The effectiveness of teriparatide in the clinical practice--attenuation of the bone mineral density outcome by increasing age and bisphosphonate pretreatment.

BACKGROUND: Teriparatide is a potent anabolic agent for severe osteoporosis. OBJECTIVES: A primary objective of this retrospective study was to define the efficacy of teriparatide in terms of bone mineral density (BMD) changes and relief of back pain in clinical practice. METHODS: The patient population comprises 119 osteoporotic patients treated with teriparatide for median 539 (range 179-926) days. RESULTS: The mean BMD gain was 0.9% in the total hip (P = 0.0075), 2.1% in the femoral neck (P = 0.0006), and 8.5% in the lumbar spine (P = 0.0085). In the whole patient population age associated inversely with BMD changes in the total hip (P = 0.019) and in the femoral neck (P = 0.0036). A history of significant bisphosphonate pretreatment (n = 90) reduced BMD response in the total hip (P = 0.039). The total exposure of any prior bisphosphonate was negatively correlated with BMD response in the total hip (P = 0.0421). Half of the patients reported relief of back pain during the treatment. Leg pain, nausea, and dizziness were most frequent adverse concerns. CONCLUSIONS: Teriparatide works in clinical practice as well as in clinical trials. Younger subjects benefited more than older patients from teriparatide in the total hip and in the femoral neck. Bisphosphonate pretreatment attenuated teriparatide-induced BMD gain.

Teriparatide treatment complicated by malignant myeloma.

Recombinant human parathyroid hormone (1-34) (rhPTH 1-34), teriparatide (Forsteo in Europe), is a new compound that has been introduced and shown to be successful in the treatment of osteoporosis. The mechanisms of action include a pulsative influence on the RANKL/OPG system resulting in osteoblast activation and increased bone formation by teriparatide. In malignant myeloma there is an imbalance between osteoclast and osteoblast activity with involvement of the RANKL/OPG system among others. We report a case with monoclonal gammopathy of uncertain significance (MGUS) who developed malignant myeloma after teriparatide treatment and we suggest that in addition to malignant myeloma and smouldering myeloma, MGUS should also be considered contraindicated for teriparatide treatment.

Malignant myeloma in a patient after treatment for osteoporosis with teriparatide; a rare coincidence.

A breakthrough in understanding of mechanisms of bone structure regulation has brought about the introduction of the new synthetic recombinant human parathyroid hormone 1-34 (PTH1-34; Teriparatide) in the treatment of osteoporosis. These mechanisms, involving the RANKL, RANK, and osteoprotegerin system, are also known to be involved in malignant myeloma (MM) and tumor and bone metastasis development. We report a case in which MM was found after treatment of osteoporosis with teriparatide. We were unable to demonstrate any direct association between the MM and teriparatide treatment. However, it seemed intriguing that similar mechanisms are activated in the development of MM as those being working during teriparatide treatment. In the view of our case, we propose that MM by examination of serum protein fraction should be searched for prior to treatment with teriparatide as it is an exclusion criterion in teriparatide treatment of secondary osteoporosis. A search for other metastatic diseases prior to teriparatide treatment should eventually also be considered. The theoretical basis for our proposal is discussed.