Prolia
denosumab
Species
Monkey
Longest study
52 wk
Genotox
Not conducted Not conducted
Carcinogenicity
Not conducted Not conducted
Repro
Conducted Conducted
First dose
Not conducted Not stated publicly
Speciesopen answer page →
Species
Cynomolgus monkey only
“Since denosumab recognizes and neutralizes RANKL in non human primates, the cynomolgus monkey was identified as a relevant species and the main studies have been conducted in ovariectomized animals.”
Why that species
Binds and neutralizes human and monkey RANKL (binding epitope fully conserved); does not recognize rodent RANKL
“This absence is acceptably justified by the fact that the RANKL domain to which denosumab binds is entirely conserved between cynomolgus monkeys and humans.”
Surrogate molecule
Yes: huRANKL knock-in mice and OPG-Fc surrogate in rodents, used for pharmacology, fracture healing and neonatal bone/tooth studies
“Several studies have been conducted with a transgenic huRANKL knock-in mouse model expressing chimeric RANKL that can be recognized and neutralized by denosumab.”
Species: general tox
Cynomolgus monkey only
“In the 1 month repeat dose toxicity study (101447) in young adult Cynomolgus monkeys, as the only potentially drug-related change of statistically significant elevated thyroid weights were noted in females of the high dose group that were not confirmed by histopathological findings.”
Species: DART
Cynomolgus monkey; RANKL knockout mice for prenatal development
“The effects of denosumab on prenatal development have been studied in both cynomolgus monkeys and genetically engineered mice in which RANK ligand (RANKL) expression was turned off by gene removal (a "knockout mouse").”
Species: carcinogenicity
Not conducted, per regulatory guidance
“No carcinogenicity studies were conducted in accordance with available regulatory guidance.”
Surrogate used in
Yes: OPG-Fc (RANKL inhibitor) and RANK/RANKL knockout mice for rodent pharmacodynamics, as denosumab is primate-specific
“Because the biological activity of denosumab in animals is specific to nonhuman primates, evaluation of genetically engineered ("knockout") mice or use of other biological inhibitors of the RANK/RANKL pathway, namely OPG-Fc, provided additional information on the pharmacodynamic properties of denosumab.”
Study lengthopen answer page →
Longest pivotal study
52 weeks
“In 6/12-Month Repeated-dose Study in Monkeys (102090) denosumab was administrated at doses of 0, 1, 10, and 50 mg/kg.”
Pivotal GLP studies
Cynomolgus monkey 1-month and 6/12-month SC studies, once monthly at 0, 1, 10, 50 mg/kg
“SC injection, 0, 1, 10 and 50 mg/kg once/month for 6 or 12 months)”
Route in tox
Subcutaneous (once monthly)
“SC injection, 0, 1, 10 and 50 mg/kg once/month for 6 or 12 months)”
Skipped studiesopen answer page →
Genotoxicity
Not conducted; not necessary for a recombinant protein
“No studies were conducted. Denosumab is a recombinant protein and contains no inorganic or synthetic organic linkages or other non-protein portions.”
Carcinogenicity
Not conducted per regulatory guidance; no preneoplastic lesions in OVX monkeys treated up to 16 months
“No carcinogenicity studies were conducted in accordance with available regulatory guidance. Ovariectomized monkey treated for up to 16 months with denosumab showed no evidence of pre neoplastic lesions.”
Reproductive & developmental
Monkey PPND (50 mg/kg throughout pregnancy): fetal loss, stillbirths, postnatal mortality, absent lymph nodes, abnormal bone growth; fertility unaffected
“In utero denosumab exposure from cynomolgus monkeys dosed monthly with denosumab throughout pregnancy at a dose 50-fold higher than the recommended human dose based on body weight resulted in increased fetal loss, stillbirths, and postnatal mortality, and absent lymph nodes, abnormal bone growth, and decreased neonatal growth”
Safety pharmacology
Single-dose monkey CV/respiratory study plus ECG within repeat-dose study; no ECG evidence of cardiotoxicity after 53 weeks
“There was no ECG evidence of cardiotoxicity after 53 weeks of treatment with denosumab.”
Genotox: Ames
Not conducted (ICH S6)
“No studies were conducted. Denosumab is a recombinant protein and contains no inorganic or synthetic organic linkages or other non-protein portions.”
Genotox: in vitro mammalian
Not conducted (ICH S6)
“No studies were conducted. Denosumab is a recombinant protein and contains no inorganic or synthetic organic linkages or other non-protein portions.”
Genotox: in vivo
Not conducted (ICH S6)
“No studies were conducted. Denosumab is a recombinant protein and contains no inorganic or synthetic organic linkages or other non-protein portions.”
Carcinogenicity model
Not conducted; no preneoplastic lesions in ovariectomized monkeys treated up to 16 months
“No carcinogenicity studies were conducted in accordance with available regulatory guidance. Ovariectomized monkey treated for up to 16 months with denosumab showed no evidence of pre neoplastic lesions.”
Carcinogenicity timing
Not required: absence of carcinogenicity studies justified
“The absence of genotoxicity and carcinogenicity studies was sufficiently justified.”
hERG / QT
No ECG evidence of cardiotoxicity in monkeys after 53 weeks
“There was no ECG evidence of cardiotoxicity after 53 weeks of treatment with denosumab.”
First doseopen answer page →
First-in-human starting dose
Not stated in public reviews
Why it's blank
The public FDA and EMA reviews of Prolia don't say how the first human dose was chosen. That rationale is in the IND, which is confidential, so it is missing for most approved products.
How it's usually set for monoclonal antibodies
Use pharmacology data (target binding, receptor occupancy, in vitro human cells, PK/PD modelling) to estimate the lowest dose expected to have any biological effect (MABEL) and the active dose (PAD), and, for healthy volunteers, start at an exposure below the PAD unless robustly justified.
“these data should be used to determine the minimal anticipated biological effect level (MABEL) in humans and an estimation of the pharmacologically active dose (PAD) and/or anticipated therapeutic dose range (ATD) in humans.”
This product's starting point
NOAEL / key findings: No target organ toxicity at doses up to 50 mg/kg in 6/12-month monkey study (EMA assessment report, p. 16)
NOAEL / key findings
No target organ toxicity at doses up to 50 mg/kg in 6/12-month monkey study
“In 6/12-Month Repeated-dose Study in Monkeys (102090) denosumab was administrated at doses of 0, 1, 10, and 50 mg/kg. Overall, no effects on organ weights or macroscopic or microscopic evidence of target organ toxicity were noted.”
Risksopen answer page →
Immune & cytokine safety
Highly immunogenic in monkeys (ADA in most studies); no major immunomodulatory changes; no dedicated immunotoxicity studies
“Studies on immunomodulatory effects were incorporated in some pharmacology and toxicology studies in cynomolgus monkeys. These studies did not reveal any major differences compared to controls.”
Biodistribution & persistence
Wide distribution in monkey without bone sequestration; limited BBB, testis and placental crossing
“There were indications that denosumab has limited potential to cross the blood/brain barrier, the blood/testis barrier as well as the placental barrier, although this data is confounded by the presence of radiolabel in blood vessels and an unknown contribution of free radiolabel.”
Modality-specific risk
RANKL inhibition: hypocalcemia, impaired bone growth/tooth eruption, lymph node agenesis, impaired lactation, embryo-fetal harm
“RANK/RANKL knockout mice also exhibited absence of lymph node formation, as well as an absence of lactation due to inhibition of mammary gland maturation (lobulo-alveolar gland development during pregnancy)”
Anti-drug antibodies: animals
High ADA incidence in monkeys; antibodies markedly increased denosumab elimination, confounding high-dose PK
“In general, the high percentage of animals developing anti-drug-antibodies impacted the PK analysis. Especially at the high dose range, the PK data need to be interpreted with caution. The formation of these antibodies appeared to markedly increase the rate of elimination of denosumab.”
Anti-drug antibodies: patients
<1% (55/8113) binding antibodies over up to 5 years; no neutralizing antibodies
“Using an electrochemiluminescent bridging immunoassay, less than 1% (55 out of 8113) of patients treated with Prolia for up to 5 years tested positive for binding antibodies (including pre-existing, transient, and developing antibodies). None of the patients tested positive for neutralizing antibodies, as was assessed using a chemiluminescent cell-based in vitro biological assay.”
Label warnings
Boxed warning: Severe hypocalcemia in patients with advanced kidney disease
- Severe Hypocalcemia and Mineral Metabolism Changes
- Drug Products with Same Active Ingredient
- Hypersensitivity
- Osteonecrosis of the Jaw
- Atypical Subtrochanteric and Diaphyseal Femoral Fractures
- Multiple Vertebral Fractures (MVF) Following Discontinuation of Prolia Treatment
- Serious Infections
- Dermatologic Adverse Reactions
- Musculoskeletal Pain
- Suppression of Bone Turnover
- Hypercalcemia in Pediatric Patients with Osteogenesis Imperfecta
NephrotoxicityMetabolic & endocrineHypersensitivity & infusion reactionsMusculoskeletalInfectionsSkin reactions
US prescribing information, Boxed Warning and Warnings and PrecautionsDailyMed ↗
Tox packageopen answer page →
Before first-in-human
First-in-human: where
Not stated in public reviews
Not reported in the public reviews. Reviewers summarise selectively, so this usually means it wasn't discussed publicly, not that it wasn't studied.
Repeat-dose tox before first-in-human
Not stated in public reviews
Not reported in the public reviews. Reviewers summarise selectively, so this usually means it wasn't discussed publicly, not that it wasn't studied.
First-in-human starting dose
Not stated in public reviews
Why it's blank
The public FDA and EMA reviews of Prolia don't say how the first human dose was chosen. That rationale is in the IND, which is confidential, so it is missing for most approved products.
How it's usually set for monoclonal antibodies
Use pharmacology data (target binding, receptor occupancy, in vitro human cells, PK/PD modelling) to estimate the lowest dose expected to have any biological effect (MABEL) and the active dose (PAD), and, for healthy volunteers, start at an exposure below the PAD unless robustly justified.
“these data should be used to determine the minimal anticipated biological effect level (MABEL) in humans and an estimation of the pharmacologically active dose (PAD) and/or anticipated therapeutic dose range (ATD) in humans.”
This product's starting point
NOAEL / key findings: No target organ toxicity at doses up to 50 mg/kg in 6/12-month monkey study (EMA assessment report, p. 16)
Longest repeat-dose systemic studies
Longest repeat-dose study and recovery
Cynomolgus monkey SC study (study 102090), 53 weeks of dosing, with 3-month recovery
“(n=3/group, 3 months recovery n=2/group, There was no ECG evidence of cardiotoxicity after 53 weeks of treatment with denosumab. Isolated cases of slight bradycardia, fused P-T wave or slight tachycardia were observed in 102090”
Pivotal GLP studies
Cynomolgus monkey 1-month and 6/12-month SC studies, once monthly at 0, 1, 10, 50 mg/kg
“SC injection, 0, 1, 10 and 50 mg/kg once/month for 6 or 12 months)”
DART package
Species: DART
Cynomolgus monkey; RANKL knockout mice for prenatal development
“The effects of denosumab on prenatal development have been studied in both cynomolgus monkeys and genetically engineered mice in which RANK ligand (RANKL) expression was turned off by gene removal (a "knockout mouse").”
Reproductive & developmental
Monkey PPND (50 mg/kg throughout pregnancy): fetal loss, stillbirths, postnatal mortality, absent lymph nodes, abnormal bone growth; fertility unaffected
“In utero denosumab exposure from cynomolgus monkeys dosed monthly with denosumab throughout pregnancy at a dose 50-fold higher than the recommended human dose based on body weight resulted in increased fetal loss, stillbirths, and postnatal mortality, and absent lymph nodes, abnormal bone growth, and decreased neonatal growth”
PPND / ePPND: when
Not stated in public reviews
Not reported in the public reviews. Reviewers summarise selectively, so this usually means it wasn't discussed publicly, not that it wasn't studied.
Carcinogenicity
Species: carcinogenicity
Not conducted, per regulatory guidance
“No carcinogenicity studies were conducted in accordance with available regulatory guidance.”
Carcinogenicity model
Not conducted; no preneoplastic lesions in ovariectomized monkeys treated up to 16 months
“No carcinogenicity studies were conducted in accordance with available regulatory guidance. Ovariectomized monkey treated for up to 16 months with denosumab showed no evidence of pre neoplastic lesions.”
Carcinogenicity timing
Not required: absence of carcinogenicity studies justified
“The absence of genotoxicity and carcinogenicity studies was sufficiently justified.”
Safety marginopen answer page →
Safety margin at NOAEL
No effect on fertility or male reproductive organs in monkeys at 13- to 50-fold the 60 mg human dose (mg/kg)
“Denosumab had no effect on female fertility or male reproductive organs in monkeys at doses that were 13- to 50-fold higher than the recommended human dose of 60 mg subcutaneously administered once every 6 months, based on body weight (mg/kg).”
NOAEL / key findings
No target organ toxicity at doses up to 50 mg/kg in 6/12-month monkey study
“In 6/12-Month Repeated-dose Study in Monkeys (102090) denosumab was administrated at doses of 0, 1, 10, and 50 mg/kg. Overall, no effects on organ weights or macroscopic or microscopic evidence of target organ toxicity were noted.”
Efficacy evidenceopen answer page →
Efficacy evidence
Ovariectomized cynomolgus monkey model of postmenopausal osteoporosis
“The disease model in ovariectomized cynomolgus monkeys is considered a relevant model for the indication of postmenopausal osteoporosis.”
Why that model
Denosumab does not recognize rodent RANKL; huRANKL knock-in mice expressing chimeric RANKL used for rodent studies
“Denosumab is a fully human IgG2 mAb and does not recognize rodent RANKL. Several studies have been conducted with a transgenic huRANKL knock-in mouse model expressing chimeric RANKL that can be recognized and neutralized by denosumab.”
Reviewer's view of the efficacy data
EMA: preclinical studies characterized pharmacology and demonstrated activity in vitro and in vivo
“Overall the preclinical studies characterized the pharmacological, pharmacodynamic and toxicological properties of denosumab and demonstrated its activity in vitro and in vivo.”
Flexibilityopen answer page →
Flexibility accepted
CarcinogenicityCriticised but accepted
No carcinogenicity studies; ovariectomized monkeys treated up to 16 months without preneoplastic lesions
Why: Regulatory guidance; no preneoplastic lesions in monkeys, though RANKL/OPG pathway dysregulation could matter for tumour development · Within the guideline · Weight of evidence
“No carcinogenicity studies were conducted in accordance with available regulatory guidance. Ovariectomized monkey treated for up to 16 months with denosumab showed no evidence of pre neoplastic lesions.”
“The absence of genotoxicity and carcinogenicity studies was sufficiently justified. However, the multiple signalling pathways involved in OPG effects and recent literature indicating a role of OPG and RANKL in angiogenesis and endothelial cell function suggest a potential for dysregulation of functions critical in e.g. tumour devlopment.”
OtherQuestioned
No dedicated immunotoxicity studies; immune effects inferred from monkey studies and OPG-Fc/OPG-transgenic rodent literature
Why: Literature indicates RANKL has no significant role in functional immune responses of adults with an intact immune system
“The relevance of using these models instead of denosumab in studies on immunomodulatory effects is uncertain and considering the mechanism of action of denosumab, potential effects on immunomodulation and immunosuppression cannot be ruled out.”
“No specific studies on potential for immunotoxicity have been conducted and it is referred to literature data that RANKL has no significant role in the functional responses of an adult animal with an intact immune system while RANKL has a role in the developing immune system”
Safety pharmacologyCriticised but acceptedBeyond the letter
Respiratory function assessed only by clinical observation within monkey studies
Why: No indication of an effect on respiratory function · Weight of evidence
“According to the guideline, clinical observation of animals is generally not adequate to assess respiratory function. However, since no indication of denosumab to affect respiratory function were noted, the current study is considered sufficient.”
DARTVerdict not stated
Monkey embryofetal study covered only the first trimester and did not examine fetal lymph nodes
“However, this study only assessed fetal toxicity during the first trimester, and fetal lymph nodes were not examined.”
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