Transient severe hypotension with once-weekly subcutaneous injection of teriparatide in osteoporotic patient: a case report and insight for the drug interaction between hypotensive agents and teriparatide

Abstract

Teriparatide, a recombinant form of parathyroido hormone, were well recognized as a useful option for the treatment of the osteoporosis (1-3). Intermittent injection of teriparatide activates osteoblasts and results in incresase in bone mineral density (1,3). It has been demonstrated to effectively reduce vertebral and nonvertebral fractures, and back pain in postmenopausal osteoporotic patients (3 -6). Some side effects of teriparatide include headache, nausea, dizziness, and limb pain were reported as "common" to "very common" by the European Medicines Agency (3,7,8). Although reports of decreased blood pressure after injection of teriparatide were present, there is no detailed case report about the severe reduction in blood pressure of each injection and suggesting drug interaction between hypotensive agents and teriparatide. This potential drug interaction and its clinical consequences have not been discussed.Here we present a 80 -year -old woman of transient asymptomatic hypotension as acute -phase reactions with once -weekly subcutaneous injection of teriparatide for the treatment of osteoporosis with hypertension disease. Systolic, diastolic blood pressure and heart rate after injection were studied. To the best of our knowledge, this is the first report about the severe reduction in blood pressure of each injection of once -weekly teriparatide and suggesting drug interaction with hypotensive agents. CASE PRESENTATION :A 80 -year-old woman with hypertension disease had a chronic low back pain due to spondylolisthesis at L4/5 and old lumbar compression fractures at L2, L3, and L4 ( Figure 1). She consulted our clinic to relief of her low back pain. She was 54 kg and 144 cm ; body mass index was 26.0 kg/m 2 . Bone metabolic markers, P1NP and TRAcP -5b, and bone mineral density at spine and femoral neck were evaluated before and after treatment (Table 1). She had not been receiving anti-osteoporotic medical therapy, although the patient had hypertension disease treated with hypotensive agents, valsartan (80 mg/day), hydrochlorothiazide (12.5 mg/day), atenolol (25 mg/day), and amlodipine besilate (6.93 mg/day), once a day in the morning. The physical examination was normal without neurological signs, except for an apparent slight thoraco -lumbar kyphosis. All laboratory findings were within normal limits. She has no history of autonomic dysfunction and transient hypotensive reaction.Once-weekly subcutouneous injection of teriparatide (hPTH (1-34), teriparatide acetate, TERIBONE TM , 56.5 μg, Asahi Kasei Pharma, Tokyo, Japan), injected at 14 O'clock, was applied to the patient for 24 weeks. As a safety management, systolic, diastolic blood pressure and heart rate were measured before, 30 min. after, and 60 min. after every subcutaneous injection of teriparatide. Blood pressure was measured using automatic devices (AC 05P, SUZUKEN CO., LTD. Aichi, Japan.) in sitting position with the CASE REPORT

Beneficial effects of sulfonamide-based gallates on osteoblasts in vitro

“…The disease can result in electrolyte imbalance and bone fracture, severely affecting quality of life in elderly patients. Current therapies for osteoporosis, including bisphosphonates, denosumab and teriparatide (parathyroid hormone), are associated with the following side effects: Osteonecrosis (1,2), prolonged union time for fractures (3), hypocalcaemia (4–6), headaches, nausea, dizziness, limb pain and transient severe hypotension (7). Furthermore, the cathepsin K inhibitor odanacatib, the anti-sclerostin antibody romosozumab and anti-Dickkopf-related protein 1 antibody exert their anti-osteoporotic effects via biological pathways, which may induce undesirable effects with long-term use.…”

Impact of Weekly Teriparatide on the Bone and Mineral Metabolism in Hemodialysis Patients With Relatively Low Serum Parathyroid Hormone: A Pilot Study

“…Similar to a previous report , weekly teriparatide had frequent adverse effects specific for HD patients, including hypotension and malaise. Weekly teriparatide might induce vasodilation compared to daily agents due to the high dose of each administration . Furthermore, HD patients with diabetes mellitus or arteriosclerosis frequently have a dysregulation of vascular tonus or compliance, thus requiring careful judgment when considering the use of weekly teriparatide.…”

CGK733 alleviates ovariectomy-induced bone loss through blocking RANKL-mediated Ca2+ oscillations and NF-κB/MAPK signaling pathways

“… 22 There is no denying that these medications work, but there are some unavoidable side effects, such as bisphosphonates, RANKL antibodies, which may lead to jaw bone death and atypical femur fractures, 23 selective estrogen receptor modulators, which may potentially increase the risk of endometrial and breast cancer with long-term use, 24 and teriparatide, which most commonly causes nausea, headaches, and dizziness. 25 Therefore, it is critical to investigate medications that can cure osteoporosis yet have fewer negative effects.…”