Can a patient with osteoporosis and hypocalcemia take Wyost (Teriparatide)?

Teriparatide (Wyost) Use in Patients with Osteoporosis and Hypocalcemia

Patients with osteoporosis should not take Wyost (teriparatide) if they have hypocalcemia, as hypocalcemia must be corrected before initiating teriparatide therapy. 1

Rationale for Recommendation

Teriparatide (Wyost) affects calcium metabolism in several important ways:

• Teriparatide causes transient increases in serum calcium, beginning approximately 2 hours after dosing and reaching maximum concentration between 4-6 hours (median increase of 0.4 mg/dL) 1
• The FDA drug label specifically indicates that calcium status should be optimized before starting teriparatide therapy 1
• Vitamin D deficiency should be corrected before treating with medications that affect calcium metabolism because hypocalcemia has been reported in patients with unrecognized vitamin D deficiency 2

Management Algorithm for Patients with Osteoporosis and Hypocalcemia

1. First step: Correct hypocalcemia

   • Optimize calcium intake (1,000-1,200 mg/day) 2, 3
   • Ensure adequate vitamin D intake (600-800 IU/day with target serum level ≥20 ng/ml) 2, 3
   • Consider active vitamin D metabolites if needed 2
   • Monitor serum calcium until normalized

2. After calcium normalization:

   • Initiate teriparatide therapy at standard dose (20 mcg subcutaneously once daily) 1
   • Monitor serum calcium 4-6 hours after dosing during initial therapy 1
   • Be vigilant for symptoms of hypercalcemia (nausea, vomiting, constipation, lethargy, muscle weakness) 1

3. Ongoing monitoring:

   • Check serum calcium levels regularly during treatment
   • Adjust calcium supplementation as needed based on serum levels
   • Consider dose reduction if serum calcium exceeds upper limit of normal (10.6 mg/dL) 1

Important Clinical Considerations

Risk of Hypercalcemia

While hypocalcemia is a contraindication to starting teriparatide, once therapy begins, there is a risk of developing hypercalcemia:

• In clinical trials, 11.1% of women treated with teriparatide had at least one serum calcium value above the upper limit of normal (10.6 mg/dL) compared with 1.5% of women treated with placebo 1
• 3% of women treated with teriparatide had consecutive elevated calcium measurements compared with 0.2% of women treated with placebo 1
• Severe hypercalcemia has been reported in case studies, though sustained hypercalcemia is uncommon 4

Alternative Treatment Options

If hypocalcemia cannot be corrected or persists, consider alternative osteoporosis treatments:

• Oral bisphosphonates are recommended as first-line therapy for osteoporosis 3
• For patients at high risk of fracture, IV bisphosphonates or denosumab may be considered 2
• For glucocorticoid-induced osteoporosis, oral bisphosphonates are still first-line, with IV bisphosphonates, denosumab, or raloxifene (for postmenopausal women) as alternatives 2

Special Populations

For patients with renal impairment:

• Intravenous bisphosphonates are generally not recommended in patients with creatinine clearance less than 30 mL/min 2
• Oral bisphosphonates appear to have better renal safety in patients with lower creatinine clearance 2

Conclusion

Teriparatide should only be initiated after hypocalcemia has been corrected. The medication's effect on calcium metabolism makes it unsuitable for patients with persistent hypocalcemia. Proper calcium and vitamin D supplementation should be established before starting teriparatide therapy to prevent complications.