Parathyroid hormone was associated with significantly greater increases in BMD and fewer vertebral fractures — but not nonvertebral fractures.
Clinicians should address the prevention or treatment of osteoporosis in patients taking glucocorticoids. In this randomized trial, researchers compared alendronate (Fosamax) and teriparatide (Forteo; the recombinant human parathyroid hormone that stimulates bone formation) in 428 patients who were taking steroids, mostly for rheumatologic disorders. All patients had received the equivalent of at least 5 mg of prednisone daily for at least 3 months, and had either bone-mineral density (BMD) T scores of –2.0 or less, or previous fragility fractures plus T scores of –1.0 or less. The study was supported by the maker of teriparatide, which employs five of the eight authors.
Patients received subcutaneous teriparatide or oral alendronate daily, plus placebos for the opposite treatment. At 18 months, the mean increase in BMD was significantly greater with teriparatide than with alendronate at both the lumbar spine (7.2% vs. 3.4%) and the hip (3.8% vs. 2.4%). Radiographic vertebral fractures occurred significantly less frequently with teriparatide than with alendronate (1 vs. 10 fractures); in contrast, nonvertebral fractures occurred slightly (but not significantly) more frequently with teriparatide than with alendronate (12 vs. 8 fractures).
Comment: Bone density outcomes and vertebral, but not nonvertebral, fracture outcomes in this trial favored teriparatide over alendronate. The study is continuing for another 18 months, after which it will be important to examine longer-term outcomes. Drawbacks of teriparatide include the need for daily injections and the cost, which can reach $10,000 per year. In addition, alendronate tablets were "overencapsulated" to make them look like placebo tablets; one hopes that this didn’t result in reduced absorption and bias against alendronate.
Published in Journal Watch General Medicine November 27, 2007
Saag KG et al. Teriparatide or alendronate in glucocorticoid-induced osteoporosis. N Engl J Med 2007 Nov 15; 357:2028.