Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate.

n engl j med 358;12 www.nejm.org march 20, 2008 1304 approved indications in postmenopausal and male osteoporosis, we recommended that teriparatide be considered for patients at high risk for fracture who require sustained use of glucocorticoids and who have either osteoporosis or low bone mass with a prevalent fracture. In his editorial, Sambrook suggests the use of teriparatide as a firstline therapy. We believe that the gain in bone mineral density achieved with teriparatide may outweigh the potential drawbacks of higher cost and greater inconvenience in certain patients with or at risk for severe glucocorticoid-induced osteoporosis. Nori and colleagues sound a cautionary note about the use of teriparatide in patients with chronic kidney disease and in kidney-transplant recipients with secondary hyperparathyroidism. Patients with kidney disease, defined as a serum creatinine level that, in the opinion of the investigator, indicated significant renal impairment or a creatinine clearance of 30 ml per minute or less were excluded from our trial. This is consistent with Food and Drug Administration labeling, which states that there is limited information available to evaluate the safety of teriparatide in patients with kidney disease. We concur that clinical evaluation and judgment are needed before prescribing any medication. Kenneth G. Saag, M.D.