Teriparatide in a Patient with Severe Osteomalacia and Multiple Vertebral Fractures: Case Report

Abstract

Osteomalacia is a metabolic bone disorder characterized by defective mineralization, mostly associated with vitamin D or calcium deficiency. The standard treatment consists solely of these deficiencies. However, in critical situations, a complementary approach may be necessary to accelerate bone recovery. Case Report: We present the case of a 36-year-old woman with autoimmune hepatitis awaiting liver transplantation, who was hospitalized for severe bone pain due to multiple vertebral fractures. During her admission, she was found to have vitamin D deficiency (9 ng/mL), elevated alkaline phosphatase (432 UI/L), and a characteristic pattern of osteomalacia on bone scintigraphy. As her compromised bone health precluded necessary transplantation, treatment with teriparatide 20 mcg/day was initiated in addition to calcium and vitamin D supplementation to rapidly improve bone quality. During treatment, no new fractures occurred, pain relief was almost immediate, and a liver transplant was successfully performed a year later. Ten years after diagnosis, and despite multiple complications, the patient maintains bone stability. Discussion: Osteomalacia in a patient with liver failure is a rare clinical entity, primarily caused by vitamin D deficiency due to multiple factors. While vitamin D and calcium supplementation is the standard treatment for osteomalacia, the severity of the condition due to liver failure and the presence of multiple fractures led to the use of teriparatide to accelerate bone regeneration. This is an exceptional, off-label use, motivated by a critical clinical situation, as teriparatide is not a standard treatment for osteomalacia.