From the Guidelines
I strongly recommend Romosozumab (Evenity) as the preferred treatment option for this patient with severe osteoporosis at the spine (T-score 4.1) and a history of fractures, given its dual mechanism of action and superior bone mineral density improvements at the spine compared to other options, including Teriparatide (Forteo) 1. The patient's significant T-score discordance, with severe osteoporosis at the spine but only osteopenia at the femoral neck and total hip, suggests a high risk of vertebral fractures, which can be effectively addressed by Romosozumab's ability to both increase bone formation and decrease bone resorption. Some key points to consider in this patient's treatment include:
- The patient's history of inhaled steroid use for asthma and PPI use, which may contribute to osteoporosis risk, and previous fractures (toe and ankles), which increase the risk of future fractures 1.
- The standard regimen for Romosozumab is 210 mg administered as two separate subcutaneous injections once monthly for 12 months, followed by transition to an antiresorptive agent to maintain gains, which aligns with current sequential treatment approaches for severe osteoporosis 1.
- While Teriparatide (Forteo) is also an effective treatment option, Romosozumab's once-monthly dosing may improve adherence compared to daily injections with Forteo, and its limited 12-month course followed by maintenance therapy may be beneficial for this patient 1.
- The patient's dental implants are not a contraindication for Romosozumab, but it is essential to monitor for any potential adverse effects, such as osteonecrosis of the jaw, although this is rare 1. Overall, considering the patient's severe osteoporosis at the spine, history of fractures, and other risk factors, Romosozumab (Evenity) is the most appropriate treatment option to reduce the risk of future fractures and improve bone mineral density, particularly at the spine 1.
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
- Current use of Proton Pump Inhibitors (PPI)
- History of toe and ankle fractures
Treatment Options
- Teriparatide (Forteo)
- Romosozumab (Evenity)
Comparison of Treatment Options
- A study published in 2017 2 compared the effects of romosozumab and teriparatide on bone mineral density (BMD) in women with postmenopausal osteoporosis transitioning from bisphosphonate therapy. The results showed that romosozumab led to gains in hip BMD that were not observed with teriparatide.
- Another study published in 2020 3 discussed the challenges of sequential therapy for osteoporosis, including the need for antiresorptive agents after treatment with bone-forming agents like teriparatide and romosozumab.
- A 2025 study 4 found that romosozumab following daily or weekly administration of teriparatide was relatively safe and effective in patients with primary osteoporosis, with significant increases in BMD at the spine and total hip.
- A systematic review and meta-analysis published in 2024 5 compared the efficacy and safety of teriparatide and denosumab with bisphosphonates in patients with osteoporosis who had not previously received bisphosphonate treatment. The results showed that teriparatide was superior to bisphosphonates in decreasing the risk of fracture and increasing BMD.
Considerations for Treatment Choice
- The patient's history of dental implants, asthma, and use of PPIs should be considered when choosing a treatment option.
- The patient's T-scores at different skeletal sites (spine, femoral neck, and total hip) show discordance, which is a common phenomenon in osteoporosis diagnosis 6.
- The choice between teriparatide and romosozumab should be based on the patient's individual risk factors, medical history, and treatment goals, as well as the potential benefits and risks of each medication.