Short-term teriparatide therapy as an adjunctive modality for bisphosphonate-related osteonecrosis of the jaws

To review the effect of teriparatide as an adjunctive modality for bisphosphonate-related osteonecrosis of the jaws (BRONJ), we describe a series of cases of teriparatide therapy for the treatment of BRONJ and serial changes of serum osteoclacin (s-OC) and serum C-terminal telopeptide cross-link of type I collagen (s-CTX). Management of BRONJ is quite challenging and the currently recommended modalities for BRONJ are still suboptimal. For the improvement of bony remodeling, some clinicians advocated bisphosphonate holiday although validity of this drug holiday has been debated so far. Recently, the use of teriparatide was introduced in several cases, but the number of the publication is limited and mostly anecdotal so far. Bisphosphonate was suspended and teriparatide was given to six patients diagnosed with BRONJ by single bone specialist. Medical record review and interviews were carried out. S-CTX and s-OC were measured at the baseline, 2 months and 3 months later teriparatide therapy. The outcome of the treatment and the change of biochemical markers were compared. In all six patients, s-OC values were significantly elevated within 2 months after teriparatide treatment and the BRONJ lesions were healed. S-CTX values were also elevated in four patients, whereas those of the rest two patients stayed within minimal change. The change was marginally significant at 3 months. In terms of the multifactorial etiology of BRONJ, bone formation suppression was noticed in the patients. Based upon this finding, the short-term use of teriparatide might be beneficial to the resolution of BRONJ lesions by improving suppressed bone remodeling.