Management of Severe Osteoporosis with Prior Romosozumab Treatment
Recommendation for Teriparatide Continuation
Yes, the patient should complete the full 2-year course of Forteo (teriparatide) despite prior Evenity (romosozumab) treatment, as teriparatide is specifically indicated for glucocorticoid-induced osteoporosis in high-risk patients with severe osteoporosis. 1
Rationale for Treatment Decision
Patient Risk Assessment
- 67-year-old patient with severe osteoporosis of the femoral neck
- Frequent prednisone use for asthma exacerbations - placing patient at high risk for glucocorticoid-induced osteoporosis (GIOP)
- Prior treatment with Evenity (romosozumab) for 7 months, discontinued due to insurance issues
- Currently on Forteo (teriparatide)
Evidence Supporting Teriparatide Continuation
Specific Indication for GIOP: Teriparatide is specifically indicated for glucocorticoid-induced osteoporosis, which is particularly relevant for this patient with frequent prednisone use 1
Anabolic Agent Preference: For patients with very severe osteoporosis (T-score ≤ -3.0), anabolic agents like teriparatide are preferred over antiresorptive agents 1
Treatment Duration: The FDA-approved duration for teriparatide treatment is 2 years, which should be completed to maximize bone formation benefits 2
Sequential Therapy Considerations: While the patient received 7 months of romosozumab, this is not a contraindication to completing a full course of teriparatide, as sequential anabolic therapy can be beneficial in severe cases 1
Treatment Algorithm
1. Continue Teriparatide (Forteo)
- Complete the full 2-year course of teriparatide at 20 mcg daily subcutaneous injection
- Do not reduce duration based on prior romosozumab treatment
- Monitor for side effects including transient hypercalcemia (occurs in 11% of women and 6% of men) 2
2. Ensure Adequate Supplementation
- Maintain calcium intake of 1,000-1,200 mg/day
- Ensure vitamin D intake of 600-800 IU/day
- These supplements support bone formation during teriparatide treatment 3
3. Post-Teriparatide Management
- After completing the 2-year teriparatide course, transition to an antiresorptive agent (bisphosphonate or denosumab) to maintain bone gains 1
- Without this transition, bone mineral density gains may be lost within 1-2 years
Special Considerations for This Patient
Glucocorticoid-Induced Osteoporosis Management
- The American College of Rheumatology recommends teriparatide as a treatment option for GIOP in high-risk patients 3
- For patients receiving frequent or chronic prednisone, teriparatide may be more effective than bisphosphonates at increasing BMD 3, 1
Monitoring During Treatment
- Perform BMD testing every 1-3 years during treatment due to the patient's high-risk status (severe osteoporosis with glucocorticoid use) 3
- Consider earlier BMD testing within this range due to the patient's very high-dose glucocorticoid exposure 3
Lifestyle Modifications
- Implement fall prevention strategies
- Encourage weight-bearing and resistance exercises as tolerated
- Recommend smoking cessation and limiting alcohol intake if applicable
Important Caveats
- FDA Warning: Teriparatide carries a boxed warning about potential risk of osteosarcoma with long-term use, which limits lifetime exposure to 2 years 2
- Avoid Concurrent Bisphosphonates: Concurrent therapy with bisphosphonates may blunt the anabolic response to teriparatide 1
- Asthma Management: Consider strategies to minimize glucocorticoid exposure for asthma management when possible, as both inhaled and systemic steroids can contribute to bone loss 4, 5
In conclusion, despite the prior 7 months of romosozumab treatment, completing the full 2-year course of teriparatide is appropriate and recommended for this 67-year-old patient with severe osteoporosis and frequent glucocorticoid use for asthma exacerbations.