Poster Presentation ESA-SRB 2023 in conjunction with ENSA

A surprising case of delayed drug hypersensitivity to Teriparatide (#309)

Annabel Jones 1 , David Buxton 1 , Shoshana Sztal-Mazer 1 2
  1. Department of Endocrinology and Diabetes, Alfred, Melbourne, Victoria, Australia
  2. School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia

A 63-year-old lady commenced teriparatide in the setting of severe osteoporosis (T Score -3.1 at femoral neck) with three atraumatic fractures on IV bisphosphonate therapy.  After the second dose, our patient reported a vague non-localised sensation of whole body itch. After the third dose, our patient reported intense pruritis and patchy whole body urticariafacial urticaria affecting the eyelids, nasolabial folds, and chin; and mild periorbital and lip angioedema without airway compromise (Figures1-4). The agent was ceased.

Symptom onset was several hours after administration. The rash was not typical of other causes of a pruritic rash, such as atopic dermatitis, contact dermatitis of bullous pemphigoid. Serum tryptase testing was normal (6.0mcg/L) and delay in presentation precluded biopsy.  The immunology team confirmed urticaria possibly attributable to the commencement of teriparatide and suggested that re-challenge with high dose antihistamine and steroid cover could also be trialled, however the patient declined.

Compared with other treatments for osteoporosis, Teriparatide (recombinant parathyroid hormone) is generally well tolerated, a minority of patients report limited and or minor side effects (1). Nausea, arthralgia, headache and limb pain are the most common reported side effects (2). Additionally, hypercalcaemia (which is usually transient) and hypercalciuria are clinically significant adverse effects related to disruption of calcium homeostasis (3). As with any biologic compound, allergy (manifesting as anaphylaxis, angioedema, urticaria or hypersensitivity) is also a potential concern (4). Based on real world reporting data, the prevalence of allergic reactions to teriparatide injections is estimated to be less than 1 per 1000 patients treated (5). However, despite this, case reports of urticaria attributable to teriparatide are lacking within the literature and in correspondence with colleagues internationally.

We report an unusual case of delayed drug hypersensitivity resulting in urticaria and mild-angio-oedema related to teriparatide, an adverse reaction that has not been reported before.

 

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  1. Ebeling PR. New drugs for osteoporosis. Australian Prescriber. 2011;34(6):176-181. doi:10.18773/AUSTPRESCR.2011.093
  2. Eastell R, Nickelsen T, Marin F, et al. Sequential treatment of severe postmenopausal osteoporosis after teriparatide: final results of the randomized, controlled european study of forsteo (EUROFORS). Journal of Bone and Mineral Research. 2009;24(4):726-736. doi:10.1359/jbmr.081215
  3. RM Neer, CD Arnaud, JR Zanchetta, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. The New England journal of medicine. 2001;344(19):1434-1441. doi:10.1056/NEJM200105103441904
  4. Gülsen, A., Wedi, B. & Jappe, U. Hypersensitivity reactions to biologics (part II): classifications and current diagnostic and treatment approaches. Allergo J Int 29, 139–154 (2020). https://doi.org/10.1007/s40629-020-00127-5
  5. DT Gold, BS Pantos, DN Masica, da Misurski, R Marcus. Initial experience with teriparatide in the United States. Current medical research and opinion. 2006;22(4):703-708. doi:10.1185/030079906X100159