From the Guidelines
The efficacy of Tymlos (abaloparatide) following treatment with Evenity (romosozumab) is not well established, and the decision to use this sequence should be individualized based on the patient's fracture risk, treatment history, and response to previous therapy. Theoretically, transitioning from Evenity to Tymlos might maintain anabolic effects on bone, but the actual clinical benefit remains uncertain. According to the most recent guideline evidence 1, abaloparatide is supported by the strongest data with respect to BMD changes, but there is limited information on its use after Evenity.
When considering this sequence, it's essential to note that both medications have limited treatment durations (Evenity for 12 months maximum, Tymlos for up to 2 years) due to safety concerns. After completing Evenity therapy, most patients are typically transitioned to an antiresorptive medication like a bisphosphonate or denosumab rather than another anabolic agent, as recommended by the American College of Rheumatology guideline 1.
Some key points to consider when making this decision include:
- The patient's fracture risk, as assessed by FRAX and BMD using dual-energy x-ray absorptiometry (DXA) with vertebral fracture assessment (VFA) testing or spinal x-rays 1
- The patient's treatment history and response to previous therapy, including any previous use of anabolic or antiresorptive agents 1
- The potential benefits and harms of sequential therapy, including the risk of rebound bone loss and vertebral fractures after discontinuation of DEN, romosozumab, and PTH/PTHrP 1
Close monitoring of bone mineral density and bone turnover markers would be advisable if considering this uncommon sequence. Ultimately, the decision to use Tymlos after Evenity should be based on a thorough evaluation of the patient's individual needs and circumstances, taking into account the latest evidence and guidelines.
From the Research
Efficacy of Tymlos (abaloparatide) following treatment with Evenity (romosozumab)
- The efficacy of Tymlos (abaloparatide) following treatment with Evenity (romosozumab) is not directly addressed in the provided studies.
- However, a study 2 evaluated the efficacy of romosozumab re-administration after sequential therapy with bisphosphonates, denosumab, or teriparatide, and found that romosozumab re-administration is an effective treatment, with its efficacy varying depending on the sequential therapy used.
- Another study 3 compared the effects of romosozumab and parathyroid hormone receptor agonists, including abaloparatide, and found that abaloparatide resulted in greater BMD increases at the hip compared to teriparatide.
- There is limited information available on the direct comparison of the antifracture benefits of osteoanabolic therapies, including Tymlos (abaloparatide) and Evenity (romosozumab) 3.
- A meta-analysis 4 compared the effects of denosumab and romosozumab on bone mineral density and turnover markers in patients with osteoporosis, and found that romosozumab showed greater changes in bone mineral density and markers of bone turnover at 6 to 12 months.
Comparison of Osteoanabolic Agents
- Osteoanabolic agents, including romosozumab and parathyroid hormone receptor agonists, increase bone formation, bone mineral density, and bone strength 3.
- Romosozumab dramatically but transiently stimulates bone formation and persistently reduces bone resorption 3.
- Abaloparatide and teriparatide increase bone formation, bone mineral density, and bone strength by activating PTH receptors on osteoblasts 3.
Safety and Efficacy of Romosozumab
- Romosozumab is considered to be relatively safe in patients with primary osteoporosis compared to those with secondary osteoporosis 5.
- Romosozumab resulted in larger increases in spine BMD in patients with primary osteoporosis who were not previously treated with other anti-osteoporosis therapies and those with low spine BMD at the start of treatment 5.
- The use of romosozumab is admitted for patients with high risk of fractures but without serious vascular events 6.