RENVELA POWDER FOR ORAL SUSPENSION 0.8G 2.4G 1.6G
药品名称
通用名：碳酸司维拉姆
英文名：Sevelamer carbonate
剂型：干混悬剂。
规格：0.8g、2.4g、1.6g（欧盟）。
适应症：慢性肾病透析患者的血清磷水平控制。
用法用量：
本品起始剂量为一日3次、每次1600mg，随餐服用。根据患者血清磷水平达标(3.5～5.5g/L)情况，2周后剂量可调整至每次800mg。
特点
司维拉姆作为现今唯一一种既不含钙、又不含有金属的磷酸盐结合剂。它不会为系统吸收，故能在提供安全、有效控制血清磷作用的同时还无钙和金属蓄积的担忧。司维拉姆尚有显著的低密度脂蛋白胆固醇水平降低的额外益处。
透析人群常见血清磷水平升高，会使心血管发病率和死亡率升高。因此控制血清磷浓度是必要的。碳酸司维拉姆不仅保留了盐酸司维拉姆的所有优点．且它还能同时提供碳酸盐缓冲剂的额外益处。一项直接临床比较证实碳酸司维拉姆和盐酸司维拉姆两药控制正行透析之慢性肾病人群血清磷浓度的疗效相当，但碳酸司维拉姆治疗个体更可能维持适宜的碳酸氢盐水平，故胃肠道副反应发生率更低。
1. Name of the medicinal product
Renvela 2.4g powder for oral suspension
2. Qualitative and quantitative composition
Each sachet contains 2.4g sevelamer carbonate.
For a full list of excipients, see section 6.1.
3. Pharmaceutical form
Powder for oral suspension.
Pale yellow powder.
4. Clinical particulars
4.1 Therapeutic indications
Renvela is indicated for the control of hyperphosphataemia in adult patients receiving haemodialysis or peritoneal dialysis.
Renvela is also indicated for the control of hyperphosphataemia in adult patients with chronic kidney disease patients not on dialysis with serum phosphorus > 1.78 mmol/l.
Renvela should be used within the context of a multiple therapeutic approach, which could include calcium supplement, 1,25-dihydroxy Vitamin D3 or one of its analogues to control the development of renal bone disease.
4.2 Posology and method of administration
Posology:
Starting dose
The recommended starting dose of sevelamer carbonate is 2.4 g or 4.8 g per day based on clinical needs and serum phosphorus level. Renvela powder for oral suspension must be taken three times per day with meals.
Serum phosphorus level in patients
Total daily dose of sevelamer carbonate to be taken over 3 meals per day
1.78 – 2.42 mmol/l (5.5 – 7.5 mg/dl)
2.4 g*
> 2.42 mmol/l (> 7.5 mg/dl)
4.8 g*
*Plus subsequent titrating as per instructions
For patients previously on phosphate binders (sevelamer hydrochloride or calcium based), Renvela should be given on a gram for gram basis with monitoring of serum phosphorus levels to ensure optimal daily doses.
Titration and Maintenance
Serum phosphorus should be monitored and the dose of sevelamer carbonate titrated every 2‑4 weeks until an acceptable serum phosphorus level is reached, with regular monitoring thereafter.
Patients taking Renvela should adhere to their prescribed diets.
In clinical practice, treatment will be continuous based on the need to control serum phosphorus levels and the daily dose is expected to be an average of approximately 6 g per day.
Paediatric population
The safety and efficacy of Renvela has not been established in children below the age of 18 years. Renvela is not recommended in children below the age of 18 years.
Method of administration
The powder should be dispersed in 60 ml of water per sachet prior to administration. The suspension should be ingested within 30 minutes after being prepared.
4.3 Contraindications
• Hypersensitivity to the active substance or to any of the excipients.
• Hypophosphataemia
• Bowel obstruction.
4.4 Special warnings and precautions for use
Efficacy and safety of Renvela has not been studied in children below the age of 18 years.
The safety and efficacy of Renvela have not been established in adult patients with chronic kidney disease not on dialysis with serum phosphorus < 1.78 mmol/l. Therefore Renvela is currently not recommended for use in these patients.
The safety and efficacy of Renvela have not been established in patients with the following disorders:
• dysphagia
• swallowing disorders
• severe gastrointestinal motility disorders including untreated or severe gastroparesis, retention of gastric contents and abnormal or irregular bowel motion
• active inflammatory bowel disease
• major gastrointestinal tract surgery
Therefore caution should be exercised when Renvela is used in these patients.
Intestinal obstruction and ileus/subileus
In very rare cases, intestinal obstruction and ileus/subileus have been observed in patients during treatment with sevelamer hydrochloride, which contains the same active moiety as sevelamer carbonate. Constipation may be a preceding symptom. Patients who are constipated should be monitored carefully while being treated with Renvela. Renvela treatment should be re‑eva luated in patients who develop severe constipation or other severe gastrointestinal symptoms.
Fat‑soluble vitamins
Patients with CKD may develop low levels of fat-soluble vitamins A, D, E and K, depending on dietary intake and the severity of their disease. It cannot be excluded that Renvela can bind fat‑soluble vitamins contained in ingested food. In patients not taking supplemental vitamins but on sevelamer, serum vitamin A, D, E and K status should be assessed regularly. It is recommended that vitamin supplements be given if necessary. It is recommended that CKD patients not on dialysis are given vitamin D supplements (approximately 400 IU of native vitamin D daily) which can be part of a multivitamin preparation to be taken apart from their dose of Renvela. In patients undergoing peritoneal dialysis additional monitoring of fat-soluble vitamins and folic acid is recommended, since vitamin A, D, E and K levels were not measured in a clinical study in these patients.
Folate deficiency
There is at present insufficient data to exclude the possibility of folate deficiency during long term Renvela treatment.
Hypocalcaemia/hypercalcaemia
Patients with CKD may develop hypocalcaemia or hypercalcaemia. Renvela does not contain any calcium. Serum calcium levels should therefore be monitored at regular intervals and elemental calcium should be given as a supplement if required.
Metabolic acidosis
Patients with chronic kidney disease are predisposed to developing metabolic acidosis. As part of good clinical practice, monitoring of serum bicarbonate levels is therefore recommended.
Peritonitis
Patients receiving dialysis are subject to certain risks for infection specific to dialysis modality. Peritonitis is a known complication in patients receiving peritoneal dialysis and in a clinical study with sevelamer hydrochloride, a greater number of peritonitis cases were reported in the sevelamer group than in the control group. Patients on peritoneal dialysis should be closely monitored to ensure the correct use of appropriate aseptic technique with the prompt recognition and management of any signs and symptoms associated with peritonitis.
Anti‑arrhythmic and anti‑seizure medicinal products
Caution should be exercised when prescribing Renvela to patients also taking anti‑arrhythmias and anti‑seizure medicinal products (see section 4.5).
Hypothyroidism
Closer monitoring of patients with hypothyroidism co-administered with sevelamer carbonate and levothryroxine is recommended (see section 4.5).
Long‑term chronic treatment
In a clinical trial of one year, no evidence of accumulation of sevelamer was seen. However the potential absorption and accumulation of sevelamer during long‑term chronic treatment (> one year) cannot be totally excluded (see section 5.2).
Hyperparathyroidism
Renvela is not indicated for the control of hyperparathyroidism. In patients with secondary hyperparathyroidism Renvela should be used within the context of a multiple therapeutic approach, which could include calcium as supplements, 1,25 - dihydroxy Vitamin D3 or one of its analogues to lower the intact parathyroid hormone (iPTH) levels.
4.5 Interaction with other medicinal products and other forms of interaction
Interaction studies have not been conducted in patients on dialysis.
In interaction studies in healthy volunteers, sevelamer hydrochloride, which contains the same active moiety as Renvela, decreased the bioavailability of ciprofloxacin by approximately 50% when co-administered with sevelamer hydrochloride in a single dose study. Consequently, Renvela should not be taken simultaneously with ciprofloxacin.
Reduced levels of ciclosporin, mycophenolate mofetil and tacrolimus have been reported in transplant patients when co-administered 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 ciclosporin, mycophenolate mofetil and tacrolimus should be considered during the use of combination and after its withdrawal.
Very rare cases of hypothyroidism have been reported in patients co-administered sevelamer hydrochloride, which contains the same active moiety as sevelamer carbonate, and levothyroxine. Closer monitoring of thyroid stimulating hormone (TSH) levels is therefore recommended in patients receiving sevelamer carbonate and levothyroxine.
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 Renvela to patients also taking these medicinal products.
In interaction studies in healthy volunteers, sevelamer hydrochloride, which contains the same active moiety as Renvela, had no effect on the bioavailability of digoxin, warfarin, enalapril or merolol.
Renvela is not absorbed compound 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 Renvela, or the physician should consider monitoring blood levels.
4.6 Fertility, pregnancy and lactation
Pregnancy:
There are no data from the use of sevelamer in pregnant women. Studies in animals have shown some reproductive toxicity when sevelamer was administered to rats at high doses (see section 5.3). Sevelamer has also been shown to reduce the absorption of several vitamins including folic acid (see sections 4.4 and 5.3). The potential risk to humans is unknown. Renvela 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.
Lactation:
It is unknown whether sevelamer is excreted in human breast milk. The non‑absorbed nature of sevelamer indicates that excretion of sevelamer in breast milk is unlikely. A decision on whether to continue/discontinue breast‑feeding or to continue/discontinue therapy with Renvela should be made taking into account the benefit of breast‑feeding to the child and the benefit of Renvela therapy to the woman.
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.
4.7 Effects on ability to drive and use machines
No studies on the effects on ability to drive and use machines have been performed.
4.8 Undesirable effects
The safety of sevelamer (as either carbonate and hydrochloride salts) has been investigated in numerous clinical trials involving a total of 969 haemodialysis patients with treatment duration of 4 to 50 weeks (724 patients treated with sevelamer hydrochloride and 245 with sevelamer carbonate), 97 peritoneal dialysis patients with treatment duration of 12 weeks (all treated with sevelamer hydrochloride) and 128 patients with CKD not on dialysis with treatment duration of 8 to 12 weeks (79 patients treatment with sevelamer hydrochloride and 49 with sevelamer carbonate).
The most frequently occurring (≥ 5% of patients) undesirable effects possibly or probably related to sevelamer were all in the gastrointestinal disorders system organ class. Most of these adverse reactions were mild to moderate in intensity. Data possibly or probably related to sevelamer from these studies are listed by frequency in the table below. The reporting rate is classified as very common (≥1/10), common (≥1/100, <1/10), uncommon (≥1/1,000, <1/100), rare (≥1/10,000, <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data).
Gastrointestinal disorders
Very common : Nausea, vomiting, upper abdominal pain, constipation
Common : Diarrhoea, dyspepsia, flatulence, abdominal pain
Post-marketing experience: During post-approval use, cases of pruritus, rash, intestinal obstruction, ileus/subileus, and intestinal perforation have been reported in patients during treatment with sevelamer.
4.9 Overdose
No cases of overdose have been reported. Sevelamer hydrochloride, which contains the same active moiety as sevelamer carbonate, has been given to normal healthy volunteers in doses of up to 14 grams per day for eight days with no undesirable effects. In CKD patients, the maximum average daily dose studied was 14.4 grams of sevelamer carbonate in a single daily dose.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Treatment of hyperphosphataemia. ATC code: V03A E02.
Renvela contains sevelamer, a non-absorbed phosphate binding crosslinked polymer, free of metal and calcium. Sevelamer contains multiple amines separated by one carbon from the polymer backbone which become protonated in the stomach. These protonated amines bind negatively charged ions such as dietary phosphate in the intestine. By binding phosphate in the gastrointestinal tract and decreasing absorption, sevelamer lowers the phosphorus concentration in the serum. Regular monitoring of serum phosphorus levels is always necessary during phosphate binder administration.
In two randomised, cross over clinical studies, sevelamer carbonate has been shown to be therapeutically equivalent to sevelamer hydrochloride and therefore effective in controlling serum phosphorus in CKD patients on haemodialysis. These also demonstrated that sevelamer carbonate in both tablet and powder formulations are therapeutically equivalent to sevelamer hydrochloride.
The first study demonstrated that sevelamer carbonate tablets dosed three times per day was equivalent to sevelamer hydrochloride tablets dosed three times per day in 79 haemodialysis patients treated over two randomised 8 week treatment periods (mean serum phosphorus time-weighted averages were 1.5 ± 0.3 mmol/l for both sevelamer carbonate and sevelamer hydrochloride). The second study demonstrated that sevelamer carbonate powder dosed three times per day was equivalent to sevelamer hydrochloride tablets dosed three times per day in 31 hyperphosphataemic (defined as serum phosphorus levels ≥ 1.78 mmol/l) haemodialysis patients over two randomised 4 week treatment periods (mean serum phosphorus time-weighted averages were 1.6 ± 0.5 mmol/l for sevelamer carbonate powder and 1.7 ± 0.4 mmol/l for sevelamer hydrochloride tablets).
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 a 12 week study involving peritoneal dialysis patients however, similar iPTH reductions were seen compared with patients receiving calcium acetate. In patients with secondary hyperparathyroidism Renvela should be used within the context of a multiple therapeutic approach, which could include calcium as supplements, 1,25 – dihydroxy Vitamin D3 or one of its analogues to lower the intact parathyroid hormone (iPTH) levels.
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 of sevelamer, both the mean total-cholesterol and LDL-cholesterol declined by 15-39%. The decrease in cholesterol has been observed after 2 weeks of treatment and is maintained with long-term treatment. Triglycerides, HDL-cholesterol and albumin levels did not change following sevelamer treatment.
Because sevelamer binds bile acids, it may interfere with the absorption of fat soluble vitamins such as A, D, E and K.
Sevelamer does not contain calcium and decreases the incidence of hypercalcaemic episodes as compared to patients using calcium based phosphate binders alone. The effects of sevelamer on phosphorus and calcium were proven to be maintained throughout a study with one year follow-up. This information was obtained from studies in which sevelamer hydrochloride was used.
5.2 Pharmacokinetic properties
Pharmacokinetic studies have not been carried out with sevelamer carbonate. Sevelamer hydrochloride, which contains the same active moiety as sevelamer carbonate, is not absorbed from the gastrointestinal tract, as confirmed by an absorption study in healthy volunteers.
5.3 Preclinical safety data
Non-clinical data with sevelamer reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity or genotoxicity.
Carcinogenicity studies with oral sevelamer hydrochloride were conducted in mice (doses of up to 9 g/kg/day) and rats (0.3, 1, or 3 g/kg/day). There was an increased incidence of urinary bladder transitional cell papilloma in male rats of the high dose group (human equivalent dose twice the maximum clinical trial dose of 14.4 g). There was no increased incidence of tumors observed in mice (human equivalent dose 3 times the maximum clinical trial dose).
In an in vitro mammalian cytogenetic test with metabolic activation, sevelamer hydrochloride caused a statistically significant increase in the number of structural chromosome aberrations. Sevelamer hydrochloride was not mutagenic in the Ames bacterial mutation assay.
In rats and dogs, sevelamer reduced absorption of fat soluble vitamins D, E and K (coagulation factors), and folic acid.
Deficits in skeletal ossification were observed in several locations in foetuses of female rats dosed with sevelamer at intermediate and high doses (human equivalent dose less than the maximum clinical trial dose of 14.4 g). The effects may be secondary to vitamin D depletion.
In pregnant rabbits given oral doses of sevelamer hydrochloride by gavage during organogenesis, an increase of early resorptions occurred in the high-dose group (human equivalent dose twice the maximum clinical trial dose).
Sevelamer hydrochloride did not impair the fertility of male or female rats in a dietary administration study in which the females were treated from 14 days prior to mating through gestation and the males were treated for 28 days prior to mating. The highest dose in this study was 4.5 g/kg/day (human equivalent dose 2 times the maximum clinical trial dose of 13 g/day, based on a comparison of relative body surface area).
6. Pharmaceutical particulars
6.1 List of excipients
Propylene glycol alginate
Citrus Cream flavour
Sodium chloride
Sucralose
Iron oxide yellow (E172)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
The shelf‑life for the powder for oral suspension is 3 years.
The reconstituted suspension must be administered within 30 minutes of reconstitution.
6.4 Special precautions for storage
The medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
Sachet of ethylene methacrylic acid copolymer, polyester, low density polyethylene and aluminium foil laminate, with a heat seal, containing a single dose.
Each sachet contains 2.4g of sevelamer carbonate. Each carton contains 60 or 90 sachets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
The powder should be dispersed in 60 ml of water per sachet prior to administration. The suspension powder is pale yellow with a citrus flavour.
No special requirements for disposal.
7. Marketing authorisation holder
Genzyme Europe B.V.
Gooimeer 10
1411 DD Naarden
The Netherlands
8. Marketing authorisation number(s)
EU/1/09/521/006
EU/1/09/521/007
9. Date of first authorisation/renewal of the authorisation
10/06/2009
