Conditions: Bone Density Bone Loss Anorexia Nervosa Eating Disorder Atypical Anorexia Nervosa
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 30
Healthy volunteers: no

Brief summary:
This protocol is a randomized, double-blind, placebo-controlled clinical trial which aims to investigate the effect of denosumab on BMD in women with anorexia nervosa. The investigators hypothesize that 12 months of denosumab administration will result in an increase in bone mineral density, decrease in markers of bone resorption and improvement in bone microarchitecture in osteopenic women with anorexia nervosa compared with placebo.

An optional extension study will offer subjects 12-month administration of open-label alendronate (an oral bisphosphonate) after the initial 12 month administration of denosumab or placebo. We hypothesize that 12 months of denosumab followed by 12 months of open-label alendronate will result in a greater increase in BMD compared to 12 months of placebo followed by 12 months of open-label alendronate. Within the group of women who receive sequential therapy with 12 months of denosumab followed by 12 months of alendronate, we hypothesize that BMD will be maintained between 12 and 24 months while on alendronate.

Detailed description:

Arms:
arm 1: Denosumab 60mg injection at baseline study visit and 6 month study visit. Alendronate 70mg PO weekly starting at Month 12 through 24 months. arm 2: Placebo injection at baseline study visit and 6 month study visit. Alendronate 70mg PO weekly starting at Month 12 through 24 months.

Interventions: intervention 1: Denosumab 60 MG [Prolia] intervention 2: Placebo Injection intervention 3: Alendronate 70Mg Tab
Intervention descriptions: intervention 1: Denosumab 60mg injection at baseline and 6 months intervention 2: Placebo Injection at baseline and 6 months intervention 3: Alendronate 70mg PO weekly starting at Month 12 through 24 months.

Protocol document:
Prot_000.pdf: 
Effects of Denosumab on Bone Mineral Density, Markers of Bone Metabolism and Bone 
Microarchitecture in Women with Anorexia Nervosa: A Pilot Study 
NCT # 03292146 
Version Date: March 2, 2021 


PARTNERS HUMAN RESEARCH COMMITTEE 
PROTOCOL SUMMARY 
Partners Human Subjects Research Application Form  
 
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
1 
 
Answer all questions accurately and completely in order to provide the PHRC with the relevant 
information to assess the risk-benefit ratio for the study.  Do not leave sections blank. 
 
PRINCIPAL/OVERALL INVESTIGATOR 
Karen Klahr Miller, MD 
 
PROTOCOL TITLE 
Effects of Denosumab on Bone Mineral Density, Markers of Bone Metabolism 
and Bone Microarchitecture in Women with Anorexia Nervosa: A Pilot Study 
 
FUNDING 
Departmental Funds 
 
VERSION DATE 
03.02.2021 
 
SPECIFIC AIMS 
Concisely state the objectives of the study and the hypothesis being tested. 
 
This protocol is a randomized, double-blind, placebo-controlled clinical trial which aims to 
investigate the effect of denosumab on bone mineral density (BMD) in women with anorexia 
nervosa. We will also investigate the safety of denosumab in women with anorexia nervosa. We 
hypothesize that 12 months of denosomab administration will result in an increase in bone 
mineral density, decrease in markers of bone resorption and improvement in bone 
microarchitecture in osteopenic women with anorexia nervosa compared with placebo. 
 
Specific Aim 1: We hypothesize that 12 months of denosomab administration will result in an 
increase in bone mineral density in women with anorexia nervosa with low bone mass or 
osteoporosis compared with placebo. 
 
We will investigate in women with anorexia nervosa in a 12 month study whether treatment with 
denosumab will increase BMD as measured by dual energy xray absorptiometry (DXA) 
compared with placebo. The primary endpoint will be lumbar spine BMD at 12 months. Bone 
density will be measured at baseline, 6 months, and 12 months. 
 
Specific Aim 2: We hypothesize that 12 months of denosomab administration will result in a 
significant reduction of markers of bone resorption in osteopenic women with anorexia nervosa 
compared with placebo. 
 
We will investigate in women with anorexia nervosa in a 12 month study whether markers of 
bone metabolism, including CTx, will decrease in the denosumab group more than in the placebo 
group. Markers of bone metabolism will be measured at baseline, 1 month, 3 months, 6 months, 
7 months, 9 months, and 12 months.   
 


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Specific Aim 3: In this exploratory aim, we hypothesize that 12 months of denosomab 
administration will result in improved bone microarchitecture and strength in osteopenic women 
with anorexia nervosa compared with placebo. 
 
We will investigate in women with anorexia nervosa in a 12 month study whether treatment with 
denosumab will improve parameters of bone microarchitecture, as assessed by HR-pQCT, and 
improve bone strength, as estimated by microfinite element analysis compared with placebo. 
HRpQCT of the tibia and radius will be performed and the following will be measured: 
trabecular thickness and spacing; cortical thickness and porosity; ITS (individual trabecula 
segmentation); finite element analysis modeling of bone strength. HRpQCT will be measured at 
baseline, 6 months, and 12 months. 
 
Alendronate Extension Study Specific Aims: 
 
Specific Aim 1: Sequential therapy with denosumab followed by a bisphosphonate will increase 
bone mineral density and decrease bone resorption in women with AN. 
 
We hypothesize that 12 months of denosumab followed by 12 months of open-label alendronate 
will result in a greater increase in BMD compared to 12 months of placebo followed by 12 
months of open-label alendronate. 
 
Specific Aim 2: We hypothesize that within the group of women who receive sequential therapy 
with 12 months of denosumab followed by 12 months of alendronate, BMD will be maintained 
between 12 and 24  months while on alendronate.  
 
We will investigate in a 12-month extension study whether 12 months of open-label treatment 
with alendronate will maintain the hypothesized gains in BMD achieved after 12 months of 
denosumab administration.  
 
Specific Aim 3: We hypothesize that within the group of women who receive sequential therapy 
with 12 months of denosumab followed by 12 months of alendronate, bone microarchitecture 
and strength will be maintained between 12 and 24 months while on alendronate.  
 
We will investigate in a 12-month extension study whether 12 months of open-label treatment 
with alendronate will maintain the hypothesized gains in bone microarchitecture, as assessed by 
HR-pQCT, and bone strength, as estimated by microfinite element analysis, achieved after 12 
months of denosumab administration.  
 
 
BACKGROUND AND SIGNIFICANCE 
Provide a brief paragraph summarizing prior experience important for understanding the 
proposed study and procedures. 
 
Anorexia nervosa (AN) is a serious disease leading to severe bone loss at multiple skeletal sites. 
The illness affects 1-2% of young women in the U.S. and is chronic in more than 50% of 
affected women. Bone loss is a severe, frequent and often permanent comorbid medical 
complication resulting in debilitating vertebral crush fractures. The majority of women with 
anorexia nervosa have bone loss, and 50% have bone density measurements greater than 2 


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standard deviations below normative means. It is not uncommon for bone mass in these young 
women to be comparable to postmenopausal women in their 7th and 8th decades.  
 
Although bone density increases with weight recovery, osteopenia is often a permanent 
consequence of anorexia nervosa. Significant persistent osteopenia in women with anorexia 
nervosa has been shown in many studies and both cortical and trabecular bone mineral density 
(BMD) remain low more than ten years after recovery. Because bone mass remains persistently 
low despite recovery, such women remain at a high fracture risk throughout life, estimated to be 
7.1 times that of healthy women in this age range. These data suggest that there may be a 
therapeutic window during which effective treatment should be implemented to prevent 
significant, lifelong bone mass reduction in this vulnerable population. 
 
Adulthood in anorexia nervosa is characterized by a negative balance in bone metabolism, with 
increased bone resorption and decreased bone formation. This is in contrast to adolescence, 
which is characterized by a low turnover state – both low bone resorption and formation. A 
number of therapies targeting the high resorptive state in women with anorexia nervosa have 
been studied in women with anorexia nervosa, primarily by our group. We have shown that 
neither low-dose estrogen at postmenopausal hormone replacement doses or oral contraceptives 
are effective in women with anorexia nervosa, and bisphosphonates increase bone density 
significantly but not to normal. Therefore, there is a rationale for antiresorptive therapy in 
women with anorexia nervosa and data supporting its effectiveness, but a more potent 
antiresorptive therapy is needed. In addition, as anorexia nervosa is a psychologic illness and 
such patients are often overwhelmed by the requirements of therapy and the illness itself, a 
treatment such as denosumab which is administered every 6 months would likely have the 
benefit of increased compliance and therefore efficacy.  
 
There are no therapies that normalize BMD or that are FDA-approved for bone loss in anorexia 
nervosa, and in contrast to postmenopausal osteoporosis in which therapy may be life-long, the 
goal in patients with anorexia nervosa is treatment during the acute illness to reduce further bone 
loss and fracture risk. We propose that an early relatively short-term intervention with a potent 
antiresorptive therapy such as denosumab during the period of rapid bone loss may prevent 
significant osteopenia and reduce fracture risk in women with anorexia nervosa.  
 
We therefore propose a pilot study to determine whether denosumab increases bone density in 
women with anorexia nervosa. The data generated by this study will provide preliminary data for 
an application to the NIH for a definitive study to determine whether denosomab is an effective 
therapy for the treatment of bone loss in women with anorexia nervosa.   
 
Although bone loss in women with anorexia nervosa is severe and may persist after weight 
normalization, strategies to effectively maximize BMD are lacking. In this proposal, the 
hypothesis that denosumab administration will improve BMD, bone microarchitecture 
parameters and bone strength in young women with anorexia nervosa will be tested.  
 
Alendronate Extension Study: 
 
Our recent data provide strong evidence supporting the effectiveness of a bisphosphonate to 
decrease bone resorption and increase BMD in young women with AN. We hypothesize that 
bisphosphonates, because of their potent anti-resorptive effects, will consolidate the effects of 
denosumab to increase BMD in AN. We propose that maximal effectiveness to increase bone 


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mass in AN will be achieved with sequential therapy with 12 months of denosumab followed by 
12 months of alendronate 70 mg once weekly. All extension study participants will continue the 
standard calcium and Vitamin D supplementation for the full 12-month study duration. We 
propose that this therapy may be effective in reversing bone loss and increasing BMD during a 
time of active disease. 
 
 
RESEARCH DESIGN AND METHODS 
Briefly describe study design and anticipated enrollment, i.e., number of subjects to be enrolled 
by researchers study-wide and by Partners researchers.  Provide a brief summary of the 
eligibility criteria (for example, age range, gender, medical condition).  Include any local site 
restrictions, for example, “Enrollment at Partners will be limited to adults although the sponsor’s 
protocol is open to both children and adults.”
 
Subjects: Approximately 75 women will be screened for eligibility in order to identify 30 
eligible women with anorexia nervosa, ages 20 to 60, to enroll in the study. Subjects will be 
randomized in a double-blind fashion to one of 2 groups for 12 months: 1) Denosumab 60mg at 
baseline and 6 months or 2) identical placebo injection to determine effects on BMD, markers of 
bone metabolism, bone microarchitecture, and bone strength at trabecular and cortical sites. All 
subjects will meet the DSM-V criteria for AN or atypical anorexia and will be assessed for study 
suitability and monitored throughout the study period for their overall psychiatric clinical state in 
coordination with the patients’ clinical care team by a study psychologist or psychiatric nurse 
practitioner. 
 
Subject eligibility for the extension study will be based on participation in the main study. 
Subjects will be given a 6-month supply of alendronate to take home with them at the Month-12 
study visit and again at the Month-18 study visit. For subjects who do not live locally or are 
completing the visit remotely, a 6-month supply of alendronate will be mailed to the subject at 
the Month 12 and Month 18 study visits. Additionally, subjects will receive medication 
counseling from a study MD/NP upon initiation of alendronate therapy and will receive the FDA 
approved alendronate patient medication guide. Treatment compliance with alendronate therapy 
will be assessed at each study visit by a study MD/NP asking subjects how many tablets have 
been missed and documenting this on the case report form. 
 
Subjects who were previously enrolled and completed the study when it was a 6-month study of 
Denosumab or placebo will now have the opportunity to complete months 6 through 12 of the 
study. For subjects who were participating in the open-label alendronate extension study after 
completing the 6-month study, they will stop taking the alendronate, complete months 6 through 
12 of the main study, and then have the opportunity to take 12 months of open-label alendronate 
70 mg once weekly after completing months 6 through 12 of the main study. 
 
Inclusion/Exclusion Criteria:  
 
Inclusion Criteria: 
• Female 
• Age 20-60 years, skeletally mature with closed epiphyses 
• Anorexia nervosa or atypical anorexia nervosa defined by DSM-V diagnostic criteria 
• BMD T-score < -1.0  


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• Normal serum 25-OH vitamin D (>30 ng/mL) and calcium levels 
• For women of reproductive age, agree to use an effective contraceptive method. Highly 
effective methods of birth control include:  
o Combined (estrogen and progestogen) hormonal methods (pills, vaginal ring, or 
skin patch) 
o Intrauterine device (IUD) 
o Intraduterine hormonal-releasing system (IUS) 
o Surgery to tie both fallopian tubes (bilateral tubal ligation/occlusion) 
o Your male partner has had a vasectomy and testing shows there is no sperm in the 
semen 
• Dental check up within the past year 
 
Exclusion Criteria: 
• Any disease known to affect bone, including untreated thyroid dysfunction, Cushing’s or 
renal failure 
• Any medication known to affect bone metabolism within 3 months of the study, 
excluding oral contraceptives or other forms of estrogen administration. Bisphosphonates 
must have been discontinued for at least one year before participation 
• Immunodeficiency or taking immunosuppressive therapy 
• Serum potassium <3.0 meq/L 
• Serum ALT >3 times upper limit of normal 
• eGFR of less than 30 ml/min 
• Hypocalcemia   
• Diabetes mellitus 
• Active substance abuse, including alcohol 
• History of malignancy 
• Paget disease of bone 
• Osteomalacia 
• Osteonecrosis of the jaw (ONJ) or risk factor for ONJ, such as invasive dental procedures 
(eg, tooth extraction, dental implants, oral surgery in the past 6 months), poor oral 
hygiene, periodontal and/or pre-existing dental disease, and current use of corticosteroids. 
• Planned invasive dental procedure over the next 24 months.  
• Known senstivity to any of the products or components to be administered during dosing 
or known sensitivity to mammalian cell derived drug products 
• Sensitivity to calcium or vitamin D supplements 
• Pregnant, planning to become pregnant with 7 months after the end of treatment and/or 
breastfeeding 
 
Alendronate Extension Exclusion Criteria: 
 
Exclusion Criteria: 
• Subjects with a known esophageal disease  
• Abnormalities of the esophagus such as stricture or achalasia 
• Inability to sit/stand upright for at least 30 minutes 
• Hypersensitivity to any component of alendronate 
 


Partners Human Subjects Research Application Form 
  
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
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Briefly describe study procedures.  Include any local site restrictions, for example, “Subjects 
enrolled at Partners will not participate in the pharmacokinetic portion of the study.”  Describe 
study endpoints.
 
Screening Visit: A “Screening Visit” will be conducted by a member of the study clinical team 
to determine eligibility for the protocol. All subjects will be seen at Massachusetts General 
Hospital (MGH) for an outpatient visit including the following: A complete medical history, 
physical examination and urine pregnancy test. History taking will include complete eating 
disorder, weight, menstrual, and medication histories. In addition, the following will be 
performed: 
 
1. Blood draw for comprehensive metabolic panel, cbc, and 25 OH Vitamin D    
2. Nutritional evaluation, including weight in a gown, height, frame size, calculation of percent 
IBW and body mass index (BMI) 
3. DXA scan of the spine, hip, radius, and total body is required if the subject has not had a 
DXA scan within 6 months prior to the screening visit and optional if she has 
4. Determination of anorexia nervosa diagnosis and subtype (restricting or binge/purge) using 
DSM-V criteria   
5. Verification of the anorexia nervosa diagnosis  
6. Verification of lack of severe comorbid concerns (i.e. suicidality, substance use) that would 
preclude safe study participation will occur by the study psychologist or psychiatric nurse 
practitioner. Suicidality is assessed through a verbal conversation with a psychiatric health 
professional. If the subject has been suicidal in the past, the psychiatric professional will ask 
questions to assess their level of suicidality, and whether it would be a risk to their health to 
partake in a study. If a subject appears to be actively suicidal, study staff will make 
appropriate referrals, which will often include the Acute Psychiatric Service at MGH; all 
efforts will be made to contact the subject’s clinical treatment team. 
7. Plain film of wrist/hand to determine bone age in women with primary amenorrhea who have 
not received estrogen for ≥1 year. 
 
Baseline Visit: Eligible study subjects (n=30 women with anorexia nervosa or atypical anorexia) 
will be assessed at an outpatient visit at MGH for baseline testing.    
1. A complete medical history including menstrual history and instructions on keeping a 
menstrual diary, consumptive habits (smoking, alcohol, caffeinated beverages) will be 
recorded, oral temperature, height and weight in gown, pulse and blood pressure, and 
physical examination will be performed 
2. Urine pregnancy test 
3. DXA scan of the spine, hip, radius, and total body if screen visit did not take place within 1 
month of baseline visit or if a DXA scan was not performed at the screening visit.  
4. Baseline hormone and safety blood testing 
5. HR-pQCT and FEA of the radius and tibia on two machines as we are transitioning the study 
from the XCT1 machine to the XCT2 machine because the XCT1 machine is being taken out 
of service 
6. Subjects will take a standard dose of 1200 mg calcium and 800 IU Vitamin D supplements 
daily throughout the study. 
7. Eating Disorder Examination—Questionnaire 
8. Eating Disorder Inventory-2 
9. Paffenbarger Exercise Questionnaire  


Partners Human Subjects Research Application Form 
  
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10. Calcium and vitamin D food frequency questionnaire 
 
Randomization to treatment or placebo group will occur at the baseline visit. Twenty subjects 
will be randomized to active denosumab (one 60 mg dose) and 10 subjects will be randomized to 
an identical placebo injection. Randomization will be stratified for presence or absence of 
atypical anorexia nervosa, defined as Body Mass Index (BMI) t 18.5 kg/m2 vs. < 18.5 kg/m2. A 
second injection of active denosumab (one 60 mg dose) or an indentical placebo injection will be 
given at the month 6 visit. 
 
After the baseline visit, follow-up blood testing for electrolytes, including calcium, and a CBC, 
will occur at 10 days, 1 month, 3 months, 6 months, 6 months and 10 days, 7 months, 9 months 
and 12 months after baseline testing. A pregnancy test and clinical evaluation will be performed 
at the 1, 3, 6, 7, 9 and 12-month visits, as will a nutrition evaluation, including weight in a gown, 
height, and calculation of percent IBW and body mass index (BMI) and completion of 
questionnaires (calcium and vitamin D food frequency questionnaire and Paffenbarger exercise 
questionnaire).  BMD at the spine, hip, radius and total body will be performed 6 and 12 months 
after baseline. HR-pQCT and FEA of the radius and tibia will be performed at 6 and 12 months 
after baseline. Markers of bone metabolism will be measured at months 1, 3, 6, 7, 9 and 12 
months. A 25 OH Vitamin D will be assessed at the 12-month study visit. 
 
Alendronate Extension Study: 
Subjects with a known esophageal disease cannot participate in the alendronate extension study. 
Subjects who enroll in the extension study will return for two additional study visits at 18 and 24 
months. A clinical evaluation and pregnancy test will be performed at both visits, as will a 
nutrition evaluation, including weight in a gown, height, and calculation of percent IBW and 
body mass index (BMI) and completion of questionnaires (calcium and vitamin D food 
frequency questionnaire at 24 Months and Paffenbarger exercise questionnaire at 18 Months and 
24 Months). BMD at the spine, hip, radius and total body and HR-pQCT and FEA of the radius 
and tibia will be performed at the 24 month study visit.   The HR-pQCT and FEA of the radius 
and tibia will be performed on two scanners because the study is transitioning from one scanner 
to another. 
 
Subjects who do not live locally will be permitted to have their blood drawn and pregnancy test 
performed offsite for lab tests required for the visit. Subjects who choose this option will also 
have an interim history performed by our staff by telephone. For visits which involve 
questionnaires, those will be mailed or sent electronically to the subject to be completed and 
returned to study staff.  Tests that need to be run in real time will be done at local laboratories, 
with the results provided online to investigators. Otherwise, the samples will be mailed to 
investigators.  
 
Study Visit 
Screen Baseline Day 
10 
M1 
M3 
M6 
Day 
10 
M7 M9 M12 M18 
M24 
Consent 
X 
 
 
 
 
 
 
 
 
X 
 
 
Clinical assessment and HCG 
X 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
Safety Labs (comprehensive 
metabolic panel including 
calcium, CBC) 
X 
X 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Nutrition Evaluation (height, 
weight) 
X 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 


Partners Human Subjects Research Application Form 
  
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
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For studies involving treatment or diagnosis, provide information about standard of care at 
Partners (e.g., BWH, MGH) and indicate how the study procedures differ from standard care.  
Provide information on available alternative treatments, procedures, or methods of diagnosis.
 
No treatment thus far has been successful in increasing bone density in women with anorexia 
nervosa. Weight gain is associated with some increase in bone density, but is difficult to attain 
(occurs in only 50%) and sustain. The DXA scan is the best validated method currently used 
clinically to assess bone mass and fracture risk. This is the standard method of diagnosis at 
Partners, and is provided for free to study subjects. There are currently no FDA-approved 
therapies for anorexia nervosa-induced bone loss. 
 
Alternate strategies to address low bone density in AN  
Recovery of weight and menses: Although weight and menses recovery is associated with some 
increase in BMD, this increase is not sufficient to cause bone accrual to normalize, and BMD 
remains lower than in controls.  Additionally, recovery can be hard to attain and sustain.   
 
Calcium and vitamin D supplementation: Many studies have now shown that calcium and 
vitamin D supplementation is not sufficient to increase BMD in AN. BMD remains low in these 
women despite higher calcium and vitamin D intake than in controls    
 
Alternate strategies to assess bone microarchitecture and strength: MRI of the peripheral 
skeleton has lower resolution, longer scan time and increased susceptibility to image post-
processing.   
 
Describe how risks to subjects are minimized, for example, by using procedures which are 
consistent with sound research design and which do not unnecessarily expose subjects to risk or 
by using procedures already being performed on the subject for diagnostic or treatment purposes.
 
The intervention being provided involves no more than two subcutaneous injections for a period 
of 12 months. For subjects enrolling in the alendronate substudy, they will be taking a tablet once 
weekly for 12 months from month 12 to month 24. A number of procedures will be instituted to 
protect against potential risk involved in this protocol. All subjects will have pregnancy tests at 
the screening visit and at the baseline visit, prior to any radiologic procedures and prior to 
receiving any study medication.  Subjects will be instructed on the importance of contraception 
Bone Markers (CTX, P1NP, 
osteocalcin) 
 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
IGF-1, estradiol, SHBG, 
testosterone 
 
X 
 
 
 
X 
 
 
 
X 
 
 
25 OH VitD 
X 
 
 
 
 
 
 
 
 
X 
 
 
BMD (DXA) 
X 
X 
 
 
 
X 
 
 
 
X 
 
X 
Bone Strength with FEA (Xtreme 
CT) 
 
X 
 
 
 
X 
 
 
 
X 
 
X 
EDI-2 
 
X 
 
 
X 
X 
 
 
X 
X 
X 
X 
EDE-Q 
 
X 
 
 
X 
X 
 
 
X 
X 
X 
X 
Paffenbarger Questionnaire 
(exercise quantification) 
 
X 
 
 
 
X 
 
 
 
X 
X 
X 
Calcium and Vitamin D Food 
Frequency Questionnaire 
 
X 
 
 
 
X 
 
 
 
X 
 
X 


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during the course of the study and will also have pregnancy tests at each study visit. Any subject 
who becomes pregnant during the course of the study and is discharged from participation will 
undergo a follow-up study visit. This will include assessment by an MD or NP for study 
medication related side effects, including hypocalcemia, and measurement of a calcium level if it 
has not been done clinically. Patients will be carefully monitored by clinicians for side effects 
and potential toxicities. 
 
All unanticipated problems, including adverse events will be reported to the Partners Healthcare 
Research Committee (PHRC) as required.  
 
Describe explicitly the methods for ensuring the safety of subjects.  Provide objective criteria for 
removing a subject from the study, for example, objective criteria for worsening disease/lack of 
improvement and/or unacceptable adverse events.  The inclusion of objective drop criteria is 
especially important in studies designed with placebo control groups.
 
Subjects will be instructed to call us if they develop any potantial side-effects. Subsequent 
management will be decided based on the severity of the side-effect.  
 
Serious side effects related to study drug will necessitate protocol discontinuation. If a subject 
develops a minor side effect, she will be asked to continue as per the protocol. To minimize the 
risk from radiation, scans will not be performed on subjects until a negative pregnancy test result 
is obtained. If lab abnormalities are discovered, the subject and their physician, if authorized by 
the subject, will be notified.   
 
If subjects are uncomfortable with any portion of any study visit, this portion will be 
discontinued or not performed. 
 
Drop criteria for subjects: 
1. Pregnancy (for any subject)  
• If a subject has an invasive dental procedure (eg, tooth extraction, dental implants, oral 
surgery) during the study their participation in the study may be paused or discontinued 
after consultation with their dentist or oral surgeon.  
2. Medical instability, which will be determined by the study physician. Patients in this 
category will be assessed by the DSMB, and continue to be assessed according to study 
protocol   
3. Serious study–related adverse event 
 
FORESEEABLE RISKS AND DISCOMFORTS 
Provide a brief description of any foreseeable risks and discomforts to subjects.  Include those 
related to drugs/devices/procedures being studied and/or administered/performed solely for 
research purposes.  In addition, include psychosocial risks, and risks related to privacy and 
confidentiality.  When applicable, describe risks to a developing fetus or nursing infant.
 
Blood Sampling: 
There is a risk of superficial bruising and discomfort at the venepuncture site. Rarely, fainting 
(from a vasovagal episode) or a treatable infection may occur.   
 


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In concordance with the IRB guidelines, the total amount of blood drawn will not exceed 550 cc 
over an eight-week period for study subjects whose weights are above 75% of ideal body weight 
and at least 110 pounds. 
   
Radiation: 
The main research study involves exposure to radiation from four or five DXA scans and three 
HR-pQCT scans. The total radiation dose the subject will receive from all of the scans is 0.225 
milliSievert (mSv). This amount of radiation is approximately 7 % of the yearly natural 
background radiation from the earth and the sky (equivalent to 26 days of background radiation). 
There are no known health risks associated with such a dose.   
 
Subjects will have the option to repeat scans once if there is a technical issue with the machine, 
which is a rare occurrence. If each scan was repeated twice at each visit, this would add no more 
than 0.045 mSv of radiation exposure, making the total radiation dose the subject would receive 
from all of the scans no more than 0.27 mSv. This amount of radiation is equal to about 9% of 
the annual background radiation from the earth and the sky (equivalent to 31 days of background 
radiation). Subjects have the option to refuse to be re-scanned.   
 
The alendronate substudy involves exposure to radiation from one additional set of DXA scans 
and two HR-pQCT scans. The total radiation dose the subject will receive from these additional 
scans is 0.04 milliSievert (mSv). This amount of radiation is approximately 1% of the yearly 
natural background radiation from the earth and the sky (equivalent to 5 days of background 
radiation). 
 
All patients will have pregnancy tests on admission prior to receiving any radiation. Subjects will 
also have serial pregnancy tests performed at every study visit. BMD measurements will occur at 
four times (5 times if subject is participating in the extension study), and HR-pQCT of the radius 
and tibia will be performed four times over the course of 24 months.  
 
Complications of medications:  
Denosumab is administered as a single subcutaneous injection once every 6 months.  Denosumab 
is approved by the FDA to treat osteoporosis in women after menopause that are at high risk for 
fracture. Denosumab has been used successfully in the treatment of postmenopausal women with 
osteoporosis at high risk for fracture with few side effects. Since it was first approved for sale in 
May 2010, approximately 11.8 million people have been prescribed denosumab. Taking 
denosumab 60mg may cause all, some or none of the side effects listed. 
 
Very Common side effects (which may affect more than 1 person in 10): 
• Transient (going away quickly) mild irritation or tenderness at the injection 
site.  
• Joint pain 
• Pain in extremity 
 
Common side effects (which may affect between 1 and 10 people in every 100):  
• Cataracts 
• Cough 
• Decreased skin sensation 
• Dizziness 


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• Difficulty emptying the bladder 
• Eczema 
• Low blood calcium levels (especially if you have kidney problems) 
• Muscle and bone pain 
• Osteoarthritis 
• High cholesterol 
• Hair loss (alopecia) 
 
Uncommon side effects (which may affect between 1 and 10 people in every 1,000): 
• Skin infections 
• Broken bones in your spine after stopping denosumab   
• Rash that may occur on the skin or sores in the mouth 
 
Rare side effects (which may affect 1 and 10 people in every 10,000): 
• Allergic reaction: hives, rash, headache, difficulty breathing; swelling of your 
face, lips, tongue, or throat, nausea and sometimes vomiting 
• Allergic reaction that can damage blood vessels mainly in the skin (e.g., 
purple or brownish-red spots, hives or skin sores) (hypersensitivity vasculitis) 
• Osteonecrosis of the jaw (breakdown and non healing of jaw tissue) 
• Unusual thigh bone fractures (atypical femoral fractures) 
  
Side effect of unknown prevalence: 
• Severe allergic reaction with skin eruptions/blisters, fever and increased 
eosinophil counts (a type of white blood cell) with possible organ damage 
(drug rash with eosinophilia and systemic symptoms) 
 
 
The potential effects of denosumab on the fetus are not known, and therefore precautions against 
administration to pregnant patients will be instituted. All patients will have pregnancy tests on 
admission prior to receiving study medication and serial pregnancy tests at every study visit and 
will be required to use contraception in order to participate in the protocol. 
 
Hypocalcemia may be exacerbated by the use of Denosumab. All potential subjects will have 
their calcium level tested at the screening study visit. Any pre-existing hypocalcemia will be 
reported to the subject and their clinical care team and corrected prior to initiating therapy with 
Denosumab. Additionally, all subjects will be adequately supplemented with 1200 mg of calcium 
and 800 IU of Vitamin D throughout study participation. These supplements are required for 
study participation. 
 
After patients start taking densoumab 60mg, it is possible that their body may make antibodies or 
may cause side effects. The development of antibodies to densoumab in patients has been 
uncommon and has had no clinical effects and has not reduced the effect of densoumab on 
bones.  
 
The potential risk of alendronate in this study is not greater than that associated with its common 
use in clinical practice. These risks include abdominal or stomach pain, skin rash, diarrhea, 
headache and joint pain. Less common side effects include severe abdominal pain or stomach 
pain, stomach cramping, belching, bone pain, blurred vision or change in vision, chest pain, 


Partners Human Subjects Research Application Form 
  
Filename: Protocol Summary 
Version Date:  June 1, 2005 
 
  
12 
constipation, cough, dizziness, dry eyes, fever, general feeling of discomfort or fullness, leg 
cramps, nausea, ringing in the ears, swelling of feet or lower legs, and weakness. On rare 
occasion, red sore eyes have been reported. Although the long-term risk of alendronate in young 
women is unknown, bisphosphonates have been used in premenopausal women to treat 
osteopenia due to glucocorticoids. In addition, these medications are used widely in the 
community and it is essential that their efficacy be assessed.  Bisphosphonates remain in the 
bones for many years after administration, and it is unknown whether bisphosphonates may be 
secreted from bone during pregnancy or breastfeeding.   
 
There may be other risks of denosumab and alendronate that are currently unknown. 
 
Oral calcium can cause constipation and a metallic taste in the mouth. 
Vitamin D in the doses being administered does not cause any side effects. 
 
EXPECTED BENEFITS 
Describe both the expected benefits to individual subjects participating in the research and the 
importance of the knowledge that may reasonably be expected to result from the study.  Provide 
a brief, realistic summary of potential benefits to subjects, for example, “It is hoped that the 
treatment will result in a partial reduction in tumor size in at least 25% of the enrolled subjects.”  
Indicate how the results of the study will benefit future patients with the disease/condition being 
studied and/or society, e.g., through increased knowledge of human physiology or behavior, 
improved safety, or technological advances. 
 
Each subject will have a complete nutritional analysis and BMD performed. These data, 
including relative fracture risk and calcium intake will be made available to the patient. In 
addition, a physical exam and blood tests will be performed in all patients, and these data will 
also be made available to the patient.  
 
Subjects may not receive a benefit personally from participating in this study. Denosumab and 
alendronate are shown to have beneficial effects on bone density in postmenopausal women at high 
risk for fracture. It is unclear whether women with anorexia nervosa will benefit in a similar fashion. 
Subjects will be informed of the study results.   
 
EQUITABLE SELECTION OF SUBJECTS 
The risks and benefits of the research must be fairly distributed among the populations that stand 
to benefit from it.  No group of persons, for example, men, women, pregnant women, children, 
and minorities, should be categorically excluded from the research without a good scientific or 
ethical reason to do so.  Please provide the basis for concluding that the study population is 
representative of the population that stands to potentially benefit from this research.
 
This study does not exclude the participation of any individual on the basis of race or ethnicity.  
We will employ broad methods of recruitment, in the hope of including women of all ethnicities. 
 
When people who do not speak English are excluded from participation in the research, provide 
the scientific rationale for doing so.  Individuals who do not speak English should not be denied 
participation in research simply because it is inconvenient to translate the consent form in 
different languages and to have an interpreter present.

SAP_001.pdf: 
Effects of Denosumab on Bone Mineral Density, Markers of Bone Metabolism and Bone 
Microarchitecture in Women with Anorexia Nervosa: A Pilot Study 
 
NCT # 03292146 
 
Version Date: July 13, 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


VI.Biostatistical Analysis 
 
Sample Size and Justification: Group sample sizes of  20 (active therapy) to 10 (placebo) for a 
total N=30 will achieve 87% power to reject the null hypothesis of equal means when the 
population mean difference is 4.5 with a standard deviation of both groups of 3.4 and with a 
significance level of (alpha) of 0.050 using a 2-sided 2-sample equal-variance t-test. This is 
based on the difference in percent change in spine bone density between the denosumab and 
placebo groups in McClung MR et al. (26). 
 
Data Analysis Plan:  
The data analysis plan for the main study and the substudy will be as follows: Variables will be 
tested for normality using the Shapiro-Wilk test, and if non-normal, variables will be log-
transformed before analysis. Mean percent change from baseline in bone mineral density, 
HRpQCT variables and markers of bone metabolism with be analyzed using analysis of 
covariance, with treatment as the main effect, and baseline value as a covariate. For the substudy, 
a secondary analysis will be performed to determine whether gains achieved in the denosumab 
group are maintained through the subsequent 12-month study period using a repeated measures 
within group model.  
 
Main Study Endpoints: 
Primary:  
Percent change from baseline in lumbar spine bone mineral density by dual energy xray 
absorptiometry (DXA) at 12 months. 
 
Secondary: 
Percent change from baseline in bone mineral density of hip (total and femoral neck) and radius 
by DXA at 12 months. 
 
Percent change from baseline in markers of bone metabolism: CTx, P1NP, Osteocalcin over 12 
months. 
 
Exploratory: 
Percent change from baseline in HRpQCT of the tibia and radius variables: trabecular thickness 
and spacing; cortical thickness and porosity; percent change from baseline in ITS variables; 
percent change from baseline in finite element analysis modeling of bone strength  
 
Substudy Endpoints: 
Primary: 
Lumbar spine BMD at 24 months. 
 
Exploratory: 
Radial and tibial HRpQCT variables at 24 months: trabecular thickness and spacing; cortical 
thickness and porosity; percent change from baseline in ITS variables; percent change from 
baseline in finite element analysis modeling of bone strength  
 
Markers of bone metabolism at 24 months: CTx, P1NP, Osteocalcin.