From the Guidelines
Before receiving a Prolia (denosumab) injection, it is essential to conduct laboratory tests, including a comprehensive metabolic panel, vitamin D levels, and a baseline bone mineral density test, to ensure safe treatment and minimize the risk of hypocalcemia and other adverse effects. According to the most recent guidelines, denosumab is recommended for patients with castration-resistant prostate cancer and bone metastases to prevent or delay disease-associated skeletal-related events (SREs) 1. The study highlights the importance of monitoring calcium levels, as denosumab can cause hypocalcemia, and recommends correcting any deficiency before starting treatment. Additionally, vitamin D deficiency should be addressed, as adequate vitamin D is essential for calcium absorption and bone health 1.
Some key laboratory tests to consider before Prolia injection include:
- Comprehensive metabolic panel to assess kidney function and calcium levels
- Vitamin D levels to ensure adequate vitamin D for calcium absorption and bone health
- Baseline bone mineral density test to assess bone health
- Pregnancy test for women of childbearing age, as Prolia is contraindicated during pregnancy
- Phosphorus levels and parathyroid hormone status may also be checked by some providers
Regular monitoring of calcium levels is recommended after starting treatment, particularly in patients with kidney impairment who are at higher risk for hypocalcemia 1. It is also crucial to evaluate renal function and serum calcium levels before each administration of zoledronic acid, and to measure serum calcium before each denosumab injection 1. A baseline dental evaluation is mandatory before initiating denosumab or zoledronic acid, and close monitoring of oral conditions is strongly recommended to detect early osteonecrosis of the jaw (ONJ) 1.
From the FDA Drug Label
- 2 Laboratory Testing in Patients with Advanced Chronic Kidney Disease Prior to Initiation of Prolia
In patients with advanced chronic kidney disease [i.e., estimated glomerular filtration rate (eGFR) < 30 mL/min/1. 73 m2], including dialysis-dependent patients, evaluate for the presence of chronic kidney disease mineral and bone disorder (CKD-MBD) with intact parathyroid hormone (iPTH), serum calcium, 25(OH) vitamin D, and 1,25 (OH)2 vitamin D prior to decisions regarding Prolia treatment Consider also assessing bone turnover status (serum markers of bone turnover or bone biopsy) to evaluate the underlying bone disease that may be present
- Lab tests before Prolia injection:
- Intact parathyroid hormone (iPTH)
- Serum calcium
- 25(OH) vitamin D
- 1,25 (OH)2 vitamin D
- Serum markers of bone turnover (in patients with advanced chronic kidney disease)
- Bone biopsy (in patients with advanced chronic kidney disease)
- These lab tests are specifically recommended for patients with advanced chronic kidney disease, but pregnancy testing is also required for all females of reproductive potential prior to administration of Prolia 2
From the Research
Lab Testing Before Prolia Injection
Lab testing before Prolia (denosumab) injection is crucial to assess the risk of hypocalcemia, a potential side effect of the treatment. The following tests are recommended:
- Serum calcium levels: to assess the risk of hypocalcemia 3, 4, 5, 6
- 25-hydroxyvitamin D levels: to assess vitamin D deficiency and optimize supplementation 3, 4, 7
- Estimated glomerular filtration rate (eGFR): to assess kidney function and risk of hypocalcemia 3, 4, 5, 6
- Albumin-corrected serum calcium levels: to accurately assess calcium levels 6
Risk Factors for Hypocalcemia
Several risk factors for hypocalcemia have been identified, including:
- Advanced chronic kidney disease (CKD) 3, 4, 5, 6
- Lower baseline serum calcium levels 6, 7
- Lower 25-hydroxyvitamin D levels 7
- Male sex 3
- Stages 4 and 5 CKD 3
Prevention and Management of Hypocalcemia
To prevent and manage hypocalcemia, the following strategies can be employed: