(pah ri KAL si tole)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Zemplar: 1 mcg, 2 mcg, 4 mcg [contains alcohol, usp]
Generic: 1 mcg, 2 mcg, 4 mcg
Zemplar: 2 mcg/mL (1 mL); 5 mcg/mL (1 mL, 2 mL) [contains alcohol, usp, propylene glycol]
Generic: 2 mcg/mL (1 mL); 5 mcg/mL (1 mL, 2 mL)
Brand Names: U.S.
- Vitamin D Analog
Decreased renal conversion of vitamin D to its primary active metabolite (1,25-hydroxyvitamin D) in chronic renal failure leads to reduced activation of vitamin D receptor (VDR), which subsequently removes inhibitory suppression of parathyroid hormone (PTH) release; increased serum PTH (secondary hyperparathyroidism) reduces calcium excretion and enhances bone resorption. Paricalcitol is a synthetic vitamin D analog which binds to and activates the VDR in kidney, parathyroid gland, intestine and bone, thus reducing PTH levels and improving calcium and phosphate homeostasis.
Healthy subjects: Oral: 34 L; IV: 24 L
Stage 3 and 4 CKD: Oral: 44 to 46 L
Stage 5 CKD: Oral: 38 to 49 L; IV: 31 to 35 L
Hydroxylation and glucuronidation via hepatic and nonhepatic enzymes, including CYP24, CYP3A4, UGT1A4; forms metabolites (at least one active)
Healthy subjects: Feces (oral: 70%; IV: 63%); urine (oral: 18%, IV: 19%); 51% to 59% as metabolites
Time to Peak
Plasma: 3 hours: Delayed by food
Healthy subjects: Oral: 4 to 6 hours; IV: 5 to 7 hours
Stage 3 and 4 CKD: Oral: 17 to 20 hours
Stage 5 CKD (on HD or PD): Oral: 14 to 18 hours; IV: 14 to 15 hours
Special Populations: Renal Function Impairment
Hemodialysis and peritoneal dialysis have essentially no effect on paricalcitol elimination. However, compared with healthy subjects, stage 5 chronic kidney disease subjects showed a decreased Cl and increased half-life.
Special Populations: Hepatic Function Impairment
The pharmacokinetics of unbound paricalcitol were similar across the range of hepatic function evaluated in this study. The influence of severe hepatic impairment on the pharmacokinetics of paricalcitol has not been evaluated.
Use: Labeled Indications
IV: Prevention and treatment of secondary hyperparathyroidism associated with stage 5 chronic kidney disease (CKD)
Oral: Prevention and treatment of secondary hyperparathyroidism associated with stage 3 and 4 CKD and stage 5 CKD patients on hemodialysis or peritoneal dialysis
Hypersensitivity to paricalcitol or any component of the formulation; patients with evidence of vitamin D toxicity; hypercalcemia
Note: In stage 3 to 5 CKD maintain Ca x P <55 mg2/dL2, reduce or interrupt dosing if recommended calcium phosphorus product (Ca x P) is exceeded or hypercalcemia is observed (K/DOQI Clinical Practice Guidelines, 2003).
Secondary hyperparathyroidism associated with chronic renal failure (stage 5 CKD):
IV: 0.04 to 0.1 mcg/kg (2.8 to 7 mcg) given as a bolus dose no more frequently than every other day at any time during dialysis; dose may be increased by 2 to 4 mcg every 2 to 4 weeks; doses as high as 0.24 mcg/kg (16.8 mcg) have been administered safely; the dose of paricalcitol should be adjusted based on serum intact PTH (iPTH) levels, as follows:
Same or increasing iPTH level: Increase paricalcitol dose
iPTH level decreased by <30%: Increase paricalcitol dose
iPTH level decreased by >30% and <60%: Maintain paricalcitol dose
iPTH level decrease by >60%: Decrease paricalcitol dose
iPTH level 1.5 to 3 times upper limit of normal: Maintain paricalcitol dose
Oral: Initial dose, in mcg, based on baseline iPTH level divided by 80. Administered 3 times weekly, no more frequently than every other day. Note: To reduce the risk of hypercalcemia initiate only after baseline serum calcium has been adjusted to ≤9.5 mg/dL.
Titration dose (mcg) = Most recent iPTH level (pg/mL) divided by 80
Note: In situations where monitoring of iPTH, calcium, and phosphorus occurs less frequently than once per week, a more modest initial and dose titration rate may be warranted:
Modest titration dose (mcg) = Most recent iPTH level (pg/mL) divided by 100
Dosage adjustment for hypercalcemia or elevated Ca x P: Decrease calculated dose by 2 to 4 mcg. If further adjustment is required, dose should be reduced or interrupted until these parameters are normalized. If applicable, phosphate binder dosing may also be adjusted or withheld, or switched to a noncalcium-based phosphate binder
Secondary hyperparathyroidism associated with stage 3 and 4 CKD: Adults: Oral: Initial dose based on baseline serum iPTH:
iPTH ≤500 pg/mL: 1 mcg/day or 2 mcg 3 times/week
iPTH >500 pg/mL: 2 mcg/day or 4 mcg 3 times/week
Dosage adjustment based on iPTH level relative to baseline, adjust dose at 2- to 4-week intervals:
iPTH same or increased: Increase paricalcitol dose by 1 mcg/day or 2 mcg 3 times/week
iPTH decreased by <30%: Increase paricalcitol dose by 1 mcg/day or 2 mcg 3 times/week
iPTH decreased by ≥30% and ≤60%: Maintain paricalcitol dose
iPTH decreased by >60%: Decrease paricalcitol dose by 1 mcg/day* or 2 mcg 3 times/week
iPTH <60 pg/mL: Decrease paricalcitol dose by 1 mcg/day* or 2 mcg 3 times/week
*If patient is taking the lowest dose on a once-daily regimen, but further dose reduction is needed, decrease dose to 1 mcg 3 times/week. If further dose reduction is required, withhold drug as needed and restart at a lower dose and frequency. If applicable, calcium-phosphate binder dosing may also be adjusted or withheld, or switched to noncalcium-based binder.
Refer to adult dosing.
Secondary hyperparathyroidism associated with chronic renal failure (stage 5 CKD): IV: Children ≥5 years: Refer to adult dosing.
Dosing: Renal Impairment
No dosage adjustment necessary.
Dosing: Hepatic Impairment
Mild to moderate impairment: No dosage adjustment necessary.
Severe impairment: No dosage adjustment provided in manufacturer’s labeling (has not been studied).
Oral: May be administered with or without food. With the 3 times/week dosing schedule, doses should not be given more frequently than every other day.
IV: Administered as a bolus dose at anytime during dialysis. Doses should not be administered more often than every other day.
May be taken with or without food. Some products may contain coconut or palm kernel oil.
Store at 25°C (77°F); excursions permitted between 15°C to 30°C (59°F to 86°F).
Aluminum Hydroxide: Vitamin D Analogs may increase the serum concentration of Aluminum Hydroxide. Specifically, the absorption of aluminum may be increased, leading to increased serum aluminum concentrations. Avoid combination
Bile Acid Sequestrants: May decrease the serum concentration of Vitamin D Analogs. More specifically, bile acid sequestrants may impair absorption of Vitamin D Analogs. Management: Avoid concomitant administration of vitamin D analogs and bile acid sequestrants (e.g., cholestyramine). Separate administration of these agents by several hours to minimize the potential risk of interaction. Monitor plasma calcium concentrations. Consider therapy modification
Calcium Salts: May enhance the adverse/toxic effect of Vitamin D Analogs. Monitor therapy
Cardiac Glycosides: Vitamin D Analogs may enhance the arrhythmogenic effect of Cardiac Glycosides. Monitor therapy
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Paricalcitol. Monitor therapy
Danazol: May enhance the hypercalcemic effect of Vitamin D Analogs. Monitor therapy
Digoxin: Paricalcitol may enhance the adverse/toxic effect of Digoxin. Monitor therapy
Mineral Oil: May decrease the serum concentration of Vitamin D Analogs. More specifically, mineral oil may interfere with the absorption of Vitamin D Analogs. Management: Avoid concomitant, oral administration of mineral oil and vitamin D analogs. Consider separating the administration of these agents by several hours to minimize the risk of interaction. Monitor plasma calcium concentrations. Consider therapy modification
Multivitamins/Fluoride (with ADE): May enhance the adverse/toxic effect of Vitamin D Analogs. Avoid combination
Multivitamins/Minerals (with ADEK, Folate, Iron): May enhance the adverse/toxic effect of Vitamin D Analogs. Avoid combination
Orlistat: May decrease the serum concentration of Paricalcitol. Management: Monitor clinical response to paricalcitol closely when used with orlistat. When this combination must be used, consider administering paricalcitol at least 2 hours before or after the administration of orlistat. Consider therapy modification
Sucralfate: Vitamin D Analogs may increase the serum concentration of Sucralfate. Specifically, the absorption of aluminum from sucralfate may be increased, leading to an increase in the serum aluminum concentration. Avoid combination
Thiazide and Thiazide-Like Diuretics: May enhance the hypercalcemic effect of Vitamin D Analogs. Monitor therapy
Vitamin D Analogs: May enhance the adverse/toxic effect of other Vitamin D Analogs. Avoid combination
In predialysis patients, paricalcitol may increase serum creatinine and therefore decrease the estimated GFR (eGFR).
Gastrointestinal: Nausea (5% to 13%), diarrhea (7% to 12%)
Infection: Infection (bacterial, fungal, viral: 3% to 15%)
2% to 10%:
Cardiovascular: Hypertension (7%), edema (6% to 7%), hypotension (5%), palpitations (3%), chest pain (3%), peripheral edema (3%), syncope (3%)
Central nervous system: Pain (4% to 8%), dizziness (5% to 7%), chills (5%), insomnia (5%), vertigo (5%), headache (3% to 5%), anxiety (3%), depression (3%), fatigue (3%), malaise (3%)
Dermatologic: Skin rash (4% to 6%), dermal ulcer (3%), ecchymoses (3%)
Endocrine & metabolic: Hypervolemia (5%), dehydration (3%), hypoglycemia (3%)
Gastrointestinal: Vomiting (5% to 8%), gastrointestinal hemorrhage (5%), peritonitis (5%), constipation (4% to 5%), abdominal pain (4%), dyspepsia (3%), xerostomia (3%)
Genitourinary: Uremia (3%), urinary tract infection (3%)
Hypersensitivity: Hypersensitivity reaction (6%)
Infection: Influenza (5%), sepsis (5%)
Neuromuscular & skeletal: Arthralgia (5%), arthritis (5%), weakness (3% to 5%), back pain (3% to 4%), leg cramps (3%), muscle spasm (3%)
Respiratory: Nasopharyngitis (8%), pneumonia (5%), rhinitis (5%), oropharyngeal pain (4%), bronchitis (3%), cough (3%), sinusitis (3%)
Miscellaneous: Fever (3% to 5%)
<2% (Limited to important or life-threatening): Abnormal gait, abnormal hepatic function tests, anemia, angioedema (including laryngeal edema), atrial flutter, burning sensation of skin, cardiac arrest, cardiac arrhythmia, cerebrovascular accident, confusion, conjunctivitis, delirium, dysphagia, erectile dysfunction, extravasation reactions, gastritis, gastroesophageal reflux disease, glaucoma, hirsutism, hypercalciuria, hypercalcemia, hyperparathyroidism, hyperkalemia, hyperphosphatemia, hypocalcemia, hypoparathyroidism, increased serum creatinine, ischemic bowel disease, lymphadenopathy, malignant neoplasm of breast, myalgia, myoclonus, night sweats, ocular hyperemia, orthopnea, paresthesia, prolonged bleeding time, pruritus, pulmonary edema, rectal hemorrhage, upper respiratory tract infection, urticaria, vaginal infection, weight loss, wheezing
Concerns related to adverse effects:
• Excessive vitamin D: Excessive vitamin D administration may lead to over suppression of PTH, progressive or acute hypercalcemia, hypercalciuria, hyperphosphatemia and adynamic bone disease.
• Hypercalcemia: Progressive and/or acute hypercalcemia may increase risk of cardiac arrhythmias and seizures; chronic hypercalcemia may lead to generalized vascular and other soft-tissue calcification. Phosphate and vitamin D (and its derivatives) should be withheld during therapy to avoid hypercalcemia. Risk of hypercalcemia may be increased by concomitant use of calcium-containing supplements and/or medications that increase serum calcium (eg, thiazide diuretics).
Concurrent drug therapy issues:
• Aluminum: Avoid regular administration of aluminum-containing preparations (eg, antacids, phosphate binders) to prevent aluminum overload and bone toxicity. Dialysate concentration of aluminum should be maintained at <10 mcg/L.
• Cardiac glycosides: Use with caution in patients taking cardiac glycosides; digitalis toxicity is potentiated by hypercalcemia.
Signs and symptoms of vitamin D intoxication; signs and symptoms of hypercalcemia (eg, feeling tired, difficulty thinking clearly, loss of appetite, nausea, vomiting, constipation, increased thirst, increased urination, weight loss).
Serum calcium and phosphorus (closely monitor levels during dosage titration and after initiation of a strong CYP3A4 inhibitor):
IV: Twice weekly during initial phase, then at least monthly once dose established
Oral: At least every 2 weeks for initial 3 months or following dose adjustment, then monthly for 3 months, then every 3 months
Serum or plasma intact PTH (iPTH):
IV: Every 2 to 4 weeks, then every 3 months once dose established
Oral: At least every 2 weeks for 3 months or following dose adjustment, then monthly for 3 months, then every 3 months
Pregnancy Risk Factor
Adverse events were observed in some animal reproduction studies.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience dizziness, nausea, vomiting, or diarrhea. Have patient report immediately to prescriber signs of fluid and electrolyte problems (mood changes, confusion, muscle pain or weakness, abnormal heartbeat, very bad dizziness or passing out, fast heartbeat, more thirst, seizures, feeling very tired or weak, not hungry, unable to pass urine or change in the amount of urine produced, dry mouth, dry eyes, or nausea or vomiting), signs of high calcium (weakness, confusion, feeling tired, headache, nausea and vomiting, constipation, or bone pain); polyuria; weight loss; severe headache; black, tarry, or bloody stools; muscle cramps; muscle spasms; abdominal pain; or swelling of arms or legs (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
More about paricalcitol
- Other brands: Zemplar