Safety and Efficacy of Denosumab in an HIV-Infected Patient with Osteoporosis

Presentation Number: SUN 328
Date of Presentation: April 2nd, 2017

Dania S Assad*1 and Wael Taha2
1Wayne State University, Detroit, MI, 2Wayne State University/Detroit Medical Center, Detroit, MI

Abstract

Introduction: WHO statistics showed that there are 36.7 million people living with HIV in 2015. The prevalence of osteoporosis among patients with HIV treated with antiretroviral therapy (ART) has increased significantly. Alendronate (ALN) and zoledronate (ZOL) are the only two osteoporosis treatments proven to be effective and safe in HIV-infected patients. Denosumab is a very effective treatment of osteoporosis; however, it is thought to negatively affect the immune system. Therefore, denosumab treatment is not considered in HIV due to the fear of opportunistic infections. We report a case of an HIV-infected patient with osteoporosis managed with denosumab.

Case Report: A 73-year-old HIV positive African American male-to-female transgender patient presented for evaluation of severe osteoporosis. The first dual-energy x-ray absorptiometry (DEXA) scan done by Hologic scanner showed a bone mineral density (BMD) at the lumbar spine (LS) of 0.604 g/cm² (t score -3.9) and at the left femoral neck (LFN) of 0.389 g/cm² (t score -3.3). Her medical history was significant for HIV treated with efavirenz/emtricitabine/tenofovir, CKD with eGFR 50-60 and a 50-pack-year smoking history. She denied any fracture history, loss of height or any chronic glucocorticoid use. She does not tolerate milk but eats cheese daily. The HIV viral load was undetectable with a CD4 count of 972 cells/mm3. She was treated with ALN 70 mg in addition to calcium and vitamin D supplements. She stopped ALN after a few months due to dyspepsia. At the endocrine clinic, ZOL treatment was suggested, but she declined due to CKD and asked for a treatment that does not affect the kidney. Given the severity of her osteoporosis, she was started on denosumab injections after detailed counseling of the risk. She tolerated the treatment well and reported no skin or other infections. A follow-up DEXA scan by Lunar scanner one year later showed significant improvement in the BMD of the LS, measuring 0.831 g/cm² and LFN of 0.618 g/cm². During all her follow-up visits, she continued to feel well and denied having any infections.

Discussion: Osteoporosis is a growing concern among HIV-infected patients because of the recognized risk of fractures and high morbidity and mortality. Prospective studies of HIV-infected individuals have shown a bone loss of between 2- 6% in the hip and spine during the first year of treatment. ALN and ZOL have been studied in HIV-infected individuals. Denosumab is a fully human monoclonal antibody that inhibits bone resorption through inhibition of the receptor activator of nuclear factor K-ligand. There are concerns about the risk of serious infections with the use of denosumab, limiting its use in HIV-infected patients.

Conclusion: This case suggests denosumab as an effective and safe bone agent that may be used in controlled HIV cases. To our knowledge, this is the first case of denosumab use in an HIV patient.

 

Nothing to Disclose: DSA, WT