Sevelamer: prescribing information – dosing, contraindications, interactions, side effects

Renagel is indicated for the control of hyperphosphataemia in adult patients receiving haemodialysis or peritoneal dialysis. Renagel should be used within the context of a multiple therapeutic approach, which could include calcium supplements, 1,25-dihydroxy Vitamin D3 or one of its analogues to control the development of renal bone disease.

Posology

Starting dose
The recommended starting dose of sevelamer hydrochloride is 2.4 g, 3.6 g or 4.8 g per day based on clinical needs and serum phosphorus level. Renagel must be taken three times per day with meals.

Serum phosphate level in patients not on phosphate binders
Starting dose of Renagel 400 mg tablets

Posology

Starting dose
The recommended starting dose of sevelamer hydrochloride is 2.4 g or 4.8 g per day based on clinical needs and serum phosphorus level. Renagel must be taken three times per day with meals.

Serum phosphate level in patients not on phosphate binders
Starting dose of Renagel 800 mg tablets

• Hypersensitivity to sevelamer or to any of the excipients listed in section 6.1.
• Hypophosphataemia
• Bowel obstruction.

Summary of the safety profile

The most frequently occurring (≥5% of patients) adverse reactions were all in the gastrointestinal disorders system organ class.

Tabulated list of adverse reactions
Parallel design studies involving 244 haemodialysis patients with treatment duration of up to 54 weeks and 97 peritoneal dialysis patients with treatment duration of 12 weeks were conducted.
Adverse reactions from these studies (299 patients), from uncontrolled clinical trials (384 patients), and that were spontaneously reported from post-marketing experience are listed by frequency in the table below. The reporting rate is classified as very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data).

MedDRA
System Organ
Class
Very
Common
Common
Uncommon Very Rare
Not known
Immune system disorders

Hypersensitivity*
Metabolism and nutrition disorders

Acidosis, increased serum chloride levels

Gastrointestinal disorders
Nausea, vomiting
Diarrhoea, dyspepsia, flatulence, upper abdominal pain, constipation

Abdominal pain, intestinal obstruction, ileus/subileus, diverticulitis, intestinal perforation1, gastrointestinal hemorrhage*1, intestinal ulceration*1, gastrointestinal necrosis*1, colitis*1, intestinal mass*1 Skin and subcutaneous tissue disorders

Pruritus, rash
Investigations

Crystal deposit intestine*1
*post-marketing experience
1 See inflammatory gastrointestinal disorders warning in section 4.4

Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.

Summary of the safety profile
The most frequently occurring (≥5% of patients) adverse reactions were all in the gastrointestinal disorders system organ class.

Tabulated list of adverse reactions
In parallel design studies involving 244 haemodialysis patients with treatment duration of up to 54 weeks and 97 peritoneal dialysis patients with treatment duration of 12 weeks were conducted.
Adverse reactions from these studies (299 patients), from uncontrolled clinical trials (384 patients), and that were spontaneously reported from post-marketing experience are listed by frequency in the table below. The reporting rate is classified as very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated form the available data).

MedDRA
System Organ
Class
Very
Common
Common
Uncommon Very Rare
Not known
Immune system disorders

Hypersensitivity*
Metabolism and nutrition disorders

Acidosis, increased serum chloride levels

Gastrointestinal disorders
Nausea, vomiting
Diarrhoea, dyspepsia, flatulence, upper abdominal pain, constipation

Abdominal pain, intestinal obstruction, ileus/subileus, diverticulitis, intestinal perforation1, gastrointestinal hemorrhage*1, intestinal ulceration*1, gastrointestinal necrosis*1, colitis*1, intestinal mass*1 Skin and subcutaneous tissue disorders

Pruritus, rash
Investigations

Crystal deposit intestine*1
*post-marketing experience
1 See inflammatory gastrointestinal disorders warning in section 4.4

Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.

Efficacy and safety of Renagel has not been studied in patients with:
- swallowing disorders
- active inflammatory bowel disease
- gastrointestinal motility disorders including untreated or severe gastroparesis, diverticulosis retention of gastric contents and abnormal or irregular bowel motion • patients with a history of major gastrointestinal surgery Therefore caution should be exercised when Renagel is used in patients with these disorders.

Intestinal obstruction and ileus/subileus
In very rare cases, intestinal obstruction and ileus/subileus have been observed in patients during treatment with sevelamer hydrochloride. Constipation may be a preceding symptom. Patients who are constipated should be monitored carefully while being treated with sevelamer hydrochloride. Renagel treatment should be re-evaluated in patients who develop severe constipation or other severe gastrointestinal symptoms.

Fat-soluble vitamins
Depending on diet intake and the nature of end stage renal failure, dialysis patients may develop low vitamin A, D, E and K levels. It cannot be excluded that Renagel can bind fat-soluble vitamins contained in ingested food. Therefore, in patients not taking these vitamins, monitoring vitamin A, D and E levels and assessing vitamin K status through the measurement of thromboplastin time should be considered and the vitamins should be supplemented if necessary. Additional monitoring of vitamins and folic acid is recommended in patients receiving peritoneal dialysis, since in the clinical study, vitamin A, D, E and K levels were not measured in these patients.

Folate deficiency
There is at present insufficient data to exclude the possibility of folate deficiency during long term Renagel treatment.

Hypocalcaemia/hypercalcaemia
Patients with renal insufficiency may develop hypocalcaemia or hypercalcaemia. Renagel does not contain calcium. Serum calcium levels should be monitored as is done in normal follow-up of a dialysis patient. Elemental calcium should be given as a supplement in case of hypocalcaemia.

Metabolic acidosis
Patients with chronic renal failure are predisposed to developing metabolic acidosis. Worsening of acidosis has been reported upon switching from other phosphate binders to sevelamer in a number of studies where lower bicarbonate levels in the sevelamer-treated patients compared to patients treated with calcium-based binders were observed. Closer monitoring of serum bicarbonate levels is therefore recommended.

Peritonitis
Patients receiving dialysis are subject to certain risks for infection specific to the dialysis modality.
Peritonitis is a known complication in patients receiving peritoneal dialysis (PD) and in a clinical study with Renagel, a number of peritonitis cases were reported. Therefore, patients on PD should be closely monitored to ensure the reliable use of appropriate aseptic technique with the prompt recognition and management of any signs and symptoms associated with peritonitis.

Swallowing and choking difficulties
Uncommon reports of difficulty swallowing the Renagel tablet have been reported. Many of these cases involved patients with co-morbid conditions including swallowing disorders or oesophageal abnormalities. Caution should be exercised when Renagel is used in patients with difficulty swallowing.

Hypothyroidism
Closer monitoring of patients with hypothyroidism co-administered with sevelamer hydrochloride and levothyroxine is recommended (see section 4.5).

Long term chronic treatment
As data on the chronic use of sevelamer for over one year are not yet available, potential absorption and accumulation of sevelamer during long-term chronic treatment cannot be totally excluded (see section 5.2).

Hyperparathyroidism
Renagel alone is not indicated for the control of hyperparathyroidism. In patients with secondary hyperparathyroidism Renagel should be used within the context of a multiple therapeutic approach, which could include calcium supplements, 1,25-dihydroxy Vitamin D3 or one of its analogues to lower the intact parathyroid hormone (iPTH) levels.

Serum chloride
Serum chloride may increase during Renagel treatment as chloride may be exchanged for phosphorus in the intestinal lumen. Although no clinically significant serum chloride increase has been observed in the clinical studies, serum chloride should be monitored as is done in the routine follow-up of a dialysis patient. One gram of Renagel contains approximately 180 mg (5.1 mEq) chloride.

Inflammatory Gastrointestinal Disorders
Cases of serious inflammatory disorders of different parts of the gastrointestinal tract (including serious complications such as haemorrhage, perforation, ulceration, necrosis, colitis and colonic/caecal mass) associated with the presence of sevelamer crystals have been reported (see section 4.8).
Inflammatory disorders may resolve upon sevelamer discontinuation. Sevelamer hydrochloride treatment should be re-evaluated in patients who develop severe gastrointestinal symptoms.

Efficacy and safety of Renagel has not been studied in patients with:
• swallowing disorders
• active inflammatory bowel disease
• gastrointestinal motility disorders including untreated or severe gastroparesis, diverticulosis retention of gastric contents and abnormal or irregular bowel motion • patients with a history of major gastrointestinal surgery Therefore caution should be exercised when Renagel is used in patients with these disorders.

Intestinal obstruction and ileus/subileus
In very rare cases, intestinal obstruction and ileus/subileus have been observed in patients during treatment with sevelamer hydrochloride. Constipation may be a preceding symptom. Patients who are constipated should be monitored carefully while being treated with sevelamer hydrochloride. Renagel treatment should be re-evaluated in patients who develop severe constipation or other severe gastrointestinal symptoms.

Fat-soluble vitamins
Depending on diet intake and the nature of end stage renal failure, dialysis patients may develop low vitamin A, D, E and K levels. It cannot be excluded that Renagel can bind fat-soluble vitamins contained in ingested food. Therefore, in patients not taking these vitamins, monitoring vitamin A, D and E levels and assessing vitamin K status through the measurement of thromboplastin time should be considered and the vitamins should be supplemented if necessary. Additional monitoring of vitamins and folic acid is recommended in patients receiving peritoneal dialysis, since in the clinical study, vitamin A, D, E and K levels were not measured in these patients.

Folate deficiency
There is at present insufficient data to exclude the possibility of folate deficiency during long term Renagel treatment.

Hypocalcaemia/hypercalcaemia
Patients with renal insufficiency may develop hypocalcaemia or hypercalcaemia. Renagel does not contain calcium. Serum calcium levels should be monitored as is done in normal follow-up of a dialysis patient. Elemental calcium should be given as a supplement in case of hypocalcaemia.

Metabolic acidosis
Patients with chronic renal failure are predisposed to developing metabolic acidosis. Worsening of acidosis has been reported upon switching from other phosphate binders to sevelamer in a number of studies where lower bicarbonate levels in the sevelamer-treated patients compared to patients treated with calcium-based binders were observed. Closer monitoring of serum bicarbonate levels is therefore recommended.

Peritonitis
Patients receiving dialysis are subject to certain risks for infection specific to the dialysis modality.
Peritonitis is a known complication in patients receiving peritoneal dialysis (PD) and in a clinical study with Renagel, a number of peritonitis cases were reported. Therefore, patients on PD should be closely monitored to ensure the reliable use of appropriate aseptic technique with the prompt recognition and management of any signs and symptoms associated with peritonitis.

Swallowing and choking difficulties
Uncommon reports of difficulty swallowing the Renagel tablet have been reported. Many of these cases involved patients with co-morbid conditions including swallowing disorders or oesophageal abnormalities. Caution should be exercised when Renagel is used in patients with difficulty swallowing.

Hypothyroidism
Closer monitoring of patients with hypothyroidism co-administered with sevelamer hydrochloride and levothyroxine is recommended (see section 4.5).

Long term chronic treatment
As data on the chronic use of sevelamer for over one year are not yet available, potential absorption and accumulation of sevelamer during long-term chronic treatment cannot be totally excluded (see section 5.2).

Hyperparathyroidism
Renagel alone is not indicated for the control of hyperparathyroidism. In patients with secondary hyperparathyroidism Renagel should be used within the context of a multiple therapeutic approach, which could include calcium supplements, 1,25-dihydroxy Vitamin D3 or one of its analogues to lower the intact parathyroid hormone (iPTH) levels.

Serum chloride
Serum chloride may increase during Renagel treatment as chloride may be exchanged for phosphorus in the intestinal lumen. Although no clinically significant serum chloride increase has been observed in the clinical studies, serum chloride should be monitored as is done in the routine follow-up of a dialysis patient. One gram of Renagel contains approximately 180 mg (5.1 mEq) chloride.

Inflammatory Gastrointestinal Disorders
Cases of serious inflammatory disorders of different parts of the gastrointestinal tract (including serious complications such as haemorrhage, perforation, ulceration, necrosis, colitis and colonic/caecal mass) associated with the presence of sevelamer crystals have been reported (see section 4.8).
Inflammatory disorders may resolve upon sevelamer discontinuation. Sevelamer hydrochloride treatment should be re-evaluated in patients who develop severe gastrointestinal symptoms.

Dialysis
Interaction studies have not been conducted in patients on dialysis.

Ciprofloxacin
In interaction studies in healthy volunteers, sevelamer hydrochloride decreased the bioavailability of ciprofloxacin by approximately 50% when co-administered with Renagel in a single dose study.
Consequently, Renagel should not be taken simultaneously with ciprofloxacin.

Anti-arrhythmics and anti-seizure medicinal products
Patients taking anti-arrhythmic medicinal products for the control of arrhythmias and anti-seizure medicinal products for the control of seizure disorders were excluded from clinical trials. Caution

should be exercised when prescribing sevelamer hydrochloride to patients also taking these medicinal products.

Levothyroxine
During post marketing experience, very rare cases of increased thyroid stimulating hormone (TSH) levels have been reported in patients co-administered sevelamer hydrochloride and levothyroxine.
Closer monitoring of TSH levels is therefore recommended in patients receiving both medicinal products.

Ciclosporin, mycophenolate mofetil and tacrolimus in transplant patients
Reduced levels of ciclosporin, mycophenolate mofetil and tacrolimus have been reported in transplant patients when coadministered with sevelamer hydrochloride without any clinical consequences (i.e graft rejection). The possibility of an interaction cannot be excluded and a close monitoring of blood concentrations of mycophenolate mofetil, ciclosporin and tacrolimus should be considered during the use of combination and after its withdrawal.

Digoxin, warfarin, enalapril or metoprolol
In interaction studies in healthy volunteers, Renagel had no effect on the bioavailability of digoxin, warfarin, enalapril or metoprolol.

Proton pump inhibitors
During post-marketing experience, very rare cases of increased phosphate levels have been reported in patients taking proton pump inhibitors co-administered with sevelamer hydrochloride.

Bioavailability
Renagel is not absorbed and may affect the bioavailability of other medicinal products. When administering any medicinal product where a reduction in the bioavailability could have a clinically significant effect on safety or efficacy, the medicinal product should be administered at least one hour before or three hours after Renagel, or the physician should consider monitoring blood levels.

Pregnancy
The safety of sevelamer hydrochloride has not been established in pregnant women. In animal studies there was no evidence that sevelamer induced embryo-foetal toxicity. Renagel should only be given to pregnant women if clearly needed and after a careful risk/benefit analysis has been conducted for both the mother and the foetus (see section 5.3).

Breast-feeding
The safety of sevelamer hydrochloride has not been established in breast-feeding women. Renagel should only be given to breast-feeding women if clearly needed and after a careful risk/benefit analysis has been conducted for both the mother and the infant (see section 5.3).

Fertility
There are no data from the effect of sevelamer on fertility in humans. Studies in animals have shown that sevelamer did not impair fertility in male or female rats at exposures at a human equivalent dose 2 times the maximum clinical trial dose of 13 g/day, based on a comparison of relative body surface area.

Sevelamer has no or negligible influence on the ability to drive and use machines.

Renagel has been given to normal healthy volunteers in doses up to 14 grams, the equivalent of thirty five 400 mg tablets per day for eight days with no undesirable effects.

PHARMACOLOGICAL PROPERTIES

Renagel has been given to normal healthy volunteers in doses up to 14 grams, the equivalent of seventeen 800 mg tablets per day for eight days with no undesirable effects.

PHARMACOLOGICAL PROPERTIES

Pharmacotherapeutic group: Treatment of hyperphosphatemia. ATC code: V03AE02.

Renagel contains sevelamer, a non-absorbed phosphate binding poly (allylamine hydrochloride) polymer, free of metal and calcium. It contains multiple amines separated by one carbon from the polymer backbone. These amines become partially protonated in the intestine and interact with phosphate molecules through ionic and hydrogen bonding. By binding phosphate in the gastrointestinal tract, sevelamer lowers the phosphate concentration in the serum.

In clinical trials, sevelamer has been shown to be effective in reducing serum phosphorus in patients receiving haemodialysis or peritoneal dialysis.

Sevelamer decreases the incidence of hypercalcaemic episodes as compared to patients using calcium based phosphate binders alone, probably because the product itself does not contain calcium. The effects on phosphate and calcium were proven to be maintained throughout a study with one year follow-up.

Sevelamer has been shown to bind bile acids in vitro and in vivo in experimental animal models. Bile acid binding by ion exchange resins is a well-established method of lowering blood cholesterol. In clinical trials mean total and LDL cholesterol declined by 15-31%. This effect is observed after 2 weeks is maintained with long-term treatment. Triglycerides, HDL cholesterol and albumin did not change.

In the clinical studies in haemodialysis patients, sevelamer alone did not have a consistent and clinically significant effect on serum intact parathyroid hormone (iPTH). In the 12 week study involving peritoneal dialysis patients however, similar iPTH reductions were seen compared with patients receiving calcium acetate. In patients with secondary hyperparathyroidism Renagel should be used within the context of a multiple therapeutic approach, which could include calcium supplements, 1,25-dihydroxy Vitamin D3 or one of its analogues to lower the iPTH levels.

In a clinical trial of one-year duration, Renagel had no adverse effect on bone turnover or mineralisation compared to calcium carbonate.

Renagel is not absorbed from the gastrointestinal tract according to a single dose pharmacokinetic study in healthy volunteers. Pharmacokinetic studies have not been carried out in renal failure patients (see section 4.4).