Systemic ion balance

BindRen binds phosphate and bile acid, with the release of chloride which is available for systemic absorption. Changes in systemic ion balance with an increase in chloride and decrease in bicarbonate are therefore possible. However, BindRen did not induce any clinically relevant change in chloride and bicarbonate on treatment for up to one year.

4.5 Interaction with other medicinal products and other forms of interaction
 BindRen is not absorbed from the gastrointestinal tract but may affect the bioavailability or absorption rate of other medicinal products. In addition, reduced bioavailability of other medicinal products by changes in enterohepatic circulation, for example, steroid hormones with potential impairment of the effectiveness of oral contraceptives, have been reported for medicinal products with a similar mechanism of action to BindRen. When administering any medicinal product where a reduction in the bioavailability could have a clinically relevant effect on safety or efficacy, the medicinal product should be administered at least 1 hour before, or 3 hours after taking BindRen. Concomitant treatment with medicinal products with a narrow therapeutic window requires close monitoring of drug concentrations or adverse reactions, on initiation or dose-adjustment of either BindRen or the concomitant medicinal product.

Interaction studies have been conducted in healthy volunteers. Interactions have not been studied at doses >9 g daily, and greater interaction effects at higher doses of BindRen cannot be excluded.

Single dose interaction studies demonstrated that the bioavailability of ciprofloxacin, warfarin and enalapril were not affected when co-administered with BindRen (6-9 g/day). BindRen lowered the bioavailability of digoxin by 16% and Cmax by 17%, and the Cmax of enalapril by 27%.

Due to the high in vitro binding potential between BindRen and levothyroxine, closer monitoring of thyroid stimulating hormone (TSH) levels in patients receiving BindRen and levothyroxine is recommended.

No in vivo data are available on the possible interaction of BindRen on the absorption of the immunosuppressant medicinal products mycophenolate mofetil, ciclosporin or tacrolimus. However, decreased blood concentrations have been reported for medicinal products with a similar mechanism of action to BindRen. Caution should be exercised when prescribing BindRen to patients receiving immunosuppressants.

Patients with seizure disorders were excluded from clinical trials with BindRen. Caution should be exercised when prescribing BindRen to patients also taking anti-seizure medicinal products.

4.6 Fertility, pregnancy and lactation
 BindRen is not absorbed and is not systemically available. No direct effects of BindRen are thus anticipated. However, other effects of BindRen may affect pregnant and breast-feeding women or influence fertility, see sections 4.4 and 4.5.

Pregnancy

No data are available to assess the safety and efficacy in pregnant women.

Patients that become pregnant and where a benefit/risk assessment confirms continued treatment with BindRen, supplementation of vitamins may be required, see section 4.4.

Breast-feeding

No data are available to assess the safety and efficacy in breast-feeding w