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When intestinal microecology is disrupted, LPS enters blood circulation, activates the Toll-like receptor 4 (TLR4) signaling, and upregulates the expression of the NF-B pathway, which in turn promotes the differentiation and activity of osteoclasts, leading to severe bone loss and osteoporosis (62)

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It is a requirement straight from Eli Lilly, the manufacturer, and reinforced by the FDA prescribing information for both Mounjaro and Zepbound