Zemplar nova

generacija VDRA
(specifinost
delovanja,
selektivnost)
VDRA-Aktivator vitamin D
receptora (Vitamin D Receptor
Activator)
Zemplar is Selective
Zemplar stimulates less
calcium resorption from
the bone and absorption
from the gut
Serum calcium doesnt
tell the complete story
Necessary to look
beyond serum calcium
to calcium load
Small differences in
calcium load can lead to
big differences in
calcification over time
Introduction

Zemplar is the only selective VDRA in our markets
Zemplar is the only selective VDRA therapy among the 3 classes of SHPT
therapies: non-selective VDRA, selective VDRA, and Calcimimetics.
For VDRAs, selectivity means differential VDR binding, transcription, and
comodulator recruitment.
Reference: Issa, et al., J Bone Miner Res. 2002
Zemplars selectivity can be illustrated in both gene-specific and cell/tissue-
specific ways.
Reference: 1. Wu-Wong et al., Atherosclerosis 2006;
2. Slatopolsky et al., Am J Kidney Dis 1998
Overview of the SHPT Treatment Options
OH HO
OH
OH HO OH HO
OH HO
OH
Non-Selective VDRA Selective
VDRA
1
st
Generation 2
nd
Generation
Calcitriol
1,25-dihydroxyvitamin D
3

Mimics endogenous
VDR hormone

Calcijex

(IV)
Rocaltrol (Oral)
Generics (IV & Oral)

SHPT in CKD (pre-dialysis)
Osteoporosis,
Hypocalcemia
Alfacalcidol/Doxercalciferol
1-hydroxyvitamin D
3
/D
2

Molecular modifications
at the side-chain

One Alpha
Hectorol

SHPT in CKD
Osteoporosis,
Hypocalcemia
Paricalcitol
19-nor-1,25-
dihydroxyvitamin D
2

Molecular modifications
at the side-chain and
A-ring
Zemplar

SHPT in CKD
(Stage 3, 4, 5)
Calcimimetics
F
3
C
HCl
Cinacalcet


CaR activator


Sensipar

Mimpara

SHPT in CKD
(Stage 5 only)
Therapeutic
Target
VDR
VDR
RXR
Ligand binding
Heterodimerization
DNA binding
RNA Pol II
CoReg
Transactivation / Transrepression
RNA Pol II
Nucleus
mRNA
VDR
VDR
VDR
RXR
RXR
B
VDRE
Parikalcitol
Interactions of the Ligand-activated VDR-RXR Heterodimer Complex with the Nuclear
Proteins Facilitate the Assembly of the Transcription Preinitiation Complex and
Regulate the Rate of Transcription of the Target Gene by RNA Polymerase II
RXR = retinoid x receptor; VDRE = vitamin D
responsive element.
Dusso et al., Semin Nephrol. 2004;24:10-16.
OH
H
3
C
CH
3
CH
3
HO
CH
3
OH
RNA Pol II
VDR Bound to Selective VDRAs and Non-
selective VDRAs Recruits Different Coactivators
Takeyama et al., Mol Cell Biol 1999; 19:1049-55
RXR
VDR
RNA Pol II
RXR
VDR
SRC1 SRC1
TIF2 TIF2
VDR
AIB-1 AIB-1
Non-selective
VDRA*

Selective
VDRA**
*1,25(OH)2D3; ** OCT = 22-Oxa-calcitriol
RXR = retinoid x receptor
Gene-Specific Selectivity: Zemplar Activates and
Inactivates Different Genes in Vascular Smooth Muscle
Cells from those Regulated by Calcitriol
Wu-Wong et al., Atherosclerosis 2006; 186:20-28
Zemplar and calcitriol
activate and inactivate
different genes
As such, clinical differences
observed with these products
cannot be explained simply as
a dosing effect
Red: Increased activation
Blue: Increased inactivation
*Human coronary artery smooth muscle cells treated with
0.1 M calcitriol or Zemplar for 30 h
Zemplar Calcitriol
Selectivity: Differential VDR Binding, Transcription and
Comodulator Recruitment of Different VDRAs
Issa, et al., J Bone Miner Res. 2002; 17:879-90.
Rat Osteosarcoma (ROS) cells Yeast 2-hybrid Assay
Inhibitory constant (IC 50) indicates the
relative binding affinity of VDRAs for
VDR compared to calcitriol
Transcriptional activities of VDRAs were
assessed in ROS 17/2.8 cells transfected
with osteocalcin reporter
Zemplar induction of VDR
homodimerization VDR-RXR
heterodimerisation and VDR coactivator
interactions
0
25
50
75
100
125
150
175
%

C
a
l
c
i
t
r
i
o
l

VDR Binding VDR:VDR VDR:RXR
VDR:GRIP1 VDR:RAC3
VDR binding
(IC
50
nM)
Gene
transactivatio
n (ED
50
nM)
Calcitriol 0.40.3 0.70.1
Zemplar 3.70.9 0.110.03
VDR Binding Affinities and Transcriptional
Activities of Zemplar and Calcitriol
Cell/Tissue-Specific Selectivity: Zemplar Therapy Associated with
Significantly Less Intestine VDR Expression Compared to Calcitriol
Slatopolsky et al., Am J Kidney Dis 1998;32:S40-47.
0
50
100
150
200
UREMIC
25
3
H
-
C
a
l
c
i
t
r
i
o
l

s
p
e
c
i
f
i
c

b
i
n
d
i
n
g

(
f
m
o
l
/
m
g

p
r
o
t
e
i
n
)

Calcitriol

Zemplar

100 ng 6 2 0 Normal
*
*
**
*P<0.01 vs. 6 ng calcitriol treated uremic rats; **P<0.05 vs. 6 ng calcitriol treated uremic rats.
Introduction
Pre-clinical Studies:
Less calcemic and phosphatemic than non-selective VDRAs
Reference: 1. Brown et al., J Am Soc Nephrol 2000; 2. Slatopolsky et al., Am J Kidney Dis 1998; 3.
Slatopolsky et al., Kidney Int 2002; 4. Nakane et al., J Steroid Biochem. Mol. Biol 2007.
Clinical Studies:
18% less intestine Ca absorption and soft tissue Ca loading than calcitriol.
Reference: Lund et al., Nephrol Dial Transplant 2006
Fewer episodes of hypercalcemia or elevated CaxP than calcitriol.
Reference: Sprague et al., Kidney Int. 2003
.

Zemplar is the selective VDRA with minimal impact on Ca and P, and
effective PTH suppression
At Equivalent Doses, Zemplar Demonstrated
Significantly Lower Calcemic and Phosphatemic Effects
than Calcitriol in Normal Rats
n = 4
*p<0.05 Zemplar vs calcitriol

Dose = 240 pmol/day

Brown et al., J Am Soc Nephrol 2000;11:208894
I
n
c
r
e
a
s
e

i
n

S
e
r
u
m

C
a
l
c
i
u
m

(
m
g
/
d
L
)

Treatment (d)
Calcitriol

Zemplar

* *
0.0
0.5
1.0
1.5
2.0
2.5
0 1 2 3 4 5 6 7
*p<0.01 vs uremic control, dosing daily
Slatopolsky et al., Am J Kidney Dis 1998;32:S40-47
0 10 20 30 40 50 60 70 80 90
Dose (ng)
4
5
6
7
8
9
10
S
e
r
u
m

P

(
m
g
/
d
L
)

Calcitriol
Zemplar

*
Doxercalciferol Induced Progressive Increases in Serum
Ca and P in Uremic Rats, While those of the Zemplar
Groups Remained Unchanged
50 100 250
Dose (ngs)
8
9
10
11
12
13
C
a

(
m
g
/
d
l
)

5
6
7
8
9
10
P
i


(
m
g
/
d
l
)

50 100 250
Dose (ngs)
Slatopolsky et al. Kidney Int 2002;62:127784
Zemplar

Doxercalciferol

Vehicle Calcitriol Zemplar Doxercalciferol
10 ng
100 ng
100 ng
Zemplar had Less Effect on Intestine Absorption of Ca
and P Than the Non-selective Calcitriol and
Doxercalciferol in Normal Rats
n=21; *p< 0.01 vs. control rats;

p< 0.01 vs. Zemplar-treated rats

P
h
o
s
p
h
o
r
u
s

a
b
s
o
r
b
e
d
/
2
4

h

(
%
)

*

30
35
40
45
50
25
23%
4%

*

C
a
l
c
i
u
m

a
b
s
o
r
b
e
d
/
2
4

h

(
%
)

10
15
20
25
30
35
40
Vehicle Calcitriol Zemplar Doxercalciferol
39%

10 ng
9%

100 ng
100 ng
*

*

Slatopolsky et al. Kidney Int 2002;62:127784
1x
dosing
10x
dosing
10x
dosing
1x
dosing
10x
dosing
10x
dosing

Nakane et al, J Steroid Biochem. Mol. Biol 2007;103: 84-89
Zemplar does not Increase Intestine Ca Transport while
Non-selective VDRAs Do in a Dose-dependent Manner
1
8
7
6
5
4
3
2
0
S
e
r
o
s
a
l

/

M
u
c
o
s
a
l

R
a
t
i
o

*P < 0.05 vs Nave
***P < 0.001 vs Nave
n = 7-17/grp
Veh calcitriol

Doxer-
calciferol

Vehicle

Zemplar

Treatment (g/kg, i.p.)

***

***

*

20
10
C
a
2
+

T
r
a
n
s
p
o
r
t

(
n
m
o
l
/
m
i
n
)

30
0
Zemplar

**

*

calcitriol

Doxer-
calciferol

Ctr

-9

-8

-7

-9

-8

-7

-9

-8

-7

*

Test Agent [log M]
In 5/6 Nephrectomized Rats In Caco-2 Cell Culture
Zemplar Showed a 18% Overall Decrease in Ca
Absorption Relative to Calcitriol in Hemodialysis
Patients
F
x
A
b
s

o
n

Z
e
m
p
l
a
r


t
h
e
r
a
p
y

M
e
a
n

C
a

a
b
s
o
r
p
t
i
o
n

(
%
)

12.0
12.5
13.0
13.5
14.0
14.5
15.0
15.5
16.0
Zemplar Calcitriol
*
Lund et al. Nephrol Dial Transplant 2006;21(Suppl 7):EDTA 2006 Poster
Due to the intestinal absorption difference in Ca, compared to Zemplar, calcitriol could
result in up to 46 mg more Ca accumulation in bone and soft tissue everyday (assuming 2
g of daily average elemental Ca from diet), which could lead to the doubling of extra-
skeletal Ca in 6 months a severe risk for soft tissue calcification.
p=0.022 for Zemplar vs calcitriol Shows combined results of 2 different regimens (calcitriol 2 g, Zemplar 6 g)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40
15% 31%
26%
13%
Regression Equation:
Zemplar FxAbs = 0.007+0.815* Calcitriol FxAbs
R-Square = 0.813
FxAbs on calcitriol therapy
Zemplar dosed 3x to 1x
calcitriol
13.5%
15.8%
IV Zemplar Patients Had Significantly Fewer Sustained
Episodes of Hypercalcemia and/or Increased Ca x P Than
Calcitriol
Calcitriol (n=133)
Zemplar (n=130)
0
5
10
15
20
25
30
35
P
a
t
i
e
n
t
s

(
%
)

w
i
t
h

e
v
e
n
t
s

Sprague et al. Kidney Int 2003;63:1483-1490
*p=0.008 for patients with hypercalcemia for at least 2 consecutive blood draws and/or a Ca
P product >75 on at least 1 of 4 consecutive blood draws
33%
18%*
Introduction

Zemplar is better at improving bone health relative to all SHPT
therapies
Pre-clinical Studies:
Less Ca release from the bone and greater collagen synthesis for bone formation
Reference: Nakane et al, J. Steroid Biochem. Mol. Biol 2006

Clinical Studies:
Reduction in bone-specific alkaline phosphatase and osteocalcin.
Reference: 1. Ross et al., ASN 2006;
2. Coyne et al., Am J Kidney Dis. 2006.
Cinacalcet as a mono-therapy has unproven impact on bone biomarkers.
Reference: Block et al., N Engl J Med 2004
Rats were treated with 19-nor-1, 25-(OH)2D2 (19-nor-1,25-D2), 1-(OH)D2, or 1, 25-(OH)2D3 (1,25-D3). Delta serum calcium
was calculated by subtracting the mean of serum calcium in the vehicle treated group from serum calcium in each of the drug
treated animals. Values shown are the meanS.E.M. (n = 1216 per treatment group). (*) Different statistically from vehicle
control animals; P < 0.001. Statistical comparisons were performed by ANOVA analysis.
Adapted from Nakane et al, J. Steroid
Biochem. Mol. Biol 2006, 98, 72-77
Compared to Non-selective VDRAs, Zemplar has the Least
Impact on Serum Ca Mobilized from the Bone
0
D
e
l
t
a

S
e
r
u
m

C
a
l
c
i
u
m

v
s
.

C
o
n
t
r
o
l

(
m
g
/
d
L
)

1
2
3
4
5
6
0.001 0.01 0.1 1 10
* p<0.001
doxercalciferol

Zemplar

calcitriol

*
*
*
*
*
*
*
*
*
*
*
Dose, g / kg / day; i.p., q.d., 7 days
Compared to Non-selective VDRAs, Zemplar is Associated
with Less Ca Release from the Bone and Greater Collagen
Synthesis for Bone Formation
Zemplar caused less Ca
release from mouse
calvariae bone primary
organ culture compared to
calcitriol and 25-OH-
doxercalciferol


Zemplar stimulated
greater collagen
synthesis from mouse
calvariae than calcitriol and
25-OH-doxercalciferol
0
10
20
30
40
50
60
70
Zemplar
Calcitriol Active doxercalciferol
*
***
**
***
**
**
***

C
a

r
e
l
e
a
s
e

(
n
g
/

L

m
e
d
i
u
m
)

[log M]
0
1
2
3
4
5
6
7
Zemplar Calcitriol Active doxercalciferol
***
***
***
***
**
***
**
**
***
***
***
C
o
l
l
a
g
e
n

S
y
n
t
h
e
s
i
s

(
%

o
f

t
o
t
a
l

p
r
o
t
e
i
n
)

[log M]
Adapted from Nakane et al, J. Steroid
Biochem. Mol. Biol 2006, 98, 72-77
ZEMPLAR Capsule Significantly Decreases Bone Turnover,
as Indicated by a Reduction in Corresponding Bone Activity
Biomarker Levels (BSAP and Serum Osteocalcin)
Similarly, Zemplar also significantly reduces the level of two other bone activity biomarkers, CTx (C-terminal Telopeptide of
Collagen, P<0.001) and TRAP-5b (Tartarate Resistant Acid Phosphatase type 5b, P<0.05) from baseline by 21% and
18%, respectively (compared to 22% and 11% increase in the placebo groups, respectively).
Ross EA, et al. J AM Soc Nephrol 2006;17: 691A. ASN 2006 Poster (Abbott study M03-635 Data on file, 2006)
-27%
33.6%
-40
-30
-20
-10
0
10
20
30
40
ZEMPLAR Placebo
-5.6%
40%
-10
0
10
20
30
40
50
ZEMPLAR Placebo
%

C
h
a
n
g
e

f
r
o
m

b
a
s
e
l
i
n
e

Serum Bone Specific Alkaline
Phosphatase (ng/mL)
Serum Osteocalcin (ng/mL)
n = 55 n = 24 n = 54 n = 23
p <0.001 p <0.001
%

C
h
a
n
g
e

f
r
o
m

b
a
s
e
l
i
n
e

Paricalcitol Caused Less Calcium Release From Mouse
Calvariae Compared With Calcitriol and Doxercalciferol
*p<0.05;**p<0.01;***p<0.001; n=1216 per treatment group for 4 days
0
10
20
30
40
50
60
70
25-OH-
doxercalciferol
(active)
Paricalcitol Calcitriol

***
*
C
a
l
c
i
u
m

(
n
g
/

l

m
e
d
i
u
m
)

**
**
***
***
**
Nakane M, et al. J Steroid Biochem Mol Biol 2006;98:727
1
Male 5/6 nephrectomized rats
were placed on a high P diet
for 4 weeks to induce
advanced secondary
hyperparathyroidism
Treatment was initiated with
vehicle, paricalcitol,
doxercalciferol or calcitriol, IP,
three times a week, for 12
days
24 hours after last dose, small
intestine was collected for
measurement of Ca absorption
Ca transport was determined in
the mucosal-to-serosal
direction
Nakane M, et al. Steroid Biochem Mol Biol 2007;103:849
Effects of Selective and Non-selective VDRAs on Intestinal
Calcium Transport in 5/6 Nx Rats
8
7
6
5
4
3
2
0
m
e
a
n
s

S
E
M

S
e
r
o
s
a
l

/

M
u
c
o
s
a
l

R
a
t
i
o

n=717/grp
Veh Calcitriol

Doxer-
calciferol

Veh

Pari-
calcitol

Treatment (g/kg, IP)

***

***

*

#
Separate experiment. Different from vehicle control
*p<0.05; ***p<0.001 vs Nave
20
10
C
a
2
+

T
r
a
n
s
p
o
r
t

(
n
m
o
l
/
m
i
n
)

Cells grown on permeable
filter supports were treated
with increasing
concentrations of
paricalcitol, calcitriol, of
doxercalciferol for 48 h
starting on the 13
th
day in
culture
Ca transport was
determined in the apical to
basolateral direction
Values represent means
SD from four determinations
Calcium Transport in Caco-2 Cells
30
0
Paricalcitol

**

*

Calcitriol

Doxercalciferol

Ctr

-9

-8

-7

-9

-8

-7

-9

-8

-7

*

Concentrations (log M)
*p<0.05; **p<0.01 vs control
Nakane M, et al. Steroid Biochem Mol Biol 2007;103:849
Effect of Paricalcitol and Doxercalciferol on Serum
Phosphorus in Uremic Rats
5
6
7
8
9
10
P
i


(
m
g
/
d
L
)

50 100 250
Dose (ngs)
Doxercalciferol
Paricalcitol
Slatopolsky E, et al. Kidney Int 2002;62:127784
Effect of Paricalcitol and Doxercalciferol on Serum
Ca in Uremic Rats
50 100 250
Dose (ngs)
8
9
10
11
12
13
C
a

(
m
g
/
d
L
)

Slatopolsky E, et al. Kidney Int 2002;62:127784
Doxercalciferol
Paricalcitol
T
o
t
a
l

C
a

(
m
g
/
d
L
)

Treatment (d)
Paricalcitol 1000 ng
Paricalcitol 100 ng
Calcitriol 10 ng
Paricalcitol 10 ng
Vehicle
3 6 10 0
8
10
12
14
16
Dosing daily IP for 10 days

Slatopolsky E, et al. Am J Kidney Dis 1995;26:85260
Paricalcitol Produced Similar Increases in Ca at Doses 10
Times Higher Than Calcitriol in Uremic Rats
Paricalcitol did not Increase P in any Dosing Group;
However, Calcitriol was Associated With Significant
Increases in Uremic Rats
*p<0.01 vs uremic control, dosing daily
0 10 20 30 40 50 60 70 80 90
Dose
(ng)
4
5
6
7
8
9
10
S
e
r
u
m

P

(
m
g
/
d
L
)

Calcitriol
Paricalcitol

*
Slatopolsky E, et al. Am J Kidney Dis 1995;26:85260
Doxercalciferol Induced Progressive Increases in
Ca x P in Uremic Rats, While Paricalcitol Groups Remained
Unchanged
IP 3 x week for 2 weeks
*p<0.01 vs control rats; **p<0.001 vs control rats
Slatopolsky E, et al. Kidney Int 2002;62:127784
*
**
125
100
75
50
25
0
50 ng 100 ng 250 ng 50 ng 100 ng 250 ng
Vehicle
19-nor-1,25(OH)
2
D
2
1(OH)D
2
C
a

P

p
r
o
d
u
c
t

(
m
g
2
/
d
L
2
)

Paricalcitol
(n=10)
Doxercalciferol
(n=9)
Paricalcitol Showed a 17% Overall Decrease in Ca Absorption
Relative to Calcitriol in Hemodialysis Patients in a Double-blind
Crossover Study
p=0.022 for paricalcitol vs calcitriol
Shows combined results of 2 different regimens (calcitriol 2 g, paricalcitol 6 g)
M
e
a
n

C
a

a
b
s
o
r
p
t
i
o
n

(
%
)

F
x
A
b
s

o
n

p
a
r
i
c
a
l
c
i
t
o
l

t
h
e
r
a
p
y

0.0
0.1
0.2
0.3
0.4
12
13
14
15
16
Paricalcitol Calcitriol
0.0
0.1
0.2
0.3
0.4
0.0 0.1 0.2 0.3 0.4
15% 31%
26%
13%
Regression Equation:
Paricalcitol FxAbs = 0.007+0.815* Calcitriol FxAbs
R-Square = 0.813
FxAbs on calcitriol
therapy
*
Paricalcitol dosed 3 x
to 1 x calcitriol; equipotent PTH
suppression in both groups
Lund R, et al. Nephrol Dial Transplant 2006;21(Suppl 4):219A