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Overview
Tetraferric tricitrate decahydrate is a phosphate binder that is FDA approved for the treatment of serum phosphorus levels in patients with chronic kidney disease on dialysis. Common adverse reactions include diarrhea, discolored feces, constipation, nausea, and vomiting.
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
Indications
Auryxia (ferric citrate) is a phosphate binder indicated for the control of serum phosphorus levels in patients with chronic kidney disease on dialysis.
Dosage
The recommended starting dose is 2 tablets orally 3 times per day with meals. Serum phosphorus levels should be monitored and the dose of Auryxia titrated in decrements or increments of 1 to 2 tablets per day as needed to maintain serum phosphorus at target levels, up to a maximum dose of 12 tablets daily. Dose can be titrated at 1-week or longer intervals.
In a clinical trial conducted in the United States, patients required an average of 8 to 9 tablets a day to control serum phosphorus levels.
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Tetraferric tricitrate decahydrate in adult patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Tetraferric tricitrate decahydrate in adult patients.
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Tetraferric tricitrate decahydrate in pediatric patients.
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Tetraferric tricitrate decahydrate in pediatric patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Tetraferric tricitrate decahydrate in pediatric patients.
Contraindications
Auryxia is contraindicated in patients with iron overload syndromes (e.g., hemochromatosis)
Warnings
Iron Overload
Iron absorption from Auryxia may lead to excessive elevations in iron stores. Increases in serum ferritin and transferrin saturation (TSAT) levels were observed in clinical trials. In a 56-week safety and efficacy trial in which concomitant use of Auryxia and IV iron was permitted, 55 (19%) of patients treated with Auryxia had a ferritin level >1500 ng/mL as compared with 13 (9%) of patients treated with active control.
Assess iron parameters (e.g., serum ferritin and TSAT) prior to initiating Auryxia and monitor iron parameters while on therapy [see Contraindications (4), Overdosage (10) and Clinical Pharmacology (12.2)]. Patients receiving IV iron may require a reduction in dose or discontinuation of IV iron therapy.
5.2 Accidental Overdose of Iron
Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years of age. Keep this product out of the reach of children. In case of accidental overdose, call a doctor or poison control center immediately.
5.3 Patients with Gastrointestinal Bleeding or Inflammation
Patients with inflammatory bowel disease or active, symptomatic gastrointestinal bleeding were excluded from clinical trials. Safety has not been established in these populations.
Adverse Reactions
Clinical Trials 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 adverse reaction rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Adverse reactions to a drug are most readily ascertained by comparison with placebo, but there is little placebo-controlled experience with Auryxia, so this section describes adverse events with Auryxia, some of which may be disease-related, rather than treatment-related.
A total of 289 patients were treated with Auryxia and 149 patients were treated with active control (sevelamer carbonate and/or calcium acetate) during the 52-week, randomized, open-label, active control phase of a trial in patients on dialysis. A total of 322 patients were treated with Auryxia for up to 28 days in three short-term trials. Across these trials, 557 unique patients were treated with Auryxia; dosage regimens in these trials ranged from 210 mg to 2,520 mg of ferric iron per day, equivalent to 1 to 12 tablets of Auryxia. In these trials, adverse events reported for Auryxia were similar to those reported for the active control group.
Adverse events reported in more than 5% of patients treated with Auryxia in these trials included diarrhea (21%), nausea (11%), constipation (8%), vomiting (7%), and cough (6%).
During the 52-week, active-control period, 60 patients (21%) on Auryxia discontinued study drug because of an adverse event, as compared to 21 patients (14%) in the active control arm. Patients who were previously intolerant to any of the active control treatments (calcium acetate and sevelamer carbonate) were not eligible to enroll in the study. Gastrointestinal adverse reactions were the most common reason for discontinuing Auryxia (14%).
Auryxia is associated with discolored feces (dark stools) related to the iron content, but this staining is not clinically relevant and does not affect laboratory tests for occult bleeding, which detect heme rather than non-heme iron in the stool.
Postmarketing Experience
There is limited information regarding Postmarketing Experience of Tetraferric tricitrate decahydrate in the drug label.
Body as a Whole
Cardiovascular
Digestive
Endocrine
Hematologic and Lymphatic
Metabolic and Nutritional
Musculoskeletal
Neurologic
Respiratory
Skin and Hypersensitivy Reactions
Special Senses
Urogenital
Miscellaneous
Drug Interactions
There are no empirical data on avoiding drug interactions between Auryxia and most concomitant oral drugs. For oral medications where a reduction in the bioavailability of that medication would have a clinically significant effect on its safety or efficacy, consider separation of the timing of the administration of the two drugs. The duration of separation depends upon the absorption characteristics of the medication concomitantly administered, such as the time to reach peak systemic levels and whether the drug is an immediate release or an extended release product. Consider monitoring clinical responses or blood levels of concomitant medications that have a narrow therapeutic range.
There are no adequate and well-controlled studies in pregnant women. It is not known whether Auryxia can cause fetal harm when administered to a pregnant woman. Animal reproduction studies have not been conducted.
The effect of Auryxia on the absorption of vitamins and other nutrients has not been studied in pregnant women. Requirements for vitamins and other nutrients are increased in pregnancy. An overdose of iron in pregnant women may carry a risk for spontaneous abortion, gestational diabetes and fetal malformation
Pregnancy Category (AUS):
Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Tetraferric tricitrate decahydrate in women who are pregnant.
Labor and Delivery
The effects of Auryxia on labor and delivery are unknown.
Nursing Mothers
Data from rat studies have shown the transfer of iron into milk by divalent metal transporter-1 (DMT-1) and ferroportin-1 (FPN-1). Hence, there is a possibility of infant exposure when Auryxia is administered to a nursing woman.
Pediatric Use
The safety and efficacy of Auryxia have not been established in pediatric patients.
Geriatic Use
Clinical studies of Auryxia included 106 subjects aged 65 years and older (33 subjects aged 75 years and older). Overall, the clinical study experience has not identified any obvious differences in responses between the elderly and younger patients in the tolerability or efficacy of Auryxia.
Gender
There is no FDA guidance on the use of Tetraferric tricitrate decahydrate with respect to specific gender populations.
Race
There is no FDA guidance on the use of Tetraferric tricitrate decahydrate with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Tetraferric tricitrate decahydrate in patients with renal impairment.
Hepatic Impairment
There is no FDA guidance on the use of Tetraferric tricitrate decahydrate in patients with hepatic impairment.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Tetraferric tricitrate decahydrate in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Tetraferric tricitrate decahydrate in patients who are immunocompromised.
Administration and Monitoring
Administration
Oral
Monitoring
Assess iron parameters (e.g., serum ferritin and TSAT) prior to initiating Auryxia and monitor iron parameters while on therapy
IV Compatibility
There is limited information regarding IV Compatibility of Tetraferric tricitrate decahydrate in the drug label.
Overdosage
No data are available regarding overdose of Auryxia in patients. In patients with chronic kidney disease on dialysis, the maximum dose studied was 2,520 mg ferric iron (12 tablets of Auryxia) per day. Iron absorption from Auryxia may lead to excessive elevations in iron stores, especially when concomitant IV iron is used [see Warnings and Precautions [see Warnings and Precautions (5.1)].
In clinical trials, one case of elevated iron in the liver as confirmed by biopsy was reported in a patient administered IV iron and Auryxia.
Because accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years of age, this product must be kept out of the reach of children. In case of accidental overdose, a doctor or poison control center should be contacted immediately [
Pharmacology
There is limited information regarding Tetraferric tricitrate decahydrate Pharmacology in the drug label.
There is limited information regarding Patient Counseling Information of Tetraferric tricitrate decahydrate in the drug label.
Precautions with Alcohol
Alcohol-Tetraferric tricitrate decahydrate interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
