What is the best medication for a patient with a T score of 4.1 at the spine, -1.8 at the femoral neck, and -0.8 at the total hip, indicating big discordance, and a history of dental implants, asthma treated with inhaled steroids (corticosteroids), proton pump inhibitor (PPI) use, and previous toe and ankle fractures?

From the Guidelines

The patient should be started on teriparatide (Forteo) or one of its biosimilars at a dose of 20 mcg subcutaneously daily for up to 2 years, given the severe osteoporosis at the spine (T-score -4.1), significant discordance between skeletal sites, and multiple risk factors for fracture. This recommendation is based on the 2023 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1. The patient's history of inhaled corticosteroid use for asthma, proton pump inhibitor (PPI) therapy, and previous fractures (toe and ankles) contribute to bone loss, making an anabolic agent like teriparatide the best choice.

Key Considerations

• The patient's T-scores indicate severe osteoporosis at the spine, with significant discordance between skeletal sites, which increases the risk of fracture.
• The patient has multiple risk factors for fracture, including a history of inhaled corticosteroid use, PPI therapy, and previous fractures.
• Teriparatide stimulates new bone formation, making it ideal for severe cases with existing fractures.
• After completing the teriparatide course, the patient should transition to an antiresorptive agent like denosumab or a bisphosphonate to maintain bone gains.

Additional Recommendations

• The patient should take calcium (1000-1200 mg daily) and vitamin D (1000-2000 IU daily) supplements to support bone health.
• Consider tapering the PPI if possible, and use the lowest effective dose of inhaled steroids to minimize their impact on bone loss.
• A comprehensive approach should also include fall prevention strategies and weight-bearing exercises to further reduce fracture risk, as recommended by the guideline 1.

From the FDA Drug Label

The efficacy of alendronate sodium in men with hypogonadal or idiopathic osteoporosis was demonstrated in two clinical studies. The efficacy and safety of Prolia in the treatment to increase bone mass in men with osteoporosis was demonstrated in a 1-year, randomized, double-blind, placebo-controlled trial.

The patient has a T score of 4.1 at the spine, which is not indicative of osteoporosis, but the T scores at the femoral neck and total hip are -1.8 and -0.8, respectively. Given the patient's history of dental implants, asthma treated with inhaled steroids, proton pump inhibitor (PPI) use, and previous toe and ankle fractures, the best medication for this patient cannot be directly determined from the provided information.

• Alendronate and denosumab are both used to treat osteoporosis, but the patient's discordant T scores and complex medical history require careful consideration of the potential benefits and risks of each medication.
• The FDA drug label for alendronate provides information on its efficacy in preventing bone loss and increasing bone mass in postmenopausal women and men with osteoporosis 2.
• The FDA drug label for denosumab provides information on its efficacy in increasing bone mass and reducing the risk of fractures in postmenopausal women and men with osteoporosis 3. However, without more specific information about the patient's condition and how it relates to the indications and contraindications for these medications, no conclusion can be drawn.

From the Research

Patient Profile

• T score of 4.1 at the spine
• T score of -1.8 at the femoral neck
• T score of -0.8 at the total hip
• History of dental implants
• Asthma treated with inhaled steroids (corticosteroids)
• Proton pump inhibitor (PPI) use
• Previous toe and ankle fractures

Treatment Options

• Denosumab and bisphosphonates are antiresorptives that target osteoclasts and inhibit bone resorption 4
• Denosumab achieves greater suppression of bone turnover and greater increases of bone mineral density (BMD) at all skeletal sites 4
• Bisphosphonates reach a plateau in BMD response after 2-3 years, while denosumab increases BMD progressively for as long as it is administered 4
• Combination therapy with teriparatide and denosumab or zoledronate has achieved higher BMD gains compared to each agent alone 4, 5

Considerations for Treatment Choice

• Denosumab should be preferred in patients with impaired renal function 4
• Discontinuation of denosumab should be discouraged, especially in previously treatment-naïve patients, due to the risk of fractures 4
• Calcium and vitamin D supplementation may be beneficial to enhance BMD gains in patients under denosumab treatment 6
• Sequential treatment from bisphosphonate to denosumab improves lumbar spine bone mineral density in postmenopausal osteoporosis patients 7
• Teriparatide and denosumab exhibit similar or even superior characteristics to bisphosphonates in preventing glucocorticoid-induced osteoporosis 8

Potential Treatment Strategy

• Consider denosumab as a treatment option due to its ability to increase BMD progressively and its potential benefits in patients with impaired renal function 4
• Evaluate the patient's renal function and consider denosumab as a preferred treatment option if impaired renal function is present 4
• Consider combination therapy with teriparatide and denosumab or zoledronate for higher BMD gains 4, 5
• Ensure adequate calcium and vitamin D supplementation to enhance BMD gains 6
• Monitor the patient's response to treatment and adjust the treatment strategy as needed to minimize the risk of fractures and optimize BMD gains 4, 7, 8