The Calcium Culprit: A Case of Denosumab-induced Hypocalcemia

Kalayanamitra, Ricci; Yaghnam, Ibrahim; Patel, Ravi; Groff, Andrew; Jain, Rohit

doi:10.7759/cureus.4768

Cited by 7 publications

(6 citation statements)

References 12 publications

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“…The risk of hypocalcemia following denosumab use for osteoporosis has been demonstrated in multiple case reports and case series for patients with chronic kidney disease [ 7 – 10 ] and in individual case reports for patients with primary sclerosing cholangitis [ 11 ], Crohn's disease [ 8 , 12 , 13 ], and a history of sleeve gastrectomy for marginal gastric ulcers [ 12 ]. A few cases of hypocalcemia with denosumab have been reported in patients with a history of bariatric surgery, but each of these was likely secondary to vitamin D deficiency [ 14 , 15 ].…”

Section: Discussionmentioning

confidence: 99%

Denosumab-Induced Hypocalcemia after Billroth II Gastric Bypass Surgery

Schmucker

Green

Montemuro

2020

Case Reports in Endocrinology

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Hypocalcemia is a known risk following bariatric surgery and can contribute to the development of osteoporosis. Osteoporosis is commonly treated with denosumab, though denosumab can exacerbate underlying abnormalities in calcium homeostasis. We present the case of a 59-year-old female with severe hypocalcemia who had been treated with denosumab for osteoporosis three months before and had Billroth II gastric bypass surgery 15 years before, for bariatric purposes. Intravenous calcium supplementation was used to correct the initial electrolyte abnormality, and the patient was able to maintain appropriate calcium levels on high doses of oral calcium before discharge. Denosumab-induced hypocalcemia has been previously reported in patients with predisposing conditions including chronic kidney disease, primary sclerosing cholangitis, Crohn’s disease, and a history of sleeve gastrectomy for marginal gastric ulcers. A few cases of hypocalcemia have been reported in patients with a history of bariatric surgery secondary to vitamin D deficiency, but this report is unique in demonstrating denosumab-induced hypocalcemia after bariatric surgery with normal vitamin D levels, suggesting a primary malabsorption of calcium. The risk of severe hypocalcemia should be considered before initiating denosumab to treat osteoporosis in patients with a history of bariatric surgery. If denosumab is initiated, serum calcium levels should be closely monitored, and patients should be educated about the importance of adherence to calcium supplementation.

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Section: Discussionmentioning

confidence: 99%

Denosumab-Induced Hypocalcemia after Billroth II Gastric Bypass Surgery

Schmucker

Green

Montemuro

2020

Case Reports in Endocrinology

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“…53 Although denosumab treatment has many benefits, a prospective cohort study published in 2016 found that approximately 25.9% of patients treated with denosumab develop persistent hypocalcemia due to its antiresorptive properties. 54 The risk is most severe in patients with chronic kidney disease. To prevent this com plication careful baseline assessment, calcium, and vita min D supplementation if appropriate, and observation, is warranted for all patients treated with denosumab.…”

Section: Antiresorptive Agentsmentioning

confidence: 99%

An overview of the management of osteoporosis in the aging female population

Amin

McPartland

O’Sullivan

et al. 2023

Womens Health (Lond Engl)

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Osteoporosis is a systemic skeletal disease that is a cause of morbidity and mortality. It can affect all ages but most frequently postmenopausal women. It is a silent condition, however, osteoporotic fractures can lead to significant pain and disability. In this review article, we aim to review the clinical approach to the management of postmenopausal osteoporosis. We include risk assessment, investigations, and the various pharmacological and non-pharmacological options used in the treatment of osteoporosis. We have discussed the pharmacological options individually including their mechanism of action, safety profile, effects on bone mineral density and fracture risks, and duration of use. Potential new treatments are also discussed. The importance of sequence in the use of osteoporotic medicine is also highlighted in the article. An understanding of the different treatment options will hopefully help in the management of this very common and debilitating condition.

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“…In both patient populations, it has contributed to cases of severe hypocalcemia and hypophosphatemia. While some patients experience severe weakness and tetany, even those with asymptomatic electrolyte abnormalities can display electrocardiogram changes that predispose them to life-threatening cardiac arrhythmias [ 8 ].…”

Section: Introductionmentioning

confidence: 99%

“…Case presentations in the literature additionally cite low body mass index, glomerular filtration rate, menopause, bone and prostate malignancies, and vitamin D deficiencies as risk factors that predispose patients to adverse electrolyte imbalances. While a 2016 study demonstrated that a quarter of patients who receive denosumab develop persistent asymptomatic hypocalcemia, [ 8 ] we present the case of a patient with a history of prostate cancer who developed refractory symptomatic severe hypocalcemia, hypophosphatemia, and metabolic acidosis following denosumab.…”

Section: Introductionmentioning

confidence: 99%

Diagnosis and Management of Denosumab-Induced Hypocalcemia and Hypophosphatemia in the Setting of Metastatic Prostate Cancer

Flood¹,

Rowley²,

Basnet³

2022

Cureus

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Denosumab, a receptor activator of nuclear factor kappa-Β ligand (RANK-L) monoclonal antibody used in osteoporosis and various malignancies, has been shown to cause hypocalcemia shortly after initiation of treatment. There have been few case reports of electrolyte abnormalities in patients managed with longterm treatment with this medication. This report presents the case of a 43-year-old male with metastatic prostate cancer who presented with severe hypophosphatemia and hypocalcemia, initially resistant to repletion. After more aggressive and persistent repletion with IV calcium, phosphorus, and vitamin D, as well as time for the denosumab to dissipate, the patient's electrolytes stabilized and he was able to be discharged with oral replacement and close follow-up. Therefore, long-term monitoring of electrolytes for patients on denosumab should be carefully considered.

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The Calcium Culprit: A Case of Denosumab-induced Hypocalcemia

Cited by 7 publications

References 12 publications

Denosumab-Induced Hypocalcemia after Billroth II Gastric Bypass Surgery

Denosumab-Induced Hypocalcemia after Billroth II Gastric Bypass Surgery

An overview of the management of osteoporosis in the aging female population

Diagnosis and Management of Denosumab-Induced Hypocalcemia and Hypophosphatemia in the Setting of Metastatic Prostate Cancer

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