Forteo (teriparatide) followed by HRT: My Experience

@chikris
My tentative plan is to stay on HRT as primary (and only) maintenance tool, though I am prepared for Forteo retreatment if my DXA scores show significant regression - specifically if the L-spine Tscore drops to -3.0 or the total hip to -2.5. I’m comfortable using HRT for at least 5yrs, at which point I’ll re-evaluate based on the latest data regarding breast cancer risks. Raloxifene could be one of my back-up options as an antiresorptive.

I actually have a DXA coming up in a few months, which will provide the first objective look at how my BMD is holding up on HRT alone. So far, my resorption markers have been consistently low during second year of HRT, and I'm hopeful this will translate to BMD stability on the DXA 🤞

Are you currently on any treatment?

@mayblin - I'm following your progress, as I also tentatively plan to stay on HRT as my primary and only maintenance after the Evenity course. A DXA is scheduled for a month following the last Evenity injection & I will utilize bone turnover markers to attempt to track my progress in the months to follow.

@singingbones
From what I recall, you've already been on systemic estrogen for a few months - would you be open to sharing your dosage and form? Having that continuous transdermal or oral estrogen in place should help attenuate the expected CTX rebound after discontinuing Evenity. Monitoring your fasting CTX levels will give an early signal of whether your current HRT dose is sufficient to keep bone resorption suppressed.

As for my timeline, I checked baseline BTMs right at the completion of Forteo and before initiating HRT. then at 1, 3, and 6mo post-HRT, as I wanted to verify whether my low-dose (0.025 mg/day) estradiol patch was providing adequate antiresorptive protection. I am almost at the 2yr mark on HRT now and have a DXA scan scheduled in a few months - will report back.

Please keep us updated with your progress. Your experience with HRT as a follow-up for Evenity will be very valuable for others considering a similar path!

@mayblin - after I sent this post I realize I had already shared w/you in the past--oops!

From https://melioguide.com/medications/evenity-a-physicians-perspective/

Apparently BTMs behave a bit differently for Evenity:

"EVENITY’s effect on bone turnover markers looks different from the other anabolic agents. With Forteo and Tymlos, both P1NP (a marker of bone formation) and CTX (a marker of bone resorption) rise. With EVENITY, P1NP rises while CTx decreases, reflecting its unique dual action: promoting bone formation while simultaneously reducing resorption, without directly stimulating either side of the remodeling cycle."

Yes, you are correct - I had my estradiol increased to address bone health less than 2 months ago & my last Evenity injection will be tomorrow - yay! I have been on a low dose of compounded vaginal estradiol/estrone for several yrs to address recurring UTIs - prescribed by a urologist! My integrative dr noticed the omission of progesterone & added that to my regime. The dosage was barely enough to register in any blood serum labs, so my very recent new dr modified the vaginal bi-est just a bit & then added 0.25 mg daily topical gel to address bone health systemically & kept the oral progesterone at 100 mg.

So, I won't have a clear delineation of before/after like you, but I am convinced HRT will be helpful - even at 73 yrs of age.

My osteo dr referred me to a Liftmor-type of exercise class given at a rehab medical facility here in CA, so I started that almost 8 mo ago. Like many on this forum, we've thrown everything we can at OP, so it's tricky to extract what has helped the most.

My current focus is on maintaining the gains that I suspect Evenity will have provided. I have a few other components I am considering, too, but much too long to include on this post. I stay active on Inspire.com and as far as I can tell, no one else has reported attempting to maintain gains without a prescription drug following Evenity. I'll keep you updated!

@singingbones
I want to point out that there are no clinical trials studying HRT as the sole follow-up antiresorptive after any anabolic (Forteo/teriparatide, Tymlos/abaloparatide, or Evenity/romosozumab). That doesn't mean it can't work - it just means we're in uncharted territory and need to monitor closely so we don’t lose the precious gains.

The bone density (BMD) gained with Evenity tends to be lost at a faster rate after stopping compared to the gains from Forteo or Tymlos, if no antiresorptive follows, according to observational studies. This is because Evenity suppresses bone breakdown during treatment, and when it's stopped, bone breakdown (CTX) rebounds, sometimes even higher than it was before treatment started. Forteo and Tymlos don't cause this kind of rebound. This makes the choice and adequacy of the follow-up treatment after Evenity especially important.

Have you checked how your dose of estrogen gel compares to the doses typically associated with bone benefits? The most-studied dose for fracture prevention is equivalent to about a 50 mcg estradiol patch (or oral estradiol 1–2 mg). Lower doses could still help, but the evidence is strongest at standard doses. It may be worth discussing with your doctor whether a dose titration plan makes sense - or having a backup antiresorptive plan ready. I had one year worth of prescriptions written in advance to step up from 25 to 37.5 to 50 mcg patches if my bone markers or DXA suggest lower dose isn't enough.

@mayblin - thanks for the additional Evenity info. Yes, many of us are in uncharted territory. These forums are so helpful in sifting/sorting our OP journeys when the studies are just not available at this time.

Yes, I am aware of optimal levels of estradiol to impact bone integrity. I've only had one appt w/my new dr & she will be evaluating at our next appt. It's so refreshing to have finally found someone who actually is familiar w/the correlation to bone strength--my previous ones were still basing doses on symptoms.

How wonderful that your Dr provided those prescriptions in advance - saves both of you time/money. I might mention that to my Dr at the next appt. Your dose strength examples are helpful to me as I navigate this journey.

@singingbones, you might have already noticed that I ended up staying on the low-dose 25mcg/day estradiol patch, since my CTX showed adequate suppression. I hope your transition goes smoothly!

@singingbones
I want to point out that there are no clinical trials studying HRT as the sole follow-up antiresorptive after any anabolic (Forteo/teriparatide, Tymlos/abaloparatide, or Evenity/romosozumab). That doesn't mean it can't work - it just means we're in uncharted territory and need to monitor closely so we don’t lose the precious gains.

The bone density (BMD) gained with Evenity tends to be lost at a faster rate after stopping compared to the gains from Forteo or Tymlos, if no antiresorptive follows, according to observational studies. This is because Evenity suppresses bone breakdown during treatment, and when it's stopped, bone breakdown (CTX) rebounds, sometimes even higher than it was before treatment started. Forteo and Tymlos don't cause this kind of rebound. This makes the choice and adequacy of the follow-up treatment after Evenity especially important.

Have you checked how your dose of estrogen gel compares to the doses typically associated with bone benefits? The most-studied dose for fracture prevention is equivalent to about a 50 mcg estradiol patch (or oral estradiol 1–2 mg). Lower doses could still help, but the evidence is strongest at standard doses. It may be worth discussing with your doctor whether a dose titration plan makes sense - or having a backup antiresorptive plan ready. I had one year worth of prescriptions written in advance to step up from 25 to 37.5 to 50 mcg patches if my bone markers or DXA suggest lower dose isn't enough.