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Effects of intermittent senolytic therapy on bone metabolism in postmenopausal women: a phase 2 randomized controlled trial

Abstract

Preclinical evidence demonstrates that senescent cells accumulate with aging and that senolytics delay multiple age-related morbidities, including bone loss. Thus, we conducted a phase 2 randomized controlled trial of intermittent administration of the senolytic combination dasatinib plus quercetin (D + Q) in postmenopausal women (n = 60 participants). The primary endpoint, percentage changes at 20 weeks in the bone resorption marker C-terminal telopeptide of type 1 collagen (CTx), did not differ between groups (median (interquartile range), D + Q −4.1% (−13.2, 2.6), control −7.7% (−20.1, 14.3); P = 0.611). The secondary endpoint, percentage changes in the bone formation marker procollagen type 1 N-terminal propeptide (P1NP), increased significantly (relative to control) in the D + Q group at both 2 weeks (+16%, P = 0.020) and 4 weeks (+16%, P = 0.024), but was not different from control at 20 weeks (−9%, P = 0.149). No serious adverse events were observed. In exploratory analyses, the skeletal response to D + Q was driven principally by women with a high senescent cell burden (highest tertile for T cell p16 (also known as CDKN2A) mRNA levels) in which D + Q concomitantly increased P1NP (+34%, P = 0.035) and reduced CTx (−11%, P = 0.049) at 2 weeks, and increased radius bone mineral density (+2.7%, P = 0.004) at 20 weeks. Thus, intermittent D + Q treatment did not reduce bone resorption in the overall group of postmenopausal women. However, our exploratory analyses indicate that further studies are needed testing the hypothesis that the underlying senescent cell burden may dictate the clinical response to senolytics. ClinicalTrials.gov identifier: NCT04313634.

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Fig. 1: CONSORT flow diagram.
Fig. 2: Overall study design.
Fig. 3: Percentage changes in bone turnover markers.
Fig. 4: Time course of changes in bone turnover markers based on T3 and T1/T2 groups.
Fig. 5: Percentage changes in BMD based on T3 and T1/T2 groups.

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Data availability

All information on materials and reagents is provided in the Methods and Supplementary Methods. Individual deidentified participant data that underlie the results reported in this article (text, tables, figures) are available as an Excel file in the Supplementary Information. The study protocol, which includes the statistical analysis plan, is also available in the Supplementary Information. No restrictions are placed on the availability of this data. Source data are provided with this paper.

Code availability

No code was used in the analyses.

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Acknowledgements

We thank the Mayo Clinic Immunochemical Core laboratory for performing the CTx and P1NP assays. This work was supported by National Institutes of Health grant nos R21 AG065868 (J.N.F. and S.K.), P01 AG062413 (J.N.F., N.K.L., J.L.K., S.K.), R01 AG 076515 (S.K., D.G.M.), R01 DK128552 (J.N.F.), R01 AG055529 (N.K.L.), R37 AG13925 (J.L.K.) and R33 AG61456 (J.L.K.). The funders played no role in the conduct or analyses in this study.

Author information

Authors and Affiliations

Authors

Contributions

J.N.F. and S.K. conceived and directed the project, with input from E.J.A., J.S., M.T.D., T.T., N.K.L., J.L.K., M.D., D.S. and D.G.M. T.L.V. and A.J.T. recruited the study participants and conducted the study. E.J.A. and S.J.A. performed all the statistical analyses. I.B., K.Y. and N.K.L. provided population samples for T cell p16 assays. S.J.V. and M.R. were responsible for handling and managing all study samples. J.N.F. and S.K. wrote the manuscript, which all authors then reviewed and approved.

Corresponding authors

Correspondence to Joshua N. Farr or Sundeep Khosla.

Ethics declarations

Competing interests

N.K.L., T.T. and J.L.K. have a financial interest related to this research, including patents and pending patents covering senolytic drugs and their uses that are held by Mayo Clinic. This research has been reviewed by the Mayo Clinic Conflict of Interest Review Board and was conducted in compliance with the Mayo Clinic’s conflict of interest policies. The remaining authors declare no competing interests.

Peer review

Peer review information

Nature Medicine thanks Kimberly Templeton and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Primary Handling Editor: Sonia Muliyil, in collaboration with the Nature Medicine team.

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Extended data

Extended Data Fig. 1 Alternative splicing of the human p16 proximal promoter produces two distinct variants.

Schematic representation of the proximal p16 promoter and alternative splicing patterns of the pre-mRNA, indicating the p16-variant 1 mRNA (Exons 1/2/4; NM_000077) and the p16-variant 5 mRNA (Exons 1/2/3/4; NM_001195132). The protein products between the two variants encode identical proteins from amino acids 1-152, however the p16-variant 5 protein has a unique 15 amino acid C-terminal sequence in place of the 4 amino acid C-terminal sequence of the p16-variant 1 protein, due to the retained Exon 3 in the p16-variant 5 mRNA. PCR primer sequences are indicated, demonstrating that the p16_variant 1 + 5 primer pair amplifies both variant 1 and 5 isoforms, whereas the p16_variant 5 primer pair only amplifies p16-variant 5.

Source data

Extended Data Fig. 2 Distribution by age and age correlations of p16 variants in women aged < 60 years.

Distribution by age in a cohort (n = 228, age 23-88 years) of women for (a) the p16_variant 1 + 5 and (b) the p16_variant 5. Correlations with age for (c) p16_variant 1 + 5 and (d) p16_variant 5 in women < 60 years of age (n = 42). Spearman correlation coefficients are shown.

Source data

Extended Data Fig. 3 Age correlations of p16 variants in women aged > 60 years.

Correlation with age for (a) p16_variant 1 + 5 and (b) p16_variant 5 in women > 60 years of age (n = 186). Correlations with age specifically in the study participants for (c) p16_variant 1 + 5 and (d) p16_variant 5 (n = 60). Spearman correlation coefficients are shown.

Source data

Extended Data Fig. 4 Percent changes in BMD.

Percent changes from baseline in (a) radius, (b) femur neck, and (c) lumbar spine BMD. n = 55, 57, and 46 for radius, femur neck, and lumbar spine BMD. Data are shown as Median (IQR); P-values based on two-sided Wilcoxon rank-sum tests.

Source data

Extended Data Fig. 5 Time course of changes in bone turnover markers based on T3 and T1/T2 tertiles derived from p16_variant 1 + 5.

Percent changes over time in (a) serum P1NP and (b) serum CTx in the T3 group; percentage changes over time in (c) serum P1NP and (d) serum CTx in the T1/T2 group. n = 20 T3 and 40 T1/T2 at 2 weeks; n = 19 T3 and 40 T1/T2 at 4 weeks; n = 18 T3 and 38 T1/T2 at 20 weeks. Data are shown as Median (IQR); P-values based on two-sided Wilcoxon rank-sum tests.

Source data

Extended Data Fig. 6 Select SASP factors in T1/T2 vs T3 groups.

(a) Sclerostin, (b) Fas, (c) MMP2, (d) PARC, (e) Osteoactivin, and (f) TNFR1 levels in the T1/T2 vs T3 groups. n = 21 T3 and 39 T1/T2 weeks. Data are shown as Median (IQR); P-values based on two-sided Wilcoxon rank-sum tests.

Source data

Extended Data Table 1 Adverse events in the study participants
Extended Data Table 2 Baseline circulating senescence-associated secretory phenotype (SASP) factors in the study subjects stratified by p16 tertiles
Extended Data Table 3 Comparisons of percentage changes in circulating senescence-associated secretory phenotype (SASP) factors at 2 weeks in the T3 study subjects between the control and D + Q groups
Extended Data Table 4 Primer sequences

Supplementary information

Source data

Source data

Source data for Table 1, Figs 3a-f, 4a-d, 5a-c, Extended Data Tables 2, 3 and Extended Data Figs 2a-d, 3a-d, 4a-c, 5a-d, 6a-f .

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Farr, J.N., Atkinson, E.J., Achenbach, S.J. et al. Effects of intermittent senolytic therapy on bone metabolism in postmenopausal women: a phase 2 randomized controlled trial. Nat Med (2024). https://doi.org/10.1038/s41591-024-03096-2

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