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Dear Editor,

We read with great interest the recently published article by Singer et al (1) related to practice guideline of Paget's disease. In the guideline, bisphosphonates, especially iv bisphosphonate zoledronat, was principally suggested for treatment of Paget's disease. Bisphosphonates are primarily cleared via renal extraction and may also cause deterioration of renal function via acute tubular necrosis or focal segmental gloerulosclerosis (2). Therefore, it cannot be used in patients with severe renal impairment (the patients having glomerular filtration rate < 35 mL/min) (1, 2). The author suggested parenteral calcitonin as alternative treatment for Paget's disease with impairment renal function (1). However, in most patients, calcitonin treatment was not achieved for adequate bone turnover normalization (1).

Receptor activator of nuclear factor-κB ligand is essential for osteoclastogenic activity. Denosumab is a human monoclonal antibody that it is inhibitory effect on receptor activator of nuclear factor-κB ligand. Thus, it supresses osteoclastic activity. Denosumab has been used for osteoporosis and malign hypercalcemia. It is cleared by the reticuloendothelial system. Recently studies demonstrated that renal impairment had no crucial effect on the pharmacokinetic and pharmacodynamics profile of denosumab, and dose adjustments are not required for these patients (3, 4). It has been also reported that denosumab is an effective drug for treatment of adult and juvenile Paget's disease (5–7). Reviewing the literature, we observed a case report related to using of denosumab for the patient with Paget's disease that has renal insufficiency (6). Schwarz et al (6) suggested that denosumab was a safety drug for patient with Paget's disease who had preexisting renal impairment.

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