Indications and Limitations of Use

Sensipar® (cinacalcet) is indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis.
Sensipar® is not indicated for use in patients with CKD who are not on dialysis because of an increased risk of hypocalcemia.
Sensipar® (cinacalcet) is indicated for the treatment of hypercalcemia in adult patients with primary hyperparathyroidism (HPT) for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy.
Sensipar® (cinacalcet) is indicated for the treatment of hypercalcemia in adult patients with parathyroid carcinoma.

Other Indications

Primary Hyperparathyroidism    Parathyroid Carcinoma

Primary Hyperparathyroidism (HPT): Hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy1
Dosage1
The recommended starting oral dose of Sensipar® is 30 mg twice daily in adult patients with primary HPT with severe hypercalcemia (calcium [Ca] > 12.5 mg/dL).1
  • The dose of Sensipar® should be titrated every 2 to 4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, 90 mg twice daily, and 90 mg 3 or 4 times daily as necessary to normalize serum calcium levels
  • Sensipar® must be taken orally, and should be taken with food or shortly after a meal
  • The tablets should always be taken whole and not chewed, crushed, or divided.
Lab Tests1
Serum calcium should be measured within 1 week after initiation or dose adjustment of Sensipar®. Once maintenance dose levels have been established, serum calcium should be measured every 2 months.
Adverse Reactions1,2
The safety profile of Sensipar® in these patient populations is generally consistent with that seen in patients with chronic kidney disease (CKD) on dialysis.
  • The most commonly reported side effects of Sensipar® in a clinical study of patients with primary HPT were nausea (59%), vomiting (35%), and paresthesia (29%)1,2
  • Treatment-related hypocalcemia (< 8.4 mg/dL) occurred in 2 patients (12%)2
  • Four patients (24%) withdrew from the study because of adverse events2
Clinical Trials1

Sixty-seven patients with primary HPT who met criteria for parathyroidectomy on the basis of corrected total serum calcium (> 11.3 mg/dL [2.82 mmol/L] and ≤ 12.5 mg/dL [3.12 mmol/L]), but who were unable to undergo parathyroidectomy participated in a randomized, double-blind, placebo-controlled study.  A total of 33 patients were randomized to Sensipar® and 34 patients randomized to placebo.  The mean age of the patients was 72 years, 52% were female, 61% were Caucasian, and 5% were Blacks.  The study started with a 12-week titration phase, followed by a 16-week efficacy assessment phase.  Cinacalcet was initiated at a dose of 30 mg twice daily and titrated to maintain a corrected total serum calcium concentration within the normal range.  During the efficacy period a significantly higher percentage of cinacalcet-treated patients compared with the placebo-treated patients achieved mean corrected total serum calcium concentration(≤ 10.3 mg/dL [2.57 mmol/L], 75.8% vs 0%, P < 0.001) and ≥ 1 mg/dL [0.25 mmol/L] decrease from baseline in mean corrected total serum calcium concentration (84.8% vs 5.9%, P < 0.001).  The median dose of Sensipar® at the completion of the study was 60 mg/day.

In a randomized double-blind, placebo-controlled study of 67 patients with primary hyperparathyroidism for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo surgery, the most common adverse reactions were nausea (30%), muscle spasms (18%), headache (12%), and back pain (12%).

Clinical Trials1: Sensipar® reduced mean calcium levels from baseline to the end of the variable-length titration phase and sustained these reductions over 80 weeks1,2

B = baseline; EOTP = end of titration phase.
Normal range as defined by Marcocci and colleagues was calcium 8.4–10.3 mg/dL.
Adapted from Marcocci et al, J Clin Endocrinol Metab, 2009.

Seventeen patients with severe hypercalcemia due to primary HPT, who had failed or had contraindications to parathyroidectomy, participated in an open-label, single-arm study. The study consisted of 2 phases, a dose-titration phase and a maintenance phase. In this trial, severe hypercalcemia was defined as a screening serum calcium level of > 12.5 mg/dL. Patients initially received 30 mg cinacalcet twice daily and then were titrated every 2 weeks to a maximum dose of 90 mg 4 times daily. Dosage escalation during the variable-length (2 to 16 weeks) titration phase continued until the serum calcium concentration was ≤ 10 mg/dL (2.5 mmol/L), the patient reached the highest possible dosage, or adverse events precluded further dosage increases.1

Seventeen patients entered the study. The median exposure to cinacalcet was 270 days (range: 32 to 1105). At baseline the mean (SE) serum calcium was 12.7 (0.2) mg/dL. At the end of the titration phase the mean (SE) serum calcium was 10.4 (0.3) mg/dL, which is a mean reduction of 2.3 (0.3) mg/dL from baseline. The graph above illustrates mean serum calcium (mg/dL) over time for all patients still on study at each time point from the beginning of titration to study visit week 80. Daily dose during the study ranged from 30 mg twice a day to 90 mg 4 times a day.1
  • 88% (n = 15) of patients treated with Sensipar® achieved a reduction of ≥ 1 mg/dL in serum calcium at the end of the titration period2
*Individualized, variable-length titration phase occurred over 2 to 16 weeks. Sensipar® dose titrations were continued until calcium reached target of ≤ 10 mg/dL, the maximum dose of 90 mg 4 times daily was reached, or an adverse event precluded a dose increase. At the end of the individualized titration phase, the maintenance phase began and was followed for up to 136 weeks.
Parathyroid Carcinoma: Hypercalcemia in patients with parathyroid carcinoma
Dosage1
The recommended starting oral dose of Sensipar® is 30 mg twice daily
  • The dose of Sensipar® should be titrated every 2 to 4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, 90 mg twice daily, and 90 mg 3 or 4 times daily as necessary to normalize serum calcium levels
  • Sensipar® must be taken orally, and should be taken with food or shortly after a meal
  • The tablets should be taken whole and should not be divided
Lab Tests1
Serum calcium should be measured within 1 week after initiation or dose adjustment of Sensipar®. Once maintenance dose levels have been established, serum calcium should be measured every 2 months.
Adverse Reactions1,2
The safety profile of Sensipar® in these patient populations is generally consistent with that seen in patients with chronic kidney disease (CKD) on dialysis.
  • Twenty-nine patients with parathyroid carcinoma were treated with cinacalcet in a single-arm study
  • Five (17%) of the patients withdrew from the study due to adverse events
  • The most frequent adverse reactions and the most frequent cause of withdrawal were nausea (66%) and vomiting (52%)
  • Severe or prolonged cases of nausea and vomiting can lead to dehydration and worsening hypercalcemia, so careful monitoring of electrolytes is recommended in patients with these symptoms
Clinical Trials1
Twenty-nine patients with parathyroid carcinoma were enrolled in a single-arm, open-label study. The study consisted of 2 phases, a dose-titration phase and a maintenance phase. Patients initially received 30 mg cinacalcet twice daily and then were titrated every 2 weeks to a maximum dose of 90 mg 4 times daily. Dosage escalation during the variable-length (2 to 16 weeks) titration phase continued until the serum calcium concentration was ≤ 10 mg/dL (2.5 mmol/L), the patient reached the highest possible dosage, or adverse events precluded further dosage increases.

Twenty-nine patients entered the study. The median exposure to cinacalcet was 229 days (range: 1 to 1051). At baseline the mean (SE) serum calcium was 14.1 (0.4) mg/dL. At the end of the titration phase, the mean (SE) serum calcium was 12.4 (0.5) mg/dL, which is a mean reduction of 1.7 (0.6) mg/dL from baseline. The graph below illustrates mean serum calcium (mg/dL) over time for all patients still on study at each time point from the beginning of titration to study visit week 80. Daily dose during the study ranged from 30 mg twice daily to 90 mg 4 times daily.
Serum calcium values in patients with parathyroid carcinoma receiving Sensipar® at baseline, titration, and maintenance phase1
n = Number of patients with non-missing values at the time point.
End of titration (EOT) phase could occur at any visit from week 2 to 16.
Patients at EOT are those who completed titration.
Important Safety Information

Contraindication: Sensipar® (cinacalcet) treatment initiation is contraindicated if serum calcium is less than the lower limit of the normal range (8.4 mg/dL).

Hypocalcemia: Sensipar® lowers serum calcium and can lead to hypocalcemia. Life threatening events and fatal outcomes associated with hypocalcemia have been reported in patients treated with Sensipar®, including pediatric patients. The safety and effectiveness of Sensipar® have not been established in pediatric patients.

Decreases in serum calcium can prolong the QT interval, potentially resulting in ventricular arrhythmia. Cases of QT prolongation and ventricular arrhythmia have been reported in patients treated with Sensipar®. Patients with conditions that predispose to QT interval prolongation and ventricular arrhythmia may be at increased risk for QT interval prolongation and ventricular arrhythmias if they develop hypocalcemia due to Sensipar®. Closely monitor corrected serum calcium and QT interval in patients at risk receiving Sensipar®.

Significant reductions in calcium may lower the threshold for seizures. Monitor serum calcium levels in patients with seizure disorders on Sensipar®.

Concurrent administration of Sensipar® with calcium-lowering drugs including other calcimimetics could result in severe hypocalcemia. Parsabiv™ (etelcalcetide) and Sensipar® should not be given together. Closely monitor serum calcium in patients receiving Sensipar® and concomitant therapies known to lower serum calcium levels.

Patients with secondary HPT: Serum calcium and serum phosphorus should be measured within 1 week and PTH should be measured 1 to 4 weeks after initiation or dose adjustment of Sensipar®. Once the maintenance dose has been established, serum calcium and serum phosphorus should be measured approximately monthly, and PTH every 1 to 3 months.

Patients with primary HPT or parathyroid carcinoma: Serum calcium should be measured within 1 week after initiation or dose adjustment of Sensipar®. Once maintenance dose levels have been established, serum calcium should be measured every 2 months.

Upper Gastrointestinal Bleeding: Cases of gastrointestinal (GI) bleeding, mostly upper GI bleeding, have occurred in patients using calcimimetics, including Sensipar®, from postmarketing and clinical trial sources. The exact cause of GI bleeding in these patients is unknown.

Patients with risk factors for upper GI bleeding, such as known gastritis, esophagitis, ulcers or severe vomiting, may be at increased risk for GI bleeding with Sensipar®. Monitor patients for worsening of common Sensipar® GI adverse reactions and for signs and symptoms of GI bleeding and ulcerations during Sensipar® therapy.

Hypotension, Worsening Heart Failure and/or Arrhythmias: In Sensipar® postmarketing use, isolated, idiosyncratic cases of hypotension, worsening heart failure, and/or arrhythmia were reported in patients with impaired cardiac function. The causal relationship to Sensipar® therapy could not be completely excluded and may be mediated by reductions in serum calcium levels.

Adynamic Bone: Adynamic bone disease may develop if intact parathyroid hormone (iPTH) levels are suppressed below 100 pg/mL.

Adverse Reactions: In clinical trials of patients with secondary HPT comparing Sensipar® to placebo, the most commonly reported side effects were nausea (31% vs. 19%), vomiting (27% vs. 15%), and diarrhea (21% vs. 20%).
In clinical trials of patients with primary HPT and parathyroid carcinoma treated with Sensipar®, the most commonly reported side effects were nausea (63%), vomiting (46%), and paresthesia (20%)

Indications

Sensipar® (cinacalcet) is indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis.

Sensipar® (cinacalcet) is indicated for the treatment of hypercalcemia in adult patients with primary hyperparathyroidism (HPT) for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy.

Sensipar® (cinacalcet) is indicated for the treatment of hypercalcemia in adult patients with parathyroid carcinoma.

Limitations of Use:
Sensipar® is not indicated for use in patients with CKD who are not on dialysis because of an increased risk of hypocalcemia.

References: 1. Sensipar® (cinacalcet) prescribing information, Amgen. 2. Marcocci C, Chanson P, Shoback D, et al. Cinacalcet reduces serum calcium concentrations in patients with intractable primary hyperparathyroidism. J Clin Endocrinol Metab. 2009;94:2766-2772. 3. Silverberg SJ, Rubin MR, Faiman M, et al. Cinacalcet hydrochloride reduces the serum calcium concentration in inoperable parathyroid carcinoma. J Clin Endocrinol Metab. 2007;92:3803-3808.