Denosumab is a bone anti-resorptive drug used for the treatment of the following:
Denosumab is a total human IgG2 monoclonal antibody that binds to receptor activator of NF kappa B ligand (RANKL) and competitively inhibits its binding to receptor activator of NF kappa B (RANK). Soluble RANKL is a trimer and a member of the tumor necrosis factor (TNF) family of ligands. Each RANKL trimer can bind and oligomerize up to three receptors. When bound to RANK, RANKL potentiates osteoclast differentiation from hematopoietic stem cells and activates and prolongs the survival of mature osteoclasts. Osteoclasts' primary function then is to promote bone resorption. Denosumab binds to RANKL with high affinity and blocks it from binding to and oligomerizing its receptor RANK, thus inhibiting osteoclast maturation and bone resorption.
The administration of denosumab should be via subcutaneous injection only and should not be administered intravenously or intramuscularly. Injection sites include the upper arm, upper thigh, or abdomen. No observation or premedication is required. Dosing is prescribed as 120 mg/1.7 mL (70 mg/mL) solution in a single-dose vial or as a single-use pre-filled syringe containing 60 mg in a 1 mL solution. Administer vitamin D and calcium as necessary to treat or prevent hypocalcemia — no dosing adjustments required for hepatic or renal impairment. The distribution and timing of doses depend on the pathology, as shown below.
Adverse effects include the following based on body systems:
Central nervous system:
Hematologic and oncologic:
Neuromuscular and skeletal:
Clinicians should evaluate possible pregnancy before initiation of treatment. Obtaining vitamin D level and clearance from a dentist is suggested before the initiation of therapy. Within the first few weeks of treatment, recommended monitoring of serum creatinine, calcium, phosphorus, and magnesium. Monitor for signs and symptoms of hypocalcemia as well as hypercalcemia upon discontinuation of denosumab. A dental exam is a recommendation if osteonecrosis of the jaw is suspected. The evaluation of bone mineral density should occur anywhere between one to two years after initiating treatment. The recommendation is for periodic monitoring of vitamin D and serum calcium throughout the treatment duration.
Atypical bone fractures: Although the incidence remains low, an association with atypical bone fractures exists with prolonged bisphosphonate therapy. However, clinicians have also observed these fractures in those receiving denosumab for osteoporosis or metastatic bone disease. These fractures are usually located in the subtrochanteric region or along the shaft of the femur. Patients tend to feel prodromal pain from weeks to months leading up to the fracture. Fractures commonly occur with little to no trauma in the area. Experts are unsure at this time if the atypical fractures occur secondary to denosumab toxicity or the patient’s underlying osteoporosis. Patients should receive counseling regarding the potential for new hip or thigh pain and the contralateral limb examined if an atypical fracture is suspected. Upon diagnosis of an atypical fracture, possible discontinuation of denosumab is an option. If discontinued, consider initiating a different osteoporosis therapy due to an increased risk of fracture.
Hypersensitivity: Reports exist of clinically severe and anaphylactic reactions. Symptoms may include rash, pruritus, urticaria, facial edema, airway edema, and possibly hypotension. If these symptoms occur, initiate appropriate treatment and subsequently discontinue denosumab.
Hypocalcemia: Due to its anti-resorptive effects, denosumab has the potential to cause hypocalcemia. There is documentation of severe, even fatal, cases of denosumab-induced hypocalcemia. Those with severe renal dysfunction may have an increased risk of developing hypocalcemia. Clinicians should obtain serum calcium, and preexisting hypocalcemia corrected at the initiation of treatment. In patients with preexisting hypocalcemia, serum calcium requires frequent monitoring. Use denosumab with caution in those who have predisposing conditions to hypocalcemia.
Osteonecrosis of the jaw (ONJ): Reports of ONJ have been observed in those receiving denosumab. Symptoms may include jaw pain, tooth infection, bone, and gingival erosion, toothache. An increased risk of being diagnosed with ONJ correlates directly to the duration of denosumab exposure. Those with predisposing factors, such as poor dentition and recent tooth extraction, are at a higher risk. If ONJ is suspected, make arrangements for a thorough dental exam. The risk of ONJ is considerably higher in patients with malignancy receiving denosumab than in patients with osteoporosis receiving denosumab. Denosumab should not be initiated until dental health is optimized. While on denosumab for cancer therapy, dental procedures are contraindicated. If ONJ is suspected, discontinue denosumab.
Dermatologic reactions: Reports of dermatitis, eczema, and rash have been observed. If symptoms are severe, consider discontinuation of denosumab.
Healthcare workers, including primary care physicians and nurse practitioners who prescribe denosumab, should monitor the patients. Pharmacists should assist in monitoring for side effects. The patient should get a baseline evaluation from the dentist before initiating treatment. At regular intervals, the patient's electrolytes and renal function also require monitoring. The most severe complication of therapy is osteonecrosis of the jaw, and thus an oral exam is necessary at each visit. Periodic bone density evaluation every 1 to 2 years is the recommended interval for followup. Only through close monitoring of the patient can the morbidity of this agent be decreased.
|||Ahern E,Smyth MJ,Dougall WC,Teng MWL, Roles of the RANKL-RANK axis in antitumour immunity - implications for therapy. Nature reviews. Clinical oncology. 2018 Sep 19 [PubMed PMID: 30232468]|
|||Jamshidi K,Gharehdaghi M,Hajialiloo SS,Mirkazemi M,Ghaffarzadehgan K,Izanloo A, Denosumab in Patients with Giant Cell Tumor and Its Recurrence: A Systematic Review. The archives of bone and joint surgery. 2018 Jul [PubMed PMID: 30175172]|
|||Tsourdi E,Makras P,Rachner TD,Polyzos S,Rauner M,Mandanas S,Hofbauer LC,Anastasilakis AD, Denosumab effects on bone density and turnover in postmenopausal women with low bone mass with or without previous treatment. Bone. 2018 Oct 4 [PubMed PMID: 30292818]|
|||Iwamoto N,Okamoto M,Tsuji S,Endo Y,Takatani A,Shimizu T,Umeda M,Fukui S,Sumiyoshi R,Igawa T,Koga T,Kawashiri SY,Aramaki T,Ichinose K,Tamai M,Nakamura H,Origuchi T,Eguchi K,Ueki Y,Kawakami A, Denosumab is effective toward glucocorticoid-induced osteoporosis patients complicated with rheumatic diseases regardless of prior anti-osteoporotic drugs. Journal of bone and mineral metabolism. 2018 Sep 5 [PubMed PMID: 30187273]|
|||Briot K,Paccou J,Beuzeboc P,Bonneterre J,Bouvard B,Confavreux CB,Cormier C,Cortet B,Hannoun-Lévi JM,Hennequin C,Javier RM,Lespessailles E,Mayeur D,Artus PM,Vieillard MH,Debiais F, French Recommendations for Osteoporosis Prevention and Treatment in Patients with Prostate Cancer Treated by Androgen Deprivation. Joint, bone, spine : revue du rhumatisme. 2018 Oct 1 [PubMed PMID: 30287350]|
|||Otto S,Pautke C,Van den Wyngaert T,Niepel D,Schiødt M, Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases. Cancer treatment reviews. 2018 Sep [PubMed PMID: 30055439]|
|||Chung TL,Chen NC,Chen CL, Severe hypophosphatemia induced by denosumab in a patient with osteomalacia and tenofovir disoproxil fumarate-related acquired Fanconi syndrome. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2018 Aug 31 [PubMed PMID: 30171299]|
|||Saleem S,Patel S,Ahmed A,Saleem N, Denosumab causing severe, refractory hypocalcaemia in a patient with chronic kidney disease. BMJ case reports. 2018 May 30 [PubMed PMID: 29848528]|
|||Starr J,Tay YKD,Shane E, Current Understanding of Epidemiology, Pathophysiology, and Management of Atypical Femur Fractures. Current osteoporosis reports. 2018 Aug [PubMed PMID: 29951870]|
|||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. Journal of clinical pharmacy and therapeutics. 2018 Aug 24 [PubMed PMID: 30144112]|