Does a 69-year-old female patient on Forteo (teriparatide) with a diagnosis of osteoporosis at the lumbar spine and osteopenia at the femoral neck and total hip require additional medication?

From the Guidelines

This 69-year-old female on Forteo (teriparatide) does not require additional medication at this time, as Forteo is a powerful anabolic agent that stimulates new bone formation and is typically prescribed for patients with severe osteoporosis or high fracture risk, as indicated by her DEXA scan results showing osteoporosis in the spine (T-score -3.1) and osteopenia in the hip regions 1. The patient's current treatment with Forteo is appropriate, given her severe osteoporosis and high fracture risk. The standard treatment duration for Forteo is 24 months, and patients should complete this full course before considering a switch to another medication.

• The American College of Physicians recommends that clinicians offer pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis, but this patient is already on Forteo, which is a suitable treatment for her condition 1.
• After completing Forteo therapy, a transition to an antiresorptive agent like a bisphosphonate (alendronate, risedronate) or denosumab (Prolia) is recommended to maintain the bone gains achieved, as supported by the EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures 1. While on Forteo, the patient should ensure adequate calcium intake (1000-1200mg daily) and vitamin D (800-1000 IU daily), along with weight-bearing exercise and fall prevention strategies.
• Regular monitoring with follow-up DEXA scans is important to assess treatment response, typically performed after completing the Forteo course, as recommended by the American College of Physicians and EULAR/EFORT guidelines 1.

From the FDA Drug Label

The primary efficacy endpoint was the occurrence of new radiographically diagnosed vertebral fractures defined as changes in the height of previously undeformed vertebrae. Teriparatide, when taken with calcium and vitamin D and compared with calcium and vitamin D alone, reduced the risk of 1 or more new vertebral fractures from 14.3% of women in the placebo group to 5. 0% in the teriparatide group Teriparatide increased lumbar spine BMD in postmenopausal women with osteoporosis. Statistically significant increases were seen at 3 months and continued throughout the treatment period Postmenopausal women with osteoporosis who were treated with teriparatide had statistically significant increases in BMD from baseline to endpoint at the lumbar spine, femoral neck, total hip, and total body

The patient is already on Forteo (Teriparatide). Given that the patient has Osteoporosis at the AP Spine (L1-L4) with a T-score of -3.1 and Osteopenia at other sites, the use of Teriparatide is appropriate.

• The patient's current treatment with Forteo is aimed at reducing the risk of vertebral fractures and increasing bone mineral density (BMD).
• The decision to add additional medication should be based on the patient's response to Forteo and their overall clinical condition.
• However, based on the provided information, it is unclear if the patient requires additional medication, as the effect of Forteo on the patient's BMD and fracture risk is not provided 2.

From the Research

Patient's Current Condition

The patient is currently on Forteo (teriparatide) and has recently undergone a DEXA scan, which shows:

• Osteoporosis in the AP Spine (L1-L4) with a BMD of 0.703, T-score of -3.1, and Z-score of -1.1
• Osteopenia in the Femoral Neck (Left) with a BMD of 0.728, T-score of -1.1, and Z-score of 0.6
• Osteopenia in the Total Hip (Left) with a BMD of 0.714, T-score of -1.9, and Z-score of -0.4
• Osteopenia in the Femoral Neck (Right) with a BMD of 0.670, T-score of -1.6, and Z-score of 0.1
• Osteopenia in the Total Hip (Right) with a BMD of 0.680, T-score of -2.1, and Z-score of -0.7
• Osteopenia in the Total Hip Mean with a BMD of 0.697, T-score of -2.0, and Z-score of -0.6

Treatment Options

Based on the studies, teriparatide has been shown to be effective in increasing bone mineral density (BMD) and reducing the risk of fractures in patients with osteoporosis 3, 4, 5, 6, 7. The patient is already on teriparatide, and the DEXA scan results show that they have osteoporosis in the AP Spine and osteopenia in other areas.

Considerations for Additional Medication

Some key points to consider:

• Teriparatide has been shown to be effective in reducing the risk of vertebral fractures and increasing BMD in the lumbar spine and femoral neck 4, 5, 6, 7
• The patient's current treatment with teriparatide may be sufficient, but additional medication may be considered to further reduce the risk of fractures or improve BMD
• The choice of additional medication would depend on various factors, including the patient's medical history, lifestyle, and preferences

Key Findings

Some key findings from the studies include:

• Teriparatide was superior to bisphosphonates in increasing BMD in the lumbar spine, femoral neck, and total hip 4, 5, 6, 7
• Teriparatide was also shown to reduce the risk of vertebral fractures compared to bisphosphonates 4, 5, 6, 7
• Denosumab was also shown to be effective in increasing BMD and reducing the risk of fractures, but its effectiveness compared to teriparatide is still being studied 4, 6