What is the efficacy of Tymlos (abaloparatide) following treatment with Evenity (romosozumab)?

From the Guidelines

The efficacy of Tymlos (abaloparatide) following Evenity (romosozumab) treatment is supported by the strongest data with respect to BMD changes, as indicated in the 2024 evidence-based guideline for the management of osteoporosis in men 1. When transitioning from Evenity to Tymlos, patients can generally expect continued bone mineral density (BMD) gains, though possibly at a different rate than with direct Tymlos initiation. Tymlos is typically administered as a daily 80 mcg subcutaneous injection for up to 2 years, and is most effective when combined with adequate calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation. The transition from Evenity to Tymlos should occur immediately after completing the 12-month Evenity course to avoid bone loss during a gap in therapy. Some key points to consider in the management of osteoporosis include:

• The use of oral anti-resorptive agents as first-line agents in men at a high risk of fracture
• The use of bone-forming agents followed sequentially by anti-resorptive agents in men at a very high risk of fracture
• The importance of adequate calcium and vitamin D supplementation
• The need for sequential therapy after discontinuation of certain osteoporosis medications, such as denosumab and romosozumab, to prevent rebound bone loss and vertebral fractures 1. Mechanistically, this sequence makes physiological sense as Evenity works by both increasing bone formation and decreasing bone resorption, while Tymlos primarily stimulates bone formation. However, since both medications stimulate bone formation (though through different pathways), there may be some overlap in their mechanisms that could theoretically reduce the incremental benefit of sequential therapy compared to using either agent alone or in different sequences. Monitoring BMD at 12-month intervals is recommended to assess treatment response during this transition. It is also important to consider the potential harms of certain medications, such as the risk of major myocardial infarction, stroke, and death associated with romosozumab 1. Overall, the decision to use Tymlos after Evenity should be based on a careful consideration of the individual patient's risk factors, medical history, and treatment goals.

From the Research

Efficacy of Tymlos (abaloparatide) Following Treatment with Evenity (romosozumab)

• The efficacy of Tymlos (abaloparatide) following treatment with Evenity (romosozumab) can be inferred from studies comparing the effects of different osteoanabolic agents on bone mineral density (BMD) and fracture risk 2.
• A study comparing romosozumab and parathyroid hormone receptor agonists found that abaloparatide resulted in greater BMD increases at the hip compared to teriparatide, although no differences in vertebral or non-vertebral fracture risk were observed between the two drugs 2.
• Another study evaluating the effects of romosozumab re-administration on BMD found that BMD increased significantly at all sites for patients who received teriparatide as sequential therapy, suggesting a potential benefit of using Tymlos after Evenity treatment 3.
• However, there is limited direct evidence comparing the efficacy of Tymlos following Evenity treatment, and more research is needed to fully understand the effects of this treatment sequence.

Comparison of Osteoanabolic Agents

• Osteoanabolic agents, including romosozumab and parathyroid hormone receptor agonists like abaloparatide, increase BMD and bone strength while reducing fracture risk in postmenopausal women 2.
• A meta-analysis of denosumab and romosozumab found that both treatments have antiosteoporotic effects, with greater effects on BMD and bone turnover markers observed within 12 months of romosozumab treatment 4.
• The choice of osteoanabolic agent may depend on individual patient factors, such as history of tumor or major cardiovascular events, as well as convenience of administration and reimbursement by national health systems 2.

Sequential Treatment Strategies

• Romosozumab following anti-resorptive treatment can be an effective sequential treatment strategy to improve bone strength 5.
• A study found that transitioning to romosozumab after denosumab improved lumbar spine BMD and trabecular bone score greater than denosumab continuation in postmenopausal women 5.
• The efficacy of sequential treatment strategies, including the use of Tymlos after Evenity, may depend on the specific treatment sequence and individual patient factors, and further research is needed to optimize treatment approaches 3, 5.