Results:
`
`0
`
`0 No mortality, no signs, ophthalmic effects, body weight effects, serum chemistry, urine
`.
`chemistry, macroscopic or microscopic effects
`‘
`o PTH decreased at 2h post dose beginning after first dose in all groups. PTH levels reduced
`in HDm and in MDf, HDf on Day28.
`Serum ionized calcium slightly reduced (17%) in MD, HD, on Day 27, at 2-4h post dose
`up to 8b post dose.
`No effects on serum or urine bone markers (resorption or formation)
`Increase in cortical bone area, decrease in trabecular bone area of femur inMDf and HDf
`Increase in total metaphyseal BMD offemur in HDf
`Increase in kidney weight in HDm
`Decrease in platelet count in HDf after recovery
`AUC parent: 21, 72,220 ngxh/mL in LD, MD, HD (Day 1). AUC decreased after 27 days
`
`Conclusion:
`
`'
`
`-
`
`Potential changes in bone resorption/formation resulting in relative increase in cortical bone
`and increase in BMD at low AUC levels (100-200 ngxh/mL). This may be related to decrease
`in PTH and reduced bone resorption. Suppressed bone resorption in young animals may lead
`to grth effects or effects on bone marrow and hematopoiesis.
`
`28-day oral toxicity study in juvenile dogs with a 28-day recovefl period (Study Nr. 1019381
`Methods:
`
`Juvenile dogs (10 weeks, N=7/s/g) were dosed by oral gavage at 0, 0.5, 1.5, 5 mg/kg/day for
`28 days, or for 28 days-+ 28 days recovery. The HD of S'mkd was the NOAEL in the 28-day
`adult dog study. Plasma concentrations, ionized Ca, and PTH, and bone biomarkers (serum,
`urine) were measured. Femur was analyzed by pQCT.
`‘
`
`Results:
`
`_
`
`.
`
`0 No mortality, no signs, ophthalmic effects, body weight effects
`0 No effects on hematology, coagulation, urinalysis, urine chemistry, organ weights,
`macroscopic findings
`0 ‘No effects on bone markers or pQCT parameters (BMC, BMD, area)
`Slight increase in serum P in HDm on ,D27, slight decrease in ionized calcium in MD, HD
`on DO, D27. No clear effects on PTH
`)
`0 Heart (post recovery): lefi ventricular arterial hypertrophy, in all groups including control
`but with increased incidence and severity in MDm, HDm,f. Multifocal left ventricular ‘
`myocardial fibrosis with minimal arterial hypertrophy in 1/7 HDm
`0 . AUC parent: dose-dependent exposure in all dose groups. AUC decreased on D27 as
`compared to D1 (autoinduction?) AUC values 4.5, 15.8, 62 ngxh/mL in LD, MD, HD. No
`sex difference.
`
`Tabte 8. Summary 01 Cardiac Flndlngs in the 28-Day Juvenile 009 Study at the
`
`48
`
`Left Ventricular
`Arterial Hypertrophy
`Minimal
`Slight
`Moderate
`
`

`

`RAT AND MONKEY TOXICITY STUDIES OF 23-MONTH DURATION '
`
`A 26-WEEK ORAL GAVAGE TOXICITY STUDY OF AMG 099073-01 IN THE ALBINO RAT WITH A
`
`'
`
`.
`4-WEEK RECOVERY
`Project No. 88583; Sponsor Study Nr. 100082
`Conducting laboratory:m
`Study period: March — October 1998
`GLP compliance: Y
`QA report included
`
`.Purity: 99.7%
`Lot Nr. 709001 ,
`_
`Assay of test compound (in vehicle-prepared dosing solution): HPLC
`Vehicle/control: 0.5% methylcellulose in distilled water (batch nr. 126H1424)
`
`METHODS
`
`'
`
`Spraguc-Dawley CD (Crl:CDR(SD)BR) rats (Rattus norvegicus) (20 or lS/sex/dose group, 15 for experiment, 5
`for recovery), age at start 6 weeks, body weight 130-220 gram, were dosed orally, by gavage, with 0, 5, 25, 100
`mg/kg/day, for 26 weeks (10 ml/kg/day). Additionally, 6/sex/grp were dosed for TK and ionized Ca evaluation.
`Feeding was ad libitum. pQCT scans of right distal femur (metaphysis, diaphysis) performed ex vivo in Wks 26,
`31. Histopathology at sacrifice (see Appendix I). Toxicokinetics on Day 1, Wks 13, 26, 31: predose, 0.5, l, 2, 4,
`8, 12, 24h postdose. Samples used for assay of drug assay (LC-MS/MS) and ionized Ca determination.
`'
`8
`
`.
`
`da_:
`
`N/sex ' K, Ca
`
`N/sex/_ro n mam stud
`N/scx termmalsacrlfioe
`
`RESULTS
`
`. Mortality — None
`Signs — MainfSal‘iyvation and abnormal respiratory sounds in MD and HD
`
`Body weight - A
`
`males
`
`15'
`
`Da 210
`
`'ecove
`
`’m
`
`“4
`
`.
`
`23
`
`428
`
`,
`
`-—
`——
`387 (9l%)
`263
`
`l00% %
`
`67%
`
`49
`
`

`

`Food consumption - reduced by 0-5% in MDm, and by 10-20%V(g/anima1) in HDm and HDf throughout
`treatment period; no significant differences in recovery period
`‘
`
`Ocular finding - Cataracts (small,'mu1tifocal opacities in anterior cortex) in almost all Group 4 animals, on Day
`88/87, Day 172/171, and recovery, similar at all times
`
`Hematolo -
`
`_
`
`—.?£II
`
`‘statistically significantly different from control
`
`Clinical Chemis
`
`—--‘ e
`Contr lO
`
`
`
`— -
`
`Wk31'
`
`
`'
`
`M
`
`D .
`
`Wk31
`
`Other finding: glucose decreased slightly but significantly in HD groups, in Wk 13 and Wk 27 in males, in Wk27
`in females
`.
`
`
`
`Serum PTH
`
`0
`
`O Males: Serum PTH decreased from ca. 60-80 pg/mL (predosing) to < 20 pg/ml (wks 1-13) or <40-50 pg/mL
`(wk26) @Zhrs after dosing, in non-dose-related manner.
`I
`Females: Decrease from 40-80 pg/mL (predosing) to Q0 pg/mL (wks 1-4), or <50 pg/mL (wk 13), or <60
`pg/mL (wk 26) @Zhrs post dose, also non-dose—related manner“
`-
`Predose levels were slightly lowered in Wks 4-13 in HD groups, but retumed to control levels in all dose
`groups by Wk 26. Apparently, some adaptation in PTH response occurred.
`'
`
`' 0
`
`Ionized calcium
`
`Ionized Ca mg/dL) (not normalized for H)
`_I-I§--__-I§l_—_
`
`50
`
`

`

`
`
`‘slatistically significantly different from control
`
`a
`0
`0
`
`' Ionized Ca values minimal at ca. 6-!2h post dose.
`24h and pre-dose levels remained lower throughout study in treated groups.
`Ionized Ca values recovered at Wk30.
`
`figure 1. Mean Normalized Ionized Calclum Levels ln Male and Female Rats
`'
`Administered Clnacalcet HCI Over a 24 hr Period at Week 26
`
`~ ~«
`
`~ -
`
`~
`
`m '5" -~ ~~ ,
`§—-----~-—v-«~— —--v
`— - — '“l
`15%
`l
`g + 0mm?
`14
`g
`«v- 5m 4‘
`
`g 153: W i
`»~-——:°m 5
`z—4- mm .
`’
`z
`:3?»
`,
`‘
`-/
`v ‘2
`‘31..
`/\‘r”::- d
`E
`L”
`‘“““‘
`11 Q
`‘\
`‘r’
`/
`Z
`'
`:
`\
`1
`:g m
`Rx ,nw 4......d/
`.
`8 on
`1""
`|‘
`on
`-.
`‘
`g '91
`05—;
`o5
`
`‘
`'
`
`.
`v
`
`>
`
`a
`M iw-.~W—w-_mww._w,w-r .— w.._ .. ..V _
`presses.”
`a
`2
`4
`e
`9'
`r2
`:4
`Timur-lows}
`
`
`
`le.WM...WWW.
`
`' Bone effectsl -—
`
`Increased unbecular BMD distal femur Decreased conical BMD distal femur
`
`Reduced bone len ;
`Increased bone diameter
`
`
`
`51
`
`

`

`Shorter bone (both sexes), trabecular and conical BMD and area/thickness effect in different directions in m and f. Unclear effects on bone.
`
`
`
`
`
`—--In-
`
`
`
`
`__—m-
`Not recovered: (males) liver, lung; gonads, brain; (females) lung, adrenal, brain
`
`_-—-
`m—
`
`-
`
`Gross pathology: stomach, area depressed: m 0-0-0-1; f 0-1-1—3
`
`
`_
`
`
`
`
`Eye, lenticular degeneration (clusters of
`swollen/vacuolated/mptured/liquefied, i.e., abnormal
`
`
`
`fibers in anterior cortex of lens
`» Kidney, mineralization, pelvis diverticulum (clusters
`ofcrystalloid material, free or beneath pelvis
`
`epithelium or in lumen of distal collecting tubules,
`
`sometimes with thickenin_ of - 1vis e-ithelium
`
`Cecum, hyperplasia, mucosa] (increased cellular
`basophilia and mitotic figures, goblet cell loss,
`
`inflammato
`cell increase
`
`—
`
`Heart, degeneration and/or necrosis, myocardial
`
`
`(small collections of mononuclear cells in left
`»
`
`
`
`
`ventricle and ventricular papillary muscle, sometimes
`
`
`
`associated with fibrosis and/or degenerated and/or
`'
`necrotic m ocardial fibers
`
`
`Lun alveolarhistioc sis
`_ _
`_Im_
`Th
`us 1 mu-hoidatroh —
`_nm—
`“_—
`_—
`lncidence out of
`Incidence out of
`
`
`
`
`52
`
`
`
`——
`
`
`
`Im—
`
`—__—_
`
`Lun, histioc tosis
`,
`Th mus,l mhoid atro-h
`
`
`Histo - atholo,
`
`TREATMENT PERIOD
`
`Incidence out of
`15,15,15,15
`
`Incidence out of
`15,15,15,15
`
`-
`
`,
`
`Slight to mild
`
`

`

`0
`
`Eye and kidney findings were not reversed. The lens finding was probably related to hypocalcernia (ref) and
`an irreversible efi‘ect. The kidney finding of mineralization (material in lumen) and associated epithelial
`'changes may have been related to serum calcium and phosphate changes (CaxP product increased) or
`increased urine calcium concentration, more likely the latter since Ca (urine) in m and f correlated to
`microscopic change. It is unclear why this was not reversed.
`‘
`0 Myocardial degeneration and/or necrosis (reversible) finding was interpreted by study pathologist as a
`background change (i.e., spontaneous cardiomyopathy) although dose-related increase in incidence in
`females was recognized. The cause of this finding was unclear, but the incidence suggests it was drug-
`related.
`‘
`'
`‘
`'
`
`0
`
`Cecurn finding of hyperplasia/inflammation was observed only in treated animals and was dose-related in
`females. The effect was reversible. Effect appeared to be drug-related.
`
`Toxicokinetics -
`
`Analysis of parent drug AMG-073 (males and female average)
`
`Day 1
`
`
`
`PlasmaAMG099073(rig/ml)
`
`
`
` Mean
`
`Nd not determined
`
`Na not applicablel
`
`
`‘Rat TK data (males and females searate
`
`53
`
`

`

`
`
`‘ectimated
`
`I
`
`Metabolites were not measured in this study. Metabolite AMGIOZ664 (M7) was measured in the carcinogenicity study. Exposure(AUC,
`ngxh/mL) to M7 was on average 50 times higher than to parent drug.
`
`TK conclusions
`
`~
`
`0
`0
`
`AUC was linear with dose in m and f over dose range of 5-100 mg/kg/day. Cmax was less than proportional. This suggests decreased
`rate of absorption at higher doses
`Cmax, AUC (l) > Cmax, AUC (m) at 100 mkd (Wks 13, 26, but not Day l)~
`Accumulation varied from 2.5—3.5 (AUC Day lBO/AUC Day 1)
`
`Summary and evaluation —
`
`Effects of AMG-073 in a 6-month toxici
`
`stud in albino rats
`
`
`
`
`
`
`
`_ TREATMENT
`—
`Signs
`
`-
`
`
`
`
`
`_
`
`'
`
`_— RECOVERY PERIOD
`Im_——
`Abnormal breathing, dehydration, salivation, MD, HD
`Abnormal breathing in HD m
`broken teeth, thin, fur staining, fur wet, fur
`and f
`thin
`
`Body weight
`
`BW and BW gain reduced
`
`—
`,HD“
`
`FC reduced
`
`HD —20%
`
`D
`H -20%
`
`BW gains similar in HD and
`controls
`FC in HD similar as in controls
`
`Ocular effects
`
`Early cataract formation
`(small, multi-focal opacities in anterior
`cortex, similar in Wks 13, 26, 3]
`
`——_
`HD (all)
`HD (all)
`Effect persistent
`
`;
`
`.
`
`‘
`
`
`—
`
`Clinical chem) .
`Wk27
`
`Hematolo
`‘-
`— PTT elevated
`-
`Cincrease neutrohils
`
`PT elevated
`
`a total or ionized decrease
`increase
`K decrease
`reatinine increase
`
`00
`ALT Alk Phos increases
`
`LD, MD“ HD“
`LD“ MD‘, HD‘
`MD, HD‘
`
`LD,MD*,HD‘
`
`—
`
`Albumin decrease (slight), beta and. gamma-
`r
`-lobulin increase sli _ht-moderate
`— Glucose decrease
`’
`"
`Sliht decreases in: Cl, K, increase in Na
`
`
`
`
`
`
`
`
`
`
`ll
`A .arameters recovered
`
`Recovered in m f
`Recovered in m
`Partial]
`recovered
`
`2.5 3 2
`N
`ecovered in m
`ecovered in m
`
`Recovered in m
`_
`
`_
`
`—
`Normalized in m,f
`Normalized in m, reversed in f
`
`
`
`
`Endocrinolo 3
`
`Serum PTH decrease uredose
`
`LD, MD HD
`
`LD,MD,HD '
`
`Increase in urinary Ca content (up to 3-5x)
`
`LD’, MD“, HD“
`
`MD‘, HD‘
`
`— Decrease in urine Na, K down to 0.5x
`—
`
`Unremarkable
`
`MD, HD“
`
`MD, HD“
`
`
`
`
`
`
`
`
`
`54
`
`
`
`
`_O
`
`rgan weight
`change .
`
`Absolute organ weight decreases (liver,
`spleen, heart, lungs, kidney, gonads, brain,
`thyroids, adrenals, thymus)
`Relative-to-body organ weight increases
`(liver, lun adrenal, brain
`‘statistically significant effects
`
`.
`
`
`
`

`

`
`
`Human Cmax (175 mg dose) =' V AUC == 648 ng.h/ml (median, Study 20000187, 7-day dosing, renal impaired patients)
`
`NOTE: The multiples of the human plasma levels were calculated on the basis ofparent drug The parent drug
`constitutes <1% of the circulating compound~related material, and the remainder1s metabolites.
`The effect on (ionized) calcium (transient or persistent decrease)IS related to the expected effect of the drug to
`' suppress PTH secretion from the parathyroid. PTH increases tubular reabsorption of calcium in the distal
`convoluted tubule and low levels cause reduced calcium reabsorption with increased urinary levels. An increase
`in calcitonin release from thyroid C—cells may also have contributed to hypocalcemia due to a suppression of
`osteoclastic calcium reso1ption. The effect on phosphorus is probably due to an increase of P reabsorption due to
`low PTH levels, since PTH normally suppresses this reabsorption in the proximal tubule.
`
`The hypocalcemia probably caused the clinical signs of salivation and abnormal breathing through effects on
`CNS or smooth muscle function. Hyperphosphatemia is generally thought to have no significant effects.
`
`The cataracts were probably caused by hypocalcemia as described for rodents
`
`Clotting parameters (PT, APTI) may have been elevated due to decrease in serum calcium and inhibition of
`calcium-dependent clotting factors
`
`Cause and significance of other hematology findings (WBC increase), and clinical chemistry changes (CK
`decrease, ALT and ALP increase, serum protein changes) is unclear
`
`Effects on BUN and creatinine may have been related to kidney mineralization and urinary tract obstruction, or
`dehydration.
`
`The effect on serum glucose (decrease) at the high dose may be related to an inhibition by AMG-O73 of the
`KATP channel (ATP-sensitive potassium channel) in pancreatic beta-cells. This channel is instrumental in the
`‘ stimulation of insulin release from B-cells, and blockers of this channel can cause hypoglycemia.
`
`‘ The urine changes (increased Ca, decreased Na, K) were due to the effect of decreased PTH on tubular calcium
`reabsorption, and possibly direct effects of AMG-O73 on Na and K excretion/reabsorption.
`
`At the HD femoral length was reduced in both sexes, possibly secondary to FC and BW effects. At the MD
`' (females) and at the HD (both sexes), total bone area, cortical bone area and thickness, and endocortical
`circumference were slightly increased1n distal femur metaphysis and mid femur diaphysis. There were no clear
`BMD effects Thus, at 100 mg/kg/day, bone was shorter and had a slightly thicker cortex. Effects were not
`reversed in '4 weeks. The effect on bone (BMD and size) was probably the combined result of the reduction in
`serum PTH, increase in calcitonin, and other potential effects of AMG-073 on bone, including direct effects on
`bone cells
`
`,
`
`‘
`
`.,~ ..
`
`The effect on serum P (increase) is due to increased renal reabsorption.
`
`The changes in absolute and relative organ weight were probably due to decreases in body weight.
`
`The toxicological relevance of the cecum hyperplasia and cardiac findings is unclear.
`
`In conclusion, the main potential target organs for toxicity of AMG—O73 appear to be:
`Eye, kidney, liver, pancreas, bone, heart
`
`Similar results from 3—month rodent dietary toxicig studies
`
`55
`
`

`

`Decreased body weight gain (rat, mouse)
`Serum Ca decrease, P increase (rat, mouse)
`Kidney weight decrease (rat)
`Kidney pelvicdilation (rat, mouse)
`Kidney transitional cell hyperplasia (male rat)
`
`Histoatholo_1nvento
`S . nsor Stud # 100020
`
`
`
`Species: Monkey
`
`Pathology
`
`
`
`
`
`
`
`
`
`
`
`
`
`Organ
`
`wei_ t
`X
`xt
`_—
`_—
`_—
`_—
`_—
`mam—_—
`
`> w
`
`Bone Marrow smear (sternum)
`
`
`
`
`
`
`
`
`
`
`
`__—
`__—
`\ m——
`
`__—
`__—
`__—
`__—
`__—
`__—
`__—
`__—
`l_——
`__—
`M—
`-__—
`__—Liver .
`
`
`
`__—
`__—
`__—
`m———
`__—
`__—
`~ u——
`
`
`
`, __—
`Parath
`id
`_—
`__—
`__-
`MERE—_—
`
`__—
`__—
`__—
`__—
`__—
`__-
`S-inalcord
`_—
`__—
`
`__—
`
`
`

`

`
`
`
`
`
`, _—————
`
`‘ }
`
`
`
`
`
`vawmd
`i' organ weight obtained
`
`_—
`
`
`
`ES_——
`_-—
`———
`——— .
`_——
`—_—
`nu bladder
`_—
`
`
`
`'
`
`57
`
`

`

`THREE-MONTH ORAL TOXICITY STUDY WITH AMG 099073—01 IN CYNOMOLGUS MONKEYS ‘
`WITH A 2-WEEK RECOVERY PERIOD
`Sponsor Study Nr. 100020
`Performing Laboratory:
`Laboratory study identification:
`Study period January-June 1998
`
`GLP and QA statements included, not signed.
`Lot Nr. 709001
`
`
`
`
`Study Nr. 6271-165
`
`Purity: Assumed to be 100%
`Assay of test compound (in vehicle-prepared dosing solution): HPLC
`Vehicle/control: 0.5% methylcellulose1n distilled water.
`METHODS
`stock colony, age at start
`Cynomolgus monkeys (Macacafascicularis) (4 or 6/sex/dose group) from
`3-6 years, body weight range 23-2.7 kg (m), 20-32 kg (1), were dosed orally, by nasal gastric intubation, with
`0, 5, 50, 100, 150/100 (Dayl-15)/(Day 16«end) mg/kg/day, for at least 13 weeks (5 ml/kg/day). Groups 1-4
`received dose once daily. Group _5 was dosed bid with 2x75mg/kg/day on Days 1-15, and dosed bid with
`2x50mg/kgiday from Day 16 through termination. Each dose was flushed with 5 ml tap water. Food consumption
`and feeding schedule were not given. In Group 1 and Group 4, 2 recovery animals were taken off treatment at ca.
`13 weeks, and continued in study for 2 weeks.
`
`
`
`
`
`Observation times:
`
`Clinical signs
`Body weights
`Food consumption
`Ophthalmoscopy
`fl
`Hematology
`Clinical chemistry
`Pl};
`Ionized Ca
`Urinalysis
`Gross pathology b
`Or ans wei
`ed
`Histopathology
`Toxicokinetics
`
`‘
`
`|
`
`RESULTS
`
`Clinical signs
`No deaths
`
`Twice daily
`Day 1, then weekly
`.
`Not recorded
`Predosing, and pn'or to necropsy
`Predosing, and prior to necropsy
`Weeks -2, 5, 8, 12, 15
`Weeks -2, 5, 8, 12, 15
`Day 1, and Weeks 4, 8, 12. Samples predose and 2h postdose
`Assayed in samples for toxicokinetic analysis
`,
`Weeks 2, 5, 8, 12, 15
`,
`At sacrifice (see Histopathology Inventory1n Appendix I)
`Listed1n histopathologyinventory (Appendix I)
`At sacrifice (see Appendix I)
`Day 1 and end of Weeks 4, 12: (A) Groups l-4rprior to dose,,
`0.5,1,2,4,8,12,24h postdose; (B) Group 5: prior to dose, 0.5,l,2,4,6h
`post dose (2x/day). Samples used for assay of drug and ionized Ca.
`
`1
`
`«
`
`On Day 16, HD2 was reduced from 75 mg/kg twice daily to 50 mg/kg twice daily based on emesis, poor
`appetite, soft feces (HDl was given 100 mg/kg daily).
`
`~
`»
`
`~
`
`-' ~~ .
`,
`-
`
`1
`
`~
`
`58‘
`
`

`

`V
`Signs
`-poor to fair appetite in most or all MD,HD,,I-ID2 m,f
`-emesis in 1 to 4 MD,HD.,HD2 m,f
`-soft/liquid feces in 1 to 4 LD, MD, l-II).,HD2 m, and in 1 to 3 MD, HD.,HD2 f
`-excessive salivation (particularly during and post dosing) in 2 to 5 MD,HD1,HDZ m,f
`-all signs reversible
`
`Body weights
`Wk 1-2: Weight loss Or reduced weight gain in HD.;
`Wkl-l3, and Wk 14-16: See Tables
`
`Bu wei tdata
`
`
`
`Weekl3
`
`m 3
`2
`
`
`
`_
`m - -
`_ -
`‘
`
`‘statistically significantly different from control
`
`Bod wei t _ain data
`
`
`
`
`
`
`
`m
`__-- -
`. m——— l!-
`
`_IZ-m— Ill-
`
`-a-n-—— —
`
`mm— _
`——-
`-
`‘statistically significantly different from control
`
`Food consumption
`' No data
`
`0 hthalmosco
`
`No test article related‘findings
`
`
`EKG
`
`Prolonged QT intervals in HD, m,f and HD2 m,f (probably due to hypocalcemia)
`.rolon ation in Week 13
`_
`
`N/sex
`
`V
`
`incidence of animals with increased QT interval (>20
`msec above upper range of QT interval normal for
`articularHeart Rate
`'
`Interval
`
`
`
`—_— ,
`
`-
`
`I T interval
`
`Dose group
`
`
`
`
`
`
`Oral-2 D __
`W__
`mum—l-
`_—_l-
`“mm—I-
`
`
`___
`Determined: Heart rate, Heart rhythm, P-QRS-T complexes and intervals, Mean electrical axis
`
`Subsequently, Sponsor performed a statistical analysis of QT data and established a correlation between serum
`Ca levels and QTc (rr —0.7)
`‘
`
`
`
`

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`n:
`
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`‘ statistically significantly different from control
`“ extremely high WBC and Monocyte counts in 1 out of the 4 HD; females
`
`' No changes in MCV, MCH, MCHC, platelet count, reticulocyte count, neutrophil, lymphocyte counts.
`
`Summary Results Hematology (Week 12)
`
`t72743J56597
`
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`
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`Week
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`
`“ statistically significantly different from control
`
`Reversibility of hematology effects
`control and HD., 2 animals/- on 2 week recovery):
`
`Clinical'chemis
`
`Serum chemi
`
`- data
`
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`No significant effects on: urea, ALK P, creatinine, total protein, total bilirubin, GGT, serum
`' electrolytes, glucose.
`,
`.
`.
`Reversibility: All parameters affected were reversed, except cholesterol which was still lower
`after 2 w‘eeks‘rec‘o'very.
`
`ewnwwamm-Mu-m
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`SerumPTH
`- No conclusive data obtained (serum levels below LLQ)
`
`mum
`Decrease in serum ionized Ca:
`LD (m,f) groups:
`Day I: from 2-4h to 8-12h postdosing
`Week 4: fiom 0.5-2h to 8-12h postdosing
`Week 12: from 2-4h to 8h postdosing
`MD,HD (m,f) groups:
`Day 1: from 2h to 24h postdosing
`Week 4: at all time points (pre and postdosing)
`Week 12: at all time points (pre and postdosing)
`
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`
`Serum pH:
`Increase in serum pH in MD,HD (In only) groups:
`Day ,1: at 4h postdosing
`Weeks 4, 12: no effects
`
`,
`,
`V
`Urinalysis
`No treatment related findings
`
`Gross pathology
`
`
`
`62
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`Organ weight (Organ list: see Appendix)
`
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`ficant changes
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`
`Kidney
`
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`
`Testis
`
`prdidymis
`
`Liver/gallbladde
`
`Spleen
`
`Thyroid/parathy
`roid
`ly s:w
`*Bolded arrows represent statisu
`related
`dose-
`DR7
`' Odd result (pituitary)
`
`Histopathologx (Organ list: see Appendix)
`
`Histoatholo; data
`
`- MALES
`
`Terminal Sacrifice
`
`.
`
`_
`
`Macro-hm intimate
`Polykaryocytosis,
`, “
`-
`urothelium, clvis
`_ Tubule I”mention
`De ' enemtion -
`Skeletal muscle
`Liver
`Necrosis
`nvolution
`Thus
`on estion
`vemle
`
`Kidney
`
`Testis
`
`Recovery Sacnfce
`
`control
`
`Kidne
`Skeletal muscle
`
`Tubule reeneration
`De - eneralion
`
`
`
`
`
`
`
`

`

`Other findings:
`One MD male had pneumonia, diagnosed as tuberculosis.
`Parasitic lesions were seen in multiple animals, usually in one animal/sex of one or two dose groups (including
`controls). Parasites were present in stomach, intestine, esophagus, lung, skeletal muscle and tongue.
`In multiple tissues, lymphohistiocytic infiltrates were observed (liver, kidney, tongue, trachea, urethra, vagina).
`Treatment-relatedness, mechanism and relevance of this effect were inconsistent and/or unclear.
`
`Toxicokinetics
`Determined:
`
`Cmax, Tmax, AUC (0-24h), CL/F, Tl/2
`-
`0 Day 1, 27, 83
`
`Toxicokinetic data avera e values
`_—
`_ IIl__—IIJ_
`_-
`— ——-—
`mm
`_-
`__—
`—IEII
`_-
`
`r l
`
`4
`
`
`
`
`
`
`
`iii/WW
` LJ
`
`
`
`
`
`
`
`—_—_—_—
`mun—“l—
`___———
`——-____
`Ml—
`_--—__
`——_——__
`_—-————
`ru‘h/ml
`—_—————
`_——_——_
`_M
`—_-—_Im__
`—_-H-———
`——___——
`”HEM—__—
`C———-_—III-
`___-——Ii—
`——m——__
`—_— 134 __n-
`__-_Ii—lfi—I_
`——_————
`m-_m——_Ir_
`—————n5-_
`—_-—_—E_
`_—M-__
`_—__——l_
`_—--——I_
`* Values for Day I (AUC) may be underestimated (most values BLQ)
`“Nd = Not determined: T1/2 not determined for HD2 group (bid dosing schedule)
`
`Number of animals for which TK uarameters were deterrnined
`-W---
`——-—-—-——-
`m—m__-—l-_l-
`I-l-l-l-m-l-I-ml-
`n-m-II-l-l-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`

`

`_
`Summary toxicokinetics:
`Large variability in Cmax and AUC data, ie, inconsistent changes with dose and over time
`T1/2 varied from 5-10h
`Tmax varied from 2-15h
`
`Dosingbid. increased AUC as compared to dosing q.d. (compare BB] and HD2)
`Values suggest that AUC and Tm values in LD groups may be inaccurate and/or underestimated
`CL/F was not significantly related to dose
`Cmax and AUC non~linearly increased with dose, possibly due to relative decrease in absorption at higher
`doses
`'
`
`_
`
`0
`
`0
`
`0
`
`Sponsor concluded that AUC (f) < AUC (m). Although statistically CL/F was overall significantly higher in
`females than in males, examination of AUC values does not support consistent differences (cg AUC values
`on Day 83 are similar in HD males and HD females)
`'
`Sponsor concluded that CL/F (Day83)>CL/F(Day27). The increase in CL/F over time suggests induction of
`clearance (metabolism). Reviewer concurs with this conclusion.
`There was no evidence of accumulation of parent drug over time.
`
`SUMMARY AND EVALUATION
`Introduction:
`
`The pharmacologic action of the calcimimetic AMGO73 consists of a lowering of parathyroid gland PTH
`secretion and reduction of serum calcium levels. PTH levels are elevated in patients with hyperparathyroidism
`(HPT). In primary HPT this is due to excessive PTH secretion, and in secondary HPT it is usually due to renal
`failure with chronic hypocalcemia and an adaptive increase in PTH secretion. The compound AMG—073 is being
`developed for the treatment of primary and secondary HPT.
`
`.
`Summary:
`Effects of AMG~073 in a 3-month toxici
`
`stud in c
`
`omol- us monke s
`
`——m
`m_ SoMiuid feces
`LD, MD, HD
`LD, MD, HD
`_—__
`BW ain reduced
`LD, MD, HD*
`LD‘,MD‘,HD‘
`————
`Timerval rolon_ed I'll-III—
`_—_—
`Hb Hctdecrease.
`Im- LD W H)"
`—_—_
`_—_ MD.HD‘
`Monocyte/eosinophil“
`MD, HD"
`decrease
`‘
`
`
`
`__—_
`Clinical chemi
`-
`Total cholesteroldecreasc MM
`—__—
`__—IE—
`__ HDI HDZ‘ _ ...... w. - M, . - .
`— Ca total or ionized decrease
`LD,MD",HD*
`‘
`LD MD‘,HD’
`—_ LD,MD.HD*
`umm HD*
`——m_n_
`____
`"__Efl—IE—
`————
`m— HD1',HD2
`LD,MD,HD
`LD: MD, Hm: H132
`MD,HD1‘,HD2 _
`Hmaunz —
`lsdecrease
`-_ Eidid
`— Liver/ailbladderincrease NEE—IE—
`_ n r/Parath oid decrease
`MD,HD _
`_I——_
`—_—_
`Histopathology
`Kidney polykaryocytosis,
`elvic urothelium
`
`
`
`
`
`
`
`
`
`65
`
`

`

`K.,.,,,,:,.7.-ra-a~.~-,.-.p 4 ,-.n4...,-,...,
`
`u
`
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`—_ Lemma —
`‘statistically significant effects
`
`NOAEL 6 mg/kg/day
`LOAEL 5 mg/kg/day
`
`The effects first observed at the LOAEL (LD 5 mg/kg/day) were (in both sexes):
`Abnormal clinical signs (m,f)
`'
`Body weight gain reduction (bin) 1
`Hemoglobin and hematocrit decrease (f>m)
`Serum Ca decrease and P increase (m,f)
`Thymus weight decrease (m,f)
`Thymus involution (m)
`
`The effects first observed at the next higher dose (MD 50 mg/kg/day) were:
`WBC decrease (f>m)
`’
`Cholesterol decrease (m,f)
`Testis weight decrease (m)
`Liver/gallbladder weight increase (m>f)
`Thyroid/parathyroid weight decrease (m)
`Kidney pelvic polykaryocytosis (f>m)
`Spleen congestion (f)
`
`The effects first observed at the next higher dose (HD 100 mg/kg/day) were:
`Prolonged QT interval (f>m)
`PT increase (In)
`Triglyceride increase (m)
`ALT increase (f>m)
`Creatine kinase increase (m>f)
`Kidney weight increase (0
`Epididymis weigth decrease (In)
`.Spleen weight increase (0
`Thymus small (m,f)
`’
`Thymus involution (m)
`Liver necrosis (f)
`
`Safeg Evaluation:
`
`W4 .. we
`
`The currently reviewed study indicates that AMG-073, as expected, lowers serum calcium in healthy '
`normocalcemic animals. Although data on P’I‘H were not provided it is likely that this is the result of lowering
`_ PTH secretion by the parathyroid gland. The hypocalcemia was seen at all doses applied (5-50-100 mg/kg/day).
`
`" "
`
`'
`
`The hypocalcemia is expected to cause a number of secondary changes in clinical and histo—pathology. The
`findings of emesis, sofi feces, reduced body weight gain, extended PT time, and a prolonged cardiac QT interval,
`seen in this study, are probably (or at least partly) hypocalcemia—related.
`
`However, various other findings have an unclear relationship to the hypocalcemia. These include hematology
`findings, serum chemistry changes, gross pathology and histopathology changes and organ weight changes.
`
`The decrease in Hb and Hot values in males and females, and the reduced RBC in females was small but
`significant, and appeared not to be reversed afier 2 weeks. The WBC decrease which was more prominent in
`females appeared to be partially transient over time, and reversible upon recovery. The mechanism of these
`:hematology changes is unclear.
`'
`
`66
`
`

`

`,
`
`‘
`
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`
`The cholesterol decrease may have been related to some effect of the test compound on hepatic lipid
`metabolism, and the ALT increase in the HD groups suggests possrble liver cell injury. Cholesterol increase was
`partially and ALT increase was completely reversed in 2 weeks.
`
`The creatine kinase increase at high doses suggests muscle injury, and may be related to hypocalcemia.
`
`'
`
`The thymus involution in drug-treated males, and the incidence of small thymus and the (non dose-related) ,
`' thymus weight decrease in both sexes, particularly females, is unexplained. The (non-dose related)
`thyroid/parathyroid weight decrease in males may be a study artifact or may be related to the pharmacologic
`effect of the test compound to inhibit parathyroid PTH release. The kidney weight increase seen in high dose
`females is unexplained. The mechanism of the testicular and epididymal weight decrease in males is also unclear.
`
`Regarding the increased liver weight, particularly in males, the Sponsor has stated in a telephone conversation
`with this Reviewer (March 8, 1999) that the compound induces microsomal enzyme activity and that this is the
`underlying cause of the liver weight and serum enzyme increases. Reviewer feels that the toxicokinetic data on
`CL/F may support this conclusion.
`
`Histopathologically, there were findings in kidney, spleen and liver. Accompanying this were weight increases of
`all three organs in HD groups. The kidney findings included polykaryocytosis of pelvic urothelium in MD and
`HD males and females. The toxicological relevance of this finding and its relation to the increased kidney weight
`observed in females is unclear. Spleen congestion was seen in 1 MD and 2 HD females and its cause is unClear.
`Liver necrosis was observed in I out of 4 females monkeys in the HI); group. The relevance of this finding is
`unsettled. The animal with focal necrosis had slightly elevated ALT values. However, other animals e.g. in the
`HD, group had much higher ALT values while no observed liver histopathology abnormalities.
`
`Drug-related histopathology findings for testis/epididymis, or thyroid/parathyroid, i.e., organs whose weight was
`reduced by drug treatment, were not observed.
`
`In conclusion, the main potential target organs for toxicity of AMG-073 appear to be:
`kidney, spleen, liver, testis and epididymis, thymus, thyroid/parathyroid.
`'
`
`Comparison with results from rodent toxicity studies
`Findings from previously reported rat and mouse three-month toxicity studies with AMG—073 (Submission date:
`August 14, 1998, Review date: September 17,2998) that were similar to findingsin the 3-month monkey study
`were.
`
`Decreased body weight gain (rat, mouse)
`Serum Ca decrease, P increase (rat, mouse)
`Kidney pelvic dilation (rat, mouse)
`Kidney transitional cell hyperplasia (male rat)
`
`Other findingsin the rodent studies werenot seen or werenot consistentwith the present findingsin the monkey. ,
`Forexample, except for theanticipatedserum Ca and P changes, there were no significant hematology or serum ,
`-. chemistry findings, and Several organ weights, including liver and kidney,were decreased rather than increased.
`The species specificity of the test compound’s effects may be related to species:-specific drug metabolism
`
`,
`
`CONCLUSION
`
`In the currentstudy report, except for. the calcium lowering effect of the test compound, the Sponsor did either
`not comment on the apparently treatment-related effects, or stated that the effects were not considered
`toxicologically adverse, or that they were possibly due to nonspecific stress of test article administration.
`Reviewer feels there is no satisfactory explanation for the treatment-related findings in monkeys that were not
`clearly related to the hypocalcemic action of the drug, nor do we know their clinical relevance. These findings
`included Hb, Hct, RBC and WBC decreases, serum cholesterol decrease and ALT increase, testis and
`epididymes weight decrease, kidney weight increase, thymus weight decrease and involution, liver weight
`increase and necrosis, spleen weight increase and congestion.
`
`67
`
`....
`
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`
`

`

`
`
`Adrenals
`
`
`
`
`S . nsor Stud # 100020
`l l
`
`
`Species: Monkey
`Organ
`
`
`
`wei t
`
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`
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`Bone mrmow rib
`Bone femur
`one sternum
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`
`Epididymis
`suha_us
`
`Fallopian tube
`Gall bladder
`toss lesions
`Harder-inn gland
`
`Hyphophysis
`
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`Je'unum
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