Forteo (Teriparatide (rhPTH 1-34))
Also sold as: Forteo, Terrosa, Bonista, Osteotide, Forsteo (EU)
Pregnancy
Cat C
Lactation
Avoid
Schedule
H
Forms
Pre-filled pen injection: 20 mcg/80 mcg/mL (2.4 mL pen = 28 doses of 20 mcg SC)
Indications
- Severe osteoporosis with high fracture risk (postmenopausal women, men) — when antiresorptive therapy failed or contraindicated
- Glucocorticoid-induced osteoporosis (severe, high fracture risk)
- Osteoporosis with very low BMD (T-score ≤ −3.5) or multiple prior fragility fractures
Adult Dosing
Osteoporosis (anabolic treatment)
20 mcg SC once daily into thigh or abdomen
Treatment duration MAXIMUM 24 months (lifetime) — based on osteosarcoma risk data in rats (FDA label). After completing teriparatide, MUST transition to antiresorptive therapy (bisphosphonate or denosumab) to maintain gains — BMD is lost rapidly if no follow-on therapy.
Pediatric Dosing
Only for adults with closed epiphyses
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| CrCl < 30 mL/min | Use with caution — risk of hypercalcaemia (reduced calcium excretion). Monitor calcium closely. |
Hepatic Adjustment
No specific adjustment required for hepatic disease
Pregnancy & Lactation
Pregnancy: Category C
AVOID in pregnancy — animal studies show fetal skeletal abnormalities. Women of childbearing age: use effective contraception. Not established in pregnancy.
Lactation: Avoid
No data in breastfeeding — manufacturer advises avoiding. Teriparatide not orally bioavailable but avoid in lactation.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Digoxin | Teriparatide causes transient hypercalcaemia — can predispose to digoxin toxicity; use with caution in digitalis-treated patients | Moderate |
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Side Effects
Common
- Nausea (especially first dose)
- Dizziness and leg cramps
- Headache
- Transient hypercalcaemia (4–6 hours post-injection)
- Injection site pain
- Hypercalciuria
Serious / Discontinue If
- Osteosarcoma (animal rats — dose- and duration-dependent; FDA black box; no confirmed cases in humans at standard doses/duration; contraindicated > 24 months lifetime)
- Orthostatic hypotension (first few doses — sit or lie down for 15 minutes after injection)
- Hypercalcaemia (monitor calcium)
Contraindications
- Paget's disease of bone (increased osteosarcoma risk)
- Prior radiation to skeleton
- Metastatic bone disease or bone malignancy
- Hypercalcaemia (pre-existing)
- Open epiphyses (children)
- Metabolic bone diseases other than osteoporosis (hyperparathyroidism)
- Previous teriparatide for > 24 months lifetime
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Forteo 20 mcg pen | Eli Lilly India | 28-dose pen ₹14,500 |
| Bonista 20 mcg pen | Sun Pharma | 28-dose pen ₹9,800 |
| Osteotide 20 mcg pen | Cipla | 28-dose pen ₹10,200 |
Monitoring Required
- BMD (DEXA — at baseline, 12 months, and 24 months — end of treatment)
- Serum calcium (at 1–3 months after starting; if symptoms of hypercalcaemia)
- Urine calcium/creatinine (hypercalciuria — stone risk)
- Serum alkaline phosphatase (increases — expected anabolic response)
- Blood pressure (first 1–2 doses — orthostatic hypotension)
- Plan for sequential antiresorptive therapy after 24 months
Patient Counseling Points
- Inject once daily (at same time, different spots on thigh or abdomen) with the pre-filled pen
- After your first few injections, sit or lie down for 15 minutes — you may feel dizzy
- Store the pen in the refrigerator — take out just before injecting; never freeze
- Treatment is for 24 months MAXIMUM in a lifetime — after that, your doctor will start a different bone medicine to keep the benefit
- Regular bone density scans and blood calcium checks are needed during treatment
- ⚠️ NOT for patients who have had radiation to the skeleton or have bone cancer
- After completing the 24-month course: do NOT stop all bone treatment — you must continue with a bisphosphonate or another bone medicine immediately
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Clinically reviewed by: Dr. Anand Prabhakar, DM (Nephrology), Consultant Nephrologist
Last reviewed: 2026-04-01
References
- AACE Osteoporosis Guidelines 2020
- IOF Osteoporosis Guidelines 2022
- BNF — Teriparatide
- Endocrine Society Osteoporosis Guidelines
- FDA Forteo Prescribing Information (Black Box)