An 86-year-old male with a history of metastatic castrate sensitive prostate cancer received a single dose of Denosumab for his bony metastases. Two weeks later, he presented to the hospital due to left foot cellulitis and was incidentally found to have profound hypocalcemia whereas his serum calcium was normal at the time of Denosumab injection. A thorough workup was undertaken which showed severe Vitamin D deficiency. He was diagnosed with Denosumab induced hypocalcemia with underlying Vitamin D deficiency which was refractory to supplemental calcium and Vitamin D. This case demonstrates the potential of Denosumab to cause profound hypocalcemia which can be resistant to therapy. Bone metastasis is a common clinical encounter and Denosumab is an effective therapy to prevent skeletal related events (SRE). Therefore, given its widespread use, it is extremely important to identify and treat risk factors that may aggravate hypocalcemia when treated with Denosumab.
Introduction Untreated polycythemia leads to complications including thrombosis. Obstructive sleep apnea (OSA) is commonly associated with secondary erythrocytosis, which testosterone therapy can perpetuate. Effects of positive airway pressure (PAP) on elevated hematocrit (HCT) is unknown. We hypothesize PAP adherence can reduce HCT in men with OSA and polycythemia. Methods Retrospective chart review of male outpatients with newly diagnosed OSA and HCT≥45% at or 3 months before polysomnography (PSG) was conducted. Intervention group consisted of patients initiating PAP for OSA. HCT within 6 months of PAP initiation and PSG were recorded for intervention and control groups, respectively. Primary endpoint was time-to-HCT reduction of HCT<50% plus 3% decrease. Cox proportional-hazards analysis was used to assess time-to-HCT response. Demographics, smoking history, testosterone administration, STOP-Bang score, AHI, and PAP compliance data were obtained. Patients excluded if PAP not indicated, or if PSG, PAP compliance, or repeat HCT were unavailable. Results 41 men with OSA had HCT≥45%, of which 16 had HCT≥50%. Median age was 60 years and median BMI was 32 kg/m2. 28 started PAP. 21 met definition for PAP compliance within 6 months. Median AHI of intervention and control groups were 23 and 19 events/hr, respectively. Mean baseline HCT of both groups were 49 and 50, respectively. No significant difference in age, BMI, smoking history, testosterone therapy, and baseline HCT between both groups noted. 39% of intervention group exhibited HCT response at 1 or more longitudinal assessments, versus 38% of control. Intervention group had higher mean STOP-Bang than control (mean 5.9 vs. 4.6, p=0.01) and trended towards higher mean baseline AHI (27.4 vs. 19.0, p= 0.06). Time-to-event analysis controlling for STOP-Bang and AHI demonstrated PAP was not associated with time-to-HCT response (HR = 1.3, 95% CI = 0.4–4.4). In moderate-severe OSA patients, 40% of intervention group had HCT response compared to 14% of control, though difference was not significant (HR = 2.5, 95% CI = 0.3–20.0). Conclusion Moderate-severe OSA patients trended towards reduction in HCT with PAP, although not statistically significant. Testosterone administration did not affect HCT response to PAP in this cohort. Larger studies are required to determine HCT response to PAP in these patients. Support (if any):
INTRODUCTION AND OBJECTIVE: Untreated polycythemia can lead to complications including thrombosis. Obstructive sleep apnea (OSA) is commonly associated with secondary erythrocytosis. Testosterone administration can perpetuate secondary erythrocytosis. The effects of positive airway pressure (PAP) on elevated hematocrit (HCT) is unknown. We hypothesize that PAP adherence can reduce HCT in men with OSA and polycythemia.METHODS: We conducted a retrospective chart review of male outpatients with newly diagnosed OSA and HCT !45% at or 3 months prior to polysomnography (PSG). The intervention group consisted of patients who initiated PAP for OSA. HCT within 6 months of PAP initiation and PSG were recorded for intervention and control group, respectively. Primary endpoint was time-to-HCT reduction of HCT <50% plus 3% decrease. Cox proportional hazards analysis was used to assess time-to-HCT response. Baseline demographics, smoking history, testosterone administration, STOP-Bang score, apnea-hypopnea index (AHI), and PAP compliance data were obtained. Patients were excluded if PAP was not indicated or if PSG, PAP compliance, or repeat HCT were not available.RESULTS: 41 men with OSA had HCT !45%, of which 16 had HCT !50%. Median age was 60 (IQR[49e68) years and median BMI was 32 kg/m 2 . 68% (n[28) started PAP. 21 met the definition for PAP compliance within 6 months. Median AHI of the intervention and control groups were 23 and 19 events/hr, respectively. Mean baseline HCT of the two groups were 49 and 50, respectively. There was no significant difference in age, BMI, smoking history, receipt of testosterone, and baseline HCT between both groups. 39% of the intervention group exhibited HCT response at 1 or more longitudinal assessments, versus 38% of the control. The intervention group had higher mean STOP-Bang than the control (mean 5.9 vs. 4.6, p[0.01) and trended towards higher mean baseline AHI (27.4 vs. 19.0, p[0.06). Time-toevent analysis controlling for STOP-Bang and AHI demonstrated PAP was not associated with time-to-HCT response (HR [ 1.3, 95% CI [0.4e4.4). In moderate-severe OSA patients, 40% of the intervention group had HCT response compared to 14% in the control, though the difference was not significant (HR[2.5, 95% CI [0.3e20.0).CONCLUSIONS: Moderate-severe OSA patients trended towards reduction in HCT with PAP, although not statistically significant.Testosterone administration does not affect HCT response to PAP in this cohort. Larger studies are required to determine the HCT response to PAP in moderate-severe OSA patients.
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