Abaloparatide Tolerability Compared to Teriparatide
Abaloparatide appears to be slightly less well-tolerated than teriparatide, with higher rates of hypercalcemia being less common with abaloparatide, but overall discontinuation rates due to adverse effects being somewhat higher.
Side Effect Profile
According to the 2020 AACE/ACE guidelines, both medications share similar mild and transient side effects including 1:
- Nausea
- Orthostatic hypotension (typically with first few doses, responds to recumbent posture)
- Leg cramps
- Dizziness
The key tolerability difference is hypercalcemia: it occurs less frequently with abaloparatide than with teriparatide 1. When hypercalcemia does occur with either agent, it is usually mild, asymptomatic, and transient. Blood should be drawn at least 16 hours after drug administration if measuring serum calcium.
Discontinuation Rates
However, research evidence suggests abaloparatide may have higher overall discontinuation rates:
A 2018 review found abaloparatide appears to have "a somewhat higher risk for adverse effects, discontinuation as a result of adverse effects, and serious or severe adverse effects than teriparatide" 2
A 2025 compliance study showed abaloparatide patients had significantly higher non-compliance rates (56.9% vs 31.0%, p=0.018) and shorter time to non-compliance (4.1 vs 8.8 months, p=0.027) compared to teriparatide 3
Side effects leading to abaloparatide discontinuation specifically include nausea, postural hypotension, dizziness, headache, and palpitations 4
Practical Considerations
Both agents carry identical black box warnings for osteosarcoma risk based on rat studies 1, though this has not materialized in human use with teriparatide since 2002 4.
The guideline notes that side effects with both agents "usually do not necessitate discontinuation of the drug" and occur primarily "in association with the first few doses" 1.
Clinical Bottom Line
While abaloparatide has the advantage of lower hypercalcemia risk, real-world compliance data suggests patients may find it harder to tolerate overall, with nearly twice the discontinuation rate of teriparatide. For patients particularly sensitive to gastrointestinal or cardiovascular side effects (nausea, palpitations, hypotension), teriparatide may be the better-tolerated choice despite its higher hypercalcemia risk. For patients with baseline elevated calcium or concerns about hypercalcemia, abaloparatide would be preferred.
Both require monitoring of serum calcium, PTH, 25(OH)D, and alkaline phosphatase before treatment 1.