Resolution of Osteonecrosis of the Jaw After Teriparatide [Recombinant Human PTH-(1-34)] Therapy

Abstract

To the Editor: Although exceedingly rare in the population with postmenopausal osteoporosis, osteonecrosis of the jaw (ONJ) has a significant impact on the morbidity of the unfortunate patients who develop it. Currently recommended treatments have proven to be suboptimal, as many patients remain unresponsive. We describe the second case of teriparatide therapy for treatment of ONJ that was unresponsive to conventional therapies. Bisphosphonates are one of the most prescribed drugs in North America, with over 17 million prescriptions per year1. There are several different indications for the use of bisphosphonates, and several forms are available, including an intravenous (IV) form (i.e., pamidronate and zoledronate) in the treatment of hypercalcemia in malignant diseases of bone such as multiple myeloma and breast cancer metastasis to the bone. IV bisphosphonates are also used in the pediatric population to treat osteogenesis imperfecta and idiopathic juvenile arthritis. Finally, the most common indication for bisphosphonates is in the treatment of osteoporosis, where an oral form is typically used (e.g., alendronate, risedronate). Osteonecrosis of the jaw (ONJ) is a serious side effect of bisphosphonate therapy that has only been recently recognized. Since first described by Marx, et al in 2003, where 36 oncologic patients taking pamidronate or zoledronate presented with osteonecrosis of the jaw2, hundreds of cases have been reported in cancer patients treated with IV bisphosphonates; but more recently, cases have also been reported in patients with osteoporosis treated with oral bisphosphonates. Based on current literature, 94% of patients with reported bisphosphonate-induced ONJ were treated with an IV form, while the remaining 6% were treated with an oral bisphosphonate3. The estimated incidence of ONJ in patients receiving IV bisphosphonate therapy in the setting of multiple myeloma ranges from 4.5 to 12.8%4, and from 1.2 to 12.0% in the … Address reprint requests to Dr. Adachi. E-mail: jd.adachi{at}sympatico.ca