Denosumab for Smoldering Multiple Myeloma

Inclusion Criteria

• Patient has confirmed SMM according to the definition of the International Myeloma Working Group (IMWG) definition: serum M-protein ≥3 g/dL or BMPC >10% but less than 60%, or both, along with normal organ and marrow function (CRAB) within 4 weeks prior to baseline. C: Absence of hypercalcemia, evidenced by a calcium ≤11 mg/dL. R: Absence of renal failure, evidenced by a creatinine ≤ 2.0mg/dL A: Absence of anemia, evidenced by a hemoglobin ≥10 g/dL.

B: Absence of lytic bone lesions per IMWG recommendations:

One of either PET-CT, low-dose whole-body CT (LDWBCT) or MRI of the whole body or spine. Increased uptake on PET-CT alone is not adequate for the diagnosis of multiple myeloma; evidence of underlying osteolytic bone destruction is needed on the CT portion of the examination.

• One of the risk factors below that portends for an increased risk of progression to MM:
• An abnormal free light chain ratio
• M-spike ≥ 4 g/dL
• ≥ 50% bone marrow plasma cells
• Immunoparesis ≥ 20% less than the institutional normal standard of the uninvolved immunoglobulins
• Serum calcium or albumin-adjusted serum calcium ≥ 2.1 mmol/L (8.4 mg/dL) and ≤ 2.9mmol/L (11.5 mg/dL) (Reference range 8.5-10.8 mg/dL)
• Able to tolerate daily supplementation of calcium and vitamin D
• Must have a vitamin D level ≥ 30 ng/mL after repletion
• Participants must have normal organ as defined below:
• Total bilirubin ≤ 2.0 x institutional upper limit of normal (ULN); patients diagnosed with Gilbert's syndrome can enroll with a total bilirubin > 2 after review of the principal investigator
• AST(SGOT) ≤2.5 × institutional ULN
• ALT(SGPT) ≤2.5 × institutional ULN
• Age ≥ 18 years.
• ECOG PS ≤1
• Life expectancy greater than 12 months
• Subjects with reproductive potential must be willing to use, in combination with his/her partner, 2 highly effective methods of effective contraception or practice sexual abstinence throughout the study and continue for 5 months after the study duration. Subjects who are surgically sterile (e.g. history of bilateral tubal ligation, hysterectomy) or whose sexual partner is sterile (e.g. history of vasectomy) are not required to use additional contraceptive measures.
• Ability to understand and the willingness to sign a written informed consent document.

-Patient is willing and able to comply with the protocol for the duration of the study including undergoing treatment and scheduled visits and examinations including follow up.

• Statement on Inclusion of Women and Minorities - Men and women of all ethnicities and racial backgrounds are eligible for this study.

Exclusion Criteria

• Prior administration of denosumab.
• Any history of IV bisphosphonate use prior to or during the study
• Prescription oral fluorides or bisphosphonate usage > 3 months within the past 2 years
• Systemic corticosteroids > 10mg prednisone per day
• Known secondary cause for osteopenia or osteoporosis
• Patient has symptomatic MM, as defined by any of the following:
• Lytic lesions or pathologic fractures.
• Anemia (hemoglobin 11.0 mg/dL)
• Renal insufficiency (creatinine > 2.0 mg/dL).
• Clonal bone marrow plasma cells > 60%
• An involved serum free light chain (kappa or Lambda) > 100mg/L with the ratio of the involved/uninvolved free light chains also > 100 mg/L
• One or more osteolytic lesions on radiography, but more than one lesion is required if 5mm in size.
• Other: symptomatic hyperviscosity, amyloidosis, plasma cell leukemia, POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein)
• Prior history or current evidence of osteonecrosis/osteomyelitis of the jaw.
• Active dental or jaw condition that requires oral surgery, including tooth extraction.
• Non-healed dental/oral surgery, including tooth extraction.
• Planned invasive dental procedures during the course of study.
• Evidence of any of the following conditions per subject self-report or medical chart review:
• Any