Would you recommend teriparatide (Forteo) for a 70-year-old diabetic man with recent humeral surgical head repair?

Teriparatide for a 70-Year-Old Diabetic Man with Recent Humeral Surgical Head Repair

Teriparatide is not recommended for this 70-year-old diabetic man with recent humeral surgical head repair who is showing good union at 8 weeks post-surgery. Instead, an oral bisphosphonate would be the preferred first-line treatment if osteoporosis therapy is indicated.

Rationale for Not Recommending Teriparatide

Patient-Specific Considerations

• Age and Gender: At 70 years old, this male patient falls into the category where oral bisphosphonates are recommended as first-line therapy for osteoporosis 1
• Diabetes: The patient has diabetes, which increases fracture risk, but current guidelines for diabetic patients do not specifically recommend teriparatide as a preferred agent 1
• Fracture Healing Status: The patient is "doing well" with union at 8 weeks post-surgery, indicating no delayed healing that might warrant anabolic therapy

Treatment Algorithm Based on Guidelines

1. First-line therapy: Oral bisphosphonates (alendronate or risedronate) are recommended as first-line treatment for men ≥40 years with moderate-to-high fracture risk 1, 2
2. Second-line options (if oral bisphosphonates are not appropriate):
   • IV bisphosphonates
   • Teriparatide
   • Denosumab

Specific Concerns with Teriparatide in This Patient

1. Cost and Burden of Therapy:

   • Teriparatide requires daily subcutaneous injections 1
   • It is significantly more expensive than bisphosphonates 1, 3

2. Limited Duration:

   • Teriparatide treatment is limited to 2 years maximum 4
   • Requires follow-up with an antiresorptive agent to maintain benefits

3. Appropriate Patient Selection:

   • Teriparatide is generally reserved for patients with more severe forms of osteoporosis, usually with presence or history of multiple fractures 3
   • This patient has a single fracture that is healing well

When Teriparatide Would Be Appropriate

Teriparatide could be considered in this patient only if:

• He has severe osteoporosis with multiple fractures
• He has contraindications to or has failed bisphosphonate therapy
• He develops a non-union of the humeral fracture despite adequate surgical management 5

Recommended Management Approach

1. Assess Fracture Risk:

   • Perform bone mineral density testing (DEXA scan)
   • Calculate FRAX score (adjusted for glucocorticoid use if applicable)

2. Initiate First-Line Therapy:

   • Oral bisphosphonate (alendronate 70mg weekly or risedronate 35mg weekly)
   • Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) intake 1, 2

3. Lifestyle Modifications:

   • Regular weight-bearing and resistance exercises
   • Smoking cessation if applicable
   • Limit alcohol intake to 1-2 drinks per day 2

4. Monitoring:

   • Follow-up DEXA scan after 1-2 years of therapy
   • Monitor for adherence and side effects

Conclusion

For this 70-year-old diabetic man with a well-healing humeral surgical head repair, oral bisphosphonates represent the most appropriate first-line therapy if osteoporosis treatment is indicated. Teriparatide should be reserved for cases of severe osteoporosis or when first-line therapies have failed or are contraindicated.