Components:
Treatment option:
Medically reviewed by Kovalenko Svetlana Olegovna, PharmD. Last updated on 27.03.2022
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Форстео is indicated in adults.
Treatment of osteoporosis in postmenopausal women and in men at increased risk of fracture. In postmenopausal women, a significant reduction in the incidence of vertebral and non-vertebral fractures but not hip fractures has been demonstrated.
Treatment of osteoporosis associated with sustained systemic glucocorticoid therapy in women and men at increased risk for fracture.
Posology
The recommended dose of Форстео is 20 micrograms administered once daily.
The maximum total duration of treatment with Форстео should be 24 months. The 24-month course of Форстео should not be repeated over a patient's lifetime.
Patients should receive supplemental calcium and vitamin D supplements if dietary intake is inadequate.
Following cessation of Форстео therapy, patients may be continued on other osteoporosis therapies.
Special populations
Patients with renal impairment
Форстео must not be used in patients with severe renal impairment. In patients with moderate renal impairment, Форстео should be used with caution. No special caution is required for patients with mild renal impairment.
Patients with hepatic impairment
No data are available in patients with impaired hepatic function. Therefore, Форстео should be used with caution.
Paediatric population and young adults with open epiphyses
The safety and efficacy of Форстео in children and adolescents less than 18 years has not been established. Форстео should not be used in paediatric patients (less than 18 years), or young adults with open epiphyses.
Elderly patients
Dosage adjustment based on age is not required.
Method of administration
Форстео should be administered once daily by subcutaneous injection in the thigh or abdomen.
Patients must be trained to use the proper injection techniques. A user manual is also available to instruct patients on the correct use of the pen.
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- Pregnancy and breast-feeding
- Pre-existing hypercalcaemia
- Severe renal impairment
- Metabolic bone diseases (including hyperparathyroidism and Paget's disease of the bone) other than primary osteoporosis or glucocorticoid-induced osteoporosis
- Unexplained elevations of alkaline phosphatase
- Prior external beam or implant radiation therapy to the skeleton
- Patients with skeletal malignancies or bone metastases should be excluded from treatment with teriparatide
Serum and urine calcium
In normocalcaemic patients, slight and transient elevations of serum calcium concentrations have been observed following teriparatide injection. Serum calcium concentrations reach a maximum between 4 and 6 hours and return to baseline by 16 to 24 hours after each dose of teriparatide. Therefore, if blood samples for serum calcium measurements are taken, this should be done at least 16 hours after the most recent Форстео injection. Routine calcium monitoring during therapy is not required.
Форстео may cause small increases in urinary calcium excretion, but the incidence of hypercalciuria did not differ from that in the placebo-treated patients in clinical trials.
Urolithiasis
Форстео has not been studied in patients with active urolithiasis. Форстео should be used with caution in patients with active or recent urolithiasis because of the potential to exacerbate this condition.
Orthostatic hypotension
In short-term clinical studies with Форстео, isolated episodes of transient orthostatic hypotension were observed. Typically, an event began within 4 hours of dosing and spontaneously resolved within a few minutes to a few hours. When transient orthostatic hypotension occurred, it happened within the first several doses, was relieved by placing subjects in a reclining position, and did not preclude continued treatment.
Renal impairment
Caution should be exercised in patients with moderate renal impairment.
Younger adult population
Experience in the younger adult population, including premenopausal women, is limited. Treatment should only be initiated if the benefit clearly outweighs risks in this population.
Women of childbearing potential should use effective methods of contraception during use of Форстео. If pregnancy occurs, Форстео should be discontinued.
Duration of treatment
Studies in rats indicate an increased incidence of osteosarcoma with long-term administration of teriparatide. Until further clinical data become available, the recommended treatment time of 24 months should not be exceeded.
Форстео has no or negligible influence on the ability to drive and use machines. Transient, orthostatic hypotension or dizziness was observed in some patients. These patients should refrain from driving or the use of machines until symptoms have subsided.
Summary of the safety profile
The most commonly reported adverse reactions in patients treated with Форстео are nausea, pain in limb, headache and dizziness.
Tabulated list of adverse reactions
Of patients in the teriparatide trials, 82.8 % of the Форстео patients and 84.5 % of the placebo patients reported at least 1 adverse event.
The adverse reactions associated with the use of teriparatide in osteoporosis clinical trials and post-marketing exposure are summarised in the table below. The following convention has been used for the classification of the adverse reactions: very common (> 1/10), common (> 1/100 to < 1/10), uncommon (> 1/1,000 to < 1/100), rare (> 1/10,000 to < 1/1,000), very rare (< 1/10,000).
| Blood and lymphatic system disorders Common: Anaemia |
| Immune System Disorder Rare: Anaphylaxis |
| Metabolism and nutrition disorders Common: Hypercholesterolaemia Uncommon: Hypercalcaemia greater than 2.76 mmol/L, hyperuricaemia Rare: Hypercalcaemia greater than 3.25 mmol/L |
| Psychiatric disorders Common: Depression |
| Nervous system disorders Common: Dizziness, headache, sciatica, syncope |
| Ear and labyrinth disorders Common: Vertigo |
| Cardiac disorders Common: Palpitations Uncommon: Tachycardia |
| Vascular disorders Common: Hypotension |
| Respiratory, thoracic and mediastinal disorders Common: Dyspnoea Uncommon: Emphysema |
| Gastrointestinal disorders Common: Nausea, vomiting, hiatus hernia, gastro-oesophageal reflux disease Uncommon: Haemorrhoids |
| Skin and subcutaneous tissue disorders Common: Sweating increased |
| Musculoskeletal and connective tissue disorders Very common: Pain in limb Common: Muscle cramps Uncommon: Myalgia, arthralgia, back cramp/pain* |
| Renal and urinary disorders Uncommon: Urinary incontinence, polyuria, micturition urgency, nephrolithiasis Rare: Renal failure/impairment |
| General disorders and administration site conditions Common: Fatigue, chest pain, asthenia, mild and transient injection site events, including pain, swelling, erythema, localised bruising, pruritus and minor bleeding at injection site Uncommon: Injection site erythema, injection site reaction Rare: Possible allergic events soon after injection: acute dyspnoea, oro/facial oedema, generalised urticaria, chest pain, oedema (mainly peripheral) |
| Investigations Uncommon: Weight increased, cardiac murmur, alkaline phosphatase increase |
* Serious cases of back cramp or pain have been reported within minutes of the injection.
Description of selected adverse reactions
In clinical trials the following reactions were reported at a > 1 % difference in frequency from placebo: vertigo, nausea, pain in limb, dizziness, depression, dyspnoea.
Форстео increases serum uric acid concentrations. In clinical trials, 2.8 % of Форстео patients had serum uric acid concentrations above the upper limit of normal compared with 0.7 % of placebo patients. However, the hyperuricaemia did not result in an increase in gout, arthralgia, or urolithiasis.
In a large clinical trial, antibodies that cross-reacted with teriparatide were detected in 2.8 % of women receiving Форстео. Generally, antibodies were first detected following 12 months of treatment and diminished after withdrawal of therapy. There was no evidence of hypersensitivity reactions, allergic reactions, effects on serum calcium, or effects on Bone Mineral Density (BMD) response.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Ireland: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517; website: www.hpra.ie; e-mail: [email protected], or United Kingdom: Yellow Card Scheme; website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
Signs and symptoms
Форстео has been administered in single doses of up to 100 micrograms and in repeated doses of up to 60 micrograms/day for 6 weeks.
The effects of overdose that might be expected include delayed hypercalcaemia and risk of orthostatic hypotension. Nausea, vomiting, dizziness, and headache can also occur.
Overdose experience based on post-marketing spontaneous reports
In post-marketing spontaneous reports, there have been cases of medication error where the entire contents (up to 800 mcg) of the teriparatide pen have been administered as a single dose. Transient events reported have included nausea, weakness/lethargy and hypotension. In some cases, no adverse events occurred as a result of the overdose. No fatalities associated with overdose have been reported.
Overdose management
There is no specific antidote for Форстео. Treatment of suspected overdose should include transitory discontinuation of Форстео, monitoring of serum calcium, and implementation of appropriate supportive measures, such as hydration.
Pharmaco-therapeutic group: Calcium homeostasis, parathyroid hormones and analogues, ATC code: H05 AA02.
Mechanism of action
Endogenous 84-amino-acid parathyroid hormone (PTH) is the primary regulator of calcium and phosphate metabolism in bone and kidney. Форстео (rhPTH[1-34]) is the active fragment (1-34) of endogenous human parathyroid hormone. Physiological actions of PTH include stimulation of bone formation by direct effects on bone-forming cells (osteoblasts) indirectly increasing the intestinal absorption of calcium and increasing the tubular re-absorption of calcium and excretion of phosphate by the kidney.
Pharmacodynamic effects
Форстео is a bone formation agent to treat osteoporosis. The skeletal effects of Форстео depend upon the pattern of systemic exposure. Once-daily administration of Форстео increases apposition of new bone on trabecular and cortical bone surfaces by preferential stimulation of osteoblastic activity over osteoclastic activity.
Clinical efficacy
Risk Factors
Independent risk factors, for example, low BMD, age, the existence of previous fracture, family history of hip fractures, high bone turnover and low body mass index should be considered in order to identify women and men at increased risk of osteoporotic fractures who could benefit from treatment.
Premenopausal women with glucocorticoid-induced osteoporosis should be considered at high risk for fracture if they have a prevalent fracture or a combination of risk factors that place them at high risk for fracture (e.g., low bone density [e.g., T-score ≤−2], sustained high dose glucocorticoid therapy [e.g., >7.5 mg/day for at least 6 months], high underlying disease activity, low sex steroid levels).
Postmenopausal osteoporosis
The pivotal study included 1,637 postmenopausal women (mean age 69.5 years). At baseline, ninety percent of the patients had one or more vertebral fractures and on average, vertebral BMD was 0.82 g/cm2 (equivalent to a T-score = -2.6). All patients were offered 1,000 mg calcium per day and at least 400 IU vitamin D per day. Results from up to 24 months (median: 19 months) treatment with Форстео demonstrate statistically significant fracture reduction (Table 1). To prevent one or more new vertebral fractures, 11 women had to be treated for a median of 19 months.
| Table 1 Fracture Incidence in Postmenopausal Women | |||
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| Placebo (N = 544) (%) | Форстео (N = 541) (%) | Relative Risk (95% CI) vs placebo |
| New vertebral fracture (>1)a | 14.3 | 5.0 b | 0.35 (0.22, 0.55) |
| Multiple vertebral fractures (>2)a | 4.9 | 1.1 b | 0.23 (0.09, 0.60) |
| Non-vertebral fragility fractures c | 5.5 | 2.6 d | 0.47 (0.25, 0.87) |
| Major non-vertebral fragility fracturesc (hip, radius, humerus, ribs and pelvis) | 3.9 | 1.5 d | 0.38 (0.17, 0.86) |
| Abbreviations: N = number of patients randomly assigned to each treatment group; CI = Confidence Interval. a The incidence of vertebral fractures was assessed in 448 placebo and 444 Форстео patients who had baseline and follow-up spine radiographs b p≤0.001 compared with placebo c A significant reduction in the incidence of hip fractures has not been demonstrated d p≤0.025 compared with placebo | |||
After 19 months (median) treatment, bone mineral density (BMD) had increased in the lumbar spine and total hip, respectively, by 9 % and 4 % compared with placebo (p < 0.001).
Post-treatment management: Following treatment with Форстео, 1,262 postmenopausal women from the pivotal trial enrolled in a post-treatment follow-up study. The primary objective of the study was to collect safety data of Форстео. During this observational period, other osteoporosis treatments were allowed and additional assessment of vertebral fractures was performed.
During a median of 18 months following discontinuation of Форстео, there was a 41 % reduction (p = 0.004) compared with placebo in the number of patients with a minimum of one new vertebral fracture.
In an open-label study, 503 postmenopausal women with severe osteoporosis and a fragility fracture within the previous 3 years (83 % had received previous osteoporosis therapy) were treated with Форстео for up to 24 months. At 24 months, the mean increase from baseline in lumbar spine, total hip and femoral neck BMD was 10.5 %, 2.6 %, and 3.9 % respectively. The mean increase in BMD from 18 to 24 months was 1.4 %, 1.2 %, and 1.6 % at the lumbar spine, total hip and femoral neck, respectively.
A 24-month, randomized, double-blind, comparator-controlled Phase 4 study included 1,360 postmenopausal women with established osteoporosis. 680 subjects were randomised to Форстео and 680 subjects were randomised to oral risedronate 35 mg/week. At baseline, the women had a mean age of 72.1 years and a median of 2 prevalent vertebral fractures; 57.9 % of patients had received previous bisphosphonate therapy and 18.8 % took concomitant glucocorticoids during the study. 1,013 (74.5 %) patients completed the 24-month follow-up. The mean (median) cumulative dose of glucocorticoid was 474.3 (66.2) mg in the teriparatide arm and 898.0 (100.0) mg in the risedronate arm. The mean (median) vitamin D intake for the teriparatide arm was 1433 IU/day (1400 IU/day) and for the risedronate arm was 1191 IU/day (900 IU/day). For those subjects who had baseline and follow-up spine radiographs, the incidence of new vertebral fractures was 28/516 (5.4 %) in Форстео- and 64/533 (12.0 %) in risedronate-treated patients, relative risk (95 % CI) = 0.44 (0.29-0.68), P < 0.0001. The cumulative incidence of pooled clinical fractures (clinical vertebral and non vertebral fractures) was 4.8 % in Форстео and 9.8 % in risedronate-treated patients, hazard ratio (95 % CI) = 0.48 (0.32-0.74), P=0.0009.
Male osteoporosis
437 patients (mean age 58.7 years) were enrolled in a clinical trial for men with hypogonadal (defined as low-morning free testosterone or an elevated FSH or LH) or idiopathic osteoporosis. Baseline spinal and femoral neck bone mineral density mean T-scores were -2.2 and -2.1, respectively. At baseline, 35 % of patients had a vertebral fracture and 59 % had a non-vertebral fracture.
All patients were offered 1,000 mg calcium per day and at least 400 IU vitamin D per day. Lumbar spine BMD significantly increased by 3 months. After 12 months, BMD had increased in the lumbar spine and total hip by 5 % and 1 %, respectively, compared with placebo. However, no significant effect on fracture rates was demonstrated.
Glucocorticoid-induced osteoporosis
The efficacy of Форстео in men and women (N =428) receiving sustained systemic glucocorticoid therapy (equivalent to 5 mg or greater of prednisone for at least 3 months) was demonstrated in the 18-month primary phase of a 36-month, randomised, double-blind, comparator-controlled study (alendronate 10 mg/day). Twenty-eight percent of patients had one or more radiographic vertebral fractures at baseline. All patients were offered 1,000 mg calcium per day and 800 IU vitamin D per day.
This study included postmenopausal women (N =277), premenopausal women (N =67), and men (N =83). At baseline, the postmenopausal women had a mean age of 61 years, mean lumbar spine BMD T-score of −2.7, median prednisone equivalent dose of 7.5 mg/day, and 34 % had one or more radiographic vertebral fractures; premenopausal women had a mean age of 37 years, mean lumbar spine BMD T-score of −2.5, median prednisone equivalent dose of 10 mg/day, and 9 % had one or more radiographic vertebral fractures; and men had a mean age of 57 years, mean lumbar spine BMD T-score of −2.2, median prednisone equivalent dose of 10 mg/day, and 24 % had one or more radiographic vertebral fractures.
Sixty-nine percent of patients completed the 18-month primary phase. At the 18-month endpoint, Форстео significantly increased lumbar spine BMD (7.2 %) compared with alendronate (3.4 %) (p<0.001). Форстео increased BMD at the total hip (3.6 %) compared with alendronate (2.2 %) (p<0.01), as well as at the femoral neck (3.7 %) compared with alendronate (2.1 %) (p<0.05). In patients treated with teriparatide, lumbar spine, total hip and femoral neck BMD increased between 18 and 24 months by an additional 1.7 %, 0.9 %, and 0.4 %, respectively.
At 36 months, analysis of spinal X-rays from 169 alendronate patients and 173 Форстео patients showed that 13 patients in the alendronate group (7.7 %) had experienced a new vertebral fracture compared with 3 patients in the Форстео group (1.7 %) (p=0.01). In addition, 15 of 214 patients in the alendronate group (7.0 %) had experienced a non-vertebral fracture compared with 16 of 214 patients in the Форстео group (7.5 %) (p=0.84).
In premenopausal women, the increase in BMD from baseline to 18-month endpoint was significantly greater in the Форстео group compared with the alendronate group at the lumbar spine (4.2 % versus −1.9 %; p<0.001) and total hip (3.8 % versus 0.9 %; p =0.005). However, no significant effect on fracture rates was demonstrated.
Distribution
The volume of distribution is approximately 1.7 L/kg. The half-life of Форстео is approximately 1 hour when administered subcutaneously, which reflects the time required for absorption from the injection site.
Biotransformation
No metabolism or excretion studies have been performed with Форстео, but the peripheral metabolism of parathyroid hormone is believed to occur predominantly in liver and kidney.
Elimination
Форстео is eliminated through hepatic and extra-hepatic clearance (approximately 62 L/hr in women and 94 L/hr in men).
Elderly
No differences in Форстео pharmacokinetics were detected with regard to age (range 31 to 85 years). Dosage adjustment based on age is not required.
Teriparatide was not genotoxic in a standard battery of tests. It produced no teratogenic effects in rats, mice or rabbits. There were no important effects observed in pregnant rats or mice administered teriparatide at daily doses of 30 to 1,000 µg/kg. However, foetal resorption and reduced litter size occurred in pregnant rabbits administered daily doses of 3 to 100 µg/kg. The embryotoxicity observed in rabbits may be related to their much greater sensitivity to the effects of PTH on blood-ionised calcium compared with rodents.
Rats treated with near-lifetime daily injections had dose-dependent exaggerated bone formation and increased incidence of osteosarcoma most probably due to an epigenetic mechanism. Teriparatide did not increase the incidence of any other type of neoplasia in rats. Due to the differences in bone physiology in rats and humans, the clinical relevance of these findings is probably minor. No bone tumours were observed in ovariectomised monkeys treated for 18 months or during a 3-year follow-up period after treatment cessation. In addition, no osteosarcomas have been observed in clinical trials or during the post-treatment follow-up study.
Animal studies have shown that severely reduced hepatic blood flow decreases exposure of PTH to the principal cleavage system (Kupffer cells) and consequently clearance of PTH(1-84).
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
Форстео is supplied in a pre-filled pen. Each pen should be used by only one patient. A new, sterile needle must be used for every injection. Each Форстео pack is provided with a User Manual that fully describes the use of the pen. No needles are supplied with the product. The device can be used with insulin pen injection needles. After each injection, the Форстео pen should be returned to the refrigerator.
Форстео should not be used if the solution is cloudy, coloured or contains particles.
Please also refer to the user manual for instructions on how to use the pen.
Any unused product or waste material should be disposed of in accordance with local requirements.
