Renalog/Renalog DS

Renalog: Yellow colored, capsule shaped, bi-convex film-coated tablet, plain on both sides.
Each film-coated tablet contains: Calcium-4-methyl-2-oxovalerate (α-ketoanalogue of leucine, calcium salt) 101 mg, Calcium-3-methyl-2-oxobutyrate (α-ketoanalogue of valine, calcium salt) 86 mg, Calcium-2-oxo-3-phenylpropionate (α-ketoanalogue of phenylalanine, calcium salt) 68 mg, Calcium-3-methyl-2-oxovalerate (α-ketoanalogue of isoleucine, calcium salt) 67 mg, Calcium-DL-2-hydroxy-4-(methylthio)-butyrate (α-hydroxyanalogue of methionine, calcium salt) 59 mg, L-Lysine Acetate 105 mg, L-Threonine 53 mg, L-Histidine 38 mg, L-Tyrosine 30 mg, L-Tryptophan 23 mg, Calcium content/tablet 1.25 mmol≅0.05 mg. Total nitrogen content 36 mg.
Colour: Lake of Quinoline yellow and Titanium Dioxide B.P.
Renalog DS: Yellow coloured, capsule shaped, bi-convex film-coated tablet, plain on both sides.
Each film-coated tablet contains: Calcium-4-methyl-2-oxovalerate (α-ketoanalogue of leucine, calcium salt) 202 mg, Calcium-3-methyl-2-oxobutyrate (α-ketoanalogue of valine, calcium salt) 172 mg, Calcium-2-oxo-3-phenylpropionate (α-ketoanalogue of phenylalanine, calcium salt) 136 mg, Calcium-3-methyl-2-oxovalerate (α-ketoanalogue of isoleucine, calcium salt) 134 mg, Calcium-DL-2-hydroxy-4-(methylthio)-butyrate (α-hydroxyanalogue of methionine, calcium salt) 118 mg, L-Lysine Acetate USP 210 mg, L-Threonine USP 106 mg, L-Histidine USP 76 mg, L-Tyrosine USP 60 mg, L-Tryptophan USP 46 mg, Calcium content/tablet 2.50 mmol≅0.10 mg. Total nitrogen content 72 mg.
Colours: Titanium Dioxide USP and Lake of Quinoline Yellow.

Pharmacotherapeutic group: Amino acids, including combinations with polypeptides. ATC code: V06DD.
Pharmacological classification: Renal Nutrition Therapy (Nutrition Therapy in Chronic Kidney Disease).
Introduction: Alpha Ketoanalogues + Essential Amino Acids (Renalog/Renalog DS) tablet is an oral nutritional formulation, which contains all essential nutritional salts, which help in reduction of Nitrogen supply and provide calcium, used in reduction of kidney disease. It contains all amino acids essential for uremic patients, five out of them are keto or hydroxyanalogue in the form of calcium salts. Therefore it allows reduction in the nitrogen supply and provides calcium. In combination with very low protein diet/low protein diet, it helps in delaying the progression of kidney disease.
Pharmacology: Alpha ketoanalogues of valine, leucine, isoleucine, methionine, phenylalanine, and (in one instance) tryptophan and histidine, along with the remaining essential amino acids, were administered orally to 10 patients with severe chronic uremia fed a diet low in protein but adequate in calories. Ketoacid dosage varied from 6 to 14 g daily, as sodium or calcium salts. Net nitrogen intake, calculated as intake minus urinary protein nitrogen, averaged 1.8 g/day. The urea space was either estimated or measured with ["4C] urea and daily changes in the body urea pool were calculated. Urea appearance was measured as the sum of urea excretion and the change in urea pool. If these ketoacids were converted to amino acids and utilized for protein synthesis, a fall in urea nitrogen appearance should occur. In five subjects, ketoacids were given for 15-18 days and then withdrawn. Urea nitrogen appearance increased 1.55 g/day on withdrawing ketoacids, and corrected nitrogen balance decreased by 1.73 g/day. In two other subjects ketoacid administration was followed, on two occasions each, by a period of administration of nine essential amino acids. In three of these four instances, urea appearance rose significantly with amino acids. In four patients studied at high blood urea levels, ketoacid treatment was relatively ineffective; two of these patients responded more favorably when studied again after peritoneal dialysis. One of these improved enough clinically to be managed as an outpatient for short intervals, despite virtual anuria. No accumulation of ketoacids in plasma or urine could be detected, and no toxicity was identified.
Alpha ketoanalogues of the essential amino acids might be useful in the treatment of uremia. This proposal was based on several earlier observations: (a) urea is continually degraded to ammonia and carbon dioxide by intestinal urease in normal subjects, as well as in patients with uremia; (b) uremic patients respond favorably to restriction of dietary protein; (c) urea or ammonia can be utilized for protein synthesis, particularly when dietary protein is restricted; and (d) alpha-ketoanalogues of most of the essential amino acids can promote growth in rats fed diets devoid of the corresponding amino acids. Thus, urea nitrogen might be reutilized for conversion of ketoacids to essential amino acids, lowering blood urea concentration and promoting protein synthesis simultaneously. Because of the scarcity of these ketoacids this proposal has not been tested, but it has been shown that two ketoacids, the analogues of valine and phenylalanine, can replace valine or phenylalanine in the diet of normal as well as uremic individuals, though not with complete efficiency. The present study was undertaken to evaluate the efficacy, safety, and feasibility of administering these ketoacids as supportive therapy in the management of severe chronic uremia. Seven potentially useful keto analogues are known, but because of difficulties in obtaining two of them, most of these studies were conducted using only five, the analogues of valine, leucine, isoleucine, methionine, and phenylalanine. Apparently, only two (the analogues of valine and phenylalanine) have previously been administered to human subjects.
Histidine is a heterocyclic amino acid which is essential for infant growth and which may be essential for some other groups, such as patients with uraemia. Histidine and histidine hydrochloride are used as dietary supplements.
Histidine, like glycine, is sometimes used in conjunction with antacid in the treatment of gastric hyperacidity. Threonine is an aliphatic amino acid which is an essential constituent of the diet. It is used as a dietary supplement. Threonine has been investigated for the treatment of various spastic disorders.
Tryptophan is an essential amino acid which has also been used in the management of depression. It has, however, been associated with an outbreak of the eosinophilia-myalgia syndrome. Essential constituent of the diet, Tryptophan and DL-tryptophan have been used as dietary supplements. Tryptophan is readily absorbed from the gastro-intestinal tract. Tryptophan is extensively bound to plasma albumin. It is metabolized in the liver by tryptophan pyrrolase. Metabolites include hydroxytryptophan, which is then converted to serotonin, and kynurenine derivatives. Some tryptophan is converted to nicotinic acid and nicotinamide. Pyridoxine and ascorbic acid are cofactors in the decarboxylation and hydroxylation respectively of tryptophan; pyridoxine apparently prevents the accumulation of the kynurenine metabolites.
Renalog DS: Pharmacodynamics: Following absorption, the keto and hydroxy-analogues are transaminated to the corresponding essential amino acids by taking nitrogen from non-essential amino acids, thereby decreasing the formation of urea by re-using the amino group. Hence, the accumulation of uraemic toxins is reduced. Keto and hydroxy acids do not induce hyperfiltration of the residual nephrons. Ketoacid containing supplements exert a positive effect on renal hyperphosphataemia and secondary hyperparathyroidism. Moreover, renal osteodystrophy may be improved. The use of Alpha Ketoanalogues + Essential Amino Acids (Renalog DS) in combination with a very low protein diet allows to reduce nitrogen intake while preventing the deleterious consequences of inadequate dietary protein intake and malnutrition.
Pharmacokinetics: The plasma kinetics of amino acids and their integration in the metabolic pathways are well established. It should nevertheless be noted that in uraemic patients, the cause of the changed plasma levels, which occur frequently in these patients, does not seem to be the absorption of the supplied amino acids, i.e. the absorption itself is not disturbed. The change plasma levels seem to be due to impaired post-absorptive kinetics, which can be detected in a very early stage of the disease.
In healthy individuals, the plasma levels of ketoacids increase within 10 min after oral administration. Increases of up to the 5-fold baseline levels are achieved. Peak levels occur within 20-60 min, and after 90 min levels stabilise in the range of the base levels. Gastrointestinal absorption is thus very rapid. The simultaneous increases in the levels of the ketoacids and the corresponding amino acids show that the ketoacids are transaminated very rapidly. Due to the physiological utilisation pathways of ketoacids in the body it is likely that exogenously supplied ketoacids are very rapidly integrated into the metabolic cycles. Ketoacids follow the same catabolic pathways as classical amino acids. No specific study on ketoacid excretion has been performed to date.

Prevention and therapy of damages due to faulty or deficient protein metabolism in chronic renal insufficiency in connection with limited protein in food 40 g per day (for adults) and less i.e. generally in patients with glomerular filtration rate (GFR) below 25 mL/min or between 5 and about 15 mL/min.

Renalog: Dosage: In general, unless prescribed otherwise, four to eight tablets are swallowed whole three times a day during meals. This dosage applies to adults (70 kg bodyweight) (1 tablet/5 kg body weight/day).
Duration of Treatment: Formulation/tablets are given as long as the glomerular filtration rate is between 5 and about 15 mL/min. Simultaneously, food should contain 40 g/day protein or less in adults.
Administration: It should be taken with food (swallow whole, do not chew/crush).
Renalog DS: Dosage: In general, unless prescribed otherwise, two to four tablets are swallowed whole three times a day during meals. This dosage applies to adults (70 kg bodyweight) (1 tablet/10 kg body weight/day).
Duration of Treatment: Alpha Ketoanalogues + Essential Amino Acids (Renalog DS) tablets are given as long as the glomerular filtration rate is between 5 and about 15 mL/min. Simultaneously, food should contain 40 g/day protein or less in adults.
Route of Administration: Oral, it should be taken with food (swallow whole, do not chew/crush).

Renalog DS: No case of overdose has been reported.

Hypercalcaemia, disturbed amino acid metabolism. In case of hereditary phenylketonuria, it has to be taken into account that this product contains phenylalanine.

No experience has been made so far with the application in pediatrics. Alpha Ketoanalogues + Essential Amino Acids (Renalog/Renalog DS) tablet should be taken during meals to allow proper absorption and metabolism into the corresponding amino acids. The serum calcium levels should be monitored regularly. Ensure sufficient calorie intake.

Renalog: No experience has been made so far with the application in pregnancy.
Renalog DS: There are no adequate data from the use of Alpha Ketoanalogues + Essential Amino Acids (Renalog DS) in pregnant women.
Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development.
Caution should be exercised when prescribing to pregnant women.
No experience has been made so far with use during lactation.

Renalog: Hypercalcaemia may develop. In this case, it is recommended to decrease vitamin D intake. If the hypercalcaemia persists, reduce the dosage of formulation as well as any other source of calcium.
Renalog DS: Metabolism and nutrition disorders: Very rare: Hypercalcaemia.
If hypercalcaemia occurs, the intake of vitamin D should be reduced. In case of persisting hypercalcaemia, the dose of the product as well as the intake of any other calcium sources has to be reduced.

Simultaneous administration of medicinal products that contain calcium (e.g. acetolyte) may trigger, or worsen, a pathological increase in the serum calcium level. As the uremic symptoms improve under therapy with formulation/tablets, the dose of aluminum hydroxide administered should be reduced, as appropriate. The patient should be monitored for reduced levels of serum phosphate. In order not to interfere with absorption, an appropriate interval should be observed between administration of formulation/tablets and medicinal products which form poorly soluble compounds with calcium (e.g. tetracylines, quinolones such as ciprofloxacin and norfloxacin, preparations that contains iron, fluoride and estramustin). An interval of at least 2 hours should be observed between the intake of formulation/tablets and such preparations. If administration of formulation/tablets leads to increased blood levels of calcium, the sensitivity to medicinal products which increase heart action (cardiac glycosides) and thus also the risk of cardiac arrhythmia is increased.

Store at temperatures not exceeding 30°C.
Keep in a cool and dry place.
Shelf-Life: 36 months.

Other Drugs Acting on the Genito-Urinary System

A16AA - Amino acids and derivatives ; Used in treatment of alimentary tract and metabolism problems.

Rx