Calcitonin is NOT routinely combined with teriparatide in osteoporosis treatment
Current evidence and guidelines do not support the combination of calcitonin with teriparatide for osteoporosis management. In fact, combining teriparatide with any antiresorptive agent (including calcitonin) is not more effective than teriparatide monotherapy 1.
Why This Combination Is Not Recommended
Lack of Evidence for Combination Therapy
- Combination therapy with teriparatide and antiresorptive agents has been specifically studied and found to provide no additional benefit over teriparatide alone 1.
- The 2013 ACOG guideline explicitly states that "combination therapy is not recommended" for osteoporosis treatment 2.
Calcitonin's Diminished Role in Osteoporosis
- Calcitonin is no longer widely used for osteoporosis treatment and has been excluded from current treatment algorithms 2.
- The 2017 American College of Physicians guideline update specifically removed calcitonin from consideration, noting it "is no longer widely used for osteoporosis treatment" 2.
- The European Medicines Agency withdrew or severely limited the license for calcitonin in osteoporosis treatment due to safety concerns 3.
Sequential, Not Concurrent, Therapy Is Appropriate
- After completing the maximum two-year course of teriparatide, patients should be transitioned to antiresorptive therapy (typically bisphosphonates, not calcitonin) to maintain bone mineral density gains 1.
- This represents sequential therapy, not combination therapy.
Current Treatment Paradigm
First-Line Therapy
- Bisphosphonates (alendronate, risedronate, zoledronic acid) remain the first-line pharmacologic treatment for osteoporosis in both men and women 2.
When Teriparatide Is Indicated
- Teriparatide is reserved for patients at very high fracture risk, those with severe osteoporosis with documented fractures, or those who have failed or cannot tolerate first-line bisphosphonate therapy 4.
- The American College of Rheumatology conditionally recommends teriparatide over anti-resorptives only in patients at very high fracture risk 4.
Limited Role for Calcitonin
- If calcitonin is used at all, it should be reserved for patients with less serious osteoporosis who cannot tolerate other treatments 2.
- Its primary remaining utility is for acute pain management in osteoporotic vertebral fractures, not for fracture prevention 5, 6, 7.
Common Pitfall to Avoid
The misconception that combining anabolic (teriparatide) and antiresorptive (calcitonin) agents would provide additive benefits is not supported by evidence. Teriparatide monotherapy for up to two years, followed by transition to bisphosphonate therapy, represents the evidence-based approach 1.