Forteo Discontinuation Before Implantation
No, it is not mandatory to discontinue Forteo (teriparatide) before implantation procedures; in fact, continuing teriparatide perioperatively may improve surgical outcomes in patients undergoing spinal instrumentation.
Evidence for Continuing Teriparatide During Implantation
Spinal Instrumentation Procedures
- The Congress of Neurological Surgeons (2021) provides Grade B evidence that clinicians should consider preoperative teriparatide in osteoporotic patients undergoing spinal instrumentation to decrease postoperative adverse events 1
- Teriparatide reduces screw loosening (7% vs 13% with bisphosphonates) and improves fusion rates (82% vs 68%) in patients undergoing spinal surgery 1
- Level II evidence demonstrates teriparatide superiority over bisphosphonates for earlier fusion (8 months vs 10 months), higher fusion rates at interim timepoints, and reduced pedicle screw loosening 1
Mechanism Supporting Continued Use
- Teriparatide is an anabolic agent that directly stimulates bone formation by activating osteoblasts, which would theoretically enhance bone healing and implant integration 2, 3
- The drug improves bone mineral density, bone structure, strength, and quality through histomorphometric changes that support osseointegration 2
- Teriparatide rapidly increases markers of bone formation, which is beneficial during the critical perioperative healing period 3
Important Clinical Considerations
Dental Implantation Exception
- If the implantation involves dental procedures and the patient has existing osteonecrosis of the jaw (ONJ), bisphosphonates should be absolutely avoided, but teriparatide does not carry the same ONJ risk 4
- Teriparatide is not associated with increased ONJ risk compared to bisphosphonates, which are the primary concern for dental implant procedures 5, 4
Orthopedic Implantation
- For orthopedic implants (hip, knee, shoulder replacements), there is no evidence requiring discontinuation of teriparatide 1
- The anabolic effects of teriparatide may actually facilitate bone healing around prosthetic implants, similar to the benefits seen in spinal fusion 1
Treatment Duration and Monitoring
- Teriparatide treatment is limited to a maximum of 2 years during a patient's lifetime 1, 6, 7
- After completing teriparatide therapy, patients should transition to antiresorptive therapy (bisphosphonates or denosumab) to maintain bone density gains 8
- Calcium supplementation (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) should be maintained throughout treatment 1, 7
Contraindications to Consider
- Teriparatide should be avoided in patients with open epiphyses, Paget's disease, bone metastases, history of skeletal malignancies, or prior radiation therapy involving the skeleton 1
- These contraindications relate to the underlying disease process rather than concerns about implantation procedures 1
Common Pitfall to Avoid
Do not confuse teriparatide with bisphosphonates or denosumab when considering perioperative management. Bisphosphonates require careful consideration before invasive dental procedures due to ONJ risk 5, 4, but teriparatide does not carry this same risk and may actually improve surgical outcomes in orthopedic procedures 1.