1
|
Kato K, Yaginuma T, Kobayashi A, Nakashima A, Ohkido I, Yokoo T. Long-term effects of denosumab on bone mineral density and turnover markers in patients undergoing hemodialysis. J Bone Miner Metab 2024; 42:264-270. [PMID: 38512458 PMCID: PMC10982096 DOI: 10.1007/s00774-024-01505-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Denosumab, a fully human anti-RANKL monoclonal antibody, is a widely used osteoporosis treatment that is increasingly being used in patients undergoing dialysis; however, its long-term efficacy and safety in these patients remain unknown. MATERIALS AND METHODS This observational study comprised individuals aged ≥ 20 years undergoing hemodialysis and receiving denosumab. After denosumab administration, we analyzed the long-term changes in bone mineral density (BMD) and levels of bone turnover markers (BTMs) and calcium. RESULTS The study included 45 patients who have been receiving denosumab for a median duration of 3.8 (interquartile range, 2.5-6.7) years. Tartrate-resistant acid phosphatase 5b (TRACP-5b) levels decreased from a median of 595 (434-778) mU/dL at baseline to 200 (141-430) mU/dL after 6 months of denosumab administration (P < 0.001) and remained low thereafter. Similarly, bone-specific alkaline phosphatase (BAP) levels decreased from a median of 18.2 (15.9-25.8) μg/L at baseline to 12.4 (9.9-15.6) μg/L after 6 months (P < 0.001) and remained low thereafter. Meanwhile, BMD, as assessed with dual energy X-ray absorptiometry and measured at the distal 1/3 of the radius, did not decrease (0.465 ± 0.112 g/cm2 at baseline vs. 0.464 ± 0.112 g/cm2 after administration; P = 0.616). Regarding hypocalcemia, corrected calcium levels reached were the lowest at 7 days after administration and normalized within 30 days. CONCLUSION The study showed long-term suppression of TRACP-5b and BAP levels and sustaining BMD after denosumab administration over an extended period in patients undergoing hemodialysis.
Collapse
Affiliation(s)
- Kazuhiko Kato
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Arisa Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| |
Collapse
|
2
|
Bitar ZI, Hajjiah AMA, Maadarani OS, Elzoueiry MM, Gohar MR, Abdelfatah M, Alabdali F. Hypocalcemia in Patients With Osteoporosis and Normal Renal Function, Treated With Denosumab, a Retrospective Analysis. Nutr Metab Insights 2024; 17:11786388231223604. [PMID: 38205220 PMCID: PMC10775727 DOI: 10.1177/11786388231223604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/13/2023] [Indexed: 01/12/2024] Open
Abstract
Objective The reported hypocalcemia in postmenopausal women with osteoporosis who received Denosumab was low (0.05%-1.7% to 7.4%). The major prediction factors were vitamin D and calcium levels and renal function. The objective is to evaluate the incidence of hypocalcemia in patients with osteoporosis, normal renal function, and vitamin D who received Denosumab. Method A retrospective analysis was conducted using the medical records (2022-2023). We looked for hypocalcemia (albumin-adjusted calcium lower than 2.2 mmol/L). Results Two hundred one postmenopausal women diagnosed with osteoporosis and received denosumab treatment were included. All patients received vitamin D3 capsules and calcium supplementation. The mean age of the patient was 75.7 ± 7.0 years (56-91 years). Hypocalcemia was observed in 46 (23%) patients following a subcutaneous dose of Denosumab 60 mg. Median calcium was 2.25 mmol/L (minimum: 0.890 mmol/L, maximum: 2.6 mmol/L). Fourteen (30.4%) patients had severe hypocalcemia (<1.8 mmol/L) and required parenteral correction. A comparison between hypocalcemia and patients with normal calcium indicated that the significant predictor of hypocalcemia was pretreatment parathyroid hormone levels (9.9 ± 11.8vs 7.6 ± 2.56 pmol/L, respectively; P < .005). The prognostic role of parathyroid hormone for the denosumab-associated hypocalcemia was assessed using ROC curve analysis. For the cut-off value of Parathyroid hormone = 6.8 pmol/L, giving serum parathyroid measurement an AUC of 0.668 (0.599-0.737) - P = .0007; sensitivity 85%; specificity 52%. Conclusion Hypocalcemia induced by the denosumab treatment is more prevalent than previously shown in patients with osteoporosis receiving adequate calcium and vitamin D supplements. An elevated parathyroid hormone predicts hypocalcemia related to denosumab therapy in patients with normal calcium and vitamin D levels.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Fawaz Alabdali
- Endocrinology and Diabetic Unit, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait
| |
Collapse
|
3
|
Kim JT, Kim YM, Jung KY, Choi H, Lee SY, Kim HJ. Efficacy and safety of denosumab treatment for Korean patients with Stage 3b-4 chronic kidney disease and osteoporosis. Korean J Intern Med 2024; 39:148-159. [PMID: 38145616 PMCID: PMC10790049 DOI: 10.3904/kjim.2023.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/08/2023] [Accepted: 09/16/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND/AIMS We evaluated the efficacy and safety of denosumab treatment in severe chronic kidney disease (CKD) patients with osteoporosis. We also investigated whether the treatment affects the coronary artery calcifications. METHODS Twenty-seven postmenopausal women with Stage 3b-4 CKD and osteoporosis were enrolled. Twenty patients received denosumab plus calcium carbonate and vitamin D, and seven controls received calcium carbonate and vitamin D for 1 year. Dual-energy X-ray absorptiometry and coronary artery calcium (CAC) scoring computed tomography were performed before and after treatment. Hypocalcemic symptoms and serum calcium levels were evaluated. RESULTS After 1 year of treatment, the percent changes of femur neck (3.6 ± 3.2% vs. -0.7 ± 4.4%, p = 0.033) and total hip (3.4 ± 3.8% vs. -1.9 ± 2.1%, p = 0.001) bone mineral density (BMD) were significantly increased in the denosumab treated group compared to the control group. However, the percent change of lumbar spine BMD did not differ between two groups (5.6 ± 5.9% vs. 2.7 ± 3.9%, p = 0.273). The percent change of bone alkaline phosphatase was significantly different in the denosumab-treated group and control group (-31.1 ± 30.0% vs. 0.5 ± 32.0%, p = 0.027). CAC scores did not differ between groups. No hypocalcemic events occurred in both groups. CONCLUSION If carefully monitored and supplemented with calcium and vitamin D, denosumab treatment for 1 year provides significant benefits in patients with Stage 3b-4 CKD and osteoporosis. However, denosumab treatment did not affect coronary artery calcifications in these patients.
Collapse
Affiliation(s)
- Jin Taek Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul,
Korea
| | - You Mi Kim
- Division of Nephrology, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul,
Korea
| | - Kyong Yeun Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul,
Korea
| | - Hoonsung Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - So Young Lee
- Division of Nephrology, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul,
Korea
| | - Hyo-Jeong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul,
Korea
| |
Collapse
|
4
|
Zhu P, Yang T, Le J, Fu X, Zhang L. Efficacy of denosumab on bone metabolism and bone mineral density in renal transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100793. [PMID: 37659288 DOI: 10.1016/j.trre.2023.100793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Post-transplant bone disease (PTBD) is a common complication in kidney transplant recipients. This systematic review and meta-analysis evaluates the efficiency and safety of denosumab for the treatment of PTBD in kidney transplant recipients. METHODS Comprehensive search of PubMed Central, SCOPUS, EMBASE, MEDLINE, Cochrane trial registry, Google Scholar, and Clinicaltrials.gov databases was done for studies, published until April 2023. Primary outcomes included changes in bone mineral density (BMD) and T-scores. Secondary outcomes included incidence of fractures, alterations in bone turnover markers, and the incidence of adverse events. RESULTS Eleven studies with a total of 511 participants that underwent kidney transplant were included. Denosumab treatment resulted in a significant improvement in lumbar spine BMD (SMD: -0.31, 95% CI: -0.56 to -0.06) and T-score (SMD: -1.07, 95% CI: -1.51 to -0.64), while no differences were detected in hip/femoral neck BMD and the T-score. There was no marked change in the fracture incidence (OR: 0.42, 95% CI: 0.06 to 3.07). However, patients who received denosumab treatment had an increased incidence rate of hypocalcemia (OR: 9.98, 95% CI: 1.72 to 57.88). CONCLUSIONS Denosumab treatment may improve lumbar spine BMD and T-scores in patients with PTBD. However, it does not significantly affect fracture incidence and may increase the risk of hypocalcemia. These findings underline the necessity for well-powered, randomized controlled trials to further clarify the role of denosumab in managing PTBD.
Collapse
Affiliation(s)
- Peiqin Zhu
- Department of Internal Medicine, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, PR China
| | - Tong Yang
- Department of Respiratory and Critical Care Medicine, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, PR China
| | - Jun Le
- Orthopedics Department, Hangzhou TCM Hospital Affliated to Zhejiang Chinese Medical University, PR China
| | - Xiaoting Fu
- Orthopedics Department, Hangzhou TCM Hospital Affliated to Zhejiang Chinese Medical University, PR China
| | - Liang Zhang
- Orthopedics Department, Hangzhou TCM Hospital Affliated to Zhejiang Chinese Medical University, PR China.
| |
Collapse
|
5
|
Kanagalingam T, Khan T, Sultan N, Cowan A, Thain J, Hoy C, Ledger S, Clemens KK. Reducing the risk of denosumab-induced hypocalcemia in patients with advanced chronic kidney disease: a quality improvement initiative. Arch Osteoporos 2023; 18:138. [PMID: 37985504 DOI: 10.1007/s11657-023-01341-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023]
Abstract
Denosumab can improve bone health in advanced kidney disease (CKD) but is associated with hypocalcemia. We created a clinical care pathway focused on the safe provision of denosumab in advanced CKD that reduced the risk of hypocalcemia by 37% at our hospital. Similar pathways could be adopted and tested in other centers. PURPOSE There is an increased risk of hypocalcemia with denosumab in advanced chronic kidney disease (CKD). We aimed to reduce the proportion of patients with advanced CKD who experienced denosumab-induced hypocalcemia at our center. METHODS We conducted a quality improvement (QI) project of patients with CKD stage 3b or less (i.e., estimated glomerular filtration rate <45 mL/min/1.73m2 including dialysis) who were part of the Osteoporosis and Bone Disease Program at St. Joseph's Health Care London (Canada) between December 2020 and January 2023. Our intervention was a clinical care pathway which optimized CKD mineral and bone disorder (CKD-MBD) and 25-hydroxyvitamin levels; provided calcium and vitamin D prophylaxis; promoted multidisciplinary communication between bone and kidney specialists; and carefully monitored calcium post-denosumab injection. Our primary outcome measure was the proportion of patients with hypocalcemia (defined by albumin-corrected serum calcium <1.9mmol/L) at 60 days. Process measures included the appropriate provision of calcium and vitamin D prophylaxis. Balance measures included the development of hypercalcemia and hyperphosphatemia following prophylaxis. We used plan-do-see-act cycles to study four tests of change and presented results using descriptive statistics and run charts. RESULTS There were 6 patients with advanced CKD treated with denosumab prior to the implementation of our care pathway (March 2015-October 2020; 83% receiving dialysis). At the time of their denosumab injection, 83% were using 500-1000 mg of calcium, and 83% used 1000-2000 IU of vitamin D3. Fifty percent developed denosumab-induced hypocalcemia. Following the implementation of our care pathway, 15 patients (40% receiving dialysis) were treated with denosumab. Ninety-three percent received calcium at a daily dose of 350 to 2250 mg and 87% received 1000-2000 IU of vitamin D3. Thirteen percent developed denosumab-induced hypocalcemia. There was no hypercalcemia or hyperphosphatemia. CONCLUSIONS A clinical care pathway focused on the safe provision of denosumab in advanced CKD reduced the risk of hypocalcemia in patients treated in our hospital. Similar pathways could be adopted and tested in other centers.
Collapse
Affiliation(s)
- Tharsan Kanagalingam
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Tayyab Khan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada
| | - Nabil Sultan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Andrea Cowan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Jenny Thain
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Division of Geriatrics, Western University, London, ON, Canada
| | - Cindy Hoy
- St Joseph's Health Care London, London, ON, Canada
| | | | - Kristin K Clemens
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada.
- St Joseph's Health Care London, London, ON, Canada.
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
- Lawson Health Research Institute, London, ON, Canada.
- ICES, London, ON, Canada.
| |
Collapse
|
6
|
Abduelkarem AR, Guella A, Hamrouni AM, Hassanein MM, Nasr A, Rana O. Denosumab Use in Chronic Kidney Disease Associated Osteoporosis: A Narrative Review. Risk Manag Healthc Policy 2023; 16:1809-1813. [PMID: 37719685 PMCID: PMC10503558 DOI: 10.2147/rmhp.s426869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023] Open
Abstract
Chronic kidney disease (CKD) and hemodialysis (HD) patients have a high incidence of bone disease and increased fracture risk, making effective management of their bone health a clinical challenge. Denosumab, a human monoclonal antibody, has been investigated as a therapeutic option in this patient population. In this review, we summarize the current evidence on the efficacy and safety of denosumab in CKD and HD patients. A comprehensive search of the relevant literature was conducted, including randomized controlled trials, observational studies, and meta-analyses. The findings suggest that denosumab reduces the risk of fractures and improves bone mineral density in all stages of CKD. The results of this review support the use of denosumab as a promising option for managing bone disease in CKD and HD patients.
Collapse
Affiliation(s)
- Abduelmula R Abduelkarem
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
- Research Institute for Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Adnane Guella
- Department of Nephrology, University Hospital Sharjah, Sharjah, United Arab Emirates
| | - Amar M Hamrouni
- Department of Pharmaceutical Sciences, College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates
| | - Mohammed M Hassanein
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
| | - Ahmed Nasr
- Pharmacy Department, University Hospital Sharjah, Sharjah, United Arab Emirates
| | - Owais Rana
- Department of Internal Medicine, University Hospital Sharjah, Sharjah, United Arab Emirates
| |
Collapse
|
7
|
Okuno F, Ito-Masui A, Hane A, Maeyama K, Ikejiri K, Ishikura K, Yanagisawa M, Dohi K, Suzuki K. Severe hypocalcemia after denosumab treatment leading to refractory ventricular tachycardia and veno-arterial extracorporeal membrane oxygenation support: a case report. Int J Emerg Med 2023; 16:52. [PMID: 37635211 PMCID: PMC10463425 DOI: 10.1186/s12245-023-00529-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Severe hypocalcemia may lead to life-threatening arrhythmias. Denosumab is an effective treatment for osteoporosis that allows long intervals between doses. However, there is a risk of hypocalcemia in some patients. Due to the long half-life of denosumab, emergency physicians caring for patients presenting with symptoms of hypocalcemia may not be aware of the medication, and adverse effects may last longer. CASE PRESENTATION A 55-year-old woman with a history of systemic lupus erythematosus (SLE) and anxiety disorder called for an ambulance for symptoms of hyperventilation and muscle cramps. After evaluation at the local hospital, she developed pulseless ventricular tachycardia and was resuscitated by defibrillation by the hospital staff. After conversion to sinus rhythm, she was transported to a tertiary center. Upon arrival, pulseless ventricular tachycardia occurred again, and veno-arterial extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) were implemented. Laboratory results showed severe hypocalcemia (corrected calcium level of 5.3 mg/dL) whereupon intravenous calcium supplementation was started. She had received the first dose of denosumab (60 mg) by subcutaneous injection 24 days prior to hospitalization. She was eventually weaned from ECMO and IABP support. CONCLUSION Cardiac arrest due to hypocalcemia is relatively rare but can be fatal. In the present case, hyperventilation may have acutely exacerbated pre-existing hypocalcemia, leading to ventricular tachycardia. The patient had a slightly decreased serum calcium level prior to denosumab. Close monitoring may be preferable after the primary dose of denosumab in selected patients. Emergency physicians caring for patients who may be suffering from symptoms/signs of hypocalcemia must be mindful of medications that have long half-lives and affect electrolyte balance when treating fatal arrhythmia due to hypocalcemia.
Collapse
Affiliation(s)
- Fumito Okuno
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Asami Ito-Masui
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan.
| | - Atsuya Hane
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Keiko Maeyama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Kaoru Ikejiri
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Ken Ishikura
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Masashi Yanagisawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Kei Suzuki
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| |
Collapse
|
8
|
Dadana S, Gundepalli S, Kondapalli A. Severe Refractory Hypocalcemia Caused by Denosumab. Cureus 2023; 15:e39866. [PMID: 37404446 PMCID: PMC10315058 DOI: 10.7759/cureus.39866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/06/2023] Open
Abstract
Denosumab is a fully human monoclonal antibody that binds to the receptor activator of nuclear factor kappa-Β ligand, an essential cytokine factor in bone resorption, which reduces bone resorption and has been shown to decrease the incidence of skeletal-related events in patients with malignancy and bone metastasis. Severe hypocalcemia is a rare and life-threatening adverse effect of denosumab therapy. Here, we discuss the case of a patient with stage 4 estrogen receptor-positive, progesterone receptor-negative, human epidermal growth factor receptor 2-negative breast cancer who was on treatment with denosumab for bony metastases and presented with severe refractory hypocalcemia.
Collapse
Affiliation(s)
- Sriharsha Dadana
- Internal Medicine, Cheyenne Regional Medical Center, Cheyenne, USA
| | - Sai Gundepalli
- Internal Medicine, Cheyenne Regional Medical Center, Cheyenne, USA
| | | |
Collapse
|
9
|
Gronskaya S, Belaya Z, Rozhinskaya L, Mamedova E, Vorontsova M, Solodovnikov A, Golounina O, Melnichenko G. Denosumab for osteoporosis in patients with primary hyperparathyroidism and mild-to-moderate renal insufficiency. Endocrine 2023:10.1007/s12020-023-03381-z. [PMID: 37133642 DOI: 10.1007/s12020-023-03381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/18/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE We aimed to assess the efficacy and safety of denosumab in postmenopausal women with primary hyperparathyroidism (PHPT)-related osteoporosis and chronic kidney disease (CKD). METHODS Women over 50 years of age with PHPT or postmenopausal osteoporosis (PMO) were retrospectively recruited into this longitudinal study. These PHPT and PMO groups were further categorized into subgroups based on the presence of CKD (Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2). All patients were given denosumab over 24 months due to verified osteoporosis. The primary outcomes were changes in bone mineral density (BMD) and serum calcium levels. RESULTS 145 postmenopausal women median age 69 [63;77] were recruited and assigned to one of the subgroups: PHPT patients with CKD (n = 22), PHPT patients without CKD (n = 38), PMO patients with CKD (n = 17) and PMO patients without CKD (n = 68). Denosumab treatment significantly increased BMD in patients with PHPT-related osteoporosis and CKD: median T-score L1-L4 from -2.0 to -1.35 (p < 0.001), femur neck from -2.4 to -2.1 (p = 0.012), radius 33% from -3.2 to -3 (p < 0.05)) at 24 months. Changes in BMD were similar in all four studied groups compared to baseline. A marked decline in calcium was noted in the primary study group of PHPT with CKD (median ΔCa = -0.24 mmol/L p < 0.001), compared to PHPT without CKD (median ΔCa = -0.08 mmol/L p < 0.001) and PMO with or without CKD. Denosumab treatment was well-tolerated with no serious adverse events. CONCLUSION Denosumab treatment was similarly effective at increasing BMD in patients with PHPT and PMO with and without renal insufficiency. The calcium lowering effects of denosumab were most significant in patients with PHPT and CKD. The safety of denosumab did not differ among participants with and without CKD.
Collapse
Affiliation(s)
- Sofia Gronskaya
- Endocrinology Research Centre, Department of Neuroendocrinology and Bone Disease, Moscow, Russia
| | - Zhanna Belaya
- Endocrinology Research Centre, Department of Neuroendocrinology and Bone Disease, Moscow, Russia.
| | - Liudmila Rozhinskaya
- Endocrinology Research Centre, Department of Neuroendocrinology and Bone Disease, Moscow, Russia
| | - Elizaveta Mamedova
- Endocrinology Research Centre, Department of Neuroendocrinology and Bone Disease, Moscow, Russia
| | - Maria Vorontsova
- Endocrinology Research Centre, Department of Neuroendocrinology and Bone Disease, Moscow, Russia
- Lomonosov Moscow State University, Laboratory for Molecular Endocrinology, Moscow, Russia
| | | | - Olga Golounina
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - Galina Melnichenko
- Endocrinology Research Centre, Department of Neuroendocrinology and Bone Disease, Moscow, Russia
| |
Collapse
|
10
|
Tsai TY, You ZH, Tsai SF, Wu MJ, Yu TM, Chuang YW, Lin YC, Deng YL, Hsu CY, Chen CH. Adverse Effects of Denosumab in Kidney Transplant Recipients: A 20-Year Retrospective Single-Center Observation Study in Central Taiwan. Transplant Proc 2023:S0041-1345(23)00145-8. [PMID: 37055293 DOI: 10.1016/j.transproceed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/13/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Bone loss can be noted in kidney transplantation recipients (KTRs) and can be related to fracture events. Denosumab, a potent monoclonal antibody to RANK ligand, increases lumbar bone mineral density. However, safety data for denosumab remain limited regarding transplant recipients. Hypocalcemia and increased genital tract infections have been mentioned as adverse effects in KTRs after being prescribed denosumab. METHODS We retrospectively analyzed the electronic medical records of KTRs during the recent 20 years who had been prescribed antiresorptive therapy and were >18 years old. Medical records and their clinical data were reviewed and analyzed. We compared the frequency of adverse effects between denosumab with other antiresorptive therapies. RESULTS A total of 70 KTRs were enrolled, with 46 patients being given denosumab and the first injection being noted on October 31, 2014. No significant differences were seen in mortality rate, opportunistic infection, pneumonia, or genitourinary tract infection. One diagnosis of osteonecrosis of the jaw was noted in the denosumab group (2.2%). A higher incidence of hypocalcemia (<8.4 mg/dL) was noted in the denosumab group (34.8%), and a higher but nonsignificant difference in the incidence of severe hypocalcemia was also noted in the group. CONCLUSIONS Denosumab may be considered as safe as other antiresorptive therapies for KTRs. However, more hypocalcemia events have been noted, so medical personnel may need to be cautious when prescribing its use.
Collapse
Affiliation(s)
- Tsung-Yin Tsai
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital Chiayi Branch, Chiayi, Taiwan
| | - Zi-Hong You
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital Chiayi Branch, Chiayi, Taiwan
| | - Shang-Feng Tsai
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Tung-Min Yu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ya-Wen Chuang
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yung-Chieh Lin
- Department of Urology, Hsinchu Branch, MacKay Memorial Hospital, New Taipei, Taiwan
| | - Ya-Lian Deng
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chiann-Yi Hsu
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Department of Life Science, Tunghai University, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| |
Collapse
|
11
|
Cowan A, Jeyakumar N, McArthur E, Fleet JL, Kanagalingam T, Karp I, Khan T, Muanda FT, Nash DM, Silver SA, Thain J, Weir MA, Garg AX, Clemens KK. Hypocalcemia Risk of Denosumab Across the Spectrum of Kidney Disease: A Population-Based Cohort Study. J Bone Miner Res 2023; 38:650-658. [PMID: 36970786 DOI: 10.1002/jbmr.4804] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/28/2023] [Accepted: 03/21/2023] [Indexed: 04/11/2023]
Abstract
Denosumab can be used in patients with chronic kidney disease (CKD) but has been linked with cases of severe hypocalcemia. The incidence of and risk factors for hypocalcemia after denosumab use are not well established. Using linked health care databases at ICES, we conducted a population-based cohort study of adults >65 years old with a new prescription for denosumab or a bisphosphonate between 2012 and 2020. We assessed incidence of hypocalcemia within 180 days of drug dispensing and stratified results by estimated glomerular filtration rate (eGFR in mL/min/1.73 m2 ). We used Cox proportional hazards to assess risk factors for hypocalcemia. There were 59,151 and 56,847 new denosumab and oral bisphosphonate users, respectively. Of the denosumab users, 29% had serum calcium measured in the year before their prescription, and one-third had their serum calcium checked within 180 days after their prescription. Mild hypocalcemia (albumin corrected calcium <2.00 mmol/L) occurred in 0.6% (95% confidence interval [CI] 0.6, 0.7) of new denosumab users and severe hypocalcemia (<1.8 mmol/L) in 0.2% (95% CI 0.2, 0.3). In those with an eGFR <15 or receiving maintenance dialysis, the incidence of mild and severe hypocalcemia was 24.1% (95% CI 18.1, 30.7) and 14.9% (95% CI 10.1, 20.7), respectively. In this group, kidney function and baseline serum calcium were strong predictors of hypocalcemia. We did not have information on over-the-counter vitamin D or calcium supplementation. In new bisphosphonate users, the incidence of mild hypocalcemia was 0.3% (95% CI 0.3, 0.3) with an incidence of 4.7% (95% CI 1.5, 10.8) in those with an eGFR <15 or receiving maintenance dialysis. In this large population-based cohort, we found that the overall risk of hypocalcemia with new denosumab use was low but increased substantially in those with eGFR <15 mL/min/1.73 m2 . Future studies should investigate strategies to mitigate hypocalcemia. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Collapse
Affiliation(s)
- Andrea Cowan
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
| | - Nivethika Jeyakumar
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Eric McArthur
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Jamie L Fleet
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Igor Karp
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Tayyab Khan
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Danielle M Nash
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | | | - Jenny Thain
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | - Matthew A Weir
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Amit X Garg
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Kristin K Clemens
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| |
Collapse
|
12
|
Li H, Huang Y, Chen Z, Zeng A, Zhang H, Yu Y, Wei S, Li Q, Wang X, Wang X, Wang X, Yang R, Dai X, Bi M, Sun T, Zhang Q, Han C, Li Y, Kang X, Liu Y, Zhang L. Efficacy and Safety of Denosumab Biosimilar QL1206 Versus Denosumab in Patients with Bone Metastases from Solid Tumors: A Randomized Phase III Trial. BioDrugs 2023; 37:259-269. [PMID: 36802320 PMCID: PMC9971153 DOI: 10.1007/s40259-023-00579-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Denosumab has been approved for the treatment of bone metastases from solid tumors. QL1206 is the first denosumab biosimilar and needs to be compared with denosumab in a phase III trial. OBJECTIVE This phase III trial aims to compare the efficacy, safety, and pharmacokinetics between QL1206 and denosumab in patients with bone metastases from solid tumors. METHODS This randomized, double-blind, phase III trial was conducted in 51 centers in China. Patients aged 18-80 years, with solid tumors and bone metastases, and an Eastern Cooperative Oncology Group performance status of 0-2 were eligible. This study was divided into a 13-week double-blind period, a 40-week open-label period, and a 20-week safety follow-up period. In the double-blind period, patients were randomly assigned (1:1) to receive three doses of QL1206 or denosumab (120 mg subcutaneously every 4 weeks, each). Randomization was stratified by tumor types, previous skeletal-related events, and current systemic anti-tumor therapy. In the open-label period, up to ten doses of QL1206 could be given in both groups. The primary endpoint was percentage change in urinary N-telopeptide/creatinine ratio (uNTX/uCr) from baseline to Week 13. Equivalence margins were ± 0.135. Secondary endpoints included percentage change in uNTX/uCr at Week 25 and 53, percentage change in serum bone-specific alkaline phosphatase at Week 13, 25, and 53, and time to on-study skeletal-related events. The safety profile was evaluated based on adverse events and immunogenicity. RESULTS From September 2019 to January 2021, in the full analysis set, 717 patients were randomly assigned to receive QL1206 (n = 357) or denosumab (n = 360). Median percentage changes in uNTX/uCr at Week 13 in two groups were - 75.2% and - 75.8%, respectively. Least-squares mean difference in the natural log-transformed ratio of uNTX/uCr at Week 13 to baseline between the two groups was 0.012 (90% confidence interval - 0.078 to 0.103), within the equivalence margins. There were no differences in the secondary endpoints between the two groups (all p > 0.05). Adverse events, immunogenicity, and pharmacokinetics were similar in the two groups. CONCLUSIONS Denosumab biosimilar QL1206 had promising efficacy, tolerable safety, and pharmacokinetics equivalent to denosumab and could benefit patients with bone metastases from solid tumors. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04550949, retrospectively registered on 16 September, 2020.
Collapse
Affiliation(s)
- Huiping Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yan Huang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, China.
| | - Zhendong Chen
- Department of Oncology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Aiping Zeng
- Department of Chemotherapy, Guangxi Medical University Affiliated Tumor Hospital, Nanjing, China
| | - Helong Zhang
- Department of Oncology, Tangdu Hospital of the Fourth Military Medical University of the Chinese People's Liberation Army, Xi'an, China
| | - Yan Yu
- Department of Respiratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Shihong Wei
- Thoracic Oncology, Gansu Provincial Cancer Hospital, Lanzhou, China
| | - Qingshan Li
- Department of Oncology, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Xiaojia Wang
- Department of Breast Medical Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Xiangcai Wang
- Department of Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Xiuwen Wang
- Department of Chemotherapy, Qilu Hospital of Shandong University, Jinan, China
| | - Runxiang Yang
- Department of Internal Medicine, Yunnan Cancer Hospital, Kunming, China
| | - Xiumei Dai
- Department of Oncology, Xuzhou Central Hospital, Xuzhou, China
| | - Minghong Bi
- Department of Medical Oncology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Tao Sun
- Department of Breast Medical Oncology, Liaoning Cancer Hospital, Shenyang, China
| | - Qingyuan Zhang
- Department of Breast Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Cuicui Han
- Clinical Research Center, Qilu Pharmaceutical Co., Ltd, Jinan, China
| | - Yujie Li
- Clinical Research Center, Qilu Pharmaceutical Co., Ltd, Jinan, China
| | - Xiaoyan Kang
- Clinical Research Center, Qilu Pharmaceutical Co., Ltd, Jinan, China
| | - Yaxin Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Li Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, China.
| |
Collapse
|
13
|
Hussain M, Khan F, Al Hadidi S. The use of bone-modifying agents in multiple myeloma. Blood Rev 2023; 57:100999. [PMID: 36050125 DOI: 10.1016/j.blre.2022.100999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 01/28/2023]
Abstract
Multiple myeloma is a hematological neoplasm characterized by abnormal proliferation of plasma cells in the bone marrow and is usually associated with increased bone pain and skeletal-related events such as pathological fracture and/or spinal cord compression. Myeloma bone disease results in changes in the bone-marrow microenvironment evidenced by increased osteoclastic activity and/or decreased osteoblastic activity, which negatively affect quality of life. Treatment of myeloma bone disease includes bisphosphonates or denosumab (bone-modifying agents). These agents do not induce the formation of new bone or repair existing bone damage, but they can decrease bone pain and the risk of pathological fracture. While these agents improve quality of life, it is not known whether they improve overall survival. This review focuses on different classes of bone-modifying agents, their mechanisms of action, time of initiation, duration of therapy, and potential survival benefits.
Collapse
Affiliation(s)
- Munawwar Hussain
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Fatima Khan
- Department of Hematology Oncology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| |
Collapse
|
14
|
Boots JMM, Quax RAM. High-Dose Intravenous Iron with Either Ferric Carboxymaltose or Ferric Derisomaltose: A Benefit-Risk Assessment. Drug Saf 2022; 45:1019-1036. [PMID: 36068430 PMCID: PMC9492608 DOI: 10.1007/s40264-022-01216-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/22/2022]
Abstract
The intravenous iron formulations ferric carboxymaltose (FCM) and ferric derisomaltose (FDI) offer the possibility of administering a large amount of iron in one infusion. This results in faster correction of anemia and the formulations being better tolerated than oral iron formulations. This triad of logistic advantages, improved patient convenience, and fast correction of anemia explains the fact that intravenous iron formulations nowadays are frequently prescribed worldwide in the treatment of iron deficiency anemia. However, these formulations may result in hypophosphatemia by inducing a strong increase in active fibroblast growth factor-23 (FGF-23), a hormone that stimulates renal phosphate excretion. This effect is much more pronounced with FCM than with FDI, and therefore the risk of developing hypophosphatemia is remarkably higher with FCM than with FDI. Repeated use of FCM may result in severe osteomalacia, which is characterized by bone pain, Looser zones (pseudofractures), and low-trauma fractures. Intravenous iron preparations are also associated with other adverse effects, of which hypersensitivity reactions are the most important and are usually the result of a non-allergic complement activation on nanoparticles of free labile iron-Complement Activation-Related Pseudo-Allergy (CARPA). The risk on these hypersensitivity reactions can be reduced by choosing a slow infusion rate. Severe hypersensitivity reactions were reported in < 1% of prospective trials and the incidence seems comparable between the two formulations. A practical guideline has been developed based on baseline serum phosphate concentrations and predisposing risk factors, derived from published cases and risk factor analyses from trials, in order to establish the safe use of these formulations.
Collapse
Affiliation(s)
- Johannes M M Boots
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
| | - Rogier A M Quax
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
| |
Collapse
|
15
|
Cohen A, Chacko B. Severe hypocalcaemia following denosumab and iron infusion. Nephrology (Carlton) 2022; 27:781-782. [PMID: 35746864 PMCID: PMC9543461 DOI: 10.1111/nep.14078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/09/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Adrienne Cohen
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Bobby Chacko
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| |
Collapse
|
16
|
Eatz TA, Chertman L, Levis S, Lagari V. Denosumab-associated hypocalcemia in a patient with chronic kidney disease and Paget's disease. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2022. [DOI: 10.1016/j.jecr.2022.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
17
|
Ikegami K, Hashiguchi M, Kizaki H, Yasumuro O, Funakoshi R, Hori S. Development of Risk Prediction Model for Grade 2 or Higher Hypocalcemia in Bone Metastasis Patients Treated with Denosumab plus Cholecalciferol (Vitamin D3)/Ca Supplement. J Clin Pharmacol 2022; 62:1151-1159. [PMID: 35383950 DOI: 10.1002/jcph.2057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/01/2022] [Indexed: 11/09/2022]
Abstract
Denosumab-induced hypocalcemia is sometimes severe, and although a natural vitamin D/Ca combination is used to prevent hypocalcemia, some patients rapidly develop severe hypocalcemia even under supplementation. It is clinically important to predict this risk. This study aimed to develop a risk prediction model for grade 2 or higher hypocalcemia within 28 days after the first denosumab dose under natural vitamin D/Ca supplementation. Using a large database containing multicenter practice data, 2,399 bone metastasis patients who were treated with denosumab between June 2013 and May 2020 were retrospectively analyzed. Background factors in patients who developed grade 2 or higher hypocalcemia within 28 days after the first denosumab dose and those who did not were compared by univariate analysis. Multivariate analysis was conducted to develop a risk prediction model. The model was evaluated for discriminant performance (ROC-AUC: receiver operating characteristic - area under the curve, sensitivity, specificity) and predictive performance (calibration slope). A total of 124 patients in the hypocalcemia group and 1,191 patients in the non-hypocalcemia group were extracted. A risk prediction model consisting of sex, Ca, albumin, alkaline phosphatase, osteoporosis, breast cancer, gastric cancer, proton pump inhibitor combination, and pretreatment with zoledronic acid was developed. The ROC-AUC was 0.87. Sensitivity and specificity were 83% and 81%, respectively, and the calibration slope indicated acceptable agreement between observed and predicted risk. This model appears to be useful to predict the risk of denosumab-induced hypocalcemia and thus should be helpful for risk management of denosumab treatment in patients with bone metastases. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Keisuke Ikegami
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Masayuki Hashiguchi
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Hayato Kizaki
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Osamu Yasumuro
- Department of Pharmacy, Kameda General Hospital, Chiba, Japan
| | | | - Satoko Hori
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| |
Collapse
|
18
|
Interpretation of expert consensus on prevention and treatment of osteoporosis in perimenopausal and postmenopausal women. GLOBAL HEALTH JOURNAL 2022. [DOI: 10.1016/j.glohj.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
19
|
Park SY, Kim J, Chung HY. Denosumab-induced hypocalcemia in a patient with hyperthyroidism: a case report. Osteoporos Int 2022; 33:305-308. [PMID: 34232341 PMCID: PMC8758617 DOI: 10.1007/s00198-021-06059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
Denosumab is a humanized monoclonal antibody targeting the receptor activator of nuclear factor kappa-B ligand (RANKL). Denosumab is an effective treatment for osteoporosis but can cause hypocalcemia. We present a case of denosumab-induced hypocalcemia in a patient with hyperthyroidism with a high bone turnover state. A 48-year-old postmenopausal woman was diagnosed with hyperthyroidism and osteoporosis and received antithyroid drugs (propylthiouracil 200 mg/day) and denosumab. After 2 months of taking medication, the patient complained of numbness and tingling in the hands and feet and was diagnosed with hypocalcemia (calcium, 5.8 mg/dL; ionized calcium, 0.83 mmol/L). Alfacalcidol (0.5 μg/day) and calcium carbonate (3000 mg/day) were prescribed. Subsequently, the patient's symptoms improved, and her serum calcium level normalized. The risk of denosumab-induced hypocalcemia may be increased in patients with diseases related to high bone turnover, such as hyperthyroidism; therefore, caution is needed.
Collapse
Affiliation(s)
- S Y Park
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - J Kim
- Department of Endocrinology and Metabolism, Chaum, Seoul, Republic of Korea
| | - H Y Chung
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, Republic of Korea.
| |
Collapse
|
20
|
Xing Y, Ju S, Sun M, Xiang S. Case report: Denosumab-associated acute heart failure in patients with cardiorenal insufficiency. Front Endocrinol (Lausanne) 2022; 13:970571. [PMID: 36187135 PMCID: PMC9515392 DOI: 10.3389/fendo.2022.970571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/29/2022] [Indexed: 11/20/2022] Open
Abstract
Denosumab is a pivotal treatment for postmenopausal women with osteoporosis. Although its clinical use is generally well tolerated by patients, denosumab in patients with renal insufficiency may increase the risk of hypocalcemia. Thus, we have to consider the population of denosumab in the treatment of osteoporosis and preventive measures for related complications. In a patient with cardiorenal insufficiency, we reported a case of denosumab-induced hypocalcemia complicated by acute left heart failure due to delayed administration of active vitamin D and calcium supplements. The patient's symptoms did not improve after anti-heart failure treatment. However, after adequate calcium and vitamin D supplementation subsequently, the patient's symptoms of heart failure were rapidly relieved, and the serum calcium level returned to normal within three weeks. Therefore, our case showed that the application of denosumab in patients requires assessment of cardiac and renal function, timely calcium and vitamin D supplementation, and enhanced monitoring of serum calcium levels to prevent acute left heart failure induced by denosumab-related hypocalcemia.
Collapse
|
21
|
Saito Y, Takekuma Y, Komatsu Y, Sugawara M. Risk Analysis of Denosumab-Induced Hypocalcemia in Bone Metastasis Treatment: Renal Dysfunction Is Not a Risk Factor for Its Incidence in a Strict Denosumab Administration Management System with Calcium/Vitamin D Supplementation. Biol Pharm Bull 2021; 44:1819-1823. [PMID: 34853264 DOI: 10.1248/bpb.b21-00653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have reported that a strict denosumab administration management system with oral calcium/vitamin D supplementation attenuates denosumab-induced hypocalcemia in 158 cancer patients with bone metastasis. In this report, 27.8% of the patients experienced hypocalcemia, including 0.6% with grade 2. So far, the risk factors for ≥grade 2 hypocalcemia incidence have been identified in denosumab-treated cancer patients, including patients without calcium/vitamin D supplementation. Therefore, the present study aimed to reveal the factors that affect all-grade hypocalcemia incidence with calcium/vitamin D supplementation and team medical care according to the management system. A receiver operating characteristic curve analysis suggested that the cutoff of baseline serum calcium level for all-grade hypocalcemia incidence was 9.3 mg/dL. Multivariate analysis revealed that age ≥65 years (odds ratio, 95% confidence interval: 2.57, 1.11-5.95, p = 0.03), grade 1 or higher serum alkaline phosphatase elevation (3.70, 1.71-8.00, p < 0.01), an adjusted serum calcium level of less than 9.3 mg/dL (3.21. 1.25-8.24, p = 0.02) at baseline, and co-administration of cytotoxic agents (2.33, 1.06-7.11, p = 0.03) are risk factors for the incidence of all-grade hypocalcemia. However, renal dysfunction, which has been suggested to be a risk factor in previous reports, was not a factor. In conclusion, we revealed the risk factors for all-grade hypocalcemia in calcium/vitamin D supplementation and awareness, as demonstrated by the management system. Moreover, renal dysfunction was not a risk factor in our strict denosumab administration management system. Our results support the value of early detection of hypocalcemia incidence to guide the selection of an appropriate management strategy.
Collapse
Affiliation(s)
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital
| | | | - Mitsuru Sugawara
- Department of Pharmacy, Hokkaido University Hospital.,Laboratory of Pharmacokinetics, Faculty of Pharmaceutical Sciences, Hokkaido University
| |
Collapse
|
22
|
Gouli S, Wang J, Patel A, Allerton J. Hypocalcemia in a Patient With Metastatic Prostate Cancer From Denosumab Treatment. Cureus 2021; 13:e17046. [PMID: 34522524 PMCID: PMC8427738 DOI: 10.7759/cureus.17046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 12/24/2022] Open
Abstract
Denosumab is a humanized monoclonal antibody that binds RANKL to inhibit osteoclast activity. It is indicated for the prevention of skeletal-related events (SRE) in patients with solid tumors who have bone metastasis and in patients with multiple myeloma. Hypocalcemia is one of the known side effects of denosumab, which can be prevented with calcium supplementation. We present a case of a 72-year-old male with diagnosed metastatic prostate cancer who had received one dose of denosumab 10 days prior to presentation with fatigue, insomnia, and somnolence. His labs showed severe (Grade 4) hypocalcemia, which improved with intravenous calcium supplementation. This case highlights a known but life-threatening side effect of denosumab and the potential need for prolonged calcium monitoring in patients placed on the drug.
Collapse
Affiliation(s)
- Sugam Gouli
- Internal Medicine, Bassett Medical Center, Cooperstown, USA
| | - Jimmy Wang
- Internal Medicine, Bassett Medical Center, Cooperstown, USA
| | - Anush Patel
- Hematology / Oncology, Bassett Medical Center, Cooperstown, USA
| | | |
Collapse
|
23
|
Cianciolo G, Tondolo F, Barbuto S, Iacovella F, Zavatta G, Altieri P, Grandinetti V, Comai G, Cozzolino M, La Manna G. Denosumab-Induced Hypocalcemia and Hyperparathyroidism in de novo Kidney Transplant Recipients. Am J Nephrol 2021; 52:611-619. [PMID: 34518468 DOI: 10.1159/000518363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/03/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Denosumab represents a realistic treatment option to increase bone mineral density in kidney transplant recipients (KTRs). It is still unknown how and at what extent posttransplantation bone disease and graft function influence the effects of denosumab on mineral metabolism indexes. In this study, we analyze risk factors of hypocalcemia and parathyroid hormone (PTH) increase after denosumab administration in eighteen de novo KTRs and its management before and after this treatment. METHODS We conducted a monocentric, observational, prospective study on de novo KTRs. All KTRs enrolled received a single 60 mg subcutaneous dose of denosumab every 6 months. Before kidney transplantation, no patients were treated with calcio-mimetic. After kidney transplantation and before antiresorptive therapy, no patients were treated with calcio-mimetic drugs and/or vitamin D receptor agonists, while all patients received nutritional vitamin D supplementation (from 1,000 IU to 1,500 IU daily). RESULTS Hypocalcemia was related to the degree of lumbar osteoporosis (p = 0.047); the increase in the PTH level was correlated to baseline bone turnover markers (bone alkaline phosphatase, serum osteocalcin, and β-C-terminal telopeptide), the 25 OH status, and eGFR. The introduction of calcitriol, after the PTH increase, in addition to cholecalciferol was necessary to ensure an adequate control of serum calcium and PTH during a follow-up of 15 months. Following the treatment with denosumab, it was observed an improvement of areal bone mineral density both at lumbar and femoral sites with a mean percentual increase of 1.74% and 0.25%, respectively. CONCLUSIONS Denosumab is an effective treatment for bone disease in KTRs. In our study, the increase in PTH is not a transient event but prolonged throughout the follow-up period and requires continuous supplementation therapy with calcitriol.
Collapse
Affiliation(s)
- Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy,
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Simona Barbuto
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Francesca Iacovella
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Guido Zavatta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Università Alma Mater Studiorum di Bologna, Bologna, Italy
| | - Paola Altieri
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Università Alma Mater Studiorum di Bologna, Bologna, Italy
| | - Valeria Grandinetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| |
Collapse
|
24
|
Gopaul A, Kanagalingam T, Thain J, Khan T, Cowan A, Sultan N, Clemens KK. Denosumab in chronic kidney disease: a narrative review of treatment efficacy and safety. Arch Osteoporos 2021; 16:116. [PMID: 34319515 DOI: 10.1007/s11657-021-00971-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/04/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED People with chronic kidney disease (CKD) are at high risk of bone fractures. In this review, we summarize the complexity of fracture prevention in CKD, describe the usefulness of a medication called denosumab, and review its safety in this population. Our article will help doctors manage brittle bones in CKD and encourage researchers to conduct more studies to improve bone health in CKD. PURPOSE Patients with CKD are at increased risk of fragility fractures and associated consequences. We discuss the complexity of fracture prevention in CKD, summarize the efficacy and safety of denosumab, and provide an approach to denosumab-induced hypocalcemia. METHODS Using predefined terms, we searched PubMed, MEDLINE, and Google Scholar for studies on fracture prevention in CKD and the efficacy and safety of denosumab. We included observational studies, randomized controlled trials (RCTs), meta-analyses, evidence-based reviews, and clinical practice guidelines. RESULTS The diagnosis of osteoporosis and prevention of related fragility fractures is complex in CKD, particularly in those with advanced and end-staged kidney disease (ESKD). Prior to initiating denosumab, it is important to assess for and optimize CKD-mineral and bone disorders (CKD-MBD). In observational studies and small RCTs, denosumab has been shown to improve bone mineral density and reduce bone turnover in CKD, but there have been no studies focused upon its fracture efficacy. Denosumab-induced hypocalcemia has also been reported, which disproportionately impacts those with ESKD. Risk factors for hypocalcemia with denosumab use in CKD include lower baseline serum calcium and 25 hydroxyvitamin D and both low and high bone turnover. Choosing the "right patient" for denosumab, supplementing with calcium and vitamin D, adjusting calcium dialysate, and close clinical monitoring are essential if considering this drug. CONCLUSION With optimization of CKD-MBD, calcium and vitamin D supplementation, and close monitoring, denosumab can be considered in CKD. There are however opportunities to better understand its fracture efficacy and safety in an RCT setting.
Collapse
Affiliation(s)
- Aquila Gopaul
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tharsan Kanagalingam
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jenny Thain
- Division of Geriatrics, Western University, London, ON, Canada
| | - Tayyab Khan
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada.,St. Joseph's Health Care London, London, ON, Canada
| | - Andrea Cowan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Nabil Sultan
- Division of Nephrology, Western University, London, ON, Canada.,London Health Sciences Centre, London, ON, Canada
| | - Kristin K Clemens
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada. .,St. Joseph's Health Care London, London, ON, Canada. .,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada. .,ICES, Ontario, Canada.
| |
Collapse
|
25
|
Differentiating the causes of adynamic bone in advanced chronic kidney disease informs osteoporosis treatment. Kidney Int 2021; 100:546-558. [PMID: 34102219 DOI: 10.1016/j.kint.2021.04.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022]
Abstract
Patients with chronic kidney disease (CKD) have an increased fracture risk because of impaired bone quality and quantity. Low bone mineral density predicts fracture risk in all CKD stages, including advanced CKD (CKD G4-5D). Pharmacological therapy improves bone mineral density and reduces fracture risk in moderate CKD. Its efficacy in advanced CKD remains to be determined, although pilot studies suggest a positive effect on bone mineral density. Currently, antiresorptive agents are the most commonly prescribed drugs for the prevention and therapy of osteoporosis. Their use in advanced CKD has been limited by the lack of large clinical trials and fear of causing kidney dysfunction and adynamic bone disease. In recent decades, adynamic bone disease has evolved as the most predominant form of renal osteodystrophy, commonly associated with poor outcomes, including premature mortality and progression of vascular calcification. Evolving evidence indicates that reduction of bone turnover by parathyroidectomy or pharmacological therapies, such as calcimimetics and antiresorptive agents, are not associated with premature mortality or accelerated vascular calcification in CKD. In contrast, chronic inflammation, oxidative stress, malnutrition, and diabetes can induce low bone turnover and associate with poor prognosis. Thus, the conditions causing suppression of bone turnover rather than the low bone turnover per se may account for the perceived association with outcomes. Anabolic treatment, in contrast, has been suggested to improve turnover and bone mass in patients with advanced CKD and low bone turnover; however, uncertainty about safety even exceeds that of antiresorptive agents. Here, we critically review the pathophysiological concept of adynamic bone disease and discuss the effect of low bone turnover on the safety and efficacy of anti-osteoporosis pharmacotherapy in advanced CKD.
Collapse
|
26
|
Zaitsev VG, Zheltova AA, Martynova SA, Tibirkova EV. Can conventional clinical chemistry tests help doctors in the monitoring of oncology patients? RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The use of laboratory assays in the diagnostic care of oncology patients can markedly increase the efficacy of cancer treatments. Many cancer-specific biomarker assays have been developed. However, the use of these has some limitations due to their cost. Moreover, not every diagnostic laboratory can perform a complete set of these assays. On the other hand, the smart use of conventional clinical chemistry tests could improve the management of cancer. They could be especially valuable tools in the long-term care of patients with a verified diagnosis. In this review, we discuss the utilization of the conventional clinical chemistry assays for the diagnosis, monitoring and prognosis of various oncological diseases. The use of conventional blood tests to assess the levels of chemical elements, metabolites and proteins (including enzymatic activity measurements) in the care of oncology patients is discussed. We have shown that some clinical chemistry assays could be used in the management of distinct kinds of cancer.
Collapse
|
27
|
Robinson DE, Ali MS, Strauss VY, Elhussein L, Abrahamsen B, Arden NK, Ben-Shlomo Y, Caskey F, Cooper C, Dedman D, Delmestri A, Judge A, Javaid MK, Prieto-Alhambra D. Bisphosphonates to reduce bone fractures in stage 3B+ chronic kidney disease: a propensity score-matched cohort study. Health Technol Assess 2021; 25:1-106. [PMID: 33739919 PMCID: PMC8020200 DOI: 10.3310/hta25170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bisphosphonates are contraindicated in patients with stage 4+ chronic kidney disease. However, they are widely used to prevent fragility fractures in stage 3 chronic kidney disease, despite a lack of good-quality data on their effects. OBJECTIVES The aims of each work package were as follows. Work package 1: to study the relationship between bisphosphonate use and chronic kidney disease progression. Work package 2: to study the association between using bisphosphonates and fracture risk. Work package 3: to determine the risks of hypocalcaemia, hypophosphataemia, acute kidney injury and upper gastrointestinal events associated with using bisphosphonates. Work package 4: to investigate the association between using bisphosphonates and changes in bone mineral density over time. DESIGN This was a new-user cohort study design with propensity score matching. SETTING AND DATA SOURCES Data were obtained from UK NHS primary care (Clinical Practice Research Datalink GOLD database) and linked hospital inpatient records (Hospital Episode Statistics) for work packages 1-3 and from the Danish Odense University Hospital Databases for work package 4. PARTICIPANTS Patients registered in the data sources who had at least one measurement of estimated glomerular filtration rate of < 45 ml/minute/1.73 m2 were eligible. A second estimated glomerular filtration rate value of < 45 ml/minute/1.73 m2 within 1 year after the first was requested for work packages 1 and 3. Patients with no Hospital Episode Statistics linkage were excluded from work packages 1-3. Patients with < 1 year of run-in data before index estimated glomerular filtration rate and previous users of anti-osteoporosis medications were excluded from work packages 1-4. INTERVENTIONS/EXPOSURE Bisphosphonate use, identified from primary care prescriptions (for work packages 1-3) or pharmacy dispensations (for work package 4), was the main exposure. MAIN OUTCOME MEASURES Work package 1: chronic kidney disease progression, defined as stage worsening or starting renal replacement. Work package 2: hip fracture. Work package 3: acute kidney injury, hypocalcaemia and hypophosphataemia identified from Hospital Episode Statistics, and gastrointestinal events identified from Clinical Practice Research Datalink or Hospital Episode Statistics. Work package 4: annualised femoral neck bone mineral density percentage change. RESULTS Bisphosphonate use was associated with an excess risk of chronic kidney disease progression (subdistribution hazard ratio 1.12, 95% confidence interval 1.02 to 1.24) in work package 1, but did not increase the probability of other safety outcomes in work package 3. The results from work package 2 suggested that bisphosphonate use increased fracture risk (hazard ratio 1.25, 95% confidence interval 1.13 to 1.39) for hip fractures, but sensitivity analyses suggested that this was related to unresolved confounding. Conversely, work package 4 suggested that bisphosphonates improved bone mineral density, with an average 2.65% (95% confidence interval 1.32% to 3.99%) greater gain in femoral neck bone mineral density per year in bisphosphonate users than in matched non-users. LIMITATIONS Confounding by indication was a concern for the clinical effectiveness (i.e. work package 2) data. Bias analyses suggested that these findings were due to inappropriate adjustment for pre-treatment risk. work packages 3 and 4 were based on small numbers of events and participants, respectively. CONCLUSIONS Bisphosphonates were associated with a 12% excess risk of chronic kidney disease progression in participants with stage 3B+ chronic kidney disease. No other safety concerns were identified. Bisphosphonate therapy increased bone mineral density, but the research team failed to demonstrate antifracture effectiveness. FUTURE WORK Randomised controlled trial data are needed to demonstrate antifracture efficacy in patients with stage 3B+ chronic kidney disease. More safety analyses are needed to characterise the renal toxicity of bisphosphonates in stage 3A chronic kidney disease, possibly using observational data. STUDY REGISTRATION This study is registered as EUPAS10029. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 17. See the NIHR Journals Library website for further project information. The project was also supported by the National Institute for Health Research Biomedical Research Centre, Oxford.
Collapse
Affiliation(s)
- Danielle E Robinson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
| | - M Sanni Ali
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
- Faculty of Epidemiology and Population Health, Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Y Strauss
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Leena Elhussein
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Bo Abrahamsen
- Open Patient data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Nigel K Arden
- Arthritis Research UK Sports, Exercise and Osteoarthritis Centre, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Fergus Caskey
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- UK Renal Registry, Bristol, UK
| | - Cyrus Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Daniel Dedman
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Antonella Delmestri
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research (NIHR) Bristol Biomedical Research Centre (BRC), University Hospitals Bristol NHS Foundation Trust, University of Bristol, Southmead Hospital, Bristol, UK
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
- Grup de Recerca en Malalties Prevalents de l'Aparell Locomotor (GREMPAL) Research Group and Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFes), University Institute for Primary Care Research (IDIAP) Jordi Gol, Universitat Autonoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain
| |
Collapse
|
28
|
Hiramatsu R, Ubara Y, Sawa N, Sakai A. Hypocalcemia and bone mineral changes in hemodialysis patients with low bone mass treated with denosumab: a 2-year observational study. Nephrol Dial Transplant 2021; 36:1900-1907. [PMID: 33544866 DOI: 10.1093/ndt/gfaa359] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Increases in bone mineral density (BMD) following a single dose of denosumab and increased incidence of denosumab-associated acute hypocalcemia (DAAH) have been reported in chronic kidney disease (CKD) patients. Little is known about clinical risk factors related to DAAH and the long-term effect of denosumab on BMD in hemodialysis patients. METHODS An observational non-controlled study involving 47 hemodialysis patients was conducted to determine the independent risk factors related to percent changes in serum Ca levels associated with denosumab using multivariate regression analysis. Optimal predictive markers for DAAH were explored by receiver operating characteristic (ROC) analysis. Percent changes of BMD at the lumbar spine (LS) and femoral neck (FN) over 24 months were investigated. RESULTS The incidence of DAAH (serum corrected Ca (cCa) ≤ 8 mg/dL) following denosumab was 25.5%. Multivariate regression analysis showed baseline bone alkaline phosphatase (BAP) was independently related to percent changes in cCa levels (β = -0.407, P = 0.008). Tartrate-resistant acid phosphatase (TRACP-5b) was found to be the most accurate marker to predict DAAH with AUC of 0.750 (95% CI; 0.546-0.954, P = 0.02) and the optimal cut-off level was 670 mU/mL with sensitivity; 0.727 and specificity; 0.733. BMD significantly increased by 5.9 ± 1.7% (P = 0.01) at LS and 4.2 ± 1.5% (P = 0.04) at FN at 24 months. CONCLUSION In hemodialysis patients, high bone turnover was an independent risk factor for the Ca declines induced by denosumab. Denosumab significantly increased BMD at LS and FN over 24 months.
Collapse
Affiliation(s)
- Rikako Hiramatsu
- Nephrology Centre, Toranomon Hospital, Tokyo, Japan.,Department of Orthopedic Surgery, University of Occupational and Environmental Health, Japan
| | | | - Naoki Sawa
- Nephrology Centre, Toranomon Hospital, Tokyo, Japan
| | - Akinori Sakai
- Department of Orthopedic Surgery, University of Occupational and Environmental Health, Japan
| |
Collapse
|
29
|
Broadwell A, Chines A, Ebeling PR, Franek E, Huang S, Smith S, Kendler D, Messina O, Miller PD. Denosumab Safety and Efficacy Among Participants in the FREEDOM Extension Study With Mild to Moderate Chronic Kidney Disease. J Clin Endocrinol Metab 2021; 106:397-409. [PMID: 33211870 PMCID: PMC7823314 DOI: 10.1210/clinem/dgaa851] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Indexed: 12/23/2022]
Abstract
CONTEXT The effects of long-term exposure to denosumab in individuals with renal insufficiency are unknown. OBJECTIVE This post hoc analysis evaluates the long-term safety and efficacy of denosumab in individuals with mild-to-moderate chronic kidney disease (CKD) (stages 2 and 3) using data from the pivotal phase 3, double-blind, 3-year FREEDOM (NCT00089791) and open-label, 7-year extension (NCT00523341) studies. PARTICIPANTS AND METHODS Women age 60 to 90 years with a bone mineral density (BMD) T-score of less than -2.5 to greater than -4.0 at the total hip or lumbar spine were randomly assigned 1:1 to receive denosumab 60 mg subcutaneously every 6 months (long-term arm) or placebo (cross-over arm) in FREEDOM; eligible participants could enroll in the extension to receive denosumab 60 mg subcutaneously every 6 months. Change in estimated glomerular filtration rate (eGFR) from study baseline and annualized rates of fracture and adverse events (AEs) were the main outcome measures. RESULTS Most participants (1259/1969 [64%] long-term arm; 1173/1781 [66%] crossover arm) with baseline CKD stage 2 or 3 remained within the same CKD subgroup at study completion; less than 3% progressed to CKD stage 4. Participants in all eGFR subgroups showed similar, persistent BMD gains over time and a low incidence of fractures. The percentage of participants reporting serious AEs was similar among renal subgroups (normal, CKD stage 2, CKD stage 3a, CKD stage 3b) both for the long-term (54% vs 52% vs 57% vs 58%) and crossover (43% vs 42% vs 43% vs 68%) arms, except CKD stage 3b subgroup, crossover arm. CONCLUSION The safety and efficacy of denosumab did not differ among participants with mild to moderate CKD.
Collapse
Affiliation(s)
- Aaron Broadwell
- Rheumatology and Osteoporosis Specialists, Shreveport, Louisiana, USA
- Correspondence and Reprint Requests: Aaron Broadwell, MD, Rheumatology and Osteoporosis Specialists, 820 Jordan St, Ste 201, Shreveport, LA 71101, USA. E-mail:
| | | | | | - Edward Franek
- Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | | | | | - David Kendler
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul D Miller
- Colorado Center for Bone Research, Lakewood, Colorado, USA
| |
Collapse
|
30
|
So J, Mok CC. Glucocorticoid-Induced Osteoporosis: The Potential Role of Romosozumab. JOURNAL OF CLINICAL RHEUMATOLOGY AND IMMUNOLOGY 2020. [DOI: 10.1142/s2661341720300074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Glucocorticoid (GC)-induced osteoporosis (GIOP) is a major problem in patients with rheumatic diseases. The deleterious effect of GC on bone turnover is rapid and dose-dependent, with a predilection on the trabecular bone, resulting in vertebral fractures. Early recognition and prompt treatment of GIOP helps prevent bone loss and reduce fractures. There are pitfalls in current assessment tools for GIOP by dual-energy X-ray absorptiometry (DXA) and fracture risk assessment tool (FRAX) estimation formula. In this review, we evaluate different assessment methods for GIOP and summarize current therapies of GIOP, including the antiresorptive and anabolic agents. The potential role of newer anti-osteoporosis agent romosozumab, an anti-sclerostin monoclonal antibody, is also discussed.
Collapse
Affiliation(s)
- Jacqueline So
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Chi Chiu Mok
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong SAR, China
| |
Collapse
|
31
|
Diker-Cohen T, Amitai O, Shochat T, Shimon I, Tsvetov G. Denosumab-associated hypocalcemia: Does gender play a role? Maturitas 2020; 142:17-23. [PMID: 33158483 DOI: 10.1016/j.maturitas.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/20/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE It is well recognized that the presentation, treatment, and outcomes of various diseases may differ between men and women. We recently reported a 7.4% rate of denosumab-associated hypocalcemia in community-dwelling osteoporotic patients. This study sought to investigate the role of gender in this complication. STUDY DESIGN Retrospective community-dwelling cohort. METHOD The databases of a large health maintenance organization were searched for adult patients treated with denosumab for osteoporosis in 2010-2018. Rates and predictors of denosumab-associated hypocalcemia (serum calcium ≤8.5 mg/mL) were analyzed by gender. RESULTS The cohort included 1871 women and 134 men. Compared with the women, the men were characterized by older median age (81 vs. 77 years, p = 0.005), higher likelihood to receive denosumab as a first-line treatment (22% vs. 6%, p < 0.001), less treatment with calcium supplements (42% vs. 53%, p = 0.012), and lower median eGFR level (66.1 vs. 79.8 mL/min/1.73m2, p < 0.001). Denosumab-associated hypocalcemia developed in 133 women (7.1%) and 16 men (11.9%) (p = 0.04); the drug was discontinued in 75% and 61%, respectively. The strongest predictors of hypocalcemia in women were levels of pretreatment albumin-adjusted serum calcium (OR 0.08, 95% CI (0.04, 0.14)) and creatinine (OR 2.43, 95% CI (1.45, 4.05)). There were no predictors in men. On propensity matching of 126 men and 126 women, gender was not a predictor of hypocalcemia. CONCLUSION Denosumab-treated men were significantly older than treated women and had a lower eGFR and more advanced osteoporosis. These findings suggest that selection bias rather than male genderper se underlies the higher rate of denosumab-associated hypocalcemia in men.
Collapse
Affiliation(s)
- Talia Diker-Cohen
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Department of Medicine A, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997802, Israel.
| | - Oren Amitai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997802, Israel; Clalit Healthcare Services, Dan-Petach Tikva District, Israel.
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel.
| | - Ilan Shimon
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997802, Israel.
| | - Gloria Tsvetov
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997802, Israel.
| |
Collapse
|
32
|
Hsu CY, Chen LR, Chen KH. Osteoporosis in Patients with Chronic Kidney Diseases: A Systemic Review. Int J Mol Sci 2020; 21:ijms21186846. [PMID: 32961953 PMCID: PMC7555655 DOI: 10.3390/ijms21186846] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with the development of mineral bone disorder (MBD), osteoporosis, and fragility fractures. Among CKD patients, adynamic bone disease or low bone turnover is the most common type of renal osteodystrophy. The consequences of CKD-MBD include increased fracture risk, greater morbidity, and mortality. Thus, the goal is to prevent the occurrences of fractures by means of alleviating CKD-induced MBD and treating subsequent osteoporosis. Changes in mineral and humoral metabolism as well as bone structure develop early in the course of CKD. CKD-MBD includes abnormalities of calcium, phosphorus, PTH, and/or vitamin D; abnormalities in bone turnover, mineralization, volume, linear growth, or strength; and/or vascular or other soft tissue calcification. In patients with CKD-MBD, using either DXA or FRAX to screen fracture risk should be considered. Biomarkers such as bALP and iPTH may assist to assess bone turnover. Before initiating an antiresorptive or anabolic agent to treat osteoporosis in CKD patients, lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake are important. Managing hyperphosphatemia and SHPT are also crucial. Understanding the complex pathogenesis of CKD-MBD is crucial in improving one’s short- and long-term outcomes. Treatment strategies for CKD-associated osteoporosis should be patient-centered to determine the type of renal osteodystrophy. This review focuses on the mechanism, evaluation and management of patients with CKD-MBD. However, further studies are needed to explore more details regarding the underlying pathophysiology and to assess the safety and efficacy of agents for treating CKD-MBD.
Collapse
Affiliation(s)
- Chia-Yu Hsu
- Department of Rehabilitation Medicine, Ten-Chan General Hospital, Zhongli, Taoyuan 320, Taiwan;
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan 320, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 300, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan
- Department of Medicine, School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-2662-89779
| |
Collapse
|
33
|
Lau LH, Cliff ERS, Wong V, Wong H, Torkamani N, Eer A, Weickhardt A, Grossmann M. Hypocalcaemia following denosumab in prostate cancer: A clinical review. Clin Endocrinol (Oxf) 2020; 92:495-502. [PMID: 32017154 DOI: 10.1111/cen.14169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/24/2020] [Accepted: 02/02/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Denosumab is often used in men with advanced prostate cancer to prevent skeletal-related events, but can be associated with severe hypocalcaemia. Our objective was to review the pathophysiology, identify risk factors and provide recommendations for prevention and management of denosumab-associated hypocalcaemia. DESIGN We reviewed the literature regarding denosumab-associated severe hypocalcaemia, defined as necessitating hospitalization for intravenous calcium treatment, in the context of prostate cancer. PATIENTS Men with prostate cancer with severe denosumab-associated hypocalcemia. RESULTS We identified 20 men with prostate cancer with severe denosumab-associated hypocalcemia, including the present case. Median age (range) was 70 years (45-86). All had skeletal metastases and presented with symptomatic hypocalcemia 16 days (4-35) after the initial (n = 18) or second (n = 2) denosumab treatment, with a serum total calcium of 1.36 mmol/L (1.13-1.91). The key risk factor was presence of active osteoblastic metastases, evidenced by elevated serum alkaline phosphatase, 838 U/L (58-2620) and supportive imaging. Other risk factors reported in some men included vitamin D deficiency (<50 nmol/L), 25-OH vitamin D 44 nmol/L (22-81), renal impairment, serum creatinine 103 μmol/L (62-1131) and hypomagnesaemia, 0.82 mmol/L (0.29-1.20). Men received intravenous calcium infusions for 16 days (1-90), and median total intravenous elemental calcium requirements were 3.17 g (0.47-26.65). CONCLUSIONS Denosumab treatment in men with metastatic prostate cancer can be associated with life-threatening hypocalcaemia requiring prolonged hospitalization for intravenous calcium treatment. Modifiable risk factors should be corrected before denosumab administration. In men with active osteoblastic metastases, consideration should be given to delay denosumab treatment until underlying disease activity is controlled, and/or be administered with close monitoring and proactive treatment with calcium and calcitriol.
Collapse
Affiliation(s)
- Lik-Hui Lau
- Department of Endocrinology, Austin Health, Melbourne, Vic., Australia
| | - Edward R S Cliff
- Department of General Medicine, Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - Vanessa Wong
- Department of Oncology, Austin Health, Melbourne, Vic., Australia
| | - Henry Wong
- Department of Endocrinology, Austin Health, Melbourne, Vic., Australia
| | | | - Audrey Eer
- Department of Endocrinology, Austin Health, Melbourne, Vic., Australia
| | | | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Melbourne, Vic., Australia
- Department of Medicine-Austin Health, The University of Melbourne, Melbourne, Vic., Australia
| |
Collapse
|
34
|
Zhang N, Zhang ZK, Yu Y, Zhuo Z, Zhang G, Zhang BT. Pros and Cons of Denosumab Treatment for Osteoporosis and Implication for RANKL Aptamer Therapy. Front Cell Dev Biol 2020; 8:325. [PMID: 32478071 PMCID: PMC7240042 DOI: 10.3389/fcell.2020.00325] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/16/2020] [Indexed: 12/26/2022] Open
Abstract
Osteoporosis is age-related deterioration in bone mass and micro-architecture. Denosumab is a novel human monoclonal antibody for osteoporosis. It is a receptor activator of nuclear factor-κB ligand (RANKL) inhibitor, which binds to and inhibits osteoblast-produced RANKL, in turn reduces the binding between RANKL and osteoclast receptor RANK, therefore decreases osteoclast-mediated bone resorption and turnover. However, adverse events have also been reported after denosumab treatment, including skin eczema, flatulence, cellulitis and osteonecrosis of the jaw (ONJ). Extensive researches on the mechanism of adverse reactions caused by denosumab have been conducted and may provide new insights into developing new RANKL inhibitors that achieve better specificity and safety. Aptamers are single-stranded oligonucleotides that can bind to target molecules with high specificity and affinity. They are screened from large single-stranded synthetic oligonucleotides and enriched by a technology named SELEX (systematic evolution of ligands by exponential enrichment). With extra advantages such as high stability, low immunogenicity and easy production over antibodies, aptamers are hypothesized to be promising candidates for therapeutic drugs targeting RANKL to counteract osteoporosis. In this review, we focus on the pros and cons of denosumab treatment in osteoporosis and the implication for novel aptamer treatment.
Collapse
Affiliation(s)
- Ning Zhang
- School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Zong-Kang Zhang
- School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Yuanyuan Yu
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Zhenjian Zhuo
- School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Ge Zhang
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Bao-Ting Zhang
- School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| |
Collapse
|
35
|
Tsvetov G, Amitai O, Shochat T, Shimon I, Akirov A, Diker-Cohen T. Denosumab-induced hypocalcemia in patients with osteoporosis: can you know who will get low? Osteoporos Int 2020; 31:655-665. [PMID: 31838550 DOI: 10.1007/s00198-019-05261-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/05/2019] [Indexed: 02/08/2023]
Abstract
UNLABELLED Hypocalcemia was reported at low rates (0.05-1.7%) in denosumab-treated postmenopausal women with osteoporosis. This real-life study shows a 7.4% rate of denosumab-induced hypocalcemia in community-dwelling osteoporotic men and women. Pretreatment serum calcium and creatinine levels are major predictors for this complication. Serum-calcium monitoring may help to identify and prevent severe hypocalcemia. PURPOSE RCTs have reported a 0.05-1.7% rate of hypocalcemia in denosumab-treated postmenopausal women with osteoporosis, but long-term real-life data are lacking. We assessed the rate of hypocalcemia in osteoporotic community-dwelling patients treated with denosumab. METHODS A retrospective analysis was conducted based on medical records (2010-2018) from a large HMO. An albumin-adjusted serum calcium concentration lower than 8.5 mg/dL was defined as hypocalcemia. RESULTS We included 2005 patients (93% women, mean age 76 ± 9 years). Hypocalcemia developed during treatment in 149 patients (7.4%; 1% less than 8 mg/dL): in 66 after 0.5-1 years; 48 after 1-2 years; 35 after > 2 years. On comparison of the hypocalcemic and normocalcemic patients, the strongest predictors of hypocalcemia were pretreatment levels of albumin-adjusted serum calcium (9.1 ± 0.4 vs. 9.4 ± 0.5 mg/dL, respectively; p < 0.05) and creatinine (0.9 ± 0.5 vs. 0.8 ± 0.3 mg/dL, respectively; p < 0.05). The hypocalcemia rate increased in parallel to a decrease in eGFR (p = 0.032 for the difference between eGFR ranges). Baseline calcium level ≤ 9.31 mg/dL predicted hypocalcemia with a sensitivity of 77% and specificity of 56%. A model of (- 2)*calcium + creatinine predicted hypocalcemia (3.7% when lower and 17.1% when higher than - 17.4). Gender, age, 25-hydroxyvitamin-D, parathyroid hormone, alkaline phosphatase, and whether denosumab was given as first or advanced line of osteoporotic therapy had no predictive value. CONCLUSION Real-life rates of denosumab-induced hypocalcemia are higher than previously reported. Hypocalcemia might develop after each dose of denosumab in ongoing treatment. Adequate calcium and vitamin D supplementation are needed. Serum calcium monitoring is advised in high-risk patients for early detection of severe hypocalcemia.
Collapse
Affiliation(s)
- G Tsvetov
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Amitai
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Clalit Healthcare Services, Petah-Tikva, Israel
| | - T Shochat
- Statistical Consulting Unit, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
| | - I Shimon
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Akirov
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T Diker-Cohen
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Department of Medicine A, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel.
| |
Collapse
|
36
|
Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab 2019; 104:1595-1622. [PMID: 30907953 DOI: 10.1210/jc.2019-00221] [Citation(s) in RCA: 387] [Impact Index Per Article: 77.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective is to formulate clinical practice guidelines for the pharmacological management of osteoporosis in postmenopausal women. CONCLUSIONS Evidence from clinical trials and insights from clinical experience with pharmacologic therapies for osteoporosis were critically evaluated in formulating this guideline for the management of postmenopausal osteoporosis. Patient preferences, data on adherence and persistence, and risks and benefits from the patient and provider perspectives were also considered in writing committee deliberations. A consensus by the Writing Committee members was achieved for four management principles: (i) The risk of future fractures in postmenopausal women should be determined using country-specific assessment tools to guide decision-making. (ii) Patient preferences should be incorporated into treatment planning. (iii) Nutritional and lifestyle interventions and fall prevention should accompany all pharmacologic regimens to reduce fracture risk. (iv) Multiple pharmacologic therapies are capable of reducing fracture rates in postmenopausal women at risk with acceptable risk-benefit and safety profiles.
Collapse
Affiliation(s)
| | | | - Dennis M Black
- University of California San Francisco, San Francisco, California
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota
| | - Dolores Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Medicine, University of California San Francisco, San Francisco, California
| |
Collapse
|
37
|
Miyaoka D, Imanishi Y, Ohara M, Hayashi N, Nagata Y, Yamada S, Mori K, Emoto M, Inaba M. Impaired residual renal function predicts denosumab-induced serum calcium decrement as well as increment of bone mineral density in non-severe renal insufficiency. Osteoporos Int 2019; 30:241-249. [PMID: 30187112 DOI: 10.1007/s00198-018-4688-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/26/2018] [Indexed: 12/27/2022]
Abstract
UNLABELLED Denosumab treatment of osteoporotic patients, except those with severe renal insufficiency, reduced cCa levels. Low baseline cCa, low estimated glomerular filtration rate, and high bone turnover increased the risk of lower cCa, while increasing bone mineral density. Pretreatment with antiresorptive agents was beneficial in reducing the risk of hypocalcemia. INTRODUCTION Although denosumab-induced hypocalcemia has been frequently observed in patients with chronic kidney disease (CKD) stages 4-5D being treated with denosumab for osteoporosis, few studies have assessed the risk factors for serum-corrected calcium (cCa) reductions in patients with non-severe renal insufficiency. This study assessed the risk factors for reduced cCa concentration following denosumab administration and analyzed factors predictive of changes in bone mineral density (BMD). METHODS Seventy-seven osteoporotic patients, not including those with CKD stages 4-5D, were treated with 60 mg denosumab once every 6 months. Biochemical parameters and BMD were analyzed from prior to the initial dose until 1 month after the second dose. RESULTS Following the first administration of denosumab, cCa levels decreased, reaching a minimum on day 7. Multiple linear regression analyses showed that baseline cCa, estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, tartrate-resistant acid phosphatase-5b (TRACP-5b), and bone alkaline phosphatase (BAP) or pretreatment with antiresorptive agents were significant factors independently associated with the absolute reduction in cCa from baseline to day 7 (ΔcCa0-7 days). ΔcCa0-7 days after the second dose of denosumab was significantly lower than that after the first dose. After 6 months of denosumab treatment, both LS-BMD and FN-BMD significantly increased from baseline. LS-BMD and FN-BMD correlated significantly with baseline TRACP-5b or BAP and eGFR, respectively. CONCLUSIONS Both low eGFR and high bone turnover were independent risk factors for denosumab-induced cCa decrement, and for increases in BMD. Pretreatment with antiresorptive agents may reduce the risk of hypocalcemia.
Collapse
Affiliation(s)
- D Miyaoka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Y Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - M Ohara
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - N Hayashi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Y Nagata
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - S Yamada
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - K Mori
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - M Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - M Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| |
Collapse
|
38
|
Denosumab-Induced Severe Hypocalcaemia in Chronic Kidney Disease. Case Rep Nephrol 2018; 2018:7384763. [PMID: 30519493 PMCID: PMC6241374 DOI: 10.1155/2018/7384763] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/03/2018] [Accepted: 10/24/2018] [Indexed: 12/19/2022] Open
Abstract
Background Hypocalcaemia is increasingly recognized as a complication of denosumab use in Chronic Kidney Disease (CKD) patients with osteoporosis. Despite Therapeutic Goods Administration (TGA) notifications in 2013, we have subsequently encountered several cases of denosumab-induced hypocalcaemia, raising concern about lack of widespread awareness among prescribing practitioners. Aims We reviewed the morbidity and healthcare intervention needs of CKD patients with hypocalcaemia attributed to denosumab. Methods A retrospective case series of CKD patients with clinically significant hypocalcaemia after exposure to denosumab, encountered at the tertiary care referral hospital from December 2013 to February 2017, was undertaken. Results Eight patients (52-85 years of age) with stage 4-5 CKD developed clinically significant hypocalcaemia (corrected calcium 1.45±0.21mmol/L) following denosumab therapy for osteoporosis. Seven of the eight patients required inpatient management with three patients requiring intravenous calcium replacement and cardiac monitoring in a high dependency unit. Our study also identified additional factors that could potentially contribute to hypocalcaemia such as lack of calcium supplementation, use of noncalcium based phosphate binders, absence of or use of lower doses of calcitriol supplementation, low vitamin D levels, concomitant treatment with loop diuretics, history of parathyroidectomy, or presence of acute medical illness. Conclusion Multiple cases of severe hypocalcaemia in CKD patients following denosumab exposure were encountered after TGA warnings, resulting in considerable morbidity and intensive healthcare interventions in CKD patients. We advocate greater awareness amongst the medical profession, careful consideration before using denosumab in CKD patients, and close follow-up after administration to prevent morbidity.
Collapse
|
39
|
Shrosbree JE, Elder GJ, Eisman JA, Center JR. Acute hypocalcaemia following denosumab in heart and lung transplant patients with osteoporosis. Intern Med J 2018; 48:681-687. [PMID: 29363863 DOI: 10.1111/imj.13744] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/21/2017] [Accepted: 01/17/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Osteoporosis is highly prevalent in the heart and lung transplant population. Given high rates of concurrent renal impairment, there is increasing use of denosumab in this population. However, denosumab may be associated with hypocalcaemia, particularly in patients with chronic kidney disease (CKD). AIM To explore the risk of hypocalcaemia in a heart and lung transplant cohort prescribed denosumab for osteoporosis. METHODS We performed a retrospective database review of all surviving heart and lung transplant patients who had received denosumab for osteoporosis between January 2012 and November 2015. We assessed the rates of hypocalcaemia in this cohort and collected baseline clinical data to determine associated factors. RESULTS Ten patients received denosumab and had laboratory results available within 3 months of the dose. Of these, three patients developed severe (grade 4) hypocalcaemia, while two patients developed mild (grade 1) hypocalcaemia. In comparison to the five patients who remained normocalcaemic, patients with hypocalcaemia had significantly lower baseline mean estimated glomerular filtration rate but similar baseline mean corrected serum calcium. Unexpectedly, patients developing hypocalcaemia had non-significantly higher levels of 25-hydroxyvitamin D and lower baseline doses of prednisone. CONCLUSIONS In heart and lung transplant patients, denosumab should be used judiciously in patients with advanced renal disease due to the risk of hypocalcaemia.
Collapse
Affiliation(s)
- Julia E Shrosbree
- Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, New South Wales, Australia
| | - Grahame J Elder
- Department of Endocrinology, St. Vincent's Hospital, Sydney, Australia.,Department of Renal Medicine, Westmead Hospital, Sydney, Australia
| | - John A Eisman
- Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, New South Wales, Australia.,Department of Endocrinology, St. Vincent's Hospital, Sydney, Australia.,School of Medicine Sydney, University of Notre Dame Australia, St Vincent's Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacqueline R Center
- Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, New South Wales, Australia.,Department of Endocrinology, St. Vincent's Hospital, Sydney, Australia
| |
Collapse
|
40
|
Skjødt MK, Frost M, Abrahamsen B. Side effects of drugs for osteoporosis and metastatic bone disease. Br J Clin Pharmacol 2018; 85:1063-1071. [PMID: 30192026 DOI: 10.1111/bcp.13759] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/17/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022] Open
Abstract
Osteoporosis is a common condition that leads to substantial morbidity and mortality and affects an increasing number of persons worldwide. Several pharmacological therapies that inhibit bone resorption, promote bone formation, or both, are available for the treatment of osteoporosis. The osteoanabolic treatment spectrum was recently expanded by the introduction of a novel bone-forming agent in the United States, and clinical trials indicate that a new class of bone anabolic therapy may become available. Both antiresorptive and bone anabolic therapies are associated with common and rare adverse effects, which are particularly important to address as these drugs are used for long-term treatment in numerous patients with a large proportion being elderly and/or having multimorbidity. In addition, antiresorptive drugs are used to inhibit bone resorption in patients with malignant hypercalcaemia or to prevent skeletal events in cancer patients, and bisphosphonates have been repurposed as a cancer preventive therapy. However, therapeutic doses are generally higher when antiresorptive drugs are used in the oncological setting, which influence the prevalence of adverse effects significantly. This review highlights key issues and controversies regarding adverse effects of currently available and emerging drugs used for osteoporosis and metastatic bone diseases.
Collapse
Affiliation(s)
- Michael Kriegbaum Skjødt
- Department of Medicine, Holbaek Hospital, Holbaek, Denmark.,Department of Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Morten Frost
- Department of Endocrinology M, Odense University Hospital, Odense C, Denmark.,Steno Diabetes Centre Odense, Odense C, Denmark
| | - Bo Abrahamsen
- Department of Medicine, Holbaek Hospital, Holbaek, Denmark.,Odense Patient Data Explorative Network, Institute of Clinical Research University of Southern Denmark and Odense University Hospital, Odense C, Denmark
| |
Collapse
|
41
|
Severe Hypocalcemia and Hypomagnesemia with Denosumab in Advanced Chronic Kidney Disease: Case Report and Literature Review. Case Rep Oncol Med 2018; 2018:2059364. [PMID: 30405927 PMCID: PMC6204163 DOI: 10.1155/2018/2059364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/17/2018] [Indexed: 11/18/2022] Open
Abstract
Background Denosumab has become the preferred agent over zolendronic acid to help prevent skeletal-related events in patients with metastatic bone disease and multiple myeloma because it is approved for use in those with kidney dysfunction. However, denosumab has been linked to cases of hypocalcemia, particularly in those with advanced kidney disease. Case Presentation We present the case of a patient with metastatic prostate cancer and chronic kidney disease due to obstructive nephropathy who developed severe hypocalcemia and hypomagnesemia after denosumab injection, which required intensive care unit admission, aggressive calcium supplementation, and hemodialysis assistance. We reviewed the evidence behind the safety profile of denosumab in chronic kidney disease, and we also looked at additional factors that may precipitate severe hypocalcemia with denosumab in advanced kidney disease. Conclusion We believe that denosumab should be avoided in advanced chronic kidney disease due to the potential life-threatening, severe hypocalcemia that has been observed.
Collapse
|
42
|
Body JJ, von Moos R, Niepel D, Tombal B. Hypocalcaemia in patients with prostate cancer treated with a bisphosphonate or denosumab: prevention supports treatment completion. BMC Urol 2018; 18:81. [PMID: 30236112 PMCID: PMC6148993 DOI: 10.1186/s12894-018-0393-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 08/31/2018] [Indexed: 12/17/2022] Open
Abstract
Background Most patients with advanced prostate cancer develop bone metastases, which often result in painful and debilitating skeletal-related events. Inhibitors of bone resorption, such as bisphosphonates and denosumab, can each reduce the incidence of skeletal-related events and delay the progression of bone pain. However, these agents are associated with an increased risk of hypocalcaemia, which, although often mild and transient, can be serious and life-threatening. Here we provide practical advice on managing the risk of hypocalcaemia in patients with advanced prostate cancer who are receiving treatment with bone resorption inhibitors. Relevant references for this review were identified through searches of PubMed with the search terms ‘prostate cancer’, ‘bone-targeted agents’, ‘anti-resorptive agents’, ‘bisphosphonates’, ‘zoledronic acid’, ‘denosumab’, ‘hypocalcaemia’, and ‘hypocalcemia’. Additional references were suggested by the authors. Main text Among patients with advanced cancer receiving a bisphosphonate or denosumab, hypocalcaemia occurs most frequently in those with prostate cancer, although it can occur in patients with any tumour type. Consistent with its greater ability to inhibit bone resorption, denosumab has shown superiority in the prevention of skeletal-related events in patients with bone metastases from solid tumours. Consequently, denosumab is more likely to induce hypocalcaemia than the bisphosphonates. Likewise, various bisphosphonates have differing potencies for the inhibition of bone resorption, and thus the risk of hypocalcaemia varies between different bisphosphonates. Other risk factors for the development of hypocalcaemia include the presence of osteoblastic metastases, vitamin D deficiency, and renal insufficiency. Hypocalcaemia can lead to treatment interruption, but it is both preventable and manageable. Serum calcium concentrations should be measured, and any pre-existing hypocalcaemia should be corrected, before starting treatment with inhibitors of bone resorption. Once treatment has started, concomitant administration of calcium and vitamin D supplements is essential. Calcium concentrations should be monitored during treatment with bisphosphonates or denosumab, particularly in patients at high risk of hypocalcaemia. If hypocalcaemia is diagnosed, patients should receive treatment with calcium and vitamin D. Conclusion With preventative strategies and treatment, patients with prostate cancer who are at risk of, or who develop, hypocalcaemia should be able to continue to benefit from treatment with bisphosphonates or denosumab.
Collapse
Affiliation(s)
- Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Place A.Van Gehuchten 4, 1020, Brussels, Belgium.
| | - Roger von Moos
- Kantonsspital Graubünden, Loëstrasse 170, CH-7000, Chur, Switzerland
| | - Daniela Niepel
- Global Medical Affairs, Amgen (Europe) GmbH, Zug, Switzerland
| | - Bertrand Tombal
- Institute of Clinical Research, Université Catholique de Louvain, Avenue Mounier 50, 1200, Brussels, Belgium
| |
Collapse
|
43
|
Imatoh T, Sai K, Takeyama M, Hori K, Karayama M, Furuhashi K, Segawa K, Kimura M, Kawakami J, Saito Y. Identification of risk factors and development of detection algorithm for denosumab-induced hypocalcaemia. J Clin Pharm Ther 2018; 44:62-68. [DOI: 10.1111/jcpt.12753] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/07/2018] [Accepted: 06/14/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Takuya Imatoh
- Division of Medicinal Safety Science; National Institute of Health Sciences; Kawasaki Japan
| | - Kimie Sai
- Division of Medicinal Safety Science; National Institute of Health Sciences; Kawasaki Japan
| | - Mayu Takeyama
- Division of Medicinal Safety Science; National Institute of Health Sciences; Kawasaki Japan
- Graduate School of Pharmaceutical Sciences; Tohoku University; Sendai Japan
| | - Katsuhito Hori
- Department of Hospital Pharmacy; School of Medicine; Hamamatsu University; Hamamatsu Japan
| | - Masato Karayama
- Department of Clinical Oncology; School of Medicine; Hamamatsu University; Hamamatsu Japan
| | - Kazuki Furuhashi
- Department of Internal Medicine; School of Medicine; Hamamatsu University; Hamamatsu Japan
| | - Katsunori Segawa
- Division of Medicinal Safety Science; National Institute of Health Sciences; Kawasaki Japan
| | - Michio Kimura
- Department of Medical Informatics; School of Medicine; Hamamatsu University; Hamamatsu Japan
| | - Junichi Kawakami
- Department of Hospital Pharmacy; School of Medicine; Hamamatsu University; Hamamatsu Japan
| | - Yoshiro Saito
- Division of Medicinal Safety Science; National Institute of Health Sciences; Kawasaki Japan
| |
Collapse
|
44
|
|
45
|
Yee AJ, Raje NS. Denosumab for the treatment of bone disease in solid tumors and multiple myeloma. Future Oncol 2017; 14:195-203. [PMID: 29052442 DOI: 10.2217/fon-2017-0403] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Bone is a common site for malignant involvement, either as a site of metastasis, especially in breast or prostate cancer, or as a defining characteristic of the disease, as in multiple myeloma. Bone disease is a major source of morbidity, and half of patients with bone involvement develop skeletal-related events such as pathological fractures or cord compression requiring surgery and/or radiation. Skeletal involvement also increases mortality, as pathologic fractures increase the risk of dying by 20-40%. Osteoclast inhibition with bisphosphonates such as zoledronic acid and recently denosumab has been a significant improvement for bone disease. This review will focus on denosumab in the treatment of bone metastases and highlight the recent findings in multiple myeloma.
Collapse
Affiliation(s)
- Andrew J Yee
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA.,Harvard Medical School, Boston, MA 02114, USA
| | - Noopur S Raje
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA.,Harvard Medical School, Boston, MA 02114, USA
| |
Collapse
|
46
|
Salim SA, Nair LR, Thomas L, Garla V, Palabindala V, Agarwal M, Fülöp T. Denosumab-Associated Severe Hypocalcemia in a Patient With Chronic Kidney Disease. Am J Med Sci 2017; 355:506-509. [PMID: 29753381 DOI: 10.1016/j.amjms.2017.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 08/27/2017] [Accepted: 09/18/2017] [Indexed: 02/04/2023]
Abstract
Denosumab is a monoclonal antibody directed against the receptor activator of nuclear factor kappa B ligand (RANKL). Denosumab has been shown to reduce the risk of skeletal-related events, including spinal cord compression, pathologic fracture and hypercalcemia of malignancy in patients with bone metastases. Hypocalcemia is a known side effect of denosumab, occurring in an estimated 8-14% of the patients. Here, we present an asymptomatic patient with stage-5 chronic kidney disease and severe hypocalcemia who had received denosumab 1 month earlier.
Collapse
Affiliation(s)
- Sohail Abdul Salim
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi.
| | | | - Litty Thomas
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Vishnu Garla
- Divison of Endocrinology, University of Mississippi Medical Center, Jackson, Mississippi
| | | | - Mohit Agarwal
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; FMC Extracorporeal Life Support Center - Fresenius Medical Care, Esztergom, Hungary
| |
Collapse
|
47
|
Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
48
|
McClung MR. Denosumab for the treatment of osteoporosis. Osteoporos Sarcopenia 2017; 3:8-17. [PMID: 30775498 PMCID: PMC6372782 DOI: 10.1016/j.afos.2017.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 12/13/2022] Open
Abstract
Denosumab, a specific inhibitor of RANK ligand, is a novel therapy for postmenopausal osteoporosis and related disorders. An extensive clinical development program has evaluated the clinical efficacy and safety of denosumab with several thousand patients being followed for up to 10 years. Combined with more than six years of postmarketing experience, these studies provide substantial confidence that denosumab is a convenient and appropriate treatment for patients, including Asians, at high risk for fracture. This review will summarize the clinical development of denosumab and lessons learned since its approval for clinical use in 2010.
Collapse
Affiliation(s)
- Michael R McClung
- Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia.,Oregon Osteoporosis Center, 2881 NW Cumberland Road, Portland, OR 97210, USA
| |
Collapse
|