CASE POINT Ms. B’s history of compression fractures suggests the need for potent pharmacologic options to treat her osteoporosis. SERMS and calcitonin nasal spray are felt to be less potent and therefore are not the preferred treatment recommendations for her.
Parathyroid hormone analogs. The availability of the parathyroid hormone analogs teriparatide and abaloparatide gives patients and health care providers another treatment option for osteoporosis.11 These potent stimulators of bone remodeling help reduce future fracture risk. Teriparatide and abaloparatide are considered anabolic bone agents, rather than antiresorptive medications. These medications are administered subcutaneously daily for no more than two years. Many health care providers use parathyroid hormone analogs for patients with severe osteoporosis (T score, ≤ –3.5 without fragility fracture history or ≤ –2.5 with fragility fracture history).12 The cost of these agents must be considered when recommending them to eligible patients.8
Parathyroid hormone analogs do carry a black box warning because of an increased risk for osteosarcoma observed in rat studies.13,14 These products should therefore be avoided in patients with increased risk for osteosarcoma: those who have Paget disease of the bone or unexplained elevations of alkaline phosphatase; pediatric and young adult patients with open epiphyses; or those who have had external beam or implant radiation therapy involving the skeleton.13,14
CASE POINT Because of Ms. B’s prior history of breast cancer requiring radiation treatment, parathyroid hormone analogs are not recommended.
Denosumab is a human monoclonal antibody, a RANKL inhibitor, that works by preventing the development of osteoclasts. This medication is administered subcutaneously every six months. There are no dosing adjustments recommended for hepatic impairment.11 The denosumab package insert does not specify a dosage adjustment for patients with renal impairment; however, clinical studies have indicated that patients who have a creatine clearance < 30 mL/min or who are on dialysis are more likely to experience hypocalcemia with denosumab use.15 As with other newer osteoporosis treatments, cost considerations should be discussed with patients.
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