g or adjusting the dose of doxercalciferol in patients receiving digitalis compounds [see warnings and precautions ( 5.2 )]. cytochrome p450 inhibitors clinical impact doxercalciferol is activated by cyp 27 in the liver. cytochrome p450 inhibitors may inhibit the 25-hydroxylation of doxercalciferol and thus reduce the formation of active doxercalciferol moiety [see clinical pharmacology ( 12.3 )]. examples ketoconazole and erythromycin intervention if a patient initiates or discontinues therapy with a cytochrome p450 inhibitor, dose adjustment of doxercalciferol may be necessary. monitor intact pth and serum calcium concentrations closely. enzyme inducers clinical impact doxercalciferol is activated by cyp 27 in the liver. enzyme inducers may affect the 25-hydroxylation of doxercalciferol [see clinical pharmacology ( 12.3 )]. examples glutethimide and phenobarbital intervention if a patient initiates or discontinues therapy with an enzyme inducer, dose adjustment of doxercalciferol may be necessary. monitor intact pth and serum calcium concentrations closely. magnesium-containing products clinical impact concomitant administration of doxercalciferol and high doses of magnesium-containing products may increase the risk of hypermagnesemia. examples magnesium-containing products such as antacids intervention avoid use of magnesium-containing products and doxercalciferol in patients on chronic renal dialysis. table 4: clinically significant drug interactions with doxercalciferol capsules cholestyramine clinical impact cholestyramine has been reported to reduce intestinal absorption of fat-soluble vitamins. therefore, it may impair intestinal absorption of doxercalciferol capsules. intervention administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking cholestyramine. mineral oil or other substances that may affect absorption of fat clinical impact the use of mineral oil or other substances that may affect absorption of fat may influence the absorption and availability of doxercalciferol. intervention administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking mineral oil or other substances that may affect absorption of fat. cytochrome p450 inhibitors: formation of the active doxercalciferol moiety may be hindered and may necessitate dosage adjustment. monitor intact pth and serum calcium concentrations closely. ( 7 ) enzyme inducers: formation of the active doxercalciferol moiety may be affected and may necessitate dosage adjustment. monitor intact pth and serum calcium concentrations closely. ( 7 ) magnesium-containing products: combined use may cause hypermagnesemia. monitor serum magnesium concentrations more frequently and adjust dose as needed. ( 7 ) cholestyramine: may impair absorption of doxercalciferol capsules. administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking cholestyramine. ( 7 ) mineral oil or other substances that may affect absorption of fat: may impair absorption of doxercalciferol capsules. administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking substances that may affect absorption.

n treatment initiation for hypersensitivity reactions. should a reaction occur, discontinue and treat. ( 5.3 ) adynamic bone disease: may develop and increase risk of fractures if intact pth levels are suppressed to abnormally low levels. monitor intact pth levels to avoid oversuppression and adjust dose if needed. ( 5.4 ) 5.1 hypercalcemia hypercalcemia may occur during doxercalciferol treatment. acute hypercalcemia may increase the risk of cardiac arrhythmias and seizures and may potentiate the effect of digitalis on the heart [see warnings and precautions ( 5.2 )] . chronic hypercalcemia can lead to generalized vascular calcification and other soft-tissue calcification. severe hypercalcemia may require emergency attention. hypercalcemia may be exacerbated by concomitant administration of high doses of calcium-containing preparations, thiazide diuretics, or other vitamin d compounds [see drug interactions ( 7 )]. in addition, high intake of calcium and phosphate concomitantly with vitamin d compounds may lead to hypercalciuria and hyperphosphatemia. patients with a history of hypercalcemia prior to initiating therapy may be at increased risk for development of hypercalcemia with doxercalciferol. in these circumstances, frequent serum calcium monitoring and doxercalciferol dose adjustments may be required. when initiating doxercalciferol or adjusting doxercalciferol dose, measure serum calcium frequently (weekly in patients with ckd on dialysis or every 2 weeks for patients with stage 3 or 4 ckd). once a maintenance dose has been established, measure serum calcium monthly for 3 months and then every 3 months . if hypercalcemia occurs, reduce the dose or discontinue doxercalciferol until serum calcium is normal [see dosage and administration ( 2 )] . inform patients about the symptoms of elevated calcium (feeling tired, difficulty thinking clearly, loss of appetite, nausea, vomiting, constipation, increased thirst, increased urination and weight loss) and instruct them to report new or worsening symptoms when they occur. 5.2 digitalis toxicity doxercalciferol can cause hypercalcemia [see warnings and precautions ( 5.1 )] which increases the risk of digitalis toxicity. in patients using doxercalciferol concomitantly with digitalis compounds, monitor both serum calcium and patients for signs and symptoms of digitalis toxicity. increase the frequency of monitoring when initiating or adjusting the dose of doxercalciferol [see drug interactions ( 7 )]. 5.3 serious hypersensitivity reactions hypersensitivity reactions include anaphylaxis with symptoms of angioedema (involving face, lips, tongue and airways), hypotension, unresponsiveness, chest discomfort, shortness of breath, and cardiopulmonary arrest. these reactions may occur separately or together. monitor patients receiving doxercalciferol upon initiation of treatment for hypersensitivity reactions. should a hypersensitivity reaction occur, discontinue doxercalciferol, monitor and treat if indicated [see contraindications ( 4 )]. 5.4 adynamic bone disease adynamic bone disease with subsequent increased risk of fractures may develop if intact pth levels are suppressed by doxercalciferol to abnormally low levels. monitor intact pth levels to avoid oversuppression and adjust the doxercalciferol dose, if needed [see dosage and administration ( 2 )].

2 dosage recommendations for doxercalciferol capsules in patients with stage 3 or 4 ckd initiate doxercalciferol capsules at a dose of 1 mcg orally once daily. target the maintenance dose of doxercalciferol to intact parathyroid hormone (pth) levels within the desired therapeutic range and serum calcium within normal limits. monitor serum calcium, phosphorus, and intact pth levels at least every two weeks for 3 months after initiation of therapy or dose adjustment, then monthly for 3 months, and every 3 months thereafter. titrate the dose of doxercalciferol capsules based on intact pth. the dose may be increased at 2-week intervals by 0.5 mcg to achieve the desired therapeutic range of intact pth. the maximum recommended dose of doxercalciferol capsules is 3.5 mcg administered once daily. prior to raising the dose, ensure serum calcium is within normal limits. suspend or decrease the dose if intact pth is persistently and abnormally low to reduce the risk of adynamic bone disease [see warnings and precautions ( 5.4 )] or if serum calcium is consistently above the normal range to reduce the risk of hypercalcemia [see warnings and precautions ( 5.1 )]. if suspended, the drug should be restarted after one week at a dose that is at least 0.5 mcg lower. 2.3 dosage recommendations for doxercalciferol capsules in patients with ckd on dialysis initiate doxercalciferol capsules at a dose of 10 mcg orally administered three times weekly at dialysis (no more frequently than every other day). target the maintenance dose of doxercalciferol to intact parathyroid hormone (pth) levels within the desired therapeutic range and serum calcium within normal limits. monitor serum calcium, phosphorus, and intact pth levels frequently (e.g., weekly) after initiation of therapy or dose adjustment. titrate the dose of doxercalciferol capsules based on intact pth. the dose may be increased at 8-week intervals by 2.5 mcg to achieve the desired therapeutic range of intact pth. the maximum recommended dose of doxercalciferol is 20 mcg administered three times weekly at dialysis for a total dose of 60 mcg weekly. prior to raising the dose, ensure serum calcium is within normal limits. suspend or decrease the dose if intact pth is persistently and abnormally low to reduce the risk of adynamic bone disease [see warnings and precautions ( 5.4 )] or if serum calcium is consistently above the normal range to reduce the risk of hypercalcemia [see warnings and precautions ( 5.1 )]. if suspended, the drug should be restarted one week later at a dose that is at least 2.5 mcg lower. 2.6 drug interactions that may require dosage adjustments of doxercalciferol increased monitoring of serum calcium and dose adjustment of doxercalciferol may be necessary when given concomitantly with drugs that may increase the risk of hypercalcemia [see drug interactions ( 7 )]. increased monitoring of both serum calcium and intact pth as well as dose adjustment of doxercalciferol may be necessary when given concomitantly with cytochrome p450 inhibitors or enzyme inducers [see drug interactions ( 7 )].

experience because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. adverse reactions in patients with stage 3 or 4 ckd doxercalciferol capsules have been evaluated in two placebo-controlled, double-blind 24 week studies in patients with stage 3 or 4 ckd. patients were treated with doxercalciferol capsules (n=27) or placebo (n=28) [see clinical studies ( 14.1 )] . adverse reactions occurring in the doxercalciferol capsules group at a frequency of 5% or greater and more frequently than in the placebo group are presented in table 1. table 1: adverse reactions occurring in ≥5% doxercalciferol capsule-treated patients with ckd on predialysis and greater than placebo in two double-blind clinical studies adverse reaction pooled data on adverse reactions from clinical study reports (studies bci-ch-115 and bci-ch-119). doxercalciferol (n=27) % placebo (n=28) % infection/bacterial infection/viral infection 30 25 constipation 26 11 rhinitis 22 11 anemia 19 4 cough 19 4 dyspnea 19 11 paresthesia 15 11 asthenia 15 11 insomnia 15 4 hypertonia 11 4 angina pectoris 8 0 dehydration 7 4 depression 7 0 dyspepsia 7 4 edema 7 4 urinary tract infection 7 4 leukopenia 7 0 chest pain 7 4 pruritus 7 4 sinusitis 7 4 adverse reactions in patients with ckd on dialysis doxercalciferol capsules have been evaluated in two placebo-controlled, double-blind studies in patients with ckd on hemodialysis. patients were treated with doxercalciferol capsules (n=61) or placebo (n=61) [see clinical studies ( 14.2 )] . after randomization to two groups, eligible patients underwent an 8-week washout period during which no vitamin d derivatives were administered to either group. subsequently, all patients received doxercalciferol capsules in an open-label fashion for 16 weeks followed by a double-blind period of 8 weeks during which patients received either doxercalciferol capsules or placebo. adverse reactions occurring in the doxercalciferol capsule groups at a frequency of 2% or greater, and more frequently than in the placebo group are presented in table 2. table 2: adverse reactions occurring in ≥2% doxercalciferol capsule-treated patients with ckd on dialysis and greater than placebo in two double-blind clinical studies adverse reaction a patient who reported the same medical term more than once was counted only once for that medical term. doxercalciferol (n=61) % placebo (n=61) % edema 34 21 malaise 28 20 headache 28 18 nausea/vomiting 21 20 dizziness 12 10 dyspnea 12 7 pruritus 8 7 bradycardia 7 5 anorexia 5 3 dyspepsia 5 2 arthralgia 5 0 weight increase 5 0 abscess 3 0 sleep disorder 3 0 6.2 postmarketing experience the following adverse reactions have been identified during postapproval use of doxercalciferol. because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency or to establish a causal relationship to drug exposure. hypersensitivity reactions include anaphylaxis with symptoms of angioedema (involving face, lips, tongue and airways), hypotension, unresponsiveness, chest discomfort, shortness of breath, cardiopulmonary arrest, pruritus, and skin burning sensation.

g or adjusting the dose of doxercalciferol in patients receiving digitalis compounds [see warnings and precautions ( 5.2 )]. cytochrome p450 inhibitors clinical impact doxercalciferol is activated by cyp 27 in the liver. cytochrome p450 inhibitors may inhibit the 25-hydroxylation of doxercalciferol and thus reduce the formation of active doxercalciferol moiety [see clinical pharmacology ( 12.3 )]. examples ketoconazole and erythromycin intervention if a patient initiates or discontinues therapy with a cytochrome p450 inhibitor, dose adjustment of doxercalciferol may be necessary. monitor intact pth and serum calcium concentrations closely. enzyme inducers clinical impact doxercalciferol is activated by cyp 27 in the liver. enzyme inducers may affect the 25-hydroxylation of doxercalciferol [see clinical pharmacology ( 12.3 )]. examples glutethimide and phenobarbital intervention if a patient initiates or discontinues therapy with an enzyme inducer, dose adjustment of doxercalciferol may be necessary. monitor intact pth and serum calcium concentrations closely. magnesium-containing products clinical impact concomitant administration of doxercalciferol and high doses of magnesium-containing products may increase the risk of hypermagnesemia. examples magnesium-containing products such as antacids intervention avoid use of magnesium-containing products and doxercalciferol in patients on chronic renal dialysis. table 4: clinically significant drug interactions with doxercalciferol capsules cholestyramine clinical impact cholestyramine has been reported to reduce intestinal absorption of fat-soluble vitamins. therefore, it may impair intestinal absorption of doxercalciferol capsules. intervention administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking cholestyramine. mineral oil or other substances that may affect absorption of fat clinical impact the use of mineral oil or other substances that may affect absorption of fat may influence the absorption and availability of doxercalciferol. intervention administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking mineral oil or other substances that may affect absorption of fat. cytochrome p450 inhibitors: formation of the active doxercalciferol moiety may be hindered and may necessitate dosage adjustment. monitor intact pth and serum calcium concentrations closely. ( 7 ) enzyme inducers: formation of the active doxercalciferol moiety may be affected and may necessitate dosage adjustment. monitor intact pth and serum calcium concentrations closely. ( 7 ) magnesium-containing products: combined use may cause hypermagnesemia. monitor serum magnesium concentrations more frequently and adjust dose as needed. ( 7 ) cholestyramine: may impair absorption of doxercalciferol capsules. administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking cholestyramine. ( 7 ) mineral oil or other substances that may affect absorption of fat: may impair absorption of doxercalciferol capsules. administer doxercalciferol capsules at least 1 hour before or 4 to 6 hours after taking substances that may affect absorption.

to 20%, respectively. clinical considerations disease-associated maternal and/or embryo/fetal risk chronic kidney disease in pregnancy increases the risk for maternal hypertension and preeclampsia, miscarriage, preterm delivery polyhydramnios, stillbirth, and low-birth-weight infants. data animal data there were no adverse effects on fetal development when doxercalciferol was administered at doses up to 20 mcg/kg/day in pregnant rats or doses up to 0.1 mcg/kg/day in pregnant rabbits during the period of organogenesis. 8.2 lactation risk summary there is no information available on the presence of doxercalciferol in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. infants exposed to doxercalciferol through breast milk should be monitored for signs and symptoms of hypercalcemia [see clinical considerations] . the developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for doxercalciferol and any potential adverse effects on the breastfed child from doxercalciferol or from the underlying maternal condition. clinical considerations monitoring of serum calcium in the infant should be considered. 8.4 pediatric use safety and efficacy of doxercalciferol in pediatric patients have not been established. 8.5 geriatric use clinical studies of doxercalciferol did not include sufficient numbers of patients 65 years or over to determine whether they respond differently from younger subjects. 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 or cardiac function, and of concomitant disease or other drug therapy. 8.6 hepatic impairment patients with hepatic impairment may not metabolize doxercalciferol appropriately. more frequent monitoring of intact pth, calcium, and phosphorus levels should be done in patients with hepatic impairment.

considerations disease-associated maternal and/or embryo/fetal risk chronic kidney disease in pregnancy increases the risk for maternal hypertension and preeclampsia, miscarriage, preterm delivery polyhydramnios, stillbirth, and low-birth-weight infants. data animal data there were no adverse effects on fetal development when doxercalciferol was administered at doses up to 20 mcg/kg/day in pregnant rats or doses up to 0.1 mcg/kg/day in pregnant rabbits during the period of organogenesis.

doxercalciferol does not require the involvement of the kidneys. specific populations patients with renal impairment the mean elimination half-life of 1α,25-(oh) 2 d 2 in patients with end-stage renal disease (esrd) and in healthy volunteers appears to be similar following an oral dose. hemodialysis causes a temporary increase in 1α,25- (oh) 2 d 2 mean concentrations, presumably due to volume contraction. 1α,25-(oh) 2 d 2 is not removed from blood during hemodialysis.

on. 1α,25-(oh) 2 d 2 is not removed from blood during hemodialysis.

imately 3 times the maximum recommended human oral dose of 60 mcg/week based on mcg/m 2 body surface area).

m recommended human oral dose of 60 mcg/week based on mcg/m 2 body surface area).

y. the dosage of doxercalciferol capsules was adjusted as necessary by the investigator to reduce intact pth levels to a target of ≥30% below post-washout baseline. the maximum dosage was limited to 3.5 mcg per day. if at any time during the trial intact pth fell below 15 pg/ml, doxercalciferol capsules were immediately suspended and restarted at a lower dosage the following week. decreases in the mean plasma intact pth from baseline values were calculated using as baseline the average of the last 2 values obtained during the 8-week washout phase. in analyses of pooled data from the two studies, intact pth levels decreased from baseline by an average of 101 pg/ml in the doxercalciferol capsules group and by 4 pg/ml in the placebo group (p<0.001). twenty (74%) of 27 subjects in the doxercalciferol capsules group achieved mean plasma intact pth suppression of ≥30% from baseline for the last four weeks of treatment, whereas two (7%) of the 28 subjects treated with placebo achieved this level of intact pth suppression. 14.2 clinical studies of doxercalciferol capsules in patients with ckd on dialysis the safety and effectiveness of doxercalciferol capsules were evaluated in two double-blind, placebo-controlled, multicenter clinical studies (study a and study b) in a total of 138 patients with ckd on hemodialysis. patients in study a were an average age of 52 years (range: 22 to 75), were 55% male, and were 58% african-american, 31% caucasian, and 11% hispanic, and had been on hemodialysis for an average of 53 months. patients in study b were an average of 52 years (range: 27 to 75), were 45% male, and 99% african-american, and 1% caucasian, and had been on hemodialysis for an average of 56 months. after randomization to two groups, eligible patients underwent an 8-week washout period during which no vitamin d derivatives were administered to either group. subsequently, all patients received doxercalciferol capsules in an open-label fashion for 16 weeks followed by a double-blind period of 8 weeks during which patients received either doxercalciferol capsules or placebo. the initial dose of doxercalciferol capsules during the open-label phase was 10 mcg after each dialysis session (3 times weekly) for a total of 30 mcg per week. the dosage of doxercalciferol was adjusted as necessary by the investigator to achieve intact pth levels within 150 pg/ml to 300 pg/ml. the maximum dosage was limited to 20 mcg after each dialysis session (60 mcg/week). if at any time during the trial intact pth fell below 150 pg/ml, doxercalciferol was immediately suspended and restarted at a lower dosage the following week. mean weekly doses during the 16-week open-label period ranged from 15 mcg to 29 mcg in study a and from 19 mcg to 28 mcg in study b. one hundred and six (77%) of the 138 patients who were treated with doxercalciferol capsules during the 16- week open-label phase achieved intact pth levels ≤300 pg/ml. ninety-four (68%) of these patients exhibited plasma intact pth levels ≤300 pg/ml on at least 3 occasions. eighty-seven (63%) patients had plasma intact pth levels <150 pg/ml on at least one occasion during the open-label phase of study participation. decreases in plasma intact pth from baseline values were calculated using as baseline the average of the last 3 values obtained during the 8-week washout phase and are displayed in table 5. table 5: intact pth summary data for patients with ckd on dialysis receiving doxercalciferol capsules in studies a and b * all subjects; last value carried to discontinuation. na = not applicable intact pth (pg/ml) means ± sd (n)* p-value vs baseline p-value vs placebo doxercalciferol capsules placebo study a baseline 797.2 ± 443.8 (30) na 0.97 847.1 ± 765.5 (32) – – week 16 (open-label) 384.3 ± 397.8 (24) <0.001 0.72 526.5 ± 872.2 (29) <0.001 – week 24 (double-blind) 404.4 ± 262.9 (21) <0.001 0.008 672.6 ± 356.9 (24) 0.70 – study b baseline 973.9 ± 567.0 (41) na 0.81 990.4 ± 488.3 (35) – – week 16 (open-label) 476.1 ± 444.5 (37) <0.001 0.91 485.9 ± 443.4 (32) <0.001 – week 24 (double-blind) 459.8 ± 443.0 (35) <0.001 <0.001 871.9 ± 623.6 (30) <0.065 – doxercalciferol capsules treatment resulted in a statistically significant reduction from baseline in mean intact pth levels during the 16-week open-label treatment period in more than 94% of the 138 treated patients. during the double-blind period (weeks 17 to 24), the reduction in mean intact pth levels was maintained in the doxercalciferol capsules treatment group compared to a return to near baseline in the placebo group.

iption drugs, and supplements they are taking. advise patients to also inform their physician that they are receiving doxercalciferol if a new medication is prescribed [see drug interactions ( 7 )] . manufactured for: rising pharmaceuticals, inc. east brunswick, nj 08816 made in france revised: 08/2022 pir23050-00