What precautions should be taken when Xgeva (denosumab) is stopped?

[Music] what precautions should be taken when ex Teva or DiNozzo mob is stopped xt VII also called DiNozzo map is a rent lying and inhibitor that means the drug inhibits rank ligand that is a protein that activates osteoclast so what does a drug do it starves the osteoclast and the staff or still class cannot really do its activity and resort bone then you get you know some F or extrema and you get treatment for for instance one or two years and you stop the treatment the cells are hungry and they produce after they get a protein that stimulates the growth and the survivor they have an over activation of the activity that means you have an increased bone loss at the time you stop the DiNozzo map that means you have to get treated this bisphosphonates at the same time so that's very in convenient many doctors do not throw this so it's very important and you only know some that before you stop that you get a couple doses this bisphosphonates to stop the over activation of the osteoclasts it's very effective so it lowers the it lowers the effect of those osteoclasts or those bone-eating cells and they produce calcium and if you stop that in awesome up they they restart their program and they eat the bone again and produce those calcium and protocals or al kind of get the calcium out of the bowl into the blood so that's a so called rebound and it's helpful to have maybe one cycle of the bisphosphonates again to kind of counteract this this effect and usually it's not a big deal we can do that we know how to do that you just have to be aware and have to measure it we also recommend vitamin D and calcium because especially where I'm from in Buffalo we don't have too much Sun so a lot of us have a too low vitamin D level so vitamin D we can measure it but also vitamin D and calcium together with bisphosphonates or with the DiNozzo map help to recloser bone it's not proven but it's the theory is very strong that this is true myeloma bone disease experts at Massachusetts General discussed the use of X Jeeva they'll sometimes bridge and they'll stop the extreme give us a few doses of some ada to my knowledge there's almost no data currently in myeloma to really address this question effectively and were extrapolating in the osteoporosis literature and how it might be affecting myeloma we don't know the right thing and that may be the best way to do it oftentimes patients who get stopped on their xgv are Zometa are doing it for a reason sometimes they're done with therapy sometimes they've had a complication and both of those could affect your willingness to have a bridging therapy you don't want to have necessarily bridging therapy if you're stopping X Jeeva because of osteonecrosis of the jaw whereas you may be willing to do it if you're stopping it simply because you're ending therapy for myeloma [Music]