Yilin Zhu
Liangyi Xiao- Changsha Hospital of Traditional Chinese Medicine (Changsha No. 8 Hospital), Changsha City, Hunan Province, China
Osteoporosis is, a common bone disease, and it has become a prominent health problem of the elderly in modern society. As a new type of cell death, ferroptosis plays an important role in the occurrence and development of osteoporosis. Therefore, regulation of iron metabolism is helpful for the treatment of osteoporosis. This article not only reviews the molecular mechanism of ferroptosis in osteoporosis, but also focuses on the three-dimensional regulatory network of iron metabolism disorder, lipid peroxidation, and bone homeostasis imbalance. Natural active ingredients with potential inhibiting ferroptosis, including traditional Chinese medicine, and their corresponding targets, are also evaluated from the perspective of natural product chemistry and molecular pharmacology. Finally, the research and development prospects of natural ingredient delivery systems in the treatment of osteoporosis are discussed. Advances in these therapeutic strategies provide new opportunities to address the challenges in the management of osteoporosis and may improve the quality of life of elderly patients. This article comprehensively reviews the related studies of ferroptosis and osteoporosis, providing a valuable reference for research and clinical practice in this field, and contributing to the further development of osteoporosis treatment research.
1 Introduction
Osteoporosis is a common skeletal condition marked by a decrease in bone mass and the degradation of the microstructure of bone tissue, resulting in increased fragility of bones and an elevated likelihood of fractures (1). The primary clinical manifestations include bone pain, fatigue, spinal deformity, and fractures (2). With the intensification of population aging, the incidence of fractures and complications associated with osteoporosis is rising annually, significantly impacting public health. Consequently, osteoporosis has emerged as a prominent health concern in modern society. The National Osteoporosis Foundation approximates that 10.2 million individuals in the United States suffer from osteoporosis, while an extra 43.4 million exhibit low bone mass. Additionally, forecasts indicate that by 2030, the total number of adults dealing with osteoporosis and low bone mass is expected to increase to 71 million (3). According to the latest statistics from China, the incidence of osteoporosis among individuals aged 50 and above is 19.2%, with rates of 6.0% in men and 32.1% in women (4). In European countries, the prevalence among men over 50 is 7.2% (Luxembourg), and among women, it is 23.5% (France) (5).
In recent times, ferroptosis, an innovative type of cellular demise, has attracted considerable interest within the domain of bone metabolism. A growing number of research suggests a strong connection between ferroptosis and osteoporosis. The regulation of iron metabolism plays a crucial role in upholding the body’s iron homeostasis, involving iron uptake, storage, transport, and utilization. As a key component of hemoglobin, cytochromes, and iron–sulfur clusters, iron is essential for various biological processes, including the transport of oxygen, energy metabolism, and DNA synthesis, among others. In contrast to classical forms of cell death such as necrosis and apoptosis, ferroptosis is distinguished by its lack of cell membrane rupture or swelling, and it does not cause cellular shrinkage, pyknosis, nuclear fragmentation, or the formation of apoptotic bodies. The defining features of ferroptosis include a reduction in size and a decrease in mitochondria, potential elimination of cristae, increased membrane density, and membrane rupture, along with blebbing, while exhibiting minimal changes in nuclear morphology (6). The mechanism of ferroptosis is primarily associated with disorders in iron metabolism, imbalances in the amino acid antioxidant system, and the accumulation of lipid peroxides. The buildup of lipid peroxides plays a key role in ferroptosis, while glutathione peroxidase 4 (GPX4), an essential antioxidant enzyme, is capable of blocking, thus inhibiting ferroptosis (7). Moreover, an excess of iron plays a crucial role in ferroptosis, since iron ions produce a considerable quantity of reactive oxygen species via the Fenton reaction, which in turn enhances lipid peroxidation and triggers ferroptosis (8).
This review intends to explore the molecular mechanisms underlying ferroptosis in the development and progression of osteoporosis, focusing on elucidating the three-dimensional regulatory network involving iron metabolism disorders, lipid peroxidation, and imbalances in bone homeostasis. At the same time, it assesses natural active compounds with potential anti-ferroptosis effects and their respective targets, drawing from the fields of natural product chemistry and molecular pharmacology.
Finally, it explores the research and development prospects of natural component delivery systems (such as exosomes) based on ferroptosis regulation, aiming to provide a theoretical basis and new directions for drug development in the precise prevention and treatment of osteoporosis.
2 The mechanism between osteoporosis and ferroptosis
2.1 Ferroptosis affects bone metabolism
2.1.1 Iron metabolism disorder
The communication between osteoblasts and osteoclasts is essential for the fine regulation of bone remodeling in the process of maintaining bone homeostasis (9). During this process, osteoclasts attach to the old bone and dissolve minerals and digest bone matrix by releasing proteases and acidic products. Osteoblasts, on the other hand, guide the deposition of extracellular matrix and promote bone formation by secreting alkaline phosphatase, osteopontin and osteocalcin. An elevation in osteoclast activity or a reduction in osteoblast activity caused by any reason will disrupt the balance and lead to the occurrence of osteoporosis. Iron, an important trace element in the human body, plays a vital role in the regulation of bone homeostasis. Whether iron overload or deficiency, it will affect the differentiation and activity of osteoclasts and osteoblasts, thereby disrupting the bone homeostasis and accelerating bone loss. For instance, iron deficiency can directly or indirectly regulate the activity and function of osteoblasts and osteoclasts by inducing hypoxia and disorder of vitamin D metabolism, ultimately destructing bone homeostasis (10). Furthermore, extremely low levels of iron concentration inhibit the activity of osteoblasts, affect their functions, and subsequently lead to osteoporosis (11). When the iron concentration is excessive, osteoblasts are inibited, while osteoclasts maintain mitochondrial function through excessive iron to complete the process of bone resorption, thereby disrupting bone homeostasis (12).
Abnormal iron metabolism resulting in iron overload is a key feature of ferroptosis. This surplus of free iron ions produces an overabundance of reactive oxygen species (ROS) through the Fenton reaction and enhances the activity of lipoxygenase. Lipoxygenase can cause lipid peroxidation of unsaturated fatty acids in the cell membrane, thereby inhibiting cell activity (13, 14). Studies have shown that iron overload reduces the viability of mouse embryonic osteoblast precursor cells (MC3T3-E1) and induces cell apoptosis (15). And this leads to a proliferation defect and imbalance in osteogenic/adipogenic differentiation of bone marrow mesenchyml stem cell (BMSCs) (16). Iron overload also promotes oxidative stress, leading to trabecular bone damage and bone homeostasis imbalance, which in turn causes bone loss in mice (17). Furthermore, excessive iron can also increase the ratio of RANKL/osteoprotegerin (OPG) in bone cells, ultimately enhancing the differentiation and bone-resorbing function of osteoclasts, and inducing the occurrence of osteoporosis (18).
Mitochondria serve as crucial storage locations for iron ions in cells, and alterations in their ultrastructure are key features of ferroptosis. Additionally, disturbances in mitochondrial iron metabolism are strongly associated with ferroptosis (19). For example, irregular expression or dysfunction of mitochondrial ferritin may result in mitochondrial iron ion overload, thereby promoting lipid peroxidation and ferroptosis.
Moreover, during ferroptosis, the generation of ROS can exacerbate lipid peroxidation, thereby establishing a harmful cycle that facilitates the onset of ferroptosis (20). In conclusion, iron metabolism is closely related to the bone microenvironment, and ferroptosis may play an important role in the pathogenesis of osteoporosis.
2.1.2 Lipid peroxidation
Lipid peroxidation reactions exacerbate the process of ferroptosis. Free polyunsaturated fatty acids (PUFAs) serve as crucial substrates for lipid oxidation. Their binding to the phospholipid bilayer leads to excessive oxidation, which damages both the mitochondrial membrane and the cell membrane, subsequently triggering ferroptosis (21). Molecules such as lysophosphatidylcholine acyltransferase-3 (LPCAT3) and long-chain acyl-CoA synthetase 4 (ACSL4) also influence the lipid peroxidation process of membrane PUFAs and aggravating ferroptosis (22). By modulating signaling pathways, reducing the levels of ROS, and enhancing the activity of GPX4, the toxicity of lipid peroxides can be mitigated, thereby inhibiting osteoblast ferroptosis (23, 24). Therefore, preventing the buildup of lipid peroxides appears to be a promising approach for addressing ferroptosis.
2.1.3 Imbalance of the amino acid antioxidant system
The disruption of the amino acid antioxidant system plays a crucial role in ferroptosis. System Xc- functions as an anti-transporter that is extensively found within the phospholipid bilayer, serving as an essential component of the cellular antioxidant framework (25). It can transport extracellular cystine into the cell and serve as a raw material for cysteine production, further synthesizing glutathione (GSH) (26). GPX4 is an important component of the human antioxidant system. Under the action of GPX4, GSH maintains a dynamic equilibrium with oxidized glutathione (GSSH). As an auxiliary factor of GPX4, GSH can reduce the toxicity of lipid peroxides and protect the biological membrane system from damage caused by ferroptosis. Studies have shown that activating transcription factor 3 (ATF3) can mediate ferroptosis of osteoblasts in a high-glucose environment by inhibiting the activity of System Xc-, thereby inducing osteoporosis (27), and more studies have targeted GPX4 to inhibit ferroptosis, with the aim of treating osteoporosis (23, 24). Although GPX4 is the primary mechanism for inhibiting iron poisoning, studies have shown that cells deficient in GPX4 can still survive in the activated state of ferroptosis. Based on this observation, a previously unknown iron death suppressor protein 1 (FSP1) was discovered. Further research confirmed that FSP1 inhibits ferroptosis through NAD(P)H-dependent coenzyme Q10. The protective role of FSP1 is realized through its ability to catalyze the ongoing regeneration of CoQ10 and enhancing the capacity to capture free radicals, thereby inhibiting ferroptosis. Notably, FSP1 demonstrates a protective effect against ferroptosis that is triggered by the deficiency of GPX4 (28, 29).
2.2 Bone-related cells and ferroptosis
2.2.1 Osteoblasts and ferroptosis
Osteoblasts are pivotal cells in bone tissue formation, originating from BMSCs. They not only synthesize and secrete the organic components of the bone matrix but also release matrix vesicles, participating in matrix mineralization. In terms of bone physiology, iron deficiency was previously thought to adversely affect bone homeostasis (30). However, studies indicate that low levels of iron exhibit a biphasic influence on osteoblasts; mild deficiency in iron enhances the activity of osteoblasts, while a severe deficiency hampers their activity (11). Moreover, increased iron levels due to ferroptosis have also been reported as one of the factors inhibiting bone formation.
Studies demonstrate that iron overload inhibits bone formation and promotes osteoporosis. The mechanism involves iron overload suppressing the expression of bone formation-related transcription factors, including runt-related transcription factor 2 (RunX2), osteocalcin (OCN), and alkaline phosphatase (ALP), which subsequently reduces SLC7A11/GPX4 levels and ultimately induces ferroptosis (31). Furthermore, iron overload reduces superoxide dismutase (SOD), GSH, and mitochondrial adenosine dinucleotide (MAD) levels, increases ROS production, exacerbates lipid peroxidation, and promotes osteoblast ferroptosis, thereby impairing osteoblast function. Additionally, iron overload induces mitochondrial ultrastructural alterations in MC3T3-E1 cells, including generalized mitochondrial enucleation, increased mitochondrial membrane density, and reduced cristae number, with some cases showing complete disappearance (32). Recent studies have reported that DNMT abnormalities induce epigenetic suppression of GPX4, which subsequently triggers osteoblast ferroptosis, which is a key mechanism underlying osteoporosis (33). Furthermore, activation of the AMPK/ULK1 signaling pathway promotes selective ferroptosis of ferritin, leading to free iron release and lipid peroxidation accumulation, ultimately causing osteoblast ferroptosis (34). In summary, osteoblast ferroptosis may be one of the mechanisms that affect bone formation and osteoporosis (Figure 1).
Figure 1. The effect of ferroptosis on bone-related cells. Osteoblasts originate from BMSCs. Iron overload exacerbates lipid peroxidation by modulating the RUNX2/ALP/OCN axis or affecting ferroptosis-related proteins, ultimately inducing osteoblast ferroptosis. AMPK/UKL1 promotes osteoblast ferroptosis by affecting free iron levels, while DNMT1/3a/3b inhibits GPX4 expression. Activating ATF3/TFR1 to suppress SLC7A11, or inhibiting HO-1 via NRF2-c-JUN interaction, can exacerbate lipid peroxidation and promote osteocytotoxic ferroptosis. The reduced binding of PSMD14-SLC7A11 inhibits cystine expression, inducing osteoclast ferroptosis and promoting osteoporosis. Osteoclasts derive from the HSCs. RANKL induces osteoclast ferroptosis via the iron starvation response mechanism, thereby inhibiting osteoporosis. Inhibition of MZF1 by promoting the Nrf2/GPX4 axis can suppress osteoclast ferroptosis and promote osteoporosis.
2.2.2 Osteoclasts and ferroptosis
Osteoclasts, derived from the monocyte–macrophage lineage within the hematopoietic stem cells (HSCs), play a vital role in the process of bone resorption in the human body. Osteoclasts primarily acquire iron through transferrin receptor 1 (TFR1)-mediated iron uptake, a mechanism that facilitates osteoclast differentiation and bone resorption (35). The results showed that RANKL induced osteoclast ferroptosis under normal oxygen condition, and the key mechanism was iron starvation response, which was manifested as decreased ferritin heavy chain (FTH), ferroportin (FPN) and increased TFR1. This process led to the increase of free iron ion concentration, which promoted lipid peroxidation and finally induced osteoclast ferroptosis (36). The downregulation of myeloid zinc finger 1 (MZF1) expression, which activates the Nrf2/GPX4 pathway and inhibits rankl-induced ferroptosis in osteoclasts during early cell differentiation, may be a key mechanism underlying ovarian removal (OVX) mice models of postmenopausal osteoporosis (37). Recent studies have reported that the natural diphenylstilbene compound Gnetol (GT) can effectively induce osteoclast ferroptosis via the TNFAIP3-SLC7A11 axis, providing a novel therapeutic approach for osteoporosis (38) (Figure 1).
2.2.3 Osteocytes and ferroptosis
Osteocytes, which are the predominant cell type in bone tissue, have the ability to detect mechanical stress and manage both the formation and breakdown of bone. Consequently, they are regarded as the main regulators of bone activity. Recent research has progressively acknowledged the essential function of osteocytes in the processes of bone remodeling and maintaining homeostasis (39). The study revealed that high expression of ATF3 in senescent osteocytes promotes iron uptake by upregulating TFR1, while simultaneously inhibiting cystine uptake mediated by SLC7A11. This leads to iron overload and lipid peroxidation, ultimately resulting in ferroptosis (40). Furthermore, glucocorticoids directly inhibit the binding of the deubiquitinating enzyme PSMD14 to SLC7A11, thereby promoting the ubiquitination and subsequent proteasomal degradation of SLC7A11. This significantly reduces cystine uptake, leading to osteoclast apoptosis and ultimately accelerating the development of osteoporosis (41). Furthermore, studies on diabetic osteoporosis (DOP) mouse models demonstrate that heme oxygenase-1 (HO-1) is significantly upregulated in ferroptotic osteocytes. HO-1’s expression is regulated by the interaction between its promoter activity and the upstream transcription factors NRF2 and c-JUN, which plays a pivotal role in DOP-induced ferroptosis of osteocytes (42). Therefore, osteocyte ferroptosis may accelerate the process of osteoporosis by interfering with the balance of bone formation and bone resorption (Figure 1).
2.3 The signaling pathway mechanisms of ferroptosis in regulating bone metabolism
Ferroptosis significantly impacts the metabolic balance of bone through various mechanisms and signaling pathways, thereby contributing to the promotion of osteoporosis. The primary mechanisms and pathways involved are as follows.
2.3.1 Antioxidant stress pathway
The Nrf2/HO-1 signaling pathway plays a vital role in regulating iron balance and demonstrates effects that are anti-resorptive to bone, as well as protective against oxidative stress, inflammation, and apoptosis. By activating the Nrf2/HO-1 pathway, the levels of ROS are reduced, while the levels of solute carrier family 7 member 11 (SLC7A11) are increased, enhancing GPX4 activity. This cascade ultimately mitigates the toxicity of lipid peroxides and inhibits ferroptosis in osteoblasts (23, 24). Additionally, a study has shown that dexamethasone (DEX) induces glucocorticoid-induced osteonecrosis and MC3T3-E1 cells ferroptosis by regulating P53/SLC7A11/GPX4 axis (43), indicating that this pathway may be a potential strategy for treating osteoporosis. Moreover, the ASK1- p38 signaling pathway plays a crucial role in regulating the survival, differentiation, and function of osteoblasts under the influence of stress signals (44).
2.3.2 Iron homeostasis regulatory pathway
The iron regulatory pathway is crucial for the induction of osteoporosis through ferroptosis. The research indicates that the absence of NOL1/NOP2/Sun domain family, member 5 (NSUN5) leads to a reduction in the levels of 5-methylcytosine in ferritin heavy chain 1(FTH1)/ferritin light chain (FTL) RNA, which results in increased iron concentration in BMSCs, downregulation of GPX4, and accumulation of ROS and lipid peroxidation products (45). Therefore, modulating the NSUN5-FTH1/FTL pathway presents a potential strategy to inhibit ferroptosis and enhance the survival rate of BMSCs (45).
2.3.3 Cellular metabolism and survival regulation pathways
The PI3K/AKT/mTOR pathway, as a classic pro-survival pathway, is involved in the maintenance of bone homeostasis. Studies have found that high-dose DEX induces ferroptosis in BMSCs through the PI3K/AKT/mTOR signaling pathway (46). Melatonin notably reduces glucocorticoid-triggered ferroptosis in BMSCs and prevents ferroptosis through the stimulation of the PI3K/AKT/mTOR signaling pathway, thereby preventing the onset of steroid-induced osteoporosis (SIOP) (43).
2.3.4 Bone remodeling balance regulatory pathway
The RANKL/OPG pathway serves a crucial regulatory role in the differentiation and activation of osteoclasts, with its ratio being a significant determinant of bone integrity and mass (47). Elevated iron levels lead to an increased RANKL/OPG ratio, which enhances osteoclast differentiation and bone resorption (48). Conversely, effectively reducing the RANKL/OPG ratio, increasing the expression of GPX4, and inhibiting the ferroptosis pathway can thereby treat osteoporosis (49, 50).
In conclusion, bone metabolism is affected by ferroptosis via multiple pathways, playing a role in the progression of osteoporosis. Targeting these signaling pathways presents potential strategies for the treatment of osteoporosis. Future research should further elucidate the interactions among different pathways and investigate drug delivery systems that can specifically modulate ferroptosis (Figure 2).
Figure 2. The signaling pathway mechanisms of ferroptosis in regulating bone metabolism. Key signaling pathways regulating ferroptosis in bone cells and their significant roles in bone homeostasis. The Nrf2/HO-1 pathway effectively inhibits osteoblast ferroptosis by reducing ROS, upregulating SLC7A11 gene expression, and enhancing GPX4 activity. The P53/SLC7A11/GPX4 and ASK1-P38 pathways suppress ferroptosis by inhibiting ROS. NSUN5 gene deletion induces abnormal iron storage through reduced FTH1/FTL RNA methylation, leading to iron overload and ferroptosis that disrupt iron homeostasis. Meanwhile, the PI3K/AKT/mTOR pathway promotes cell survival and regulates lipid peroxidation to inhibit BMSCs ferroptosis. Additionally, the RANKL/OPG pathway induces osteoclast differentiation while blocking osteoblast ferroptosis through GPX4 expression suppression.
2.3.5 Emerging regulatory factors and interaction networks
In recent years, research into the mechanisms of ferroptosis across various fields has led to the discovery of numerous new targets and pathways that have garnered significant attention. Sirtuin 1 (SIRT1) plays a critical regulatory role in ferroptosis. The downregulation of SIRT1 diminishes the inhibitory effect of vitamin K-2 (VK2) on ferroptosis in BMSCs exposed to high glucose, consequently contributing to bone loss (51). Recent research indicates that ELAV-like RNA binding protein 1 (ELAVL1) inhibits the translation of SIRT1, disrupts osteoblast differentiation mediated by ferroptosis, and thereby impedes the progression of osteoporosis (52). Furthermore, some studies have proposed a novel mechanism involving the NRF2-iron-ornithine metabolic axis in osteoclasts. In this study, the glycine uptake inhibitor bitopertin was employed to diminish the binding of kelch-like ECH-associated protein 1(Keap1)-Nrf2, resulting in a reduction of Nrf2 protein degradation. Nrf2 transcriptionally activates the gene encoding the iron transporter Slc40a1, thereby decreasing the iron content within osteoclasts. Additionally, the lack of Nrf2 or the addition of iron leads to an increase in the activity of the ornithine metabolism enzyme Odc1, which subsequently reduces ornithine levels and accelerates osteoclast differentiation (53). However, it is important to note that this study was conducted solely in mice, and no clinical trials have been performed to assess its feasibility and safety in humans. Further investigations have revealed that ferroptosis represents a significant mode of bone cell death in cortical bone during the aging process. Moreover, single-cell transcriptome analysis has determined that the ATF3 is a key driver of bone cell ferroptosis. The elevated level of ATF3 in aging bone cells promotes iron absorption through the upregulation of TFR1, while concurrently suppressing cystine uptake facilitated by SLC7A11. The described process causes an accumulation of iron and increases lipid peroxidation, which eventually results in ferroptosis and worsens the reduction of cortical bone mass (40). The results from this research offer encouraging approaches for both the prevention and management of osteoporosis and fractures.
2.4 The relationship between ferroptosis and different clinical subtypes of osteoporosis
The clinical subtypes of osteoporosis primarily include postmenopausal osteoporosis, diabetic osteoporosis, glucocorticoid-induced osteoporosis, and thalassemia-related osteoporosis. Although the core driving factors of these various types of osteoporosis differ, existing studies indicate aclose relationship with ferroptosis. However, the triggers that initiate ferroptosis, along with the associated mechanisms and cellular targets, exhibit distinct characteristics (54, 55) (Table 1). Furthermore, we have found that diabetes-induced osteoporosis, post-menopausal osteoporosis, and senile osteoporosis are associated with certain endocrine levels. This indicates that they may have different treatment strategies. For instance, estrogen replacement therapy is used to treat post-menopausal osteoporosis (56, 57). Regulating insulin signaling in osteoblasts promotes the activity of osteocalcin in patients with diabetic osteoporosis (58), and supplementing vitamin D and using parathyroid hormone analogs can treat senile osteoporosis (59). However, at present, there is still a lack of direct evidence to prove that regulating the endocrine level can treat osteoporosis by correcting ferroptosis.
Table 1. Ferroptosis and different types of osteoporosis.
3 Targeting ferroptosis anti-osteoporosis drugs
The primary features of ferroptosis include an excess of iron and the buildup of ROS, with lipid peroxidation being its key mechanism (60). Therefore, inhibiting lipid peroxidation, regulating iron metabolism, and counteracting oxidative stress are crucial strategies for treating ferroptosis and osteoporosis. The primary features of ferroptosis include an excess of iron and the buildup of reactive oxygen species, with lipid peroxidation serving as its essential mechanism.
3.1 Regulation of iron metabolism
Iron chelators demonstrate significant clinical efficacy in patients with osteoporosis resulting from iron overload, primarily by reducing intracellular free iron levels. Currently, the iron chelators commonly utilized in clinical practice include deferoxamine, deferiprone, and deferasirox (61). Desferrioxamine methylsulfonate has been demonstrated to effectively increase bone density in postmenopausal patients with osteoporosis (62). This compound not only positively influences the maturation and function of osteoblasts (12), but also reduces the generation of osteoclasts and inhibits the enzymatic activity of mitochondrial complexes along with the expression of their subunits (63, 64). As a bone-forming angiogenic agent, desferroxamine enhances vascularization at the metaphysis and promotes osteoblast activity, thereby preventing and treating bone loss in estrogen-deficient mice (65). Furthermore, desferrioxamine exhibits a protective effect against osteogenesis inhibition induced by iron overload in zebrafish models, restoring mineralization ability by inhibiting ferroptosis (66). Similarly, deferiprone reduces iron ion concentration in osteoblasts, increases the activity of ALP and demonstrates a stronger effect than deferoxamine (67). Interestingly, other research suggests that deferoxamine can prevent ferroptosis and maintain osteoblast differentiation, irrespective of iron overload clearance (68). Deferasirox is widely utilized for the management of chronic iron overload resulting from frequent blood transfusions in pediatric patients with β-thalassemia. Furthermore, in adult patients with transfusion-dependent β-thalassemia who receiving dilazep therapy, the incidence of osteoporosis was markedly diminished (69, 70). Thalassemia patients receiving long-term deferasirox treatment, regardless of their use of bisphosphonate therapy, hormone replacement therapy, or supplements of calcium and vitamin D, observed a noteworthy rise in average lumbar spine bone mineral density (71). Additionally, there was a significant decrease in the number of patients identified with lumbar spine osteoporosis (71). Deferasirox showed therapeutic effects in reducing bone loss in postmenopausal mice with iron accumulation. The mechanism might be through lowering serum ferritin levels, reducing iron overload, inhibiting ferroptosis, thereby increasing bone trabeculae and enhancing bone density (72). In vitro investigations have validated that deferasirox can inhibit abnormal bone metabolism induced by iron overload, with its mechanism potentially linked to the suppression of NF-κB pathway activity, thereby impeding the differentiation of mouse monocyte RAW264.7 cells into osteoclasts (73).
In conclusion, regulating iron metabolism is a crucial approach to inhibiting ferroptosis. Commonly used iron chelating agents in clinical practice may treat osteoporosis by reducing iron overload and inhibiting ferroptosis, presenting a potential strategy for managing this disease.
3.2 Antioxidant stress and inhibition of lipid peroxidation
Vitamins are natural antioxidants. For instance, nutrients such as vitamin D, vitamin K, and calcium play an important role in the maintenance of healthy bones. Vitamins may prevent and treat osteoporosis by mechanisms such as antioxidative stress and inhibition of lipid peroxidation, thereby blocking ferroptosis (Table 2).
Table 2. Vitamin-regulated ferroptosis in the treatment of osteoporosis.
Furthermore, there are some drugs that can treat osteoporosis-related ferroptosis by inhibiting lipid peroxidation and oxidative stress, among other mechanisms. Melatonin, for example, has been demonstrated to prevent osteoblast ferroptosis through the activation of the Nrf2/HO-1 signaling pathway, thereby enhancing bone microstructure in both in vivo and in vitro studies (23). Zoledronic acid induces osteoclast ferroptosis by triggering the ubiquitination degradation of p53 mediated by F-box protein 9, thereby improving osteoporosis. This is accompanied by an increase in Fe2+, ROS and MDA levels, as well as a decrease in GPX4 and GSH levels (74). Interestingly, current research indicates that hypoglycemic drugs also have the potential to treat osteoporosis (75). Experiments in vitro demonstrated that metformin inhibits osteoblast ferroptosis induced by high glucose and palmitic acid, significantly enhances the expression of ferroptosis protective proteins (GPX4, FTH1, SLC7A11), and reduces lipid peroxidation products and iron ion levels. In vivo studies also suggest that metformin can alleviate bone loss and microstructural deterioration in DOP rats. The mechanism is related to activating the AMPK/Nrf2 pathway, enhancing antioxidant capacity, and inhibiting iron death-related processes (76). Furthermore, rosiglitazone exerts protective effects on the cartilage of mice with osteoarthritis by inhibiting lipid peroxidation and restoring iron homeostasis, and it also shows anti-ferroptosis effects. However, there is still a lack of large-scale clinical studies to support this (77). Rosiglitazone, by inhibiting lipid peroxidation and restoring iron homeostasis, exerts a protective effect on the cartilage of osteoarthritis mice and demonstrates anti-ferroptosis effects (77), indicating that rosiglitazone may treat osteoporosis and other bone joint diseases through this mechanism.
3.3 Traditional Chinese medicine (TCM) compound and monomer components
3.3.1 TCM compound prescriptions and single herbs
Numerous individual Chinese herbal medicines and herbal formulas have demonstrated efficacy in the prevention and treatment of osteoporosis, potentially through the inhibition of ferroptosis. Studies indicate that Fructus Ligustri Lucidi significantly inhibits ferroptosis in postmenopausal osteoporotic rats, thereby safeguarding their osteogenic capacity, an effect linked to the activation of the Nrf2/HO-1 signaling pathway (78). Furthermore, Qing e Pill (QEP) mitigates osteoblast apoptosis in primary osteoporosis via the ATM serine/threonine kinase (ATM) and PI3K/AKT pathways, thereby exerting its therapeutic effects on osteoporosis (79). The Eucommia-Dipsacus herb pair enhances serum estradiol levels, as well as GPX4 and FTH1 protein levels in ovariectomized osteoporotic rats, inhibits femoral ferroptosis, and consequently increases femoral bone mineral density, alleviating osteoporosis (80). The latest research also reports that psoraleae fructus combined with walnut kernels improves postmenopausal osteoporosis by inhibiting ferroptosis through the Nrf2/GPX4/SLC7A11 pathway (81). Additionally, Er-Xian decoction inhibits ferroptosis and alleviates osteoporosis caused by ovariectomy by regulating fatty acid metabolism and the IGF1/PI3K/AKT signaling pathway (82). Additionally, Bugushengsui formula regulates oxidative stress and iron accumulation in osteoporosis model rats following bilateral ovariectomy, potentially exerting anti-osteoporotic effects via the cellular ferroptosis pathway (83).
3.3.2 Monomeric components of TCM
The active components of certain traditional Chinese medicines can inhibit ferroptosis through multiple targets and pathways, thereby preventing and treating osteoporosis (Table 3). Mangiferin (C19H18O11) is a flavonoid glucoside commonly isolated from mangoes and is also found in medicinal plants such as anemarrhena asphodeloides, belamcanda chinensis, and gentiana scabra (84–86). Studies have demonstrated that mangiferin promotes bone formation and inhibits ferroptosis in both in vivo models (osteoporotic mice, iron-overloaded mice) and in vitro models (osteoblast ferroptosis, iron-overloaded osteoblasts) (87). The underlying mechanism involves mangiferin’s direct binding to Keap1 and the subsequent activation of the downstream Nrf2/SLC7A11/GPX4 pathway (87). Asperosaponin VI (AVI), a triterpenoid saponin extracted from dipsacus asper, has the molecular formula C47H76O18. Research indicates that AVI effectively reverses hypermethylation by inhibiting DNMT1/3a, restores GPX4 expression, and mitigates ferroptosis pathology associated with DOP (88). Additionally, recent studies have reported that gstrodin and ginsenoside can improve neurological dysfunction and myocardial ischemia by inhibiting ferroptosis-related pathways (89, 90), suggesting that they may also exert therapeutic effects on osteoporosis through this mechanism, providing a potential therapeutic approach.
Table 3. Monomer components of TCM regulating ferroptosis for osteoporosis treatment.
3.4 Other natural active ingredients
Many natural active substances have a positive effect on the treatment of osteoporosis. The natural compound, named poliumoside, can inhibit the bone degradation and ferroptosis caused by high glucose and high fat (HGHF). The mechanism is to promote the GSH levels and reduce MDA, lipid peroxidation, and mitochondrial reactive oxygen ROS (91). The natural active component, arecoline, can alleviate the inhibitory effect of ferroptosis on the osteogenic process of fish larvae, manifested by increased bone mineralization and upregulation of osteogenic genes. Moreover, it is indicated that heme oxygenase-1 (HO-1) is the key mediator for its inhibition of ferroptosis and promotion of osteogenesis (92). Gnetol l (GT) is a naturally occurring divinyl compound. In the treatment of osteoporosis, it inhibits the differentiation and activity of osteoclasts by promoting lipid peroxidation, depleting intracellular GSH (38). Silymarin is a flavonoid compound extracted from the seeds of milk thistle, and it exhibits significant antioxidant properties. Silymarin has been proven to enhance the expression of RUNX2 and SIRT1, inhibit ferroptosis of osteoblasts, thereby promoting the activity and differentiation of osteoblasts. Moreover, in animal models of osteoporosis, it was found that silymarin can improve bone loss by inhibiting iron depletion (93). Equally important, there are also some natural active ingredients, for instance, geniposide extracted from gardenia flowers, which has demonstrated the effect of inhibiting ferroptosis in other diseases (94), and at the same time can regulate osteoblast apoptosis through the Nrf2/ NF-kB pathway, preventing and treating osteoporosis. This also provides new ideas and strategies for the possible treatment of osteoporosis by geniposide through inhibiting the ferroptosis pathway (95). Furthermore, PAC, which is widely present in plants such as grapes and sea buckthorn, has recently been recognized as having certain potential for treating osteoporosis. Studies have shown that PAC has certain potential in alleviating osteoporosis through the SIRT6/Nrf2/GPX4 pathway. Its manifestation is to improve the structure of bone trabeculae and enhance the expression of key osteogenic proteins (96). In conclusion, natural active substances have the advantages of multi-target and easy acceptance in the treatment of osteoporosis, but also have the disadvantages of complex composition and difficult quality control. There is still a long way to go to use natural active substances to treat human osteoporosis.
3.5 Hormones and novel regulatory factors
The suppression of interferon regulatory factor 9 (IRF9) enhances the differentiation of osteoclasts, consequently hindering ferroptosis and potentially offering a new avenue for the treatment of osteoporosis (97). Melatonin prevents ferroptosis in osteoblasts through the activation of the Nrf2/HO-1 signaling pathway, which subsequently enhances bone microstructure both in vivo and in vitro (23). Moreover, it significantly alleviates glucocorticoid-induced ferroptosis of BMSCs and prevents the occurrence of SIOP by inhibiting ferroptosis through activation of the PI3K/AKT/mTOR signaling pathway (46). The latest research reports that melatonin is a powerful endogenous antioxidant. It can alleviate oxidative stress caused by sodium sulfite (a food additive), inhibit ferroptosis, restore the function of osteoblasts, and reduce bone loss in mice. This study suggests that melatonin is a promising therapeutic agent that can be used for the prevention and treatment of this condition (98). Interestingly, there are also some studies that have focused on the impact of ferroptosis on endothelial cells in osteoporosis. For instance, a recent report indicates that Eldecalcitol (1alpha,25-dihydroxy-2beta-(3-hydroxypropoxy) vitamin D3) may treat osteoporosis by alleviating ferroptosis in endothelial cells. This also provides a new perspective for treating osteoporosis through the ferroptosis pathway (99).
3.6 Advanced delivery systems targeting ferroptotic hubs
Although the research on natural ingredients combined with advanced delivery systems is limited, it is still an innovation and a future research direction. Some studies have synthesized iron-suppressing nanoparticles capable of delivering the natural compound curcumin to the bone marrow using tetrahedral framework nucleic acids (tFNA). Experiments conducted both in vitro and in vivo have demonstrated that nanoparticles can hinder ferroptosis and enhance the osteogenic differentiation of BMSCs by diminishing the overproduction of ROS, decreasing the levels of Fe2+, and stimulating the KEAP1/NRF2 pathway, which in turn boosts the expression of GPX4 within the diabetic microenvironment (100). Another study integrated genetic engineering with bone-targeting peptide modification to develop an innovative exosome for bone-targeting engineering. The team synthesized F6-(DSS)6-exo, which effectively delivered curcumin to target specific sites. By inhibiting ferroptosis and ROS, this approach restored the osteogenic differentiation potential of BMSCs and alleviated bone loss in smoking-related osteoporosis (SROP) mouse models (117).
Although few studies have demonstrated the molecular mechanism that directly regulates the relationship between ferroptosis and osteoporosis through the ferroptosis pathway. But in the latest research, it seems that we have seen relatively clear results. The study combines natural derivatives with advanced delivery systems and reports an injectable natural tremella-derived hydrogel that is used to reverse the microenvironment imbalance of osteoporosis mediated by ferroptosis and promote bone regeneration. It also directly confirms that regulating the ferroptosis pathway (improving the endogenous iron metabolism and anti-lipid peroxidation metabolism of osteoblasts) can protect the mitochondrial structure of osteoblasts damaged by ferroptosis (101).
In conclusion, although current research integrating natural active ingredients with advanced delivery systems remains limited, but the natural component delivery system presents a novel approach for treating osteoporosis by precisely modulating the ferroptosis pathway. Future efforts should prioritizeclinical translation and the integration of interdisciplinary technologies to tackle challenges such as delivery efficiency, safety, and individualized treatment, ultimately facilitating the transition from laboratory research toclinical practice.
4 Conclusion and outlook
This article reviews the molecular mechanisms of ferroptosis-induced osteoporosis, summarizes the signaling pathways through which ferroptosis affects bone metabolism, and focuses on the three-dimensional regulatory network of iron metabolism disorder, lipid peroxidation and bone homeostasis imbalance. What is more innovative is that from the perspectives of natural product chemistry and molecular pharmacology, we evaluated the potential of natural active ingredients, traditional Chinese medicines and their corresponding targets to inhibit ferroptosis, and also envisioned their combination with advanced delivery systems, highlighting their potential in developing new therapeutic strategies.
However, there remains significant scope for exploration and several issues that require attention in the research on ferroptosis and bone metabolism: currently, research on the regulatory role of ferroptosis in osteoporosis predominantly focuses on two mechanisms: iron overload and lipid peroxidation. We propose the development of next-generation iron chelators specifically targeting bone or the regulation of the hepcidin pathway to mitigate iron overload, thereby alleviating osteoporosis associated with ferroptosis and providing novel strategies for treating iron metabolism-related diseases. Furthermore, as new pathways of ferroptosis are continuously being discovered, the potential for other regulatory mechanisms and triggering factors urgently warrants further exploration.
Research on ferroptosis in senile osteoporosis is limited. Given the aging population, it is essential to establish a scientific animal model to elucidate the relationship between ferroptosis and primary osteoporosis, distinguishing it from other osteoporosis types. Furthermore, the heterogeneity of the disease is a critical factor that warrants consideration. Osteoporosis, a prevalent bone disease, not only encompasses multiple types but also exhibits significant variability in pathogenesis among patients within the same type. This variability suggests that the role of ferroptosis in osteoporosis may differ among individuals, necessitating the development of personalized treatment strategies tailored to each patient’s specific condition. Such personalized approaches can better address patient needs and enhance treatment efficacy.
A notable focus in current research is the precise targeting of key molecules, including GPX4, System Xc-, and FSP1. Treatment strategies encompass gene therapy, the development of small molecule activators or mimics, and methods to enhance cysteine uptake. However, challenges remain in addressing issues related to targeting, safety, and delivery efficiency. For instance, ferroptosis, an emerging form of cell death, is influenced by the systemic regulation of related genes, such as GPX4, which can affect multiple organ systems, particularly vital organs like the liver and heart. These organs exhibit high sensitivity to ferroptosis, and systemic regulation may lead to functional disorders. Therefore, when conducting ferroptosis-related gene therapy, it is crucial to consider the systemic effects and implement corresponding measures to protect these key organs, presenting a significant challenge for the clinical applicability of this approach.
Research is currently underway to prevent and treat osteoporosis utilizing natural active components through the ferroptosis mechanism. These natural active components can inhibit ferroptosis via multiple targets and pathways, thereby offering promising strategies for osteoporosis prevention and treatment. While some positive outcomes have been observed in cell and animal studies, substantial barriers remain before these results can be implemented in clinical settings. First, at the current stage, the relevant clinical studies are mostly divided into two categories: correlation studies and retrospective studies. The former reported that there were differences in the levels of ferroptosis-related indicators between non-osteoporotic subjects and osteoporotic patients (102, 103). The latter indicates that traditional Chinese medicine has also been applied in clinical research. For instance, a retrospective study suggests that Eucommia ulmoides may treat osteoporosis by regulating ferroptosis-related indicators (104). However, the above-mentioned clinical studies have limitations such as small sample size, single research center, and single clinical type of osteoporosis, which lack persuasiveness. That is to say, although conclusive evidence from human clinical or epidemiological studies is still being accumulated, the content related to ferroptosis has not yet become a routine standard for clinical diagnosis. Currently, there is almost no evidence suggesting a direct association between ferroptosis and human osteoporosis. Second, regarding the detection value and reliability of iron death-related targets in the transition from animal models to human clinical applications, we still need to conduct an analysis with caution and optimism. In the relevant clinical studies, most of the indicators measured in human blood are taken, but there is a drawback of low specificity, making it difficult to prove that the changes in these indicators are derived from iron death in the bones. And the key proteins discovered from animal models, such as GPX4, SLC7A11, ACSL4, etc., are extremely difficult and unethical to obtain from healthy human bodies, especially in early bone tissue samples of osteoporosis.
Furthermore, the assessment indicators for osteoporosis in animals and in vitro studies are diverse. How these indicators can be effectively linked to the clinical observation parameters of human osteoporosis is one of the key points for achieving clinical translation. Currently, the main assessment indicators for human osteoporosis are based on DXA measurements of bone density values. While the assessment indicators or methods in animal models, such as Micro-CT, directly simulate the degeneration of bone structure in human osteoporosis, and the Micro-CT indicators are highly correlated with the bone mineral density measured by DXA, also indicating the risk of fractures. Additionally, bone turnover biochemical markers (BTMs) reflect the overall rate of bone turnover and correspond to clinical-detected BTMs, which are of great significance for non-invasive detection of disease status and therapeutic efficacy. The evaluation indicators in in vitro studies focus on the functions of osteoblasts and osteoclasts, allowing us to better understand the pathological mechanism of osteoporosis and providing a mechanistic perspective for understanding the imbalance in bone turnover.
To translate basic research findings into effective clinical treatments, it is imperative to conduct multi-center, large-sample, high-quality prospective clinical studies to verify the safety and efficacy of these therapeutic strategies. Concurrently, there is a need for the development of more precise detection methods to accurately assess patients’ conditions in clinical practice and to monitor and follow up on treatment effects. Moreover, challenges related to the stability, bioavailability, and complexity of the action mechanisms of these active components significantly hinder their clinical application and warrant further investigation.
In summary, future research will focus on several key areas: First, we will actively explore and identify new therapeutic targets to provide more effective intervention strategies for disease treatment. Second, we will carefully formulate and optimize combination treatment strategies that leverage the synergy of multiple therapeutic methods to enhance their efficacy. Third, we aim to achieve significant breakthroughs in interdisciplinary technologies by integrating advanced methodologies from various fields, including biology, medicine, and information science, which will offer robust technical support for disease research and treatment. Finally, we will vigorously promote translational clinical research to accelerate the conversion of fundamental research findings into clinical applications, ensuring that these results are swiftly translated into actual diagnostic and therapeutic practices to benefit patients.
Author contributions
YZ: Conceptualization, Funding acquisition, Writing – original draft. XW: Investigation, Writing – original draft. XP: Writing – review & editing, Visualization. HH: Visualization, Writing – review & editing. ZH: Writing – review & editing, Investigation. LX: Writing – review & editing, Conceptualization, Funding acquisition.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This review was funded by the Health and Medical Science Research Project of Hunan Province (20256759 and 20254881), Research Project on Traditional Chinese Medicine in Changsha City (B202301), and Research Project of Changsha Municipal Health Commission (KJ-B2023078).
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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The author(s) declared that Generative AI was not used in the creation of this manuscript.
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Keywords: ferroptosis, lipid peroxidation, natural active ingredients, osteoporosis, traditional Chinese medicine
Citation: Zhu Y, Wu X, Peng X, He H, Hu Z and Xiao L (2026) The role of ferroptosis in osteoporosis: from pathogenic mechanisms to natural product-driven therapeutic innovations. Front. Med. 12:1713327. doi: 10.3389/fmed.2025.1713327
Edited by:
Jianjing Lin, Peking University, ChinaReviewed by:
Wei Wei, Harbin Medical University, ChinaJian Zhang, Guizhou University of Traditional Chinese Medicine, China
Copyright © 2026 Zhu, Wu, Peng, He, Hu and Xiao. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Liangyi Xiao, OTAwMzE0dmVuaW5AMTYzLmNvbQ==