How to transition from Prolia (denosumab) to Forteo (teriparatide)?

From the Guidelines

Transitioning from Prolia (denosumab) to Forteo (teriparatide) should be done by starting Forteo immediately after the last scheduled Prolia dose or within 1 month of when the next Prolia injection would be due, to avoid rapid bone loss and increased fracture risk, as recommended by the most recent guidelines 1.

Key Considerations

• The transition from Prolia to Forteo requires careful planning to prevent accelerated bone loss and increased fracture risk.
• The typical Forteo regimen involves daily self-injections of 20 mcg for up to 24 months, which is the maximum FDA-approved duration.
• Before starting this transition, baseline bone mineral density testing and laboratory tests to check calcium, vitamin D, and parathyroid hormone levels are necessary.
• During the transition, maintaining adequate calcium intake (1000-1200 mg daily) and vitamin D supplementation (800-1000 IU daily) is crucial.
• Regular monitoring with a healthcare provider during this transition period is essential to ensure effectiveness and manage any side effects.

Rationale

The American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1 provides the most recent and highest quality evidence for transitioning between osteoporosis treatments.

• The guideline conditionally recommends using teriparatide (Forteo) over anti-resorptive treatments like denosumab (Prolia) for adults with high or very high fracture risk.
• The guideline also recommends optimizing dietary and supplemental calcium and vitamin D in addition to lifestyle modifications for all patients beginning or continuing chronic glucocorticoid treatment.

Monitoring and Follow-up

Regular monitoring with a healthcare provider during the transition period is essential to:

• Ensure the effectiveness of the transition
• Manage any side effects
• Adjust the treatment plan as needed to minimize the risk of fracture and optimize bone health. By following these guidelines and recommendations, patients can safely transition from Prolia to Forteo and minimize the risk of rapid bone loss and increased fracture risk.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Transitioning from Prolia to Forteo

To transition from Prolia (denosumab) to Forteo (teriparatide), it is essential to consider the effects of these medications on bone turnover markers and density.

• The study 2 suggests that switching from denosumab to teriparatide results in bone mineral density (BMD) loss, whereas switching from teriparatide to denosumab results in continued BMD gains.
• Another study 3 found that 24 months of concomitant teriparatide and denosumab therapy increases BMD more than therapy with either medication alone.
• The effects of denosumab on bone turnover markers were evaluated in the study 4, which found that denosumab decreases bone remodeling, increases bone density, and reduces fracture risk.
• The relationship between bone turnover and density with teriparatide, denosumab, or both was investigated in the study 5, which found that early changes in bone turnover markers predict 2-year BMD gains, especially at the spine.

Key Considerations

• When transitioning from denosumab to teriparatide, patients may experience a reduction in total and cortical volumetric BMD, cortical thickness, and estimated strength 2.
• In contrast, switching from teriparatide to denosumab or using combined teriparatide/denosumab followed by denosumab alone may result in improvements in these parameters 2.
• The use of teriparatide after denosumab should be avoided, and the use of combined teriparatide/denosumab followed by denosumab alone may be a useful treatment strategy in those with severe osteoporosis 2.

Bone Turnover Markers

• Denosumab provides a rapid and sustained decrease in bone turnover marker values compared to placebo 6.
• The median change in serum type 1 C-telopeptide (sCTX) levels at month 1 was -90% in the denosumab group and -3% in the placebo group (p  <  0.0001) 6.
• Suppression of bone turnover markers was consistent with marked increases in bone mineral density reported previously 6.