A phase III study of the efficacy and safety of a novel iron-based phosphate binder in dialysis patients

Abstract

Efficacy of PA21 (sucroferric oxyhydroxide), a novel calcium-free polynuclear iron(III)-oxyhydroxide phosphate binder, was compared with that of sevelamer carbonate in an open-label, randomized, active-controlled phase III study. Seven hundred and seven hemo- and peritoneal dialysis patients with hyperphosphatemia received PA21 1.0-3.0 g per day and 348 received sevelamer 4.8-14.4 g per day for an 8-week dose titration, followed by 4 weeks without dose change, and then 12 weeks maintenance. Serum phosphorus reductions at week 12 were -0.71 mmol/l (PA21) and -0.79 mmol/l (sevelamer), demonstrating non-inferiority of, on average, three tablets of PA21 vs. eight of sevelamer. Efficacy was maintained to week 24. Non-adherence was 15.1% (PA21) vs. 21.3% (sevelamer). The percentage of patients that reported at least one treatment-emergent adverse event was 83.2% with PA21 and 76.1% with sevelamer. A higher proportion of patients withdrew owing to treatment-emergent adverse events with PA21 (15.7%) vs. sevelamer (6.6%). Mild, transient diarrhea, discolored feces, and hyperphosphatemia were more frequent with PA21; nausea and constipation were more frequent with sevelamer. After 24 weeks, 99 hemodialysis patients on PA21 were re-randomized into a 3-week superiority analysis of PA21 maintenance dose in 50 patients vs. low dose (250 mg per day (ineffective control)) in 49 patients. The PA21 maintenance dose was superior to the low dose in maintaining serum phosphorus control. Thus, PA21 was effective in lowering serum phosphorus in dialysis patients, with similar efficacy to sevelamer carbonate, a lower pill burden, and better adherence.

Figure 1

Study design.

Figure 2

Patient disposition, stage 1.

Figure 3

Serum phosphorus concentrations and changes versus baseline during the study period. (a) Mean (±s.d.) serum phosphorus concentrations and mean (±s.d.) serum phosphorus changes from baseline (full analysis set (FAS); N=1041). (b) Mean (±s.d.) serum phosphorus concentrations and mean (±s.d.) serum phosphorus changes from baseline (per-protocol set (PPS); N=685). LOCF, last observation carried forward.

Figure 4

Mean (±s.d.) daily number of tablets taken (full analysis set (FAS); N=1041).

Figure 5

Mean (±s.d.) serum phosphorus concentrations in stage 2 (primary efficacy set (PES); N=93). LOCF, last observation carried forward.

Figure 6

Time to first-onset of diarrhea in patients treated with PA21 (sucroferric oxyhydroxide), by severity (safety set (SS); N=707).

Figure 7

Median iron parameters (±interquartile range) at baseline and at week 24 end point (safety set (SS); N=1055). Interquartile ranges are shown as error bars. *Indicates a statistically significant difference between PA21 and sevelamer carbonate groups (Iron: P=0.0296; Transferrin saturation: P<0.0001), based on the Wilcoxon Mann–Whitney test.