| Practice points for clinicians: |
| Prior to denosumab administration: |
| (1) Consult with the patient’s primary nephrologist prior to commencement of denosumab in |
| patients with Stage 4–5 CKD. Review the indication for denosumab. |
| (2) Check baseline calcium level prior to each dose of denosumab. |
| (3) Correct hypocalcaemia prior to initiating therapy. Review calcium-based phosphate binders |
| and calcitriol supplementation dosing, or initiate this therapy if hypocalcaemic. |
| (4) Identify other medications that may predispose to hypocalcaemia such as loop diuretics |
| (frusemide), calcimimetics (cinacalcet), steroids, bisphosphonates, calcitonin, barbiturates |
| and ketoconazole. |
| After denosumab administration: |
| (1) Clearly notify denosumab administration to all clinicians involved to raise awareness of |
| potential hypocalcaemia. |
| (2) Calcium levels should be monitored at least weekly following denosumab administration, |
| for up to 12 weeks. |
| (3) Identify declining calcium levels early. Optimize calcium and calcitriol therapy early to |
| prevent severe hypocalcaemia. |
| Information for patients: |
| (1) Patients with Stage 4–5 CKD should be counselled about the increased risk of hypocalcaemia |
| with denosumab. |
| (2) Patients should understand the importance of blood tests for detecting hypocalcaemia early. |
| (3) Patients should be advised about the signs and symptoms of hypocalcaemia. |
| (4) Patients should be advised to seek immediate medical attention should the following occur: |
| unusual fatigue, paraesthesia, muscle spasm, twitching, stiffness, confusion and/or seizures. |
