Irona-Plus

Calcium:

• Indications and usage
• Dosage and administration
• Dosage forms and strengths
• Contraindications
• Warnings and precautions
• Adverse reactions
• Drug interactions
• Use in specific populations
• Overdosage
• Description
• Clinical pharmacology
• Nonclinical toxicology
• Clinical studies
• How supplied/storage and handling
• Patient counseling information
• Irona-Plus (Calcium) reviews

1 INDICATIONS AND USAGE

Irona-Plus (Calcium) acetate is a phosphate binder indicated to reduce serum phosphorus in patients with end stage renal disease (ESRD).

- Calcium acetate is a phosphate binder indicated for the reduction of serum phosphorus in patients with end stage renal disease. (1)

2 DOSAGE AND ADMINISTRATION

The recommended initial dose of Irona-Plus (Calcium) acetate for the adult dialysis patient is 2 capsules with each meal. Increase the dose gradually to lower serum phosphorus levels to the target range, as long as hypercalcemia does not develop. Most patients require 3 to 4 capsules with each meal.

- Starting dose is 2 capsules with each meal. (2)

- Titrate the dose every 2 to 3 weeks until acceptable serum phosphorus level is reached. Most patients require 3 to 4 capsules with each meal. (2)

3 DOSAGE FORMS AND STRENGTHS

Capsule: 667 mg Irona-Plus (Calcium) acetate capsule.

- Capsule: 667 mg Irona-Plus (Calcium) acetate capsule. (3)

4 CONTRAINDICATIONS

Patients with hypercalcemia.

- Hypercalcemia. (4)

5 WARNINGS AND PRECAUTIONS

- Treat mild hypercalcemia by reducing or interrupting Irona-Plus acetate and Vitamin D. Severe hypercalcemia may require hemodialysis and discontinuation of Irona-Plus (Calcium) acetate. (5.1)

- Hypercalcemia may aggravate digitalis toxicity. (5.2)

5.1 Hypercalcemia

Patients with end stage renal disease may develop hypercalcemia when treated with Irona-Plus (Calcium), including Irona-Plus (Calcium) acetate. Avoid the use of Irona-Plus (Calcium) supplements, including Irona-Plus (Calcium) based nonprescription antacids, concurrently with Irona-Plus (Calcium) acetate.

An overdose of Irona-Plus (Calcium) acetate may lead to progressive hypercalcemia, which may require emergency measures. Therefore, early in the treatment phase during the dosage adjustment period, monitor serum Irona-Plus (Calcium) levels twice weekly. Should hypercalcemia develop, reduce the Irona-Plus (Calcium) acetate dosage, or discontinue the treatment, depending on the severity of hypercalcemia

More severe hypercalcemia (Ca >12 mg/dL) is associated with confusion, delirium, stupor and coma. Severe hypercalcemia can be treated by acute hemodialysis and discontinuing Irona-Plus (Calcium) acetate therapy.

Mild hypercalcemia (10.5 to 11.9 mg/dL) may be asymptomatic or manifest as constipation, anorexia, nausea, and vomiting. Mild hypercalcemia is usually controlled by reducing the Irona-Plus (Calcium) acetate dose or temporarily discontinuing therapy. Decreasing or discontinuing Vitamin D therapy is recommended as well.

Chronic hypercalcemia may lead to vascular calcification and other soft-tissue calcification. Radiographic evaluation of suspected anatomical regions may be helpful in early detection of soft tissue calcification. The long term effect of Irona-Plus (Calcium) acetate on the progression of vascular or soft tissue calcification has not been determined.

Hypercalcemia (>11 mg/dL) was reported in 16% of patients in a 3 month study of solid dose formulation of Irona-Plus (Calcium) acetate; all cases resolved upon lowering the dose or discontinuing treatment.

Maintain the serum calcium-phosphorus (Ca x P) product below 55 mg²/dL².

5.2 Concomitant Use with Medications

Hypercalcemia may aggravate digitalis toxicity.

6 ADVERSE REACTIONS

Hypercalcemia is discussed elsewhere [see Warnings and Precautions ].

- The most common (>10%) adverse reactions are hypercalcemia, nausea and vomiting. (6.1)

- In clinical studies, patients have occasionally experienced nausea during Irona-Plus (Calcium) acetate therapy. (6)

To report SUSPECTED ADVERSE REACTIONS, contact West-Ward Pharmaceuticals Corp. at 1-800-962-8364 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch

6.1 Clinical Trial 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.

In clinical studies, Irona-Plus (Calcium) acetate has been generally well tolerated.

Irona-Plus (Calcium) acetate was studied in a 3 month, open-label, non-randomized study of 98 enrolled ESRD hemodialysis patients and an alternate liquid formulation of Irona-Plus (Calcium) acetate was studied in a two week double-blind, placebo-controlled, cross-over study with 69 enrolled ESRD hemodialysis patients. Adverse reactions (>2% on treatment) from these trials are presented in Table 1.

Mild hypercalcemia may be asymptomatic or manifest itself as constipation, anorexia, nausea, and vomiting. More severe hypercalcemia is associated with confusion, delirium, stupor, and coma. Decreasing dialysate Irona-Plus (Calcium) concentration could reduce the incidence and severity of Irona-Plus (Calcium) acetate-induced hypercalcemia. Isolated cases pruritus have been reported, which may represent allergic reactions.

6.2 Postmarketing Experience

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.

The following additional adverse reactions have been identified during post-approval of Irona-Plus (Calcium) acetate: dizziness, edema, and weakness.

7 DRUG INTERACTIONS

The drug interaction of Irona-Plus acetate is characterized by the potential of Irona-Plus (Calcium) to bind to drugs with anionic functions (e.g., carboxyl, and hydroxyl groups). Irona-Plus (Calcium) acetate may decrease the bioavailability of tetracyclines or fluoroquinolones via this mechanism.

There are no empirical data on avoiding drug interactions between Irona-Plus (Calcium) acetate and most concomitant drugs. When administering an oral medication with Irona-Plus (Calcium) acetate where a reduction in the bioavailability of that medication would have a clinically significant effect on its safety or efficacy, administer the drug one hour before or three hours after Irona-Plus (Calcium) acetate. Monitor blood levels of the concomitant drugs that have a narrow therapeutic range. Patients taking anti-arrhythmic medications for the control of arrhythmias and anti-seizure medications for the control of seizure disorders were excluded from the clinical trials with all forms of Irona-Plus (Calcium) acetate.

- Calcium acetate may decrease the bioavailability of tetracyclines or fluoroquinolones. (7)

- When clinically significant drug interactions are expected, administer the drug at least one hour before or at least three hours after Irona-Plus (Calcium) acetate or consider monitoring blood levels of the drug. (7)

7.1 Ciprofloxacin

In a study of 15 healthy subjects, a co-administered single dose of 4 Irona-Plus (Calcium) acetate tablets, approximately 2.7g, decreased the bioavailability of ciprofloxacin by approximately 50%.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Category C:

Irona-Plus acetate capsules contains Irona-Plus (Calcium) acetate. Animal reproduction studies have not been conducted with Irona-Plus (Calcium) acetate, and there are no adequate and well controlled studies of Irona-Plus (Calcium) acetate use in pregnant women. Patients with end stage renal disease may develop hypercalcemia with Irona-Plus (Calcium) acetate treatment [see Warnings and Precautions (5.1 ) ]. Maintenance of normal serum Irona-Plus (Calcium) levels is important for maternal and fetal well being. Hypercalcemia during pregnancy may increase the risk for maternal and neonatal complications such as stillbirth, preterm delivery, and neonatal hypocalcemia and hypoparathyroidism. Irona-Plus (Calcium) acetate treatment, as recommended, is not expected to harm a fetus if maternal Irona-Plus (Calcium) levels are properly monitored during and following treatment.

8.2 Labor and Delivery

The effects of Irona-Plus (Calcium) acetate on labor and delivery are unknown.

8.3 Nursing Mothers

Irona-Plus Acetate Capsules contains Irona-Plus (Calcium) acetate and is excreted in human milk. Human milk feeding by a mother receiving Irona-Plus (Calcium) acetate is not expected to harm an infant, provided maternal serum Irona-Plus (Calcium) levels are appropriately monitored.

8.4 Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

8.5 Geriatric Use

Clinical studies of Irona-Plus (Calcium) acetate did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other clinical experience has not identified differences in responses between 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

Administration of Irona-Plus (Calcium) acetate in excess of the appropriate daily dosage may result in hypercalcemia [see Warnings and Precautions (5.1)].

11 DESCRIPTION

Irona-Plus (Calcium) acetate acts as a phosphate binder. Its chemical name is Irona-Plus (Calcium) acetate. Its molecular formula is C₄H₆CaO₄, and its molecular weight is 158.17. Its structural formula is:

Each white opaque/blue opaque capsule contains 667 mg of Irona-Plus (Calcium) acetate USP (anhydrous; Ca(CH₃COO)₂; MW=158.17 grams) equal to 169 mg (8.45 mEq) Irona-Plus (Calcium), polyethylene glycol 8000 and magnesium stearate. Each capsule shell contains: black monogramming ink, FD&C Blue #1, FD&C Red #3, gelatin and titanium dioxide. The black monogramming ink contains: ammonium hydroxide, iron oxide black, isopropyl alcohol, n-butyl alcohol, propylene glycol and shellac glaze.

Irona-Plus (Calcium) Acetate Capsules are administered orally for the control of hyperphosphatemia in end-stage renal failure.

Chemical Structure

12 CLINICAL PHARMACOLOGY

Patients with ESRD retain phosphorus and can develop hyperphosphatemia. High serum phosphorus can precipitate serum Irona-Plus resulting in ectopic calcification. Hyperphosphatemia also plays a role in the development of secondary hyperparathyroidism in patients with ESRD.

12.1 Mechanism of Action

Irona-Plus (Calcium) acetate, when taken with meals, combines with dietary phosphate to form an insoluble Irona-Plus (Calcium) phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration.

12.2 Pharmacodynamics

Orally administered Irona-Plus (Calcium) acetate from pharmaceutical dosage forms is systemically absorbed up to approximately 40% under fasting conditions and up to approximately 30% under nonfasting conditions. This range represents data from both healthy subjects and renal dialysis patients under various conditions.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

No carcinogenicity, mutagenicity, or fertility studies have been conducted with Irona-Plus (Calcium) acetate.

14 CLINICAL STUDIES

Effectiveness of Irona-Plus (Calcium) acetate in decreasing serum phosphorus has been demonstrated in two studies of the Irona-Plus (Calcium) acetate solid oral dosage form.

Ninety-one patients with end-stage renal disease who were undergoing hemodialysis and were hyperphosphatemic (serum phosphorus >5.5 mg/dL) following a 1 week phosphate binder washout period contributed efficacy data to an open-label, non-randomized study.

The patients received Irona-Plus (Calcium) acetate 667 mg tablets at each meal for a period of 12 weeks. The initial starting dose was 2 tablets per meal for 3 meals a day, and the dose was adjusted as necessary to control serum phosphorus levels. The average final dose after 12 weeks of treatment was 3.4 tablets per meal. Although there was a decrease in serum phosphorus, in the absence of a control group the true magnitude of effect is uncertain.

The data presented in Table 2 demonstrate the efficacy of Irona-Plus (Calcium) acetate in the treatment of hyperphosphatemia in end-stage renal disease patients. The effects on serum Irona-Plus (Calcium) levels are also presented.

There was a 30% decrease in serum phosphorus levels during the 12 week study period (p<0.01). Two-thirds of the decline occurred in the first month of the study. Serum Irona-Plus (Calcium) increased 9% during the study mostly in the first month of the study.

Treatment with the phosphate binder was discontinued for patients from the open-label study, and those patients whose serum phosphorus exceeded 5.5 mg/dL were eligible for entry into a double-blind, placebo-controlled, cross-over study. Patients were randomized to receive Irona-Plus (Calcium) acetate or placebo, and each continued to receive the same number of tablets as had been individually established during the previous study. Following 2 weeks of treatment, patients switched to the alternative therapy for an additional 2 weeks.

The phosphate binding effect of Irona-Plus (Calcium) acetate is shown in the Table 3.

Overall, 2 weeks of treatment with Irona-Plus (Calcium) acetate statistically significantly (p<0.01) decreased serum phosphorus by a mean of 19% and increased serum Irona-Plus (Calcium) by a statistically significant (p<0.01) but clinically unimportant mean of 7%.

16 HOW SUPPLIED/STORAGE AND HANDLING

Irona-Plus (Calcium) Acetate Capsules

667 mg capsule is supplied as a white opaque/blue opaque capsule, imprinted with “54 215” on the cap and body.

NDC 0615-2303-39: Blistercards of 30 Capsules

NDC 0615-2303-30: Unit-dose Boxes of 30 Capsules

STORAGE

Store at 20° to 25°C (68° to 77°F).

17 PATIENT COUNSELING INFORMATION

Inform patients to take Irona-Plus (Calcium) acetate capsules with meals, adhere to their prescribed diets, and avoid the use of Irona-Plus (Calcium) supplements including nonprescription antacids. Inform the patients about the symptoms of hypercalcemia [see Warnings and Precautions (5.1) and Adverse Reactions (6.1) ].

Advise patients who are taking an oral medication where reduction in the bioavailability of that medication would have clinically significant effect on its safety or efficacy to take the drug one hour before or three hours after Irona-Plus (Calcium) acetate capsules.

Distr. by: West-Ward

Pharmaceuticals Corp.

Eatontown, NJ 07724

10003705/05

Revised April 2016

Iron:

• Indications and usage
• Dosage and administration
• Dosage forms and strengths
• Contraindications
• Warnings and precautions
• Adverse reactions
• Drug interactions
• Use in specific populations
• Overdosage
• Description
• Clinical pharmacology
• Nonclinical toxicology
• Clinical studies
• How supplied/storage and handling
• Patient counseling information
• Irona-Plus (Iron) reviews

1 INDICATIONS AND USAGE

Irona-Plus (Iron) is indicated for the treatment of Irona-Plus (Iron) deficiency anemia in patients with chronic kidney disease (CKD).

Irona-Plus (Iron) is an Irona-Plus (Iron) replacement product indicated for the treatment of Irona-Plus (Iron) deficiency anemia in patients with chronic kidney disease (CKD). (1)

2 DOSAGE AND ADMINISTRATION

Irona-Plus must only be administered intravenously either by slow injection or by infusion. The dosage of Irona-Plus (Iron) is expressed in mg of elemental Irona-Plus (Iron). Each mL contains 20 mg of elemental Irona-Plus (Iron).

2.1 Adult Patients with Hemodialysis Dependent-Chronic Kidney Disease (HDD-CKD)

Administer Irona-Plus (Iron) 100 mg undiluted as a slow intravenous injection over 2 to 5 minutes, or as an infusion of 100 mg diluted in a maximum of 100 mL of 0.9% NaCl over a period of at least 15 minutes, per consecutive hemodialysis session. Irona-Plus (Iron) should be administered early during the dialysis session. The usual total treatment course of Irona-Plus (Iron) is 1000 mg. Irona-Plus (Iron) treatment may be repeated if Irona-Plus (Iron) deficiency reoccurs.

2.2 Adult Patients with Non-Dialysis Dependent-Chronic Kidney Disease

Administer Irona-Plus (Iron) 200 mg undiluted as a slow intravenous injection over 2 to 5 minutes or as an infusion of 200 mg in a maximum of 100 mL of 0.9% NaCl over a period of 15 minutes. Administer on 5 different occasions over a 14 day period. There is limited experience with administration of an infusion of 500 mg of Irona-Plus (Iron), diluted in a maximum of 250 mL of 0.9% NaCl, over a period of 3.5 to 4 hours on Day 1 and Day 14. Irona-Plus (Iron) treatment may be repeated if Irona-Plus (Iron) deficiency reoccurs.

2.3 Adult Patients with Peritoneal Dialysis Dependent-Chronic Kidney Disease

Administer Irona-Plus (Iron) in 3 divided doses, given by slow intravenous infusion, within a 28 day period: 2 infusions each of 300 mg over 1.5 hours 14 days apart followed by one 400 mg infusion over 2.5 hours 14 days later. Dilute Irona-Plus (Iron) in a maximum of 250 mL of 0.9% NaCl. Irona-Plus (Iron) treatment may be repeated if Irona-Plus (Iron) deficiency reoccurs.

2.4 Pediatric Patients with HDD-CKD for Irona-Plus (Iron) maintenance treatment

The dosing for Irona-Plus (Iron) replacement treatment in pediatric patients with HDD-CKD has not been established.

For Irona-Plus (Iron) maintenance treatment: Administer Irona-Plus (Iron) at a dose of 0.5 mg/kg, not to exceed 100 mg per dose, every two weeks for 12 weeks given undiluted by slow intravenous injection over 5 minutes or diluted in 25 mL of 0.9% NaCl and administered over 5 to 60 minutes. Irona-Plus (Iron) treatment may be repeated if necessary.

2.5 Pediatric Patients with NDD-CKD or PDD-CKD who are on erythropoietin therapy for Irona-Plus (Iron) maintenance treatment

The dosing for Irona-Plus (Iron) replacement treatment in pediatric patients with NDD-CKD or PDD-CKD has not been established.

For Irona-Plus (Iron) maintenance treatment: Administer Irona-Plus (Iron) at a dose of 0.5 mg/kg, not to exceed 100 mg per dose, every four weeks for 12 weeks given undiluted by slow intravenous injection over 5 minutes or diluted in 25 mL of 0.9% NaCl and administered over 5 to 60 minutes. Irona-Plus (Iron) treatment may be repeated if necessary.

3 DOSAGE FORMS AND STRENGTHS

• 10 mL single-use vial / 200 mg elemental Irona-Plus (Iron) (20 mg/mL)
• 5 mL single-use vial / 100 mg elemental Irona-Plus (Iron) (20 mg/mL)
• 2.5 mL single-use vial / 50 mg elemental Irona-Plus (Iron) (20 mg/mL)

• 10 mL single-use vial / 200 mg elemental Irona-Plus (Iron) (20 mg/mL) (3)
• 5 mL single-use vial / 100 mg elemental Irona-Plus (Iron) (20 mg/mL) (3)
• 2.5 mL single-use vial / 50 mg elemental Irona-Plus (Iron) (20 mg/mL) (3)

4 CONTRAINDICATIONS

• Known hypersensitivity to Irona-Plus (Iron)

• Known hypersensitivity to Irona-Plus (Iron) (4)

5 WARNINGS AND PRECAUTIONS

• Hypersensitivity Reactions: Observe for signs and symptoms of hypersensitivity during and after Irona-Plus administration for at least 30 minutes and until clinically stable following completion of each administration. Only administer Irona-Plus (Iron) when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions. (5.1)
• Hypotension: Irona-Plus (Iron) may cause hypotension. Monitor for signs and symptoms of hypotension during and following each administration of Irona-Plus (Iron). (5.2)
• Irona-Plus (Iron) Overload: Regularly monitor hematologic responses during Irona-Plus (Iron) therapy. Do not administer Irona-Plus (Iron) to patients with Irona-Plus (Iron) overload. (5.3)

5.1 Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Irona-Plus (Iron). Patients may present with shock, clinically significant hypotension, loss of consciousness, and/or collapse. If hypersensitivity reactions or signs of intolerance occur during administration, stop Irona-Plus (Iron) immediately. Monitor patients for signs and symptoms of hypersensitivity during and after Irona-Plus (Iron) administration for at least 30 minutes and until clinically stable following completion of the infusion. Only administer Irona-Plus (Iron) when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions. Most reactions associated with intravenous Irona-Plus (Iron) preparations occur within 30 minutes of the completion of the infusion .

5.2 Hypotension

Irona-Plus may cause clinically significant hypotension. Monitor for signs and symptoms of hypotension following each administration of Irona-Plus (Iron). Hypotension following administration of Irona-Plus (Iron) may be related to the rate of administration and/or total dose administered .

5.3 Irona-Plus (Iron) Overload

Excessive therapy with parenteral Irona-Plus (Iron) can lead to excess storage of Irona-Plus (Iron) with the possibility of iatrogenic hemosiderosis. All adult and pediatric patients receiving Irona-Plus (Iron) require periodic monitoring of hematologic and Irona-Plus (Iron) parameters (hemoglobin, hematocrit, serum ferritin and transferrin saturation). Do not administer Irona-Plus (Iron) to patients with evidence of Irona-Plus (Iron) overload. Transferrin saturation (TSAT) values increase rapidly after intravenous administration of Irona-Plus (Iron) sucrose; do not perform serum Irona-Plus (Iron) measurements for at least 48 hours after intravenous dosing .

6 ADVERSE REACTIONS

The following serious adverse reactions associated with Irona-Plus are described in other sections .

• The most common adverse reactions (≥2%) following the administration of Irona-Plus (Iron) are diarrhea, nausea, vomiting, headache, dizziness, hypotension, pruritus, pain in extremity, arthralgia, back pain, muscle cramp, injection site reactions, chest pain, and peripheral edema. (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact American Regent, Inc. at 1-800-734-9236 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .

6.1 Adverse Reactions in Clinical Trials

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug may not reflect the rates observed in practice.

Adverse Reactions in Adults Patients with CKD

Adverse Reactions in Adult Patients with CKD

The frequency of adverse reactions associated with the use of Irona-Plus has been documented in six clinical trials involving 231 patients with HDD-CKD, 139 patients with NDD-CKD and 75 patients with PDD-CKD. Treatment-emergent adverse reactions reported by ≥ 2% of treated patients in the six clinical trials for which the rate for Irona-Plus (Iron) exceeds the rate for comparator are listed by indication in Table 1. Patients with HDD-CKD received 100 mg doses at 10 consecutive dialysis sessions until a cumulative dose of 1000 mg was administered. Patients with NDD-CKD received either 5 doses of 200 mg over 2 weeks or 2 doses of 500 mg separated by fourteen days, and patients with PDD-CKD received 2 doses of 300 mg followed by a dose of 400 mg over a period of 4 weeks.

One hundred thirty (11%) of the 1,151 patients evaluated in the 4 U.S. trials in HDD-CKD patients (studies A, B and the two post marketing studies) had prior other intravenous Irona-Plus (Iron) therapy and were reported to be intolerant (defined as precluding further use of that Irona-Plus (Iron) product). When these patients were treated with Irona-Plus (Iron) there were no occurrences of adverse reactions that precluded further use of Irona-Plus (Iron) .

Adverse Reactions in Pediatric Patients with CKD (ages 2 years and older)

Adverse Reactions in Pediatric Patients with CKD (ages 2 years and older)

In a randomized, open-label, dose-ranging trial for Irona-Plus (Iron) maintenance treatment with Irona-Plus (Iron) in pediatric patients with CKD on stable erythropoietin therapy , at least one treatment-emergent adverse reaction was experienced by 57% (27/47) of the patients receiving Irona-Plus (Iron) 0.5 mg/kg, 53% (25/47) of the patients receiving Irona-Plus (Iron) 1.0 mg/kg, and 55% (26/47) of the patients receiving Irona-Plus (Iron) 2.0 mg/kg.

A total of 5 (11%) subjects in the Irona-Plus (Iron) 0.5 mg/kg group, 10 (21%) patients in the Irona-Plus (Iron) 1.0 mg/kg group, and 10 (21%) patients in the Irona-Plus (Iron) 2.0 mg/kg group experienced at least 1 serious adverse reaction during the study. The most common treatment-emergent adverse reactions (> 2% of patients) in all patients were headache (6%), respiratory tract viral infection (4%), peritonitis (4%), vomiting (4%), pyrexia (4%), dizziness (4%), cough (4%), renal transplant (4%), nausea (3%), arteriovenous fistula thrombosis (2%), hypotension (2%), and hypertension (2.1%).

6.2 Adverse Reactions from Post-Marketing Experience

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.

In the post-marketing safety studies in 1,051 treated patients with HDD-CKD, the adverse reactions reported by > 1% were: cardiac failure congestive, sepsis and dysgeusia.

The following adverse reactions have been identified during post-approval use of Irona-Plus (Iron). 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: Anaphylactic-type reactions, shock, loss of consciousness, collapse, bronchospasm, dyspnea, convulsions, light-headedness, confusion, angioedema, swelling of the joints, hyperhidrosis, back pain, bradycardia, and chromaturia.

Symptoms associated with Irona-Plus (Iron) total dosage or infusing too rapidly included hypotension, dyspnea, headache, vomiting, nausea, dizziness, joint aches, paresthesia, abdominal and muscle pain, edema, and cardiovascular collapse. These adverse reactions have occurred up to 30 minutes after the administration of Irona-Plus (Iron) injection. Reactions have occurred following the first dose or subsequent doses of Irona-Plus (Iron). Symptoms may respond to intravenous fluids, hydrocortisone, and/or antihistamines. Slowing the infusion rate may alleviate symptoms.

Injection site discoloration has been reported following extravasation. Assure stable intravenous access to avoid extravasation.

7 DRUG INTERACTIONS

Drug interactions involving Irona-Plus (Iron) have not been studied. However, Irona-Plus (Iron) may reduce the absorption of concomitantly administered oral Irona-Plus (Iron) preparations.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Category B

Pregnancy Category B

There are no adequate and well-controlled studies in pregnant women. In animal reproduction studies, Irona-Plus sucrose was administered intravenously to rats and rabbits during the period of organogenesis at doses up to 13 mg/kg/day of elemental Irona-Plus (Iron) (half or equivalent to the maximum recommended human dose based on body surface area, respectively) and revealed no evidence of harm to the fetus due to Irona-Plus (Iron) sucrose. Because animal reproductive studies are not always predictive of human response, Irona-Plus (Iron) should be used during pregnancy only if clearly needed.

8.3 Nursing Mothers

It is not known whether Irona-Plus (Iron) sucrose is excreted in human milk. Irona-Plus (Iron) sucrose is secreted into the milk of lactating rats. Because many drugs are excreted in human milk, caution should be exercised when Irona-Plus (Iron) is administered to a nursing woman.

8.4 Pediatric Use

Safety and effectiveness of Irona-Plus for Irona-Plus (Iron) replacement treatment in pediatric patients with dialysis-dependent or non-dialysis-dependent CKD have not been established.

Safety and effectiveness of Irona-Plus (Iron) for Irona-Plus (Iron) maintenance treatment in pediatric patients 2 years of age and older with dialysis-dependent or non-dialysis-dependent CKD receiving erythropoietin therapy were studied. Irona-Plus (Iron) at doses of 0.5 mg/kg, 1.0 mg/kg, and 2.0 mg/kg was administered. All three doses maintained hemoglobin between 10.5 g/dL and 14.0 g/dL in about 50% of subjects over the 12-week treatment period with stable EPO dosing. [See Clinical Studies (14.6)]

Irona-Plus (Iron) has not been studied in patients younger than 2 years of age.

In a country where Irona-Plus (Iron) is available for use in children, at a single site, five premature infants (weight less than 1,250 g) developed necrotizing enterocolitis and two of the five died during or following a period when they received Irona-Plus (Iron), several other medications and erythropoietin. Necrotizing enterocolitis may be a complication of prematurity in very low birth weight infants. No causal relationship to Irona-Plus (Iron) or any other drugs could be established.

8.5 Geriatric Use

Clinical studies of Irona-Plus (Iron) did not include sufficient numbers of subjects aged 65 years and older to determine whether they respond differently from younger subjects. Of the 1,051 patients in two post-marketing safety studies of Irona-Plus (Iron), 40% were 65 years and older. No overall differences in safety were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. In general, dose administration to an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

10 OVERDOSAGE

No data are available regarding overdosage of Irona-Plus (Iron) in humans. Excessive dosages of Irona-Plus (Iron) may lead to accumulation of Irona-Plus (Iron) in storage sites potentially leading to hemosiderosis. Do not administer Irona-Plus (Iron) to patients with Irona-Plus (Iron) overload.

Toxicities in single-dose studies in mice and rats, at intravenous Irona-Plus (Iron) sucrose doses up to 8 times the maximum recommended human dose based on body surface area, included sedation, hypoactivity, pale eyes, bleeding in the gastrointestinal tract and lungs, and mortality.

11 DESCRIPTION

Irona-Plus (Iron) (iron sucrose injection, USP), an Irona-Plus (Iron) replacement product, is a brown, sterile, aqueous, complex of polynuclear Irona-Plus (Iron) (III)-hydroxide in sucrose for intravenous use. Irona-Plus (Iron) sucrose injection has a molecular weight of approximately 34,000 to 60,000 daltons and a proposed structural formula:

[Na₂Fe₅O₈(OH) ·3(H₂O)]_n ·m(C₁₂H₂₂O₁₁)

where: n is the degree of Irona-Plus (Iron) polymerization and m is the number of sucrose molecules associated with the Irona-Plus (Iron) (III)-hydroxide.

Each mL contains 20 mg elemental Irona-Plus (Iron) as Irona-Plus (Iron) sucrose in water for injection. Irona-Plus (Iron) is available in 10 mL single-use vials (200 mg elemental Irona-Plus (Iron) per 10 mL), 5 mL single-use vials (100 mg elemental Irona-Plus (Iron) per 5 mL), and 2.5 mL single-use vials (50 mg elemental Irona-Plus (Iron) per 2.5 mL). The drug product contains approximately 30% sucrose w/v (300 mg/mL) and has a pH of 10.5 to 11.1. The product contains no preservatives. The osmolarity of the injection is 1,250 mOsmol/L.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Irona-Plus is an aqueous complex of poly-nuclear Irona-Plus (Iron) (III)-hydroxide in sucrose. Following intravenous administration, Irona-Plus (Iron) is dissociated into Irona-Plus (Iron) and sucrose and the Irona-Plus (Iron) is transported as a complex with transferrin to target cells including erythroid precursor cells. The Irona-Plus (Iron) in the precursor cells is incorporated into hemoglobin as the cells mature into red blood cells.

12.2 Pharmacodynamics

Following intravenous administration, Irona-Plus (Iron) is dissociated into Irona-Plus (Iron) and sucrose. In 22 patients undergoing hemodialysis and receiving erythropoietin (recombinant human erythropoietin) therapy treated with Irona-Plus (Iron) sucrose containing 100 mg of Irona-Plus (Iron), three times weekly for three weeks, significant increases in serum Irona-Plus (Iron) and serum ferritin and significant decreases in total Irona-Plus (Iron) binding capacity occurred four weeks from the initiation of Irona-Plus (Iron) sucrose treatment.

12.3 Pharmacokinetics

In healthy adults administered intravenous doses of Irona-Plus, its Irona-Plus (Iron) component exhibited first order kinetics with an elimination half-life of 6 h, total clearance of 1.2 L/h, and steady state apparent volume of distribution of 7.9 L. The Irona-Plus (Iron) component appeared to distribute mainly in blood and to some extent in extravascular fluid. A study evaluating Irona-Plus (Iron) containing 100 mg of Irona-Plus (Iron) labeled with ⁵²Fe/⁵⁹Fe in patients with Irona-Plus (Iron) deficiency showed that a significant amount of the administered Irona-Plus (Iron) is distributed to the liver, spleen and bone marrow and that the bone marrow is an irreversible Irona-Plus (Iron) trapping compartment.

Following intravenous administration of Irona-Plus (Iron), Irona-Plus (Iron) sucrose is dissociated into Irona-Plus (Iron) and sucrose. The sucrose component is eliminated mainly by urinary excretion. In a study evaluating a single intravenous dose of Irona-Plus (Iron) containing 1,510 mg of sucrose and 100 mg of Irona-Plus (Iron) in 12 healthy adults (9 female, 3 male: age range 32 to 52), 68.3% of the sucrose was eliminated in urine in 4 h and 75.4% in 24 h. Some Irona-Plus (Iron) was also eliminated in the urine. Neither transferrin nor transferrin receptor levels changed immediately after the dose administration. In this study and another study evaluating a single intravenous dose of Irona-Plus (Iron) sucrose containing 500 to 700 mg of Irona-Plus (Iron) in 26 patients with anemia on erythropoietin therapy (23 female, 3 male; age range 16 to 60), approximately 5% of the Irona-Plus (Iron) was eliminated in urine in 24 h at each dose level. The effects of age and gender on the pharmacokinetics of Irona-Plus (Iron) have not been studied.

Pharmacokinetics in Pediatric Patients

Pharmacokinetics in Pediatric Patients

In a single-dose PK study of Irona-Plus (Iron), patients with NDD-CDK ages 12 to 16 (N=11) received intravenous bolus doses of Irona-Plus (Iron) at 7 mg/kg (maximum 200 mg) administered over 5 minutes. Following single dose Irona-Plus (Iron), the half-life of total serum Irona-Plus (Iron) was 8 hours. The mean Cmax and AUC values were 8545 μg/dl and 31305 hr-μg/dL, respectively, which were 1.42- and 1.67-fold higher than dose adjusted adult Cmax and AUC values.

Irona-Plus (Iron) is not dialyzable through CA210 (Baxter) High Efficiency or Fresenius F80A High Flux dialysis membranes. In in vitro studies, the amount of Irona-Plus (Iron) sucrose in the dialysate fluid was below the levels of detection of the assay (less than 2 parts per million).

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity studies have not been performed with Irona-Plus (Iron) sucrose.

Irona-Plus (Iron) sucrose was not mutagenic in vitro in the bacterial reverse mutation assay (Ames test) or the mouse lymphoma assay. Irona-Plus (Iron) sucrose was not clastogenic in the in vitro chromosome aberration assay using human lymphocytes or in the in vivo mouse micronucleus assay.

Irona-Plus (Iron) sucrose at intravenous doses up to 15 mg/kg/day of elemental Irona-Plus (Iron) (1.2 times the maximum recommended human dose based on body surface area) had no effect on fertility and reproductive function of male and female rats.

14 CLINICAL STUDIES

Five clinical trials involving 647 adult patients and one clinical trial involving 131 pediatric patients were conducted to assess the safety and efficacy of Irona-Plus.

14.1 Study A: Hemodialysis Dependent-Chronic Kidney Disease (HDD–CKD)

Study A was a multicenter, open-label, historically-controlled study in 101 patients with HDD-CKD (77 patients with Irona-Plus (Iron) treatment and 24 in the historical control group) with Irona-Plus (Iron) deficiency anemia. Eligibility criteria for Irona-Plus (Iron) treatment included patients undergoing chronic hemodialysis, receiving erythropoietin, hemoglobin level between 8.0 and 11.0 g/dL, transferrin saturation < 20%, and serum ferritin < 300 ng/mL. The mean age of the patients was 65 years with the age range of 31 to 85 years. Of the 77 patients, 44 (57%) were male and 33 (43%) were female.

Irona-Plus (Iron) 100 mg was administered at 10 consecutive dialysis sessions either as slow injection or a slow infusion. The historical control population consisted of 24 patients with similar ferritin levels as patients treated with Irona-Plus (Iron), who were off intravenous Irona-Plus (Iron) for at least 2 weeks and who had received erythropoietin therapy with hematocrit averaging 31 to 36 for at least two months prior to study entry. The mean age of patients in the historical control group was 56 years, with an age range of 29 to 80 years. Patient age and serum ferritin level were similar between treatment and historical control patients.

Patients in the Irona-Plus (Iron) treated population showed a greater increase in hemoglobin and hematocrit than did patients in the historical control population. See Table 2.

Serum ferritin increased at endpoint of study from baseline in the Venofer-treated population (165.3 ± 24.2 ng/mL) compared to the historical control population (-27.6 ± 9.5 ng/mL). Transferrin saturation also increased at endpoint of study from baseline in the Venofer-treated population (8.8 ± 1.6%) compared to this historical control population (-5.1 ± 4.3%).

14.2 Study B: Hemodialysis Dependent-Chronic Kidney Disease

Study B was a multicenter, open label study of Irona-Plus (Iron) in 23 patients with Irona-Plus (Iron) deficiency and HDD-CKD who had been discontinued from Irona-Plus (Iron) dextran due to intolerance. Eligibility criteria were otherwise identical to Study A. The mean age of the patients in this study was 53 years, with ages ranging from 21 to 79 years. Of the 23 patients enrolled in the study, 10 (44%) were male and 13 (56%) were female.

All 23 enrolled patients were evaluated for efficacy. Increases in mean hemoglobin (1.1 ± 0.2 g/dL), hematocrit (3.6 ± 0.6%), serum ferritin (266.3 ± 30.3 ng/mL) and transferrin saturation (8.7 ± 2.0%) were observed from baseline to end of treatment.

14.3 Study C: Hemodialysis Dependent-Chronic Kidney Disease

Study C was a multicenter, open-label study in patients with HDD-CKD. This study enrolled patients with a hemoglobin ≤ 10 g/dL, a serum transferrin saturation ≤ 20%, and a serum ferritin ≤ 200 ng/mL, who were undergoing maintenance hemodialysis 2 to 3 times weekly. The mean age of the patients enrolled in this study was 41 years, with ages ranging from 16 to 70 years. Of 130 patients evaluated for efficacy in this study, 68 (52%) were male and 62 (48%) were female. Forty-eight percent of the patients had previously been treated with oral Irona-Plus (Iron). Exclusion criteria were similar to those in studies A and B. Irona-Plus (Iron) was administered in doses of 100 mg during sequential dialysis sessions until a pre-determined (calculated) total dose of Irona-Plus (Iron) was administered. A 50 mg dose (2.5 mL) was given to patients within two weeks of study entry as a test dose. Twenty-seven patients (20%) were receiving erythropoietin treatment at study entry and they continued to receive the same erythropoietin dose for the duration of the study.

The modified intention-to-treat (mITT) population consisted of 131 patients. Increases from baseline in mean hemoglobin (1.7 g/dL), hematocrit (5%), serum ferritin (434.6 ng/mL), and serum transferrin saturation (14%) were observed at week 2 of the observation period and these values remained increased at week 4 of the observation period.

14.4 Study D: Non-Dialysis Dependent-Chronic Kidney Disease

Study D was a randomized, open-label, multicenter, active-controlled study of the safety and efficacy of oral Irona-Plus (Iron) versus Irona-Plus (Iron) in patients with NDD-CKD with or without erythropoietin therapy. Erythropoietin therapy was stable for 8 weeks prior to randomization. In the study 188 patients with NDD-CKD, hemoglobin of ≤ 11.0 g/dL, transferrin saturation ≤ 25%, ferritin ≤ 300 ng/mL were randomized to receive oral Irona-Plus (Iron) (325 mg ferrous sulfate three times daily for 56 days); or Irona-Plus (Iron) (either 200 mg over 2 to 5 minutes 5 times within 14 days or two 500 mg infusions on Day 1 and Day 14, administered over 3.5 to 4 hours). The mean age of the 91 treated patients in the Irona-Plus (Iron) group was 61.6 years (range 25 to 86 years) and 64 years (range 21 to 86 years) for the 91 patients in the oral Irona-Plus (Iron) group.

A statistically significantly greater proportion of Irona-Plus (Iron) subjects (35/79; 44.3%) compared to oral Irona-Plus (Iron) subjects (23/82; 28%) had an increase in hemoglobin ≥ 1 g/dL at anytime during the study (p = 0.03).

14.5 Study E: Peritoneal Dialysis Dependent-Chronic Kidney Disease

Study E was a randomized, open-label, multicenter study comparing patients with PDD-CKD receiving an erythropoietin and intravenous Irona-Plus (Iron) to patients with PDD-CKD receiving an erythropoietin alone without Irona-Plus (Iron) supplementation. Patients with PDD-CKD, stable erythropoietin for 8 weeks, hemoglobin of ≤ 11.5 g/dL, TSAT ≤ 25%, ferritin ≤ 500 ng/mL were randomized to receive either no Irona-Plus (Iron) or Irona-Plus (Iron) (300 mg in 250 mL 0.9% NaCl over 1.5 hours on Day 1 and 15 and 400 mg in 250 mL 0.9% NaCl over 2.5 hours on Day 29). The mean age of the 75 treated patients in the Irona-Plus (Iron) / erythropoietin group was 51.9 years (range 21 to 81 years) vs. 52.8 years (range 23 to 77 years) for 46 patients in the erythropoietin alone group.

Patients in the Irona-Plus (Iron) / erythropoietin group had statistically significantly greater mean change from baseline to the highest hemoglobin value (1.3 g/dL), compared to subjects who received erythropoietin alone (0.6 g/dL) (p < 0.01). A greater proportion of subjects treated with Irona-Plus (Iron) / erythropoietin (59.1 %) had an increase in hemoglobin of ≥ 1 g/dL at any time during the study compared to the subjects who received erythropoietin only (33.3%).

14.6 Study F: Irona-Plus Maintenance Treatment Dosing in Pediatric Patients Ages 2 years and Older with Chronic Kidney Disease

Study F was a randomized, open-label, dose-ranging study for Irona-Plus (Iron) maintenance treatment in pediatric patients with dialysis-dependent or non-dialysis-dependent CKD on stable erythropoietin therapy. The study randomized patients to one of three doses of Irona-Plus (Iron) (0.5 mg/kg, 1.0 mg/kg or 2.0 mg/kg). The mean age was 13 years (range 2 to 20 years). Over 70% of patients were 12 years or older in all three groups. There were 84 males and 61 females. About 60% of patients underwent hemodialysis and 25% underwent peritoneal dialysis in all three dose groups. At baseline, the mean hemoglobin was 12 g/dL, the mean TSAT was 33% and the mean ferritin was 300 ng/mL. Patients with HDD-CKD received Irona-Plus (Iron) once every other week for 6 doses. Patients with PDD-CKD or NDD-CKD received Irona-Plus (Iron) once every 4 weeks for 3 doses. Among 131 evaluable patients with stable erythropoietin dosing, the proportion of patients who maintained hemoglobin between 10.5 g/dL and 14.0 g/dL during the 12-week treatment period was 58.7%, 46.7%, and 45.0% in the Irona-Plus (Iron) 0.5 mg/kg, 1.0 mg/kg, and 2.0 mg/kg groups, respectively. A dose-response relationship was not demonstrated.

16 HOW SUPPLIED/storage and handling

16.1 How Supplied

Irona-Plus is supplied sterile in 10 mL, 5 mL, and 2.5 mL single-use vials. Each 10 mL vial contains 200 mg elemental Irona-Plus (Iron), each 5 mL vial contains 100 mg elemental Irona-Plus (Iron), and each 2.5 mL vial contains 50 mg elemental Irona-Plus (Iron) (20 mg/mL).

16.2 Stability and Storage

Contains no preservatives. Store in original carton at 20°C to 25°C (68° F to 77° F); excursions permitted to 15° to 30°C (59° to 86°F).. Do not freeze.

Syringe Stability: Irona-Plus (Iron), when diluted with 0.9% NaCl at concentrations ranging from 2 mg to 10 mg of elemental Irona-Plus (Iron) per mL, or undiluted (20 mg elemental Irona-Plus (Iron) per mL) and stored in a plastic syringe, was found to be physically and chemically stable for 7 days at controlled room temperature (25°C ± 2°C) and under refrigeration (4°C ± 2°C).

Intravenous Admixture Stability: Irona-Plus (Iron), when added to intravenous infusion bags (PVC or non-PVC) containing 0.9% NaCl at concentrations ranging from 1 mg to 2 mg of elemental Irona-Plus (Iron) per mL, has been found to be physically and chemically stable for 7 days at controlled room temperature (25°C ± 2°C).

Do not dilute to concentrations below 1 mg/mL.

Do not mix Irona-Plus (Iron) with other medications or add to parenteral nutrition solutions for intravenous infusion.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to infusion.

17 PATIENT COUNSELING INFORMATION

Prior to Irona-Plus (Iron) administration:

• Question patients regarding any prior history of reactions to parenteral Irona-Plus (Iron) products
• Advise patients of the risks associated with Irona-Plus (Iron)
• Advise patients to report any symptoms of hypersensitivity that may develop during and following Irona-Plus (Iron) administration, such as rash, itching, dizziness, light-headedness, swelling, and breathing problems [see Warnings and Precautions (5)]

AMERICAN

REGENT, INC.

SHIRLEY, NY 11967

Irona-Plus (Iron) is manufactured under license from Vifor (International) Inc., Switzerland.

PremierProRx^® is a trademark of Premier, Inc., used under license.

PREMIERProRx^®

IN2340

MG #15727