Teriparatide-Associated Late Hypercalcemia: A Report of Two Cases and Literature Review

Abstract

Introduction Teriparatide, recombinant human parathyroid hormone (1–34), is a safe and usually well-tolerated medication. We describe two cases of late-onset hypercalcemia associated with teriparatide use and report current evidence of hypercalcemia during the treatment with PTH analogs. Case report Case 1 is a 54-year-old man with a history of osteoporosis, previously treated with 6 months of teriparatide, but had not been consistent in taking the medication. Before restarting teriparatide, his serum calcium, PTH and vitamin D were normal. Six months into the treatment, he developed asymptomatic hypercalcemia of 11.2 mg/dL 24 h after the last dose. Repeat serum calcium was normal and treatment was continued. Case 2 is a 75-year old woman with a history of osteopenia and severe scoliosis. Before starting teriparatide, her calcium, PTH and vitamin D were normal. Six months into the treatment, she developed asymptomatic hypercalcemia of 12.5 mg/dL. Teriparatide was held and subsequently her serum calcium normalized. Discussion Transient hypercalcemia can occur during treatment with teriparatide and usually resolves within 16 h after administration. Late hypercalcemia, occurring more than 24 h after the dose, is rarely seen. It is usually mild, asymptomatic and rarely occurs repeatedly. Hypercalcemia occurs more often in patients with pre-existing hypercalcemia or vitamin D deficiency. It is rarely a cause of treatment disruption (0.18–4%). Conclusion Clinicians should be aware of this side effect, especially in patients who may be at risk of complications of hypercalcemia.

Teriparatide-Associated Hypercalcemia Concomitant With Acute Kidney Injury: A Case-Report

“…Transient hypercalcemia is an uncommon adverse complication of teriparatide and is reported in only 1-3% of patients [3]. Several cases of hypercalcemia due to teriparatide have been reported, most of which resolved within a few days after teriparatide discontinuation [4]. Although the pathophysiology is not fully understood, we believe that the onset of hypercalcemia in our patient was associated with increased bone resorption.…”

Delayed and significant hypercalcaemia due to teriparatide therapy: a case report and review

“…Only eight case reports of delayed hypercalcaemia were identified, with it being noted on the first calcium check performed between 8 and 52 weeks after starting teriparatide [ 2 , 6 – 11 ]. All patients were normocalcaemic at baseline and where checked serum PTH [ 6 – 11 ] and 1,25(OH)D levels [ 8 , 9 , 11 ] at the time of hypercalcaemia were suppressed or normal.…”

“…All patients were normocalcaemic at baseline and where checked serum PTH [ 6 – 11 ] and 1,25(OH)D levels [ 8 , 9 , 11 ] at the time of hypercalcaemia were suppressed or normal. Four patients were asymptomatic and had serum calcium between 2.74 and 3.23 mmol/l [ 2 , 7 , 10 ], with one resolving on continuing treatment and stopping calcium supplements [ 2 ]. However, in all other cases teriparatide was stopped, three of whom had severe hypercalcaemia (> 3.50 mmol/l) [ 6 , 8 , 11 ] and two moderately high calcium levels (3.00–3.50 mmol/l) [ 2 , 7 ].…”

“…Four patients were asymptomatic and had serum calcium between 2.74 and 3.23 mmol/l [ 2 , 7 , 10 ], with one resolving on continuing treatment and stopping calcium supplements [ 2 ]. However, in all other cases teriparatide was stopped, three of whom had severe hypercalcaemia (> 3.50 mmol/l) [ 6 , 8 , 11 ] and two moderately high calcium levels (3.00–3.50 mmol/l) [ 2 , 7 ]. Five patients were hospitalised and treated with intravenous fluids [ 6 – 9 , 11 ] with two receiving frusemide [ 6 , 7 ] and one also a bisphosphonate and calcitonin [ 11 ].…”

“…This usually resolves within 16 to 24 h and is infrequently a cause of therapy cessation. However, delayed hypercalcaemia (persisting > 24 h after teriparatide administration) has been rarely reported with unclear predisposing risk factors [ 2 ]. We report a patient who developed a delayed moderate hypercalcaemia after teriparatide therapy and review other case reports in the literature to date.…”