From the Guidelines
Forteo (teriparatide) can be used in patients with a history of kidney transplant, but requires careful consideration, particularly with regards to potential hypercalcemia and its impact on graft function, as noted in the 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1.
Key Considerations
- For kidney transplant recipients with osteoporosis, Forteo may be prescribed at the standard dose of 20 mcg subcutaneously once daily for up to 24 months, with careful monitoring of serum calcium levels, especially in the first weeks of treatment, due to the risk of hypercalcemia 1.
- Comprehensive baseline labs, including serum calcium, phosphorus, parathyroid hormone, vitamin D levels, and renal function, should be obtained before initiating therapy, as recommended in the guideline for patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) 1.
- Regular renal function tests are essential to ensure the transplanted kidney remains stable, and consultation with both the transplant nephrologist and endocrinologist is necessary to coordinate care and monitor for potential drug interactions with immunosuppressive medications 1.
- The use of Forteo in patients with a history of kidney transplant is supported by the guideline, which conditionally recommends expert evaluation for CKD-MBD in renal transplant recipients and treatment with oral or IV bisphosphonate, denosumab, PTH/PTHrP, or raloxifene based on individual patient factors 1.
Monitoring and Maintenance
- Close monitoring of serum calcium is crucial during treatment, particularly in the first weeks, as hypercalcemia is a potential side effect that could affect graft function, as noted in the study on chronic kidney disease-mineral and bone disorder: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference 1.
- Patients should also have regular renal function tests to ensure the transplanted kidney remains stable, and adequate calcium and vitamin D supplementation should be maintained during treatment, as recommended in the guideline for patients with CKD-MBD 1.
- The potential benefits of Forteo in stimulating new bone formation through its action as a recombinant parathyroid hormone analog should be weighed against the potential risks, particularly in patients with compromised bone health due to long-term immunosuppression and prior steroid use, as noted in the guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Forteo in History of Kidney Transplant
- Forteo, also known as teriparatide, is an anabolic agent that may provide a beneficial treatment option for kidney transplant recipients with osteoporosis and low bone turnover 2.
- A study found that teriparatide significantly improved bone mineral density (BMD) at the lumbar spine and total hip in kidney transplant recipients with osteoporosis and low bone turnover, showing a favorable safety profile 2.
- Another study compared the effect of alendronate and teriparatide on BMD in the treatment of osteoporosis after renal transplantation, and found that teriparatide was more effective than alendronate in improving BMD, but had more adverse effects 3.
Bone Disease in Kidney Transplant Recipients
- Kidney transplant recipients are at high risk for bone disorders, particularly low bone turnover disease, which increases fracture risk 2.
- Bisphosphonates have been shown to improve BMD at the lumbar spine and femoral neck after 12 months in renal-transplant recipients, but there is currently no widely recognized strategy for the prevention of corticosteroid-induced osteoporosis 4.
- A meta-analysis found that bisphosphonates moderately to importantly reduce the loss of vertebral and femoral bone mineral density, but there is insufficient evidence to support routine use of bisphosphonates to reduce fracture risk after kidney transplantation 5.
Management of Osteoporosis in Kidney Transplant Recipients
- Proper management and appropriate preventive health measures may improve long-term patient and allograft survival in patients with chronic kidney disease after transplantation 6.
- Teriparatide and alendronate are two treatment options for osteoporosis after renal transplantation, but more studies are needed to determine the optimal treatment strategy 3.
- The choice of treatment should be based on individual patient factors, such as the presence of low bone turnover disease, and the potential for adverse effects 2, 3.