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A. Women: Postmenopausal with osteoporosis and previous vertebral or non-vertebral fractures for at least 2 risk factors for fracture as listed below.     Risk factors for fracture:

1. Age 65 or older
2. BMI 20 or less
3. Current smoking
4. Current excessive alcohol use
5.  Family history of osteoporosis with a hip, wrist or spine fracture in a first degree relative
6.  Recurrent falls
7. Dementia
8. Immobilization (i.e. wheelchair bound)
9. Estrogen deficiency (menopause <45 or pre-menopausal amenorrhea >1 year)
10. Organ transplant or pending transplant
11. Endocrine and metabolic abnormalities (acromegaly, Cushing’s syndrome, hypercalciuria, hyperparathyroidism, hyperthyroidism, hypogonadism including anorexia nervosa, prolactinoma, renal tubular acidosis, type 1 diabetes mellitus, vitamin D deficiency)
12. Hematologic disorders (Gaucher’s disease, hemophilia, homocysteinuria, leukemia, lymphoma, multiple myeloma, pernicious anemia, thalassemia)
13. Gastrointestinal disease (celiac disease, chronic liver disease, gastrectomy, hemochromatosis, inflammatory bowel disease, parenteral nutrition, primary biliary cirrhosis)
14. Connective tissue abnormalities (amyloidosis, Ehler-Danlos syndrome, Marfan’s syndrome, osteogenesis imperfecta)
15. Rheumatologic disorders (ankylosing spondylitis, rheumatoid arthritis)
16. Drugs (Adrenocorticotropin, anticonvulsants, cyclophosphamide, cyclosporine, glucocorticosteroids, heparin, lithium, methotrexate, premenopausal tamoxifen, thyroxine 

1.  BMD testing after 1 year to monitor drug efficacy.

Description:

Teriparatide (Forteo) is a recombinant amino terminal fragment of parathyroid hormone (PTH). Endogenous PTH is the primary regulator of calcium and phosphate metabolism in the bone and kidney; it acts directly on the bone and kidney and also acts indirectly on the intestine to increase serum calcium concentrations. Teriparatide affects calcium and phosphorus metabolism in a pattern consistent with the known actions of endogenous PTH. Teriparatide binds to the same receptors as PTH and is known to exert effects identical to that of PTH on the bone and the kidney.

PTH and teriparatide stimulate bone formation and resorption and can increase or decrease bone mass, depending on the level of exposure. Teriparatide's anabolic effects manifest as in increase in skeletal mass, increase in the number of osteoblasts and osteoclasts allowing for an increase in bone remodeling, and an increase in bone strength. Osteoblasts have PTH receptors where teriparatide binds and stimulates bone-forming effects. Osteoclasts do not have PTH receptors, but appear to be activated by cytokines and other biochemical precursors that are released by stimulated osteoblasts. Teriparatide binds to the plasma-membrane receptors on osteoblasts and increases intracellular production of cyclic adenosine monophosphate (cAMP) and adenyl cyclase (AC). The release of cAMP and AC triggers osteogenesis and cAMP prompts the release of genes that drive the accumulation of osteoblasts and osteogenesis. The net result of increased number of osteoblasts and increased osteogenesis is increased bone mass and bone strength.

Teriparatide (Forteo)
dosage:
Subcutaneous dosage:
Adults: 20 mcg SC once daily for up to 2 years.

The most commonly reported adverse events include- hypercalcemia, hypercalciuria, orthostatic hypotension, dizziness, leg muscle cramps, hypertension, angina, syncope, nausea, vomiting, constipation and dyspepsia.

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