What are alternative osteoporosis treatment options for a patient experiencing side effects from Forteo (teriparatide)?

Alternative Osteoporosis Treatment Options After Forteo Intolerance

If you are discontinuing Forteo (teriparatide) due to side effects, switch to oral bisphosphonates (alendronate or risedronate) as first-line alternative therapy to prevent loss of bone gains and reduce fracture risk. 1

Immediate Management Strategy

Transition to bisphosphonates immediately after stopping teriparatide to preserve bone mineral density gains, as bone loss occurs rapidly without antiresorptive follow-up therapy. 1, 2

• Patients initially treated with anabolic agents like teriparatide must be offered an antiresorptive agent after discontinuation to preserve gains and prevent serious risk of rebound and multiple vertebral fractures. 1
• Without antiresorptive follow-up, lumbar spine BMD decreases by approximately 2-3% within 2.5 years after teriparatide cessation. 3

Recommended Treatment Hierarchy

First-Line: Oral Bisphosphonates

Prescribe generic oral bisphosphonates (alendronate or risedronate) as the preferred alternative due to high-certainty evidence for fracture reduction, excellent safety profile, and significantly lower cost. 1

• Bisphosphonates reduce hip fractures by 40-53%, vertebral fractures by 40-70%, and nonvertebral fractures by 25-40% in postmenopausal women with osteoporosis. 4
• High-certainty evidence supports bisphosphonates as first-line therapy with the most favorable balance of benefits, harms, patient values, and cost. 1
• Generic formulations are strongly recommended over brand-name medications due to equivalent efficacy at substantially lower cost. 1

Second-Line: Denosumab

Use denosumab 60 mg subcutaneously every 6 months if bisphosphonates are contraindicated or cause adverse effects. 1

• Denosumab is recommended as second-line therapy with moderate-certainty evidence for postmenopausal women and low-certainty evidence for men. 1
• Denosumab reduces fragility fractures by 39-40% compared to placebo. 1
• Denosumab resulted in no differences in serious adverse events or withdrawals due to adverse events compared to placebo in RCTs. 1

Third-Line: IV Bisphosphonates

Consider IV zoledronic acid if oral bisphosphonates are not tolerated, recognizing the higher risk profile of IV infusion compared to oral therapy. 1

• IV bisphosphonates carry a higher risk profile than oral formulations but may be necessary for patients unable to tolerate oral medications. 1

Alternative for Very High-Risk Patients: Romosozumab

For patients at very high risk of fracture (age >74, multiple prior fractures, T-score ≤-3.0, or FRAX ≥20% major fracture/≥3% hip fracture), consider romosozumab followed by bisphosphonates. 1, 5

• Romosozumab followed by alendronate probably does not increase risk for serious harms compared to bisphosphonate alone (moderate to low certainty evidence). 1
• Romosozumab increases BMD more profoundly and rapidly than alendronate and is superior in reducing vertebral and nonvertebral fractures. 4

Critical Contraindication: Osteonecrosis of the Jaw (ONJ)

If teriparatide was discontinued due to osteonecrosis of the jaw, absolutely avoid bisphosphonates and denosumab, as they significantly increase ONJ progression risk. 6

• Bisphosphonates are absolutely contraindicated in patients with existing ONJ and should be avoided. 6
• If fracture risk has improved after teriparatide, implement a drug holiday with calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation instead of transitioning to antiresorptive therapy. 6
• Maintain excellent oral hygiene and regular dental review throughout any bone-targeted therapy. 6

Essential Adjunctive Therapy for All Patients

All patients require calcium 1000-1200 mg daily and vitamin D 800-1000 IU daily regardless of pharmacologic choice. 1, 6, 5

• Adequate calcium and vitamin D intake is essential for fracture prevention in all patients with osteoporosis. 1
• Encourage weight-bearing exercise, balance training, fall prevention counseling, smoking cessation, and alcohol limitation to 1-2 drinks daily. 1, 5

Treatment Duration Considerations

Plan to continue bisphosphonate therapy for 5 years, then reassess fracture risk to determine if treatment continuation is warranted. 1

• Current evidence suggests stopping bisphosphonates after 5 years unless strong indication for continuation exists, as longer duration increases risk for osteonecrosis of the jaw and atypical femoral fractures. 1
• Bisphosphonates can be used for up to 10 years with oral formulations and 6 years with IV zoledronic acid. 4

Common Pitfalls to Avoid

• Never leave patients on calcium and vitamin D alone after stopping teriparatide unless ONJ is present—this results in rapid bone loss and increased fracture risk. 1, 2
• Do not combine teriparatide with bisphosphonates concurrently, as alendronate attenuates the anabolic effect of teriparatide. 3
• Avoid prescribing brand-name bisphosphonates when generic formulations provide equivalent efficacy at substantially lower cost. 1
• Do not use raloxifene as an alternative unless all other options are inappropriate, as it has inadequate data on vertebral and hip fracture benefits and carries clotting risks. 1