Safety and Efficacy of Tenapanor for Long-term Serum Phosphate Control in Maintenance Dialysis: A 52-Week Randomized Phase 3 Trial (PHREEDOM)

Abstract

Key Points Tenapanor is a first-in class inhibitor of NHE3 and acts via a nonphosphate-binding mechanism to reduce intestinal phosphate absorption. In the efficacy analysis set, patients randomized to tenapanor experienced a decrease in serum phosphate from 7.7 mg/dl to 5.1 mg/dl. Diarrhea was the only drug-related adverse event reported for more than 5% of patients and resulted in drug discontinuation in 16% of patients. Background Treating hyperphosphatemia is a tenet of dialysis care. This trial assessed the safety and efficacy of tenapanor for the management of hyperphosphatemia. Methods In this 52-week phase 3 study (NCT03427125), participants receiving maintenance dialysis with both hyperphosphatemia (serum phosphate 6.0–10.0 mg/dl) and a 1.5 mg/dl increase after phosphate binder washout were randomized (3:1) to tenapanor 30 mg twice daily for 26 weeks (randomized treatment period) or sevelamer carbonate (52-week safety control). Participants completing 26 weeks of treatment with tenapanor were rerandomized (1:1) to tenapanor or placebo for 12 weeks (randomized withdrawal period), and were eligible to enter the 14-week safety extension period. With input from the US Food and Drug Administration, the primary efficacy end point was the difference in the change in serum phosphate from the end of the randomized treatment period to the end of the randomized withdrawal period, among participants who achieved ≥1.2 mg/dl decrease in serum phosphate during the randomized treatment period (efficacy analysis set). Efficacy was also evaluated in the intention-to-treat (ITT) analysis set. Results Of 564 eligible participants randomized to receive tenapanor ( n =423) or sevelamer carbonate ( n =141) during the randomized treatment period, 255 (60%) in the tenapanor group subsequently were rerandomized to tenapanor ( n =128) or placebo ( n =127) during the randomized withdrawal period. In the efficacy analysis set ( n =131), the difference in estimated mean change in serum phosphate level between tenapanor and placebo from the beginning to the end of the randomized withdrawal period was −1.4 mg/dl ( P <0.0001); in the ITT analysis set ( n =243), the estimated mean difference was −0.7 mg/dl ( P =0.002). Loosened stools were the most frequently reported adverse event (53% during the randomized treatment period). Serious adverse events were reported more frequently for participants treated with sevelamer carbonate (16%–23% across the three study periods) compared with tenapanor (11%–17%). Conclusions Tenapanor reduced serum phosphate concentrations and maintained control of serum phosphate in participants receiving maintenance dialysis, with an acceptable safety and tolerability profile.

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