Pharmacy Guide

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Pharmacy Guide

Patient leaflets and SmPCs, drug interaction checker, official dosages and NHS pharmacy opening hours — all in one place.

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Stoboclo 60 mg/ml pre-filled syringe, Solution for injection

⚠ This medicine appears to have been discontinued

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.

Active substance: Denosumab
Source: electronic medicines compendium (emc)
Official leaflet: Read the PIL on emc

What it is and what it is used for

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.

What you need to know before you take it

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.

How to take it

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.

Possible side effects

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.

How to store it

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.

Contents of the pack and other information

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):

  • Carton containing pre-filled syringe Not included in the carton:
  • Alcohol swab
  • Cotton ball or gauze
  • Adhesive bandage
  • Sharps disposal container

Figure B 2. Check the expiration date on the carton (see Figure C).

  • Do not use it if the expiration date has passed. If the expiration date has passed, return the entire carton to the pharmacy.
  • The printed expiration date refers to the last day of the month.

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).

  • Do not hold by the head of the plunger rod, plunger rod, safety guard, wings, or needle cap.
  • Do not pull back on the plunger rod at any time.

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).

  • Do not use if the needle cap is missing or not securely attached.
  • Do not use if the expiration date has passed.
  • Do not shake the pre-filled syringe.

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).

  • Do not use the pre-filled syringe if the liquid is discoloured, cloudy, or has any visible particles or flakes in it.
  • You may see air bubbles in the liquid. This is normal.

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).

  • Do not warm the pre-filled syringe using heat sources such as hot water or a microwave.
  • If the syringe does not reach room temperature, this could cause the injection to feel uncomfortable.

Figure G

Preparing for the Injection

7. Choose an appropriate injection site (see Figure H). 7a. You may inject into:

  • the upper thighs.
  • the abdomen, except for the 5 cm around the belly button (navel).
  • the outer area of the upper arms (only if you are a caregiver or HCP).
  • Do not inject into moles, scars, bruises, or areas where the skin is tender, red, hard, or if there are cracks in the skin.
  • Do not inject through clothing. 7b. Choose a different injection site for each new injection at least 2.5 cm away from the area used for the last injection.

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.

  • Do not blow on or touch the injection site again before giving the injection.

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).

  • Do not hold the plunger rod while removing the cap.
  • You may notice a few drops of liquid at the tip of needle. This is normal. 10b. Dispose of the cap right away in a sharps disposal container (see Step 15 and Figure K).
  • Do not use the pre-filled syringe if it is dropped without the needle cap in place. If this happens, use a new pre-filled syringe.
  • Remove the needle cap only when you are ready to inject.
  • Do not re-cap the pre-filled syringe.
  • Do not touch the needle. Doing so may result in a needle stick injury. 11. Insert the pre-filled syringe into the injection site. 11a. Hold the body of the pre-filled syringe in one hand between the thumb and index finger. 11b. Use the other hand to gently pinch the cleaned skin between your thumb and index finger. Do not squeeze it tightly. Note: It is important to keep the skin pinched when inserting the needle to make sure that you inject under the skin (into the fatty area) but not any deeper (into muscle). 11c. With a quick and "dart-like" motion, insert the needle completely into the fold of skin at a 45-degree angle (see Figure L).
  • Do not pull back on the plunger rod at any time.

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).

  • Do not change the position of the pre-filled syringe after the injection has started.
  • If the plunger rod is not fully pressed, the safety guard will not extend to cover the needle when it is removed.

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).

  • If the needle is not covered, proceed to carefully dispose of the syringe (see Step 15. Dispose of Stoboclo).
  • Do not put the needle cap back on used pre-filled syringes.
  • Do not reuse the pre-filled syringe.
  • Do not rub the injection site.

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.

  • Keep the syringe and sharps disposal container out of the sight and reach of children.
  • If you do not have a sharps disposal container, you may use a household container that is closable and puncture resistant.
  • For the safety and health of you and others, needles and used syringes must never be re-used. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
  • 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 protect the environment.

Frequently asked questions about Stoboclo 60 mg/ml pre-filled syringe, Solution for injection

How do I take Stoboclo 60 mg/ml pre-filled syringe, Solution for injection?

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.

What is the active substance in Stoboclo 60 mg/ml pre-filled syringe, Solution for injection?

The active substance in Stoboclo 60 mg/ml pre-filled syringe, Solution for injection is denosumab.

Where does this information come from?

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.

Can I get Stoboclo 60 mg/ml pre-filled syringe, Solution for injection without a prescription?

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.

About this leaflet

The text above reproduces the patient information leaflet approved for this medicine, restructured for easier reading.

Medical disclaimer: This page is for information only and does not replace advice from your doctor or pharmacist. Always read the leaflet supplied with your medicine. If you are unwell, call NHS 111; in an emergency, call 999.

Medicines with the same active substance: Denosumab (22 medicines)
See every medicine containing this substance, or browse the full A–Z of active substances.
⚕For healthcare professionals — Summary of Product Characteristics (SmPC)Full SmPC: dosage, interactions, contraindications, warnings+
Technical information intended for healthcare professionals (doctors and pharmacists). The Summary of Product Characteristics (SmPC) is the official document approved by the MHRA/EMA. It does not replace the patient leaflet or a doctor’s advice.

4.1. Therapeutic indications

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).

4.2. Posology and method of administration

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.

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypocalcaemia (see section 4.4).

4.4. Special warnings and precautions for use

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.

4.5. Interaction with other medicinal products and other forms of interaction

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).

4.6. Fertility, pregnancy and lactation

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).

4.7. Effects on ability to drive and use machines

Denosumab has no or negligible influence on the ability to drive and use machines.

4.8. Undesirable effects

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.

4.9. Overdose

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.

🇷🇴 Known in Romania as

Medicines sold in Romania with the same active substance: Cunoscut în România ca

  • DENBRAYCE 120 mg prescriptionDENOSUMABUM · injection / infusion
  • ENWYLMA 120 mg prescriptionDENOSUMABUM · injection / infusion
  • JUBBONTI 60 mg prescriptionDENOSUMABUM · injection / infusion
  • JUBEREQ 120 mg prescriptionDENOSUMABUM · injection / infusion
  • JUNOD 60 mg prescriptionDENOSUMABUM · injection / infusion
  • KEFDENSIS 60 mg prescriptionDENOSUMABUM · injection / infusion

Same active substance. The strength, the form and whether you need a prescription can differ. Always ask a pharmacist before you switch. Romanian medicines in the UK →

🇵🇱 Known in Poland as

Medicines sold in Poland with the same active substance: W Polsce znany jako

  • ProliaDenosumabum · injection / infusion
  • XgevaDenosumabum · injection / infusion
  • JubbontiDenosumabum · injection / infusion
  • WyostDenosumabum · injection / infusion
  • XbrykDenosumabum · injection / infusion
  • ObodenceDenosumabum · injection / infusion

Same active substance. The strength, the form and whether you need a prescription can differ. Always ask a pharmacist before you switch. Polish medicines in the UK →

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