Fosrenol (R) Maintains Bone Health Status of End-Stage
Renal Disease Patients
Shire Pharmaceuticals Group plc
(NASDAQ: SHPGY, LSE: SHP.L, TSE: SHQ CN) announces that long-term treatment with
FOSRENOL® (lanthanum carbonate), a new non-calcium, non-aluminum phosphate
binder, does not promote bone softening or cause harmful effects on bone,
according to data presented today at the American Society of Nephrology (ASN)
annual meeting in St. Louis, Mo.
Even with a low-phosphorus diet, most ESRD patients develop hyperphosphatemia
(high phosphate levels in the blood). Without effective treatment,
hyperphosphatemia may lead to renal osteodystrophy, a collection of bone
diseases characterized by bone pain, brittle bones, skeletal deformities and
"Since ESRD patients often have fragile bones, it is critical that phosphate
binders not worsen bone status," said Dr. Eliseo Salinas, Shire's Chief
Scientific Officer and Executive Vice President of Global Research &
Development. "Patients who take FOSRENOL® over the long-term generally are able
to maintain their bone health status."
The U.S. Food and Drug Administration recently approved FOSRENOL® on Oct. 26.
According to experts, FOSRENOLÂ® may help simplify the management of
hyperphosphatemia because it is an effective, easy-to-take, chewable tablet that
does not have to be taken with fluids.
Data from over 400 bone biopsies representing the largest bone biopsy data set
in ESRD patients were presented at ASN.
In an important study, which evaluated bone biopsies in 197 subjects (100
patients receiving FOSRENOL® and 97 patients receiving comparator) prior to and
after one year of treatment revealed no evidence of softening of the bone
(osteomalacia) in patients receiving FOSRENOL®.
In another poster presentation, investigators used five measures of bone
structure and content to examine bone samples from 11 patients who completed
more than four years of treatment with FOSRENOL®. Treatment with FOSRENOL® for
more than four years is not associated with the toxic effects on bone associated
with aluminum-based phosphate binders, particularly softening of bone
(osteomalacia) that results from abnormal mineral metabolism.
"Since only about one-third of ESRD patients have phosphorus levels within
acceptable ranges, we need new safe and reliable methods to control phosphorus
levels," said Hartmut H. Malluche, M.D., Robert G. Luke Chair in Nephrology,
Professor of Medicine and Chief, Division of Nephrology Bone and Mineral
Metabolism at the University of Kentucky in Lexington, Kentucky. "Our
documentation that FOSRENOL® does not have the toxic, bone-softening effect
associated with aluminum-based phosphate binders is welcome news for the ESRD
Phosphorus, an element found in nearly all foods, is absorbed from the
gastrointestinal tract into the bloodstream. When the kidneys fail, they no
longer effectively remove phosphorus, even with the help of blood-cleansing
dialysis machines. While the normal adult range for phosphorus is 2.5 to 4.5 mg/dL,
the blood phosphorus levels of many patients on dialysis exceed 6.5 mg/dL. Such
levels have been linked to a significantly higher illness and death risk for
patients who have undergone at least one year of dialysis.
Of the approximately 20 million Americans who have some form of kidney disease,
as of 2002, more than 512,000 have developed ESRD, a figure that has grown 400
percent over the last 20 years.
Diet restrictions alone generally cannot control phosphorus levels and patients
traditionally manage hyperphosphatemia by taking phosphorus-binding agents at
every meal and snack. Such binders help to "soak up" phosphorus in the
gastrointestinal tract, before it can be absorbed into the blood. Despite the
availability of these agents, it remains a challenge for some ESRD patients to
maintain target ranges. According to the National Kidney Foundation's new Kidney
Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines for
Bone Metabolism and Disease, Guideline 3, Evaluation of Serum Phosphorus Levels,
fewer than 30 percent of dialysis patients are able to maintain serum phosphorus
levels in the target range.
The K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease also
note in Guideline 5, Use of Phosphate Binders in Chronic Kidney Disease (CKD),
that non-calcium and non-aluminum phosphate binders are a preferred first-line
treatment option in lowering serum phosphorus levels. Because FOSRENOL®
does not contain calcium or aluminum, it meets the K/DOQI recommendations as one
of the preferred first-line treatment options in lowering serum phosphorus
FOSRENOL® works by binding to dietary phosphorus. Once bound, the FOSRENOL®/phosphorus
complex cannot pass into the bloodstream and is eliminated from the body.
Consequently, a patient's overall absorption of phosphorus from the diet
Shire has conducted an extensive clinical research program for FOSRENOL®
involving approximately 2,000 patients, some of whom have been treated for up to
36 months. In clinical trials, FOSRENOL® was generally well-tolerated.
Please see attached full prescribing information.
Shire Pharmaceuticals Group plc
Shire Pharmaceuticals Group plc (Shire) is a global specialty pharmaceutical
company with a strategic focus on meeting the needs of the specialist physician
and currently has a range of projects and products in the areas of central
nervous system (CNS), gastrointestinal (GI), and renal disease. Shire has
operations in the world's key pharmaceutical markets (U.S., Canada, UK, France,
Italy, Spain and Germany) as well as a specialist drug delivery unit in the U.S.
For further information on Shire, please visit the Company's Web site: http://www.shire.com,
or the FOSRENOLĂ˘ Web site: http://www.FOSRENOL.com.
THE "SAFE HARBOR" STATEMENT UNDER THE PRIVATE SECURITIES LITIGATION REFORM ACT
Statements included herein that are not historical facts, are forward-looking
statements. Such forward-looking statements involve a number of risks and
uncertainties and are subject to change at any time. In the event such risks or
uncertainties materialize, Shire's results could be materially affected. The
risks and uncertainties include, but are not limited to, risks associated with
the inherent uncertainty of pharmaceutical research, product development,
manufacturing and commercialization, the impact of competitive products,
including, but not limited to, the impact on Shire's Attention Deficit
Hyperactivity Disorder (ADHD) franchise, patents, including but not limited to,
legal challenges relating to Shire's ADHD franchise, government regulation and
approval, including but not limited to the expected product approval dates of
METHYPATCH® (methylphenidate), XAGRID® (anagrelide hydrochloride) and BIPOTROL®
(carbamazepine), the implementation of Shire's planned reorganization and other
risks and uncertainties detailed from time to time in Shire's filings with the
Securities and Exchange Commission, including Shire's most recent annual report
on Form 10-K.
(Lanthanum Carbonate) 250 mg and 500 mg Chewable Tablets.
FOSRENOL® contains lanthanum carbonate (2:3) hydrate with molecular formula
La2(CO3)3 xH2O (on average x=4-5 moles of water) and molecular weight 457.8
(anhydrous mass). Lanthanum (La) is a naturally occurring rare earth element.
Lanthanum carbonate is practically insoluble in water.
Each FOSRENOL®, white to off-white, chewable tablet contains lanthanum carbonate
hydrate equivalent to 250 or 500 mg of elemental lanthanum and the following
inactive ingredients: dextrates (hydrated) NF, colloidal silicon dioxide NF,
magnesium stearate NF, and talc USP.
Patients with end-stage renal disease (ESRD) can develop hyperphosphatemia that
may be associated with secondary hyperparathyroidism and elevated calcium
phosphate product. Elevated calcium phosphate product increases the risk of
ectopic calcification. Treatment of hyperphosphatemia usually includes all of
the following: reduction in dietary intake of phosphate, removal of phosphate by
dialysis and inhibition of intestinal phosphate absorption with phosphate
binders. FOSRENOL® does not contain calcium or aluminum.
Lanthanum carbonate dissociates in the acid environment of the upper GI tract to
release lanthanum ions that bind dietary phosphate released from food during
digestion. FOSRENOL® inhibits absorption of phosphate by forming highly
insoluble lanthanum phosphate complexes, consequently reducing both serum
phosphate and calcium phosphate product.
In vitro studies have shown that in the physiologically relevant pH range of 3
to 5 in gastric fluid, lanthanum binds approximately 97% of the available
phosphate when lanthanum is present in a two-fold molar excess to phosphate. In
order to bind dietary phosphate efficiently, lanthanum should be administered
with or immediately after a meal.
Following single or multiple dose oral administration of FOSRENOL® to healthy
subjects, the concentration of lanthanum in plasma was very low (bioavailability
<0.002%). Following oral administration in ESRD patients, the mean lanthanum
Cmax was 1.0 ng/mL. During long-term administration (52 weeks) in ESRD patients,
the mean lanthanum concentration in plasma was approximately 0.6 ng/mL. There
was minimal increase in plasma lanthanum concentrations with increasing doses
within the therapeutic dose range. The effect of food on the bioavailability of
FOSRENOL® has not been evaluated, but the timing of food intake relative to
lanthanum administration (during and 30 minutes after food intake) has a
negligible effect on the systemic level of lanthanum.
In vitro, lanthanum is highly bound (>99%) to human plasma proteins, including
human serum albumin, a1-acid glycoprotein, and transferrin. Binding to
erythrocytes in vivo is negligible in rats.
In 105 bone biopsies from patients treated with FOSRENOL® for up to 4.5 years,
rising levels of lanthanum were noted over time. Estimates of elimination
half-life from bone ranged from 2.0 to 3.6 years. Steady state bone
concentrations were not reached during the period studied.
In studies in mice, rats and dogs, lanthanum concentrations in many tissues
increased over time and were several orders of magnitude higher than plasma
concentrations (particularly in the GI tract, bone and liver). Steady state
tissue concentrations in bone and liver were achieved in dogs between 4 and 26
weeks. Relatively high levels of lanthanum remained in these tissues for longer
than 6 months after cessation of dosing in dogs. There is no evidence from
animal studies that lanthanum crosses the blood-brain barrier.
Lanthanum is not metabolized and is not a substrate of CYP450. In vitro
metabolic inhibition studies showed that lanthanum at concentrations of 10 and
40 Âµg/ml does not have relevant inhibitory effects on any of the CYP450
isoenzymes tested (1A2, 2C9/10, 2C19, 2D6, and 3A4/5). Lanthanum was cleared
from plasma following discontinuation of therapy with an elimination half-life
of 53 hours.
No information is available regarding the mass balance of lanthanum in humans
after oral administration. In rats and dogs, the mean recovery of lanthanum
after an oral dose was about 99% and 94% respectively and was essentially all
from feces. Biliary excretion is the predominant route of elimination for
circulating lanthanum in rats. In healthy volunteers administered intravenous
lanthanum as the soluble chloride salt (120 Âµg), renal clearance was less than
2% of total plasma clearance. Quantifiable amounts of lanthanum were not
measured in the dialysate of treated ESRD patients.
In Vitro- Drug Interactions:
Gastric Fluid: The potential for a physico-chemical interaction (precipitation)
between lanthanum and six commonly used medications (warfarin, digoxin,
furosemide, phenytoin, metoprolol, and enalapril) was investigated in simulated
gastric fluid. The results suggest that precipitation in the stomach of
insoluble complexes of these drugs with lanthanum is unlikely.
In Vivo- Drug Interactions:
Lanthanum carbonate is neither a substrate nor an inhibitor of CYP450 enzymes.
The absorption of a single dose of 1000 mg of FOSRENOL® is unaffected by
co-administration of citrate. No effects of lanthanum were found on the
absorption of digoxin (0.5-mg), metoprolol (100-mg), or warfarin (10-mg) in
healthy subjects co-administered lanthanum carbonate (three doses of 1000 mg on
the day prior to exposure and one dose of 1000 mg on the day of
co-administration). Potential pharmacodynamic interactions between lanthanum and
these drugs (e.g., bleeding time or prothrombin time) were not evaluated. None
of the drug interaction studies was done with the maximum recommended
therapeutic dose of lanthanum carbonate. No drug interaction studies assessed
the effects of drugs on phosphate binding by lanthanum carbonate.
The effectiveness of FOSRENOL® in reducing serum phosphorus in ESRD patients was
demonstrated in one short-term, placebo-controlled, double-blind dose-ranging
study, two placebo-controlled randomized withdrawal studies and two long-term,
active-controlled, open-label studies in both hemodialysis and peritoneal
dialysis (PD) patients.
Double-Blind Placebo-Controlled Studies:
One hundred forty-four patients with chronic renal failure undergoing
hemodialysis and with elevated phosphate levels were randomized to double-blind
treatment at a fixed dose of lanthanum carbonate of 225 mg (n=27), 675 mg
(n=29), 1350 mg (n=30) or 2250 mg (n=26) or placebo (n=32) in divided doses with
meals. Fifty-five percent of subjects were male, 71% black, 25% white and 4% of
other races. The mean age was 56 years and the duration of dialysis ranged from
0.5 to 15.3 years. Steady-state effects were achieved after two weeks. The
effect after six weeks of treatment is shown in Figure 1.
Figure 1. Difference in Phosphate Reduction in the FOSRENOL®
and Placebo Group in a 6-Week, Dose-Ranging, Double-Blind
Study in ESRD Patients (with 95% Confidence Intervals)
One-hundred eighty five patients with end-stage renal disease undergoing either
hemodialysis (n=146) or peritoneal dialysis (n=39) were enrolled in two
placebo-controlled, randomized withdrawal studies. Sixty-four percent of
subjects were male, 28% black, 62% white and 10% of other races. The mean age
was 58.4 years and the duration of dialysis ranged from 0.2 to 21.4 years. After
titration of lanthanum carbonate to achieve a phosphate level between 4.2 and
5.6 mg/dl in one study (doses up to 2250 mg/day) or < 5.9 mg/dl in the second
study (doses up to 3000 mg/day) and maintenance through 6 weeks, patients were
randomized to lanthanum or placebo. During the placebo-controlled, randomized
withdrawal phase (four weeks), the phosphorus concentration rose in the placebo
group by 1.9 mg/dl in both studies relative to patients who remained on
lanthanum carbonate therapy.
Open-Label Active-Controlled Studies:
Two long-term open-label studies were conducted, involving a total of 2028
patients with ESRD undergoing hemodialysis. Patients were randomized to receive
FOSRENOL® or alternative phosphate binders for up to six months in one study and
two years in the other. The daily FOSRENOLÂ® doses, divided and taken with
meals, ranged from 375 mg to 3000 mg. Doses were titrated to reduce serum
phosphate levels to a target level. The daily doses of the alternative therapy
were based on current prescribing information or those commonly utilized. Both
treatment groups had similar reductions in serum phosphate of about 1.8 mg/dL.
Maintenance of reduction was observed for up to three years in patients treated
with FOSRENOL® in long-term, open label extensions.
No effects of FOSRENOL® on serum levels of 25-dihydroxy vitamin D3, vitamin A,
vitamin B12, vitamin E and vitamin K were observed in patients who were
monitored for 6 months.
Paired bone biopsies (at baseline and at one or two years) in 69 patients
randomized to either FOSRENOL® or calcium carbonate in one study and 71 patients
randomized to either FOSRENOL® or alternative therapy in a second study showed
no differences in the development of mineralization defects between the groups.
Vital Status was known for over 2000 patients, 97% of those participating in the
clinical program during and after receiving treatment. The adjusted yearly
mortality rate (rate/years of observation) for patients treated with FOSRENOL®
or alternative therapy was 6.6%.
INDICATIONS AND USAGE
FOSRENOL® is indicated to reduce serum phosphate in patients with end-stage
Patients with acute peptic ulcer, ulcerative colitis, Crohn's disease or bowel
obstruction were not included in FOSRENOL® clinical studies. Caution should be
used in patients with these conditions.
There were no differences in the rates of fracture or mortality in patients
treated with FOSRENOL® compared to alternative therapy for up to 3 years. The
duration of treatment exposure and time of observation in the clinical program
are too short to conclude that FOSRENOL® does not affect the risk of fracture or
mortality beyond 3 years.
Information for the Patient:
FOSRENOL® tablets should be taken with or immediately after meals. Tablets
should be chewed completely before swallowing. Intact tablets should not be
FOSRENOL® is not metabolized.
Studies in healthy subjects have shown that FOSRENOL® does not adversely affect
the pharmacokinetics of warfarin, digoxin or metoprolol. The absorption of
FOSRENOL® is unaffected by coadministration with citrate-containing compounds
(see CLINICAL PHARMACOLOGY: In Vitro/In Vivo Drug Interactions).
An in vitro study showed no evidence that FOSRENOL® forms insoluble complexes
with warfarin, digoxin, furosemide, phenytoin, metoprolol and enalapril in
simulated gastric fluid. However, it is recommended that compounds known to
interact with antacids should not be taken within 2 hours of dosing with
Carcinogenesis, Mutagenesis, Impairment of Fertility:
Oral administration of lanthanum carbonate to rats for up to 104 weeks, at doses
up to 1500 mg of the salt per kg/day [2.5 times the maximum recommended daily
human dose (MRHD) of 5725 mg, on a mg/m2 basis, assuming a 60-kg patient]
revealed no evidence of carcinogenic potential. In the mouse, oral
administration of lanthanum carbonate for up to 99 weeks, at a dose of 1500
mg/kg/day (1.3 times the MRHD) was associated with an increased incidence of
glandular stomach adenomas in male mice.
Lanthanum carbonate tested negative for mutagenic activity in an in vitro Ames
assay using Salmonella typhimurium and Escherichia coli strains and in vitro
HGPRT gene mutation and chromosomal aberration assays in Chinese hamster ovary
cells. Lanthanum carbonate also tested negative in an oral mouse micronucleus
assay at doses up to 2000 mg/kg (1.7 times the MRHD), and in micronucleus and
unscheduled DNA synthesis assays in rats given IV lanthanum chloride at doses up
to 0.1 mg/kg, a dose that produced plasma lanthanum concentrations >2000 times
the peak human plasma concentration.
Lanthanum carbonate, at doses up to 2000 mg/kg/day (3.4 times the MRHD), did not
affect fertility or mating performance of male or female rats.
Pregnancy Category C. No adequate and well-controlled studies have been
conducted in pregnant women. The effect of FOSRENOL® on the absorption of
vitamins and other nutrients has not been studied in pregnant women. FOSRENOL®
is not recommended for use during pregnancy.
In pregnant rats, oral administration of lanthanum carbonate at doses as high as
2000 mg/kg/day (3.4 times the MRHD) resulted in no evidence of harm to the fetus.
In pregnant rabbits, oral administration of lanthanum carbonate at 1500
mg/kg/day (5 times the MRHD) was associated with a reduction in maternal body
weight gain and food consumption, increased post-implantation loss, reduced
fetal weights, and delayed fetal ossification. Lanthanum carbonate administered
to rats from implantation through lactation at 2000 mg/kg/day (3.4 times the
MRHD) caused delayed eye opening, reduction in body weight gain, and delayed
sexual development (preputial separation and vaginal opening) of the offspring.
Labor and Delivery:
No lanthanum carbonate treatment-related effects on labor and delivery were seen
in animal studies. The effects of lanthanum carbonate on labor and delivery in
humans is unknown.
It is not known whether lanthanum carbonate is excreted in human milk. Because
many drugs are excreted in human milk, caution should be exercised when FOSRENOL®
is administered to a nursing woman.
Of the total number of patients in clinical studies of FOSRENOL®, 32% (538) were
>65, while 9.3% (159) were >75. No overall differences in safety or
effectiveness were observed between patients >65 years of age and younger
While growth abnormalities were not identified in long-term animal studies,
lanthanum was deposited into developing bone including growth plate. The
consequences of such deposition in developing bone in pediatric patients are
unknown. Therefore, the use of FOSRENOL® in this population is not recommended.
The most common adverse events for FOSRENOL® were gastrointestinal events, such
as nausea and vomiting and they generally abated over time with continued
In double-blind, placebo-controlled studies where a total of 180 and 95 ESRD
patients were randomized to FOSRENOL® and placebo, respectively, for 4-6 weeks
of treatment, the most common events that were more frequent (>5% difference) in
the FOSRENOL® group were nausea, vomiting, dialysis graft occlusion, and
abdominal pain (Table 1).
Table 1. Adverse Events That Were More Common on FOSRENOL® in Placebo-
Controlled, Double-Blind Studies with Treatment Periods of 4-6 Weeks.
The safety of FOSRENOL® was studied in two long-term clinical trials that
included 1215 patients treated with FOSRENOL® and 943 with alternative therapy.
Fourteen percent (14%) of patients in these comparative, open-label studies
discontinued in the FOSRENOLÂ®-treated group due to adverse events.
Gastrointestinal adverse events, such as nausea, diarrhea and vomiting, were the
most common type of event leading to discontinuation.
The most common adverse events (>5% in either treatment group) in both the
long-term (2 year), open-label, active controlled, study of FOSRENOL® vs.
alternative therapy (Study A) and the 6-month, comparative study of FOSRENOL®
vs. calcium carbonate (Study B) are shown in Table 2. In Table 2, Study A events
have been adjusted for mean exposure differences between treatment groups (with
a mean exposure of 0.9 years on lanthanum and 1.3 years on alternative therapy).
The adjustment for mean exposure was achieved by multiplying the observed
adverse event rates in the alternative therapy group by 0.71.
Table 2. Incidence of Treatment-Emergent Adverse Events that
Occurred in >5% of Patients (in Either Treatment Group) and in
Both Comparative Studies A and B
There is no experience with FOSRENOL® overdosage. Lanthanum carbonate was not
acutely toxic in animals by the oral route. No deaths and no adverse effects
occurred in mice, rats or dogs after single oral doses of 2000 mg/kg. In
clinical trials, daily doses up to 4718 mg/day of lanthanum were well tolerated
in healthy adults when administered with food, with the exception of GI
symptoms. Given the topical activity of lanthanum in the gut, and the excretion
in feces of the majority of the dose, supportive therapy is recommended for
DOSAGE AND ADMINISTRATION
The total daily dose of FOSRENOL® should be divided and taken with meals. The
recommended initial total daily dose of FOSRENOL® is 750-1500 mg. The dose
should be titrated every 2-3 weeks until an acceptable serum phosphate level is
reached. Serum phosphate levels should be monitored as needed during dose
titration and on a regular basis thereafter.
In clinical studies of ESRD patients, FOSRENOL® doses up to 3750 mg were
evaluated. Most patients required a total daily dose between 1500 mg and 3000 mg
to reduce plasma phosphate levels to less than 6.0 mg/dL. Doses were generally
titrated in increments of 750 mg/day.
Tablets should be chewed completely before swallowing. Intact tablets should not
FOSRENOL® is supplied as a chewable tablet in two dosage strengths for oral
administration: 250 mg tablets and 500 mg tablets. Each chewable tablet is white
to off-white and embossed on one side with 'S405' and the dosage strength
corresponding to the content of elemental lanthanum. The 250 mg tablets are
round/convex and the 500 mg tablets are flat with a beveled edge.
250 mg supplied in bottles of 100 NDC 54092-247-01
500 mg supplied in bottles of 100 NDC 54092-249-01
Store at 25Â°C (77Â°F): excursions permitted to 15-30Â°C (59-86Â°F)
[See USP controlled room temperature]
Protect from moisture
Manufactured for Shire US Inc.
Wayne, PA 19087-2088, USA
Revision Date: 10/2004
247 0107 001
Shire Pharmaceuticals Group plc
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