Severe hypocalcemia after denosumab
treatment leading to refractory ventricular
tachycardia and veno‐arterial extracorporeal
membrane oxygenation support: a case report

Severe hypocalcemia after denosumab
treatment leading to refractory ventricular
tachycardia and veno‐arterial extracorporeal
membrane oxygenation support: a case report

Hypocalcemia, Ventricular tachycardia, Denosumab, Veno-arterial extracorporeal membrane oxygenation,
Intra-aortic balloon pump

Background Severe hypocalcemia may lead to life-threatening arrhythmias. Denosumab is an effective treat‐
ment for osteoporosis that allows long intervals between doses. However, there is a risk of hypocalcemia in some
patients. Due to the long half-life of denosumab, emergency physicians caring for patients presenting with symptoms
of hypocalcemia may not be aware of the medication, and adverse effects may last longer.
Case presentation A 55-year-old woman with a history of systemic lupus erythematosus (SLE) and anxiety disorder
called for an ambulance for symptoms of hyperventilation and muscle cramps. After evaluation at the local hospi‐
tal, she developed pulseless ventricular tachycardia and was resuscitated by defibrillation by the hospital staff. After
conversion to sinus rhythm, she was transported to a tertiary center. Upon arrival, pulseless ventricular tachycardia
occurred again, and veno-arterial extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping
(IABP) were implemented. Laboratory results showed severe hypocalcemia (corrected calcium level of 5.3 mg/dL)
whereupon intravenous calcium supplementation was started. She had received the first dose of denosumab (60 mg)
by subcutaneous injection 24 days prior to hospitalization. She was eventually weaned from ECMO and IABP support.
Conclusion Cardiac arrest due to hypocalcemia is relatively rare but can be fatal. In the present case, hyperventila‐
tion may have acutely exacerbated pre-existing hypocalcemia, leading to ventricular tachycardia. The patient had
a slightly decreased serum calcium level prior to denosumab. Close monitoring may be preferable after the primary
dose of denosumab in selected patients. Emergency physicians caring for patients who may be suffering from symp‐
toms/signs of hypocalcemia must be mindful of medications that have long half-lives and affect electrolyte balance
when treating fatal arrhythmia due to hypocalcemia.

Fumito Okuno1

, Asami Ito‐Masui1*, Atsuya Hane1

, Keiko Maeyama2

, Kaoru Ikejiri1

, Ken Ishikura1
,

Masashi Yanagisawa3

, Kaoru Dohi3 and Kei Suzuki1

https://doi.org/10.1186/s12245-023-00529-6

2023

Peri Irawan

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