What is the preferred treatment for a 62-year-old female with a T score of -3.6 at the spine, taking inhaled steroid (corticosteroid) daily, and having a history of diverticulitis with perforation and colectomy, partial nephrectomy, and dental issues: Forteo (teriparatide), Romosozumab (Romo), or Prolia (denosumab)?

From the Guidelines

For this 62-year-old female with severe osteoporosis (T-score -3.6 at spine) and multiple complicating factors, Prolia (denosumab) would likely be the best initial choice. Prolia is administered as a 60mg subcutaneous injection every 6 months and is effective for reducing fracture risk in postmenopausal women with osteoporosis 1. Given her history of dental issues, she should have a comprehensive dental evaluation and complete any necessary dental work before starting therapy, as there is a risk of osteonecrosis of the jaw with Prolia, though this risk is relatively low. Her history of inhaled steroid use likely contributed to her bone loss, and her surgical history (colectomy and partial nephrectomy) may affect medication metabolism and bone health.

Key Considerations

• Forteo (teriparatide) and Evenity (romosozumab) are both potent anabolic agents that could be considered, but Forteo requires daily injections for up to 2 years and Evenity has cardiovascular risk considerations 1.
• Additionally, her dental issues raise concerns for both these medications as well.
• Prolia works by inhibiting bone resorption, effectively stopping further bone loss while allowing for some rebuilding, and has demonstrated efficacy in patients with steroid-induced bone loss 1.
• The American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis conditionally recommends PTH/PTHrP or DEN over BP in adults ≥40 years with high fracture risk 1.

Treatment Recommendations

• Calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation should accompany any osteoporosis treatment selected 1.
• Prolia (denosumab) is the preferred treatment option due to its efficacy in reducing fracture risk and relatively low risk of side effects compared to other options 1.

From the FDA Drug Label

In patients with glucocorticoid-induced osteoporosis, teriparatide increased lumbar spine BMD compared with baseline at 3 months through 18 months of treatment. The mean percent change in BMD from baseline to endpoint was 7.2% at the lumbar spine, 3.6% at the total hip, and 3.7% at the femoral neck (p<0.001 all sites).

The patient has a T score of -3.6 at the spine and is taking inhaled steroid (corticosteroid) daily, which suggests glucocorticoid-induced osteoporosis.

• Teriparatide (Forteo) is an anabolic agent that can increase bone mass and is effective in treating glucocorticoid-induced osteoporosis.
• Denosumab (Prolia) is an anti-resorptive agent that can also increase bone mass, but its effectiveness in this specific patient population is not directly stated in the provided label.
• Romosozumab (Romo) is not mentioned in the provided labels, so its use cannot be evaluated based on this information.

Given the patient's condition and the available information, Teriparatide (Forteo) may be considered as a treatment option for this patient, but the decision should be made by a healthcare professional considering all aspects of the patient's health 2.

From the Research

Treatment Options for Osteoporosis

The patient in question is a 62-year-old female with a T score of -3.6 at the spine, taking inhaled steroid (corticosteroid) daily, and having a history of diverticulitis with perforation and colectomy, partial nephrectomy, and dental issues. The treatment options being considered are Forteo (teriparatide), Romosozumab (Romo), or Prolia (denosumab).

Comparison of Treatment Options

• Romosozumab has been shown to increase bone mineral density (BMD) at the lumbar spine and total hip compared to placebo, alendronate, and teriparatide in postmenopausal women with low bone mass 3.
• The effect of romosozumab is affected by previous osteoporosis treatment, with the duration of previous treatment affecting the therapeutic effect of romosozumab 4.
• Combination therapy with denosumab and high-dose teriparatide has been shown to increase spine and hip BMD more than standard combination therapy 5.
• Romosozumab following daily or weekly administration of teriparatide has been shown to be relatively safe and effective in patients with primary osteoporosis 6.
• Re-administration of romosozumab has been shown to be an effective treatment option for patients at high risk of fractures despite sequential therapy with other agents 7.

Considerations for the Patient

• The patient's history of diverticulitis with perforation and colectomy, partial nephrectomy, and dental issues should be taken into consideration when selecting a treatment option.
• The patient's use of inhaled corticosteroids may affect bone density and should be considered when selecting a treatment option.
• The patient's T score of -3.6 at the spine indicates a high risk of fracture, and treatment should be selected accordingly.

Potential Treatment Options

• Romosozumab (Romo) may be a suitable treatment option for the patient, given its ability to increase BMD at the lumbar spine and total hip.
• Denosumab (Prolia) may also be a suitable treatment option, given its ability to increase BMD when used in combination with teriparatide.
• Teriparatide (Forteo) may be a suitable treatment option, given its ability to increase BMD, but its use may be affected by the patient's history of dental issues.