Denosumab is a monoclonal antibody to the RANK ligand which plays an important role in bone remodeling. Denosumab is used in the therapy of osteoporosis and for bone metastases and rare bone tumors. Denosumab therapy has not been associated with serum enzyme elevations during therapy, nor has it been implicated in cases of clinically apparent drug induced liver injury with jaundice.
Denosumab (den oh’ sue mab) is a recombinant, human monoclonal IgG2 antibody to the ligand for RANK (receptor activator of NF kappa B) which plays an important bone in bone remodeling and stimulates differentiation, maturation and activation of bone osteoclasts. Inhibition of the RANK ligand (RANK-L) inhibits osteoclast activity and increases bone density by the less or unopposed osteoblast activity. Treatment with denosumab has been shown to increase bone mineral density scores as assessed by DEXA scan, and long term therapy has been associated with a lower rate of bone fractures. Denosumab was approved for use in the United States in 2010, and current indications are for men and postmenopausal women with osteoporosis at increased risk for bone fractures and for men with reduced bone mineral density on antiandrogen and women on antiestrogen therapy. Denosumab has also been approved for use in patients with bone metastases from solid tumors and in giant cell tumor of bone. For treatment of osteoporosis, denosumab is available in single use vials or prefilled syringes of 60 mg under the brand name Prolia. The recommended dose is 60 mg subcutaneously every 6 months. Denosumab is also available in single use vials of 120 mg (70 mg/mL) for malignant bone disease under the brand name of Zgeva. The recommended dose for bone metastases is 120 mg subcutaneously every 4 weeks. More frequent dosing is used initially in treating giant cell tumor of bone. All patients receiving denosumab should also take oral calcium (1000 mg) and vitamin D (400 IU) daily. Side effects of denosumab are uncommon, but can include injection site reactions, rash, diarrhea, nausea and vomiting and headache. Rare side effects include severe infusion reactions, hypersensitivity reactions, anaphylaxis, hypocalcemia, osteonecrosis of the jaw and atypical femoral fractures.
In large clinical trials, denosumab was not associated with changes in serum aminotransferase levels during therapy and rates of most adverse reactions were similar in patients who received denosumab as placebo. There have been no published reports of clinically apparent acute liver injury attributed to denosumab therapy. Thus, significant liver injury from denosumab must be very rare, if it occurs at all.
Mechanism of Injury
Denosumab is a human monoclonal antibody and is unlikely to be inherently hepatotoxic. While most recombinant proteins are metabolized by the liver, the metabolism leads largely to small peptides and amino acids which may be reused to synthesize proteins and are unlikely to be toxic or immunogenic. The RANKL pathways is important in bone turnover and formation and is found on the surface of marrow stromal cells and activated T cells, but has no recognized effect on the liver.
REPRESENTATIVE TRADE NAMES
Denosumab – Prolia®, Xgeva®
Product labeling at DailyMed, National Library of Medicine, NIH
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References updated: 20 June 2015
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Lewiecki EM, Miller PD, McClung MR, Cohen SB, Bolognese MA, Liu Y, Wang A, et al.; AMG 162 Bone Loss Study Group. Two-year treatment with denosumab(AMG 162) in a randomized phase 2 study of postmenopausal women with low BMD. J Bone Miner Res 2007; 22: 1832-41. PubMed Citation (Continued follow-up of 412 women treated with denosumab, alendronate or placebo [McClung 2006]; the incidence of side effects was similar in all three groups and not changed during the second year of the study, and there were "no clinically relevant changes in either serum chemistry or hematology values").
Cummings SR, San Martin J, McClung MR, Siris ES, Eastell R, Reid IR, Delmas P, et al.; FREEDOM Trial. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med 2009; 361: 756-65. PubMed Citation (Among 7868 postmenopausal women with osteoporosis treated with denosumab or placebo [every 6 months] for 3 years, bone mineral increased and fractures were less in the denosumab treated patients, while rates of most adverse events were similar except for eczema [3% vs 1.7%], cellulitis [0.3% vs <0.1%] and flatulence [2.2% vs 1.4%]; no mention of ALT elevations or hepatotoxicity).
Denosumab (Prolia) for postmenopausal osteoporosis. Med Lett Drugs Ther. 2010 Oct 18; 52 (1349): 81-2. PubMed Citation (Concise review of mechanism of action, efficacy, safety and costs of denosumab shortly after its approval in the US mentions that adverse effects may include hypocalcemia and rash and more rarely infections, pancreatitis, malignancies and osteonecrosis, but does not mention ALT elevations or hepatotoxicity).
Denosumab for bone metastases. Med Lett Drugs Ther 2011; 53 (1356): 8. PubMed Citation (Short description of expansion of indications for denosumab to include bone metastases).
Dore RK. The RANKL pathway and denosumab. Rheum Dis Clin North Am 2011; 37: 433-52, vi-vii. PubMed Citation (Review of the role of RANK pathway in bone remodeling and mechanism of action, efficacy and safety of denosumab).
Teglbjærg CS, Langdahl BL, Chapurlat R, Czerwinski E, Kendler DL, Reginster JY, et al. A randomized, placebo-controlled study of the effects of denosumab for the treatment of men with low bone mineral density. J Clin Endocrinol Metab 2012; 97: 3161-9. PubMed Citation (Among 242 men with low bone mineral density treated with denosumab or placebo for 1 year, denosumab led to increases in bone density, but no different in side effects compared to placebo; no mention of ALT levels or hepatotoxicity).
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Mellström D, et al. The effect of three or six years of denosumab exposure in women with postmenopausal osteoporosis: results from the FREEDOM extension. J Clin Endocrinol Metab 2013; 98: 4483-92. PubMed Citation (Among 3547 postmenopausal women with osteoporosis treated with denosumab for 3 or 6 years, efficacy was sustained with long term use while side effects did not increase with time; no mention of ALT elevations or hepatotoxicity).
Chawla S, Henshaw R, Seeger L, Choy E, Blay JY, Ferrari S, Kroep J, et al. Safety and efficacy of denosumab for adults and skeletally mature adolescents with giant cell tumour of bone: interim analysis of an open-label, parallel-group, phase 2 study. Lancet Oncol 2013; 14: 901-8. PubMed Citation (Among 282 patients with giant cell tumor of bone treated with denosumab for an average of 10 months, side effects were uncommon, but included arthralgias, headache, nausea, fatigue, back pain, low phosphate and calcium [5%]; no mention of ALT elevations or hepatotoxicity).
Recknor C, Czerwinski E, Bone HG, Bonnick SL, Binkley N, Palacios S, Moffett A, et al. Denosumab compared with ibandronate in postmenopausal women previously treated with bisphosphonate therapy: a randomized open-label trial. Obstet Gynecol 2013; 121: 1291-9. PubMed Citation (Among 833 postmenopausal women with osteoporosis who were treated with denosumab [every 6 months] or ibandronate [monthly] for 12 months, bone density increased more with denosumab; no mention of ALT elevations or hepatotoxicity).
Peddi P, Lopez-Olivo MA, Pratt GF, Suarez-Almazor ME. Denosumab in patients with cancer and skeletal metastases: a systematic review and meta-analysis. Cancer Treat Rev 2013; 39: 97-104. PubMed Citation (Systematic review of literature on efficacy and safety of denosumab in therapy of bone metastases; no mention of ALT elevations or hepatotoxicity).
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Reginster JY, et al. A 24-month study evaluating the efficacy and safety of
denosumab for the treatment of men with low bone mineral density: results from
the ADAMO trial. J Clin Endocrinol Metab 2015; 100: 1335-42. PubMed Citation (Among 228 men with low bone mineral density treated with denosumab or placebo for 12 months who were then crossed over to an open label 12 month study, for up to 24 months, ALT elevations were not mentioned and, while serious adverse events occurred in 13 [6%] subjects, none were liver related or clearly related to denosumab).
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