Predictors for development of denosumab-induced hypocalcaemia in cancer patients with bone metastases determined by ordered logistic regression analysis

Abstract

This retrospective study was undertaken to identify predictors for the development of hypocalcaemia even with prophylactic administration of calcium and vitamin D, and to help guide future strategies to improve the safety, efficacy, and QOL of patients receiving denosumab. Between January 2016 and February 2020, a total of 327 advanced cancer patients at our hospital who were receiving denosumab were enrolled. Variables associated with the development of hypocalcaemia were extracted from the clinical records. The level of hypocalcaemia was evaluated using CTCAE version 5. Multivariate ordered logistic regression analysis was performed to identify predictors for the development of hypocalcaemia. Optimal cut off thresholds were determined using ROC analysis. Values of P < 0.05 (2-tailed) were considered significant. 54 patients have developed hypocalcemia (≥ Grade 1). Significant factors identified included concomitant use of vonoprazan [odds ratio (OR) = 3.74, 95% confidence interval (CI) 1.14-12.26; P = 0.030], dexamethasone (OR = 2.45, 95%CI 1.14-5.42; P = 0.022), pre-treatment levels of serum calcium (OR = 0.27, 95%CI 0.13-0.54; P < 0.001), ALP/100 (OR = 1.04, 95%CI 1.01-1.07; P = 0.003), and haemoglobin (OR = 0.79, 95%CI 0.68-0.93; P = 0.004). ROC curve analysis revealed that the threshold for pre-treatment levels of serum calcium was ≤ 9.3 mg/dL, ALP was ≥ 457 U/L, and haemoglobin was ≤ 10.4 g/dL. In conclusion, concomitant use of vonoprazan or dexamethasone, and pre-treatment levels of serum calcium (low), ALP (high) and haemoglobin (low) were identified as significant predictors for the development of denosumab-induced hypocalcaemia.

Figure 1

ROC curves about hypocalcaemia (≥ Grade 1) according the logistic regression significant variables. (A) ROC curve of concomitant use of vonoprazan with a sensitivity of 11.1% and specificity of 97.1% (AUC = 0.54). (B) ROC curve of dexamethasone with a sensitivity of 27.8% and specificity of 87.9% (AUC = 0.58). (C) ROC curve of the pre-treatment levels of serum calcium with a sensitivity of 63.0% and specificity of 76.6% (AUC = 0.72). (D) ROC curve of alkaline phosphatase with a sensitivity of 38.9% and specificity of 79.5% (AUC = 0.59). (E) ROC curve of haemoglobin with a sensitivity of 38.9% and specificity of 83.4% (AUC = 0.65).