NDC 0143-9596 Paricalcitol

Paricalcitol

NDC Product Code 0143-9596

NDC CODE: 0143-9596

Proprietary Name: Paricalcitol What is the Proprietary Name?
The proprietary name also known as the trade name is the name of the product chosen by the medication labeler for marketing purposes.

Non-Proprietary Name: Paricalcitol What is the Non-Proprietary Name?
The non-proprietary name is sometimes called the generic name. The generic name usually includes the active ingredient(s) of the product.

Drug Use Information

Drug Use Information
The drug use information is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate. This information is not individual medical advice and does not substitute for the advice of a health care professional. Always ask a health care professional for complete information about this product and your specific health needs.

  • Paricalcitol is a man-made active form of vitamin D, which is needed for building and keeping strong bones. Paricalcitol is used in patients with long-term kidney disease to treat or prevent high levels of a certain natural substance made by the body (parathyroid hormone). Too much parathyroid hormone can cause serious problems such as bone disorders. Most people get enough vitamin D from exposure to the sun and from fortified food products (e.g., dairy products, vitamins). Before regular vitamin D can be used by the body, it needs to be changed to the active form by the liver and kidneys. People with kidney disease cannot make enough of the active form of vitamin D. Vitamin D helps control parathyroid hormone and the levels of certain minerals (e.g., calcium, phosphorus) that are needed for building and keeping strong bones.

NDC Code Structure

  • 0143 - West-ward Pharmaceuticals Corp

NDC 0143-9596-25

Package Description: 25 VIAL, MULTI-DOSE in 1 CARTON > 2 mL in 1 VIAL, MULTI-DOSE (0143-9596-01)

NDC Product Information

Paricalcitol with NDC 0143-9596 is a a human prescription drug product labeled by West-ward Pharmaceuticals Corp. The generic name of Paricalcitol is paricalcitol. The product's dosage form is injection and is administered via intravenous form.

Labeler Name: West-ward Pharmaceuticals Corp

Dosage Form: Injection - A sterile preparation intended for parenteral use; five distinct classes of injections exist as defined by the USP.

Product Type: Human Prescription Drug What kind of product is this?
Indicates the type of product, such as Human Prescription Drug or Human Over the Counter Drug. This data element matches the “Document Type” field of the Structured Product Listing.

Paricalcitol Active Ingredient(s)

What is the Active Ingredient(s) List?
This is the active ingredient list. Each ingredient name is the preferred term of the UNII code submitted.

  • PARICALCITOL 5 ug/mL

Inactive Ingredient(s)

About the Inactive Ingredient(s)
The inactive ingredients are all the component of a medicinal product OTHER than the active ingredient(s). The acronym "UNII" stands for “Unique Ingredient Identifier” and is used to identify each inactive ingredient present in a product.

  • ALCOHOL (UNII: 3K9958V90M)
  • SORBITOL (UNII: 506T60A25R)
  • WATER (UNII: 059QF0KO0R)
  • ALCOHOL (UNII: 3K9958V90M)
  • SORBITOL (UNII: 506T60A25R)
  • WATER (UNII: 059QF0KO0R)
  • ALCOHOL (UNII: 3K9958V90M)
  • SORBITOL (UNII: 506T60A25R)
  • WATER (UNII: 059QF0KO0R)

Administration Route(s)

What are the Administration Route(s)?
The translation of the route code submitted by the firm, indicating route of administration.

  • Intravenous - Administration within or into a vein or veins.
  • Intravenous - Administration within or into a vein or veins.

Pharmacological Class(es)

What is a Pharmacological Class?
These are the reported pharmacological class categories corresponding to the SubstanceNames listed above.

  • Cholecalciferol - [CS]
  • Vitamin D3 Analog - [EPC] (Established Pharmacologic Class)

Product Labeler Information

What is the Labeler Name?
Name of Company corresponding to the labeler code segment of the Product NDC.

Labeler Name: West-ward Pharmaceuticals Corp
Labeler Code: 0143
FDA Application Number: NDA205917 What is the FDA Application Number?
This corresponds to the NDA, ANDA, or BLA number reported by the labeler for products which have the corresponding Marketing Category designated. If the designated Marketing Category is OTC Monograph Final or OTC Monograph Not Final, then the Application number will be the CFR citation corresponding to the appropriate Monograph (e.g. “part 341”). For unapproved drugs, this field will be null.

Marketing Category: NDA - A product marketed under an approved New Drug Application. What is the Marketing Category?
Product types are broken down into several potential Marketing Categories, such as NDA/ANDA/BLA, OTC Monograph, or Unapproved Drug. One and only one Marketing Category may be chosen for a product, not all marketing categories are available to all product types. Currently, only final marketed product categories are included. The complete list of codes and translations can be found at www.fda.gov/edrls under Structured Product Labeling Resources.

Start Marketing Date: 11-18-2014 What is the Start Marketing Date?
This is the date that the labeler indicates was the start of its marketing of the drug product.

Listing Expiration Date: 12-31-2021 What is the Listing Expiration Date?
This is the date when the listing record will expire if not updated or certified by the product labeler.

Exclude Flag: N What is the NDC Exclude Flag?
This field indicates whether the product has been removed/excluded from the NDC Directory for failure to respond to FDA’s requests for correction to deficient or non-compliant submissions. Values = ‘Y’ or ‘N’.

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Paricalcitol Product Labeling Information

The product labeling information includes all published material associated to a drug. Product labeling documents include information like generic names, active ingredients, ingredient strength dosage, routes of administration, appearance, usage, warnings, inactive ingredients, etc.

Product Labeling Index

1 Indications And Usage

Paricalcitol Injection is an active vitamin D2 analogue indicated for the prevention and treatment of secondary hyperparathyroidism associated with chronic kidney disease (CKD) Stage 5.

2 Dosage And Administration

For intravenous use through hemodialysis vascular access port only.The recommended starting dose of Paricalcitol Injection is 0.04 mcg/kg to 0.1 mcg/kg (2.8 – 7 mcg) administered through a hemodialysis vascular access port as a bolus dose at any time during dialysis. Dosing should not occur more frequently than every other day. The drug product should not be injected directly into a vein. Dosage should be individualized.  If a satisfactory parathyroid hormone (PTH) lowering response is not observed using the recommended starting dose, the dose may be increased by 2 to 4 mcg every 2 to 4 weeks based on PTH levels (refer to Table 1).Table 1: Suggested Dosage AdjustmentPTH Level at Follow-up VisitDosage Adjustment  Above target and PTH increased Increase Above target and PTH decreased by less than 30% Increase Above target and PTH decreased by 30 to 60% No Change Above target and PTH decreased by more than 60% Decrease At target and PTH stable No ChangeWhen initiating Paricalcitol Injection or adjusting Paricalcitol Injection dose, measure serum calcium and phosphorus frequently (e.g., twice weekly) and PTH every 2 to 4 weeks. Once a maintenance dose has been established, serum calcium and phosphorus should be measured at least monthly and plasma PTH every 3 months.

3 Dosage Forms And Strengths

  • Paricalcitol Injection is available in the following presentations:2 mcg per mL single dose vial5 mcg per mL single dose vial10 mcg per 2 mL (5 mcg per mL) multiple dose vial

4 Contraindications

  • Paricalcitol Injection is contraindicated in patients with evidence of: Hypercalcemia [see Warnings and Precautions (5.1)]
  • Vitamin D toxicity [see Warnings and Precautions (5.1)] or
  • Hypersensitivity to paricalcitol or any inactive ingredient in this product [see Adverse Reactions (6.2)]

5.1 Hypercalcemia

Hypercalcemia may occur during Paricalcitol Injection treatment and may be exacerbated by concomitant administration of high doses of calcium containing preparations, thiazide diuretics, or vitamin D (i.e., all forms). Acute hypercalcemia may exacerbate tendencies for cardiac arrhythmias and seizures and may potentiate the effect of digitalis on the heart. Chronic hypercalcemia can lead to generalized vascular calcification and other soft-tissue calcification. Hypercalcemia may be so severe as to require emergency attention.  High intake of calcium and phosphate concomitantly with vitamin D compounds may lead to hypercalcemia, hypercalciuria, and hyperphosphatemia. Prevention of such adverse reactions requires frequent serum calcium monitoring and careful Paricalcitol Injection dose adjustments.Concomitant use with other active vitamin D analogues should be avoided during Paricalcitol Injection treatment to prevent hypercalcemia.Patients also should be informed about the symptoms of elevated calcium, which include feeling tired, difficulty thinking clearly, loss of appetite, nausea, vomiting, constipation, increased thirst, increased urination and weight loss.

5.2 Digitalis Toxicity

Hypercalcemia of any cause increases the risk of digitalis toxicity. In patients using Paricalcitol Injection concomitantly with digitalis compounds, monitor both serum calcium and patients for signs and symptoms of digitalis toxicity and increase frequency of monitoring when initiating or adjusting the dose of Paricalcitol Injection [see Dosage and Administration (2)].

5.3 Risk Of Increased Paricalcitol Levels With Concomitant Use Of Strong Cyp3a Inhibitors

Concomitant use of Paricalcitol Injection with strong CYP3A inhibitors will increase the levels of paricalcitol in the blood. In patients on Paricalcitol Injection who are initiating or discontinuing therapy with drugs known to be strong CYP3A inhibitors, monitor serum calcium and PTH more frequently and adjust Paricalcitol Injection dose as required [see Drug Interactions (7.1), Clinical Pharmacology (12.3)].

5.4 Adynamic Bone Disease

Adynamic bone disease with subsequent increased risk of fractures may develop if PTH levels are suppressed to abnormally low levels. Monitor PTH levels and adjust Paricalcitol Injection dose [see Dosage and Administration (2)].

6.1 Clinical Trials Experience

Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.Safety has been evaluated in clinical studies conducted with another paricalcitol injection product in 609 patients with CKD Stage 5. In four, placebo-controlled, double-blind, multicenter studies, discontinuation of therapy due to any adverse event occurred in 6.5% of 62 patients treated with paricalcitol injection (dosage titrated as tolerated, [see Clinical Studies (14)]) and 2% of 51 patients treated with placebo for 1 to 3 months. Adverse reactions occurring with greater frequency in the paricalcitol group and at a frequency of 2% or greater are presented in the following table:Table 2: Adverse Reactions Occurring at a RateA patient who reported the same medical term more than once was counted only once for that medical term.of 2% or Greater in CKD Stage 5 Patients in Four Placebo-Controlled Studies Adverse ReactionPlacebo(n=51)%Paricalcitol Injection(n=62)% Cardiac Disorders Palpitations0.03.2 Gastrointestinal Disorders Nausea7.812.9 Vomiting5.98.1 Gastrointestinal Hemorrhage2.04.8 Dry Mouth2.03.2 General Disorders and Administration Site Conditions Edema0.06.5 Chills2.04.8 Pyrexia2.04.8 Malaise0.03.2 Infections and Infestations Pneumonia0.04.8 Sepsis2.04.8 Influenza3.94.8 Musculoskeletal and Connective Tissue Disorders Arthralgia3.94.8Specific laboratory parameters [i.e., changes in mean Calcium (Ca), Phosphorus (P), and Calcium Phosphorus product (Ca × P)] were followed in an open-label safety study conducted with another paricalcitol injection product for up to 13 months in duration in this patient population and results are shown below [see Clinical Studies (14)].Other Adverse Reactions Associated with Paricalcitol Injection Use                          The following adverse reactions occurred in less than 2% of the paricalcitol-treated patients in the above mentioned double-blind, placebo-controlled clinical trials and in additional double-blind, active-controlled and open-label studies:Blood and Lymphatic System Disorders: Anemia, lymphadenopathy Cardiac Disorders: Arrhythmia, atrial flutter, cardiac arrest Ear and Labyrinth Disorders: Ear discomfort Endocrine Disorders: Hypoparathyroidism Eye Disorders: Conjunctivitis, glaucoma, ocular hyperemia Gastrointestinal Disorders: Abdominal discomfort, constipation, diarrhea, dysphagia, gastritis, intestinal ischemia, rectal hemorrhage General Disorders and Administration Site Conditions: Asthenia, chest discomfort, chest pain, condition aggravated, edema peripheral, fatigue, feeling abnormal, gait disturbance, injection site extravasation, injection site pain, pain, swelling, thirst Infections and Infestations: Nasopharyngitis, upper respiratory tract infection, vaginal infection Laboratory Investigations and Vital Signs: Increased aspartate aminotransferase, prolonged bleeding time, irregular heart rate, decreased weight Metabolism and Nutrition Disorders: Decreased appetite, hypercalcemia, hyperkalemia, hyperphosphatemia, hypocalcemia Musculoskeletal and Connective Tissue Disorders: Joint stiffness, muscle twitching, myalgia Neoplasms Benign, Malignant and Unspecified: Breast cancerNervous System Disorders: Cerebrovascular accident, dizziness, dysgeusia, headache, hypoesthesia, myoclonus, paresthesia, syncope, unresponsive to stimuli Psychiatric Disorders: Agitation, confusional state, delirium, insomnia, nervousness, restlessness Reproductive System and Breast Disorders: Breast pain, erectile dysfunction Respiratory, Thoracic and Mediastinal Disorders: Cough, dyspnea, orthopnea, pulmonary edema, wheezing Skin and Subcutaneous Tissue Disorders: Alopecia, blister, hirsutism, night sweats, rash pruritic, pruritus, skin burning sensationVascular Disorders: Hypertension, hypotension

6.2 Postmarketing Experience

The following adverse reactions have been identified during post approval use of another paricalcitol injection product. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.Allergic reactions including rash, urticaria, and angioedema (including laryngeal edema) have been reported.

7.1 Strong Cyp3a Inhibitors

Paricalcitol is partially metabolized by CYP3A. Paricalcitol blood levels will be increased when paricalcitol is co-administered with strong CYP3A inhibitors. If a patient initiates or discontinues therapy with a strong CYP3A inhibitor, monitor both PTH and serum calcium more frequently and adjust Paricalcitol Injection dose as required [see Clinical Pharmacology (12.3)].

8.1 Pregnancy

Pregnancy Category CParicalcitol has been shown to cause minimal decreases in fetal viability (5%) when administered daily to rabbits at a dose 0.5 times the 0.24 mcg/kg human dose (based on surface area, mg/m2) and when administered to rats at a dose 2 times the 0.24 mcg/kg human dose (based on plasma levels of exposure). At the highest dose tested (20 mcg/kg 3 times per week in rats, 13 times the 0.24 mcg/kg human dose based on surface area), there was a significant increase of the mortality of newborn rats at doses that were maternally toxic (hypercalcemia). No other effects on offspring development were observed. Paricalcitol was not teratogenic at the doses tested.There are no adequate and well-controlled studies in pregnant women. Paricalcitol Injection should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus.

8.3 Nursing Mothers

Studies in rats have shown that paricalcitol is present in the milk. It is not known whether paricalcitol is excreted in human milk. In the nursing patient, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

8.4 Pediatric Use

The safety and effectiveness of paricalcitol injection were examined with another paricalcitol injection product in a 12-week randomized, double-blind, placebo-controlled study of 29 pediatric patients, aged 5-19 years, with end-stage renal disease on hemodialysis and nearly all had received some form of vitamin D prior to the study. Seventy-six percent of the patients were male, 52% were Caucasian and 45% were African-American. The initial dose of paricalcitol injection was 0.04 mcg/kg 3 times per week based on baseline iPTH level of less than 500 pg/mL, or 0.08 mcg/kg 3 times a week, based on baseline iPTH level of ≥ 500 pg/mL, respectively. The dose of paricalcitol injection was adjusted in 0.04 mcg/kg increments based on the levels of serum iPTH, calcium and Ca x P. The mean baseline levels of iPTH were 841 pg/mL for the 15 paricalcitol injection-treated patients and 740 pg/mL for the 14 placebo-treated subjects. The mean dose of paricalcitol injection administered was 4.6 mcg (range: 0.8 mcg-9.6 mcg). Ten of the 15 (67%) paricalcitol injection-treated patients and 2 of the 14 (14%) placebo-treated patients completed the trial. Ten of the placebo patients (71%) were discontinued due to excessive elevations in iPTH levels as defined by 2 consecutive iPTH levels > 700 pg/mL and greater than baseline after 4 weeks of treatment.In the primary efficacy analysis, 9 of 15 (60%) subjects in the paricalcitol injection group had 2 consecutive 30% decreases from baseline iPTH compared with 3 of 14 (21%) patients in the placebo group (95% CI for the difference between groups -1%, 63%). Twenty-three percent of paricalcitol injection vs. 31% of placebo patients had at least one serum calcium level > 10.3 mg/dL and 40% vs. 14% of paricalcitol injection vs. placebo subjects had at least one Ca x P ion product > 72 (mg/dL)2. The overall percentage of serum calcium measurements >10.3 mg/dL was 7% in the paricalcitol injection group and 7% in the placebo group; the overall percentage of patients with Ca x P product >72 (mg/dL)2 was 8% in the paricalcitol injection group and 7% in the placebo group. No subjects in either the paricalcitol injection group or placebo group developed hypercalcemia (defined as at least one calcium value > 11.2 mg/dL) during the study.

8.5 Geriatric Use

Clinical studies of paricalcitol injection did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

10 Overdosage

Overdosage of Paricalcitol Injection may lead to hypercalcemia, hypercalciuria, hyperphosphatemia, and oversuppression of PTH resulting in adynamic bone disease. [see Warnings and Precautions (5.1, 5.4)].

10.1 Treatment Of Overdosage And Hypercalcemia

The treatment of acute overdosage should consist of supportive measures, discontinuation of drug administration and supplemental calcium, institution of a low calcium diet. Serum calcium levels should be measured until normocalcemia ensues. When serum calcium levels have returned to within normal limits, Paricalcitol Injection may be reinitiated at a lower dose.Paricalcitol is not significantly removed by dialysis.

11 Description

Paricalcitol, USP, the active ingredient in Paricalcitol Injection, is a synthetically manufactured active vitamin D2 analog. It is a white powder chemically designated as 19-nor-1α,3β,25-trihydroxy-9,10-secoergosta-5(Z),7(E),22(E)-triene and has the following structural formula: Paricalcitol Injection is available as a sterile, clear, colorless, aqueous solution for intravenous injection. Each mL contains paricalcitol 2 mcg or 5 mcg and the following inactive ingredients: alcohol, 35% (v/v) and 70% sorbitol solution 7% (v/v) in water for injection.

12.1 Mechanism Of Action

Preclinical and in vitro studies have demonstrated that paricalcitol's biological actions are mediated through binding of the vitamin D receptor (VDR), which results in the selective activation of vitamin D responsive pathways. Vitamin D and paricalcitol have been shown to reduce parathyroid hormone levels by inhibiting PTH synthesis and secretion.

12.3 Pharmacokinetics

Within two hours after administering paricalcitol intravenous doses ranging from 0.04 to 0.24 mcg/kg, concentrations of paricalcitol decreased rapidly; thereafter, concentrations of paricalcitol declined log-linearly. No accumulation of paricalcitol was observed with three times a week dosing.Distribution: Paricalcitol is extensively bound to plasma proteins (≥ 99.8%). In healthy subjects, the steady state volume of distribution is approximately 23.8 L. The mean apparent volume of distribution following a 0.24 mcg/kg dose of paricalcitol in CKD Stage 5 subjects requiring hemodialysis (HD) and peritoneal dialysis (PD) is between 31 and 35 L.Metabolism: After intravenous administration of a 0.48 mcg/kg dose of 3H-paricalcitol, parent drug was extensively metabolized, with only about 2% of the dose eliminated unchanged in the feces and no parent drug found in the urine. Several metabolites were detected in both the urine and feces. Most of the systemic exposure was from the parent drug. Two minor metabolites, relative to paricalcitol, were detected in human plasma. One metabolite was identified as 24(R)-hydroxy paricalcitol, while the other metabolite was unidentified. The 24(R)-hydroxy paricalcitol is less active than paricalcitol in an in vivo rat model of PTH suppression.In vitro data suggest that paricalcitol is metabolized by multiple hepatic and non-hepatic enzymes, including mitochondrial CYP24, as well as CYP3A4 and UGT1A4. The identified metabolites include the product of 24(R)-hydroxylation (present at low levels in plasma), as well as 24,26- and 24,28-dihydroxylation and direct glucuronidation.Elimination: Paricalcitol is excreted primarily by hepatobiliary excretion. Approximately 63% of a radioactive dose was recovered in the feces and 19% was recovered in the urine in healthy subjects. In healthy subjects, the mean elimination half-life of paricalcitol is about five to seven hours over the studied dose range of 0.04 to 0.16 mcg/kg. The pharmacokinetics of paricalcitol has been studied in CKD Stage 5 subjects requiring hemodialysis (HD) and peritoneal dialysis (PD). The mean elimination half-life of paricalcitol after administration of 0.24 mcg/kg paricalcitol intravenous bolus dose in CKD Stage 5 HD and PD patients is 13.9 and 15.4 hours, respectively (Table 3).Table 3: Mean ± SD Paricalcitol Pharmacokinetic Parameters in CKD Stage 5 Subjects Following Single 0.24 mcg/kg Intravenous Bolus Dose  CKD Stage 5 HDn = 14 CKD Stage 5 PDn = 8 Cmax (ng/mL)1.680 ± 0.5111.832 ± 0.315 AUC0-∞ (ng•h/mL)14.51 ± 4.1216.01 ± 5.98 β (1/h)0.050 ± 0.0230.045 ± 0.026 t1/2(h)harmonic mean ± pseudo standard deviation, HD: hemodialysis, PD: peritoneal dialysis. The degree of accumulation was consistent with the half-life and dosing frequency.13.9 ± 7.315.4 ± 10.5 CL (L/h)1.49 ± 0.601.54 ± 0.95 Vdβ (L)30.8 ± 7.534.9 ± 9.5Specific PopulationsGeriatric: The pharmacokinetics of paricalcitol has not been investigated in geriatric patients greater than 65 years.Pediatric: The pharmacokinetics of paricalcitol has not been investigated in patients less than 18 years of age.Gender: The pharmacokinetics of paricalcitol was gender independent.Hepatic Impairment: The disposition of intravenous paricalcitol (0.24 mcg/kg) was compared in patients with mild (n=5) and moderate (n=5) hepatic impairment (as indicated by the Child-Pugh method) and subjects with normal hepatic function (n=10). The pharmacokinetics of unbound paricalcitol was similar across the range of hepatic function evaluated in this study. No dosing adjustment is required in patients with mild and moderate hepatic impairment. The influence of severe hepatic impairment on the pharmacokinetics of paricalcitol has not been evaluated.Renal Impairment: The pharmacokinetics of paricalcitol has been studied in CKD Stage 5 subjects requiring hemodialysis (HD) and peritoneal dialysis (PD). Hemodialysis procedure has essentially no effect on paricalcitol elimination. However, compared to healthy subjects, CKD Stage 5 subjects showed a decreased CL and increased half-life.Drug Interactions An in vitro study indicates that paricalcitol is not an inhibitor of CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, or CYP3A at concentrations up to 50 nM (21 ng/mL) (approximately 20-fold greater than that obtained after highest tested dose). In fresh primary cultured hepatocytes, the induction observed at paricalcitol concentrations up to 50 nM was less than two-fold for CYP2B6, CYP2C9 or CYP3A, where the positive controls rendered a six- to nineteen-fold induction. Hence, paricalcitol is not expected to inhibit or induce the clearance of drugs metabolized by these enzymes. Drug interactions with Paricalcitol Injection have not been studied. The following studies have been performed with oral paricalcitol capsules.OmeprazoleThe pharmacokinetic interaction between paricalcitol capsule (16 mcg) and omeprazole (40 mg; oral), a strong inhibitor of CYP2C19, was investigated in a single dose, crossover study in healthy subjects. The pharmacokinetics of paricalcitol was unaffected when omeprazole was administrated approximately 2 hours prior to the paricalcitol dose.Strong CYP3A InhibitorsKetoconazole Although no data are available for the drug interaction between Paricalcitol Injection and ketoconazole, a strong inhibitor of CYP3A, the effect of multiple doses of ketoconazole administered as 200 mg BID for 5 days on the pharmacokinetics of paricalcitol capsule has been studied in healthy subjects. The Cmax of paricalcitol was minimally affected, but AUC0-∞ approximately doubled in the presence of ketoconazole. The mean half-life of paricalcitol was 17.0 hours in the presence of ketoconazole as compared to 9.8 hours, when paricalcitol was administered alone [see Drug Interactions (7.1)].

13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility

In a 104-week carcinogenicity study in CD-1 mice conducted with paricalcitol, an increased incidence of uterine leiomyoma and leiomyosarcoma was observed at subcutaneous doses of 1, 3, 10 mcg/kg (2 to 15 times the AUC at a human dose of 14 mcg, equivalent to 0.24 mcg/kg based on AUC). The incidence rate of uterine leiomyoma was significantly different than the control group at the highest dose of 10 mcg/kg.In a 104-week carcinogenicity study in rats conducted with paricalcitol, there was an increased incidence of benign adrenal pheochromocytoma at subcutaneous doses of 0.15, 0.5, 1.5 mcg/kg (< 1 to 7 times the exposure following a human dose of 14 mcg, equivalent to 0.24 mcg/kg based on AUC). The increased incidence of pheochromocytomas in rats may be related to the alteration of calcium homeostasis by paricalcitol.Paricalcitol did not exhibit genetic toxicity in vitro with or without metabolic activation in the microbial mutagenesis assay (Ames Assay), mouse lymphoma mutagenesis assay (L5178Y), or a human lymphocyte cell chromosomal aberration assay. There was also no evidence of genetic toxicity in an in vivo mouse micronucleus assay. Paricalcitol had no effect on fertility (male or female) in rats at intravenous doses up to 20 mcg/kg/dose [equivalent to 13 times the highest recommended human dose (0.24 mcg/kg) based on surface area, mg/m2].

14 Clinical Studies

In three 12-week, placebo-controlled, phase 3 studies conducted with another paricalcitol injection product  in patients with Stage 5 chronic kidney disease on dialysis, the dose of paricalcitol was started at 0.04 mcg/kg 3 times per week. The dose was increased by 0.04 mcg/kg every 2 weeks until intact parathyroid hormone (iPTH) levels were decreased at least 30% from baseline, or a fifth escalation brought the dose to 0.24 mcg/kg, or iPTH fell to less than 100 pg/mL, or the Ca x P product was greater than 75 within any 2 week period, or serum calcium became greater than 11.5 mg/dL at any time.Patients treated with paricalcitol achieved a mean iPTH reduction of 30% within 6 weeks. In these studies, there was no significant difference in the incidence of hypercalcemia or hyperphosphatemia between paricalcitol and placebo-treated patients. The results from these studies are as follows:Table 4: Mean Changes from Baseline to Final Evaluation in PTH, Alkaline Phosphatase, Phosphorus and Calcium x Phosphorus Product in CKD Stage 5 Patients in Three Placebo-Controlled, Phase 3 Studies Group(No. of Pts.)BaselineMean(Range)  Mean (SE) Change From Baseline to Final EvaluationPTH (pg/mL)paricalcitol(n=40)783 (291–2076)-379 (43.7)placebo(n=38)745 (320 – 1671)-69.6 (44.8)Alkaline Phosphatase (U/L)paricalcitol(n=31)150 (40 – 600)-41.5 (10.6)placebo(n=34)169 (56 – 911)+2.6 (10.1)Phosphorus (mg/dL)paricalcitol(n=40)5.8 (3.7 – 10.2)+0.47 (0.3)placebo(n=38)6.0 (2.8 – 8.8)-0.47 (0.3)Calcium x Phosphorus Productparicalcitol(n=40)54 (32 – 106)+7.9 (2.2)placebo(n=38)54 (26 – 77)-3.9 (2.3)A long-term, open-label safety study of 164 CKD Stage 5 patients conducted with another paricalcitol injection product (mean dose of 7.5 mcg three times per week), demonstrated that mean serum Ca, P, and Ca x P remained within clinically appropriate ranges with PTH reduction (mean decrease of 319 pg/mL at 13 months).Figure 1: Mean Values for Serum iPTH, Calcium and Phosphorus Over Time in CKD Stage 5 Patients in a Phase 3 Study

16 How Supplied/Storage And Handling

Paricalcitol Injection is available in 2 mcg/mL single dose vials (NDC 0143-9625-25), 5 mcg/mL single dose vials (NDC 0143-9624-25) and 10 mcg/2 mL (5 mcg/mL) multiple dose vials (NDC 0143-9596-25) in cartons of 25 vials.NDC Number  Volume/Container Concentration  Total Content Vial Type 0143-9625-25 1 mL/Fliptop Vial2 mcg/mL2 mcg Single Dose 0143-9624-25 1 mL/Fliptop Vial5 mcg/mL5 mcg Single Dose 0143-9596-25 2 mL/Fliptop Vial5 mcg/mL10 mcg Multiple DoseStore at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature]. Do not freeze. After initial vial use, the contents of the multiple dose vial remain stable up to seven days when stored at controlled room temperature. Discard unused portion of the single dose vial.Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

17 Patient Counseling Information

  • Patients should be advised: of the most common adverse reactions with use of Paricalcitol Injection, which include nausea, vomiting and fluid retention.
  • To adhere to instructions regarding diet and phosphorus restriction.
  • To contact a health care provider if they develop symptoms of elevated calcium, (e.g. feeling tired, difficulty thinking clearly, loss of appetite, nausea, vomiting, constipation, increased thirst, increased urination and weight loss).
  • To return to their dialysis clinic/health care provider’s office for routine monitoring. More frequent monitoring is necessary during the initiation of therapy, following dose changes or when potentially interacting medications are started or discontinued.
  • To inform their health care provider of all medications, including prescription and nonprescription drugs, supplements, and herbal preparations they are taking and any change to their medical condition. Patients should also be advised to inform their health care provider prescribing a new medication that they are taking Paricalcitol Injection. Manufactured by:Exela Pharma Sciences, LLCLenoir, NC 28645 USADistributed by:WEST-WARD PHARMACEUTICAL CORP.Eatontown, NJ 07724 USA9625-0415-00           April 2015

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