0001 How ever those in the prior risedronate group had more pro nounced changes

0001 how ever those in the prior risedronate group

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0.0001). How- ever, those in the prior-risedronate group had more pro- nounced changes in bone formation and résorption mark- ers than those who had previously received alendronate. including a greater increase of PINP at 3 months (86.0 vs. 61.2 ng/mL, respectively; P < 0.001). At 12 months, patients in the prior-risedronate group also had greater improve- ments in vertebral BMD than those who had a history of alendronate therapy (P < 0.01).'"' In light of these findings, clinicians should be aware that treatment with a more po- tent antiresorptive agent may blunt the subsequent ana- bolic effects of PTH and should adjust treatment expecta- tions accordingly. Postmenopausal women with a long history of bisphos- phonate use also face the choice of continuing or stopping antiresorptive therapy when teriparatide is started. In a prospective randomized study, Cosman and colleagues evaluated the effects of adding or switching to teripara- tide in postmenopausal women with osteoporosis who were already taking alendronate or raloxifene for at least 18 months.""* Teriparatide was associated 'with improve- ments in bone turnover markers at 6 months (P < 0.001 vs. baseline) and improvements in BMD at the lumbar spine at 18 months (P < 0.01 vs. baseline) in all treatment groups. However, the magnitude of effect differed between add-on and switched therapy. For instance, patients who switched to teriparatide had greater increases in bone turnover markers than those who added teriparatide to background antiresorptive therapy. This included greater increases in PINP with s'witched than 'with add-on therapy in the alen- dronate subgroup (401% vs. 64%; respectively; P < 0.001) and the raloxifene subgroup (259% vs. 131%, respectively; P < 0.001). Conversely, patients who added teriparatide to antiresorptive therapy had more favorable changes in BMD at the lumbar spine (8.4 vs. 4.8%, respectively; P = 0.003) and total hip (3.2% vs. 0.9%, respectively; P = 0.02) than those who s'witched to teriparatide.''" This paradox underscores the complexity of bone remodeling and the tricky balance between bone résorption and new bone formation. Until more information is kno'wn, teripa- ratide should be used as monotherapy, but antiresorptives should be started once teriparatide has been discontinued to prevent the expected bone loss.'^ Intermittent Therapy Given that anabolic therapy is approved for only 24 months of use, with or without concomitant antiresorptive therapy, there is interest in extending the life of anabolic therapy by using these agents intermittently in patients with os- teoporosis. Cosman and colleagues evaluated the effects of two separate 15-month courses of teriparatide, separated by a 12-month hiatus, in women who also received con- tinuous treatment with weekly alendronate."' Teriparatide significantly increased bone turnover markers (P < 0.001) and spine BMD (P < 0.02) during both treatment courses with no differences in the magnitude of therapeutic effect between initial treatment and retreatment." In another study of intermittent teriparatide therapy, treatment-na'ive patients with osteoporosis were treated with teriparatide for 2
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