Rapid resolution with teriparatide in delayed healing of atypical fracture associated to long -term bisphosphonate

SILVINA MASTAGLIA; GABRIEL AGUILAR; BEATRIZ OLIVERI *

Roma

Congreso; European Congress of Osteoporosis and Osteoarthritis; 2013

International osteoprosis Foundation

Bisphosphonates are the drugs most widely used to treat osteoporosis due to their efficiency in reducing osteoporotic fractures and improving bone mineral density (BMD). However, recent reports associate long-term bisphosphonates use with low-impact atypical fractures and prodromal pain1. Delayed fracture healing was observed in 26% of the cases1. Teriparatide is an anabolic drug which has shown to be effective in stimulating bone formation. Purpose: To describe a patient’s clinical course when treated with alendronate over a long period, having developed a right femoral diaphyseal fracture with a delayed healing fracture, rapidly healed with teriparatide. Case Report: A 57-yr-old postmenopausal Caucasian female, with a delayed healing of her right femoral diaphyseal fracture, after 10 months, despite of an orthopedic treatment. Her fracture had been preceded by a 9-month progressive, bilateral and severe pain in thighs. Her medical history included a vulvar cancer at 44, osteoarthrosis and osteopenia treated with alendronate over 7 yrs. Menopause at 49. Her family history did not include any a maternal fragility fracture. She never smoked or consumed alcohol excessively. In first visit, she was using a walking-stick. It was considered as an atypical right femoral fracture associated to long-term alendronate use. According to this information alendronate was suspended. The following studies were performed: bone densitometry [(DXA, Lunar Prodigy, Madison, USA): Lumbar Spine (L2-L4): 0.912g/cm2; T-score: -2.4 and Left Total Femur: 0.805g/cm2; T-score: -1.6]; mineral metabolism laboratory iPTH: 40ng/ml (rv:10-65ng/ml), 25OHD: 40ng/ml (rv:>30ng/ml); sCTX: 318 ng/ml (rv:80-590ng/ml), BSAP: 76UI/l (rv:31-95UI/L)] and a left femur magnetic resonance imaging (MRI) which revealed a diaphyseal fracture from stress. Prescription: 20µg daily of subcutaneous teriparatide (recombinant human PTH1-34; Forteo; Eli Lilly&Co., IN). After a 10-day treatment, the patient expressed a significant pain reduction, no longer requiring any device to walk. In 3 months, a CT scan showed the healed fracture, thus the patient could return to her usual activities. Conclusion: Atypical fracture healing associated to a long-term alendronate use was accelerated by 20µg daily subcutaneous teriparatide, leading to a fast recovery of her mobility and quality of life.