Sequential treatment with teriparatide and strontium ranelate in a postmenopausal woman with atypical femoral fractures after long-term bisphosphonate administration

Lampropoulou-Adamidou, Kalliopi; Tournis, Symeon; Balanika, Alexia; Antoniou, Ioulia; Stathopoulos, Ioannis P.; Baltas, Christos; Triantafillopoulos, Ioannis K.; Παπαϊωάννου, Νικόλαος

doi:10.14310/horm.2002.1448

Cited by 13 publications

(13 citation statements)

References 23 publications

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“…(75,76) In the past few years, numerous case reports and small prospective studies have reported healing of AFF or ONJ, typically occurring within a few months of starting teriparatide therapy. (97)(98)(99)(100) In addition, a few reports have demonstrated a beneficial effect of strontium ranelate in AFF. (97)(98)(99) Based on available reports, a limited course of teriparatide may be considered to accelerate healing of BP-related AFFs or ONJ, consistent with the recommendations of the ASBMR Task Force on Atypical Femoral Fractures and the International Consensus report on ONJ.…”

Section: Management Of Adverse Events Related To Bisphosphonatesmentioning

confidence: 99%

Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research

Adler

Fuleihan

Bauer

et al. 2015

Journal of Bone and Mineral Research

542

270

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Bisphosphonates (BPs) are the most commonly used medications for osteoporosis, but optimal duration of therapy is unknown. This ASBMR report provides guidance on BP therapy duration with a risk benefit perspective. Two trials provided evidence for long-term BP use. In the Fracture Intervention Trial Long-term Extension (FLEX), postmenopausal women receiving alendronate for 10 years had fewer clinical vertebral fractures than those switched to placebo after 5 years. In the HORIZON extension, women who received 6 annual infusions of zoledronic acid had fewer morphometric vertebral fractures compared with those switched to placebo after 3 years. Low hip T-score between −2 and −2.5 in FLEX and below −2.5 in HORIZON extension predicted a beneficial response to continued therapy. Hence, the Task Force suggests that after 5 years of oral BP or 3 years of intravenous BP, women should be reassessed. Women with previous major osteoporotic fracture, those who fracture on therapy, or others at high risk should generally continue therapy for up to 10 years (oral) or 6 years (intravenous), with periodic risk-benefit evaluation. Older women, those with a low hip T-score or high fracture risk score are considered high risk. The risk of osteonecrosis of the jaw and atypical femoral fracture increases with BP therapy duration, but such rare events are far outweighed by fracture risk reduction with BPs in high risk patients. For women not at high fracture risk after 3–5 years of BP treatment, a drug holiday of 2–3 years can be considered, with periodic reassessment. The algorithm provided for long term BP use is based on limited evidence in mostly Caucasian postmenopausal women and only for vertebral fracture reduction. It is probably applicable to men and patients with glucocorticoid-induced osteoporosis, with some adaptations. It is unlikely that future osteoporosis trials will provide data for formulating definitive recommendations.

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Section: Management Of Adverse Events Related To Bisphosphonatesmentioning

confidence: 99%

Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research

Adler

Fuleihan

Bauer

et al. 2015

Journal of Bone and Mineral Research

542

270

View full text Add to dashboard Cite

show abstract

“…In one case report of sequential therapy with TPTD and SR in a patient with alendronate associated-AFF, the authors concluded that sequential treatment was successful and may be a rational treatment option in managing incomplete AFF (Lampropoulou-Adamidou et al, 2013). In this case, TPTD therapy was delayed for 11 months following fixation of a complete AFF, however, the patient sustained an incomplete contralateral AFF during treatment with TPTD and 22 months following the first AFF.…”

Section: Discussionmentioning

confidence: 99%

A new contralateral atypical femoral fracture despite sequential therapy with teriparatide and strontium ranelate

2017

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Atypical femoral fractures (AFFs) are a rare association of anti-resorptive therapy for osteoporosis. Limited evidence-based management guidelines on their optimal treatment exist, with observational studies suggesting a role for teriparatide (TPTD) in AFF healing. We report a case of a 65-year-old woman with postmenopausal osteoporosis who sustained an AFF following long-term bisphosphonate therapy, and who subsequently developed a new contralateral AFF after completion of TPTD therapy and initiation of strontium ranelate (SR) treatment. The sequence of events in this case report showed that TPTD and SR did not prevent the development of a new AFF, and questions the optimal treatment of these stress fractures.

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“…PTH has been proposed as an intervention for recalcitrant AFFs and has already been used off-label clinically in several case reports and case series. (10,(15)(16)(17) PTH has also been used in the context of AFF in an individual with osteogenesis imperfecta, another condition associated with long-term bisphosphonate usage. (18) However, the capacity of PTH to remobilize BP in a fracture and the mechanism underlying improved healing remain unclear.…”

Section: Discussionmentioning

confidence: 99%

PTH(1-34) Treatment Increases Bisphosphonate Turnover in Fracture Repair in Rats

Murphy

Schindeler

Cantrill

et al. 2014

Journal of Bone and Mineral Research

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Bisphosphonates (BP) are antiresorptive drugs with a high affinity for bone. Despite the therapeutic success in treating osteoporosis and metabolic bone diseases, chronic BP usage has been associated with reduced repair of microdamage and atypical femoral fracture (AFF). The latter has a poor prognosis, and although anabolic interventions such as teriparatide ) have been suggested as treatment options, there is a limited evidence base in support of their efficacy. Because PTH acts to increase bone turnover, we hypothesized that it may be able to increase BP in turnover in the skeleton, which, in turn, may improve bone healing. To test this, we employed a mixture of fluorescent Alexa647-labelled pamidronate (Pam) and radiolabeled 14 C-ZA (zoledronic acid). These traceable BPs were dosed to Wistar rats in models of normal growth and closed fracture repair. Rats were cotreated with saline or 25 mg/kg/d PTH , and the effects on BP liberation and bone healing were examined by X-ray, micro-CT, autoradiography, and fluorescent confocal microscopy. Consistent with increased BP remobilization with PTH , there was a significant decrease in fluorescence in both the long bones and in the fracture callus in treated animals compared with controls. This was further confirmed by autoradiography for 14 C-ZA. In this model of acute BP treatment, callus bone volume (BV) was significantly increased in fractured limbs, and although we noted significant decreases in callus-bound BP with PTH (1-34) , these were not sufficient to alter this BV. However, increased intracellular BP was noted in resorbing osteoclasts, confirming that, in principle, PTH increases bone turnover as well as BP turnover.

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Sequential treatment with teriparatide and strontium ranelate in a postmenopausal woman with atypical femoral fractures after long-term bisphosphonate administration

Cited by 13 publications

References 23 publications

Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research

Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research

A new contralateral atypical femoral fracture despite sequential therapy with teriparatide and strontium ranelate

PTH(1-34) Treatment Increases Bisphosphonate Turnover in Fracture Repair in Rats

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