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Forteo - What next?
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megmo84 posted:
Hello,

My two years on Forteo is nearing its end. I'd like to make an informed decision about which drug to take after Forteo to preserve the bone density I've gained. Reclast has been proposed by my physician. However, I've researched the impact of bisphophonates on bone quality so the idea of these medications scares me.

As a 27-year-old woman with amenorrhea and no previous fractures, I've toyed with the idea of not taking any follow-up drug outside of birth control (for estrogen) -- an effort to maintain bone quality with or without improved bone density. Too risky, some might say.

What have others taken as a follow-up drug to Forteo? Success? Side effects?

Your insights are much appreciated!
~megmo84
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bonebabe responded:
The proven course of treatment following Forteo is a bisphosphonate. To not take one would have you risk the new bone you've grown fracturing. Pretty much a waste then of your time and money. Birth control just won't do it. For you to have been on Forteo, your bone quality was already compromised. I'm not understanding your reluctance to take a drug that would reduce the risk of you fracturing.

All patients of ours who've completed Forteo treatment have taken a bisphosphonate after. All of them. Every single one. To not take one is like washing only half of your hair. You need to complete the process to get the full benefit.

I don't know where you've researched, but to just search the web to find answers, not knowing the background of some sites can be risky in itself. I'd advise you to stick with the National Osteo Foundation (www.nof.org ) and the the International Society of Clinical Densitometrists (www.iscd.org ) These two sites are the gold standards of all things osteoporosis, based on Results Based Medicine.

Sometimes when we read too much, it's counterproductive and can be scary. Don't ever read the info on Chantix or prednisone or Adderall, to name a few - all medications that do people a world of good.

Reclast is a good drug. It's convenient for people who have active lives and is paid out of your health, not drug, insurance.
You can take it for 5 years, then get off. If your bone density remains stable that may be all you need to do.
 
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NATIONAL OSTEOPOROSIS FOUNDATION
Adi Cohen, MD, MHS responded:
There is less information available about treatment options for premenopausal women than for postmenopausal women with osteoporosis, because the condition is uncommon. There is also very little data available to guide us in making decisions about which drugs to use (if any) after a course of teriparatide (Forteo) in a young woman. The potential benefits and risks of bisphosphonate use may be quite different in premenopausal women compared to postmenopausal women.

Alendronate (Fosamax) and risedronate (Actonel) have been approved by the U.S. Food and Drug Administration (FDA) for use in certain premenopausal women taking steroid medicines such as prednisone and cortisone. However, because of toxic effects in pregnant animals, these medicines carry a Category C rating for safety in pregnancy from
the FDA. Since bisphosphonates may remain in the skeleton for years, it should be kept in mind that there is also the potential for adverse effects after stopping bisphosphonates. In general, medications for osteoporosis should be used with great caution in premenopausal women because less information is known about how they will affect young women in the short and long term.
 
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megmo84 replied to Adi Cohen, MD, MHS's response:
I've often heard Prolia (denosomab) thrown around as yet another drug for osteoporosis. However, I never knew its mechanism of action and how it may benefit estrogen deficient women until now.

A brief summary: In normal bone physiology, estradiol causes osteoblasts to produce osteoprotegerin (OPG), which binds and neutralizes RANK ligand, a contributor to bone resportion. Similarly, Prolia targets RANK ligand, thereby inhibiting osteoclast activity. Some reports suggest that unlike bisphosphonates, Prolia may actually help build bone rather than simply stopping its destruction.

Could this be a viable option for a follow-up medication to Forteo?
 
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WyoDeb replied to Adi Cohen, MD, MHS's response:
Finally! Someone who acknowledges premenopausal osteoporosis. I started on Boniva when I was 46. My T-scores still nose dived. I am now 50 and on Forteo. After Forteo I am supposed to take a bisphosphonate-even when it did not maintain bone mass originally? Should I try a different one? My last T-score was -4.0 and I have had a spinal fracture (dumping fall leaves) so non-stressed. Should I consider infusion? Is there a Forteo infusion?
 
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bonebabe replied to WyoDeb's response:
No, there's no Forteo infusion, but there is a bisphosphonate infusion called Reclast. That is given once a year and could be a good option for you. It's possible that your scores worsened on the Boniva because your body was decreasing it's production of estrogen, you didn't consume adequate calcium to "feed" the Boniva or you could have an absorption problem. Make sure you're taking 1200 mg of calcium each day, 600 with 2 meals for best absorption. Also you need 2000 IU of Vit D to send the calcium to the bones. I'd also order the booklet "Boning Up on Osteoporosis" from the National Osteo Foundation (www.nof.org ) for more information and illustrations on proper body mechanics.
 
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megmo84 replied to bonebabe's response:
Bonebabe - Regarding my previous message, any thoughts on Prolia?
 
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bonebabe replied to megmo84's response:
The patients we have on Prolia have not been taking it long enough to track (>2yrs). However, the clinical trials and tolerance of our patients point to it being effective and having few, if any, side effects.

It's being promoted by doctors as a good followup to Forteo and it both increases bone cell production and slows down the resorption of old cells. A twice yearly injection is also very convenient for people with busy lives and for those who have GERD issues.

We'll know more about it as the time comes around for followup DXA's, but in the meantime, it looks to be a good choice.
 
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megmo84 replied to bonebabe's response:
Glad to hear your positive feedback. Thanks again.
 
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megmo84 replied to bonebabe's response:
Hi Bonebabe - Does the immunosuppresive risks of Prolia concern you or the medical staff at your facility? I'm eager to start Prolia, but am wondering if a bisphosphonate might be a safer approach. Prolia is relatively new, while bisphosphonates have received more research.

Appreciate your input!
 
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bonebabe replied to megmo84's response:
Our medical director says that Prolia is not just another choice of osteo meds. She, an osteoporosis expert and rheumatologist, says it's so complicated, that she's not even prescribed it for any of her patients. I'm not sure why she's saying this, but she's adamant that it not be used unless all other meds (except Forteo) have been tried.
 
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megmo84 replied to bonebabe's response:
Good to know. In spite of the hype surrounding their side effects, another stint of bisphosphonates looks like my safer option.
 
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Tomato05 replied to megmo84's response:
Yes, I agree with you - bisphosphonates are "safer" until more is known about Prolia.


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