Phosphodiesterase inhibitors as emerging therapeutics for skeletal disorders: A comprehensive review of mechanisms and repurposing potential

Skeletal disorders such as osteoporosis, osteoarthritis, and rheumatoid arthritis represent major global health burdens with limited therapeutic innovation. Inhibitors of phosphodiesterases (PDEs), enzymes that regulate the intracellular levels of the cyclic nucleotides cAMP and cGMP, are increasingly recognized as potential medications that can improve the health of bone and cartilage. Although they have been used in clinics for decades, their function in bone or cartilage remains unclear. In preclinical models, inhibitors that target PDE3 (e.g., cilostazol, milrinone), PDE4 (roflumilast, apremilast), and PDE5 (e.g., sildenafil, avanafil, vardenafil) exhibit promising anabolic, anticatabolic, and anti-inflammatory effects on skeletal tissues. Broad-spectrum inhibitors such as pentoxifylline and dipyridamole also demonstrate dual benefits in terms of bone regeneration and joint preservation. This review examines the mechanistic basis and therapeutic potential of clinically approved PDE inhibitors-originally developed for cardiovascular, neurological, and inflammatory conditions-for skeletal applications. Understanding the mechanism of action of PDE inhibitors can facilitate their translation into the clinic, help with their application in combined therapies, or minimize their potential adverse effects. This approach offers a cost-effective and viable path toward novel therapies for musculoskeletal health.