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Teriparatide increased BMD in high-risk patients
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Teriparatide may improve bone mineral density more than alendronate in patients with osteoporosis at high risk for fracture.
Researchers from the University of Alabama at Birmingham compared the two anabolic therapies in 428 men and women aged 22 to 89 years with glucocorticoid-induced osteoporosis.
Those assigned to 20 mcg of teriparatide (Forteo, Eli Lilly) daily had an increased BMD at the lumbar spine compared with patients assigned to 10 mg of alendronate (Fosamax, Merck) daily (7.2% vs. 3.4%).
After one year, BMD at the total hip increased in the teriparatide group, and there were fewer new vertebral fractures (0.6% vs. 6.1%). Nonvertebral fractures were similar between the teriparatide and alendronate groups (5.6% vs. 3.7%). In addition, more patients who received teriparatide had elevated serum calcium.
Though it is an FDA-indicated osteoporosis therapy, teriparatide is not used for treatment of glucocorticoid-induced osteoporosis; alendronate is used instead. – by Katie Kalvaitis
N Engl J Med. 2007;357:2028-2039.
This is a very helpful, useful clinical article that should modify patient care. My caution would be, based on my experience, if the patient has previously received alendronate for a prolonged period of time, the effectiveness of the teriparatide is reduced. I would be enthusiastic about considering teriparatide in a naive patient, but I would be somewhat reluctant to start someone on it after prolonged alendronate therapy. There is not much written or published on this, but in my experience, long-term treatment with alendronate can wipe out the bone density response of teriparatide.
Alendronate and other similar drugs have been used now for many years, and they seem quite effective in preventing bone loss in patients treated with steroids. However, it is true that no comparison was ever made with teriparatide. Unfortunately, although this was a fairly large study, it was not large enough to look at the difference in fractures, which is the main clinical consideration. It was 10-to-1 fractures in favor of teriparatide. But, of course, you cannot judge on 11 total fractures. Teriparatide is not FDA indicated for this use in patients, but off-label use is often permitted by Medicare and private insurers, although that is tricky business. If a patient has significantly low bone density that approaches or is osteoporosis, it would seem reasonable to consider that treatment, particularly if they have had a previous fracture.
– Frederick Singer, MD
Director, Endocrine/Bone Disease Program, John Wayne Cancer Institute, Santa Monica, Calif.