Teriparatide for Joint Erosions in Rheumatoid Arthritis: The TERA Trial

Inclusion Criteria:

All men and women 45 years of age or older with RA and joint erosions by plain x-ray who are taking an TNF antagonist for at least three months and who have not taken more than two weeks of a bone active agent in the last 12 months will be eligible and screened for their interest in participating in the proposed randomized trial.

1. RA will be defined according to the 2010 American College of Rheumatology/European League Against Rheumatism diagnostic and classification criteria.

2. Osteopenic bone mineral density will be defined as a t-score between -1.0 and -2.5 on either a DXA of the PA or lateral lumbar spine or the femoral neck or total hip. Potential subjects with prior minimal trauma fractures will be excluded.

   2.Subjects must be able to give written informed consent.

Exclusion Criteria:

1. A switch in DMARD in the last 3 months;
2. Current use of chronic oral glucocorticoids > 5 milligrams per day;
3. A prior history of intolerance to teriparatide;
4. T-score < -2.5 or a prior minimal trauma fracture;
5. Use of a bone active agent for over 2 weeks in the last 12 months (these agents include oral and intravenous bisphosphonates, hormone replacement therapy, calcitonin, raloxifene, teriparatide, suppressive doses of thyroxine, lithium, pharmacological doses of vitamin D (greater than 2000 IU/day or anticonvulsants);
6. History of significant cardiac, hepatic, current alcohol abuse, or major psychiatric disorders;
7. Evidence of active malignant disease, malignancies diagnosed within the previous 10 years (including hematologic malignancies and solid tumors, except basal cell carcinoma of the skin that has been excised and cured), or breast cancer diagnosed within the previous 20 years;
8. No current diagnoses of disorders known to affect bone metabolism including hyperthyroidism, hyperparathyroidism, osteomalacia, or Paget's disease. All participants will be required to have normal serum levels of 25-OH vitamin D (> 20 ng/ml), intact PTH, and TSH. If PTH and/or 25-OH D levels are abnormal, subjects may be given calcium and/or multivitamin supplements and be re-tested in 2-12 weeks;
9. Serum Ca > 10.6 mg/dl,and 24-hour urine calcium > 400 mg. If minor abnormalities are detected in any of these parameters, the test may be repeated;
10. Patients who have had external beam radiation; and
11. Patients currently on digoxin.
12. Women that are currently pregnant or breast-feeding or plan on becoming pregnant over the course of participation in the study