Teriparatide and risedronate in sequence after proximal femoral fracture in severe osteoporosis

The efficacy of teriparatide in multi-fractured elderly patients to reduce significantly the rate of complications and the relative risk of new fracture has been recognized. Recently the prolonging of these beneficial effects with sequential use of bysphosphonates has been debated. The purpose of the present study was to evaluate bone turnover markers, compliance and persistence to treatment and relative risk of new fracture in severe osteoporotic patients who are managed with teriparatide and risedronate in sequence. METHODS: 28 compliant female between 59 and 91 years-old presenting a proximal femoral fracture treated surgically associated to a previous vertebral compression fracture were recruited. During hospitalization they were undergone to a routinary instrumental examines completed by biochemical bone turnover markers and BMD by DXA. From day 15 by recovery they received a standard supplementation of calcium carbonate and colecalciferol plus daily subcutaneous teriparatide per day for 18 months and then risedronate weekly or monthly for other 12 months. All the patients repeated: xrays of affected segments at 1 and 3 months; DEXA at first, second, third year; biochemical bone turnover markers within control visit at 1, 3, 6, 12, 18, 24, 30 months. RESULTS: The healing was detected with radiograms. The vitamin D was under minimum levels at admission in all patients but the supplementation was sufficient to normalize in one month. The other biochemical variables of bone formation and resorption peaked within the consolidation processes completed in 3 months. At 6 month they were indistinguishable from baseline and maintained for 30 months. Lumbar and contralateral femoral BMD were increased in the first year and maintained for another year. At 30 month follow-up the rate of survival was 100%, persistence was decreased to 93.9% because of discontinuation of risedronate in two patients for epigastralgy; none have needed a re-operation or was afflicted by new vertebral or non vertebral fracture. CONCLUSIONS: In severe osteoporosis the sequential therapy with teriparatide in the first 18 months after femoral fracture followed by risedronate for other 12 months may contribute to recover and maintain balanced the bone turnover markers without occurence of new fragility fractures or mobilization of implants.