Introduction
Efficacy of HIF-PHIs
Opinion of the group
Author (year)ref | Study type | Studies/ Patients | HIF-PHI | Control | Setting | Hb change (ΔHb) or Hb target achievement [95%CI] | Iron parameters (mean [95% CI]) | Adverse outcomes (RR [95% CI]) |
---|---|---|---|---|---|---|---|---|
Takkavatakarn (2023)6 | Phase 2 Phase 3 Not published | 46/29,855 | Daprodustat Desidustat Enarodustat Molidustat Roxadustat Vadadustat | Placebo, ESA | NDD-CKD DD-CKD | Mean ΔHb (g/dL) vs control (placebo + ESAs) 0.66 [0.50–0.82] | Hepcidin (ng/mL) – 29 (– 34; – 24) Iron (µg/dL) 2.2 (– 0.4;4.7) TIBC (µg/dL) 44 (39;49) TSAT (%) – 0.3 (– 3.7; – 2.3) Ferritin (ng/mL) – 43 (– 57; – 29) | HIF-PHIs vs control (placebo + ESAs) MI 0.99 [0.87–1.14] Stroke: 0.97 [0.77–1.23] MACE: 1.00 [0.94–1.07] Thrombosis: 1.26 [1.00–1.57] Hypertension: 0.99 [0.91–1.09] Hyperkalemia: 0.99 [0.88–1.11] ESKD: 1.06 [0.95–1.09] Death: 0.91 [0.78–1.07] |
Minutolo (2023)7 | Phase 3 | 26/24,387 | Daprodustat Desidustat Enarodustat Molidustat Roxadustat Vadadustat | ESA | NDD-CKD DD-CKD | Mean ΔHb (g/dL) vs ESAs 0.10 [0.02–0.17] Achievement of Hb target vs ESAs OR 1.04 [0.88–1.22] | Hepcidin (ng/mL) – 19 (– 29; – 10) Iron (µg/dL) 10 (6;14) TIBC (µmol/L) 36 (32; 41) TSAT (%) 0.3 (– 1.7; 1.0) Ferritin (ng/mL) – 17 (– 32; – 1) | Cancer: 0.93 [0.76–1.13] MACE: 1.00 [0.94–1.07] MACE + : 1.01 [0.95–1.06] Thrombosis: 1.08 [0.84–1.38] AVF thrombosis: 1.02 [0.93–1.13] Death: 1.02 [0.95–1.13] |
Chen J (2023)8 | Phase 2 Phase 3 | 26/15,020 | Daprodustat Enarodustat Molidustat Roxadustat Vadadustat | Placebo, ESA | NDD-CKD DD-CKD | Mean ΔHb (g/dL) vs ESAs - Daprodustat – 0.14 [-0.45–0.16] - Enarodustat 0.24 [– 0.28 to 0.76] - Molidustat – 0.05 [– 0.45 to 0.34] - Roxadustat 0.32 [0.10–0.53] - Vadadustat – 0.07 [– 0.43 to 0.29] | HIF-PHI vs ESA Daprodustat ↓ hepcidin TSAT and ferritin ↑ TIBC Enarodustat ↓ hepcidin ↑ TIBC Molidustat No change Roxadustat ↓ hepcidin and ferritin ↑ TIBC Vadadustat ↓ hepcidin ↑ TIBC | HIF-PHI vs ESA Hypertension - Vadadustat 0.74 [0.60–0.91] - No difference for other HIF-PHIs Thrombosis - Daprodustat 2.52 [1.28–4.94] - Roxadustat 1.61 [1.22–2.12] - No difference for other HIF-PHIs |
Chen H (2021)9 | Phase 2 Phase 3 | 30/13,146 | Daprodustat Desidustat Enarodustat Molidustat Roxadustat Vadadustat | Placebo, ESA | NDD-CKD DD-CKD | WMD Hb vs ESA 0.13 [0.03–0.22] | Hepcidin (SMD) – 12 (– 23; – 1) Iron (SMD) 0.2 (0.1; 0.4) TIBC (SMD) 0.7 (0.5; 1.0) TSAT (WMD) 0.8 (– 0.02;1.5) Ferritin (SMD) – 0.1 (– 0.2; – 0.0) | HIF-PHIs vs ESA MACE: 1.02 [0.90–1.14] Heart failure: 0.95 [0.72–1.26] Hypertension: 1.02 [0.89–1.17] Hyperkalemia: 1.14 [0.69–1.89] Thrombosis: 1.31 [1.05–1.63] |
Zheng (2020)10 | Phase 2 Phase 3 | 19/2,768 | Daprodustat Desidustat Enarodustat Molidustat Roxadustat Vadadustat | Placebo, ESA | NDD-CKD | Mean ΔHb (g/dL) vs placebo - Desidustat 2.46 [0.93–3.99] - Enarodustat 1.81 [0.87–2.75] - Molidustat 1.68 [0.64–2.72] - Roxadustat 1.61 [0.99–2.22] - Daprodustat 1.55 [0.74–2.36] | NA | HIF-PHI vs placebo Death: No difference |
Chen D (2023)11 | Phase 3 | 19/14,947 | Daprodustat Desidustat Enarodustat Molidustat Roxadustat Vadadustat | ESA | DD-CKD | Mean ΔHb (g/dL) vs ESAs - Daprodustat 0.04 [– 0.11; 0.19] - Desidustat 0.14 [– 0.24; 0.52] - Enarodustat 0.06 [– 0.28; 0.40] - Molidustat – 0.30 [– 0.02; 0.61] - Roxadustat 0.19 [0.07; 0.30] - Vadadustat – 0.11 [– 0.07; 0.30] | HIF-PHI vs ESA Roxadustat ↓ hepcidin Vadadustat ↓ TSAT | HIF-PHI vs ESA CV events: No difference Hypertension - Vadadustat 0.81 [0.68–0.97] - No difference for other HIF-PHIs Hyperkalemia: No difference Cancer: No difference AVF complications - Roxadustat 1.15 [1.04–1.27] - No difference for other HIF-PHIs Gastrointestinal disorders - Enarodustat 6.92 [1.51–31.69] - No difference for other HIF-PHIs |
Natale (2022)12 | Phase 2 Phase 3 | 51/30,994 | Daprodustat Desidustat Enarodustat Molidustat Roxadustat Vadadustat | Placebo, ESA | NDD-CKD DD-CKD | Achievement of Hb target vs ESAs RR 1.00 [0.93–1.07] | NA | HIF-PHIs vs ESA CV death: 1.05 [0.88–1.26] MI: 0.91 [0.73–1.10] Stroke: 1.06 [0.71–1.56] Thrombosis: 1.09 [0.86–1.39] Hyperkalemia: 0.92 [0.82–1.04] Cancer: 0.83 [0.43–1.59] Kidney failure: 1.02 [0.91–1.15] Death: 0.98 [0.91–1.06] |
Zheng (2023)13 | Phase 2 Phase 3 | 23/15,144 | Daprodustat Desidustat Enarodustat Molidustat Roxadustat Vadadustat | Placebo, ESA | NDD-CKD DD-CKD | NA | NA | HIF-PHIs vs ESA Cardiac AEs: 1.06 [0.98–1.14] Hypertension: 0.89 [0.81–0.98] Hyperkalemia: 0.92 [0.81–1.04] ESKD: 0.99 [0.91–1.08] Death: 1.01 [0.91–1.12] |
Abdelazeem (2021)14 | Phase 2 Phase 3 | 10/5,768 | Roxadustat | Placebo, ESA | DD-CKD | SMD Hb vs control (placebo + ESAs) 0.21 [0.02–0.39] | Hepcidin (SMD) – 16 (– 28;-3) Iron (SMD) 0.3 (0.2; 0.4) TIBC (SMD) 0.8 (0.6; 1.0) TSAT (WMD) 0.04 (– 0.04; 0.11) Ferritin (SMD) – 0.1 (– 0.2; 0.1) | HIF-PHI vs control (placebo + ESA) CV adverse event: 1.03 [0.95–1.11] Hypertension: 1.04 [0.90–1.19] Hyperkalemia: 1.07 [0.85–1.35] |
Side effects of HIF-PHIs
Opinion of the group
Meta-analyses on the efficacy and safety of HIF-PHIs
Opinion of the group
Effect of HIF-PHIs on health-related quality of life (HRQoL)
Opinion of the group
Differences among HIF-PHIs
Opinion of the group
Compound | Half-Life (hours) healthy/CKD | Starting dose | Dosing Schedule | Activity on PHD isoforms | Countries with marketing authorization (setting) |
---|---|---|---|---|---|
Daprodustat | ~ 1/7 | 1–4 mg (ND) 4–12 mg (DD) | QD | PHD3 > PHD1 > PHD2 | Japan (NDD-CKD, DD-CKD) EU (DD-CKD) US (DD-CKD) |
Desidustat | 7–11.4/- | 100 mg | TIW | – | India (NDD-CKD, DD-CKD) |
Enarodustat | 9.0–11.3/14.8–15.9 | 2 mg (ND,PD) 4 mg (HD) | QD | PHD1 > PHD2 > PHD3 | Japan (NDD-CKD, DD-CKD) |
Molidustat | 4–10/- | 75 mg | QD | PHD3 > PHD1/PHD2 | Japan (NDD-CKD, DD) |
Roxadustat | 16.0/16.8–18.5 | 70 mg (if b.w. < 100 kg) 100 mg (if b.w. ≥ 100 kg) | TIW | PHD1 = PHD2 = PHD3 | China (NDD-CKD, DD-CKD) Japan (NDD-CKD, DD-CKD) Chile (NDD-CKD, DD-CKD) EU (NDD-CKD, DD-CKD) South Africa (NDD-CKD, DD) Russia (NDD-CKD, DD-CKD) South Korea (NDD-CKD, DD-CKD) Turkey (NDD-CKD, DD-CKD) Middle East (NDD-CKD, DD-CKD) |
Vadadustat | 4.7/7.9–9.1 | 300 mg | QD | PHD3 > PHD1 > PHD2 | Japan (NDD-CKD, DD) EU (DD) |
Use of HIF-PHIs in subpopulations of interest
Hyporesponsive patients with inflammation
Opinion of the group
Hyporesponsive patients with iron deficiency
Opinion of the group
Kidney transplantation
Opinion of the group
Conclusions
Agents | Potential advantages | Potential disadvantages |
---|---|---|
HIF-PHIs | Oral dosing more convenient for NDD-CKD patients, PD, Home HD May facilitate anemia treatment in patients with NDD-CKDa May improve utilization of iron for erythropoiesis, particularly useful for oral iron in NDD-CKD, PD May be more effective in chronic inflammatory states (CRP > 5 mg/l)a (although we need more data) Stability at room temperature (no refrigerator need) | Difficult to monitor adherencea Potential polypharmacy and drug–drug interactionsa - Avoiding the use too close to chelating drugs, including phosphate Less clinical experiencea Potential risk of enhancing tumor growtha Potential risk of worsening retinopathya - Caution in patients with hyperthyroidism - Caution in patients with severe cardiovascular calcifications Potential risk of cyst growth in ADPKDa |
ESAs | Adherence can be monitored with in-clinic administration in DD-CKD patientsa Extensive clinical experiencea | Treatment requires self-injection or the help of relatives or of nurses Resistance in chronic inflammatory statesa Risk of enhancing tumor growtha Antibody-mediated pure red cell aplasia (rare)a |
Iron compounds | No serious adverse effects of oral irona Reduced ESA doses Reduced cardiovascular mortality in patients with concomitant heart failure Reduced cardiovascular events in patients receiving hemodialysis | If taken orally, risk of poor gastrointestinal tolerance and non-adherence to therapya If administered IV in NDD-CKD and PD risk of damaging veins of the arms eventually necessary for a fistula If administered IV, potential risk of allergic/anaphylactic reaction (rare) increasing oxidative stress or hemosiderosis (rare)a |