Is teriparatide (parathyroid hormone-related protein) suitable for a patient with a current traumatic pelvic fracture and osteoporosis?

Teriparatide for Traumatic Pelvic Fracture with Osteoporosis

Teriparatide is an appropriate and potentially beneficial treatment option for patients with current traumatic pelvic fracture and osteoporosis, particularly when the patient has very high fracture risk or when fracture healing may be compromised. 1

Treatment Algorithm for Osteoporotic Patients with Traumatic Pelvic Fracture

First-Line Treatment:

1. For most patients with osteoporosis and traumatic pelvic fracture:

   • Oral bisphosphonates remain the first-line treatment due to their established efficacy, safety profile, and lower cost 2, 3
   • Ensure adequate calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) supplementation 3

2. When to consider teriparatide instead of bisphosphonates:

   • Patients with very high fracture risk (T-score ≤ -3.5) 3
   • Multiple previous fractures 3
   • Previous treatment failure with bisphosphonates 3
   • Fractures not expected to predictably unite 1

Evidence for Teriparatide in Pelvic Fractures:

Research has shown that teriparatide can accelerate healing in pelvic fractures:

• A study comparing parathyroid hormone (1-84) injections to no treatment in elderly women with osteoporotic pelvic fractures found significantly faster radiographic and clinical fracture healing (7.8 weeks vs. 12.6 weeks) 1
• Teriparatide has been shown to achieve earlier radiographic cortical bridging compared to placebo (7.4 weeks vs. 9.1 weeks) 1

Clinical Considerations

Dosing and Administration:

• Standard dosing is 20 μg subcutaneous injection once daily
• Treatment duration is limited to 24 months due to theoretical risk of osteosarcoma 4
• After completing teriparatide treatment, transition to an antiresorptive agent to maintain bone density gains 3

Monitoring:

• Baseline serum calcium testing before starting treatment 3
• Monitor serum calcium after 1 month of treatment 4
• No need for bone density monitoring during the 2-year treatment period 3

Contraindications and Cautions:

• Prior radiation therapy (relative contraindication due to theoretical increased risk of osteosarcoma) 5
• Hypercalcemia
• Metabolic bone diseases other than osteoporosis
• Unexplained elevations of alkaline phosphatase
• History of skeletal malignancies

Common Side Effects:

• Nausea, dizziness, headache, leg cramps 2
• Risk of withdrawal due to adverse events is higher than with bisphosphonates 2

Special Populations

Women of Childbearing Potential:

• Oral bisphosphonates are first-line therapy
• Teriparatide is considered second-line therapy 2
• Ensure effective contraception during treatment

Patients on Glucocorticoids:

• For adults receiving high-dose glucocorticoids with osteoporosis, oral bisphosphonates remain first-line
• Teriparatide can be considered for those at very high fracture risk 2

Barriers to Treatment

Despite evidence supporting teriparatide's benefits in pelvic fractures, implementation remains challenging:

• A recent study found that only 6.7% of eligible elderly female patients with low-energy pelvic fractures actually received teriparatide 6
• Major barriers include lack of evaluation for its use and insurance coverage issues 6

Practical Recommendation

For patients with traumatic pelvic fracture and established osteoporosis, consider teriparatide when:

1. The patient has severe osteoporosis (T-score ≤ -3.5)
2. The fracture is complex or at risk of delayed healing
3. The patient has failed or cannot tolerate bisphosphonates
4. The potential benefits of accelerated healing outweigh the higher cost and side effect profile

Remember that teriparatide should not be used routinely for fractures expected to heal uneventfully or in patients with metabolically normal bone 1.