Patient leaflets and SmPCs, drug interaction checker, official dosages and NHS pharmacy opening hours — all in one place.
Patient leaflets and SmPCs, drug interaction checker, official dosages and NHS pharmacy opening hours — all in one place.
The electronic medicines compendium (emc) no longer publishes a Summary of Product Characteristics for this product, which usually means it is no longer marketed in the UK. The patient leaflet below is kept for reference, but the product may not be available.
If you were prescribed this medicine, other products containing Denosumab may still be available. Do not stop your treatment — ask your pharmacist or GP what to use instead.
for
What Stoboclo is and how it works Stoboclo contains denosumab, a protein (monoclonal antibody) that interferes with the action of another protein, in order to treat bone loss and osteoporosis. Treatment with Stoboclo makes bone stronger and less likely to break. Bone is a living tissue and is renewed all the time. Oestrogen helps keep bones healthy. After the menopause, oestrogen level drops which may cause bones to become thin and fragile. This can eventually lead to a condition called osteoporosis. Osteoporosis can also occur in men due to a number of causes including ageing and/or a low level of the male hormone, testosterone. It can also occur in patients receiving glucocorticoids. Many patients with osteoporosis have no symptoms, but they are still at risk of breaking bones, especially in the spine, hips and wrists. Surgery or medicines that stop the production of oestrogen or testosterone used to treat patients with breast or prostate cancer can also lead to bone loss. The bones become weaker and break more easily. What Stoboclo is used for Stoboclo is used to treat: • osteoporosis in women after the menopause (postmenopausal) and men who have an increased risk of fracture (broken bones), reducing the risk of spinal, non-spinal and hip fractures. • bone loss that results from a reduction in hormone (testosterone) level caused by surgery or treatment with medicines in patients with prostate cancer. • bone loss that results from long-term treatment with glucocorticoids in patients who have an increased risk of fracture.
Pharmacotherapeutic group: Drugs for treatment of bone diseases – Other drugs affecting bone structure and mineralisation, ATC code: M05BX04 2.
e Stoboclo
Do not use Stoboclo • •
if you have low calcium levels in the blood (hypocalcaemia). if you are allergic to denosumab or any of the other ingredients of this medicine (listed in section 6).
Warnings and precautions Talk to your doctor or pharmacist before using Stoboclo. Whilst being treated with Stoboclo you may develop a skin infection with symptoms such as a swollen, red area of skin, most commonly in the lower leg, that feels hot and tender (cellulitis), and possibly with symptoms of fever. Please tell your doctor immediately if you develop any of these symptoms. You should also take calcium and vitamin D supplements while being on treatment with Stoboclo. Your doctor will discuss this with you. You may have low levels of calcium in your blood while receiving Stoboclo. Please tell your doctor immediately if you notice any of the following symptoms: spasms, twitches, or cramps in your muscle, and/or numbness or tingling in your fingers, toes or around your mouth, and/or seizures, confusion, or loss of consciousness. Severe low blood calcium levels leading to hospitalisation and even life-threatening reactions have been reported in rare cases. Before each dose and in patients predisposed to hypocalcaemia within two weeks after initial dose, the calcium levels in your blood will therefore be checked (via blood test). Tell your doctor if you have or have ever had severe kidney problems, kidney failure or have needed dialysis or are taking medicines called glucocorticoids (such as prednisolone or dexamethasone), which may increase your risk of getting low blood calcium if you do not take calcium supplements. Problems with your mouth, teeth or jaw A side effect called osteonecrosis of the jaw (ONJ) (bone damage in the jaw) has been reported rarely (may affect up to 1 in 1,000 people) in patients receiving denosumab for osteoporosis. The risk of ONJ increases in patients treated for a long time (may affect up to 1 in 200 people if treated for 10 years). ONJ can also occur after stopping treatment. It is important to try to prevent ONJ developing as it may be a painful condition that can be difficult to treat. In order to reduce the risk of developing ONJ, take the following precautions: Before receiving treatment, tell your doctor or nurse (health care professional) if you: • • • • • •
have any problems with your mouth or teeth such as poor dental health, gum disease, or a planned tooth extraction. don't receive routine dental care or have not had a dental check-up for a long time. are a smoker (as this may increase the risk of dental problems). have previously been treated with a bisphosphonate (used to treat or prevent bone disorders). are taking medicines called corticosteroids (such as prednisolone or dexamethasone). have cancer.
Your doctor may ask you to undergo a dental examination before you start treatment with Stoboclo.
While being treated, you should maintain good oral hygiene and receive routine dental check-ups. If you wear dentures you should make sure these fit properly. If you are under dental treatment or will undergo dental surgery (e.g. tooth extractions), inform your doctor about your dental treatment and tell your dentist that you are being treated with Stoboclo. Contact your doctor and dentist immediately if you experience any problems with your mouth or teeth such as loose teeth, pain or swelling, or non-healing of sores or discharge, as these could be signs of ONJ. Unusual thigh bone fractures Some people have developed unusual fractures in their thigh bone while being treated with denosumab. Contact your doctor if you experience new or unusual pain in your hip, groin, or thigh. Children and adolescents Stoboclo should not be used in children and adolescents under 18 years of age. Other medicines and Stoboclo Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines. It is especially important that you tell your doctor if you are being treated with another medicine containing denosumab. You should not take Stoboclo together with another medicine containing denosumab. Pregnancy and breast-feeding Stoboclo has not been tested in pregnant women. It is important to tell your doctor if you are pregnant; think you may be pregnant; or plan to get pregnant. Stoboclo is not recommended for use if you are pregnant. Women of child-bearing potential should use effective methods of contraception while being treated with Stoboclo and for at least 5 months after stopping treatment with Stoboclo. If you become pregnant during treatment with Stoboclo or less than 5 months after stopping treatment with Stoboclo, please inform your doctor. It is not known whether denosumab is excreted in breast milk. It is important to tell your doctor if you are breast-feeding or plan to do so. Your doctor will then help you decide whether to stop breast-feeding, or whether to stop taking Stoboclo, considering the benefit of breast-feeding to the baby and the benefit of Stoboclo to the mother. If you are breast-feeding during Stoboclo treatment, please inform your doctor. Ask your doctor or pharmacist for advice before taking any medicine. Driving and using machines Stoboclo has no or negligible influence on the ability to drive and use machines. Stoboclo contains sorbitol (E420) This medicine contains 47 mg sorbitol in each mL of solution. Stoboclo contains sodium This medicine contains less than 1 mmol sodium (23 mg) per 60 mg, that is to say essentially 'sodium-free'. Stoboclo contains polysorbate 20 (E432)
This medicine contains 0.1 mg of polysorbate 20 in each syringe which is equivalent to 0.1 mg/mL. Polysorbates may cause allergic reactions. Tell your doctor if you have any known allergies. 3.
Stoboclo
The recommended dose is one pre-filled syringe of 60 mg administered once every 6 months, as a single injection under the skin (subcutaneous). The best places to inject are the top of your thighs and the abdomen. Your carer can also use the outer area of your upper arm. Please consult your doctor on the date for a potential next injection. Each pack of Stoboclo contains a reminder card included in the carton and used to keep a record of the next injection date. You should also take calcium and vitamin D supplements while being on treatment with Stoboclo. Your doctor will discuss this with you. Your doctor may decide that it is best for you or a carer to inject Stoboclo. Your doctor or healthcare provider will show you or your carer how to use Stoboclo. For instructions on how to inject Stoboclo, please read the section at the end of this leaflet. Do not shake. If you forget to use Stoboclo If a dose of Stoboclo is missed, the injection should be administered as soon as possible. Thereafter, injections should be scheduled every 6 months from the date of the last injection. If you stop using Stoboclo To get the most benefit from your treatment in reducing the risk of fractures, it is important to use Stoboclo for as long as your doctor prescribes it for you. Do not stop your treatment without contacting your doctor. 4.
Like all medicines, this medicine can cause side effects, although not everybody gets them. Uncommonly, patients receiving Stoboclo may develop skin infections (predominantly cellulitis). Please tell your doctor immediately if you develop any of these symptoms while being on treatment with Stoboclo: swollen, red area of skin, most commonly in the lower leg, that feels hot and tender, and possibly with symptoms of fever. Rarely, patients receiving Stoboclo may develop pain in the mouth and/or jaw, swelling or non-healing of sores in the mouth or jaw, discharge, numbness or a feeling of heaviness in the jaw, or loosening of a tooth. These could be signs of bone damage in the jaw (osteonecrosis). Tell your doctor and dentist immediately if you experience such symptoms while being treated with Stoboclo or after stopping treatment. Rarely, patients receiving Stoboclo may have low calcium levels in the blood (hypocalcaemia); severely low blood calcium levels may lead to hospitalisation and may even be life-threatening. Symptoms include spasms, twitches, or cramps in your muscles, and/or numbness or tingling in your fingers, toes or around your mouth and/or seizures, confusion, or loss of consciousness. If any of these apply to you, tell your doctor immediately. Low calcium in the blood may also lead to a change in heart rhythm called QT prolongation which is seen by electrocardiogram (ECG).
Rarely unusual fractures of the thigh bone may occur in patients receiving Stoboclo. Contact your doctor if you experience new or unusual pain in your hip, groin or thigh as this may be an early indication of a possible fracture of the thigh bone. Rarely, allergic reactions may occur in patients receiving Stoboclo. Symptoms include swelling of the face, lips, tongue, throat or other parts of the body; rash, itching or hives on the skin, wheezing or difficulty breathing. Please tell your doctor if you develop any of these symptoms while being treated with Stoboclo. Very common side effects (may affect more than 1 in 10 people): • •
bone, joint, and/or muscle pain which is sometimes severe, arm or leg pain (pain in extremity).
Common side effects (may affect up to 1 in 10 people): • • • • • • • •
painful urination, frequent urination, blood in the urine, inability to hold your urine, upper respiratory tract infection, pain, tingling or numbness that moves down your leg (sciatica), constipation, abdominal discomfort, rash, skin condition with itching, redness and/or dryness (eczema), hair loss (alopecia).
Uncommon side effects (may affect up to 1 in 100 people): • • •
fever, vomiting and abdominal pain or discomfort (diverticulitis), ear infection, rash that may occur on the skin or sores in the mouth (lichenoid drug eruptions).
Very rare side effects (may affect up to 1 in 10 000 people): •
allergic reaction that can damage blood vessels mainly in the skin (e.g. purple or brownish-red spots, hives or skin sores) (hypersensitivity vasculitis).
Not known (frequency cannot be estimated from the available data): •
talk to your doctor if you have ear pain, discharge from the ear and/or an ear infection. These could be signs of bone damage in the ear.
Reporting of side effects If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard, or search for MHRA Yellow Card in the Google Play or Apple App Store. By reporting side effects you can help provide more information on the safety of this medicine. 5.
Stoboclo
Keep this medicine out of the sight and reach of children. Do not use this medicine after the expiry date which is stated on the label and carton after EXP. The expiry date refers to the last day of that month.
Store in a refrigerator (2°C – 8°C). Do not freeze. Keep the pre-filled syringe in the outer carton in order to protect from light. Your pre-filled syringe may be left outside the refrigerator to reach room temperature (up to 30°C) before injection. This will make the injection more comfortable. Once your syringe has been left to reach room temperature (up to 30°C), it may be stored at room temperature for a single period of up to 63 days, but not exceeding the original expiry date. If not used within this period of up to 63 days, your syringe may be returned to the refrigerator for maximum of 3 days and must be discarded if not used within this time period. Do not use your syringe after the expiry date printed on the label. Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help to protect the environment. 6.
What Stoboclo contains –
The active substance is denosumab. Each 1 mL pre-filled syringe contains 60 mg of denosumab (60 mg/mL). The other ingredients are acetic acid, sodium acetate trihydrate, sorbitol (E420), polysorbate 20 (E432) and water for injections.
What Stoboclo looks like and contents of the pack Stoboclo is a clear, colourless to pale yellow solution for injection provided in a ready to use pre-filled syringe. Each pack contains one pre-filled syringe with safety guard. Marketing Authorisation Holder Celltrion Healthcare United Kingdom Limited The Charter Building, Charter Place, Uxbridge, UB8 1JG United Kingdom Manufacturer Nuvisan France S.A.R.L 2400 Route des Colles, Biot, 06410 France Manufacturer Midas Pharma GmbH Rheinstrasse 49, West, Ingelheim Am Rhein, Rhineland-Palatinate, 55218 Germany Manufacturer Kymos S.L. Ronda de Can Fatjó, 7B Parc Tecnològic del Vallès, Cerdanyola del Vallès, Barcelona, 08290
Spain For any information about this medicine, please contact the Marketing Authorisation Holder: United Kingdom Celltrion Healthcare United Kingdom Limited Tel: +44 (0)1753 983500 This leaflet was last revised in 03/2026
Instructions for use: Read and follow the Instructions for use that come with your Stoboclo pre-filled syringe before you start using it and each time you get a refill. There may be new information. Stoboclo may be administered by healthcare professionals (HCPs), caregivers or may be self-administered by the patients if they have received training. Talk to your doctor if you have any questions about giving yourself an injection. Important Information • Stoboclo is given as an injection into the tissue just under the skin (subcutaneous injection). • Do not open the sealed carton until you are ready to use the pre-filled syringe. • Do not remove the needle cap from the pre-filled syringe until just before you give the injection. • Do not attempt to activate the pre-filled syringe prior to injection. • Do not attempt to remove the clear safety guard from the pre-filled syringe. • Do not use the pre-filled syringe if it has been dropped on a hard surface. Use a new pre-filled syringe. • Do not shake the pre-filled syringe. Strong shaking may damage the medicine. • The pre-filled syringe cannot be re-used. Dispose of the used pre-filled syringe immediately after use in a sharps disposal container (see Step 15. Dispose of Stoboclo). Storing Stoboclo • Keep the pre-filled syringe out of the sight and reach of children. Contains small parts. • Store the pre-filled syringe in a refrigerator between 2 °C and 8 oC. Do not freeze. • Once removed from the refrigerator, Stoboclo may be stored at temperature up to a maximum of 30°C for a single period of up to 63 days, but not exceeding the original expiry date. If not used within this period of up to 63 days, Stoboclo may be returned to the refrigerator for maximum of 3 days and must be discarded if not used within this time period. • Store the pre-filled syringe sealed inside its carton to protect it from light. Parts of the pre-filled syringe (see Figure A)
Figure A
Preparing for the Injection
1. Gather the supplies for the injection. 1a. Prepare a clean, flat surface, such as a table or counter top, in a well-lit area. 1b. Take the carton containing the pre-filled syringe out of the refrigerator. 1c. Make sure you have the following supplies (see Figure B):
Figure B 2. Check the expiration date on the carton (see Figure C).
Figure C 3. Remove the pre-filled syringe from the carton. 3a. Open the carton. Gripping the syringe body, lift the pre-filled syringe from the carton (see Figure D).
Figure D
Preparing for the Injection
4. Inspect the pre-filled syringe. 4a. Look at the pre-filled syringe and make sure you have the correct medicine (Stoboclo). 4b. Look at the pre-filled syringe and make sure it is not cracked or damaged. 4c. Check the expiration date on the label of the pre-filled syringe (see Figure E).
Figure E 5. Inspect the medicine. 5a. Look at the medicine and confirm that the liquid is clear, colourless to pale yellow, and does not contain any visible particles or flakes in it (see Figure F).
Figure F 6. Wait 30 minutes. 6a. Let the pre-filled syringe stand outside the box for 30 minutes at room temperature (20 °C to 30 °C) to allow it to warm up (see Figure G).
Figure G
Preparing for the Injection
7. Choose an appropriate injection site (see Figure H). 7a. You may inject into:
Figure H 8. Wash your hands. 8a. Wash your hands with soap and water and dry them thoroughly (see Figure I).
Figure I 9. Clean the injection site. 9a. Clean the injection site with an alcohol swab using a circular motion (see Figure J). 9b. Let the skin dry before injecting.
Figure J
Administering the Injection
Figure K
10. Remove the cap. 10a. Hold the body of the pre-filled syringe in one hand between the thumb and index finger. With the other hand, carefully pull the needle cap straight off (see Figure K).
Figure L 12. Give the injection. 12a. After the needle is inserted, release the pinched skin. 12b. Slowly push the plunger rod all the way down until the full dose of medicine gets injected, and the syringe is empty (see Figure M).
Figure M
Administering the Injection
13. Remove the pre-filled syringe from the injection site. 13a. After the pre-filled syringe is empty, as the needle is being taken out, slowly remove the needle by lifting your thumb from the plunger rod until the needle is completely covered by the safety guard (see Figure N).
Figure N After the Injection
Figure O
14. Care for the injection site. 14a. If some bleeding occurs, treat the injection site by gently pressing, not rubbing, a cotton ball or gauze to the site and apply an adhesive bandage if needed. 15. Dispose of the pre-filled syringe. 15a. Put the used pre-filled syringe in a sharps disposal container right away after use (see Figure O). 15b. Do not throw away (dispose of) the pre-filled syringe in your household trash.
Stoboclo 60 mg/ml pre-filled syringe, Solution for injection comes as injection containing 60mg/ml. Always follow the dose your doctor or pharmacist has given you, and read the leaflet that comes with the medicine.
The active substance in Stoboclo 60 mg/ml pre-filled syringe, Solution for injection is denosumab.
This leaflet reproduces the patient information leaflet approved for Stoboclo 60 mg/ml pre-filled syringe, Solution for injection, as published on the electronic medicines compendium (emc). The version printed inside your medicine’s packaging is the one that applies to you.
Whether a medicine is available over the counter or on prescription only depends on its licence. Check the leaflet, or ask your pharmacist — they can tell you straight away.
The text above reproduces the patient information leaflet approved for this medicine, restructured for easier reading.
Treatment of osteoporosis in postmenopausal women and in men at increased risk of fractures. In postmenopausal women denosumab significantly reduces the risk of vertebral, non-vertebral and hip fractures.
Treatment of bone loss associated with hormone ablation in men with prostate cancer at increased risk of fractures (see section 5.1). In men with prostate cancer receiving hormone ablation, denosumab significantly reduces the risk of vertebral fractures.
Treatment of bone loss associated with long-term systemic glucocorticoid therapy in adult patients at increased risk of fracture (see section 5.1).
Posology
The recommended dose is 60 mg denosumab administered as a single subcutaneous injection once every 6 months into the thigh, abdomen or upper arm.
Patients must be adequately supplemented with calcium and vitamin D (see section 4.4).
Patients treated with denosumab should be given the package leaflet and the patient reminder card.
The optimal total duration of antiresorptive treatment for osteoporosis (including both denosumab and bisphosphonates) has not been established. The need for continued treatment should be re-evaluated periodically based on the benefits and potential risks of denosumab on an individual patient basis, particularly after 5 or more years of use (see section 4.4).
Elderly (age ≥ 65)
No dose adjustment is required in elderly patients.
Renal impairment
No dose adjustment is required in patients with renal impairment (see section 4.4 for recommendations relating to monitoring of calcium).
No data is available in patients with long-term systemic glucocorticoid therapy and severe renal impairment Glomerular filtration rate (GFR < 30 mL/min).
Hepatic impairment
The safety and efficacy of denosumab have not been studied in patients with hepatic impairment (see section 5.2).
Paediatric population
Stoboclo should not be used in children aged < 18 years because of safety concerns of serious hypercalcaemia, and potential inhibition of bone growth and lack of tooth eruption (see sections 4.4 and 5.3). Currently available data for children aged 2 to 17 years are described in sections 5.1 and 5.2.
Method of administration
For subcutaneous use.
Administration should be performed by an individual who has been adequately trained in injection techniques.
The instructions for use, handling and disposal are given in section 6.6.
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Hypocalcaemia (see section 4.4).
Traceability
In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.
Calcium and vitamin D supplementation
Adequate intake of calcium and vitamin D is important in all patients.
Precautions for use
Hypocalcaemia
It is important to identify patients at risk for hypocalcaemia. Hypocalcaemia must be corrected by adequate intake of calcium and vitamin D before initiating therapy. Clinical monitoring of calcium levels is recommended before each dose and, in patients predisposed to hypocalcaemia within two weeks, after the initial dose. If any patient presents with suspected symptoms of hypocalcaemia during treatment (see section 4.8 for symptoms) calcium levels should be measured. Patients should be encouraged to report symptoms indicative of hypocalcaemia.
In the post-marketing setting, severe symptomatic hypocalcaemia (resulting in hospitalisation, life‑threatening events, and fatal cases) have been reported. While most cases occurred in the first few weeks of initiating therapy, it has also occurred later.
Concomitant glucocorticoid treatment is an additional risk factor for hypocalcaemia.
Renal impairment
Patients with severe renal impairment (creatinine clearance < 30 mL/min) or receiving dialysis are at greater risk of developing hypocalcaemia. The risks of developing hypocalcaemia and accompanying parathyroid hormone elevations increase with increasing degree of renal impairment. Severe and fatal cases have been reported. Adequate intake of calcium, vitamin D and regular monitoring of calcium is especially important in these patients, see above.
Skin infections
Patients receiving denosumab may develop skin infections (predominantly cellulitis) leading to hospitalisation (see section 4.8). Patients should be advised to seek prompt medical attention if they develop signs or symptoms of cellulitis.
Osteonecrosis of the jaw (ONJ)
ONJ has been reported rarely in patients receiving denosumab for osteoporosis (see section 4.8).
The start of treatment/new treatment course should be delayed in patients with unhealed open soft tissue lesions in the mouth. A dental examination with preventive dentistry and an individual benefit‑risk assessment is recommended prior to treatment with denosumab in patients with concomitant risk factors.
The following risk factors should be considered when evaluating a patient's risk of developing ONJ:
• potency of the medicinal product that inhibits bone resorption (higher risk for highly potent compounds), route of administration (higher risk for parenteral administration) and cumulative dose of bone resorption therapy.
• cancer, co-morbid conditions (e.g. anaemia, coagulopathies, infection), smoking.
• concomitant therapies: corticosteroids, chemotherapy, angiogenesis inhibitors, radiotherapy to head and neck.
• poor oral hygiene, periodontal disease, poorly fitting dentures, history of dental disease, invasive dental procedures (e.g. tooth extractions).
All patients should be encouraged to maintain good oral hygiene, receive routine dental check-ups, and immediately report any oral symptoms such as dental mobility, pain or swelling or non-healing of sores or discharge during treatment with denosumab. While on treatment, invasive dental procedures should be performed only after careful consideration and be avoided in close proximity to denosumab administration.
The management plan of the patients who develop ONJ should be set up in close collaboration between the treating physician and a dentist or oral surgeon with expertise in ONJ. Temporary interruption of treatment should be considered until the condition resolves and contributing risk factors are mitigated where possible.
Osteonecrosis of the external auditory canal
Osteonecrosis of the external auditory canal has been reported with denosumab. Possible risk factors for osteonecrosis of the external auditory canal include steroid use and chemotherapy and/or local risk factors such as infection or trauma. The possibility of osteonecrosis of the external auditory canal should be considered in patients receiving denosumab who present with ear symptoms including chronic ear infections.
Atypical fractures of the femur
Atypical femoral fractures have been reported in patients receiving denosumab (see section 4.8). Atypical femoral fractures may occur with little or no trauma in the subtrochanteric and diaphyseal regions of the femur. Specific radiographic findings characterise these events. Atypical femoral fractures have also been reported in patients with certain co-morbid conditions (e.g. vitamin D deficiency, rheumatoid arthritis, hypophosphatasia) and with use of certain medicinal products (e.g. bisphosphonates, glucocorticoids, proton pump inhibitors). These events have also occurred without antiresorptive therapy. Similar fractures reported in association with bisphosphonates are often bilateral; therefore, the contralateral femur should be examined in denosumab-treated patients who have sustained a femoral shaft fracture. Discontinuation of denosumab therapy in patients suspected to have an atypical femur fracture should be considered pending evaluation of the patient based on an individual benefit-risk assessment. During denosumab treatment, patients should be advised to report new or unusual thigh, hip, or groin pain. Patients presenting with such symptoms should be evaluated for an incomplete femoral fracture.
Long-term antiresorptive treatment
Long-term antiresorptive treatment (including both denosumab and bisphosphonates) may contribute to an increased risk for adverse outcomes such as osteonecrosis of the jaw and atypical femur fractures due to significant suppression of bone remodelling (see section 4.2).
Concomitant treatment with other denosumab-containing medicinal products
Patients being treated with denosumab should not be treated concomitantly with other denosumab‑containing medicinal products (for prevention of skeletal related events in adults with bone metastases from solid tumours).
Hypercalcaemia in paediatric patients
Denosumab should not be used in paediatric patients (age < 18). Serious hypercalcaemia has been reported. Some clinical trial cases were complicated by acute renal injury.
Warnings for excipients
This medicinal product contains 47 mg sorbitol in each mL of solution. The additive effect of concomitantly administered products containing sorbitol (or fructose) and dietary intake of sorbitol (or fructose) should be taken into account.
This medicinal product contains less than 1 mmol sodium (23 mg) per 60 mg that is to say essentially 'sodium-free'.
This medicinal product contains 0.1 mg of polysorbate 20 in each syringe which is equivalent to 0.1 mg/mL. Polysorbates may cause allergic reactions.
In an interaction study, denosumab did not affect the pharmacokinetics of midazolam, which is metabolised by cytochrome P450 3A4 (CYP3A4). This indicates that denosumab should not alter the pharmacokinetics of medicinal products metabolised by CYP3A4.
There are no clinical data on the co-administration of denosumab and hormone replacement therapy (oestrogen), however the potential for a pharmacodynamic interaction is considered to be low.
In postmenopausal women with osteoporosis the pharmacokinetics and pharmacodynamics of denosumab were not altered by previous alendronate therapy, based on data from a transition study (alendronate to denosumab).
Pregnancy
There are no or limited amount of data from the use of denosumab in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3).
Denosumab is not recommended for use in pregnant women and women of child-bearing potential not using contraception. Women should be advised not to become pregnant during and for at least 5 months after treatment with denosumab. Any effects of denosumab are likely to be greater during the second and third trimesters of pregnancy since monoclonal antibodies are transported across the placenta in a linear fashion as pregnancy progresses, with the largest amount transferred during the third trimester.
Breast-feeding
It is unknown whether denosumab is excreted in human milk. In genetically engineered mice in which RANKL has been turned off by gene removal (a “knockout mouse”), studies suggest absence of RANKL (the target of denosumab see section 5.1) during pregnancy may interfere with maturation of the mammary gland leading to impaired lactation post-partum (see section 5.3). A decision on whether to abstain from breast-feeding or to abstain from therapy with denosumab should be made, taking into account the benefit of breast-feeding to the newborn/infant and the benefit of denosumab therapy to the woman.
Fertility
No data are available on the effect of denosumab on human fertility. Animal studies do not indicate direct or indirect harmful effects with respect to fertility (see section 5.3).
Denosumab has no or negligible influence on the ability to drive and use machines.
Summary of the safety profile
The most common side effects with denosumab (seen in more than one patient in ten) are musculoskeletal pain and pain in the extremity. Uncommon cases of cellulitis, rare cases of hypocalcaemia, hypersensitivity, osteonecrosis of the jaw and atypical femoral fractures (see sections 4.4 and 4.8 - description of selected adverse reactions) have been observed in patients taking denosumab.
Tabulated list of adverse reactions
The data in table 1 below describe adverse reactions reported from phase II and III clinical trials in patients with osteoporosis and breast or prostate cancer patients receiving hormone ablation; and/or spontaneous reporting.
The following convention has been used for the classification of the adverse reactions (see table 1): very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1 000 to < 1/100), rare (≥ 1/10 000 to < 1/1 000), very rare (< 1/10 000) and not known (cannot be estimated from the available data). Within each frequency grouping and system organ class, adverse reactions are presented in order of decreasing seriousness.
Table 1. Adverse reactions reported in patients with osteoporosis and breast or prostate cancer patients receiving hormone ablation
MedDRA system organ class
Frequency category
Adverse reactions
Infections and infestations
Common
Common
Uncommon
Uncommon
Uncommon
Urinary tract infection
Upper respiratory tract infection
Diverticulitis1
Cellulitis1
Ear infection
Immune system disorders
Rare
Rare
Drug hypersensitivity1
Anaphylactic reaction1
Metabolism and nutrition disorders
Rare
Hypocalcaemia1
Nervous system disorders
Common
Sciatica
Gastrointestinal disorders
Common
Common
Constipation
Abdominal discomfort
Skin and subcutaneous tissue disorders
Common
Common
Common
Uncommon
Very rare
Rash
Eczema
Alopecia
Lichenoid drug eruptions1
Hypersensitivity vasculitis
Musculoskeletal and connective tissue disorders
Very common
Very common
Rare
Rare
Not Known
Pain in extremity
Musculoskeletal pain1
Osteonecrosis of the jaw1
Atypical femoral fractures1
Osteonecrosis of the external auditory canal2
1 See section Description of selected adverse reactions.
2 See section 4.4.
In a pooled analysis of data from all phase II and phase III placebo-controlled studies, influenza-like illness was reported with a crude incidence rate of 1.2% for denosumab and 0.7% for placebo.
Although this imbalance was identified via a pooled analysis, it was not identified via a stratified analysis.
Description of selected adverse reactions
Hypocalcaemia
In two phase III placebo-controlled clinical trials in postmenopausal women with osteoporosis, approximately 0.05% (2 out of 4,050) of patients had declines of serum calcium levels (less than 1.88 mmol/L) following denosumab administration. Declines of serum calcium levels (less than 1.88 mmol/L) were not reported in either the two phase III placebo-controlled clinical trials in patients receiving hormone ablation or the phase III placebo-controlled clinical trial in men with osteoporosis.
In the post-marketing setting, rare cases of severe symptomatic hypocalcaemia resulting in hospitalisation, life-threatening events, and fatal cases have been reported, predominantly in patients at increased risk of hypocalcaemia receiving denosumab, with most cases occurring in the first weeks of initiating therapy. Examples of the clinical manifestations of severe symptomatic hypocalcaemia have included QT interval prolongation, tetany, seizures and altered mental status (see section 4.4). Symptoms of hypocalcaemia in denosumab clinical studies included paraesthesias or muscle stiffness, twitching, spasms and muscle cramps.
Skin infections
In phase III placebo-controlled clinical trials, the overall incidence of skin infections was similar in the placebo and the denosumab groups: in postmenopausal women with osteoporosis (placebo [1.2%, 50 out of 4,041] versus denosumab [1.5%, 59 out of 4,050]); in men with osteoporosis (placebo [0.8%, 1 out of 120] versus denosumab [0%, 0 out of 120]); in breast or prostate cancer patients receiving hormone ablation (placebo [1.7%, 14 out of 845] versus denosumab [1.4%, 12 out of 860]). Skin infections leading to hospitalisation were reported in 0.1% (3 out of 4,041) of postmenopausal women with osteoporosis receiving placebo versus 0.4% (16 out of 4,050) of women receiving denosumab. These cases were predominantly cellulitis. Skin infections reported as serious adverse reactions were similar in the placebo (0.6%, 5 out of 845) and the denosumab (0.6%, 5 out of 860) groups in the breast and prostate cancer studies.
Osteonecrosis of the jaw
ONJ has been reported rarely, in 16 patients, in clinical trials in osteoporosis and in breast or prostate cancer patients receiving hormone ablation including a total of 23,148 patients (see section 4.4). Thirteen of these ONJ cases occurred in postmenopausal women with osteoporosis during the phase III clinical trial extension following treatment with denosumab for up to 10 years. Incidence of ONJ was 0.04% at 3 years, 0.06% at 5 years and 0.44% at 10 years of denosumab treatment. The risk of ONJ increased with duration of exposure to denosumab.
The risk of ONJ has also been assessed in a retrospective cohort study among 76,192 postmenopausal women newly initiating treatment with denosumab. The incidence of ONJ was 0.32% (95% confidence interval [CI]: 0.26, 0.39) among patients using denosumab up to 3 years and 0.51% (95% CI: 0.39, 0.65) among patients using denosumab up to 5 years of follow-up.
Atypical fractures of the femur
In the osteoporosis clinical trial programme, atypical femoral fractures were reported rarely in patients treated with denosumab (see section 4.4).
Diverticulitis
In a single phase III placebo-controlled clinical trial in patients with prostate cancer receiving androgen deprivation therapy (ADT), an imbalance in diverticulitis adverse events was observed (1.2% denosumab, 0% placebo). The incidence of diverticulitis was comparable between treatment groups in postmenopausal women or men with osteoporosis and in women undergoing aromatase inhibitor therapy for non-metastatic breast cancer.
Drug-related hypersensitivity reactions
In the post-marketing setting, rare events of drug-related hypersensitivity, including rash, urticaria, facial swelling, erythema, and anaphylactic reactions have been reported in patients receiving denosumab.
Musculoskeletal pain
Musculoskeletal pain, including severe cases, has been reported in patients receiving denosumab in the post-marketing setting. In clinical trials, musculoskeletal pain was very common in both denosumab and placebo groups. Musculoskeletal pain leading to discontinuation of study treatment was uncommon.
Lichenoid drug eruptions
Lichenoid drug eruptions (e.g. lichen planus-like reactions) have been reported in patients in the post‑marketing setting.
Other special populations
Paediatric population
Denosumab should not be used in paediatric patients (age < 18). Serious hypercalcaemia has been reported (see section 5.1). Some clinical trial cases were complicated by acute renal injury.
Renal impairment
In clinical studies, patients with severe renal impairment (creatinine clearance < 30 mL/min) or receiving dialysis were at greater risk of developing hypocalcaemia in the absence of calcium supplementation. Adequate intake of calcium and vitamin D is important in patients with severe renal impairment or receiving dialysis (see section 4.4).
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
There is no experience with overdose in clinical studies. Denosumab has been administered in clinical studies using doses up to 180 mg every 4 weeks (cumulative doses up to 1,080 mg over 6 months), and no additional adverse reactions were observed.
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