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Calcicreen Actions |
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Pharmacology: Calcicreen is the active form of vitamin D3 (cholecalciferol). The natural or endogenous supply of vitamin D in man mainly depends on ultraviolet light for conversion of 7-dehydrocholesterol to vitamin D3 in the skin. Vitamin D3 must be metabolically activated in the liver and the kidney before it is fully active on its target tissues. The initial transformation is catalyzed by a vitamin D3-25-hydroxylase enzyme present in the liver, and the product of this reaction is 25-(OH)D3 (calcifediol). The latter undergoes hydroxylation in the mitochondria of kidney tissue and this reaction is activated by the renal 25-hydroxyvitamin D3-1-α-hydroxylase to produce 1,25-(OH)2D3(Calcicreen), the active form of vitamin D3.
The known sites of action of Calcicreen are intestine, bone, kidney and parathyroid gland. Calcicreen is the most active known form of vitamin D3 in stimulating intestinal calcium transport. In acutely uremic rats, Calcicreen has been shown to stimulate intestinal calcium absorption. In bone, Calcicreen, in conjunction with parathyroid hormone (PTH), stimulates resorption of calcium; and in the kidney, Calcicreen increases the tubular reabsorption of calcium. In vitro and in vivo studies have shown that Calcicreen directly suppresses secretion and synthesis of PTH. A vitamin D-resistant state may exist in uremic patients because of the failure of the kidney to adequately convert precursors to the active compound, Calcicreen.
Calcicreen when administered by bolus injection is rapidly available in the bloodstream. Vitamin D metabolites are known to be transported in blood, bound to specific plasma proteins. The pharmacologic activity of an administered dose of Calcicreen is about 3-5 days. Two metabolic pathways for Calcicreen have been identified, conversion to 1,24,25-(OH)3D3 and to calcitroic acid.
Toxicology: Preclinical Safety Data: Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals have not been performed to evaluate the carcinogenic potential of Calcicreen. There was no evidence of mutagenicity as studied by the Ames method. No significant effects of Calcicreen on fertility were reported using oral Calcicreen.
It is very important that you use Calcicreen only as directed by your doctor. Do not use more of it, do not use it more often, and do not use it for a longer time than your doctor ordered. To do so may cause unwanted side effects or skin irritation.
Calcicreen should only be used on the skin. Do not get it into your eyes, nose, mouth, or vagina. Do not use it on skin areas that have cuts, scrapes, or burns. Do not apply Calcicreen to your nipple or areola, if you are breastfeeding. If it does get on these areas, rinse it off right away with water.
Calcicreen comes with a patient information leaflet. Read and follow the instructions carefully. Ask your doctor if you have any questions.
To use the ointment:
Do not use cosmetics or other skin care products on the treated areas unless directed to do so by your doctor.
The dose of Calcicreen will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of Calcicreen. If your dose is different, do not change it unless your doctor tells you to do so.
The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.
If you miss a dose of Calcicreen, apply it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule.
Keep out of the reach of children.
Do not keep outdated medicine or medicine no longer needed.
Ask your healthcare professional how you should dispose of any medicine you do not use.
Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.
Do not freeze or refrigerate the ointment.
Use exactly as prescribed by your doctor. Do not use in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label.
Calcicreen topical is usually applied once in the morning and once in the evening. Follow your doctor's instructions.
Do not share this medication with other people, even if they have the same symptoms you have.
Wash your hands before and after applying this medicine.
Apply a thin layer of the medication and rub it in completely.
Do not cover treated skin areas unless your doctor has told you to.
Calcicreen topical is for use only on areas of psoriasis. Avoid getting it on healthy skin areas.
Calcicreen topical should not be applied to the face or the vaginal area.
Store at room temperature away from moisture and heat. Do not allow the medicine to freeze.
Man's natural supply of vitamin D depends mainly on exposure to the ultraviolet rays of the sun for conversion of 7-dehydrocholesterol in the skin to vitamin D3 (cholecalciferol). Vitamin D3 must be metabolically activated in the liver and the kidney before it is fully active as a regulator of calcium and phosphorus metabolism at target tissues. The initial transformation of vitamin D3 is catalyzed by a vitamin D3-25-hydroxylase enzyme (25-OHase) present in the liver, and the product of this reaction is 25-hydroxyvitamin D3 [25-(OH)D3]. Hydroxylation of 25-(OH)D3 occurs in the mitochondria of kidney tissue, activated by the renal 25-hydroxyvitamin D3-1 alpha-hydroxylase (alpha-OHase), to produce 1,25-(OH)2D3 (Calcicreen), the active form of vitamin D3. Endogenous synthesis and catabolism of Calcicreen, as well as physiological control mechanisms affecting these processes, play a critical role regulating the serum level of Calcicreen. Physiological daily production is normally 0.5 to 1.0 mcg and is somewhat higher during periods of increased bone synthesis (eg, growth or pregnancy).
The two known sites of action of Calcicreen are intestine and bone. A Calcicreen receptor-binding protein appears to exist in the mucosa of human intestine. Additional evidence suggests that Calcicreen may also act on the kidney and the parathyroid glands. Calcicreen is the most active known form of vitamin D3 in stimulating intestinal calcium transport. In acutely uremic rats Calcicreen has been shown to stimulate intestinal calcium absorption. The kidneys of uremic patients cannot adequately synthesize Calcicreen, the active hormone formed from precursor vitamin D. Resultant hypocalcemia and secondary hyperparathyroidism are a major cause of the metabolic bone disease of renal failure. However, other bone-toxic substances which accumulate in uremia (eg, aluminum) may also contribute.
The beneficial effect of Calcicreen in renal osteodystrophy appears to result from correction of hypocalcemia and secondary hyperparathyroidism. It is uncertain whether Calcicreen produces other independent beneficial effects. Calcicreen treatment is not associated with an accelerated rate of renal function deterioration. No radiographic evidence of extraskeletal calcification has been found in predialysis patients following treatment. The duration of pharmacologic activity of a single dose of Calcicreen is about 3 to 5 days.
Absorption
Calcicreen is rapidly absorbed from the intestine. Peak serum concentrations (above basal values) were reached within 3 to 6 hours following oral administration of single doses of 0.25 to 1.0 mcg of Calcicreen. Following a single oral dose of 0.5 mcg, mean serum concentrations of Calcicreen rose from a baseline value of 40.0±4.4 (SD) pg/mL to 60.0±4.4 pg/mL at 2 hours, and declined to 53.0±6.9 at 4 hours, 50±7.0 at 8 hours, 44±4.6 at 12 hours, and 41.5±5.1 at 24 hours.
Following multiple-dose administration, serum Calcicreen levels reached steady-state within 7 days.
Distribution
Calcicreen is approximately 99.9% bound in blood. Calcicreen and other vitamin D metabolites are transported in blood, by an alpha-globulin vitamin D binding protein. There is evidence that maternal Calcicreen may enter the fetal circulation. Calcicreen is transferred into human breast milk at low levels (ie, 2.2±0.1 pg/mL).
Metabolism
In vivo and in vitro studies indicate the presence of two pathways of metabolism for Calcicreen. The first pathway involves the 24-hydroxylase as the first step in catabolism of Calcicreen. There is definite evidence of 24-hydroxylase activity in the kidney; this enzyme is also present in many target tissues which possess the vitamin D receptor such as the intestine. The end product of this pathway is a side chain shortened metabolite, calcitroic acid. The second pathway involves the conversion of Calcicreen via the stepwise hydroxylation of carbon-26 and carbon-23, and cyclization to yield ultimately 1α, 25R(OH)2-26, 23S-lactone D3. The lactone appears to be the major metabolite circulating in humans, with mean serum concentrations of 131±17 pg/mL. In addition, several other metabolites of Calcicreen have been identified: 1α, 25(OH)2-24-oxo-D3; 1α, 23,25(OH)3-24-oxo-D3; 1α, 24R,25(OH)3D3; 1α, 25S,26(OH)3D3; 1α, 25(OH)2-23-oxo-D3; 1α, 25R,26(OH)3-23-oxo-D3; 1α, (OH)24,25,26,27-tetranor-COOH-D3.
Excretion
Enterohepatic recycling and biliary excretion of Calcicreen occur. The metabolites of Calcicreen are excreted primarily in feces. Following intravenous administration of radiolabeled Calcicreen in normal subjects, approximately 27% and 7% of the radioactivity appeared in the feces and urine, respectively, within 24 hours. When a 1-mcg oral dose of radiolabeled Calcicreen was administered to normal subjects, approximately 10% of the total radioactivity appeared in urine within 24 hours. Cumulative excretion of radioactivity on the sixth day following intravenous administration of radiolabeled Calcicreen averaged 16% in urine and 49% in feces. The elimination half-life of Calcicreen in serum after single oral doses is about 5 to 8 hours in normal subjects.
Pediatric Pharmacokinetics
The steady-state pharmacokinetics of oral Calcicreen were determined in a small group of pediatric patients (age range: 1.8 to 16 years) undergoing peritoneal dialysis. Calcicreen was administered for 2 months at an average dose of 10.2 ng/kg (SD 5.5 ng/kg). In this pediatric population, mean Cmax was 116 pmol/L, mean serum half-life was 27.4 hours, and mean clearance was 15.3 mL/hr/kg.1
Geriatric
No studies have examined the pharmacokinetics of Calcicreen in geriatric patients.
Gender
Controlled studies examining the influence of gender on Calcicreen have not been conducted.
Hepatic Insufficiency
Controlled studies examining the influence of hepatic disease on Calcicreen have not been conducted.
Renal Insufficiency
Lower predose and peak Calcicreen levels in serum were observed in patients with nephrotic syndrome and in patients undergoing hemodialysis compared with healthy subjects. The elimination half-life of Calcicreen increased by at least twofold in chronic renal failure and hemodialysis patients compared with healthy subjects. Peak serum levels in patients with nephrotic syndrome were reached in 4 hours. For patients requiring hemodialysis peak serum levels were reached in 8 to 12 hours; half-lives were estimated to be 16.2 and 21.9 hours, respectively.
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Information checked by Dr. Sachin Kumar, MD Pharmacology
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