New Study Shows Teriparatide may be Better at Preventing Fractures than Bisphosphonates

Caucasian, postmenopausal women make up the highest percentage of patients who experience osteoporosis-related vertebral (74.4%) and nonvertebral (72.8%) fractures.¹ Fractures, especially subsequent ones, positively correlate with an increased mortality risk.²

Although many studies have shown bone mineral density increases more with teriparatide compared to bisphosphonates, only 1 study, the VERO trial (NCT01709110), directly compares fracture incidence.³

A recent article, published in the journal Medicine, compares the efficacy of teriparatide and bisphosphonates in fracture prevention in postmenopausal women with osteoporosis.³

The authors conducted a meta-analysis, pooling data from 9 different randomized controlled trials, including the VERO trial. Ouyang et al. assessed the incidence of new vertebral and non-vertebral (e.g., hip, arm) fractures in the 2 study arms.³

Overall, the analysis results support that teriparatide was better than bisphosphonates in preventing both fracture types, vertebral and nonvertebral, in postmenopausal women with osteoporosis (fracture risk not specified). These results reflect data collected at both 12- and 18-month follow-up visits.³

Women taking teriparatide did not experience more adverse events (eg, arthralgia, back pain, hyperuricemia) compared to bisphosphonates.³

Two obvious limitations exist for teriparatide use⁴:

• Cost: average wholesale price (AWP) is ~$3,000 (generic) for a 28-day supply
• Administration: daily subcutaneous injection

Oral and intravenous bisphosphonates are less expensive (AWP: ~$150) and administered anywhere from once per week to once per year.⁴

The 2020 American Association of Clinical Endocrinologists & American College of Endocrinology and 2020 Endocrine Society guidelines contain a treatment algorithm based on fracture risk and history. Currently, teriparatide is only first-line therapy in postmenopausal osteoporotic women with very high fracture risk and/or prior fracture history. Bisphosphonates are first-line in women with high risk and/or no prior fractures and are an alternative treatment to teriparatide.^5-7

Despite the positive study findings, the authors concluded a cost-benefit analysis and further studies are necessary to determine what place teriparatide truly has in treatment guidelines.³

Justyna Sudyka is a 2021 PharmD Candidate at the University of Connecticut in Storrs.

REFERENCES

1. Robinson WA, Carlson BC, Poppendeck H, et al. Osteoporosis-related vertebral fragility fractures: A review and analysis of the American Orthopaedic Association's Own the Bone database. Spine (Phila Pa 1976). 2020;45(8):E430-E438. doi:10.1097/BRS.0000000000003324
2. Lee SB, Park Y, Kim DW, et al. Association between mortality risk and the number, location, and sequence of subsequent fractures in the elderly. Osteoporos Int. 2021;32(2):233-241. doi:10.1007/s00198-020-05602-x
3. Ouyang Y, Chen S, Wan T, Zheng G, Sun G. The effects of teriparatide and bisphosphonates on new fractures in postmenopausal women with osteoporosis: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2021;100(7): e24839. doi:10.1097/MD.0000000000024839
4. RED BOOK Online. IBM Micromedex [database online]. IBM Watson Health; 2021. Accessed March 22, 2021. https://www.micromedexsolutions.com
5. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. doi:10.4158/GL-2020-0524SUPPL
6. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: An Endocrine Society* clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. doi:10.1210/jc.2019-00221
7. Shoback D, Rosen CJ, Black DM, Cheung AM, Murad MH, Eastell R. Pharmacological management of osteoporosis in postmenopausal women: An Endocrine Society guideline update. J Clin Endocrinol Metab. 2020;105(3):dgaa048. doi:10.1210/clinem/dgaa048