Consumer medicine information

Aclasta

Zoledronic acid

BRAND INFORMATION

Brand name

Aclasta

Active ingredient

Zoledronic acid

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Aclasta.

What is in this leaflet

This leaflet answers some common questions about Aclasta.

It does not contain all the available information. It does not take the place of talking to your doctor or pharmacist.

The information in this leaflet was last updated on the date listed on the final page. More recent information on the medicine may be available.

You should ensure that you speak to your pharmacist or doctor to obtain the most up-to-date information on the medicine. Those updates may contain important information about the medicine and its use of which you should be aware.

All medicines have risks and benefits. Your doctor has weighed the risks of you having Aclasta against the benefits they expect it will have for you.

If you have any concerns about having this medicine, ask your doctor or pharmacist.

Keep this leaflet. You may need to read it again.

What Aclasta is used for

The active ingredient in Aclasta is zoledronic acid, which belongs to a group of medicines called bisphosphonates.

Aclasta is used to treat osteoporosis in postmenopausal women and in men, to prevent additional fractures in men or women who have recently had a hip fracture, or to treat or prevent osteoporosis in men and women caused by treatment with steroid medicines such as prednisone. Aclasta is also used to treat Paget's disease of bone.

Osteoporosis is a disease which causes bones to become less dense, gradually making them weaker, more brittle and likely to break. This is common in women after menopause, when a woman's ovaries stop producing the female hormone, oestrogen, which keeps bones healthy. It also occurs in men and women with increasing age. Broken bones may result from injury or simple falls. Breaks may occur during normal everyday activity, such as lifting, or from minor injury that would not ordinarily fracture normal bone. Fractures in people with osteoporosis usually occur at the hip, spine or wrist. These can lead not only to pain, but also to considerable deformity and disability, such as stooped posture from curvature of the spine, and loss of mobility.

Paget's disease is a chronic disorder which may affect various bones of the skeleton. Bone is a living tissue and, just like other parts of the body, it is constantly being renewed. This process is called bone remodelling. In Paget's disease, the bone material breaks down more quickly than usual, and new bone material grows more quickly than usual and in a disordered way. The new bone that is formed may be thicker but weaker than normal, which can cause pain and may lead to fractures (broken bones).

How does it work

Aclasta works by slowing down bone resorption, which allows the bone-forming cells time to rebuild normal bone. This allows bone remodelling to go back to normal and protects the bones from being weakened.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Your doctor may have prescribed it for another reason.

Aclasta is only available with a doctor's prescription. It is not addictive.

There is not enough information to recommend the use of this medicine for children or adolescents.

Before you have Aclasta

When you must not have it

You must not have Aclasta if you have an allergy to:

  • zoledronic acid (the active ingredient in Aclasta) or any of the other ingredients listed at the end of this leaflet
  • any other bisphosphonate medicine such as alendronate (e.g. Fosamax) or risedronate (e.g. Actonel).

Some of the symptoms of an allergic reaction may include shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue or other parts of the body; rash, itching or hives on the skin.

If you are not sure whether you are allergic to other bisphosphonate medicines, talk to your doctor. Other bisphosphonate medicines have been shown to cause breathing difficulties in people with asthma who are allergic to aspirin.

Do not have Aclasta if you have low levels of calcium in your blood. Your doctor may do a blood test to check your calcium levels before you have Aclasta.

Do not have Aclasta if you are pregnant. There is no information on use of this medicine in pregnancy.

Do not breast-feed while you are having treatment with Aclasta. It is not known if the active ingredient, zoledronic acid, passes into the breast milk and could affect your baby.

Do not have Aclasta after the expiry date printed on the pack or if the packaging is torn or shows signs of tampering. If it has expired or is damaged, return it to your pharmacist.

If you are not sure whether you should be given this medicine, talk to your doctor.

Before you have it

Tell your doctor if you have been or are being treated with:

  • Zometa® which contains the same active ingredient as in Aclasta
  • another bisphosphonate medicine prior to Aclasta
  • diuretic therapy (commonly called 'fluid tablets')

Tell your doctor if:

  • you have a kidney problem. This medicine is not suitable for some people with a kidney problem.
  • you have a calcium deficiency or a vitamin D deficiency
  • you are unable to take daily calcium or vitamin D supplements
  • you have had some or all of your parathyroid or thyroid glands in your neck surgically removed
  • you have had sections of your intestine removed
  • you have or have had pain, swelling or numbness of the jaw or loosening of a tooth or any other oral issues
  • you had or have joint stiffness, aches and pains and difficulty in movement (especially of the hip, thigh, knee or upper arm) or pain around the external ear canal
  • you are under dental treatment or will undergo dental surgery. Your doctor will check your oral health before you start treatment with Aclasta. It is important to have good dental hygiene, routine dental care and regular dental check-ups. Discuss with your doctor any planned dental surgery such as a tooth extraction. Tell your dentist that you are being treated with Aclasta.
  • you have or have had uveitis or iritis (inflammatory conditions of the eye).

Taking other medicines

Tell your doctor, nurse or pharmacist if you are taking any other medicines, including medicines that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines and Aclasta can interfere with each other. These include:

  • medicines that may affect your kidneys such as fluid tablets
  • aminoglycoside medicines used to treat severe infections.

You may need to take different amounts of these medicines or you may need to take different medicines. Your doctor or pharmacist has more information.

How Aclasta is given

Follow all directions given to you by your doctor, nurse and pharmacist carefully. These directions may differ from the information contained in this leaflet.

If you do not understand the instructions, ask your doctor, nurse or pharmacist for help before treatment starts.

Make sure you drink enough fluids before and after the treatment with Aclasta as directed by your doctor. Two glasses of fluid (such as water) before and after the infusion are usually enough. This will help to prevent dehydration.

You may eat normally on the day you are treated with Aclasta.

How it will be given

Aclasta will be given to you by infusion into a vein by your doctor or nurse once a year. The infusion will take at least 15 minutes.

How much is given

A 100mL infusion will last at least 15 minutes.

How long treatment will last

  • For osteoporosis, each dose of Aclasta lasts one year. Your doctor will check your condition and may prescribe further annual doses.
  • For Paget's disease, each dose of Aclasta may work for longer than one year. Your doctor will let you know if you need to be treated again.

If you have too much (overdose)

Immediately telephone your doctor or Poisons Information Centre (telephone 13 11 26), or go to Accident and Emergency at your nearest hospital if you think that an overdose has happened. Do this even if there are no signs of discomfort or poisoning.

Tell your doctor if you have any of the following symptoms:

  • muscle spasms
  • numbness or tingling sensation, especially around the mouth
  • shortness of breath.

These symptoms may mean the level of calcium in your blood has fallen too far.

While you are being given Aclasta

Things you must do

If you get a headache, fever or other flu-like symptoms in the first three days after you are given Aclasta, take paracetamol if your doctor has told you to. Some people get short-lasting flu-like symptoms after having Aclasta. Paracetamol can provide some relief.

Take calcium and vitamin D supplements if your doctor has told you to.

  • Most people with osteoporosis do not get enough calcium and vitamin D in their diet and supplements are needed to help strengthen your bones.
  • If you are being treated with Aclasta for Paget's disease, your doctor should advise corrective treatment for a vitamin D deficiency and that you take calcium and vitamin D supplements for at least the first ten days after you have Aclasta to reduce the risk of low calcium levels in your blood.

Keep all of your doctor's appointments so that your progress can be checked. Your doctor may want you to have X-rays, bone density scans or blood tests from time to time to make sure Aclasta is working and to prevent unwanted side effects from happening.

Tell your doctor immediately if you become pregnant while having treatment with this medicine. Your doctor can discuss with you the risks of having it while you are pregnant.

Tell your doctor and dentist immediately about any dental symptoms you get while you are being treated with Aclasta. This may include persistent pain, swelling, loosening of a tooth and/or non-healing sores or discharge (pus or oozing). A dental condition called jaw osteonecrosis has been reported, primarily in patients being treated with this type of medicine for other illnesses.

If you are about to be started on any new medicine, remind your doctor and pharmacist that you are being treated with Aclasta.

Tell any other doctor, dentist or pharmacist who treats you that you are having Aclasta.

Things to be careful of

Be careful driving or operating machinery until you know how Aclasta affects you. Aclasta has no known effect on the ability to drive or use machines but, as a general precaution, if you are travelling home by car after the infusion, arrange to have someone else drive.

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are having Aclasta.

All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical attention if you get some of the side effects.

Do not be alarmed by the following list of side effects. You may not experience any of them.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor or pharmacist if you notice any of the following and they worry you:

  • short-lasting fever, sometimes with flu-like symptoms, headache, chills, pain or aching in the muscles or joints. Take paracetamol if your doctor has told you to. Paracetamol can provide some relief.
  • redness, swelling or pain where the needle for the infusion was inserted
  • upset stomach, abdominal pain, loss of appetite or other eating disorder, thirst or heartburn
  • nausea, vomiting, diarrhoea, with possible dehydration
  • constipation
  • dry mouth, toothache or sore throat
  • lack of energy, tiredness and lack of interest, weakness, dizziness, low blood pressure
  • pain in your back, neck, shoulders, arms, legs or chest muscles, swollen or stiff joints, muscle stiffness, weakness or spasm, tingling or numbness of your hands or feet
  • swollen fingers or lower legs due to fluid build-up
  • swollen, red, painful or itchy eyes or sensitivity of the eyes to light
  • pink eye (conjunctivitis)
  • palpitations (feeling of fast, forceful and/or irregular heartbeat), which may be accompanied by dizziness and breathlessness
  • excessive sweating
  • difficulty sleeping.

Contact your doctor if you experience pain, weakness or discomfort in your thigh, hip or groin as this may be an early indication of a possible fracture of the thigh bone. Unusual fracture of the thigh bone particularly in patients on long-term treatment for osteoporosis may occur.

Tell your doctor and dentist immediately about any dental symptoms you get after you have Aclasta. This may include:

  • pain in the mouth, teeth and jaw, swelling of sores inside the mouth, numbness or a feeling of heaviness in the jaw, or loosening of a tooth. These could be signs of bone damage in the jaw (osteonecrosis).

Tell your doctor immediately or go to Accident and Emergency at your nearest hospital if you notice any of the following after you have Aclasta:

  • signs of allergy such as rash, itching or hives on the skin; swelling of the face, throat, lips, tongue or other part of the body; shortness of breath, difficulty breathing or swallowing; tightness of the chest
  • signs that the level of calcium in your blood may have fallen too far, such as muscle spasms, numbness or tingling sensation, especially around the mouth, shortness of breath
  • signs that the level of phosphorus in your blood may have fallen too far, such as muscle problems and weakness, confusion, irritation, and delirium
  • signs that your kidneys may not be working properly, such as decreased urine output.

The above side effects may be serious. You may need urgent medical attention.

Tell your doctor or pharmacist if you notice anything that is making you feel unwell.

Other side effects not listed above may also occur in some people. Some of these (e.g. effects on kidney function and on the level of calcium in the blood) can only be found by laboratory testing.

After having Aclasta

Storage

It is unlikely you will have to store Aclasta at home.

If you do have to store it:

  • Store the medicine in a cool dry place at room temperature
  • Do not store Aclasta or any other medicine in the bathroom or near a sink
  • Do not leave it in the car or on a window sill.

Heat and dampness can destroy some medicines.

Keep the medicine where young children cannot reach it. A locked cupboard at least one-and-a-half metres above the floor is a good place to store medicines.

Each Aclasta vial is to be used for one injection only and then discarded.

Disposal

If you no longer need Aclasta or it has passed its expiry date, return any unused medicine to your pharmacist.

Product description

What it looks like

Aclasta solution for infusion is supplied in a transparent plastic vial containing 100mL of a clear, colourless solution. Aclasta is supplied as packs containing one vial.

Ingredients

Each vial of Aclasta contains 5mg of zoledronic acid. Each vial also contains:

  • mannitol
  • sodium citrate
  • water for injections.

Sponsor

Aclasta is supplied in Australia by:

Sandoz Pty Ltd
ABN 60 075 449 553
100 Pacific Highway
North Sydney, NSW 2060
Telephone 1800 726 369

Date of preparation

This leaflet was prepared in September 2023.

AUST R 134664

® = Registered trademark

Published by MIMS November 2023

BRAND INFORMATION

Brand name

Aclasta

Active ingredient

Zoledronic acid

Schedule

S4

 

1 Name of Medicine

Zoledronic acid.

2 Qualitative and Quantitative Composition

Aclasta 5 mg/100 mL solution for infusion contains 5 mg zoledronic acid (anhydrous), corresponding to 5.330 mg zoledronic acid monohydrate.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Solution for intravenous infusion.
Aclasta 5 mg/100 mL solution for infusion is sterile, clear and colourless.

4 Clinical Particulars

4.1 Therapeutic Indications

Treatment of osteoporosis in postmenopausal women to reduce the incidence of hip, vertebral and non-vertebral fractures.
Treatment of osteoporosis in patients over 50 years of age with a history of at least one low trauma hip fracture, to reduce the incidence of further fractures.
To increase bone mineral density in men with osteoporosis.
To increase bone mineral density in patients with osteoporosis associated with long-term glucocorticoid use.
To prevent glucocorticoid induced bone mineral density loss.
Treatment of Paget's disease of bone.

4.2 Dose and Method of Administration

General.

The incidence of postdose symptoms occurring within the first three days after administration of Aclasta can be reduced with the administration of paracetamol shortly following Aclasta administration.
Patients must be appropriately hydrated prior to administration of Aclasta. This is especially important in the elderly and for patients receiving diuretic therapy (see Section 4.4 Special Warnings and Precautions for Use). Adequate hydration can be achieved by the patient drinking two glasses of fluid (such as water) before and after the infusion.
The inclusion and exclusion criteria of the clinical trials should be used as a basis for patient selection (see Section 5.1 Pharmacodynamic Properties, Clinical trials).

Treatment of postmenopausal osteoporosis.

For the treatment of postmenopausal osteoporosis the recommended dose is a single intravenous infusion of 5 mg of Aclasta administered once a year.
Adequate supplemental calcium and vitamin D intake is important in women with osteoporosis if dietary intake is inadequate. In the treatment of postmenopausal osteoporosis trial, all women received 1000 to 1500 mg of elemental calcium plus 400 to 1200 IU of vitamin D supplements per day (see Section 5.1 Pharmacodynamic Properties, Clinical trials).

Prevention of clinical fractures after a hip fracture.

For the prevention of clinical fractures after a low trauma hip fracture, the recommended dose is a single intravenous infusion of 5 mg Aclasta administered once a year.
In patients with a recent low trauma hip fracture, a loading dose of 50,000 to 125,000 IU of vitamin D given orally or via the intramuscular route is recommended prior to the first Aclasta infusion (see Section 5.1 Pharmacodynamic Properties, Clinical trials).
Supplemental calcium and vitamin D intake is recommended for patients treated to prevent clinical fractures after a low trauma hip fracture (see Section 4.4 Special Warnings and Precautions for Use, Calcium and vitamin D supplementation).

Treatment of osteoporosis in men.

For the treatment of osteoporosis in men, the recommended dose is a single intravenous infusion of 5 mg Aclasta administered once a year.
Adequate supplemental calcium and vitamin D intake is important in men with osteoporosis if dietary intake is inadequate (see Section 4.4 Special Warnings and Precautions for Use).

Treatment and prevention of glucocorticoid induced osteoporosis.

For the treatment and prevention of glucocorticoid induced osteoporosis, the recommended dose is a single intravenous infusion of 5 mg Aclasta administered once a year.
Adequate supplemental calcium and vitamin D intake is important in patients with osteoporosis if dietary intake is inadequate (see Section 4.4 Special Warnings and Precautions for Use).

Treatment of Paget's disease of bone.

For the treatment of Paget's disease, Aclasta should be prescribed only by physicians with experience in treatment of Paget's disease of the bone. The recommended dose is a single intravenous infusion of 5 mg Aclasta.

Retreatment of Paget's disease.

After the initial treatment with Aclasta in Paget's disease, an extended remission period of 7.7 years as a mean was observed in responding patients. As Paget's disease of bone is a lifelong disease, retreatment is likely to be needed. Retreatment of Paget's disease of bone consists of an additional intravenous infusion of 5 mg Aclasta after an interval of one year or longer from initial treatment. Periodic assessment of the patient's serum alkaline phosphatase levels, e.g. every 6 to 12 months and clinical responses to treatment should guide the decision of when retreatment should occur on an individual basis. In the absence of worsening of clinical symptoms (e.g. bone pain or compression symptoms) and/or bone scan consistent with relapse of Paget's disease of bone, a second intravenous infusion of Aclasta should not be administered earlier than 12 months following the initial treatment. No experience of retreatment more than once is available (see Section 5.1 Pharmacodynamic Properties, Clinical trials).
In patients with Paget's disease, adequate vitamin D intake is recommended in association with Aclasta administration (see Section 4.4 Special Warnings and Precautions for Use, Pre-existing hypocalcaemia or vitamin D deficiency). In addition, it is strongly advised that adequate supplemental calcium corresponding to at least 500 mg elemental calcium twice daily is ensured in patients with Paget's disease for at least 10 days following Aclasta administration (see Section 4.4 Special Warnings and Precautions for Use).

Method of administration.

Aclasta (5 mg in 100 mL ready to infuse solution) is administered intravenously via a vented infusion line, given at a constant infusion rate. The infusion time must not be less than 15 minutes (see Section 4.2 Dose and Method of Administration, Instructions for use and handling).

Patients with renal impairment.

The use of Aclasta in patients with creatinine clearance < 35 mL/min is not recommended due to limited clinical safety data in such patients (see Section 4.3 Contraindications).
No dose adjustment is necessary in patients with creatinine clearance ≥ 35 mL/min.

Patients with hepatic impairment.

No dose adjustment is required for patients with hepatic impairment.

Elderly patients.

No dose adjustment is necessary (see Section 4.4 Special Warnings and Precautions for Use). However, because decreased renal function occurs more commonly in the elderly, special care should be taken to monitor renal function.

Instructions for use and handling.

Aclasta must not be mixed or given intravenously with any other medication and must be given through a separate vented infusion line at a constant infusion rate. If refrigerated, allow the refrigerated solution to reach room temperature before administration. Aseptic techniques must be followed during the preparation of the infusion.
Use in one patient on one occasion only. Any unused solution should be discarded. Only clear solution free from particles and discolouration should be used.
After opening, the solution is chemically and physically stable for at least 24 hours at 2°C to 8°C.
From a microbiological point of view, the product should be used immediately. If not used immediately, in use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C.

Incompatibilities.

Aclasta solution for infusion must not be allowed to come into contact with any calcium or other divalent cation containing solutions.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients or to any bisphosphonates; hypocalcaemia; renal impairment with creatinine clearance < 35 mL/min (see Section 4.4 Special Warnings and Precautions for Use); current or recent uveitis, or a history of bisphosphonate associated uveitis; pregnancy and lactation.

4.4 Special Warnings and Precautions for Use

General.

The dose of 5 mg zoledronic acid must be administered intravenously over at least 15 minutes.
Aclasta contains the same active ingredient found in Zometa (zoledronic acid), used for oncology indications, and a patient being treated with Zometa should not be treated with Aclasta.
Consider carefully before using Aclasta in patients who have been extensively pretreated with other bisphosphonates. Consider discontinuing Aclasta on the occurrence of atypical fractures such as subtrochanteric fractures or atypical stress fractures. The optimum duration of bisphosphonate treatment is currently unknown. The risk:benefit ratio of prolonged therapy should be estimated in each patient. No data are available on recommencing therapy after cessation of treatment.

Acute phase reaction.

Post-dose symptoms commonly occur within the first three days following Aclasta administration and may include fever, flu-like symptoms, myalgia, arthralgia and headache (see Section 4.8 Adverse Effects (Undesirable Effects); Section 4.2 Dose and Method of Administration). The incidence of these symptoms can be reduced by approximately 50% with the administration of paracetamol shortly following Aclasta administration. Non-steroidal anti-inflammatory agents are not recommended first line to manage the acute phase reaction.

Hydration.

Patients must be appropriately hydrated prior to administration of Aclasta. This is especially important in the elderly and for patients receiving diuretic therapy. Adequate hydration can be achieved by the patient drinking two glasses of fluid (such as water) before and two glasses of fluid after the infusion.

Pre-existing hypocalcaemia or vitamin D deficiency.

If there are clinical reasons to suspect hypocalcaemia, vitamin D deficiency or other disturbances of mineral metabolism (e.g. thyroid surgery, parathyroid surgery, calcium malabsorption), the appropriate tests should be performed and, if abnormalities are discovered, these should be corrected before initiating therapy with Aclasta (see Section 4.3 Contraindications). Physicians should consider clinical monitoring after treatment in patients with pre-existing disturbances of mineral metabolism.

Use in renal impairment.

The use of Aclasta in patients with severe renal impairment (creatinine clearance < 35 mL/min) is contraindicated due to an increased risk of renal failure in this population.
Renal impairment has been observed following the administration of Aclasta (see Section 4.8 Adverse Effects (Undesirable Effects), Post-marketing experience), especially in patients with pre-existing renal impairment or other risk factors including advanced age, concomitant nephrotoxic medicinal products, concomitant diuretic therapy (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions), or dehydration occurring after Aclasta administration. Renal impairment has been observed in patients after a single administration. Renal failure requiring dialysis or with fatal outcome has rarely occurred in patients with underlying renal impairment or with any of the risk factors described above.
The following precautions should be taken into account to minimise the risk of renal adverse reactions:
Creatinine clearance should be calculated (e.g. Cockcroft-Gault formula) before each Aclasta dose (see Section 4.3 Contraindications). Transient increase in serum creatinine may be greater in patients with underlying impaired renal function; interim monitoring of serum creatinine should be considered in at-risk patients;
Aclasta should be used with caution when concomitantly used with other medicinal products that could impact renal function (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions);
Patients, especially elderly patients and those receiving diuretic therapy, should be appropriately hydrated prior to administration of Aclasta (see Section 4.4 Special Warnings and Precautions for Use, Hydration);
A single dose of Aclasta should not exceed 5 mg and the duration of infusion should not be less than 15 minutes (see Section 4.2 Dose and Method of Administration).

Calcium and vitamin D supplementation.

Treatment of osteoporosis.

Adequate supplemental calcium and vitamin D intake is important in men and women with osteoporosis if dietary intake is inadequate.

Prevention of clinical fractures after a hip fracture.

Supplemental calcium and vitamin D intake is recommended for patients treated to prevent clinical fractures after a hip fracture.

Treatment of Paget's disease of bone.

Elevated bone turnover is a characteristic of Paget's disease of bone. Due to the rapid onset of effect of zoledronic acid on bone turnover, transient hypocalcaemia, sometimes symptomatic, may develop and is usually maximal within the first 10 days after infusion of Aclasta (see Section 4.8 Adverse Effects (Undesirable Effects)). Adequate vitamin D intake is recommended in association with Aclasta administration (see Section 4.4 Special Warnings and Precautions for Use, Pre-existing hypocalcaemia or vitamin D deficiency). In addition, it is strongly advised that adequate supplemental calcium corresponding to at least 500 mg elemental calcium twice daily is ensured in patients with Paget's disease for at least 10 days following Aclasta administration. Patients should be informed about symptoms of hypocalcaemia. Physicians should consider clinical monitoring for patients at risk.

Musculoskeletal pain.

Severe and occasionally incapacitating bone, joint and/or muscle pain have been infrequently reported in patients taking bisphosphonates including Aclasta.

Osteonecrosis of the jaw (ONJ).

Osteonecrosis of the jaw has been reported predominantly in cancer patients treated with bisphosphonates, including zoledronic acid. Many of these patients were also receiving chemotherapy and corticosteroids. The majority of reported cases have been associated with dental procedures such as tooth extraction. Symptoms include persistent pain and/or nonhealing sores of the mouth or jaw. Many had signs of local infection including osteomyelitis.
Discuss with the patient the need to have dental work completed before commencing Aclasta treatment. A dental examination with appropriate preventive dentistry should be considered prior to treatment with bisphosphonates in patients with concomitant risk factors (e.g. cancer, chemotherapy, antiangiogenic drugs, corticosteroids, poor oral hygiene). During treatment with zoledronic acid, it is prudent to maintain good oral hygiene, undergo routine dental check-ups, and immediately report any oral symptoms. 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. The clinical judgment of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment.
In the treatment of postmenopausal osteoporosis trial in 7714 patients who received Aclasta or placebo, ONJ has been reported in one patient with Aclasta and one patient treated with placebo. Both cases resolved. In the prevention of clinical fractures after hip fracture trial, in 2111 patients who received Aclasta or placebo there were no reports of ONJ. (See Section 5.1 Pharmacodynamic Properties, Clinical trials.)

Osteonecrosis of other bones.

Cases of osteonecrosis of other bones (including femur, hip, knee and humerus) have also been reported.

Osteonecrosis of the external auditory canal.

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.

Atypical fractures of the femur.

Atypical subtrochanteric and diaphyseal femoral fractures have been reported in association 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 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. Causality has not been established as these fractures also occur in osteoporotic patients who have not been treated with bisphosphonates.
During bisphosphonate treatment, including Aclasta, patients should be advised to report any thigh, hip or groin pain and any patient presenting with such symptoms should be evaluated for possible femur fracture.

Paediatric use.

Aclasta is not recommended for use in children and adolescents below 18 years of age due to lack of data on safety and efficacy.

Use in the elderly.

The postmenopausal osteoporosis trial included 3868 Aclasta treated patients who were at least 65 years of age, while 1497 patients were at least 75 years old. No overall differences in efficacy or safety were observed between patients under 75 years of age with those at least 75 years of age, except that the acute phase reactions occurred less frequently in the older patients.
The prevention of clinical fractures after hip fracture trial included 893 Aclasta treated patients who were at least 65 years of age, while 586 patients were at least 75 years old. Those who were 65 years and older had the same reduction in clinical fractures (35%) as those less than 65 years of age. Those 75 years and older had a 42% reduction in clinical fractures. No overall differences in safety were observed between these patients and younger patients.
However, because decreased renal function occurs more commonly in the elderly, special care should be taken to monitor renal function.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Specific drug-drug interaction studies have not been conducted with zoledronic acid. Zoledronic acid is not systemically metabolised and does not affect human cytochrome P450 enzymes in vitro (see Section 5.2 Pharmacokinetic Properties). Zoledronic acid is not highly bound to plasma proteins (approximately 43-55% bound) and interactions resulting from displacement of highly protein bound drugs are, therefore, unlikely. Zoledronic acid is eliminated by renal excretion.

Drugs that could impact renal function.

Caution is indicated when Aclasta is administered in conjunction with drugs that can significantly impact renal function (e.g. aminoglycosides or diuretics that may cause dehydration).

Drugs primarily excreted by the kidney.

In patients with renal impairment, the systemic exposure to concomitant medicinal products that are primarily excreted via the kidneys may increase.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Fertility was decreased in rats dosed subcutaneously (SC) with zoledronic acid 0.01 mg/kg/day for 71 days (males) or 15 days (females), with animal/ human exposure margins 2-8 (based on cumulative AUC for unbound drug), and preimplantation loss was increased at 0.01 mg/kg/day. Reversible testicular atrophy occurred in rats at 0.003 mg/kg/day SC for 12 months (exposure margin 1). In dogs, testicular and prostatic atrophy and oligospermia were observed at 0.2 mg/kg/day intravenously (IV) for 3 months (exposure margin 160). Testicular atrophy and/or mineralisation were additionally observed in the dog at 0.03 mg/kg IV dosed every 2 to 3 days for 6 months (exposure margin 56), although no such changes were seen at 0.1 mg/kg for 12 months (exposure margin 269). Female dogs had decreased weights of ovaries and uterus, correlated with anoestrus and, in some animals, with vaginal epithelial degeneration at 0.01 mg/kg IV daily for 3 months (exposure margin 14). There were no effects on reproductive organs in dogs dosed with up to 1 mg/kg zoledronic acid by IV infusion once every 3 weeks for 26 weeks (exposure margin 60).

Women of childbearing potential.

Women of childbearing potential should be advised to avoid becoming pregnant while receiving Aclasta. There is a theoretical risk of fetal harm (e.g. skeletal and other abnormalities) if a woman becomes pregnant while receiving 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 on this risk have not been established (see Section 4.6 Fertility, Pregnancy and Lactation, Use in pregnancy; Section 4.3 Contraindications; Section 5.3 Preclinical Safety Data, Carcinogenicity).
(Category B3)
Aclasta is contraindicated during pregnancy (see Section 4.3 Contraindications). There are no data on the use of zoledronic acid in pregnant women. Teratology studies were performed in rats and rabbits, both via subcutaneous administration. Teratogenicity was observed in rats at doses ≥ 0.2 mg/kg (0.2 times clinical exposure based on unbound AUC) and was manifested by external, visceral and skeletal malformations. Dystocia was observed at the lowest dose (0.01 mg/kg bodyweight) tested in rats. No teratological effects were observed in rabbits, but maternal toxicity and increased embryo/ foetal resorption occurred at ≥ 0.03 mg/kg (0.14 times clinical exposure based on dose adjusted for body surface area). In the absence of adequate data in pregnant women, Aclasta is contraindicated during pregnancy. Women who might become pregnant at some time in the future should be warned about the long half-life of bisphosphonates.
 Aclasta is contraindicated in breastfeeding women (see Section 4.3 Contraindications). Studies have not been performed in lactating animals, and the transfer of zoledronic acid into milk is unknown. Because many drugs are excreted in human milk, breastfeeding should be discontinued before Aclasta administration.

4.7 Effects on Ability to Drive and Use Machines

There are no data to suggest that Aclasta affects the ability to drive or use machines. However, patients should be warned about postinfusion hypocalcaemia which is usually asymptomatic but occasionally causes tetany.
Adverse effects of Aclasta include dizziness which could affect the ability to drive or use machines (see Section 4.8 Adverse Effects (Undesirable Effects)).

4.8 Adverse Effects (Undesirable Effects)

Adverse events in clinical trials.

Postmenopausal osteoporosis.

In the phase III randomised, double blind, placebo controlled, multinational study of 7736 postmenopausal women aged 65-89 years (see Section 5.1 Pharmacodynamic Properties, Clinical trials), there were no significant differences in the overall incidence of serious adverse events compared to placebo and most adverse events were mild to moderate. The incidence of all cause mortality was similar between groups: 3.4% in the Aclasta group and 2.9% in the placebo group. Aclasta was administered once yearly for three consecutive years for a total of three doses.
Consistent with the intravenous administration of bisphosphonates, Aclasta has been most commonly associated with the following postdose symptoms: fever (18.1%), myalgia (9.4%), flu-like symptoms (7.8%), arthralgia (6.8%) and headache (6.5%), the majority of which occur within the first 3 days following Aclasta administration. The majority of these symptoms were mild to moderate in nature and resolved within 3 days of the event onset. The incidence of these symptoms decreased markedly with subsequent annual doses of Aclasta.
The incidence of postdose symptoms occurring within the first 3 days after administration of Aclasta can be reduced by approximately 50% with the administration of paracetamol shortly following Aclasta administration.
Adverse events occurring in ≥ 2.0% of postmenopausal women with osteoporosis are shown in Table 1.
The safety results in the three year extension to the treatment of postmenopausal osteoporosis trial suggest that the overall safety profile for zoledronic acid 5 mg yearly is similar in patients who continued therapy for 6 years to patients who stopped treatment after 3 years.

Prevention of clinical fractures after hip fracture.

In a randomised, double blind, placebo controlled, multinational endpoint study of 2127 men and women aged 50-95 years with a recent (within 90 days) low trauma hip fracture, 1065 patients were exposed to Aclasta (zoledronic acid) and 1062 patients exposed to placebo. Aclasta was administered once annually as a single 5 mg dose in 100 mL solution infused over at least 15 minutes until at least 211 patients had a confirmed clinical fracture in the study population who were followed for an average of 2 years on study drug. All participants received 1000 to 1500 mg of elemental calcium plus 800 to 1200 IU of vitamin D supplementation per day.
Most adverse events were of mild to moderate severity and did not lead to discontinuation. The incidence of serious adverse events was 38% in the Aclasta group and 41% in the placebo group. All cause mortality was 9.6% in the Aclasta treated group compared to 13.3% in the placebo group. This corresponds to a 28% reduction in the risk of all cause mortality (p = 0.01).
Aclasta was associated with the following postdose symptoms: fever (7%) and arthralgia (3%), which occur within the first 3 days following Aclasta administration. The majority of these symptoms were mild to moderate in nature and resolved within 3 days of the event onset. The incidence of these symptoms decreased with subsequent doses of Aclasta. The main reason for the lower rate of postdose symptoms in this trial compared to the rate of postdose symptoms in the treatment of postmenopausal osteoporosis trial was that, in this prevention of clinical fractures after hip fracture trial, paracetamol was provided to patients and its use encouraged to manage postdose symptoms.
Adverse events occurring in ≥ 2.0% of men and women following hip fracture (prevention of clinical fractures after hip fracture) are shown in Table 1.

Treatment of male osteoporosis.

The safety of Aclasta in men with osteoporosis or significant osteoporosis secondary to hypogonadism was assessed in a two year randomised, multicentre, double blind, active controlled group study of 302 men aged 25-86 years. One hundred and fifty three patients were exposed to Aclasta administered once annually as a single 5 mg dose in 100 mL infused over 15 minutes for a total of two doses and 148 patients were exposed to oral alendronate 70 mg weekly for two years. All participants received 1000 mg elemental calcium plus 800 to 1000 IU vitamin D supplementation per day.
The incidence of serious adverse events was similar between the Aclasta and alendronate treatment groups. The percentage of patients experiencing at least one adverse event was comparable between the Aclasta and alendronate treatment groups, with the exception of a higher incidence of postdose symptoms in the Aclasta group that occurred within 3 days after infusion. The overall safety and tolerability profile of Aclasta in male osteoporosis was similar to that reported in the Aclasta postmenopausal osteoporosis trial.
Adverse events reported in at least 2% of men with osteoporosis and more frequently in the Aclasta treatment group than the alendronate group and either not reported in the postmenopausal osteoporosis trial or reported more frequently in the osteoporosis trial in men are presented in Table 2.

Treatment and prevention of glucocorticoid induced osteoporosis.

The safety of Aclasta in men and women in the treatment and prevention of glucocorticoid induced osteoporosis was assessed in a randomised, multicentre, double blind, active controlled, stratified study of 833 men and women aged 18-85 years treated with > 7.5 mg/day oral prednisone (or equivalent). Patients in the prevention subpopulation were treated with glucocorticoids < 3 months prior to randomisation, and the treatment subpopulation was treated with glucocorticoids > 3 months prior to randomisation.
The duration of the trial was one year, with 416 patients exposed to Aclasta administered once as a single 5 mg dose in 100 mL infused over 15 minutes and 417 patients exposed to oral risedronate 5 mg daily for one year. All participants received 1000 mg elemental calcium plus 400 to 1000 IU vitamin D supplementation per day.
The incidence of serious adverse events was similar between the Aclasta and risedronate treatment groups. Overall safety and tolerability were similar between the Aclasta and risedronate groups, with the exception of a higher incidence of postdose symptoms in the Aclasta group that occurred within 3 days after infusion. The overall safety and tolerability profile of Aclasta in glucocorticoid induced osteoporosis was similar to that reported in the Aclasta postmenopausal osteoporosis clinical trial.
Adverse events reported in at least 2% of patients that were either not reported in the postmenopausal osteoporosis trial or reported more frequently in the treatment and prevention of glucocorticoid induced osteoporosis trial are presented in Table 3.

Paget's disease of bone.

In the Paget's disease trials, two 6 month, double blind, comparative, multinational studies of 349 men and women aged > 30 years with moderate to severe disease and with confirmed Paget's disease of bone, 177 patients were exposed to Aclasta and 172 patients exposed to risedronate. Aclasta was administered once as a single 5 mg dose in 100 mL solution infused over at least 15 minutes. Risedronate was given as an oral daily dose of 30 mg for 2 months.
The signs and symptoms of acute phase reaction (influenza-like illness, pyrexia, myalgia, arthralgia and bone pain) were reported in 25% of patients in the Aclasta treated group compared to 8% in the risedronate treated group. Symptoms usually occur within the first 3 days following Aclasta administration. The majority of these symptoms resolved within 4 days of onset.
Adverse events occurring in at least 2% of the Paget's patients receiving Aclasta (single 5 mg IV infusion) or risedronate (30 mg oral daily dose for 2 months) over a 6 month study period are listed by system organ class in Table 4.

Adverse reactions with suspected relationship to product.

Table 5 lists the adverse reactions suspected (investigator assessment) to be associated with Aclasta in the pooled studies supporting the indications: treatment of osteoporosis in men and postmenopausal women, prevention of clinical fractures after low trauma hip fracture, treatment and prevention of glucocorticoid induced osteoporosis and Paget's disease of the bone by system organ class and by frequency using the following convention: very common (≥ 1/10), common (≥ 1/100, < 1/10), uncommon (≥ 1/1,000, < 1/100), rare (≥ 1/10,000, < 1/1,000) adverse drug reactions.
Additional adverse reactions which were reported in the individual studies but are not included in Table 5 (due to a lower frequency in the Aclasta group compared with that of the placebo group when the data were pooled) include:

Cardiac disorders.

Atrial fibrillation*, palpitations.

Eye disorders.

Ocular hyperemia.

Gastrointestinal disorders.

Gastritis, toothache.

General disorders and administration site conditions.

Infusion site reaction.

Investigations.

C-reactive protein increased.

Metabolism and nutrition disorders.

Hypocalcaemia.

Nervous system disorders.

Dysgeusia.
*See below 'Atrial fibrillation' in 'Description of selected adverse reactions'.

Description of selected adverse reactions.

Renal impairment.

Treatment with intravenous bisphosphonates, including zoledronic acid, has been associated with renal impairment manifested as deterioration in renal function (i.e. increased serum creatinine) and in rare cases acute renal failure. Renal impairment has been observed following the administration of zoledronic acid, especially in patients with pre-existing renal impairment or additional risk factors e.g. advanced age, oncology patients with chemotherapy, concomitant nephrotoxic medications, concomitant diuretic therapy, severe dehydration with the majority of them receiving a 4 mg dose every 3-4 weeks, but it has been observed in patients after a single administration.
In the treatment of postmenopausal osteoporosis core trial, the change in creatinine clearance (measured annually prior to dosing), and the incidence of renal failure and impairment were comparable for both the Aclasta and placebo treatment groups over 3 years. There was a transient increase in serum creatinine observed within 10 days in 1.8% of Aclasta treated patients versus 0.8% of placebo treated patients.
In the prevention of clinical fractures after hip fracture trial, the change in creatinine clearance (measured annually prior to dosing), and the incidence of renal failure and impairment were comparable for both the Aclasta and placebo treatment groups over 3 years.
In clinical trials in Paget's disease, there were no cases of renal deterioration following a single 5 mg 15 minute infusion.

Hypocalcemia.

In the treatment of postmenopausal osteoporosis trial, approximately 0.2% of patients had notable declines of serum calcium levels (less than 1.87 mmol/L) following Aclasta administration. No symptomatic cases of hypocalcemia were observed.
In the prevention of clinical fractures after hip fracture trial, there were no patients who had treatment emergent serum calcium levels below 1.87 mmol/L.
In the Paget's disease trials, symptomatic hypocalcemia was observed in approximately 1% of patients, all of which resolved.

Local reactions.

In the treatment of postmenopausal osteoporosis trial, local reactions at the infusion site such as redness, swelling and/or pain were reported (0.7%) following the administration of zoledronic acid.
In the prevention of clinical fractures after hip fracture trial, the event rate was comparable for both Aclasta and placebo treatment groups.

Osteonecrosis of the jaw (ONJ).

Cases of osteonecrosis (primarily of the jaw) have been reported predominantly in cancer patients treated with bisphosphonates, including zoledronic acid (uncommon). Many of these patients had signs of local infection including osteomyelitis, and the majority of the reports refer to cancer patients following tooth extractions or other dental surgeries. Osteonecrosis of the jaw has multiple documented risk factors including a diagnosis of cancer, concomitant therapies (e.g. chemotherapy, antiangiogenic drugs, radiotherapy, corticosteroids) and comorbid conditions (e.g. anaemia, coagulopathies, infection, pre-existing dental disease). Although causality has not been determined, it is prudent to avoid dental surgery as recovery may be prolonged.
In the treatment of postmenopausal osteoporosis core trial in 7736 intention to treated (ITT) patients, ONJ has been reported in one patient treated with Aclasta and one patient treated with placebo. Both cases resolved.
In the prevention of clinical fractures after hip fracture trial, there were no reports of osteonecrosis of the jaw.

Atrial fibrillation.

In one clinical trial, the overall incidence of atrial fibrillation was 2.5% (96 out of 3862) and 1.9% (75 out of 3852) in patients receiving Aclasta and placebo, respectively. The rate of atrial fibrillation serious adverse events was increased in patients receiving Aclasta (1.3%) (51 out of 3862) compared with patients receiving placebo (0.6%) (22 out of 3852). The mechanism behind the increased incidence of atrial fibrillation is unknown. These imbalances were not observed in other trials; the overall pooled atrial fibrillation incidences were 2.6% for Aclasta and 2.1% for placebo and for serious adverse events, the pooled incidences were 1.3% for Aclasta and 0.8% for placebo.

Eye disorders.

Cases of iritis/ uveitis/ episcleritis/ conjunctivitis have been reported in patients treated with bisphosphonates. In the treatment of postmenopausal osteoporosis trial, 9 (0.2%) patients treated with Aclasta and 1 (< 0.1%) patient treated with placebo developed iritis/ uveitis/ episcleritis. Patients who develop ocular symptoms after a zoledronic acid infusion should seek medical help.

Post-marketing experience.

The following adverse drug reactions have been derived from post-marketing experience with Aclasta via spontaneous case reports and literature cases. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency which is therefore categorized as not known. Adverse drug reactions are listed according to system organ classes in MedDRA. Within each system organ class, ADRs are presented in order of decreasing seriousness.

Eye disorders.

Scleritis, parophthalmia.

Immune system disorders.

Hypersensitivity reactions including anaphylactic reaction, anaphylactic shock, angioedema, bronchospasm, urticaria.

Metabolism and nutrition disorders.

Dehydration secondary to postdose symptoms such as pyrexia, vomiting and diarrhea; hypotension in patients with underlying risk factors; hypophosphataemia.

Musculoskeletal and connective tissue disorders.

Osteonecrosis of jaw (see Section 4.4 Special Warnings and Precautions for Use).

Renal and urinary disorders.

Renal failure requiring dialysis or with fatal outcome*, renal impairment (see Section 4.4 Special Warnings and Precautions for Use).
*Especially in patients with pre-existing renal compromise or other risk factors such as advanced age, concomitant nephrotoxic medicinal products, concomitant diuretic therapy, or dehydration in the postinfusion period.
In 2010, the Atypical Femoral Fractures Task Force Report identified that subtrochanteric and diaphyseal fractures, with or without atypical features have been estimated as 1 to 3 reports per 1,000,000 patient years of exposure to bisphosphonates.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.

4.9 Overdose

Clinical experience with acute overdosage is limited. Patients who have received doses higher than those recommended should be carefully monitored. In the event of overdose leading to clinically significant hypocalcaemia, reversal may be achieved with supplemental oral calcium and/or an infusion of calcium gluconate.
For information on the management of overdose, contact the Poison Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Pharmacotherapeutic group: Bisphosphonate (ATC code: M05B A08).
Zoledronic acid belongs to the class of nitrogen containing bisphosphonates and acts primarily on bone. It is an inhibitor of osteoclast mediated bone resorption.

Mechanism of action.

The action of bisphosphonates on bone is based on their high affinity for mineralised bone. Intravenously administered zoledronic acid is rapidly distributed to bone. The main molecular target of zoledronic acid in the osteoclast is the enzyme farnesyl pyrophosphate synthase, but this does not exclude other mechanisms.
Osteoporosis. Aclasta treatment rapidly reduced the rate of bone turnover from elevated postmenopausal levels with the nadir for resorption markers observed at 7 days, and for formation markers at 12 weeks. Thereafter, bone markers stabilised within the premenopausal range. There was no progressive reduction of bone turnover markers with repeated annual dosing.

Bone histology.

In the postmenopausal osteoporosis treatment trial, bone biopsy specimens were obtained between months 33 and 36 from 82 postmenopausal patients with osteoporosis treated with 3 annual doses of Aclasta. Of the biopsies obtained, 81 were adequate for qualitative histomorphometry assessment, 59 were adequate for partial quantitative histomorphometry assessment and 38 were adequate for full quantitative histomorphometry assessment. Micro CT analysis was performed on 76 specimens. Qualitative, quantitative and micro CT assessments showed bone of normal architecture and quality without mineralisation defects.
In the treatment and prevention of glucocorticoid induced osteoporosis trial, bone biopsy specimens were obtained at month 12 from 23 patients treated with either an annual dose of Aclasta or daily oral risedronate (12 in the Aclasta treatment group and 11 in the risedronate treatment group). All biopsies were adequate for qualitative histomorphometry assessment. Qualitative assessments showed bone of normal architecture and quality without mineralisation defects. Apparent reductions in activation frequency and remodelling rates were seen when compared with the histomorphometry results seen with Aclasta in the postmenopausal osteoporosis population. The long term consequences of this degree of suppression of bone remodelling in glucocorticoid treated patients is unknown.
Paget's disease of bone. Paget's disease of bone is a chronic, focal skeletal disorder characterised by greatly increased and disorderly bone remodelling. Excessive osteoclastic bone resorption is followed by irregular osteoblastic new bone formation, leading to the replacement of the normal bone architecture by disorganised, enlarged and weakened bone structure. Clinical manifestations of Paget's disease range from no symptoms to severe morbidity due to bone pain, bone deformity, pathological fractures, and neurological and other complications. Serum alkaline phosphatase, the most frequently used biochemical index of disease activity, provides an objective measure of disease severity and response to therapy.
In two 6 month randomised comparative, controlled clinical trials in patients with Paget's disease, biochemical markers of bone formation and resorption demonstrated normalisation of bone turnover in more Aclasta treated patients compared to risedronate treated patients (see Section 5.1 Pharmacodynamic Properties, Clinical trials).

Bone histology.

In the two trials in patients with Paget's disease, bone histology was evaluated in 7 patients 6 months after treatment with 5 mg zoledronic acid. Bone biopsy results showed bone of normal quality with no evidence of impaired bone remodelling and no evidence of mineralisation defects. These results were consistent with biochemical marker evidence of normalisation of bone turnover.

Clinical trials.

Clinical efficacy for the treatment of postmenopausal osteoporosis.

The efficacy and safety of Aclasta were demonstrated in a randomised, double blind, placebo controlled, multinational study of 7736 ambulant women aged 65 to 89 years with either a femoral neck BMD T-score less than or equal to -1.5 and at least two mild or one moderate existing vertebral fracture(s); or a femoral neck BMD T-score less than or equal to -2.5 with or without evidence of an existing vertebral fracture(s). Clinical experience in postmenopausal women without a history of low trauma hip fracture is limited to women aged over 63 years. Patients pretreated with other bisphosphonates were excluded except if they complied with a washout schedule of between two months and two years, determined by the duration of pretreatment; for instance, patients who had used oral bisphosphonates for more than 8 weeks but less than 48 weeks were eligible after a washout period of at least one year; more extensively pretreated patients were eligible after a washout period of at least 2 years. There are limited 12 month evaluated clinical data on the use of Aclasta in patients who had been extensively treated with bisphosphonates but without a washout period. In the pivotal studies, extensively pretreated patients were enrolled after a washout period of two years. This experience should be considered when selecting patients for Aclasta treatment.
Aclasta was administered once a year for three consecutive years, as a single 5 mg dose in 100 mL solution infused over at least 15 minutes for a total of three doses. The two primary efficacy variables were the incidence of morphometric vertebral fractures at 3 years and the incidence of hip fractures over a median duration of 3 years. 7736 women were evaluated for the incidence of hip and all clinical fractures. Of these, 5661 women were evaluated annually for incidence of vertebral fractures. Women who were evaluated for the incidence of vertebral fractures did not receive concomitant osteoporosis therapy, which was allowed for women contributing to the hip and all clinical fracture evaluations. Concomitant osteoporosis therapy included calcitonin, raloxifene, tamoxifen, hormone replacement therapy, tibolone; but excluded other bisphosphonates. All women received 1000 to 1500 mg of elemental calcium plus 400 to 1200 IU of vitamin D supplements per day.
Primary efficacy variables.

Effect on vertebral fracture.

Aclasta significantly decreased the incidence of one or more new vertebral fractures over three years and as early as the one year time point (see Table 6).
The reductions in vertebral fractures over three years were consistent and significantly greater than placebo regardless of age, geographical region, race, baseline body mass index, number of baseline vertebral fractures, femoral neck BMD T-score or prior bisphosphonate use. Specifically for patients aged 75 years and older, Aclasta patients had a 61% reduction in the risk of vertebral fractures compared to placebo patients (p < 0.0001).

Effect on hip fracture.

Aclasta demonstrated a 41% reduction in the risk of hip fractures over 3 years. The hip fracture event rate was 1.4% for Aclasta treated patients compared to 2.5% for placebo treated patients. The effect over time is displayed in Figure 1.
The reduction in the risk of hip fractures was similar in women who did not take concomitant osteoporosis therapy to women who were allowed to take concomitant therapy. In 6084 women who did not take concomitant osteoporosis therapy, Aclasta demonstrated a 41% reduction (95% CI, 13% to 59%) in the risk of hip fractures over this time period. In 1652 women who were allowed to take concomitant osteoporosis therapy, a comparable 42% reduction in the risk of hip fractures was observed (95% CI, -2.7% to 73%). The study was not powered to determine if this difference was statistically significant.
The reductions in hip fractures over three years were greater than placebo regardless of femoral neck BMD T-score.
Secondary efficacy variables.

Effect on vertebral fractures.

Aclasta significantly decreased the risk of one or more new/ worsening vertebral fractures at 1 year (58%), 2 years (68%) and 3 years (67%) (all p < 0.0001). Aclasta significantly decreased the risk of at least one new moderate or severe vertebral fracture at 1 year (60%), 2 years (71%) and 3 years (70%) (all p < 0.0001).

Effect on all clinical fractures.

Aclasta demonstrated superiority to placebo in reducing the incidence of all clinical fractures, clinical vertebral and nonvertebral fractures. All clinical fractures were verified based on the radiographic and/or clinical evidence. A summary of results is presented in Table 7.

Effect on bone mineral density (BMD).

Aclasta significantly increased BMD at the lumbar spine, hip and distal radius relative to treatment with placebo at all time points (6, 12, 24 and 36 months). Treatment with Aclasta resulted in a 6.7% increase in BMD at the lumbar spine, 6.0% at the total hip, 5.1% at the femoral neck and 3.2% at the distal radius over 3 years as compared to placebo.

Bone turnover markers.

Bone specific alkaline phosphatase (BSAP), serum N-terminal propeptide of type I collagen (P1NP) and serum beta-C-telopeptides (beta-CTx) were evaluated in subsets ranging from 517 to 1246 patients at periodic intervals throughout the study. Treatment with a 5 mg annual dose of Aclasta reduces bone turnover markers to the premenopausal range. Repeat dosing does not lead to further reduction of bone turnover markers.

Effect on height.

In the 3 year osteoporosis study, standing height was measured annually using a stadiometer. The Aclasta group revealed less height loss compared to placebo (4.2 mm vs.7.0 mm, respectively (p < 0.001)).

Days of disability.

Aclasta significantly reduced both the days of limited activity and the days of bed rest due to fractures compared to placebo (both p < 0.01). Aclasta also significantly reduced both the days of limited activity and the days of bed rest due to back pain compared to placebo (both p ≤ 0.008).

Effects of prolonged therapy and its discontinuation.

The effects of prolonged zoledronic acid therapy as well as its discontinuation were assessed in a 3 year extension to the treatment of postmenopausal osteoporosis trial. The extension was a randomised, double blind, multinational study in 2456 ambulatory postmenopausal women who had completed participation in the core study. The same dosing regimen of zoledronic acid was used in the extension study as in the core study (5 mg intravenous infusion once yearly). The trial design did not allow identification of the specific subset of patients likely to benefit.
The extension study demonstrated that the therapeutic benefit of continued annual zoledronic acid therapy on maintaining or increasing BMD in women with postmenopausal osteoporosis is sustained long-term, while the discontinuation of therapy results in a gradual loss of bone mass.
Compared to treatment with zoledronic acid for 3 years followed by 3 years of placebo, treatment with zoledronic acid for 6 years significantly reduced the risk of new morphometric vertebral fractures by 52% (p < 0.05) and significantly reduced the risk of new or worsening morphometric fractures by 51% (p < 0.05). No significant differences were observed between the two groups in the risk of clinical, nonvertebral, hip and clinical vertebral fractures. There is no statistically significant difference in clinical fractures between the group who received zoledronic acid for 6 years compared to the group who received zoledronic acid for 3 years followed by 3 years of placebo.
Bone marker levels remained below pretreatment levels 6 years earlier and mean values remained within the premenopausal reference range for all 3 biomarkers.
There were no cases of atypical femoral fractures in the extension study. See Figure 2.

Clinical efficacy in the prevention of clinical fractures after hip fracture.

The efficacy and safety of Aclasta in the prevention of clinical fractures in patients who suffered a recent low trauma hip fracture were demonstrated in a randomised, double blind, placebo controlled, multinational endpoint study of 2127 ambulant men and women aged 50-95 years (mean age of 74.5). The incidence of clinical fractures, including vertebral, nonvertebral and hip fractures, was evaluated in 2127 men and women with a recent (within 90 days) low trauma hip fracture (pertrochanteric or femoral neck) but not malignant fractures and fractures associated with previously implanted orthopedic devices. The washout periods for patients who had been pretreated with other bisphosphonates were the same as those in the postmenopausal osteoporosis study described above. Patients were followed for an average of 2 years on study drug. The following concomitant osteoporosis therapies were allowed: calcitonin, raloxifene, tamoxifen, hormone replacement therapy, tibolone, DHEA(s), ipriflavone and testosterone, as hormone replacement in the case of hypogonadal men; but excluded other bisphosphonates and parathyroid hormone.
Aclasta was administered once a year as a single 5 mg dose in 100 mL solution, infused over at least 15 minutes, until at least 211 patients had confirmed clinical fractures in the study population. Vitamin D levels were not routinely measured but a loading dose of vitamin D (50,000 to 125,000 IU orally or via the intramuscular route) was given to the majority of patients 2 weeks prior to infusion. All participants received 1000 to 1500 mg of elemental calcium plus 800 to 1200 IU of vitamin D supplementation per day. The primary efficacy variable was the incidence of clinical fractures over the duration of the study.
Primary efficacy variable.

Effect on all clinical fractures.

In the prevention of clinical fractures after hip fracture trial, treatment with Aclasta significantly reduced the incidence of any clinical fracture by 35% (see Table 8).
Secondary efficacy variables.

Other clinical fracture endpoints.

There was also a 46% reduction in the risk of a clinical vertebral fracture; a 27% reduction in the risk for nonvertebral fractures with Aclasta. There was a 30% reduced risk for a subsequent hip fracture that was observed for the Aclasta group that did not meet statistical significance. See Table 8.

Effect on bone mineral density (BMD).

In the prevention of clinical fractures after hip fracture trial, Aclasta treatment significantly increased BMD relative to placebo at the hip and femoral neck at all time points (12, 24 and 36 months). Treatment with Aclasta resulted in a 5.4% increase at the total hip and 4.3% at the femoral neck over 24 months as compared to placebo. Similar significant results were observed for femoral neck BMD measures.

Treatment of male osteoporosis.

The efficacy and safety of Aclasta in men with osteoporosis were assessed in a randomised, multicentre, double blind, active controlled study of 302 men aged 25 to 86 years (mean age of 64 years) with either a femoral neck BMD T-score less than or equal to -2.0 and a lumbar spine BMD T-score less than or equal to -1.0 or a femoral neck BMD T-score less than or equal to -1.0 and at least one vertebral deformity or a history of an osteoporotic fracture. The duration of the trial was two years. Patients were randomised to either Aclasta, which was administered once annually as a single 5 mg dose in 100 mL infused over 15 minutes for a total of two doses, or to oral alendronate 70 mg weekly for two years. All participants received 1000 mg elemental calcium plus 800 to 1000 IU vitamin D supplementation per day. Efficacy was demonstrated if noninferiority to alendronate was shown with respect to the percentage change in lumbar spine BMD at 24 months relative to baseline.
Aclasta has not been studied in hypogonadal men. Fracture data are not available from the study.

Effect on bone mineral density (BMD).

An annual infusion of Aclasta was noninferior to weekly alendronate for the percentage change in lumbar spine BMD at month 24 relative to baseline (Aclasta 6.1% compared to alendronate 6.2%). The percentage increases in lumbar spine BMD at month 12 were also similar between treatment groups. The criterion for noninferiority of zoledronic acid by comparison with alendronate was met as the lower bound of the 95% CI (-1.12 for the ITT population, -1.27 per protocol) exceeded the prespecified noninferiority margin of -1.5%.

Treatment and prevention of glucocorticoid induced osteoporosis.

The efficacy and safety of Aclasta in the treatment and prevention of glucocorticoid induced osteoporosis were assessed in a randomised, multicentre, double blind, stratified, active controlled study of 833 men and women aged 18 to 85 years (mean age of 54.4 years) treated with > 7.5 mg/day oral prednisone (or equivalent). Patients in the prevention subpopulation were treated with glucocorticoids < 3 months prior to randomisation, and the treatment subpopulation was treated with glucocorticoids ≥ 3 months prior to randomisation. The duration of the trial was one year. Patients were randomised to either Aclasta, which was administered once as a single 5 mg dose in 100 mL infused over 15 minutes, or to oral risedronate 5 mg daily for one year. All participants received 1000 mg elemental calcium plus 400 to 1000 IU vitamin D supplementation per day.
The study was designed to show noninferiority of a single infusion of Aclasta relative to risedronate in these two subpopulations. Efficacy was demonstrated if noninferiority to risedronate was shown sequentially with respect to the percentage change in lumbar spine BMD at 12 months relative to baseline in the treatment and prevention subpopulations, respectively.
This was not a fracture study and limited data only are available: over the 12 months of the study, new vertebral fractures detected by X-ray morphometry occurred in 5/379 (1.3%) of Aclasta treated patients and assessed, compared to 3/381 (0.8%) in the risedronate treated group. An analysis of the time to first clinical fracture during the study period showed no difference between the treatment groups. During the 12 month study, 8 Aclasta treated patients and 7 risedronate treated patients had at least one clinical fracture.

Effect on bone mineral density (BMD).

Noninferiority to risedronate was shown. There was a trend to greater increase in BMD in the Aclasta treated group in both the treatment and prevention subpopulations at all sites, which included the lumbar spine, femoral neck, total hip, trochanter and distal radius at 12 months compared to risedronate. A summary of the key results appears in Table 9.

Clinical efficacy for the treatment of Paget's disease of bone.

Aclasta was studied in male and female patients aged above 30 years with mild to moderate Paget's disease of the bone (median serum alkaline phosphatase level 2.6-3.0 times the upper limit of the age specific normal reference range at the time of study entry) confirmed by radiographic evidence.
The efficacy of one infusion of 5 mg Aclasta versus daily doses of 30 mg risedronate for 2 months was demonstrated in two 6 month controlled comparative trials. The primary objective of these trials was to show noninferiority of zoledronic acid compared to risedronate with respect to the proportion of patients who achieved a therapeutic response at 6 months. Noninferiority was defined as: zoledronic acid is noninferior to risedronate if the lower bound of a two sided 95% confidence interval for the difference between zoledronic acid and risedronate in the proportion of therapeutic responders exceeded -0.16. If noninferiority was shown and the predefined noninferiority margin was exceeded, testing for superiority would be performed.
The primary outcome variable was the proportion of patients achieving a therapeutic response defined as either normalisation of serum alkaline phosphatase (SAP) or a reduction of at least 75% from baseline in total SAP excess at the end of 6 months. SAP excess was defined as the difference between the measured level and midpoint of the normal range.
At 6 months, combined data from both trials showed that 96.0% (169/176) Aclasta treated patients achieved a therapeutic response as compared with 74.3% (127 of 171) of patients treated with risedronate (p < 0.001). In addition, at 6 months, 88.6% (156/176) of Aclasta treated patients achieved remission (normalisation of SAP levels) compared to 57.9% (99/171) of patients treated with risedronate (p < 0.0001). Noninferiority was found (the difference between combined groups was 0.22 (0.14, 0.30)).
In combined data from both trials, after 2 months, the therapeutic response rate was 90% (158/176) and the SAP normalisation rate was 63% (111/176) compared to 47% (81/171) and 26% (45/171) respectively for risedronate (all p < 0.001).
In the pooled results, a similar decrease in pain severity and pain interference scores relative to baseline were observed over 6 months for Aclasta and risedronate.
The therapeutic response by subgroup is presented in Table 10.
The adverse reaction profile reflects a very common incidence of acute phase reactions in the zoledronic acid group (influenza like illness, pyrexia, myalgia, arthralgia and bone pain).

Extended observation period.

Patients who were classified as responders at the end of the 6 month core study were eligible to enter an extended follow-up period. Of the 152 Aclasta treated patients and 115 risedronate treated patients who entered an extended observation study, after a median duration of follow-up of 3.8 years from time of dosing, the proportion of patients ending the extended observation period due to the need for retreatment (clinical judgment) was higher for risedronate (48 patients, or 41.7%) compared with zoledronic acid (11 patients, or 7.2%). The mean time of ending the extended observation period due to the need for Paget's retreatment from the initial dose was longer for zoledronic acid (7.7 years) than for risedronate (5.1 years). 135 Aclasta treated patients maintained their therapeutic response compared to 44 risedronate treated patients.
The cumulative rate of maintaining therapeutic response in the extended follow-up period is displayed in Figure 3.
Time to first loss of therapeutic response: the occurrence of an SAP level that no longer meets the criteria of a therapeutic response (less than 75% reduction in SAP excess and/or SAP above the upper limit of the normal range).
Six patients who achieved therapeutic response 6 months after treatment with Aclasta and later experienced disease relapse during the extended follow-up period were retreated with Aclasta after a mean time of 6.5 years from initial treatment to retreatment. Five of the 6 patients had serum alkaline phosphatase within the normal range at month 6.

5.2 Pharmacokinetic Properties

Single and multiple 5 and 15 minute infusions of 2, 4, 8 and 16 mg zoledronic acid in 64 patients yielded the following pharmacokinetic data, which were found to be dose independent.
After initiation of the zoledronic acid infusion, plasma concentrations of the active substance increased rapidly, achieving their peak at the end of the infusion period, followed by a rapid decline to < 10% of peak after 4 hours and < 1% of peak after 24 hours, with a subsequent prolonged period of very low concentrations not exceeding 0.1% of peak levels.

Distribution.

There was no accumulation of the active substance in plasma after multiple doses given every 28 days. The early disposition phases (alpha and beta, with t1/2 values below) presumably represent rapid uptake into bone and excretion via the kidneys.
Zoledronic acid is not highly bound to plasma proteins (approximately 30-60% bound) and binding is concentration and divalent cation ion dependent. Interactions resulting from displacement of highly protein bound drugs are unlikely.

Metabolism.

Zoledronic acid is not metabolised in humans. The substance was found to have little or no capacity as a direct acting and/or irreversible metabolism dependent inhibitor of P450 enzymes, therefore, zoledronic acid is unlikely to reduce the metabolic clearance of substances which are metabolised via the cytochrome P450 enzyme systems.

Excretion.

Intravenously administered zoledronic acid is eliminated by a triphasic process: rapid biphasic disappearance from the systemic circulation, with half-lives of t½alpha 0.24 and t½beta 1.87 hours, followed by a long elimination phase with a terminal elimination half-life of t½gamma 146 hours.
Zoledronic acid is not metabolised and is excreted unchanged via the kidney. Over the first 24 hours, 39 ± 16% of the administered dose is recovered in the urine, while the remainder is principally bound to bone tissue. From the bone tissue it is released very slowly back into the systemic circulation and eliminated via the kidney. The total body clearance is 5.04 ± 2.5 L/h, independent of dose and unaffected by gender, age, race or bodyweight. The inter- and intra-subject variation for plasma clearance of zoledronic acid was shown to be 36% and 34%, respectively. Increasing the infusion time from 5 to 15 minutes caused a 30% decrease in zoledronic acid concentration at the end of the infusion, but had no effect on the area under the plasma concentration versus time curve.
No specific drug-drug interaction studies have been conducted with zoledronic acid. Since zoledronic acid is not metabolised in humans and the substance was found to have little or no capacity as a direct acting and/or irreversible metabolism dependent inhibitor of P450 enzymes, zoledronic acid is unlikely to reduce the metabolic clearance of substances which are metabolised via the cytochrome P450 enzyme systems.

Pharmacokinetics in special patient groups.

The renal clearance of zoledronic acid was correlated with creatinine clearance, renal clearance representing 75 ± 33% of the creatinine clearance, which showed a mean of 84 ± 29 mL/min (range 22 to 143 mL/min) in the 64 patients studied. Small observed increases in AUC(0-24hr), by about 30% to 40% in mild to moderate renal impairment, compared to a patient with normal renal function, and lack of accumulation of drug with multiple doses irrespective of renal function, suggest that dose adjustments of zoledronic acid in mild (Clcr = 50-80 mL/min) and moderate (Clcr = 35-50 mL/min) renal impairment are not necessary. The use of Aclasta in patients with creatinine clearance < 35 mL/min is contraindicated due to an increased risk of renal failure in this population (see Section 4.3 Contraindications). No dose adjustment is necessary in patients with creatinine clearance ≥ 35 mL/min.

5.3 Preclinical Safety Data

Carcinogenicity.

In carcinogenicity studies, zoledronic acid was administered orally by gavage to rats and mice at daily doses of 0.1, 0.5 and 2.0 mg/kg and 0.1, 0.3 and 1.0 mg/kg, respectively, for at least 104 weeks without evidence of carcinogenic potential. Pharmacological bone changes typically observed following long-term bisphosphonate administration to young animals with growing skeletons were observed in these studies, suggesting systemic exposure to zoledronic acid in both species.

Genotoxicity.

Zoledronic acid was not mutagenic in bacterial reverse mutation tests in Salmonella typhimurium and Escherichia coli or in cultured V79 Chinese hamster lung cells. Zoledronic acid did not induce chromosome aberrations in an in vitro test in Chinese hamster ovary cells or in an in vivo micronucleus test in rats.

Long term studies.

In long-term animal studies, zoledronic acid inhibits bone resorption without adversely affecting bone formation, mineralisation or the mechanical properties of bone. Histomorphometric data from long-term rat and monkey experiments showed the typical response of bone to an anti-resorptive agent with a dose-dependent reduction in osteoclast activity and activation frequency of new remodelling sites in both trabecular and Haversian bone. Continuing bone remodelling was observed in bone samples from all animals treated with zoledronic acid. There was no evidence of a mineralising defect, no aberrant accumulation of osteoid and no woven bone in treated animals.

6 Pharmaceutical Particulars

6.1 List of Excipients

Mannitol, sodium citrate dihydrate, water for injections.

6.2 Incompatibilities

Aclasta solution for infusion must not be allowed to come into contact with any calcium- or other divalent cation-containing solutions.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 30°C. Aclasta must be kept out of the reach and sight of children. After opening, the solution is chemically and physically stable for at least 24 hours.

6.5 Nature and Contents of Container

Aclasta 5 mg/100 mL solution for infusion is supplied in a 100 mL transparent plastic vial closed with a fluoro-polymer-coated bromobutyl rubber stopper and an aluminium/polypropylene cap with a flip component. Aclasta is supplied as packs containing one vial and multipacks comprising three or six packs, each containing one vial.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

The active ingredient of Aclasta is a bisphosphonate, zoledronic acid, or 1-hydroxy-2- (1H-imidazol-1-yl) ethane-1,1- diphosphonic acid. Although zoledronic acid is marketed by Sandoz as a monohydrate, doses refer to the anhydrous substance.
Zoledronic acid monohydrate is a white, crystalline powder. It is soluble in water, most soluble at neutral pH (> 290 mg/mL; pH=6.8) and practically insoluble in organic solvents.

Chemical structure.

The chemical structure of zoledronic acid monohydrate is:
Empirical formula: C5H10N2O7P2.H2O.
Relative molecular mass: 290.11.

CAS number.

165800-06-6 (zoledronic acid monohydrate).
118072-93-8 (zoledronic acid anhydrous).

7 Medicine Schedule (Poisons Standard)

Prescription Medicine (Schedule 4).

Summary Table of Changes