What is the recommended approach for treating patients with peptides, considering their individual medical history, demographics, and specific conditions such as growth hormone deficiency or osteoporosis?

Treating Patients with Peptides

For osteoporosis treatment, PTH/PTHrP peptides (teriparatide, abaloparatide) should be reserved for very high-risk patients with prior osteoporotic fractures, T-score ≤-3.5, or FRAX 10-year major osteoporotic fracture risk ≥30%, and should always be followed by anti-resorptive therapy to prevent rapid bone loss. 1, 2, 3

Osteoporosis Treatment with PTH/PTHrP Peptides

Patient Selection Criteria

Very high-risk patients are the primary candidates for PTH/PTHrP therapy:

• Prior osteoporotic fracture(s), particularly spine, hip, wrist, or humerus 2, 3
• BMD T-score ≤-3.5 2, 3
• FRAX 10-year risk: major osteoporotic fracture ≥30% OR hip fracture ≥4.5% 2, 3
• High-dose glucocorticoid exposure (≥30 mg/day prednisone for ≥30 days or cumulative dose ≥5 g over 1 year) 1, 3

The American College of Rheumatology conditionally recommends PTH/PTHrP over anti-resorptive agents in these very high-risk scenarios. 1

Pre-Treatment Requirements

Mandatory assessments before initiating peptide therapy:

• DXA scan to establish BMD T-score 2
• FRAX calculation for 10-year fracture risk 2, 3
• Vertebral fracture assessment (VFA) or spinal x-ray to identify asymptomatic vertebral fractures 2
• Serum creatinine and creatinine clearance calculation 2
• Serum calcium, phosphate, PTH, and alkaline phosphatase 4
• Dental examination with completion of invasive dental procedures before starting therapy 2

Concurrent Supplementation (Non-Negotiable)

All patients must receive:

• Calcium 1,000-1,200 mg daily 2, 3
• Vitamin D 600-800 IU daily with target serum 25(OH)D level ≥30 ng/mL 2, 4, 3

Special Population Considerations

Chronic kidney disease (eGFR 30-60 mL/min):

• PTH/PTHrP analogs require no renal dose adjustment and can be safely used 4
• Evaluate for CKD-mineral and bone disorder by measuring serum calcium, phosphate, PTH, and alkaline phosphatase 4
• Monitor serum calcium and phosphorus at least monthly for first 3 months, then every 3 months 4

Patients who can become pregnant:

• PTH/PTHrP may be used if growth plates are closed 1
• Effective birth control is required if sexually active 1

Patients <40 years with very high risk:

• PTH/PTHrP conditionally recommended 1
• Use only in adults with closed growth plates 1

Critical Sequential Therapy Requirement

After completing PTH/PTHrP therapy, patients require subsequent anti-resorptive therapy (bisphosphonates or denosumab) to prevent rapid bone loss. 4, 3 This is not optional—failure to transition to anti-resorptive therapy results in loss of gains achieved with peptide treatment.

Monitoring During Treatment

• BMD with VFA or spinal x-ray every 1-2 years during therapy 2
• Continue monitoring every 1-2 years after discontinuation 2
• Reassess fracture risk after 3-5 years to determine need for continued anti-resorptive therapy 2

When PTH/PTHrP Is NOT Appropriate

Do not use peptide therapy in:

• Low-risk patients (no prior fracture, T-score >-2.5, FRAX major osteoporotic fracture <20%) 1, 2
• Patients with open growth plates 1
• As first-line therapy in moderate-risk patients where bisphosphonates or denosumab are appropriate 1, 2

The American College of Rheumatology strongly recommends against osteoporosis medications in low-risk patients due to known harms (osteonecrosis of jaw, atypical femur fractures, thromboembolic events) without evidence of benefit. 1, 2

Growth Hormone Peptide Treatment in Chronic Kidney Disease

Pediatric CKD Patients

Growth hormone therapy is recommended for children with stage 3-5 CKD or on dialysis aged >6 months who have:

• Height below 3rd percentile for age and sex 1
• Height velocity below 25th percentile 1
• Growth potential remaining (unfused epiphyses) 5
• Other treatable causes of growth failure adequately addressed 1

Dosing for pediatric CKD: Weekly dosage up to 0.35 mg/kg body weight divided into daily subcutaneous injections. 5

Timing considerations for dialysis patients:

• Hemodialysis: inject at night before sleep or ≥3-4 hours after hemodialysis to prevent hematoma 5
• CCPD: inject in morning after completing dialysis 5
• CAPD: inject in evening at time of overnight exchange 5

Nephropathic Cystinosis

GH therapy should be considered at all stages of CKD in children with cystinosis who have persistent growth failure, as these patients are prone to severe growth failure in early life despite mild GFR reduction due to renal Fanconi syndrome. 1

Adult Growth Hormone Deficiency

Two dosing approaches for adults with confirmed GHD:

Weight-based regimen:

• Start: ≤0.006 mg/kg daily 5
• Maximum: 0.025 mg/kg daily (age ≤35 years) or 0.0125 mg/kg daily (age >35 years) 5

Non-weight-based regimen:

• Start: 0.2 mg/day (range 0.15-0.30 mg/day) 5
• Increase gradually every 1-2 months by 0.1-0.2 mg/day increments 5

Dose titration guided by clinical response, adverse effects, and age/gender-adjusted serum IGF-1 concentrations. 5 Lower starting doses and smaller increments should be used in older patients and obese individuals. 5

Natriuretic Peptides in Heart Failure

Nesiritide (BNP analogue) is approved only for acute heart failure management, not chronic outpatient therapy. 1 Intermittent or continuous outpatient infusion of nesiritide is not recommended unless definitive studies demonstrate safety and efficacy. 1

Common Pitfalls to Avoid

Do not start osteoporosis peptide therapy without proper risk stratification—treating low-risk patients exposes them to unnecessary harm without evidence of benefit. 1, 2

Do not forget mandatory calcium and vitamin D supplementation—these are essential components, not optional additions. 2, 4, 3

Do not use PTH/PTHrP as monotherapy—sequential anti-resorptive therapy is required after completion to maintain bone gains. 4, 3

Do not use growth hormone for osteoporosis treatment—historical studies showed no skeletal mass increment with significant side effects including hyperglycemia, hypertension, and carpal tunnel syndrome. 6