Forsteo ® (teriparatide)

This information is intended for UK registered healthcare professionals only as a scientific exchange in response to your search for information.For current prescribing information for all Lilly products, including Summaries of Product Characteristics, Patient Information Leaflets and Instructions for Use, please visit: www.medicines.org.uk (England, Scotland, Wales) or www.emcmedicines.com/en-GB/northernireland/ (Northern Ireland).

Use of Forsteo® (teriparatide) after prior radiation treatment

Forsteo is contraindicated in patients with prior external beam or implant radiation therapy to the skeleton and should not be prescribed.

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Why is teriparatide contraindicated after prior radiation?

Radiation-induced osteosarcoma is a rare but well-recognized complication in human radiotherapy patients that was first reported in patients after treatment with ionizing radiation in the 1920s.1

In most radiotherapy protocols, high doses of therapeutic radiation are directed at the tumor tissue. Other tissues, including the skeleton and likely the entire body, can be exposed to comparatively low doses of unwanted radiation via scattering of radiation within the body and low level leakage from the treatment apparatus.2

Development of second malignant neoplasms, including osteosarcoma, in tissues that are located in-field (in the path of the therapeutic beam) and out-of-field (outside the path of the therapeutic beam but affected by scatter) can occur years or decades after initial treatment.1,2

Teriparatide should not be prescribed for patients who are at an increased baseline risk for osteosarcoma, including those who have had prior external beam or implant radiation therapy involving the skeleton.3,4

Examples of prior radiation therapy where teriparatide should not be used

Teriparatide should not used if patient had exposure to 

  • therapeutic external beam radiation, including
    • radiation therapy for a soft tissue malignancy, such as breast cancer, likely have experienced radiation affecting the skeleton around the breast (the sternum or ribs).
  • any type of radiation implanted into the body, including
    • brachytherapy
    • interstitial radiation
    • intracavitary radiation, or
  • stereotactic radiation, including
    • stereotactic radiosurgery
    • fractionated stereotactic radiotherapy
    • stereotactic body radiation therapy
    • Gamma Knife®
    • X-Knife®
    • CyberKnife®
    • Clinac® to the brain or other areas of the body.

Case reports of second malignant neoplasms, including osteosarcoma, have been reported in patients receiving these therapies.5-7

Examples of prior radiation therapy where teriparatide may be considered

Teriparatide use may be considered in patients who had

  • radioactive iodine therapy
  • low doses of nonpenetrative radiation (Grenz radiation) used for treatment of skin conditions
  • diagnostic radiation, including
    • radiographs
    • CT scans
    • radionuclide scans, or
  • non-radioactive forms of radiation, including
    • ultraviolet radiation
    • phototherapy.3

References

1Kalra S, Grimer RJ, Spooner D, et al. Radiation-induced sarcomas of bone: factors that affect outcome. J Bone Joint Surg Br. 2007;89-B(6):808-813. http://dx.doi.org/10.1302/0301-620X.89B6.18729

2Newhauser WD, Durante M. Assessing the risk of second malignancies after modern radiotherapy. Nat Rev Cancer. 2011;11(6):438-448. http://dx.doi.org/10.1038/nrc3069

3Data on file, Eli Lilly and Company and/or one of its subsidiaries.

4Forsteo [summary of product characteristics]. Eli Lilly Nederland B.V., The Netherlands.

5Sanno N, Hayashi S, Shimura T, et al. Intracranial osteosarcoma after radiosurgery. Neurol Med Chir (Tokyo). 2004;44(1):29-32. http://dx.doi.org/10.2176/nmc.44.29

6Abedalthagafi M, Bakhshwin A. Radiation-induced glioma following CyberKnife® treatment of metastatic renal cell carcinoma: a case report. J Med Case Rep. 2012;6:271. http://dx.doi.org/10.1186/1752-1947-6-271

7Balasubramaniam A, Shannon P, Hodaie M, et al. Glioblastoma multiforme after stereotactic radiotherapy for acoustic neuroma: case report and review of the literature. Neuro Oncology. 2007;9(4):447-453. http://dx.doi.org/10.1215/15228517-2007-027

Date of Last Review: 13 November 2019


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