid hormone replacement therapy
The objective of thyroid hormone replacement therapy is to normalize TSH levels. Some authors have suggested that treatment with levothyroxine may cause long-term osteoporosis, but there is no evidence to support this theory, and studies have shown no difference in bone density or fracture risk in patients undergoing treatment.
Previously, the effects of thyroid hormone treatment upon lumbar spine BMD were studied in a consecutive series of patients with myxedema. Patients with myxoedema did not differ from normal individuals as regards initial lumbar BMD, but levothyroxine-treatment caused a significant reduction in this variable. The median decrease in lumbar BMC after 1 year was 8.9% (95% confidence limits 1.5-15.4%, P less than 0.05). This loss of bone might be attributed to an inappropriate increase in bone turnover in the euthyroid status (Krolner et al, 1983). Accelerated bone turnover was shown to occur in women with subclinical hypothyroidism during replacement L-T4 treatment and normal TSH levels (Meier et al, 2004; Tarraga Lopez et al, 2011). In these women, bone loss was attributed to an adaptive mechanism on decreased bone turnover in pre-existent hypothyroidism. Finally, a long-term L-T4 treatment in children and adolescents with congenital hypothyroidism, diffuse goiter or with chronic lymphocytic thyroiditis did not affect BMD nor had a negative effect on the attainment of peak bone mass (Kooh et al, 1996; Saggese et al, 1996; Tumer et al, 1999). These results suggest that careful regulation of thyroid replacement is critical. Significant effects of prolonged L-T4-replacement therapy on bone tissue in patients with congenital hypothyroidism can be avoided by careful monitoring of serum TSH and adjustment of doses of L-T4 (Salerno et al, 2004).
5.2. Thyroid hormone suppressive therapy
Treatment with thyroid hormones with the objective to suppress TSH levels is used for example after surgery and radioiodine in differentiated thyroid carcinomas. The patients are maintained in subclinical hyperthyroidism, a condition associated with increased bone turnover.
Previous studies indicated that adults receiving high doses of L-T4-replacement therapy may be at risk of excessive bone loss. Reduction in BMD was observed after exogenous administration of high L-T4 doses used to fully suppress TSH in cases of thyroid cancer, goiters or nodules. Further, a review of cross-sectional and prospective studies examining the effect of thyroid hormone suppression on skeletal integrity in adults showed neither significant negative effect nor a decrease in BMD (Greenspan et al, 1990). Conflicting results were reported also in children. A significant reduction in peripheral BMD was found in children and adolescents receiving suppressive doses of L-T4 treatment for endemic goiter, Hashimoto’s thyroiditis or thyroid cancer (Radetti et al, 1993).
More recently, suppression of TSH in hyperthyroidism or after thyroid hormone treatment has been shown to result in decrease in BMD and increase in fracture risk in postmenopausal women (Vestergaard et al, 2000; Bauer et al, 2001; Jamal et al, 2005; Kim et al, 2006). Similar results have been demonstrated in premenopausal women and men by Karner et al (2005). Recently realized systematic reviews analyzing effects of subclinical hyperthyroidism showed that postmenopausal women with subclinical hyperthyroidism may present an increased risk, whereas no increased risk has been demonstrated in men and premenopausal women (Quan et al, 2002; Heemstra et al, 2006). However, both reviews found methodological differences between different studies, making a structured meta-analysis impossible. Lately, a randomized prospective controlled trial has shown significant adverse effects of TSH suppressive therapy on BMD in women ≥ 50 years of age (Sugitani et Fujimoto, 2011). However, the results have not been adjusted for confounding factors, such as menopause status, dietary calcium, vitamin D intake, and smoking.
Overall, literature data enhance the hypothesis that low TSH levels may have a deleterious effect on bone homeostasis. Nevertheless, the exact relationship between subclinical hyperthyroidism and osteoporosis remains to be explained.
6. TSH as a metabolic regulator
We previously discussed (see paragraph 1.2) the role of TSH in the control of bone remodeling in animal models (Abe E, Marians RC et al, 2003). Systemic administration of TSH to ovariectomised rats has been shown to prevent bone loss and restore bone mass (Sampath et al, 2007; Sun et al, 2008) have demonstrated that intermittent administration of exogenous TSH in ovariectomised rats and mice have anti-resorptive effects. Recent findings indicate that TSH might play a crucial role in bone turnover in humans. Bone loss has been shown in women with polymorphism in the TSHR gene (Onigata et al, 2005).
There is a growing body of evidence that variations of TSH even in its reference range may influence BMD. A higher BMD has been reported in postmenopausal women with TSH within the physiological range comparing to these with the low level of TSH (Baqi et al, 2010). Clinical observations show that patients with subclinical hyperthyroidism and normal circulating thyroid hormone levels display osteoporotic changes (De Menis et al, 1992; Kisakol et al, 2003). Strong correlation between serum TSH and bone status has been demonstrated in postmenopausal women (Bauer et al, 2001; Morris et al, 2007). Based on these findings it has been suggested that it is the suppressed TSH rather than the elevated thyroid hormones that exert a deleterious effect on bone density. In a recent observational study, low-normal TSH values were shown to be associated with high prevalence of vertebral fractures in women with post-menopausal osteoporosis or osteopenia, even after correction for age, BMD, BMI and serum free-thyroxine values (Mazziotti et al, 2010). Svare et al, 2009, in a cross-sectional, population-based study, analyzed 5778 women without and 944 with self-reported thyroid disease aged >40 years. Women with the TSH level <0.50 mU/l had lower forearm BMD than the reference group and the prevalence of osteoporosis was higher in women who reported hyperthyroidism than in women without self-reported thyroid disease. Finally, Kim et al, 2010 investigated the association between serum thyrotropin (TSH) concentration and bone mineral density (BMD) in 1478 healthy euthyroid men in a cross-sectional community based survey. Lumbar spine BMD and femoral neck BMD were shown to increase with TSH level after adjustment for age, weight and height. The odds of lower BMD were significantly increased in subjects with low-normal TSH, when compared to high-normal TSH after adjustment for confounding factors. These results suggested that a serum TSH concentration at the lower end of the reference range may be associated with low BMD in men.
The role of TSH on bone metabolism has also been analyzed through markers of bone metabolism after administration of recombinant TSH (rhTSH). TSH has been demonstrated to activate directly osteoblasts according to the increased levels of N-terminal propeptide of type I procollagen (PINP) (Martini et al, 2008). Others showed that TSH promotes the production and activity of alkaline phosphatase and of osteocalcin (Sampath et al, 2007; Abe et al, 2003), while some studies found inhibition of osteoblast differentiation induced by the administration of TSH (Abe et al, 2003). These finding suggested that TSH may enhance the differentiation of osteoblasts precursors.
Clinically, it has been found that the administration of exogenous TSH may have antiresorptive effects of TSH on bone turnover. In women monitored for thyroid carcinoma, a short-term stimulation with rhTSH had inhibitory effect on bone resorption. Acute administration of rhTSH in thyroidectomised postmenopausal women with suppressed endogenous serum TSH resulted in diminution in serum C-telopeptides of type-1 collagen and increase in bone alkaline phosphatase (Mazziotti et al., 2005). A transient inhibition of bone resorption and increase in osteoblastic activity, measured by markers of bone metabolism, after acute TSH administration was demonstrated also by other studies (Karga et al, 2010; Iakovou et al, 2010; Martini et al, 2008).
Overall, these data constitute the evidence for relationship between TSH and a change in bone mass in humans.
7. Bone effects of thyroid hormone analogues
Synthetic analogues of thyroid hormones display tissue-specific actions (Baxter and Webb 2009). They have been developed for their lipid lowering activity by preferential activation of the TRβ1 isoform in the liver while sparing the TRα1 mediated cardiac effects (Angelin & Rudling, 2010; Pramfalk et al., 2010; Webb, 2010). Previous animal and human studies have demonstrated that thyromimetics can influence bone metabolism. Skeletal effects of thyroid hormone analogues recently reported in literature on cell lines, animal models and humans are summarized in Table 1.
Previously studied selective thyromimetic, tiratricol (3,5,3’-triiodothyroacetic acid; Triac) was shown to enhance skeletal metabolic activity (Sherman, et al 1997) and to produce adverse effects on bone metabolism (Alvarez et al 2004; Brenta et al 2003; Kawaguchi et al 1994a, 1994b). DITPA, 3,5-diiodothyropropionic acid, has a higher affinity for the TRβ compared to the TRα. Administration of DITPA to humans for 24 weeks was associated with a significant rise in serum osteocalcin, N-telopeptide, and deoxypyridinoline levels, indicating an increased bone turnover (Ladenson el al 2010b). GC-1, [3,5-dimethyl-4-(4′-hydroxy-3′isopropylbenzyl)-phenoxy acetic acid], binds TRβ1 with the same affinity as T3, but TRα1 with a 10-fold lower affinity (Scanlan, 2010). Bone sparing effects in adult female rats have been observed after treatment by GC-1 for 64 days (Freitas et al, 2003). In another study, partial reversion of the skeletal development and maturation defects has been shown in hypothyroid rats after 5 week therapy by GC-1 (Freitas et al 2005). Eprotirome, (KB2115), 3-[[3,5-dibromo-4-[4-hydroxy-3-(1-methylethyl)-phenoxy]-phenyl]-amino]-3-oxopropanoic acid, displays a higher affinity for TRβ1 isoform with hepatic uptake (Berkenstam 2008). Administration of eprotirome to humans for 12 weeks has not been associated with unfavorable bone effects (Ladenson et al 2010a).
Tiratricol (Triac) | Cultured neonatal mouse calvariae: Triac vs. T3 | More potent stimulation of resorption and less potent stimulation of formation vs. T3 | Kawaguchi 1994a |
Tiratricol (Triac) | Cultured fetal rat long bones and neonatal mouse calvariae; Triac vs. T3 | Equal or greater stimulation of bone resorption by Triac than T3 | Kawaguchi 1994b |
Tiratricol (Triac) | Rats; Triac vs. T3 | Greater increase in beta-CTX levels, no alteration of BMD | Alvarez 2004 |
Tiratricol (Triac) | Randomized clinical trial (2 months); athyreotic patients: Triac vs. L-T4 | Increased serum osteocalcin and urinary excretion of calcium and pyridinium cross-links | Sherman 1997 |
Tiratricol (Triac) | Randomized clinical trial (11 months); euthyroid goitrous women: Triac vs. L-T4 | Significant increase in serum deoxypyridinoline and significant decrease in hip bone density, but ns compared to L-T4; | Brenta 2003 |
DITPA | Prospective, controlled, double-blind clinical trial (24 weeks): DITPA vs. placebo | Increase in serum osteocalcin, N-telopeptide and deoxypyridinoline | Ladenson 2010b |
Rat and mouse osteoblast-like cells | Induction of differentiation and activity of osteoblasts | Beber 2009 | |
Sobetirome (GC-1) | Female adult Wistar rats; study groups (64 days): GC-1; T3 ; control | No effects on BMD in L2-L5, femur, and tibia; no changes in histomorphometric parameters of the femur | Freitas 2003 |
Sobetirome (GC-1) | 21-day old female hypothyroid rats, treatment for 5 weeks: GC-1 vs. placebo | Induction of ossification, HC differentiation, expression of collagen II and X mRNA, increase in EGP thickness | Freitas 2005 |
Eprotirome (KB2115) | Randomized, double-blind, multicenter 12-week clinical trial: Eprotirome vs. placebo | No changes in b-ALP and type I collagen breakdown product; ns increase in PINP | Ladenson 2010a |
Altogether the data are consistent with potentially adverse skeletal effects of thyroid hormone analogues. However, no conclusive evidence can be drawn and further investigations would be justified to establish an accurate benefice/risk ratio before their clinical use.
8. Conclusion
The last decades have seen an increasing interest in the action of thyroid hormones in bone mineral homeostasis.
Clinical studies, consistently with animal data, indicate a close association between thyroid status and bone metabolism. Thyrotoxicosis results in an increased bone turnover, osteoporosis and a risk of fragility fracture. Thyroid hormone deficiency decreases bone turnover with a subsequent risk of bone fragility. Exogenous administration of suppressive doses of thyroxine was shown to negatively influences BMD and bone turnover. In future, prospective studies a prolonged time of observation will be necessary, as well as to increase the number of studied patients, in order to better assess the relative risk of osteoporosis in patients undergoing TSH-suppressive treatment. Another question that remains to be answered is if there is a benefit from treatment of subclinical thyroid disease on skeletal health.
Finally, thyroid hormone analogues represent a promising therapeutic option for their lipid lowering activity. Nevertheless, literature data suggest their potentially adverse skeletal effects. No conclusive evidence can be drawn and further investigations would be justified to establish an accurate benefice/risk ratio before their clinical use.
References
- 1.
Abe E. Marians R. C. Yu W. Wu X. B. Ando T. Li Y. Iqbal J. Eldeiry L. Rajendren G. Blair H. C. Davies T. F. Zaidi M. 2003 TSH is a negative regulator of skeletal remodeling. Cell115 151 162 - 2.
Abu E. O. Bord S. Horner A. Chatterjee V. K. K. Compston J. E. 1997 The expression of thyroid hormone receptors in human bone. Bone21 137 142 - 3.
Ahmed L. A. Schirmer H. Berntsen G. K. et al. 2006 Self-reported diseases and the risk of non-vertebral fractures: the Tromso study. Osteoporos Int17 46 53 - 4.
Akalin A. Colak O. Alatas O. Efe B. 2002 Bone remodeling markers and serum cytokines in patients with hyperthyroidism. Clin Endocrinol57 125 129 - 5.
Allain TJ, Chambers TJ, Flanagan AM, McGregor AM 1992 Tri-iodothyronine stimulates rat osteoclastic bone resorption by an indirect effect. J Endocrinol133 327 331 - 6.
Allain TJ, McGregor AM 1993 Thyroid hormones and bone. J Endocrinol139 9 18 - 7.
Alvarez L. Burgueño A. Zeni S. AS Randi Hernández. S. Hockl P. et al. 2004 Comparison of the effects of 3,5,3’-triiodothyroacetic Acid and triiodothyronine on goiter prevention and involution and on hepatic and skeletal parameters in rats. Horm. Metab. Res.36 291 7 - 8.
Angelin B. Rudling M. 2010 Lipid lowering with thyroid hormone and thyromimetics. Curr Opin Lipidol 21(6), 499-506. - 9.
Ballock R. Mita B. C. Zhou X. Chen D. H. Mink L. M. 1999 Expression of thyroid hormone receptor isoforms in rat growth plate cartilage in vivo. J Bone Miner Res14 1550 1556 - 10.
Ballock RT, Reddi AH 1994 Thyroxine is the serum factor that regulates morphogenesis of columnar cartilage from isolated chondrocytes in chemically defined medium. J Cell Biol126 1311 1318 - 11.
Ballock R. T. Zhou X. Mink L. M. Chen D. H. Mita B. C. Stewart M. C. 2000 Expression of cyclin-dependent kinase inhibitors in epiphyseal chondrocytes induced to terminally differentiate with thyroid hormone. Endocrinology.141 4552 7 - 12.
Baqi L. Payer J. Killinger Z. Susienkova K. et al. 2010 The level of TSH appeared favourable in maintaining bone mineral density in postmenopausal women. Endocr Regul.44 9 15 - 13.
Barnard J. C. et al. 2005 Thyroid hormones regulate fibroblast growth factor receptor signaling during chondrogenesis. Endocrinology146 5568 5580 - 14.
Bassett JH, Williams GR 2003 The molecular actions of thyroid hormone in bone. Trends Endocrinol Metab14 356 364 - 15.
Bassett J. H. et al. 2007a Thyroid hormone excess rather than thyrotropin deficiency induces osteoporosis in hyperthyroidism. Mol. Endocrinol.21 1095 1107 - 16.
Bassett J. H. et al. 2007b Thyroid status during skeletal development determines adult bone structure and mineralization. Mol. Endocrinol.21 1893 1904 - 17.
Bauer D. C. Ettinger B. Nevitt M. C. et al. 2001 Risk for fracture in women with low serum levels of thyroid-stimulating hormone. Ann Intern Med134 561 568 - 18.
Baxter J. D. Webb P. 2009 Thyroid hormone mimetics: Potential applications in atherosclerosis, obesity and type 2 diabetes. Nat Rev Drug Discov 8(4), 308-320. - 19.
Beber EH, Capelo LP, Fonseca TL, Costa CC, Lotfi CF, Scanlan TS, et al 2009 The thyroid hormone receptor (TR) beta-selective agonist GC-1 inhibits proliferation but induces differentiation and TR beta mRNA expression in mouse and rat osteoblast-like cells. Calcif. Tissue Int.84 324 33 - 20.
Begic-Karup S. Wagner B. Raber W. Schneider B. Hamwi A. Waldhäusl W. Vierhapper H. 2001 Serum calcium in thyroid disease. Wien Klin Wochenschr. 113(1-2):65-8. - 21.
Berkenstam A. Kristensen J. Mellstrom K. Carlsson B. Malm J. Rehnmark S. et al. 2008 The thyroid hormone mimetic compound KB2115 lowers plasma LDL cholesterol and stimulates bile acid synthesis without cardiac effects in humans. Proc Natl Acad Sci U S A 105(2), 663-667. - 22.
Bertoli A. Fusco A. Andreoli A. Magnani A. et al. 2002 Effect of subclinical hypothyroidism and obesity on whole-body and regional bone mineral content. Horm Res.57 79 84 - 23.
Beus KS, Stack BC Jr 2004 Synchronous thyroid pathology in patients presenting with primary hyperparathyroidism. Am J Otolaryngol.25 308 12 - 24.
Biondi B. Palmieri E. A. Klain M. Schlumberger M. Filetti S. Lombardi G. 2005 Subclinical hyperthyroidism: clinical features and treatment options. Eur J Endocrinol152 1 9 - 25.
Boas M. et al. 2009 Association of Thyroid Gland Volume, Serum Insulin-Like Growth Factor-I, and Anthropometric Variables in Euthyroid Prepubertal Children. J Clin Endocrinol Metab94 4031 4035 - 26.
Bookout A. L. et al. 2006 Anatomical profiling of nuclear receptor expression reveals a hierarchical transcriptional network. Cell126 789 799 - 27.
Bradley DJ, Towle HC, & Young WS 3rd 1992 Spatial and temporal expression of alpha- and beta-thyroid hormone receptor mRNAs, including the beta 2-subtype, in the developing mammalian nervous system. J Neurosci12 2288 2302 - 28.
Brenta G. Schnitman M. Fretes O. Facco E. Gurfinkel M. Damilano S. et al. 2003 Comparative efficacy and side effects of the treatment of euthyroid goiter with levo-thyroxine or triiodothyroacetic acid. J. Clin. Endocrinol. Metab.88 5287 92 - 29.
Britto JM, Fenton AJ, Holloway WR, Nicholson GC 1994 Osteoblasts mediate thyroid hormone stimulation of osteoclastic bone resorption. Endocrinology134 169 176 - 30.
MM Campos-Pastor-Torres Munoz. Escobar-Jimenez M. et F. al 1993 Bone mass in females with different thyroid disorders: influence of menopausal status. Bone and Mineral21 1 8 - 31.
Caraccio N. Natali A. Sironi A. et al. 2005 Muscle metabolism and exercise tolerance in subclinical hypothyroidism: a controlled trial of levothyroxine. J Clin Endocrinol Metab90 4057 62 - 32.
Chassande O. Fraichard A. Gauthier K. Flamant F. Legrand C. Savatier P. Laudet V. Samarut J. 1997 Identification of transcripts initiated from an internal promoter in the c-erbA alpha locus that encode inhibitors of retinoic acid receptor-alpha and triiodothyronine receptor activities. Mol Endocrinol11 1278 1290 - 33.
Cheng SY, Leonard JL, & Davis PJ 2010 Molecular aspects of thyroid hormone actions. Endocr Rev31 139 170 - 34.
Cummings SR, Nevitt MC, Browner WS, et al 1995 Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med332 767 73 - 35.
Demartini Ade. A. CA Kulak Borba. V. C. Cat M. N. Dondoni R. S. Sandrini R. et al. 2007 Bone mineral density of children and adolescents with congenital hypothyroidism. Arq Bras Endocrinol Metabol.51 1084 92 - 36.
De Menis E. Da Rin. G. Roiter I. et al. 1992 Bone turnover in overt and subclinical hyperthyroidism due to autonomous thyroid adenoma. Horm Res37 217 220 - 37.
Demeester-Mirkine N. Bergmann P. Body J. J. et al. 1990 Calcitonin and bone mass status in congenital hypothyroidism. Calcif Tissue Int46 222 6 - 38.
Eriksen E. F. Mosekilde L. Melsen F. 1986 Kinetics of trabecular bone resorption and formation in hypothyroidism: evidence for a positive balance per remodeling cycle. Bone7 101 108 - 39.
Faber J. Jensen I. W. Petersen L. Nygaard B. Hegedüs L. Siersbaek-Nielsen K. 1998 Normalization of serum thyrotrophin by means of radioiodine treatment in subclinical hyperthyroidism: effect on bone loss in postmenopausal women. Clin Endocrinol (Oxf).1998 48 285 - 40.
Flamant F. Poguet A. L. Plateroti M. Chassande O. Gauthier K. Streichenberger N. Mansouri A. Samarut J. 2002 Congenital hypothyroid Pax8(−/−) mutant mice can be rescued by inactivating the TRalpha gene. Mol Endocrinol16 24 32 - 41.
Foldes J. Tarjan G. Szathmari M. et al. 1993 Bone mineral density in patients with endogenous subclinical hyperthyroidism: is this thyroid status a risk factor for osteoporosis? Clin Endocrinol (Oxf)39 521 7 - 42.
Forrest D. Erway L. C. Ng L. Altschuler R. Curran T. 1996 Thyroid hormone receptor beta is essential for development of auditory function. Nat Genet13 354 357 - 43.
Freitas F. R. S. Capelo L. P. O’Shea P. J. Jorgetti V. AS Moriscot Scanlan. T. S. et al. 2005 The thyroid hormone receptor beta-specific agonist GC-1 selectively affects the bone development of hypothyroid rats. J. Bone Miner. Res.20 294 304 - 44.
Freitas F. R. S. AS Moriscot Jorgetti. V. Soares A. G. Passarelli M. Scanlan T. S. et al. 2003 Spared bone mass in rats treated with thyroid hormone receptor TR beta-selective compound GC-1. Am. J. Physiol. Endocrinol. Metab.285:E1135 1141 - 45.
Glass C. K. Franco R. Weinberger C. Albert V. R. Evans R. M. Rosenfeld M. G. 1987 A c-erb-A binding site in rat growth hormone gene mediates trans-activation by thyroid hormone. Nature329 738 741 - 46.
Garnero P. Vassy V. Bertholin A. Riou J. P. Delmas P. D. 1994 Markers of bone turnover in hyperthyroidism an the effects of treatment. J Clin Endocrinol Metab.78 955 959 - 47.
Gauthier K. et al. 1999 Different functions for the thyroid hormone receptors TRalpha and TRbeta in the control of thyroid hormone production and post-natal development. EMBO J.18 623 631 - 48.
Gauthier K. Plateroti M. Harvey C. B. Williams G. R. Weiss R. E. Refetoff S. Willott J. F. Sundin V. Roux J. P. Malaval L. Hara M. Samarut J. Chassande O. 2001 Genetic analysis reveals different functions for the products of the thyroid hormone receptor alpha locus. Mol Cell Biol21 4748 4760 - 49.
Gothe S. Wang Z. Ng L. Kindblom J. M. Barros A. C. Ohlsson C. Vennstrom B. Forrest D. 1999 Mice devoid of all known thyroid hormone receptors are viable but exhibit disorders of the pituitary-thyroid axis, growth, and bone maturation. Genes Dev13 1329 1341 - 50.
Gouveia CH, Schultz JJ, Bianco AC, Brent GA 2001 Thyroid hormone stimulation of osteocalcin gene expression in ROS17/2.8 cells is mediated by transcriptional and post-transcriptional mechanisms. J Endocrinol170 667 675 - 51.
Greenspan SL & Greenspan FS 1999 The effect of thyroid hormone on skeletal integrity. Annals of Internal Medicine130 750 758 - 52.
Grimnes G. Emaus N. Joakimsen R. M. Figenschau Y. Jorde R. 2008 The relationship between serum TSH and bone mineral density in men and postmenopausal women: The Tromsø study. Thyroid.18 1147 55 - 53.
Harvey C. B. O’Shea P. J. Scott A. J. Robson H. Siebler T. Shalet S. M. Samarut J. Chassande O. Williams G. R. 2002 Molecular mechanisms of thyroid hormone effects on bone growth and function. Mol Genet Metab75 17 30 - 54.
Hase H. Ando T. Eldeiry L. Brebene A. Peng Y. Liu L. Amano H. Davies T. F. Sun L. Zaidi M. Abe E. 2006 TNF mediates the skeletal effects of thyroid-stimulating hormone. Proc Natl Acad Sci USA103 12849 12854 - 55.
Heemstra KA, Hamdy NA, Romijn JA & Smit JW 2006 The effects of thyrotropin-suppressive therapy on bone metabolism in patients with well-differentiated thyroid carcinoma. Thyroid16 583 591 - 56.
Heyerdahl S. 1997 Linear growth in early treated children with congenital hypothyroidism. Acta Paediatr.86 479 83 - 57.
Himeno M. et al. 2002 Impaired vascular invasion of Cbfa1-deficient cartilage engrafted in the spleen. J. Bone Miner. Res.17 1297 1305 - 58.
Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE 2002 Serum TSH, T(4), and thyroid antibodies in the United Statuss population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab.87 489 99 - 59.
Huber G. Staub J. J. Meier C. Mitrache C. Guglielmetti M. Huber P. Braverman L. E. 2002 Prospective study of the spontaneous course of subclinical hypothyroidism: prognostic value of thyrotropin, thyroid reserve, and thyroid antibodies. J Clin Endocrinol Metab87 3221 6 - 60.
Iakovou I. Chrisoulidou A. Balaris V. Balaris C. Doumas A. Karatzas N. 2010 Acute effects of recombinant human TSH on bone markers in differentiated thyroid cancer. Hell J Nucl Med13 208 12 - 61.
Iqbal AA, Burgess EH, Gallina DL, Nanes MS, Cook CB 2003 Hypercalcemia in hyperthyroidism: patterns of serum calcium, parathyroid hormone, and 1,25-dihydroxyvitamin D3 levels during management of thyrotoxicosis. Endocr Pract9 517 21 - 62.
Jamal SA, Leiter RE, Bayoumi AM et al 2005 Clinical utility of laboratory testing in women with osteoporosis. Osteoporos Int16 534 540 - 63.
Jodar E. Munoz-Torres M. Escobar-Jimenez F. et al. 1997 Bone loss in hyperthyroid patients and in former hyperthyroid patients controlled on medical therapy: influence of aetiology and menopause. Clin Endocrinol (Oxf)47 279 85 - 64.
Karga H. Papaioannou G. Polymeris A. Papamichael K. Karpouza A. Samouilidou E. Papaioannou P. 2010 The effects of recombinant human TSH on bone turnover in patients after thyroidectomy. J Bone Miner Metab28 35 41 - 65.
Karner I. Hrgović Z. Sijanović S. Buković D. Klobucar A. Usadel K. H. Fassbender W. J. 2005 Bone mineral density changes and bone turnover in thyroid carcinoma patients treated with supraphysiologic doses of thyroxine. Eur J Med Res.10 480 8 - 66.
Kawaguchi H. Pilbeam C. C. Raisz L. G. 1994a Anabolic effects of 3,3’,5-triiodothyronine and triiodothyroacetic acid in cultured neonatal mouse parietal bones. Endocrinology135 971 6 - 67.
Kawaguchi H. Pilbeam C. C. Woodiel F. N. Raisz L. G. 1994b Comparison of the effects of 3,5,3’-triiodothyroacetic acid and triiodothyronine on bone resorption in cultured fetal rat long bones and neonatal mouse calvariae. J. Bone Miner. Res.9 247 53 - 68.
Kim DJ, Khang YH, Koh JM, Shong YK, Kim GS 2006 Low normal TSH levels are associated with low bone mineral density in healthy postmenopausal women. Clin Endocrinol (Oxf)64 86 90 - 69.
Kim BJ, Lee SH, Bae SJ, Kim HK, Choe JW, Kim HY, Koh JM, Kim GS 2010 The association between serum thyrotropin (TSH) levels and bone mineral density in healthy euthyroid men. Clin Endocrinol (Oxf).73 396 403 - 70.
Kindblom J. M. Gothe S. Forrest D. Tornell J. Vennstrom B. Ohlsson C. 2001 GH substitution reverses the growth phenotype but not the defective ossification in thyroid hormone receptor alpha 1−/−beta−/− mice. J Endocrinol171 15 22 - 71.
Kisakol G. Kaya A. Gonen S. Tunc R. 2003 Bone and calcium metabolism in subclinical autoimmune hyperthyroidism and hypothyroidism. Endocr J50 657 661 - 72.
Kocher T. 1883 Ueber Kropfexstirpation und ihre Folgen. Arch Klin Chir 29:254. - 73.
Koenig RJ, Brent GA, Warne RL, Larsen PR, Moore DD 1987 Thyroid hormone receptor binds to a site in the rat growth hormone promoter required for induction by thyroid hormone. Proc Natl Acad Sci USA84 5670 5674 - 74.
Kooh S. W. Brnjac L. Ehlrich R. M. Qureshi R. Krishnan S. 1996 Bone mass in children with congenital hypothyroidism treated with thyroxine since birth. Journal of Pediatric Endocrinology and Metabolism9 59 62 - 75.
ME Kraenzlin Kraenzlin. CA Meier C. Giunta C. Steinmann B. 2008 Automated HPLC assay for urinary collagen cross-links: effect of age, menopause, and metabolic bone diseases. Clin Chem54 1546 1553 - 76.
Krolner B. Jorgensen J. V. Nielsen S. P. 1983 Spinal bone mineral content in myxedema and thyrotoxicosis. Effects of thyroid hormone(s) and anti-thyroid treatment. Clin Endocrinol (Oxf)18 439 46 - 77.
Kumeda Y. Inaba M. Tahara H. et al. 2000 Persistent increase in bone turnover in Graves’ patients with subclinical hyperthyroidism. J Clin Endocrinol Metab85 4157 61 - 78.
Kvistad P. H. Lovas K. Boman H. et al. 2004 Retarded bone growth in thyroid hormone resistance. A clinical study of a large family with a novel thyroid hormone receptor mutation. Eur J Endocrinol150 425 430 - 79.
Ladenson P. W. JD Kristensen Ridgway. E. C. Olsson A. G. Carlsson B. Klein I. et al. 2010a Use of the thyroid hormone analogue eprotirome in statin-treated dyslipidemia. N. Engl. J. Med362 906 16 - 80.
Ladenson P. W. Mc Carren M. Morkin E. Edson R. G. Shih-C M. Warren S. R. et al. 2010b Effects of the thyromimetic agent diiodothyropropionic acid on body weight, body mass index, and serum lipoproteins: a pilot prospective, randomized, controlled study. J Clin Endocrinol Metab.95 1349 54 - 81.
Lassova L. et al. 2009 Thyroid hormone treatment of cultured chondrocytes mimics in vivo stimulation of collagen X mRNA by increasing BMP 4 expression. J. Cell. Physiol.219 595 605 - 82.
Lazar MA 1993 Thyroid hormone receptors: Multiple forms, multiple possibilities. Endocr Rev14 184 193 - 83.
Lazar MA, & Chin WW 1990 Nuclear thyroid hormone receptors. J Clin Invest86 1777 1782 - 84.
Lee J. S. Buzková P. Fink H. A. Vu J. Carbone L. Chen Z. et al. 2010 Subclinical thyroid dysfunction and incident hip fracture in older adults. Arch Intern Med.170 1876 83 - 85.
Lee WY, Oh KW, Rhee EJ, Jung CH, Kim SW et al 2006 Relationship between subclinical thyroid dysfunction and femoral neck bone mineral density in women. Archives of Medical Research37 511 516 - 86.
Leger J. Ruiz J. C. Guibourdenche J. Kindermans C. Garabedian M. Czernichow P. 1997 Bone mineral density and metabolism in children with congenital hypothyroidism after prolonged L-thyroxine therapy. Acta Paediatr.86 704 10 - 87.
Lewinson D. Harel Z. Shenzer P. Silbermann M. Hochberg Z. 1989 Effect of thyroid hormone and growth hormone on recovery from hypothyroidism of epiphyseal growth plate cartilage and its adjacent bone. Endocrinology124 937 945 - 88.
Liu J. P. Baker J. AS Perkins Robertson. E. J. Efstratiadis A. 1993 Mice carrying null mutations of the genes encoding insulin-like growth factor I (Igf-1) and type 1 IGF receptor (Igf1r). Cell75 59 72 - 89.
Ma Latif R. Zaidi R. Davies M. T. 2009 Thyroid and bone: TSH inhibits osteoclastogenesis from embryonic stem cells. Presented at the 91st Annual Meeting of the Endocrine Society. Washington DC; June10 13 - 90.
Ma Morshed R. Latif S. Zaidi R. Davies M. T. F. 2011 The influence of thyroid-stimulating hormone and thyroid-stimulating hormone receptor antibodies on osteoclastogenesis. Thyroid21 897 906 - 91.
Makihira S. et al. 2003 Thyroid hormone enhances aggrecanase-2/ADAM-TS5 expression and proteoglycan degradation in growth plate cartilage. Endocrinology144 2480 2488 - 92.
Martini G. Gennari L. De Paola V. Pilli T. Salvadori S. Merlotti D. Valleggi F. Campagna S. Franci B. Avanzati A. Nuti R. Pacini F. 2008 The effects of recombinant TSH on bone turnover markers and serum osteoprotegerin and RANKL levels. Thyroid.18 455 60 - 93.
Mazziotti G. Sorvillo F. Piscopo M. Cioffi M. Pilla P. Biondi B. Iorio S. Giustina A. Amato G. Carella C. 2005 Recombinant human TSH modulates in vivo C-telopeptides of type-1 collagen and bone alkaline phosphatase, but not osteoprotegerin production in postmenopausal women monitored for differentiated thyroid carcinoma. J Bone and Min Res20 480 486 - 94.
Mazziotti G. Porcelli T. Patelli I. Vescovi P. P. Giustina A. 2010 Serum TSH values and risk of vertebral fractures in euthyroid post-menopausal women with low bone mineral density. Bone.46 747 51 - 95.
Meier C. Beat M. Guglielmetti M. Christ-Crain M. Staub J. J. Kraenzlin M. 2004 Restoration of euthyroidism accelerates bone turnover in patients with subclinical hypothyroidism: a randomized controlled trial. Osteoporosis International15 209 216 - 96.
Melsen F. Mosekilde L. 1977 Morphometric and dynamic studies of bone changes in hyperthyroidism. Acta Pathol Microbiol Scand A. 85A:141 50 - 97.
Miell J. P. Taylor A. M. Zini M. Maheshwari G. Ross R. J. M. Valcani R. 1993 Effects of hypothyroidism and hyperthyroidism on insulin-like growth factors (IGFs) and growth hormone- and IGF-binding proteins. J Clin Endocrinol Metab.76 950 955 - 98.
Milne M. Kang M. I. Quail J. M. Baran D. T. 1998 Thyroid hormone excess increases insulin-like growth factor I transcripts in bone marrow cell cultures: divergent effects on vertebral and femoral cell cultures. Endocrinology139 2527 2534 - 99.
Milne M. Quail J. M. Rosen C. J. Baran D. T. 2001 Insulin-like growth factor binding proteins in femoral and vertebral bone marrow stromal cells: expression and regulation by thyroid hormone and dexamethasone. J Cell Biochem.81 229 40 - 100.
Mohan H. K. Groves A. M. Fogelman I. Clarke S. E. 2004 Thyroid hormone and parathyroid hormone competing to maintain calcium levels in the presence of vitamin D deficiency. Thyroid14 789 91 - 101.
Mora S. Weber G. Marenzi K. Signorini E. Rovelli R. Proverbio M. C. Chiumello G. 1999 Longitudinal changes of bone density and bone resorption in hyperthyroid girls during treatment. Journal of Bone and Mineral Research14 1971 1977 - 102.
Morris MS 2007 The association between serum thyroid stimulating hormone in its reference range and bone status in postmenopausal American women. Bone40 1128 1134 - 103.
Effects of thyroid hormones on bone and mineral metabolism. Endocrinol Metab Clin North AmMosekilde L. Eriksen E. F. Charles P. 1990 19 35 63 - 104.
The thyroid and the skeleton. Clin Endocrinol (Oxf)Murphy E. Williams G. R. 2004 61 285 298 - 105.
Nagata M. Suzuki A. Sekiguchi S. Ono Y. Nishiwaki-Yasuda K. Itoi T. et al. 2007 Subclinical hypothyroidism is related to lower heel QUS in postmenopausal women. Endocr J54 625 30 - 106.
Bone mineral density in human cases with TSH receptor gene mutations. Proceedings of the New York Academy of Sciences 1rst Conference on Skeletal Development and Remodeling in Health, Disease, and Aging, May 18-21,Onigata K. Kowasi T. Nishiyama S. Micuno H. Morikawa A. 2005 New York, NY, USA. - 107.
O’Shea P. J. Harvey C. B. Suzuki H. Kaneshige M. Kaneshige K. Cheng S. Y. Williams G. R. 2003 A thyrotoxic skeletal phenotype of advanced bone formation in mice with resistance to thyroid hormone. Mol Endocrinol17 1410 1424 - 108.
O’Shea PJ, Williams GR 2002 Insight into the physiological actions of thyroid hormone receptors from genetically modified mice. J Endocrinol175 553 570 - 109.
O’Shea P. J. et al. 2005 Contrasting skeletal phenotypes in mice with an identical mutation targeted to thyroid hormone receptor alpha1 or beta. Mol. Endocrinol.19 3045 3059 - 110.
O’Shea P. J. et al. 2006 Characterization of skeletal phenotypes of TRalpha1 and TRbeta mutant mice: implications for tissue thyroid status and T3 target gene expression. Nucl. Receptor Signal. 4, e011 - 111.
Pantazi H. Papapetrou P. D. 2000 Changes in parameters of bone and mineral metabolism during therapy for hyperthyroidism. J Clin Endocrinol Metab.85 1099 106 - 112.
Pereira R. C. Jorgetti V. Canalis E. 1999 Triiodothyronine induces collagenase-3 and gelatinase B expression in murine osteoblasts. Am J Physiol 277:E496 E504 - 113.
Pramfalk C. Pedrelli M. Parini P. 2011 Role of thyroid receptor beta in lipid metabolism. Biochim Biophys Acta1812 929 37 - 114.
Radetti G. Castellan C. Tato` L. Platter K. Gentili L. Adami S. 1993 Bone mineral density in children and adolescent females treated with high doses of L-thyroxine. Hormon Research39 127 131 - 115.
Ray RD, Asling CW, Walker DG, Simpson ME, Li CH, Evans HM 1954 Growth and differentiation of the skeleton in thyroidectomized-hypophysectomized rats treated with thyroxin, growth hormone, and combination. J Bone Joint Surg Am36 94 103 - 116.
Rivkees SA, Bode HH, Crawford JD 1988 Long-term growth in juvenile acquired hypothyroidism: the failure to achieve normal adult stature. N Engl J med3 599 602 - 117.
Robson H. Siebler T. Stevens D. A. et al. 2000 Thyroid hormone acts directly on growth plate chondrocytes to promote hypertrophic differentiation and inhibit clonal expansion and cell proliferation. Endocrinology141 3887 3897 - 118.
Sabuncu T. Aksoy N. Arikan E. Ugur B. Tasan E. Hatemi H. 2001 Early changes in parameters of bone and mineral metabolism during therapy for hyper- and hypothyroidism. Endocr Res.27 203 13 - 119.
Saggese G. Bertelloni S. Baroncelli G. I. Costa S. Ceccarelli C. 1996 Bone mineral denisty in adolescent females treated with L-thyroxine: a longitudinal study. European Journal of Pediatrics155 452 457 - 120.
Salerno M. Lettiero T. Esposito-del Puente. A. et al. . 2004 Effect of long-term L-thyroxine treatment on bone mineral density in young adults with congenital hypothyroidism. European Journal of Endocrinology151 689 694 - 121.
Sampath T. K. Simic P. Sendak R. Draca N. Bowe A. E. O’Brien S. Schiavi S. C. Mc Pherson J. M. Vukicevic S. 2007 Thyroid-stimulating hormone restores bone volume, microarchitecture, and strength in aged ovariectomized rats. J Bone Miner Res.22 849 59 - 122.
Sap J. Munoz A. Damm K. Goldberg Y. Ghysdael J. Leutz A. et al. 1986 The c-erb-A protein is a high-affinity receptor for thyroid hormone. Nature324 635 640 - 123.
Scanlan TS 2010 Sobetirome: A case history of bench-to-clinic drug discovery and development. Heart Fail Rev 15(2), 177-182. - 124.
Segni M. et al. 1999 Special features of Graves’ disease in early childhood. Thyroid9 871 877 - 125.
Sherman SI, Ringel MD, Smith MJ, Kopelen HA, Zoghbi WA, Ladenson PW 1997 Augmented hepatic and skeletal thyromimetic effects of tiratricol in comparison with levothyroxine. J. Clin. Endocrinol. Metab.82 2153 8 - 126.
Siddiqi A. Burrin J. M. Noonan K. James I. Wood D. F. CP Price Monson. J. P. 1997 A longitudinal study of markers of bone turnover in Graves’ disease and their value in predicting bone mineral density. J Clin Endocrinol Metab.82 753 759 - 127.
Siddiqi A. Burrin J. M. Wood D. F. Monson J. P. 1998 Tri-iodothyronine regulates the production of interleukin-6 and interleukin-8 in human bone marrow stromal and osteoblast-like cells. J Endocrinol.157 453 61 - 128.
Siddiqi A. Parsons M. P. Lewis J. L. et al. 2002 TR expression and function in human bone marrow stromal and osteoblast- like cells. J Clin Endocrinol Metab87 906 914 - 129.
Sjogren K. Bohlooly Y. M. Olsson B. Coschigano K. Tornell J. Mohan S. Isaksson O. G. Baumann G. Kopchick J. Ohlsson C. 2000 Disproportional skeletal growth and markedly decreased bone mineral content in growth hormone receptor−/− mice. Biochem Biophys Res Commun267 603 608 - 130.
Solomon B. L. Wartofsky L. Burman K. D. 1993 Prevalence of fractures in postmenopausal women with thyroid disease. Thyroid.3 17 23 - 131.
Stevens D. A. Hasserjian R. P. Robson H. Siebler T. Shalet S. M. Williams G. R. 2000 Thyroid hormones regulate hypertrophic chondrocyte differentiation and expression of parathyroid hormone-related peptide and its receptor during endochondral bone formation. J Bone Miner Res15 2431 2442 - 132.
Stevens D. A. et al. 2003 Thyroid hormone activates fibroblast growth factor receptor-1 in bone. Mol. Endocrinol.17 1751 1766 - 133.
St Germain, D.L. et al. 2009 Defining the roles of the iodothyronine deiodinases: current concepts and challenges. Endocrinology150 1097 1107 - 134.
Sugitani I. Fujimoto Y. 2008 Effect of postoperative thyrotropin suppressive therapy on bone mineral density in patients with papillary thyroid carcinoma: a prospective controlled study. Surgery.150 1250 7 - 135.
Sun L. et al. 2008 Intermittent recombinant TSH injections prevent ovariectomy-induced bone loss. PNAS.105 4289 4294 - 136.
Svare A. Nilsen T. I. Bjøro T. Forsmo S. Schei B. Langhammer A. 2009 Hyperthyroid levels of TSH correlate with low bone mineral density: the HUNT 2 study. Eur J Endocrinol.161 779 86 - 137.
Tárraga López PJ, López CF, de Mora FN, Montes JA, Albero JS, Mañez AN, Casas AG 2011 Osteoporosis in patients with subclinical hypothyroidism treated with thyroid hormone. Clin Cases Miner Bone Metab.8 44 8 - 138.
Thorngren KG, Hansson LI 1973 Effect of thyroxine and growth hormone on longitudinal bone growth in the hypophysectomized rat. Acta Endocrinol (Copenh)74 24 40 - 139.
Thorngren KG, Hansson LI 1974 Bioassay of growth hormone II. Determination of longitudinal bone growth with tetracycline in thyroxine-treated hypophysectomized rats. Acta Endocrinol (Copenh)75 669 682 - 140.
Thompson C. C. Weinberger C. Lebo R. Evans R. M. 1987 Identification of a novel thyroid hormone receptor expressed in the mammalian central nervous system. Science237 1610 1614 - 141.
Tumer L. Hasanoglu A. Cinaz P. Bideci A. 1999 Bone mineral density and metabolism in children treated with L-thyroxine. Journal of Pediatric Endocrinology and Metabolism12 519 523 - 142.
Turner MR et al. 2011 Levothyroxine dose and risk of fractures in older adults: nested case-control study. BMJ. 342:d2238 - 143.
Udayakumar N. Chandrasekaran M. Rasheed M. H. Suresh R. V. Sivaprakash S. 2006 Evaluation of bone mineral density in thyrotoxicosis. Singapore Med J47 947 950 - 144.
Varga F. Rumpler M. Luegmayr E. Fratzl-Zelman N. Glantschnig H. Klaushofer K. 1997 Triiodothyronine, a regulator of osteoblastic differentiation: depression of histone H4, attenuation of c-fos/c-jun, and induction of osteocalcin expression. Calcif Tissue Int61 404 411 - 145.
Vadiveloo T. Donnan P. T. Cochrane L. Leese G. P. 2011 The Thyroid Epidemiology, Audit, and Research Study (TEARS): morbidity in patients with endogenous subclinical hyperthyroidism. J Clin Endocrinol Metab96 1344 51 - 146.
Vestergaard P. Mosekilde L. 2002 Fractures in patients with hyperthyroidism and hypothyroidism: a nationwide follow-up study in 16,249 patients. Thyroid12 411 419 - 147.
Vestergaard P. Rejnmark L. Mosekilde L. 2005 Influence of hyper- and hypothyroidism, and the effects of treatment with anti-thyroid drugs and levothyroxine on fracture risk. Calcif Tissue Int77 139 144 - 148.
Vestergaard P. Rejnmark L. Weeke J. Mosekilde L. 2000 Fracture risk in patients treated for hyperthyroidism. Thyroid10 341 348 - 149.
Wagner B. Begic-Karup S. Raber W. Schneider B. Waldhäusl W. Vierhapper H. 1999 Prevalence of primary hyperparathyroidism in 13387 patients with thyroid diseases, newly diagnosed by screening of serum calcium. Exp Clin Endocrinol Diabetes.107 457 61 - 150.
Wang L. et al. 2007 Thyroid hormone interacts with the Wnt/betacatenin signaling pathway in the terminal differentiation of growth plate chondrocytes. J. Bone Miner. Res.22 1988 1995 - 151.
Webb P. 2010 Thyroid hormone receptor and lipid regulation. Curr Opin Investig Drugs 11(10), 1135-1142. - 152.
Weinberger C. Thompson C. C. Ong E. S. Lebo R. Gruol D. J. Evans R. M. 1986 The c-erb-A gene encodes a thyroid hormone receptor. Nature324 641 646 - 153.
Weiss R. E. Refetoff S. 2000 Resistance to thyroid hormone. Rev Endocr Metab Disord1 97 108 - 154.
Wejda B. Hintze G. Katschinski B. Olbricht T. Benker G. 1995 Hip fractures and the thyroid: A case study. J Intern Med237 241 247 - 155.
Williams G. R. Bland R. Sheppard M. C. 1994 Characterization of thyroid hormone (T3) receptors in three osteosarcoma cell lines of distinct osteoblast phenotype: interactions among T3, vitamin D3, and retinoid signaling. Endocrinology135 2375 2385 - 156.
Williams GR 2000 Cloning and characterization of two novel thyroid hormone receptor beta isoforms. Mol Cell Biol20 8329 8342 - 157.
Wilkis L. 1941 Epiphysial dysgenesis associated with hypothyroidism. Am J Dis Child.61 13 34 - 158.
Wikstrom L. Johansson C. Salto C. Barlow C. Campos Barros. A. Baas Forrest F. Thoren D. Vennstrom P. B. 1998 Abnormal heart rate and body temperature in mice lacking thyroid hormone receptor alpha 1. EMBO J17 455 461 - 159.
Yamoah K. Brebene A. Baliram R. et al. 2008 High-mobility group box proteins modulate tumor necrosis factor-alpha expression in osteoclastogenesis via a novel deoxyribonucleic acid sequence. Mol Endocrinol22 1141 1153