What are the recommendations for managing a postmenopausal patient with Atherosclerotic Cardiovascular Disease (ASCVD) and decreasing Bone Mineral Density (BMD) who is taking teriparatide (Forteo) and/or bisphosphonates and needs to undergo neurosurgery?

From the Guidelines

For a postmenopausal patient with Atherosclerotic Cardiovascular Disease (ASCVD) and decreasing Bone Mineral Density (BMD) who is taking teriparatide and/or bisphosphonates and needs to undergo neurosurgery, it is recommended to continue bisphosphonate therapy through the perioperative period but temporarily discontinue teriparatide for 1-2 weeks before and after surgery. This approach is based on the understanding that bisphosphonates do not impair bone healing and may provide cardiovascular benefits in ASCVD patients, as suggested by the general principles of managing osteoporosis in patients at high risk of fracture 1.

Key Considerations

• Bisphosphonates have a long half-life in bone tissue, which supports their continued use during the perioperative period without significant interruption of their therapeutic effect.
• Teriparatide's effects on surgical healing in neurosurgery are not well established, making a temporary pause prudent to avoid any potential adverse effects on wound healing or bone repair.
• The patient's cardiovascular medications, including statins, antihypertensives, and antiplatelet therapy, should be continued with possible temporary adjustment of antiplatelet/anticoagulant medications as per the neurosurgeon's guidance to minimize the risk of perioperative cardiovascular events.
• Calcium and vitamin D supplementation should be maintained throughout the perioperative period to support bone health, with recommended daily intakes of 1000-1200 mg of calcium and 800-1000 IU of vitamin D.

Post-Surgery Management

Following surgery, teriparatide can be resumed after wound healing is well-established, typically 1-2 weeks post-operation. This strategy aims to balance the need to maintain bone health with the requirement for optimal surgical outcomes, recognizing the long-term benefits of teriparatide in managing osteoporosis in high-risk patients 1.

Evidence-Based Decision

The decision to continue bisphosphonates and temporarily discontinue teriparatide is guided by the principles outlined in the 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis, which emphasizes the importance of fracture risk assessment and tailored treatment strategies for patients at moderate to high risk of fracture 1. While this guideline primarily addresses glucocorticoid-induced osteoporosis, its recommendations on the use of bisphosphonates and teriparatide can be applied to the management of postmenopausal osteoporosis in the context of neurosurgery.

From the Research

Managing Postmenopausal Patients with ASCVD and Decreasing BMD Undergoing Neurosurgery

• The management of postmenopausal patients with Atherosclerotic Cardiovascular Disease (ASCVD) and decreasing Bone Mineral Density (BMD) who are taking teriparatide (Forteo) and/or bisphosphonates and need to undergo neurosurgery requires careful consideration of the patient's bone health and the potential impact of their medications on the surgical outcome 2.
• Teriparatide, a recombinant parathyroid hormone, has been shown to increase bone formation and improve bone microarchitecture in postmenopausal women with osteoporosis 3, 4.
• The use of teriparatide in the perioperative period has been studied, and it has been found to improve radiographic evidence of bony fusion and bone fusion rates in patients undergoing spinal surgery 2.
• Bisphosphonates, on the other hand, are antiresorptive agents that can help to maintain or increase BMD, but their use in the perioperative period may not have the same beneficial effect on bone fusion as teriparatide 2, 5.
• Vitamin D status has also been found to play a role in the response to bisphosphonates, with optimal serum 25(OH) vitamin D concentrations leading to further reduction in bone loss at the hip 5.

Recommendations for Neurosurgery

• Preoperative teriparatide treatment has been shown to increase the insertional torque of pedicle screws during fusion surgery in patients with postmenopausal osteoporosis, which may help to reduce the risk of screw loosening and improve the outcome of the surgery 6.
• The duration of preoperative teriparatide treatment may not be directly correlated with the insertional torque, but starting treatment at least 1 month prior to surgery may be beneficial 6.
• The use of bisphosphonates in the perioperative period may not have the same beneficial effect on bone fusion as teriparatide, but they can still help to maintain or increase BMD 2, 5.
• Overall, the management of postmenopausal patients with ASCVD and decreasing BMD undergoing neurosurgery requires a multidisciplinary approach, taking into account the patient's bone health, cardiovascular risk factors, and the potential impact of their medications on the surgical outcome 2.