Teriparatide, Vitamin D, Cinacalcet, Sevelamer
Unlike BPs, raloxifene, denosumab, and calcitonin video (which block bone resorption),
these agents increase bone formation and bone mineral density
Osteoblasts are responsible for depositing hydroxyapatite into the bone’s organic matrix
Osteoblasts are activated by teriparatide and vitD bone mineral density
Osteoclasts are indirectly activated by teriparatide and vitD bone resorption/turnover
Bone resorption by osteoclasts leads to the release of Ca & P into blood
High serum Ca levels act directly on parathyroid gland to inhibit PTH production & secretion
o There is a calcium-sensing receptor on parathyroid gland that responds to increased
serum Ca levels
PTH stimulates osteoblasts to release RANKL RANKL binds to RANK (on osteoclast
surface) osteoclast differentiation & activity bone resorption
PTH stimulates maturation of osteoblasts bone formation
Although bone resorption & formation are both enhanced by PTH, the net effect of
endogenous PTH is to bone resorption
At the kidney, PTH increases Ca reabsorption (& increases phosphate excretion)
o Net effect of PTH: Ca, P
Third way by which PTH serum Ca levels is by 1,25-dihydroxyvitamin D (calcitriol)
o PTH increases activity of 1-hydroxylase in kidney calcitriol production
Teriparatide (recombinant PTH) in low & intermittent doses bone formation
o Intermittent doses of teriparatide stimulates maturation of osteoblasts bone
formation
o Can be used to treat osteoporosis (increase bone density)
o At the kidney, teriparatide Ca reabsorption and P excretion (this gets more Ca into
the circulation)
o teriparatide also activity of 1-hydroxylase in the kidney calcitriol
Vitamin D3 (cholecalciferol) is obtained via dairy products or UVB radiation in sunlight
Vitamin D2 (ergocalciferol) is obtained via plants
Steps for converting vitamin D2 or D3 into active vitamin D (calcitriol):
o 25-hydroxylase in liver converts vitamin D 25-hydroxyvitamin D (calcidiol)
o 1-hydroxylase in kidney converts 25-hydroxyvitamin D (calcidiol) 1,25-
dihydroxyvitamin D (calcitriol); this step is stimulated by PTH
Calcitriol stimulates reabsorption of Ca and P in the kidney
Calcitriol also stimulates intestinal absorption of Ca and P
Like PTH, calcitriol also stimulates osteoblasts to release/express RANKL activates
osteoclasts
Calcitriol feeds back to parathyroid gland to inhibit PTH production
Like PTH, calcitriol stimulates maturation of osteoblasts bone formation
Calcitriol can be used to treat osteoporosis
Calcitriol can be useful in CKD to prevent hypocalcemia (note: must give this active form of
vitD here opposed to ergo/cholecalciferol since CKD kidney has difficulty converting inactive
vitD active vitD)
Topical vitD can be used to treat psoriasis (inhibits keratinocyte proliferation)
Calcitriol is useful in the long-term management of hypocalcemia (eg, hypoparathyroidism)
o Note that vitD2 &vitD3 would be less effective in a hypoparathyroid pt since PTH is
important in activating vitD in the kidney
o Note: thyroid surgery can hypoparathyroidsm and hypocalcemia
o Hypocalcemia can cause paresthesias, muscle cramps, trismus, tetany, and
potentially even seizures
Teriparatide and vitD therapy can cause hypercalcemia
Cinacalcet (a calcimimetic) activates the calcium sensing receptor on the parathyroid gland
PTH production (essentially tricking gland that there is a lot of Ca around)
o Cinacalcet is useful in the treatment of hypercalcemia d/t hyperparathyroidism
(primary or secondary hyperparathyroidism)
Sevelamer – non-absorbable phosphate-binding polymer that decreases P absorption in GIT
o Useful in the treatment of hyperphosphatemia d/t CKD
