Effect of Teriparatide on Subsequent Fracture and Bone Mineral Density in 47 Women with Pregnancy- and Lactation-associated Osteoporosis and Vertebral Fractures

Abstract

Introduction Pregnancy- and lactation-associated osteoporosis (PLO) with predominantly vertebral fractures is a rare but severe disease which can occur in the last trimester of pregnancy or postpartum. The aim of the present study was to assess the impact of teriparatide on subsequent fractures and bone mineral density (BMD) in patients with PLO. Materials and Methods A total of 47 patients with PLO and postpartum spinal fractures (mean: 4 fractures) undergoing treatment with teriparatide were investigated. The data collection period was set between 2006 and 2018. All patients received a subcutaneous injection of 20 µg teriparatide once a day for 24 months as well as individually adapted vitamin D supplementation. After 24 months of treatment, all women received no further treatment and either had regular menstrual cycles or took oral contraceptives. Fractures were confirmed by X-ray or MRI. Changes in BMD from baseline were examined using serial DXA measurements. Results After 24 months of teriparatide treatment, we could demonstrate an increase in BMD at the lumbar spine, femoral neck and total hip of + 30.1%, + 11.7% and + 12.2% respectively (p < 0.001 for all). At 12 months after cessation of treatment, BMD remained stable compared to the 24-month measurements at the lumbar spine, femoral neck and total hip which showed non-significant changes of + 1.4%, + 2.6% and + 4.1% respectively. Out of the 47 patients with PLO with a mean of 4 existing fractures, 4 patients (7.8%) sustained a subsequent fracture, two after 3 – 5 months of treatment and two at > 6 months of treatment. Conclusion 24 months of treatment with teriparatide in women with PLO and multiple vertebral fractures significantly increased BMD, predominantly BMD of the spine. As patients were premenopausal, there was no significant decrease in BMD in the following 12 months after cessation of treatment.

Bridging the Gap: Pregnancy—And Lactation—Associated Osteoporosis

“…According to our methods, we identified the following 12 original studies (Table 1). [38][39][40][41][42][43][44][45][46][47][48][49]).…”

Proceedings of the 2023 Santa Fe Bone Symposium: Progress and Controversies in the Management of Patients with Skeletal Diseases

“…Anecdotal and uncontrolled use of bisphosphonates, teriparatide, denosumab, romosozumab, strontium ranelate, and calcitonin have been reported with 10–30 % increases in BMD achieved, but whether this exceeds what would have occurred naturally after weaning remains unknown ( 73 , 81 ). One large case series reported no difference in the magnitude of increase in BMD after use of bisphosphonates, teriparatide, or combination therapy, but found twice as many fractures subsequently occurred in those who had been treated compared to those who were not treated ( 77 ).…”

“…Use of antiresorptive medications could conceivably blunt post-weaning recovery, given that combination therapy blunted the effect of osteoanabolic treatment in women with osteoporosis ( 27 ). In postmenopausal women, any gains in BMD achieved with osteoanabolic treatment are lost in 12–18 months unless antiresorptive treatment is initiated, but limited data from women with osteoporosis associated with pregnancy and lactation suggest that the effects of osteoanabolic treatment may persist without need for antiresorptive medication ( 81 ). However, the reported follow-up was only one year.…”

“…Most women can be reassured that fractures should not recur during subsequent pregnancies, especially because many cases have been nutritional in origin. However, recurrences have been documented in 20–25 % of cases, especially when genetic causes of skeletal fragility were identified or where nutritional deficiencies were not corrected ( 73 , 81 ).…”

Crosstalk within a brain-breast-bone axis regulates mineral and skeletal metabolism during lactation

“…More frequently, anabolic agents are used to treat PLO and have demonstrated clinical improvement in pain and increases in BMD ( Stumpf et al, 2007 ; Hellmeyer et al, 2010 ; Choe et al, 2012 ; Lampropoulou-Adamidou et al, 2012 ; Lee et al, 2013 ; Bonacker et al, 2014 ; Pola et al, 2016 ; Ijuin et al, 2017 ; Laroche et al, 2017 ; Hong et al, 2018 ; Cerit and Cerit, 2020 ; Tuna et al, 2020 ). Two recently published studies have demonstrated that use of teriparatide results in improved bone density as compared to calcium and vitamin D alone ( Lee et al, 2021 ; Hadji et al, 2022 ). It is also notable that the study from Lee and colleagues demonstrated that teriparatide could be used in this setting to increase bone density and that subsequent use of an antiresorptive medication may not be necessary as patients who did not receive an anti-resorptive agent did not lose bone for up to 2 years after discontinuing anabolic therapy with PTH ( Lee et al, 2021 ).…”