- Approval Id
- c0ac51d7aa088ef4
- Drug Approval Emc Name
- Alfacalcidol 0.5 microgram soft capsules
- Drug Name
- Alfacalcidol 0.5 microgram soft capsules
- Company Name
- Strides Pharma UK Ltd
- Company Address
- Unit 4, Metro Centre, Tolpits Lane, Watford, Hertfordshire, UK
- Company Website
- //www.stridespharma.co.uk
- Company Telephone
- +44 1923 255580
- Company Medical Info Direct Line
- +44 8000 988 048
- Company Medical Info Email
- drugsafety@strides.com
- Atc Code
- A11CC03
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Strides Pharma UK Ltd.
Unit 4, The Metro Centre,
Dwight Road, Watford,
WD18 9SS
United Kingdom
- Authorisation Number
- PL 13606/0218
- Authorisation Date
- 05/08/2014
- Instruction Authorisation Holder
- Strides Pharma UK Ltd.
Unit 4, The Metro Centre,
Dwight Road, Watford,
WD18 9SS
United Kingdom
- Instruction Authorisation Number
- PL 13606/0218
- Instruction Authorisation Date
- 05/08/2014
- Instruction Composition
- Alfacalcidol 0.5 microgram soft capsules: Each capsule contains 0.5 microgram of alfacalcidol
\*\*Excipient with known effect\*\*
Each soft capsule contains 98.7 mg arachis oil (peanut oil),1 mg ethanol anhydrous, 10 mg sorbitol, and traces of soya lecithin
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Alfacalcidol 0.5 mcg soft capsules: Light pink coloured, oval shaped soft gelatin capsules containing clear oily liquid.
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Alfacalcidol is indicated in conditions where there is a disturbance of calcium metabolism due to impaired 1-α hydroxylation such as when there is reduced renal function.
The main indications are:
a) Renal osteodystrophy
b) Hyperparathyroidism (with bone disease)
c) Hypoparathyroidism
d) Nutritional and malabsorptive rickets and osteomalacia
e) Pseudo-deficiency (D-dependent) rickets and osteomalacia
f) Hypophosphataemic vitamin D resistant rickets and osteomalacia4.2 Posology and method of administration
\*\*\*\*Posology\*\*\*\*
\*\*Initial dose for all indications:\*\*
| | |
| --- | --- |
| Adults, adolescents and children > 20 kg bodyweight: | 1 microgram/day |
| Elderly: | 0.5 microgram/day |
| Children from 6 years of age and under 20 kg bodyweight: | 0.05 microgram/kg/day |
The dose of Alfacalcidol should be adjusted thereafter to avoid hypercalcaemia according to the biochemical response. Indices of response include plasma levels of calcium (ideally corrected for protein binding), alkaline phosphatase, parathyroid hormone, as well as radiographic and histological investigations.
Plasma levels should initially be measured at weekly intervals. The daily dose of Alfacalcidol may be increased by increments of 0.25-0.5 microgram. When the dose is established, measurements of calcium, phosphorous and creatinine may be taken every 2-4 weeks.
Most adult patients respond to doses between 1and 3 micrograms per day. When there is biochemical or radiographic evidence of bone healing, (and in hypoparathyroid patients when normal plasma calcium levels have been attained), the dose generally decreases. Maintenance doses are generally in the range of 0.25 to 1 microgram per day. If hypercalcaemia occurs, Alfacalcidol should be stopped until plasma calcium returns to normal (approximately 1 week) then restarted at half the previous dose.
\*\*a) Renal bone disease:\*\*
Patients with relatively high initial plasma calcium levels may have autonomous hyperparathyroidism, often unresponsive to Alfacalcidol. Other therapeutic measures may be indicated.
Before and during treatment with Alfacalcidol, phosphate binding agents should be considered to prevent hyperphosphataemia. It is particularly important to make frequent plasma calcium measurements in patients with chronic renal failure because prolonged hypercalcaemia may aggravate the decline of renal function.
\*\*b) Hyperparathyroidism:\*\*
In patients with primary or tertiary hyperparathyroidism about to undergo parathyroidectomy, pre-operative treatment with Alfacalcidol for 2-3 weeks alleviates bone pain and myopathy without aggravating pre-operative hypercalcaemia. In order to decrease post-operative hypocalcaemia, Alfacalcidol should be continued until plasma alkaline phosphatase levels fall to normal or hypercalcaemia occurs.
\*\*c) Hypoparathyroidism:\*\*
In contrast to the response to parent vitamin D, low plasma calcium levels are restored to normal relatively quickly with Alfacalcidol. Severe hypocalcaemia is corrected more rapidly with higher doses of Alfacalcidol (e.g., 3-5 micrograms) together with calcium supplements.
\*\*d) Nutritional and malabsorptive rickets and osteomalacia:\*\*
Nutritional rickets and osteomalacia can be cured rapidly with Alfacalcidol. Malabsorptive osteomalacia (responding to large doses of IM or IV parent vitamin D) will respond to small doses of Alfacalcidol.
\*\*e) Pseudo-deficiency (D-dependent) rickets and osteomalacia:\*\*
Although large doses of parent vitamin D would be required, effective doses of Alfacalcidol are similar to those required to heal nutritional vitamin D deficiency rickets and osteomalacia.
\*\*f) Hypophosphataemic vitamin D-resistant rickets and osteomalacia:\*\*
Neither large doses of parent vitamin D nor phosphate supplements are entirely satisfactory.
Treatment with Alfacalcidol at normal dosage rapidly relieves myopathy when present and increases calcium and phosphate retention. Phosphate supplements may also be required in some patients.
\*\*Method of administration\*\*
Oral use
The soft capsules should be swallowed whole with sufficient amount of fluid.4.3 Contraindications
Hypersensitivity to the active substance, arachis oil (peanut oil), soya or to any of the excipients listed in section 6.1.
Hypercalcaemia, metastatic calcification.4.4 Special warnings and precautions for use
\*Monitoring\*
During treatment with Alfacalcidol, serum calcium and serum phosphate and creatinine levels should be monitored regularly especially in children, patients with renal impairment and patients receiving high doses. PTH, alkaline phosphatase and calcium phosphates should be monitored as clinically indicated.
\*Hypercalcaemia\*
Hypercalcaemia may appear in patients treated with Alfacalcidol. For this reason, patients should be informed about the clinical symptoms connected with hypercalcaemia. Refer section 4.8 (Undesirable effects)
In case of hypercalcaemia, Alfacalcidol treatment should be stopped until serum calcium concentrations return to normal, usually in about 1 week. Alfacalcidol may then be restarted at half the last dose used with monitoring of calcium.
Prolonged hypercalcaemia may aggravate arteriosclerosis, cardiac valve sclerosis or nephrolithiasis and therefore prolonged hypercalcaemia should be avoided when Alfacalcidol is used in these patients. Transient or even long-lasting deterioration of kidney function has been observed. Alfacalcidol should also be used with caution in patients with calcification of pulmonary tissue as this may result in cardiac disease.
\*Renal\*
In patients with renal bone disease or severely reduced renal function, a phosphate binding agent could be used simultaneously with alfacalcidol to prevent increased serum phosphate and potential metastatic calcification.
\*Granulomatous diseases\*
Alfacalcidol should be used with caution in patients with granulomatous diseases such as sarcoidosis where the sensitivity to vitamin D is increased due to increased hydroxylation activity.
\*Fructose intolerance\*
This medicinal product contains sorbitol as an excipient and patients with rare hereditary problems of fructose intolerance (HFI) should not take this medicinal product.
This medicinal product contains 1 mg of alcohol (ethanol) per soft capsule, corresponding to 1% (w/w). The amount of alcohol (ethanol) in one soft capsule of this medicine is equivalent to less than 1 ml of beer or 1 ml of wine. The small amount of alcohol in this medicine has no noticeable effects.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Digitalis glycosides\*\*
Concurrent use of digitalis glycosides in the presence of hypercalcaemia due to vitamin D administration increases the potential for cardiac arrhythmias and is therefore contraindicated. Patients taking digitalis and alfacalcidol concomitantly should be frequently monitored with ECG and measurements of plasma levels of digitalis glycosides and calcium.
\*\*Thiazide diuretics and calcium containing preparations\*\*
Use with caution in patients being treated with thiazide diuretics or \*\*calcium containing\*\* \*\*preparations\*\* as they may have an increased risk of developing hypercalcaemia. Calcium levels should be monitored.
\*\*Other vitamin D containing preparations\*\*
Vitamin D or its analogous should not be given concurrently with alfacalcidol as may enhance the risk of hypercalcaemia.
\*\*Anticonvulsants\*\*
Patients taking barbiturates or anticonvulsants may require larger doses of Alfacalcidol to produce the desired effect due to the induction of hepatic detoxification enzymes.
\*\*Magnesium-containing antacids\*\*
Magnesium based antacids and laxatives should not be used during treatment with alfacalcidol due to increased risk of hypermagnesaemia.
\*\*Aluminium-containing preparations\*\*
Alfacalcidol may increase the serum concentration of aluminium. Patients taking aluminium- containing preparations (e.g. aluminium hydroxide, sucralfate) should be monitored for signs of aluminium related toxicities.
\*\*Bile acid sequestrants\*\*
Concomitant oral administration of bile acid sequestrants such as cholestyramine may impair the intestinal absorption of oral Alfacalcidol formulations. Alfacalcidol should be administered at least 1 hour before, or 4 to 6 hours after the intake of the bile acid sequestrant in order to minimise the potential risk of interaction.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
There is a limited amount of data from the use of alfacalcidol in pregnant women. Studies in animals have shown reproductive toxicity at high doses (see section 5.3).
Therefore, Alfacalcidol is not recommended during pregnancy and in women of child- bearing potential not using contraception.
\*\*Breast-feeding\*\*
Although it has not been established, it is likely that increased amounts of 1,25- dihydroxyvitamin D will be found in the milk of lactating mothers treated with Alfacalcidol. This may influence calcium metabolism in the infant.
Breast-fed infants of alfacalcidol-using mothers should be monitored closely for hypercalcaemia.
\*\*Fertility\*\*
There are no clinical studies on the effect of alfacalcidol on fertility. A pre-clinical study did not show an effect on fertility in rats.4.7 Effects on ability to drive and use machines
Alfacalcidol has no or negligible direct influence on the ability to drive and use machines. However, the patient suffering from “dizziness” or “confusional states” due to Alfacalcidol should not drive or use machines.4.8 Undesirable effects
The estimation of the frequency of undesirable effects is based on a pooled analysis of data from clinical studies and spontaneous reporting.
The most frequently reported undesirable effects are skin reactions such as pruritus and rash, hypercalcaemia, gastrointestinal pain/discomfort and hyperphosphataemia. Symptoms of hypercalcaemia are headache, weakness, anorexia, weight loss, nausea, vomiting, diarrhoea, constipation, polyuria, polydepsia, and muscle and bone pain, and metallic taste. Renal failure has been reported post-marketing.
Undesirable effects are listed by MedDRA system organ class (SOC) and the individual undesirable effects are listed starting with the most frequently reported one.
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)
| | |
| --- | --- |
| \*\*Metabolism and nutrition disorders\*\* | |
| Common | Hypercalcaemia Hyperphosphataemia |
| \*\*Psychiatric disorders\*\* | |
| Uncommon | Confusional state |
| \*\*Nervous system disorders\*\* | |
| Uncommon | Headache |
| Rare | Dizziness |
| \*\*Gastrointestinal disorders\*\* | |
| Common | Abdominal pain and discomfort |
| Uncommon | Diarrhoea Vomiting Constipation Nausea |
| \*\*Skin and subcutaneous tissue disorders\*\* | |
| Common | Rash\\* Pruritus \\*Various types of rash such as erythematous, maculo-papular and pustular have been reported. |
| \*\*Musculoskeletal and connective tissue disorders\*\* | |
| Uncommon | Myalgia |
| \*\*Renal and urinary disorders\*\* | |
| Common | Hypercalciuria |
| Uncommon | Nephrolithiasis/Nephrocalcinosis |
| Renal impairment (including acute renal failure) |
| \*\*General disorders and administration site conditions\*\* | |
| Uncommon | Fatigue/asthenia/malaise Calcinosis |
\*\*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 Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Excessive intake of Alfacalcidol may lead to the development of hypercalcaemia, however, the effect is reversed rapidly on withdrawal.
Symptoms of overdosage of Alfacalcidol strides are anorexia, lassitude, nausea and vomiting, diarrhoea, constipation, weight loss, polyuria, sweating, headache, thirst, vertigo, and raised concentrations of calcium and phosphate in plasma and urine.
In severe cases of hypercalcaemia, general supportive measures should be undertaken. Keep the patient well hydrated by i.v. infusion of saline (force diuresis), measure electrolytes, calcium and renal function indices; assess electrocardiographic abnormalities, especially in patients on digitalis. More specifically, treatment with glucocorticosteroids, loop diuretics, bisphosphonates, calcitonin and eventually haemodialysis with low calcium content should be considered.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Vitamin D and analogues. ATC code: A11CC03
\*\*Clinical efficacy and safety\*\*
Impaired 1α-hydroxylation by the kidneys reduces endogenous 1,25-dihydroxyvitamin D production. This contributes to the disturbances in mineral metabolism found in several disorders, including renal bone disease, hypoparathyroidism and vitamin D dependent rickets. These disorders, which require high doses of parent vitamin D for their correction, will respond to small doses of Alfacalcidol.
The delay in response and high dosage required in treating these disorders with parent vitamin D makes dosage adjustment difficult. This can result in unpredictable hypercalcaemia which may take weeks or months to reverse. The major advantage of Alfacalcidol is the more rapid onset of response, which allows a more accurate titration of dosage. Should inadvertent hypercalcaemia occur, it can be reversed within days of stopping treatment.
In patients with renal failure, 1 - 5 microgram/day of 1α- hydroxyvitamin D (1α-OHD3) increased intestinal calcium and phosphorus absorption in a dose-related manner. This effect was observed within 3 days of starting the drug and conversely, it was reversed within 3 days of its discontinuation.
Patients with chronic renal failure have shown increased serum calcium levels within 5 days of receiving 1α-OHD3 in a dose of 0.5- 1.0 microgram/day. As serum calcium rose, PTH levels and alkaline phosphatase decreased toward normal.
In patients with nutritional osteomalacia, increases in calcium absorption were noted within 6 hours of giving 1 µg 1α-OHD3 orally and usually peaked at 24 hours. 1α- OHD3 also produced increases in plasma inorganic phosphorus due to increased intestinal absorption and renal tubular re-absorption. This latter effect is a result of PTH suppression by 1α-OHD3. The effect of the drug on calcium was about double its effect on phosphorus absorption.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Alfacalcidol is absorbed passively and almost completely in the small intestine.
\*\*Biotransformation\*\*
Alfacalcidol is converted rapidly in the liver to 1,25-dihydroxyvitamin D. This is the metabolite of vitamin D which acts as a regulator of calcium and phosphate metabolism. Since this conversion is rapid, the clinical effects of Alfacalcidol and 1,25-dihydroxyvitamin D are very similar.
Pharmacokinetic/pharmacodynamic relationship(s)
The half-life of alfacalcidol is about 4 hours. The pharmacologic effect is 3-5 days.5.3 Preclinical safety data
\*\*Chronic toxicity:\*\*
The non-clinical toxicity of alfacalcidol is attributed to the known vitamin D-effect of calcitriol on calcium homeostasis, which is characterised by hypercalcaemia, hypercalciuria and eventually soft tissue calcification.
\*\*Genotoxicity:\*\*
Alfacalcidol is not genotoxic.
\*\*Reproduction toxicity:\*\*
No specific effects of alfacalcidol on fertility or behaviour of the offspring were noted in rats and rabbits. In terms of embryo-fetal development, fetal toxicity (post-implantation loss, lower litter size and lower pup weight) was observed at doses high enough to cause toxicity in the dams. High doses of vitamin D are known to be teratogenic in experimental animals.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
Citric acid, anhydrous
All-rac-α-Tocopherol
Propyl gallate,
Ethanol, anhydrous
Arachis oil, hydrogenated
The capsule shell contains:
Gelatin Glycerol
Anidrisorb
Purified water
Medium chain triglyceride
Lecithin (soya lecithin),
The capsules contain the following colours:
0.5 microgram capsules: titanium dioxide (E171) and ferric oxide red (E172)6.2 Incompatibilities
Not applicable.6.3 Shelf life
2 years.6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.6.5 Nature and contents of container
The finished products are Alfacalcidol 0.5 mcg capsules soft, to be marketed in white opaque HDPE container, with white opaque HDPE screw closure and induction sealing.
Pack size: 30 capsules, 50 capsules and 100 capsules
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
No special requirements.
- Instruction Content
- ## Composition
Alfacalcidol 0.5 microgram soft capsules: Each capsule contains 0.5 microgram of alfacalcidol
\*\*Excipient with known effect\*\*
Each soft capsule contains 98.7 mg arachis oil (peanut oil),1 mg ethanol anhydrous, 10 mg sorbitol, and traces of soya lecithin
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Alfacalcidol 0.5 mcg soft capsules: Light pink coloured, oval shaped soft gelatin capsules containing clear oily liquid.
## Clinical Particulars
4.1 Therapeutic indications
Alfacalcidol is indicated in conditions where there is a disturbance of calcium metabolism due to impaired 1-α hydroxylation such as when there is reduced renal function.
The main indications are:
a) Renal osteodystrophy
b) Hyperparathyroidism (with bone disease)
c) Hypoparathyroidism
d) Nutritional and malabsorptive rickets and osteomalacia
e) Pseudo-deficiency (D-dependent) rickets and osteomalacia
f) Hypophosphataemic vitamin D resistant rickets and osteomalacia4.2 Posology and method of administration
\*\*\*\*Posology\*\*\*\*
\*\*Initial dose for all indications:\*\*
| | |
| --- | --- |
| Adults, adolescents and children > 20 kg bodyweight: | 1 microgram/day |
| Elderly: | 0.5 microgram/day |
| Children from 6 years of age and under 20 kg bodyweight: | 0.05 microgram/kg/day |
The dose of Alfacalcidol should be adjusted thereafter to avoid hypercalcaemia according to the biochemical response. Indices of response include plasma levels of calcium (ideally corrected for protein binding), alkaline phosphatase, parathyroid hormone, as well as radiographic and histological investigations.
Plasma levels should initially be measured at weekly intervals. The daily dose of Alfacalcidol may be increased by increments of 0.25-0.5 microgram. When the dose is established, measurements of calcium, phosphorous and creatinine may be taken every 2-4 weeks.
Most adult patients respond to doses between 1and 3 micrograms per day. When there is biochemical or radiographic evidence of bone healing, (and in hypoparathyroid patients when normal plasma calcium levels have been attained), the dose generally decreases. Maintenance doses are generally in the range of 0.25 to 1 microgram per day. If hypercalcaemia occurs, Alfacalcidol should be stopped until plasma calcium returns to normal (approximately 1 week) then restarted at half the previous dose.
\*\*a) Renal bone disease:\*\*
Patients with relatively high initial plasma calcium levels may have autonomous hyperparathyroidism, often unresponsive to Alfacalcidol. Other therapeutic measures may be indicated.
Before and during treatment with Alfacalcidol, phosphate binding agents should be considered to prevent hyperphosphataemia. It is particularly important to make frequent plasma calcium measurements in patients with chronic renal failure because prolonged hypercalcaemia may aggravate the decline of renal function.
\*\*b) Hyperparathyroidism:\*\*
In patients with primary or tertiary hyperparathyroidism about to undergo parathyroidectomy, pre-operative treatment with Alfacalcidol for 2-3 weeks alleviates bone pain and myopathy without aggravating pre-operative hypercalcaemia. In order to decrease post-operative hypocalcaemia, Alfacalcidol should be continued until plasma alkaline phosphatase levels fall to normal or hypercalcaemia occurs.
\*\*c) Hypoparathyroidism:\*\*
In contrast to the response to parent vitamin D, low plasma calcium levels are restored to normal relatively quickly with Alfacalcidol. Severe hypocalcaemia is corrected more rapidly with higher doses of Alfacalcidol (e.g., 3-5 micrograms) together with calcium supplements.
\*\*d) Nutritional and malabsorptive rickets and osteomalacia:\*\*
Nutritional rickets and osteomalacia can be cured rapidly with Alfacalcidol. Malabsorptive osteomalacia (responding to large doses of IM or IV parent vitamin D) will respond to small doses of Alfacalcidol.
\*\*e) Pseudo-deficiency (D-dependent) rickets and osteomalacia:\*\*
Although large doses of parent vitamin D would be required, effective doses of Alfacalcidol are similar to those required to heal nutritional vitamin D deficiency rickets and osteomalacia.
\*\*f) Hypophosphataemic vitamin D-resistant rickets and osteomalacia:\*\*
Neither large doses of parent vitamin D nor phosphate supplements are entirely satisfactory.
Treatment with Alfacalcidol at normal dosage rapidly relieves myopathy when present and increases calcium and phosphate retention. Phosphate supplements may also be required in some patients.
\*\*Method of administration\*\*
Oral use
The soft capsules should be swallowed whole with sufficient amount of fluid.4.3 Contraindications
Hypersensitivity to the active substance, arachis oil (peanut oil), soya or to any of the excipients listed in section 6.1.
Hypercalcaemia, metastatic calcification.4.4 Special warnings and precautions for use
\*Monitoring\*
During treatment with Alfacalcidol, serum calcium and serum phosphate and creatinine levels should be monitored regularly especially in children, patients with renal impairment and patients receiving high doses. PTH, alkaline phosphatase and calcium phosphates should be monitored as clinically indicated.
\*Hypercalcaemia\*
Hypercalcaemia may appear in patients treated with Alfacalcidol. For this reason, patients should be informed about the clinical symptoms connected with hypercalcaemia. Refer section 4.8 (Undesirable effects)
In case of hypercalcaemia, Alfacalcidol treatment should be stopped until serum calcium concentrations return to normal, usually in about 1 week. Alfacalcidol may then be restarted at half the last dose used with monitoring of calcium.
Prolonged hypercalcaemia may aggravate arteriosclerosis, cardiac valve sclerosis or nephrolithiasis and therefore prolonged hypercalcaemia should be avoided when Alfacalcidol is used in these patients. Transient or even long-lasting deterioration of kidney function has been observed. Alfacalcidol should also be used with caution in patients with calcification of pulmonary tissue as this may result in cardiac disease.
\*Renal\*
In patients with renal bone disease or severely reduced renal function, a phosphate binding agent could be used simultaneously with alfacalcidol to prevent increased serum phosphate and potential metastatic calcification.
\*Granulomatous diseases\*
Alfacalcidol should be used with caution in patients with granulomatous diseases such as sarcoidosis where the sensitivity to vitamin D is increased due to increased hydroxylation activity.
\*Fructose intolerance\*
This medicinal product contains sorbitol as an excipient and patients with rare hereditary problems of fructose intolerance (HFI) should not take this medicinal product.
This medicinal product contains 1 mg of alcohol (ethanol) per soft capsule, corresponding to 1% (w/w). The amount of alcohol (ethanol) in one soft capsule of this medicine is equivalent to less than 1 ml of beer or 1 ml of wine. The small amount of alcohol in this medicine has no noticeable effects.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Digitalis glycosides\*\*
Concurrent use of digitalis glycosides in the presence of hypercalcaemia due to vitamin D administration increases the potential for cardiac arrhythmias and is therefore contraindicated. Patients taking digitalis and alfacalcidol concomitantly should be frequently monitored with ECG and measurements of plasma levels of digitalis glycosides and calcium.
\*\*Thiazide diuretics and calcium containing preparations\*\*
Use with caution in patients being treated with thiazide diuretics or \*\*calcium containing\*\* \*\*preparations\*\* as they may have an increased risk of developing hypercalcaemia. Calcium levels should be monitored.
\*\*Other vitamin D containing preparations\*\*
Vitamin D or its analogous should not be given concurrently with alfacalcidol as may enhance the risk of hypercalcaemia.
\*\*Anticonvulsants\*\*
Patients taking barbiturates or anticonvulsants may require larger doses of Alfacalcidol to produce the desired effect due to the induction of hepatic detoxification enzymes.
\*\*Magnesium-containing antacids\*\*
Magnesium based antacids and laxatives should not be used during treatment with alfacalcidol due to increased risk of hypermagnesaemia.
\*\*Aluminium-containing preparations\*\*
Alfacalcidol may increase the serum concentration of aluminium. Patients taking aluminium- containing preparations (e.g. aluminium hydroxide, sucralfate) should be monitored for signs of aluminium related toxicities.
\*\*Bile acid sequestrants\*\*
Concomitant oral administration of bile acid sequestrants such as cholestyramine may impair the intestinal absorption of oral Alfacalcidol formulations. Alfacalcidol should be administered at least 1 hour before, or 4 to 6 hours after the intake of the bile acid sequestrant in order to minimise the potential risk of interaction.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
There is a limited amount of data from the use of alfacalcidol in pregnant women. Studies in animals have shown reproductive toxicity at high doses (see section 5.3).
Therefore, Alfacalcidol is not recommended during pregnancy and in women of child- bearing potential not using contraception.
\*\*Breast-feeding\*\*
Although it has not been established, it is likely that increased amounts of 1,25- dihydroxyvitamin D will be found in the milk of lactating mothers treated with Alfacalcidol. This may influence calcium metabolism in the infant.
Breast-fed infants of alfacalcidol-using mothers should be monitored closely for hypercalcaemia.
\*\*Fertility\*\*
There are no clinical studies on the effect of alfacalcidol on fertility. A pre-clinical study did not show an effect on fertility in rats.4.7 Effects on ability to drive and use machines
Alfacalcidol has no or negligible direct influence on the ability to drive and use machines. However, the patient suffering from “dizziness” or “confusional states” due to Alfacalcidol should not drive or use machines.4.8 Undesirable effects
The estimation of the frequency of undesirable effects is based on a pooled analysis of data from clinical studies and spontaneous reporting.
The most frequently reported undesirable effects are skin reactions such as pruritus and rash, hypercalcaemia, gastrointestinal pain/discomfort and hyperphosphataemia. Symptoms of hypercalcaemia are headache, weakness, anorexia, weight loss, nausea, vomiting, diarrhoea, constipation, polyuria, polydepsia, and muscle and bone pain, and metallic taste. Renal failure has been reported post-marketing.
Undesirable effects are listed by MedDRA system organ class (SOC) and the individual undesirable effects are listed starting with the most frequently reported one.
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)
| | |
| --- | --- |
| \*\*Metabolism and nutrition disorders\*\* | |
| Common | Hypercalcaemia Hyperphosphataemia |
| \*\*Psychiatric disorders\*\* | |
| Uncommon | Confusional state |
| \*\*Nervous system disorders\*\* | |
| Uncommon | Headache |
| Rare | Dizziness |
| \*\*Gastrointestinal disorders\*\* | |
| Common | Abdominal pain and discomfort |
| Uncommon | Diarrhoea Vomiting Constipation Nausea |
| \*\*Skin and subcutaneous tissue disorders\*\* | |
| Common | Rash\\* Pruritus \\*Various types of rash such as erythematous, maculo-papular and pustular have been reported. |
| \*\*Musculoskeletal and connective tissue disorders\*\* | |
| Uncommon | Myalgia |
| \*\*Renal and urinary disorders\*\* | |
| Common | Hypercalciuria |
| Uncommon | Nephrolithiasis/Nephrocalcinosis |
| Renal impairment (including acute renal failure) |
| \*\*General disorders and administration site conditions\*\* | |
| Uncommon | Fatigue/asthenia/malaise Calcinosis |
\*\*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 Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Excessive intake of Alfacalcidol may lead to the development of hypercalcaemia, however, the effect is reversed rapidly on withdrawal.
Symptoms of overdosage of Alfacalcidol strides are anorexia, lassitude, nausea and vomiting, diarrhoea, constipation, weight loss, polyuria, sweating, headache, thirst, vertigo, and raised concentrations of calcium and phosphate in plasma and urine.
In severe cases of hypercalcaemia, general supportive measures should be undertaken. Keep the patient well hydrated by i.v. infusion of saline (force diuresis), measure electrolytes, calcium and renal function indices; assess electrocardiographic abnormalities, especially in patients on digitalis. More specifically, treatment with glucocorticosteroids, loop diuretics, bisphosphonates, calcitonin and eventually haemodialysis with low calcium content should be considered.
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Vitamin D and analogues. ATC code: A11CC03
\*\*Clinical efficacy and safety\*\*
Impaired 1α-hydroxylation by the kidneys reduces endogenous 1,25-dihydroxyvitamin D production. This contributes to the disturbances in mineral metabolism found in several disorders, including renal bone disease, hypoparathyroidism and vitamin D dependent rickets. These disorders, which require high doses of parent vitamin D for their correction, will respond to small doses of Alfacalcidol.
The delay in response and high dosage required in treating these disorders with parent vitamin D makes dosage adjustment difficult. This can result in unpredictable hypercalcaemia which may take weeks or months to reverse. The major advantage of Alfacalcidol is the more rapid onset of response, which allows a more accurate titration of dosage. Should inadvertent hypercalcaemia occur, it can be reversed within days of stopping treatment.
In patients with renal failure, 1 - 5 microgram/day of 1α- hydroxyvitamin D (1α-OHD3) increased intestinal calcium and phosphorus absorption in a dose-related manner. This effect was observed within 3 days of starting the drug and conversely, it was reversed within 3 days of its discontinuation.
Patients with chronic renal failure have shown increased serum calcium levels within 5 days of receiving 1α-OHD3 in a dose of 0.5- 1.0 microgram/day. As serum calcium rose, PTH levels and alkaline phosphatase decreased toward normal.
In patients with nutritional osteomalacia, increases in calcium absorption were noted within 6 hours of giving 1 µg 1α-OHD3 orally and usually peaked at 24 hours. 1α- OHD3 also produced increases in plasma inorganic phosphorus due to increased intestinal absorption and renal tubular re-absorption. This latter effect is a result of PTH suppression by 1α-OHD3. The effect of the drug on calcium was about double its effect on phosphorus absorption.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Alfacalcidol is absorbed passively and almost completely in the small intestine.
\*\*Biotransformation\*\*
Alfacalcidol is converted rapidly in the liver to 1,25-dihydroxyvitamin D. This is the metabolite of vitamin D which acts as a regulator of calcium and phosphate metabolism. Since this conversion is rapid, the clinical effects of Alfacalcidol and 1,25-dihydroxyvitamin D are very similar.
Pharmacokinetic/pharmacodynamic relationship(s)
The half-life of alfacalcidol is about 4 hours. The pharmacologic effect is 3-5 days.5.3 Preclinical safety data
\*\*Chronic toxicity:\*\*
The non-clinical toxicity of alfacalcidol is attributed to the known vitamin D-effect of calcitriol on calcium homeostasis, which is characterised by hypercalcaemia, hypercalciuria and eventually soft tissue calcification.
\*\*Genotoxicity:\*\*
Alfacalcidol is not genotoxic.
\*\*Reproduction toxicity:\*\*
No specific effects of alfacalcidol on fertility or behaviour of the offspring were noted in rats and rabbits. In terms of embryo-fetal development, fetal toxicity (post-implantation loss, lower litter size and lower pup weight) was observed at doses high enough to cause toxicity in the dams. High doses of vitamin D are known to be teratogenic in experimental animals.
## Pharmaceutical Particulars
6.1 List of excipients
Citric acid, anhydrous
All-rac-α-Tocopherol
Propyl gallate,
Ethanol, anhydrous
Arachis oil, hydrogenated
The capsule shell contains:
Gelatin Glycerol
Anidrisorb
Purified water
Medium chain triglyceride
Lecithin (soya lecithin),
The capsules contain the following colours:
0.5 microgram capsules: titanium dioxide (E171) and ferric oxide red (E172)6.2 Incompatibilities
Not applicable.6.3 Shelf life
2 years.6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.6.5 Nature and contents of container
The finished products are Alfacalcidol 0.5 mcg capsules soft, to be marketed in white opaque HDPE container, with white opaque HDPE screw closure and induction sealing.
Pack size: 30 capsules, 50 capsules and 100 capsules
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
No special requirements.
