Purpose: To explore the pathogenetic mechanisms that suppress the osteoblast function in multiple myeloma because osteogenesis results in defective new bone formation and repair. Experimental Design: Microarray gene analysis revealed the overexpression of E4BP4, a transcriptional repressor gene, in normal osteoblasts cocultured with myeloma cells that were releasing the parathyroid hormone-related protein (PTHrP). Thus, the effect of E4BP4 was assessed in PTHrP-stimulated osteoblasts by measuring the RNA levels of both Runx2 and Osterix as major osteoblast transcriptional activators. Because E4BP4 is a negative regulator of the cyclooxygenase-2 (COX-2) pathway that drives the expression of both Runx2 and Osterix, these factors were investigated after prostaglandin E 2 treatment to overcome the COX-2 defect as well as in E4BP4-silenced osteoblasts. Finally, E4BP4, PTHrP, Osterix, and osteocalcin levels were measured in vivo in patients with bone disease together with the E4BP4 protein in bone biopsies. Results: E4BP4 was specifically induced by PTHrP and inhibited both Runx2 and Osterix, whereas E4BP4-silenced osteoblasts expressed functional levels of both factors.The prostaglandin E 2 treatment of E4BP4-up-regulated osteoblasts promptly restored Runx2 and Osterix activities, suggesting that integrity of COX-2 pathway is essential for their transcription. Down-regulation of Osterix by E4BP4 was confirmed in vivo by its inverse levels in osteoblasts from myeloma patients with increased serum PTHrP, whose bone biopsies expressed the E4BP4 protein.Conclusions: Our data support the role of E4BP4 as osteoblast transcriptional repressor in inhibiting both Runx2 and Osterix in myeloma bone disease and correlate its effect with the increased PTHrP activity.Myeloma bone disease (MBD) is the hallmark of multiple myeloma. It is primarily associated with hyperactive osteoclastogenesis promoted by malignant plasma cells and the bone destruction is not accompanied by compensatory remodeling (1). Minimal bone formation occurs early within the initial bone erosions (2), whereas osteoblast activity is suppressed as the disease progresses and is reflected by low serum levels of osteogenic markers as osteocalcin, type I collagen, alkaline phosphatase, and osteoprotegerin (3). Different mechanisms concurrently lead to osteoblast suppression. The canonical Wnt signaling pathway, which regulates pre-osteoblast differentiation by mesenchymal stem cells, is deranged by inhibitors produced by myeloma cells. They mainly include dickkopf1, whose RNA levels correlate with both serum protein and skeletal involvement (4), and the soluble Frizzled related protein-2 (5). Serum levels of other osteoblast-inhibiting factors, as noggin, gremlin, interleukin (IL)-3, IL-7, IL-11, and insulin growth factor binding protein 4, are also enhanced in MBD (6, 7).Osteogenic differentiation from mesenchymal cells is critically regulated by Runx2/Cbfa1 (8), a transcription factor that, through the downstream inducer Osterix/Sp7 (9), promotes the exp...