Postpartum timing of teriparatide initiation and BMD response in pregnancy- and lactation-associated osteoporosis: an...

This observational study of teriparatide-treated PLO documents a substantial effect of postpartum treatment timing on BMD response. Women who initiated teriparatide < 12 months (M) postpartum had two-threefold larger BMD increases than those initiating teriparatide ≥ 12M postpartum. This study provides important data to inform treatment response expectations in clinical care of teriparatide-treated PLO.

Pregnancy- and lactation-associated osteoporosis (PLO) describes an early-onset osteoporosis presentation with low- or no-trauma fractures associated with pregnancy/lactation; BMD at presentation is often extremely low. PLO fractures occur in the context of skeletal demineralization associated with pregnancy/lactation; natural BMD recovery is expected postpartum/postweaning, but BMD often remains quite low. Optimal management for PLO is uncertain. Teriparatide is the most common medication investigated. Observational studies document larger average BMD increases on teriparatide versus natural recovery-but individual response varies. Since treatment may overlap with the skeletally dynamic postweaning recovery period, we hypothesized that postpartum treatment timing would affect BMD response to teriparatide.

Within our PLO Registry, BMD was assessed at baseline, 6M, and 12M in 31 women with PLO who initiated teriparatide either < 12M postpartum (EarlyRx, n = 10, initiation 7 ± 3 M postpartum) or ≥ 12M postpartum (DelayedRx, n = 21, initiation 36 ± 29 M postpartum). Groups were similar in terms of age, BMI, parity, number of fractures, and breastfeeding duration.

As expected, based on known postpartum bone physiology, baseline BMD was lower in EarlyRx vs. DelayedRx. Teriparatide was associated with significant BMD increases in both timing groups-but response differed substantially. Increases at 12M in the EarlyRx group (LS:+ 21 ± 12%, TH:+ 9 ± 6%, and FN:+ 7 ± 6%, all p < 0.01) were two-threefold larger than the DelayedRx group (LS:+ 8 ± 5%, TH:+ 4 ± 4%, and FN:+ 2 ± 3%, all p < 0.05). This effect was reproduced after controlling for baseline BMD.

These data highlight the complexity of assessing treatment response in the context of postpartum bone physiology and can inform treatment response expectations for women with PLO.