From the Guidelines
Forteo (teriparatide) should be discontinued in a 69-year-old female patient with osteoporosis who has shown no improvement in bone density after a repeat DEXA scan, and consideration should be given to transitioning to an antiresorptive medication like a bisphosphonate or denosumab to maintain bone health. The patient's lack of response to Forteo, as evidenced by no improvement in bone density, suggests that alternative treatments should be explored to reduce the risk of osteoporotic fractures 1.
Management Considerations
- Discontinue Forteo due to lack of efficacy and potential safety concerns with long-term use 1.
- Consider transitioning to an antiresorptive medication, such as:
- Bisphosphonates (e.g., alendronate 70mg weekly, risedronate 35mg weekly, or zoledronic acid 5mg IV yearly) 1.
- Denosumab (Prolia 60mg subcutaneously every 6 months) 1.
- Ensure adequate calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation continues to support bone health 1.
- Monitor renal function before starting bisphosphonates, and consider dental evaluation before initiating antiresorptives to minimize osteonecrosis risk 1.
Rationale
The sequential use of Forteo followed by an antiresorptive medication is a physiologically sound approach for long-term osteoporosis management, as Forteo stimulates new bone formation, while antiresorptives prevent further bone loss through different mechanisms 1. This approach can help maintain bone density gains and reduce the risk of osteoporotic fractures in patients who have not responded to Forteo alone 1.
From the FDA Drug Label
2.3 Recommended Treatment Duration Use of teriparatide for more than 2 years during a patient's lifetime should only be considered if a patient remains at or has returned to having a high risk for fracture [see Warnings and Precautions (5.1)].
The management consideration for a 69-year-old female patient with osteoporosis on Forteo (teriparatide) who has shown no improvement in bone density after a repeat Dual-Energy X-ray Absorbency (DEXA) scan is to re-evaluate the treatment duration. Since the patient has not shown improvement, the treatment with teriparatide should be re-assessed to determine if the patient remains at high risk for fracture. If the patient is still at high risk, continued treatment with teriparatide may be considered, but the risks and benefits of prolonged treatment should be carefully weighed 2.
- Key considerations:
- Patient's fracture risk
- Treatment duration
- Risks and benefits of continued treatment
- Next steps:
- Re-evaluate patient's fracture risk
- Consider alternative treatment options if necessary
- Monitor patient's response to treatment closely 2.
From the Research
Management Considerations for Osteoporosis Patient on Forteo
- The patient has shown no improvement in bone density after a repeat DEXA scan, indicating a need to reassess the current treatment plan with Forteo (teriparatide) 3, 4, 5, 6, 7.
- Studies suggest that switching from teriparatide to zoledronic acid or denosumab may be a valid option for patients with severe osteoporosis who have not responded to teriparatide therapy 3, 7.
- Combination therapy of denosumab and teriparatide has been shown to increase bone mineral density more than either agent alone, and may be considered for patients at high risk of fracture 4, 5.
- The effect of zoledronic acid on bone microarchitecture and strength after denosumab and teriparatide administration has been studied, and results suggest that a single dose of zoledronic acid may not be enough to maintain gains in volumetric peripheral bone density and microarchitecture 6.
- Switching to denosumab or bisphosphonates after completion of teriparatide treatment has been compared, and results suggest that denosumab may yield higher additional lumbar spine BMD gain on average compared with bisphosphonates treatment 7.
Treatment Options
- Switching to zoledronic acid or denosumab after teriparatide therapy 3, 7
- Combination therapy of denosumab and teriparatide 4, 5
- Continuing teriparatide therapy and adding another agent, such as denosumab or a bisphosphonate 4, 5