Alendronate Sandoz

Each tablet contains 70 mg alendronic acid [as sodium trihydrate].
Excipients/Inactive Ingredients: Excipients core: Microcrystalline cellulose, Colloidal anhydrous silica, Croscarmellose sodium, Magnesium stearate.
Excipients coating: Microcrystalline cellulose, Carragenan (E407), Macrogol.

Pharmacotherapeutic group: Drugs for treatment of bone diseases, bisphosphonates. ATC code: M05BA04.
PHARMACOLOGY: Pharmacodynamics: Alendronate is a bisphosphonate that inhibits osteoclastic bone resorption with no direct effect on bone formation. Preclinical studies have shown preferential localisation of Aledronate to sites of active resorption. Activity of osteoclasts is inhibited, but recruitment or attachment of osteoclasts is not affected. The bone formed during treatment with alendronic acid is of normal quality.
Treatment of post-menopausal osteoporosis: Osteoporosis is defined ad BMD of the spine or hip 2.5 SD below the mean value of a normal young population or as a previous fragility fracture, irrespective of BMD.
The therapeutic equivalence of Alendronate 70 mg (n=519) and Alendronate 10 mg daily (n=370) was demonstrated in a one-year multicentre study of post-menopausal women with osteoporosis. The mean increases from baseline in lumbar spine BMD at one year were 5.1%(95% CI: 4.8, 5.4%) in the 70 mg once-weekly group and 5.4%(95% CI:5.0, 5.8%) in the 10 mg daily group.
The effects of Alendronate on bone mass and fracture incidence in post-menopausal women were examined in two initial efficacy studies of identical design (n=994) as well as in the Fracture Intervention Trial (FIT: n=6,459).
In the initial efficacy studies, the mean bone mineral density (BMD) increses with Alendronate 10 mg/day relative to placebo at three years were 8.8%, 5.9% and 7.8% at the spine, femoral neck and trochanter, respectively. Total body BMD also increased significantly. There was a 48% reduction (Alendronate 3.2% vs placebo 6.2%) in the proportion of patients treated with Alendronate experiencing one or more vertebral fractures relative to those treated with placebo. In the two-year extension of these studies BMD at the spine and trochanter continued to increase and BMD at the femoral neck and total body were maintained.
FIT consisted of two placebo-controlled studies using Alendronate daily (5 mg daily for two years and 10 mg daily for either one or two additional years): FIT 1: A three-year study of 2,027 patients who had at least one baseline vertebral (compression) fracture. In this study Alendronate daily reduced the incidence of ≥1 new vertebral fracture by 47% (Alendronate 7.9% vs. placebo 15.0%). In addition, a statistically significant reduction was found in the incidence of hip fractures (1.1% vs. 2.2%, a reduction of 51%).
FIT 2: A four-year study of 4,432 patients with low bone mass but without a baseline vertebral fracture. In this study, a significant difference was observed in the analysis of the subgroup of osteoporotic woman (37% of the global population who correspond with the previously mentioned definition of osteoporosis) in the incidence of hip fractures (Alendronate 1.0% vs. placebo 2.2%, a reduction of 56%) and in the incidence of ≥1 vertebral fracture (2.9% vs. 5.8%, a reduction of 50%).
Paediatric patients: Alendronate sodium has been studied in a small number of patients with osteogenesis imperfecta under the age of 18 years. Results are insufficient to support the use of alendronate sodium in paediatric patients with osteogenesis imperfecta.
Pharmacokinetics: Absorption: Relative to an intravenous reference dose, the oral mean bioavailability of alendronic acid in women was 0.64% for doses ranging from 5 to 70 mg when administered after an overnight fast and two hours before a standardised breakfast. Bioavailability was decreased similarly to an estimated 0.46% and 0.39% when alendronic acid was administered one hour or half an hour before a standardised breakfast. In osteoporosis studies, alendronic was effective when administered at least 30 minutes before first food or beverage of the day. Bioavailability was negligible whether alendronic acid was administered with, of up to two hours after, a standardised breakfast. Concomitant administration of alendronic acid with coffee or orange juice reduced bioavailability by approximately 60%.
In healthy subjects, oral prednisone (20 mg three times daily for five days) did not produce a clinically meaningful change in oral bioavailability of alendronic acid (a mean increase ranging from 20% to 44%).
Distribution: Studies in rats show that alendronic acid transiently distributes soft tissues following 1 mg/kg intravenous administration but is then rapidly redistributed to bone or excreted in the urine. The mean steady-state volume of distribution, exclusive of bone, is at least 28 litres in humans. Concentrations of drug in plasma following therapeutic oral doses are too low for analytical detection (<5 ng/ml). Protein binding in human plasma is approximately 78%.
Biotransformation: There is no evidence that alendronic acid is metabolised in animals or humans.
Elimination: Following a single intravenous dose of [14C] alendronic acid, approximately 50% of the radioactivity was excreted in the urine within 72 hours and little or no radioactivity was recovered in the faeces. Following a single 10 mg intravenous dose, the renal clearance of alendronic acid was 71 ml/min, and systemic clearance did not exceed 200 ml/min. Plasma concentrations fell by more than 95% within six hours following intravenous administration. The terminal half-life in humans is estimated to exceed ten years, reflecting release of alendronic acid from the skeleton. Alendronic acid is not excreted through the acidic or basic transport systems of the kidney in rats, and thus it is not anticipated to interfere with the excretion of other medicinal products by those systems in humans.
Characteristics in patients: Preclinical studies show that the drug that is not deposited in bone is rapidly excreted in the urine. No evidence of saturation of bone uptake was found after chronic dosing with cumulative intravenous doses up to 35 mg/kg in animals. Although no clinical information is available, it is likely that, as in animals, elimination of alendronic acid via the kidney will be reduced in patients with impaired renal function (see Dosage & Administration).
Toxicology: Preclinical safety data: Preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity and carcinogenic potential. Studies in rats have shown that treatment with Alendronate during pregnancy was associated with dystocia in dams during parturition which was related to hypocalcaemia. In studies, rats given high doses showed an increased incidence of incomplete foetal ossification. The relevance to humans is unknown.

Treatment and prevention of osteoporosis in postmenopausal woman to prevent fractures, including those of the hip and spine [vertegral compression fractures].
Treatment of osteoporosis in men to prevent fractures.

Alendronate Sandoz is intended for oral use only. The recommended dosage is one 70 mg tablet once weekly.
The optimal duration of bisphosphonate treatment for osteoporosis has not been established. The need for continued treatment should be re-evaluated periodically based on the benefits and potential risks of alendronate on an individual patient basis, particularly after 5 or more years of use.
To permit adequate absorption of alendronic acid: Alendronate Sandoz must be taken at least 30 minutes before the first food, beverage, or medicinal product of the day with plain water only. Other beverages [including mineral water], food and some medicinal products are likely to reduce the absorption of Alendronate Sandoz (see Interactions).
To facilitate delivery to the stomach and thus reduce the potential for local and oesophageal irritation/adverse experiences (see Precautions): Alendronate should only be swallowed upon arising for the day with a full glass of water (not less than 200 ml or 7 fl.oz.).
Patients should only swallow alendronate whole. Patients should not crush or chew the tablet or allow the tablet to dissolve in their mouths because of a potential for oropharyngeal ulceration.
Patients should not lie down until after their first food of the day which should be at least 30 minutes after taking the tablet.
Patients should not lie down for at least 30 minutes after taking alendronate.
Alendronate should not be taken at bedtime or before arising for the day.
Patients should receive supplemental calcium and vitamin D if dietary intake is inadequate (see Precautions).
Use in the elderly: In clinical studies there was no age-related difference in the efficacy or safety profiles of alendronate. Therefore no dose adjustment is necessary for the elderly.
Use in renal impairment: No dose adjustment is necessary for patients with GFR greater than 35 ml/min. Alendronate is not recommended for patients with renal impairment where GFR is less than 35 ml/min, due to lack of experience.
Use in impaired hepatic function: No dose adjustment is necessary.
Paediatric patients: Alendronate sodium is not recommended for use in children under the age of 18 years due to insufficient data on safety and efficacy in conditions associated with paediatric osteoporosis (also see PHARMACOLOGY: Pharmacodynamics under Actions).
Alendronate Sandoz 70 mg has not been investigated in the treatment of glucocorticoid-induced osteoporosis.

Symptoms: Hypocalcaemia, hypophosphataemia and upper gastrointestinal adverse events, such as upset stomach, heartburn, oesophagitis, gastritis, or ulcer, may result from oral overdose.
Management: No specific information is available on the treatment of overdose with alendronate. Milk or antacids should be given to bind alendronate. Owing to the risk of oesophageal irritation, vomiting should not be induced and the patient should remain fully upright.

Abnormalities of the oesophagus and other factors which delay oesophageal emptying such as stricture or achalasia; Inability to stand or sit upright for at least 30 minutes; Hypersensitivity to alendronate or to any of the excipients; Hypocalcaemia.

Upper gastrointestinal adverse reactions: Alendronate can cause local irritation of the upper gastrointestinal mucosa. Because there is a potential for worsening of the underlying disease, caution should be used when alendronate is given to patients with active upper gastro-intestinal problems, such as dysphagia, oesophageal disease, gastritis, duodenitis, ulcers, or with a recent history (within the previous year) of major gastrointestinal disease such as peptic ulcer, or active gastrointestinal bleeding, or surgery of the upper gastrointestinal tract other than pyloroplasty (see Contraindications).
In patients with known Barrett's oesophagus, prescribers should consider the benefits and potential risks of alendronate on an individual patient basis.
Oesophageal reactions (sometimes severe and requiring hospitalisation), such as oesophagitis, oesophageal ulcers and oesophageal erosions, rarely followed by oesophageal stricture, have been reported in patients receiving alendronate. Physicians should therefore be alert to any signs or symptoms signalling a possible oesophageal reaction and patients should be instructed to discontinue alendronate and seek medical attention if they develop symptoms of oesophageal irritation, such as dysphagia, pain on swallowing, retrosternal pain, new or worsening heartburn.
The risk of severe oesophageal adverse experiences appears to be greater in patients who fail to take alendronate properly and/or who continue to take alendronate after developing symptoms suggestive of oesophageal irritation. It is very important that the full dosing instructions are provided to, and understood by the patient (see Dosage & Administration). Patients should be informed that failure to follow these instructions may increase their risk of oesophageal problems.
While no increased risk was observed in extensive clinical trials, there have been rare (post-marketing) reports of gastric and duodenal ulcers, some severe and with complications.
Osteonecrosis of the jaw: Osteonecrosis of the jaw, generally associated with tooth extraction and/or local infection (including osteomyelitis) has been reported in patients with cancer receiving treatment regimens including primarily intravenously administered bisphosphonates. Many of these patients were also receiving chemotherapy and corticosteroids. Osteonecrosis of the jaw has also been reported in patients with osteoporosis receiving oral bisphosphonates.
The following risk factors should be considered when evaluating an individual's risk of developing osteonecrosis of the jaw: potency of the bisphosphonate (highest for zoledronic acid), route of administration (see previous text) and cumulative dose; cancer, chemotherapy, radiotherapy, corticosteroids, angiogenesis inhibitors, smoking; a history of dental disease, poor oral hygiene, periodontal disease, invasive dental procedures and poorly fitting dentures.
A dental examination with appropriate preventive dentistry should be considered prior to treatment with oral bisphosphonates in patients with poor dental status.
While on treatment, these patients should avoid invasive dental procedures if possible. For patients who develop osteonecrosis of the jaw while on bisphosphonate therapy, dental surgery may exacerbate the condition. For patients requiring dental procedures, there are no data available to suggest whether discontinuation of bisphosphonate treatment reduces the risk of osteonecrosis of the jaw. Clinical judgement of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment.
During bisphosphonate treatment, all patients should be encouraged to maintain good oral hygiene, receive routine dental check-ups, and report any oral symptoms such as dental mobility, pain, or swelling.
Osteonecrosis of the external auditory canal has been reported with bisphosphonates, mainly in association with long-term therapy. Possible risk factors for osteonecrosis of the external auditory canal include steroid use and chemotherapy and/or local risk factors such as infection or trauma. The possibility of osteonecrosis of the external auditory canal should be considered in patients receiving bisphosphonates who present with ear symptoms including chronic ear infections.
Musculoskeletal pain: Bone, joint, and/or muscle pain has been reported in patients taking bisphosphonates. In post-marketing experience, these symptoms have rarely been severe and/or incapacitating (see Adverse Reactions). The time to onset of symptoms varied from one day to several months after starting treatment. Most patients had relief of symptoms after stopping. A subset had recurrence of symptoms when rechallenged with the same medicinal product or another bisphosphonate.
Atypical fractures of the femur: Atypical subtrochanteric and diaphyseal femoral fractures have been reported with bisphosphonate therapy, primarily in patients receiving long-term treatment for osteoporosis. These transverse or short oblique fractures can occur anywhere along the femur from just below the lesser trochanter to just above the supracondylar flare. These fractures occur after minimal or no trauma and some patients experience thigh or groin pain, often associated with imaging features of stress fractures, weeks to months before presenting with a completed femoral fracture. Fractures are often bilateral; therefore the contralateral femur should be examined in bisphosphonate-treated patients who have sustained a femoral shaft fracture. Poor healing of these fractures has also been reported. Discontinuation of bisphosphonate therapy in patients suspected to have an atypical femur fracture should be considered pending evaluation of the patient, based on an individual benefit risk assessment.
During bisphosphonate treatment patients should be advised to report any thigh, hip or groin pain and any patient presenting with such symptoms should be evaluated for an incomplete femur fracture.
Skin reaction: In post-marketing experience, there have been rare reports of severe skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis.
Missed dose: Patients should be instructed that if they miss a dose of alendronate 70 mg once weekly formulation, they should take one tablet on the morning after they remember. They should not take two tablets on the same day, but should return to taking one tablet once a week, as originally scheduled on their chosen day.
Renal impairment: Alendronate is not recommended for patients with renal impairment where creatinine clearance is less than 35 ml/min (see Dosage & Administration).
Bone and mineral metabolism: Causes of osteoporosis other than oestrogen deficiency and ageing should be considered.
Hypocalcaemia must be corrected before initiating therapy with alendronate (see Contraindications). Other disorders affecting mineral metabolism (such as vitamin D deficiency and hypoparathyroidism) should also be effectively treated. In patients with these conditions, serum calcium and symptoms of hypocalcaemia should be monitored during therapy with alendronate.
Due to the positive effects of alendronate in increasing bone mineral, decreases in serum calcium and phosphate may occur especially in patients taking glucocorticoids in whom calcium absorption may be decreased. These are usually small and asymptomatic. However, there have been rare reports of symptomatic hypocalcaemia, which have occasionally been severe and often occurred in patients with predisposing conditions (e.g. hypoparathyroidism, vitamin D deficiency and calcium malabsorption).
Ensuring adequate calcium and vitamin D intake is particularly important in patients receiving glucocorticoids.
Effects on ability to drive and use machines: Alendronate has no or negligible direct influence on the ability to drive and use machines. However, certain adverse reactions that have been reported with alendronate may affect some patients' ability to drive or operate machinery. Individual responses to alendronate may vary (see Adverse Reactions).

Pregnancy: There are no or limited amount of data from the use of alendronate in pregnant women.
Studies in animals have shown reproductive toxicity. Alendronate given during pregnancy in rats caused dystocia related to hypocalcaemia (see PHARMACOLOGY: Toxicology: Preclinical safety data under Actions). Alendronate should not be used during pregnancy.
Breast-feeding: It is unknown whether alendronate/metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded. Alendronate should not be used during breastfeeding.
Fertility: Bisphosphonates are incorporated into the bone matrix, from which they are gradually released over a period of years. The amount of bisphosphonate incorporated into adult bone, and hence, the amount available for release back into the systemic circulation, is directly related to the dose and duration of bisphosphonate use (see PHARMACOLOGY: Pharmacokinetics under Actions). There are no data on foetal risk in humans. However, there is a theoretical risk of foetal harm, predominantly skeletal, if a woman becomes pregnant after completing a course of bisphosphonate therapy. The impact of variables such as time between cessation of bisphosphonate therapy to conception, the particular bisphosphonate used, and the route of administration (intravenous versus oral) on the risk has not been studied.

Summary of safety profile: In a one-year study in post-menopausal women with osteoporosis the overall safety profiles of alendronate once-weekly 70 mg (n=519) and alendronate 10 mg/day (n=370) were similar.
In two three-year studies of virtually identical design, in post-menopausal women (alendronate 10 mg: n = 196; placebo: n = 397) the overall safety profiles of alendronate 10 mg/day and placebo were similar.
Adverse experiences reported by the investigators as possibly, probably or definitely drug-related are presented as follows if they occurred in ≥ 1% in either treatment group in the one-year study, or in ≥ 1% of patients treated with alendronate 10 mg/day and at a greater incidence than in patients given placebo in the three-year studies: See table.

Click on icon to see table/diagram/image

The following adverse experiences have also been reported during clinical studies and/or post-marketing use: Frequencies are defined as: Very common: (≥ 1/10); Common: (≥ 1/100, < 1/10); Uncommon: (≥ 1/1,000, < 1/100); Rare: (≥ 1/10,000, < 1/1,000); Very rare: (< 1/10,000).
Immune system disorders: Rare: Hypersensitivity reactions including urticaria and angioedema.
Metabolism and nutrition disorders: Rare: Symptomatic hypocalcaemia, often in association with predisposing conditions^§.
Nervous system disorders: Common: Headache, dizziness^†.
Uncommon: Dysgeusia^†.
Eye disorders: Uncommon: Eye inflammation (uveitis, scleritis, episcleritis).
Ear and labyrinth disorders: Common: Vertigo^†.
Gastrointestinal disorders: Common: Abdominal pain, dyspepsia, constipation, diarrhoea, flatulence, oesophageal ulcer*, dysphagia*, abdominal distension, acid regurgitation.
Uncommon: Nausea, vomiting, gastritis, oesophagitis*, oesophageal erosions*, melena^†.
Rare: Oesophageal stricture*, oropharyngeal ulceration*, upper gastrointestinal PUBs (perforation, ulcers, bleeding)^§.
Skin and subcutaneous tissue disorders: Common: Alopecia^†, pruritus^†.
Uncommon: Rash, erythema.
Rare: Rash with photosensitivity, severe skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis^‡.
Musculoskeletal and connective tissue disorders: Very common: Musculoskeletal (bone, muscle or joint) pain which is sometimes severe^†§.
Common: Joint swelling^†.
Rare: Osteonecrosis of the jaw^‡§; atypical subtrochanteric and diaphyseal femoral fractures (bisphosphonate class adverse reaction)^⊥.
Very rare: Osteonecrosis of the external auditory canal (bisphosphonate class adverse reaction).
General disorders and administration site conditions: Common: Asthenia^†, peripheral oedema^†.
Uncommon: Transient symptoms as in an acute phase response (myalgia, malaise and rarely, fever), typically in association with initiation of treatment^†.
^§See Precautions.
^†Frequency in clinical trials was similar in the medicinal product and placebo group.
^*See Dosage & Administration and Precautions.
^‡This adverse reaction was identified through post-marketing surveillance. The frequency of rare was estimated based on relevant clinical trials.
^⊥Identified in post-marketing experience.

If taken at the same time, it is likely that food and beverages (including mineral water), calcium supplements, antacids, and some oral medicinal products will interfere with absorption of alendronate. Therefore, patients must wait at least 30 minutes after taking alendronate before taking any other oral medicinal product (see Dosage & Administration and PHARMACOLOGY: Pharmacokinetics under Actions).
No other interactions with medicinal products of clinical significance are anticipated. A number of patients in the clinical trials received oestrogen (intravaginal, transdermal, or oral) while taking alendronate. No adverse experiences attributable to their concomitant use were identified.
Since NSAID use is associated with gastrointestinal irritation, caution should be used during concomitant use with alendronate.
Although specific interaction studies were not performed, in clinical studies alendronate was used concomitantly with a wide range of commonly prescribed medicinal products without evidence of clinical adverse interactions.

Incompatibilities: Not applicable.
Special precautions for disposal: No special requirements.

Do not store above 30°C.
This medicinal product does not require any special storage conditions. Store in the original package.

Agents Affecting Bone Metabolism

M05BA04 - alendronic acid ; Belongs to the class of bisphosphonates. Used in the treatment of bone diseases.

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