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Paricalcitol (marketed by Abbott Laboratories under the trade name Zemplar) is a drug used for the prevention and treatment of secondary hyperparathyroidism (excessive secretion of parathyroid hormone) associated with chronic renal failure. Chemically, it is 19-nor-1,25-(OH)2-vitamin D2 or 19-nor-1,25-dihydroxyvitamin D2, being an analog of 1,25-dihydroxyergocalciferol, the active form of vitamin D2. From Wikipedia
1 . PhD Marvin M. Goldenberg. Paricalcitol, a new agent for the management of secondary hyperparathyroidism in patients undergoing chronic renal dialysis. Clinical Therapeutics. March 1999.Volume 21, Issue 3 , Pages 432-441
Patients with end-stage renal disease commonly develop secondary hyperparathyroidism. Calcitriol may be administered to such patients to decrease the synthesis and secretion of parathyroid hormone (PTH) and to help maintain calcium and phosphorus homeostasis. However, the doses of calcitriol required to suppress serum PTH concentrations can lead to hypercalcemia or hyperphosphatemia in many patients undergoing hemodialysis. Paricalcitol is a new vitamin D analogue that is safe and effective in suppressing elevated concentrations of PTH in patients with established hyperparathyroidism who are maintained on chronic hemodialysis. As with vitamin D, the biologic action of paricalcitol is mediated through activation of the vitamin D receptor (VDR). The VDR functions as a ligandinduced transcription factor regulating the rate of expression of genes that are involved in controlling not only calcium homeostasis and bone remodeling but also hormone secretion, inhibition of cell growth, and induction of cell differentiation. In vitro studies have shown that paricalcitol inhibits PTH secretion from bovine parathyroid cells in a dose-dependent manner. Studies in renally insufficient rats demonstrated that paricalcitol caused approximately 10 times less elevation of serum calcium concentrations than calcitriol. In clinical studies, paricalcitol effectively decreased PTH by about 60% over a 12-week period. Mean serum concentrations of calcium were significantly increased but remained within the normal range. There were occasional (5/414 determinations) transient elevations in serum calcium above the upper limit of normal in some (5/401) patients. Serum phosphorus values did not change significantly compared with baseline, although they tended to be slightly higher in the paricalcitol-treated group than in the group receiving placebo. Elevations of the calcium-times-phosphorus product were relatively few but occurred more often in the paricalcitol than in the placebo group. The terminal half-life of paricalcitol was 5 to 7 hours in healthy subjects; in patients undergoing hemodialysis, it was 14 hours. Adverse events associated with paricalcitol use included, among others, chills, feeling unwell, fever, sepsis, palpitations, dry mouth, gastrointestinal bleeding, nausea, vomiting, edema, light-headedness, and pneumonia. Paricalcitol should be considered as an alternative to calcitriol in the treatment of patients who are undergoing maintenance hemodialysis for end-stage renal disease, as it has a decreased potential to induce hypercalcemia and hyperphosphatemia. Additional studies are required to determine the long-term effects of therapy.
2 . KJ artin, EA Gonzalez, ME Gellens et al. Therapy of secondary hyperparathyroidism with 19-nor-1alpha,25- dihydroxyvitamin D2. American Journal of Kidney Diseases. October 1998.Volume 32, Issue 4, Supplement 2 , Pages S61-S66
Secondary hyperparathyroidism contributes to significant morbidity in patients with chronic renal failure. The treatment of this disorder with vitamin D compounds, such as calcitriol, although effective at suppressing parathyroid hormone (PTH) secretion, may promote the development of hypercalcemia and hyperphosphatemia, thus increasing the risk for metastatic calcification. A new vitamin D analogue, 19-nor- 1alpha,25-(OH)2D2 (paricalcitol; Zemplar, Abbott Laboratories, Inc, Chicago, IL) has recently been developed for the treatment of secondary hyperparathyroidism, and, in experimental animals, it was found to be less calcemic and phosphatemic than calcitriol. In double-blind clinical trials, paricalcitol effectively decreased the levels of PTH by 60%, yet the mean serum calcium values remained within the normal range. The few episodes of hypercalcemia that occurred in the paricalcitol-treated patients (8 of 400 determinations > or =11.0 mg/dL in 7 patients) were associated with marked decreases in PTH levels (87% +/- 2% less than baseline) and absolute values of PTH less than 100 pg/mL in four of the seven patients. PTH values less than 100 pg/mL, however, occurred in 15 patients, but were not invariably associated with frank hypercalcemia, although serum calcium levels increased to 10.63 +/- 0.3 mg/dL, slightly greater than the upper limits of normal. Additional studies to evaluate the conversion from calcitriol to paricalcitol therapy showed that a dose ratio of 1:4 (calcitriol:paricalcitol) could maintain control of high levels of PTH without significant alterations in serum calcium and phosphorus levels. These studies indicate that effective control of hyperparathyroidism can be achieved with paricalcitol therapy with minimal perturbation of serum calcium and phosphorus levels, and may have a therapeutic advantage over current treatment strategies. (Am J Kidney Dis 1998 Oct;32(2 Suppl 2):S61-6)
3 . Cato A 3rd, WW Cady, C Soltanek et al. Effect of hemodialysis on the pharmacokinetics of 19-nor-1alpha,25- dihydroxyvitamin D2. American Journal of Kidney Diseases. October 1998.Volume 32, Issue 4, Supplement 2 , Pages S55-S60
The vitamin D2 analogue 19-nor-1alpha,25-dihydroxyvitamin D2 (paricalcitol) has been tested for the treatment of secondary hyperparathyroidism in patients with end-stage renal disease. Clinical studies have shown that paricalcitol reduces serum parathyroid hormone (PTH) levels with minimal potential to cause hypercalcemia, a common side effect of vitamin D3 therapy. Paricalcitol is typically administered intravenously after hemodialysis (HD). Because the administration of paricalcitol before or during dialysis would be desirable, the effect of HD on paricalcitol pharmacokinetics was investigated. Six patients requiring HD received a single dose of paricalcitol, 0.08 microg/kg, intravenously approximately 2 hours before HD, and blood samples were collected by venipuncture immediately before and 15 minutes after HD. Also, pairs of pre- and postdialyzer blood samples were collected approximately 1 and 2 hours after the start of HD. Plasma concentrations of paricalcitol in the samples were determined by a specific high-performance liquid chromatography (HPLC)/radioreceptor assay (RRA) with a lower limit of quantification of 40 pg/mL. Compared with previous pharmacokinetic studies in HD patients, plasma concentrations (100 to 250 pg/mL) during the 4-hour period were consistent with predicted values for this dose, and there was no apparent increase in paricalcitol clearance during HD. Pre- and postdialyzer plasma concentrations of paricalcitol were compared statistically using a paired t-test. Postdialyzer concentrations tended to be slightly higher than those predialyzer, but the differences were not statistically significant (P = 0.11). Thus, HD essentially had no effect on plasma concentrations of paricalcitol, suggesting that paricalcitol can be administered at any time during dialysis. (Am J Kidney Dis 1998 Oct;32(2 Suppl 2):S55-60)
4 . F Llach, G Keshav, MV Goldblat et al. Suppression of parathyroid hormone secretion in hemodialysis patients by a novel vitamin D analogue: 19-nor-1,25-dihydroxyvitamin D2. American Journal of Kidney Diseases. October 1998.Volume 32, Issue 4, Supplement 2 , Pages S48-S54
In this double-blind, placebo-controlled, randomized, multicenter study, 35 patients with end-stage renal disease undergoing maintenance hemodialysis were treated three times weekly for 4 weeks with either 19- nor-1,25-dihydroxyvitamin D2 (paricalcitol) intravenously at doses ranging from 0.04 to 0.24 microg/kg or placebo. Eligible patients with secondary hyperparathyroidism (HPT; intact parathyroid hormone [iPTH] level > 300 pg/mL) were initially withdrawn from any existing vitamin D therapy over a 4-week washout period and then randomized to treatment for 4 weeks with either paricalcitol or placebo. Overall, there was a clinically and statistically significant reduction in iPTH level for patients receiving paricalcitol compared with placebo (P = 0.006). The study end point for efficacy was at least a 30% reduction from maximum baseline in iPTH level for 75% of the patients receiving paricalcitol per dosing group. The study end point for efficacy was at least a 30% reduction from maximum baseline in iPTH for 75% of patients receiving paricalcitol per dosing group. Sixty-eight percent (15 of 22) of patients receiving paricalcitol attained this efficacy end point regardless of dosage received (0.04, 0.08, 0.16, and 0.24 microg/kg). Eighty-three percent (5 of 6) of the patients in each of the paricalcitol groups receiving 0.16- and 0.24-microg/kg dosages attained the efficacy end point. Only two patients receiving placebo attained the iPTH end point. There were no clinically relevant differences in serum calcium (Ca) or phosphorus (P) levels between the group treated with paricalcitol and that treated with placebo. Although there was a statistically significant difference between the change from baseline to final-visit Ca levels in the paricalcitol group and the placebo group (P < 0.001), the final-visit mean Ca level in the paricalcitol group was within the normal range (9.44 mg/dL). There was no statistically significant difference between groups for the change from baseline in P level (P = 0.625). Only one patient treated with paricalcitol developed hypercalcemia before or coincident with the iPTH end point. Three other patients receiving paricalcitol experienced elevated serum Ca levels subsequent to reaching the iPTH end point, with iPTH reductions of 83% to 98%. There were no significant differences between patients treated with paricalcitol and patients treated with placebo in adverse reactions. These results show that paricalcitol safely and effectively reduces iPTH levels in hemodialysis patients with secondary HPT. (Am J Kidney Dis 1998 Oct;32(2 Suppl 2):S48-54)
5 . E Slatopolsky, J Finch, C Ritter, F Takahashi. Effects of 19-nor-1,25(OH)2D2, a new analogue of calcitriol, on secondary hyperparathyroidism in uremic rats. American Journal of Kidney Diseases October 1998.Volume 32, Issue 4, Supplement 2 , Pages S40-S47
The active metabolite of vitamin D, calcitriol [1,25(OH)2D3] suppresses parathyroid hormone (PTH) gene transcription and PTH secretion. Although 1,25(OH)2D3 is effective in suppressing secondary hyperparathyroidism in uremic patients, the mandatory use of large amounts of calcium salts to control serum phosphorus may preclude in some patients the use of ideal therapeutic doses of 1,25(OH)2D3 because of hypercalcemia. We have studied a new analogue of calcitriol,19-nor- 1,25(OH)2D2 that possesses low calcemic and phosphatemic activity. We have clearly demonstrated that this analogue of calcitriol can suppress secondary hyperparathyroidism without inducing hypercalcemia or hyperphosphatemia in uremic rats. In addition, this analogue of vitamin D supresses pre-pro PTH messenger RNA in a similar fashion to that of 1,25(OH)2D3. Contrary to the effect of 1,25(OH)2D3 that increases the intestinal vitamin D receptor, this analogue of vitamin D suppresses the intestinal vitamin D receptor. This finding may be critical for the lack of calcemic activity of 19-nor-1,25(OH)2D2 seen in these studies. One of the explanations for the lack of an increasing intestinal VDR is the fact that 19-nor-1,25(OH)2D2 decreases endogenous levels of 1,25(OH)2D3. In summary, we have shown that 19-nor-1,25(OH)2D2, a new analogue of calcitriol is effective in suppressing PTH in uremic rats with secondary hyperparathyroidism. In addition, there is a significant decrease in the VDR in the intestine, which may explain in part the less calcemic and hyperphosphatemic effect of this analogue. (Am J Kidney Dis 1998 Oct;32(2 Suppl 2):S40-7)
6 . Piao SG, Song JC, Lim SW, Chung BH, Choi BS, Yang CW. Protective effect of paricalcitol on cyclosporine-induced renal injury in rats. Transplant Proc. 2012 Apr;44(3):642-5.
We evaluated the protective effect of paricalcitol on cyclosporine (CsA)-induced renal injury using an experimental model of chronic CsA nephropathy. Paricalcitol (50 and 200 ng/kg/d) was concomitantly administered with CsA (15 mg/kg/d) for 28 days in rats. We assessed the effects of paricalcitol by measuring degree of the tubulointerstitial fibrosis (TIF) and inflammation, a profibrotic cytokine (βig-h3), a proapoptotic gene (caspase-3), apoptotic cell death, and oxidative stress. The CsA-treated rats showed increased TIF and inflammatory cell infiltration, but paricalcitol treatment (200 ng/kg) significantly decreased those compared with the CsA-alone group. The expression of βig-h3, a biologic marker of transforming growth factor β1, which was increased in the CsA group, also decreased with paricalcitol treatment. The increased rates of excretion of urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) and expression of tissue 8-OHdG produced by CsA treatment were significantly attenuated by paricalcitol treatment. The increased expression of caspase-3 and number of TUNEL-positive cells in the CsA group were decreased with concomitant paricalcitol treatment. The effect of paricalcitol was more evident high among the rather than low-dose cohort. In conclusion, paricalcitol showed antiinflammatory and antifibrotic effects. This finding may provide a rationale for use of paricalcitol in CsA-induced renal injury.
7 . Blanco-García R, Bravo-López JJ, Moreiras-Plaza M, Nájera-de la Garza W, Cossio-Annibar C, Beato-Coo L, Rodríguez-Goyanes G. Microalbuminuria, another use for paricalcitol? Our experience in advanced chronic kidney disease. Nefrologia. 2012 May 14;32(3):401-2. doi: 10.3265/Nefrologia.pre2012.Feb.11378.
8 . Meems LM, Cannon MV, Mahmud H, Voors AA, van Gilst WH, Silljé HH, Ruifrok WP, de Boer RA. The vitamin D receptor activator paricalcitol prevents fibrosis and diastolic dysfunction in a murine model of pressure overload. J Steroid Biochem Mol Biol. 2012 Jul 16;132(3-5):282-289.
BACKGROUND: Activation of the vitamin D-vitamin D receptor (VDR) axis has been shown to reduce blood pressure and left ventricular (LV) hypertrophy. Besides cardiac hypertrophy, cardiac fibrosis is a key element of adverse cardiac remodeling. We hypothesized that activation of the VDR by paricalcitol would prevent fibrosis and LV diastolic dysfunction in an established murine model of cardiac remodeling.METHODS: Mice were subjected to transverse aortic constriction (TAC) to induce cardiac hypertrophy. Mice were treated with paricalcitol, losartan, or a combination of both for a period of four consecutive weeks.RESULTS: The fixed aortic constriction caused similar increase in blood pressure, both in untreated and paricalcitol- or losartan-treated mice. TAC significantly increased LV weight compared to sham operated animals (10.2±0.7 vs. 6.9±0.3mg/mm, p<0.05). Administration of either paricalcitol (10.5±0.7), losartan (10.8±0.4), or a combination of both (9.2±0.6) did not reduce LV weight. Fibrosis was significantly increased in mice undergoing TAC (5.9±1.0 vs. sham 2.4±0.8%, p<0.05). Treatment with losartan and paricalcitol reduced fibrosis (paricalcitol 1.6±0.3% and losartan 2.9±0.6%, both p<0.05 vs. TAC). This reduction in fibrosis in paricalcitol treated mice was associated with improved indices of LV contraction and relaxation, e.g. dPdtmax and dPdtmin and lower LV end diastolic pressure, and relaxation constant Tau. Also, treatment with paricalcitol and losartan reduced mRNA expression of ANP, fibronectin, collagen III and TIMP-1.DISCUSSION: Treatment with the selective VDR activator paricalcitol reduces myocardial fibrosis and preserves diastolic LV function due to pressure overload in a mouse model. This is associated with a reduced percentage of fibrosis and a decreased expression of ANP and several other tissue markers.
9 . Ari E, Kedrah AE, Alahdab Y, Bulut G, Eren Z, Baytekin O, Odabasi D. Antioxidant and renoprotective effects of paricalcitol on experimental contrast-induced nephropathy model. Br J Radiol. 2012 Aug;85(1016):1038-43.
Objectives: The aim of the study was to assess the effect of paricalcitol on the experimental contrast-induced nephropathy (CIN) model. We hypothesised that paricalcitol may prevent CIN. Methods: 32 Wistar albino rats were divided into four groups (n=8 each): control group, paricalcitol group, CIN group and paricalcitol plus CIN group. Paricalcitol (0.4 μg kg(-1) day(-1)) was given intraperitoneally for 5 consecutive days prior to induction of CIN. CIN was induced at day 4 by intravenous injection of indometacin (10 mg kg(-1)), Nω-nitro-l-arginine methyl ester (L-NAME, 10 mg kg(-1)) and meglumine amidotrizoate (6 ml kg(-1)). Renal function parameters, oxidative stress biomarkers, histopathological findings and vascular endothelial growth factor (VEGF) immunoexpression were evaluated. Results: The paricalcitol plus CIN group had lower mean serum creatinine levels (p=0.034) as well as higher creatinine clearance (p=0.042) than the CIN group. Serum malondialdehyde and kidney thiobarbituric acid-reacting substances levels were significantly lower in the paricalcitol plus CIN group than in the CIN group (p=0.024 and p=0.042, respectively). The mean scores of tubular necrosis (p=0.024), proteinaceous casts (p=0.038), medullary congestion (p=0.035) and VEGF immunoexpression (p=0.018) in the paricalcitol plus CIN group were also significantly lower. Conclusion: This study demonstrates the protective effect of paricalcitol in the prevention of CIN in an experimental model.
10 . Martinez-Moreno JM, Mu?oz-Casta?eda JR, Herencia C, Montes de Oca A, Estepa JC, Canalejo R, Rodriguez-Ortiz ME, Perez-Martinez P, Aguilera-Tejero E, Canalejo A, Rodriguez M, Almaden Y. In vascular smooth muscle cells paricalcitol prevents phosphate-induced Wnt/beta-catenin activation. Am J Physiol Renal Physiol. 2012 Aug 8.
The present study investigates the differential effect of two vitamin D receptor agonists, calcitriol and paricalcitol, on human aortic smooth muscle cells (HASMCs) calcification in vitro. HVSMCs were incubated in a high phosphate (HP) medium alone or supplemented with either calcitriol 10(-8)M (HP+CTR) or paricalcitol 3?10(-8)M (HP+PC). HP medium induced calcification which was associated to the up-regulation of mRNA expression of osteogenic factors such as BMP2, Runx2/Cbfa1 and Msx2 and osteocalcin. In these cells activation of Wnt/beta-catenin signaling was evidenced by the translocation of beta-catenin into the nucleus and the increase in the expression of direct target genes as Cyclin D1, Axin 2, and VCAN/versican. Addition of Calcitriol to HP medium (HP+CTR) further increased calcification and also enhanced the expression of osteogenic factors together with a significant elevation of nuclear beta-catenin levels and the expression of cyclin D1, Axin 2 and VCAN. By contrast, the addition of Paricalcitol (HP+PC) not only reduced calcification but also down-regulated the expression of BMP2 and other osteoblastic phenotype markers as well as the levels of nuclear beta-catenin and the expression of its target genes. The role of Wnt/beta-catenin on phosphate and calcitriol induced calcification was further demonstrated by the inhibition of calcification after addition of DKK-1, a specific natural antagonist of Wnt/beta-catenin signalling pathway. In conclusion, the differential effect of calcitriol and paricalcitol on vascular calcification appears to be mediated by a distinct regulation of the BMP and Wnt/beta-catenin signaling pathways.
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