Chenodal (chenodiol) Policy Number: 5.01.549 Last Review: 04/2018 Origination: 06/2013 Next Review: 04/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for Chenodal (chenodiol) when it is determined to be medically necessary because the following criteria are met. When Policy Topic is covered The use of Chenodal may be considered medically necessary for the following: FDA-Approved Indications 1. Gallstones. Approve if the patient has tried or is currently using an ursodiol product. Chenodal is indicated for patients with radiolucent stones in well-opacifying gallbladders, in whom selective surgery would be undertaken except for the presence of increased surgical risk due to systemic disease or age. 1 Two bile acids are used in the treatment of gallstones: ursodiol and chenodiol. These agents both reduce biliary cholesterol, however their exact mechanisms differ. Both agents promote the gradual dissolution of radiolucent gallstones over a period of 6 months to 2 years. 4 For the small minority of patients with small (< 6 mm), radiolucent gallstones and an opacifying gallbladder, pharmacologic treatment with either ursodiol alone or in combination with Chenodal is recommended. 5 No recommendation is made for Chenodal monotherapy. Other Uses with Supportive Evidence 2. Cerebrotendinous Xanthomatosis (CTX). Approve if Chenodal is prescribed by or in consultation with a metabolic specialist who treats patients with CTX (or a specialist who focuses in the treatment of CTX). Replacement therapy with Chenodal inhibits abnormal bile acid synthesis and is most effective in reducing elevated plasma cholestanol concentrations, and eliminating bile alcohols. 8 Although, Chenodal is not FDA-approved for use in CTX, a letter to the company (from the FDA) as well as other articles in review of CTX, note Chenodal is the best treatment for CTX. 3,7-9 Regression of the clinical presentations of CTX with long-term Chenodal treatment have been documented. 9 When Policy Topic is not covered The use of Chenodal is considered investigational for all other indications. Considerations Chenodal requires prior authorization through the Clinical Pharmacy Department.
This Blue Cross and Blue Shield of Kansas City policy Statement was developed using available resources such as, but not limited to: Hayes Medical Technology Directory, Food and Drug Administration (FDA) approvals, Facts and Comparisons, National specialty guidelines, Local medical policies of other health plans, Medicare (CMS), Local providers. Description of Procedure or Service Chenodiol is a naturally occurring bile acid, Chenodal (chenodiol tablets) is indicated for patients with radiolucent stones in well-opacifying gallbladders, in whom elective surgery would be undertaken except for the presence of increased surgical risk due to systemic disease or age. 1 Chenodal suppresses hepatic synthesis of both cholesterol and cholic acid, gradually replacing cholic acid and its metabolite (deoxycholic acid) in an expanded bile acid pool. This process contributes to biliary cholesterol desaturation and gradual dissolution of radiolucent cholesterol gallstones in the presence of a gallbladder visualized by oral cholecystography. The likelihood of successful dissolution is far greater if the stones are floatable (high cholesterol content) or small. In patients with nonfloatable stones, dissolution is less likely and added weight should be given to the risk that more emergent surgery might result from a delay due to unsuccessful treatment. Chenodal was approved as an abbreviated new drug application (ANDA) to a chenodiol product (Chenix [chenodiol tablets]) approved in 1983 with a new drug application (NDA). This previously available product was discontinued by the manufacturer in 1997 because more effective drugs and devices were utilized in the management of gallstones. 2-3 The Food and Drug Administration (FDA) asked Manchester Pharmaceuticals to return chenodiol to the US market primarily to treat a small number of individuals with a rare disorder called cerebrotendinous xanthomatosis (CTX). Rationale Gallstones The most widely used treatment for symptomatic gallstones is cholecystectomy. 4-5 Patient selection criteria for laparoscopic cholecystectomy are similar to that for open surgery and thus not all patients are candidates. 5 Although in the minority, these patients (as well as those who prefer medical treatment) may benefit from pharmacologic treatment of gallstones. Two naturally occurring bile acids are used in the treatment of gallstones: ursodeoxycholic acid (UrsoForte, Urso-250, [ursodiol tablets, generics], Actigall [ursodiol capsules, generics]) and chenodeoxycholic acid/chenodiol (Chenodal). These agents reduce biliary cholesterol; however, their exact mechanisms differ. Both Chenodal and ursodiol promote the gradual dissolution of radiolucent gallstones over a period of 6 months to 2 years. 4 Practical guidelines for the pharmacologic treatment of gallstones were published in 1994. 5 Observation is recommended in asymptomatic patients. In patients with symptomatic gallstones, laparoscopic cholecystectomy is the preferred treatment. For the small minority of patients with small (< 6 mm), radiolucent gallstones and an opacifying gallbladder, pharmacologic treatment with a bile acid may be considered. Therapy with either ursodiol alone or in combination with chenodiol is recommended. No recommendation is made for chenodiol monotherapy. A randomized, double-blind, study was conducted to compare equimolar doses of ursodeoxycholic acid and chenodeoxycholic acid (as Bilenor [Schwarz Pharma, Italy]) [dose of each 5 mg/kg/day] combination therapy to monotherapy with ursodeoxycholic acid (10 mg/kg/day) for both complete gallstone dissolution and dissolution rates over the course of 2 years in adults (n = 154) with small ( 15 mm diameter), radiolucent stones and functioning gallbladders. 6 Mean gallstone dissolution rate was similar and non-significant between the monotherapy and combination therapy treatment groups at 6 months (47% and 44%, respectively) and 12 months (59% and 53%, respectively). Complete gallstone dissolution on intention-to-treat (ITT) basis was not significantly different between the two regimens. At 24 months, complete dissolution occurred in 28% and 30% of patients treated with monotherapy and combination therapy, respectively. Both treatment regimens significantly reduced biliary pain reported prior to study initiation from 59% to 26% and 55% to 21% in patients treated with monotherapy and combination therapy, respectively, after 3 months of treatment (P < 0.001 for both vs. baseline). Side
effects were similar between treatment groups with slightly more diarrhea reported with combination than monotherapy treatment (n = 6 vs. n = 2). No significant alterations in serum amonitransferases or lipids were observed in either group. Efficacy for ursodiol and chenodiol ranges from 28% to 38% when using ITT criteria (that is, patients with any sized radiolucent stones in functioning gallbladders). 4 In patients with smaller stones < 15 mm in diameter and high compliance to long-term treatment (2 years), efficacy rates increase up to 76% in patients treated with chenodiol and 81% in those treated with ursodiol. 5 Treatment with these agents can cause various gastrointestinal side effects and discontinuation results in recurrence of gallstones in up to 50% of patients. Lifestyle modification may also benefit those with gallstones. 4 Obesity is associated with an increased risk of gallstones and therefore, weight loss may reduce this risk. Rapid weight reduction (> 3 pounds per week) may promote cholelithiasis, and only ursodiol has been approved to prevent gallstones in this patient population. Cerebrotendinous Xanthomatosis (CTX) The FDA asked Manchester Pharmaceuticals to return chenodiol to the US market primarily to treat a small number ( 50) of individuals in the US with the rare disorder, CTX. CTX is a lipid storage disorder with various clinical manifestations including juvenile cataracts, tendon xanthomas, premature atherosclerosis, and progressive neurologic disturbance (i.e., ataxia, seizures, psychiatric disorders, and peripheral neuropathy). 7 Other conditions associated with CTX include osteoarthritis, skeletal fractures, pulmonary insufficiency, renal and hepatic calculi, and childhood chronic diarrhea. CTX is the result of a mutated enzyme (cytochrome P450 27-sterol hydroxylase [CYP27]) which is normally responsible for the conversion of cholesterol to cholic acid and chenodeoxycholic acid. In CTX, reduced synthesis of cholic- and chenodeoxycholic acids seem to result in failed feedback inhibition of cholesterol production, in turn leading to hallmark laboratory findings of the disorder: increased serum cholestanol concentrations, and elevated urinary bile alcohols. 7 Replacement therapy with chenodiol inhibits abnormal bile acid synthesis and is most effective in reducing elevated plasma cholestanol concentrations, and eliminating bile alcohols. 8 Mechanistic differences between Chenodal and ursodiol make Chenodal the effective treatment of CTX. Chenodal is believed to decrease hepatic cholesterogenesis because it reduces the activity of the rate-limiting enzyme, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. 5 In contrast, ursodiol does not influence hepatic cholesterogenesis, but increases conversion of hepatic cholesterol to bile acid and, thus, rendering less cholesterol available in the cell for biliary secretion. 5 Although Chenodal is not FDA-approved for use in CTX, in an letter to the company from the FDA and in other review articles of CTX, it is noted that chenodiol is the best treatment for CTX. 3,7-9 One article notes that the remarkable efficacy of chenodiol therapy and its lack of adverse effects are advantages that are hard to surpass for the treatment of CTX. 6 Regression of the clinical presentation of CTX with longterm Chenodal treatment have been documented. 9 HMG-CoA reductase inhibitors have been used in combination with Chenodal in the treatment of CTX, but no additional benefits have been observed when compared with chenodiol monotherapy. 9 Gene therapy and liver transplant may also offer a cure for CTX. Safety Both ursodiol capsules and Chenodal are contraindicated in patients with calcified, radiopaque, or bile pigment stones as they are not effective in these situations. 1,10 In addition, ursodiol capsules and Chenodal are contraindicated in patients with compelling reasons for cholecystectomy. Ursodiol tablets, labeling does not contain language regarding these same contraindications 11 Chenodal is pregnancy category X and ursodiol products are pregnancy category B. Chenodal should not be used in patients with pre-existing liver disease; 1,10-11 dose-related serum aminotransferase (mainly serum glutamic pyruvic transaminase [SGPT]) elevations, usually not accompanied by rises in alkaline phosphatase or bilirubin, occurred in 30% of patients treated with recommended doses of Chenodal. 1 Aminotransferase elevations over three times the upper limit of normal have required discontinuation of Chenodal in 2% to 3% of patients. Although clinical and biopsy studies have not shown fulminant lesions, the possibility remains that an occasional patient may develop serious hepatic disease. Three
patients with biochemical and histologic pictures of chronic active hepatitis while on Chenodal have been reported. In contrast, urosdiol products have not been associated with liver damage because the metabolite known to be hepatotoxic (lithocholic acid) is formed in the gut less efficiently with ursodiol and in smaller amounts than that observed with Chenodal. 10-11 Additionally, abnormalities in liver enzymes have not been associated with ursodiol therapy. Diarrhea is also more commonly reported with Chenodal (30% to 40%) than ursodiol capsules (27%) and ursodiol tablets (1.32%). References: 1. Chenodal tablets [package insert]. Fort Collins, CO: Manchester Pharmaceuticals, Inc. ; October 2009. 2. [Data on file] Manchester Pharmaceuticals, Inc ; January 4, 2010. 3. [Data on file] Manchester Pharmaceuticals, Inc ; January 5, 2010. 4. Gaby AR. Nutritional approaches to prevention and treatment of gallstones. Altern Med Rev. 2009;14(3):258-267. 5. Lanzini A and Northfield TC. Pharmacological treatment of gallstones practical treatment guidelines. Drugs. 1994:47(3):458-470. 6. Petronia ML, Jazrawi RP, Pazzi P, et al; The British-Italian Gallstone Study Group. Ursodeoxycholic acid alone or with chenodeoxycholic acid for dissolution of gallstones: a randomized-controlled trial. Aliment Pharmacol Ther. 2001;15(1):123-128. 7. Lorincz MT, Rainier S, Thomas D and Fink JK. Cerebrotendinous xanthomatosis: possible higher prevalence than previously recognized. Arch Neurol. 2005;62:1459-1463. 8. Moghadasian MH, Salen G, Frohlich JJ, et al. Cerebrotendinous Xanthomatosis. Arch Neurol. 2002;59:527-529. 9. Berginer VM, Gross B, Morad K, et al. Chronic diarrhea and juvenile cataracts: think cerebrotendinous xanthomatosis and treat. Pediatrics. 2009; 123(1):143-147. 10. Ursodiol Capsules [package insert]. Morgantown, WV: Mylan Pharmaceuticals, Inc.; January 2009. 11. URSO 250 /URSO Forte tablets [package insert]. Birmingham, AL: Axcan Pharma US, Inc; September 2012. Billing Coding/Physician Documentation Information NA Chenodal is considered a pharmacy benefit Additional Policy Key Words Policy Number: 5.01.549 Policy Implementation/Update Information 06/2013 03/2014 04/2014 04/2015 04/2016 04/2017 New Policy titled Chenodal Policy reviewed no changes made Policy reviewed no changes made
State and Federal mandates and health plan contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The medical policies contained herein are for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents Blue KC and are solely responsible for diagnosis, treatment and medical advice. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, photocopying, or otherwise, without permission from Blue KC.