Consumer medicine information

Fosamax Plus D-Cal Combination pack

Alendronic acid; Colecalciferol; Calcium carbonate

BRAND INFORMATION

Brand name

Fosamax Plus D-Cal Combination pack

Active ingredient

Alendronic acid; Colecalciferol; Calcium carbonate

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Fosamax Plus D-Cal Combination pack.

What is in this leaflet

This leaflet answers some common questions about FOSAMAX PLUS D-Cal. It is particularly important that you read the sections "When to take it" and "How to take it" before you take this medicine. This leaflet does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking FOSAMAX PLUS D-Cal against the benefits they expect it will have for you.

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

Keep this leaflet with the medicine.

You may need to read it again.

What FOSAMAX PLUS D-Cal is used for

FOSAMAX PLUS D-Cal is a combination medicine consisting of 4 once weekly tablets of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) together with 48 tablets of BoneCal®.

FOSAMAX PLUS D-Cal is used to treat osteoporosis and to provide additional vitamin D and additional calcium.

Osteoporosis is caused by changes in the way bone is normally maintained. Vitamin D is an essential nutrient required for calcium absorption and healthy bones. Calcium is an essential mineral, necessary to maintain the bone structure in the body.

Understanding bone

Bone is a living, growing tissue. Throughout life, our bodies are breaking down old bone and rebuilding new bone in a continuous cycle. Until our late 20s, while bones are still developing, we gain bone by building more than we lose. From then until about age 35 the process is usually in balance, so that the amount of bone lost is about equal to the amount that is replaced. This balanced process keeps your skeleton healthy and strong. After about age 35 this balance is disturbed, with bone loss occurring at a slightly faster rate than it can be replaced. In women, after menopause, hormonal changes cause bone loss at an even faster rate. When bone loss is excessive, bones can become thinner and weaker, and therefore are more likely to break.

Osteoporosis

"Osteo" means bone, and "porosis" means something that has holes in it, like a sponge. Therefore, osteoporosis is a disease which causes bones to become more porous, gradually making them weaker, more brittle and likely to break.

Osteoporosis is common in postmenopausal women. The menopause occurs when the ovaries virtually stop producing the female hormone, oestrogen, or are removed (which may occur, for example, at the time of a hysterectomy). At this time, bone is removed faster than it is formed, so bone loss occurs and bones become weaker. The earlier a woman reaches the menopause, the greater the risk of osteoporosis.

Osteoporosis also occurs in men but is less common than in women.

Early on, osteoporosis usually has no symptoms. However, if left untreated it can result in broken bones, also called fractures. Although fractures usually cause pain, fractures of the bones of the spine may go unnoticed until they cause height loss. Fractures may occur during normal, everyday activity, such as lifting, or from minor injury that would not ordinarily fracture normal bone. Fractures usually occur at the hip, spine, or wrist and 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.

What should I know about vitamin D?

Vitamin D is an essential nutrient, required for calcium absorption and healthy bones. The main source is through exposure to summer sunlight, which makes vitamin D in our skin. Clothing or sun block can prevent enough sunlight from getting through. In addition, as people age, their skin becomes less able to make vitamin D. Very few foods are natural sources of vitamin D.

Too little vitamin D leads to inadequate calcium absorption and low phosphate-minerals that make bones strong. Even if you are eating a diet rich in calcium or taking a calcium supplement, your body cannot absorb calcium properly unless you have enough vitamin D. Too little vitamin D may lead to bone loss and osteoporosis. Severe vitamin D deficiency may cause muscle weakness which can lead to falls and a higher risk of fracture.

What should I know about calcium?

Calcium is vital for healthy teeth and bones and also plays a crucial role in other systems of the body, such as the health and functioning of nerves and muscle tissue. People at different life stages need different amounts of calcium - young children, teenagers and older men and women all have greater than average requirements. Many Australian adults do not achieve the recommended amount of calcium in their diets and can benefit from calcium supplements.

Not having enough calcium in your diet may lead to disorders like osteoporosis. Making sure you have enough calcium in your diet is an important way to slow bone loss and keep bones strong. If not enough calcium from food and supplements can be absorbed to keep blood calcium normal, the body will remove calcium from the bones. If your dietary intake of calcium is constantly low, your body will eventually remove so much calcium from the skeleton that your bones will become weak and brittle and more likely to break.

How does FOSAMAX PLUS D-Cal work?

The alendronate in FOSAMAX PLUS 70mg/140 micrograms (5600 IU) works by slowing down the process of old bone being removed, which allows the bone-forming cells time to rebuild normal bone. Alendronate not only helps prevent the loss of bone but actually helps to rebuild bone and make bone less likely to fracture. Thus, FOSAMAX PLUS 70mg/140 micrograms (5600 IU) reverses the progression of osteoporosis.

FOSAMAX PLUS 70mg/140 micrograms (5600 IU) starts working on the bone cells immediately, but measurable effects on bone mass may not be seen for several months or more.

The alendronate in FOSAMAX PLUS 70mg/140 micrograms (5600 IU) belongs to a group of non-hormonal medicines called bisphosphonates.

In addition to alendronate, FOSAMAX PLUS 70mg/140 micrograms (5600 IU) also contains vitamin D, an essential nutrient required for calcium absorption and healthy bones.

BoneCal contains calcium, an essential mineral necessary to help maintain the bone structure in the body.

Before you take FOSAMAX PLUS D-Cal

You should know that in some people, FOSAMAX PLUS 70mg/140 micrograms (5600 IU) can irritate or burn the food pipe (also called oesophagus). The chances of this happening should be reduced when you follow the instructions for 'How to take FOSAMAX PLUS D-Cal' in this leaflet.

When you must not take it

Do not take FOSAMAX PLUS 70mg/140 micrograms (5600 IU) if:

  • you have an allergy to FOSAMAX PLUS 70mg/140 micrograms (5600 IU) or any of the ingredients listed at the end of this leaflet
  • you have certain disorders of the food pipe (oesophagus) including those that cause difficulty in swallowing
  • you are unable to stand or sit upright for at least 30 minutes
  • your doctor has told you that you currently have low blood calcium
  • your dentist advises you to consult your doctor first

Do not take BoneCal if:

  • your doctor has told you that you currently have high blood calcium
  • you have kidney stone
  • you have an allergy to BoneCal or any of the ingredients listed at the end of this leaflet.

Do not take FOSAMAX PLUS D-Cal if you are pregnant or breast-feeding.

FOSAMAX Plus D-Cal has not been studied in pregnant or breast-feeding women.

Do not take FOSAMAX PLUS D-Cal if:

  • the packaging is damaged or shows signs of tampering
  • the expiry date on the blister pack has passed.
    If you take this medicine after the expiry date has passed, it may not work.

If you are not sure whether you should start taking FOSAMAX PLUS D-Cal, talk to your doctor.

Do not give FOSAMAX PLUS D-Cal to a child.

FOSAMAX PLUS D-Cal has not been studied in children.

Before you start to take it

Tell your doctor if:

  1. you plan to become pregnant or breast-feed
  2. you have any medical conditions, especially the following:
    - kidney disease
    - swallowing or digestive problems, such as ulcers
  3. you have any allergies to any other medicines or any other substances, such as foods, preservatives or dyes
  4. you have dental or jaw-bone problems or are planning to have a course of dental surgery
  5. you currently smoke or have been a smoker in the past.

If you have not told your doctor about any of the above, tell them before you take any FOSAMAX PLUS D-Cal.

Taking other medicines

Tell your doctor 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 may affect the way other medicines work.

Some medicines are likely to interfere with the absorption of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) if taken at the same time. These include:

  • antacids, medicines used to treat indigestion e.g. Gaviscon, Mylanta
  • calcium supplements such as BoneCal (as provided in this pack of FOSAMAX PLUS D-Cal) or Caltrate
  • vitamins

Therefore, take FOSAMAX PLUS 70mg/140 micrograms (5600 IU) at least 30 minutes before taking any of these or other medicines to make sure there is no problem with absorption. Check with your doctor or pharmacist if you are not sure whether you are taking any of these medicines.

You can take aspirin while you are being treated with FOSAMAX PLUS D-Cal. However, both aspirin and FOSAMAX PLUS 70mg/140 micrograms (5600 IU) may increase the chance of stomach upsets.

Your doctor or pharmacist has more information on medicines to be careful with or avoid while taking FOSAMAX PLUS D-Cal.

How to take FOSAMAX PLUS D-Cal

How much to take

Take FOSAMAX PLUS D-Cal only when prescribed by your doctor.

DAY 1
FOSAMAX PLUS 70mg/140 micrograms (5600 IU) (white tablet in the blister pack)

The usual dose of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) is one tablet once a week.

Choose the day of the week that best fits your schedule. Every week, take one tablet of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) on your chosen day (DAY 1).

Do not take BoneCal tablets on DAY 1.

DAYS 2-7
BoneCal (pale green tablets supplied in the bottle)

The usual dose of BoneCal is one or two tablets daily, as recommended by your doctor. On the day after you have taken your FOSAMAX PLUS 70mg/140 micrograms (5600 IU) tablet, take one or two BoneCal tablets. Continue taking these every day for a total of 6 days. Follow all directions given to you by your doctor carefully.

They may differ from the information contained in this leaflet.

If you do not understand the instructions on the box, ask your doctor or pharmacist for help.

When and how to take it

DAY 1: FOSAMAX PLUS 70mg/140 micrograms (5600 IU)
Take FOSAMAX PLUS 70mg/140 micrograms (5600 IU) after getting up for the day and before taking your first food, beverage or other medication. Do not take it at bedtime.

Do not take BoneCal tablets on DAY 1.

Swallow one tablet whole with a full glass of plain water [not mineral water, not coffee or tea, not juice].

Do not take any food, medicines or drinks other than plain tap water with your FOSAMAX PLUS 70mg/140 micrograms (5600 IU).

It is important to take FOSAMAX PLUS 70mg/140 micrograms (5600 IU) with plain water only, not mineral water. Food, other drugs and mineral water and other drinks, including fruit juices, coffee and tea, will reduce the effect of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) by interfering with the absorption into the body.

Stay upright for at least 30 minutes after swallowing FOSAMAX PLUS 70mg/140 micrograms (5600 IU) and do not take any food, medicines or drinks other than plain tap water during this time.

Do not lie down immediately after swallowing it.

It is important to stay upright (sitting, standing or walking around) for at least 30 minutes after swallowing your tablet.

It is also very important to stay upright until after you have eaten your first food of the day.

These actions will help make sure your tablet reaches your stomach quickly and help reduce the potential for irritation to your food pipe (oesophagus).

FOSAMAX PLUS 70mg/140 micrograms (5600 IU) is effective only if taken when your stomach is empty. Food, drinks other than plain water, and other medicines will lessen the effect of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) by interfering with its absorption into the body.

Do not chew or suck on a tablet of FOSAMAX PLUS 70mg/140 micrograms (5600 IU).

Mouth ulcers may occur if the tablet is chewed or dissolved in the mouth.

DAYS 2 to 7: BoneCal
Take one or two BoneCal tablets, as recommended by your doctor, for 6 days, starting the day after you have taken your FOSAMAX PLUS 70mg/140 micrograms (5600 IU) tablet.

BoneCal may be taken before or with food.

THIS SEVEN DAY CYCLE IS TO BE REPEATED EACH WEEK.

How long to take it

It is important that you take FOSAMAX PLUS D-Cal for as long as your doctor prescribes it. FOSAMAX PLUS D-Cal can only treat your osteoporosis, by helping prevent further loss of bone and continuing to rebuild bone, if you take it as directed. Since it is not known how long you should take FOSAMAX PLUS D-Cal, you should discuss the need to stay on this medication with your doctor periodically to determine if FOSAMAX PLUS D-Cal is still right for you.

If you forget to take it

FOSAMAX PLUS 70mg/140 micrograms (5600 IU):
If you miss a tablet, take one tablet on the morning after you remember.

Do not take two tablets on the same day. Do not take your FOSAMAX PLUS 70mg/140 micrograms (5600 IU) at the same time you take your BoneCal tablet. Return to taking one tablet of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) once a week, as originally scheduled on your chosen day (DAY 1) followed by one or two tablets of BoneCal on days 2 to 7, and then repeat the cycle.

BoneCal:
If you forget to take your BoneCal dose, then just skip that dose and continue taking your tablets on the day that you remember. Do not take more than your daily dose on any given day.

Do not take your FOSAMAX PLUS 70mg/140 micrograms (5600 IU) at the same time you take your BoneCal tablets.

If you are not sure about what to do, talk to your doctor or pharmacist.

If you have trouble remembering to take your medicine, ask your pharmacist for some hints.

If you take 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 you or anyone else may have taken a large number of tablets. Do this even if there are no signs of discomfort or poisoning.

If you take too many tablets at one time, drink a full glass of milk. Do not induce vomiting. Do not lie down.

While you are using FOSAMAX PLUS D-Cal

Things you must do

If you develop difficulty or pain upon swallowing, chest pain, or new or worsening heartburn, stop taking FOSAMAX PLUS D-Cal and call your doctor.

If you become pregnant while taking FOSAMAX PLUS D-Cal, stop taking the tablets and tell your doctor.

If you are about to be started on any new medicine, tell your doctor and pharmacist that you are taking FOSAMAX PLUS D-Cal.

If you develop a toothache or require a dental procedure, tell your dentist that you are taking FOSAMAX PLUS D-Cal.

If you develop new or unusual pain in your leg, tell your doctor.

Rarely, patients have experienced fracture in a specific part of the thigh bone.

Make sure you have an adequate intake of calcium in your diet.

Your doctor, dietician or pharmacist can tell you what foods you should eat.

Things you must not do

Do not give FOSAMAX PLUS D-Cal to anyone else, even if they have the same condition as you.

Things to be careful of

There have been side effects reported with FOSAMAX PLUS D-Cal that may affect your ability to drive or operate machinery. Individual responses to FOSAMAX PLUS D-Cal may vary (see Side Effects).

Things that would be helpful for your osteoporosis

Some self-help measures suggested below may help your osteoporosis. Talk to your doctor or pharmacist about these measures and for more information.

  • Exercise - can be helpful in building and maintaining strong bones. Regular exercise such as a brisk walk is a good idea. Talk to your doctor before you begin any exercise program.
  • Diet - eat a balanced diet. You may need to increase the amount of calcium in your diet by eating calcium-rich foods or taking a calcium supplement like BoneCal. Your doctor will advise you.
  • Smoking - appears to increase the rate at which you lose bone and, therefore, may increase your risk of fracture. Your doctor may ask you to stop smoking or at least cut down.
  • Alcohol - your doctor may advise you to cut down the amount of alcohol you drink. If you drink excessively on a regular basis, you may increase your risk of developing osteoporosis.

Side Effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking FOSAMAX PLUS D-Cal.

FOSAMAX PLUS D-Cal helps most people with osteoporosis, but it may have unwanted side effects in a few people. All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

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

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

  • stomach pain, gas in the stomach or bowel, wind
  • an uncomfortable feeling in the stomach or belching after eating, also called dyspepsia, or heartburn
  • feeling sick (nausea), vomiting
  • constipation, diarrhoea
  • headache
  • aching muscles, joints and/or bones, which rarely can be severe.
  • flu-like symptoms typically at the start of treatment, such as aching muscles, generally feeling unwell and rarely fever.
  • swelling of joints
  • dizziness or spinning sensation
  • unusual tiredness or weakness
  • swelling of hands, ankles or feet
  • hair loss
  • changed sense of taste

Most of these are the more common side effects of FOSAMAX PLUS D-Cal. For the most part, these have been mild.

Tell your doctor immediately if you notice any of the following:

  • skin rash or redness of the skin, sometimes made worse by sunlight, itchiness
  • mouth ulcers
  • blurred vision, pain or redness in the eye
  • ear pain
  • symptoms of low blood calcium levels including muscle cramps or spasms or tingling sensation in the fingers or around the mouth
  • new or unusual pain in your hip or thigh
  • symptoms of a kidney stone such as severe, lower back or abdominal pain or difficulty in passing urine. If you have a kidney stone, your dose of BoneCal may need to be reduced or discontinued.

These side effects are rare, and very rarely, may be serious.

Tell your dentist and doctor immediately if you notice any of the following:

  • Jaw-bone or dental problems (including toothache). Jaw-bone problems may include infection, and delayed healing after a tooth extraction or other work that involves drilling into the jaw-bone.

These side effects are rare and may be serious.

If any of the following happen, stop taking FOSAMAX PLUS D-Cal and tell your doctor immediately:

  • difficulty or pain upon swallowing
  • chest pain
  • new or worsening heartburn

These side effects may be due to irritation or ulceration of the food pipe. They may worsen if you continue taking the tablets. Rarely, these side effects may be serious.

If any of the following happen, stop taking FOSAMAX PLUS D-Cal and tell your doctor immediately or go to accident and emergency at your nearest hospital:

  • swelling of the face, lips, mouth, throat or tongue which may cause difficulty in breathing or swallowing
  • pinkish, itchy swellings on the skin, also called hives or nettlerash
  • severe skin reactions
  • black tar-like and/or bloody stools

These may be serious side effects. You may need urgent medical attention. These side effects are rare.

If you have the swelling described above, you may be having a serious allergic reaction to FOSAMAX PLUS D-Cal.

Rarely, stomach or duodenal ulcers (some severe) have occurred, but it is not known whether these were caused by FOSAMAX PLUS D-Cal.

Other side effects not listed above may also occur in some patients. Tell your doctor if you notice any other effects.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

FOSAMAX PLUS D-Cal is not addictive.

After using FOSAMAX PLUS D-Cal

Storage

Keep your tablets in the original containers (blister pack and bottle) until it is time to take them.

If you take the tablets out of the original containers they may not keep well.

Keep FOSAMAX PLUS D-Cal in a cool dry place where the temperature stays below 30°C. Do not freeze the product. Keep the tablets away from light or moisture. Do not store FOSAMAX PLUS D-Cal or any other medicine in the bathroom or near a sink. Do not leave it in the car or on window sills.

Heat and dampness can destroy some medicines.

Keep it where children cannot reach it.

A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking FOSAMAX PLUS D-Cal, or the tablets have passed their expiry date, ask your pharmacist what to do with any that are left over.

Product Description

What it looks like

FOSAMAX PLUS D-Cal is a combination pack consisting of a box of 4 once weekly tablets of FOSAMAX PLUS 70mg/140 micrograms (5600 IU) together with a bottle of 48 tablets of BoneCal.

FOSAMAX PLUS 70mg/140 micrograms (5600 IU): comes as a white to off-white, modified rectangle-shaped tablet with "270" on one side and a bone image on the other.

BoneCal comes as a pale green, capsule shaped tablet.

Ingredients

FOSAMAX PLUS 70mg/140 micrograms (5600 IU) contains the active ingredients:

  • alendronate sodium equivalent to 70 mg alendronic acid per tablet
  • colecalciferol 140 micrograms (5600 IU vitamin D3) per tablet

Inactive ingredients:

  • cellulose-microcrystalline
  • lactose anhydrous
  • medium chain triglycerides
  • gelatin
  • croscarmellose sodium
  • sucrose
  • silica-colloidal anhydrous
  • magnesium stearate
  • butylated hydroxytoluene
  • modified food starch
  • aluminium sodium silicate.

FOSAMAX PLUS 70mg/140 micrograms (5600 IU) does not contain gluten, tartrazine or any other azo dyes.

BoneCal contains 1250mg calcium carbonate equivalent to 500mg elemental calcium per tablet.

Inactive ingredients:

  • cellulose-microcrystalline
  • maltodextrin
  • acacia
  • crospovidone
  • hypromellose
  • titanium dioxide
  • magnesium stearate
  • macrogol 400
  • carnauba wax
  • iron oxide yellow CI77492
  • chlorophyllin copper complex

BoneCal does not contain gluten or preservatives.

Supplier

FOSAMAX PLUS D-Cal is supplied in Australia by:

Merck Sharp & Dohme (Australia) Pty Limited
Level 1, Building A,
26 Talavera Road,
Macquarie Park NSW 2113

BoneCal is supplied in Australia by:

Vitaco Health Australia Pty Ltd
Level 1, 82 Waterloo Road, North Ryde, NSW 2113

This leaflet was prepared in September 2015.

Australian Register Numbers:
FOSAMAX PLUS D-Cal
AUST R 161137

WPPI-MK0217A-T-052015

™ Trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Whitehouse Station, N.J., U.S.A.

BRAND INFORMATION

Brand name

Fosamax Plus D-Cal Combination pack

Active ingredient

Alendronic acid; Colecalciferol; Calcium carbonate

Schedule

S4

 

Name of the medicine

Fosamax.

Alendronate sodium.

Fosamax Plus Once Weekly.

Alendronate sodium, colecalciferol (vitamin D3).

Fosamax Plus D-Cal.

Combination pack containing Fosamax Plus Once Weekly (alendronate sodium and colecalciferol (vitamin D3)) in addition to BoneCal tablets (calcium carbonate).

Excipients.

Fosamax.

Microcrystalline cellulose, anhydrous lactose, croscarmellose sodium and magnesium stearate. The 10 mg tablet also contains carnauba wax.

Fosamax Plus Once Weekly.

Microcrystalline cellulose, anhydrous lactose, medium chain triglycerides, gelatin, croscarmellose sodium, sucrose, anhydrous colloidal silica, magnesium stearate, butylated hydroxytoluene, modified food starch and aluminium sodium silicate.

BoneCal.

Microcrystalline cellulose, maltodextrin, acacia, crospovidone, hypromellose, titanium dioxide, magnesium stearate, macrogol 400, carnauba wax, iron oxide yellow CI77492 and chlorophyllin copper complex.

Description

Alendronate sodium.

Chemical name: (4-amino-1-hydroxybutylidene) bisphosphonic acid monosodium salt trihydrate. Molecular formula: C4H12NNaO7P2.3H2O. MW: 325.12. CAS: 121268-17-5. Alendronate sodium is a bisphosphonate that acts as a potent, specific inhibitor of osteoclast mediated bone resorption. Bisphosphonates are synthetic analogues of pyrophosphate that bind to the hydroxyapatite found in bone. Alendronate is a white crystalline nonhygroscopic powder. It is soluble in water, very slightly soluble in alcohol and practically insoluble in chloroform.

Colecalciferol.

Chemical name: (3β,5Z,7E)-9,10-secocholesta -5,7,10(19)-trien-3-ol. Molecular formula: C27H44O. MW: 384.6. CAS: 67-97-0. Colecalciferol (vitamin D3) is a secosterol that is the natural precursor of the calcium regulating hormone calcitriol (1,25-dihydroxyvitamin D3). Colecalciferol is a white, crystalline, odourless powder. Colecalciferol is practically insoluble in water, freely soluble in usual organic solvents and slightly soluble in vegetable oils.

Calcium carbonate.

Chemical name: carbonic acid calcium salt (1:1). Molecular formula: CaCO3. MW: 100.09. CAS: 471-34-1.

Pharmacology

Pharmacokinetic properties.

Absorption.

Alendronate sodium.

Relative to an intravenous (IV) reference dose, the mean oral bioavailability of alendronate 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. There was substantial variability both within and between patients, coefficient of variation 63% and 77%, respectively. Oral bioavailability in men (0.6%) was similar to that in women.
In two two-period crossover studies, the alendronate in the Fosamax Plus (70 mg/70 microgram and 70 mg/140 microgram) tablet was shown to be bioequivalent to the alendronate in the Fosamax 70 mg tablet.
Bioavailability was decreased similarly, (by approximately 40%) whether alendronate was administered one hour or one half hour before a standardised breakfast. In osteoporosis and Paget's disease studies, Fosamax was effective when administered at least 30 minutes before the first food or beverage of the day.
Bioavailability was negligible whether alendronate was administered with or up to two hours after a standardised breakfast. Concomitant administration of alendronate with coffee or orange juice reduced bioavailability by approximately 60%.
In normal subjects, oral prednisone (20 mg three times daily for five days) did not substantially alter the oral bioavailability of alendronate (alendronate alone: 0.73%; alendronate plus prednisone: 0.87%).

Colecalciferol.

Following administration of Fosamax Plus (70 mg/70 microgram) Once Weekly tablet after an overnight fast and two hours before a standard meal, the baseline unadjusted mean area under the serum concentration time curve (AUC0-120 hrs) for vitamin D3 was 296.4 nanogram.h/mL (geometric mean ratio ((GMR) Fosamax Plus 70 mg/70 microgram/ vitamin D3 only): 0.88; 90% CI: 0.81, 0.95). The baseline unadjusted mean maximal serum concentration (Cmax) of vitamin D3 was 5.9 nanogram/mL, (GMR (Fosamax Plus 70 mg/70 microgram/ vitamin D3 only): 0.89; 90% CI: 0.84, 0.95) and the median time to maximal serum concentration (Tmax) was 12 hrs. The bioavailability of the 70 microgram (2800 IU) vitamin D3 in Fosamax Plus (70 mg/70 microgram) is similar to 70 microgram (2800 IU) vitamin D3 administered alone (using the AUC0-120 hr) and Cmax GMR values).
Following administration of Fosamax Plus 70 mg/140 microgram after an overnight fast and two hours before a standard meal, the mean area under the serum concentration time curve (AUC0-80 hrs) (unadjusted for endogenous vitamin D3 levels) for vitamin D3 was 490.2 nanogram.hr/mL (GMR (Fosamax Plus 70 mg/140 microgram/ vitamin D3 only): 0.94; 90% CI: 0.89, 1.00). The baseline unadjusted mean maximal serum concentration (Cmax) of vitamin D3 was 12.2 nanogram/mL, (GMR (Fosamax Plus 70 mg/140 microgram/ vitamin D3 only) 0.94; 90% CI: 0.88, 1.00) and the median time to maximal serum concentration (Tmax) was 10.6 hrs. The bioavailability of the 140 microgram (5600 IU) vitamin D3 in Fosamax Plus 70 mg/140 microgram is similar to 140 microgram (5600 IU) vitamin D3 administered alone (using the AUC0-80 hr and Cmax GMR values).

Calcium carbonate.

Following ingestion of BoneCal, approximately 15 to 40% of ingested calcium is absorbed from the small intestine into the circulation. The amount absorbed is under physiological regulation based on the body's needs.

Distribution.

Alendronate sodium.

Preclinical studies show that alendronate transiently distributes to soft tissues following 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 L in humans. Concentrations of alendronate in plasma following therapeutic oral doses are generally below the limits of quantification (less than 5 nanogram/mL). Protein binding in human plasma is approximately 78%.

Colecalciferol.

Following absorption, vitamin D3 enters the blood as part of chylomicrons. Vitamin D3 is rapidly distributed mostly to the liver where it undergoes metabolism to 25-hydroxyvitamin D3, the major storage form. Lesser amounts are distributed to adipose and muscle tissue and stored as vitamin D3 at these sites for later release into the circulation. Circulating vitamin D3 is bound to vitamin D binding protein.

Calcium.

Calcium is present throughout the body. Approximately 99% of calcium in the body is concentrated in bones and teeth. The remaining 1% is present in the intra and extracellular fluids. About 50% of the total plasma calcium content is the physiologically active ionized form, 10% is complexed with citrate, phosphate or other anions, and the remaining 40% is bound to proteins, principally albumin.

Metabolism.

Alendronate sodium.

There is no evidence that alendronate is metabolised in animals or humans.

Colecalciferol.

Vitamin D3 is rapidly metabolised by hydroxylation in the liver to 25-hydroxyvitamin D3 and subsequently metabolised in the kidney to 1,25-dihydroxyvitamin D3, which represents the biologically active form. Further hydroxylation occurs prior to elimination. A small percentage of vitamin D3 undergoes glucuronidation prior to elimination.

Elimination.

Alendronate sodium.

Following a single 10 mg IV dose of [14C]-alendronate, approximately 50% of the radioactivity was excreted in the urine within 72 hours and little or no radioactivity was recovered in the faeces; the renal clearance of alendronate was 71 mL/min. Plasma concentrations fell by more than 95% within 6 hours following IV administration, due to distribution to the bone and excretion in the urine. The terminal half-life in humans is estimated to exceed 10 years, reflecting release of alendronate from the skeleton. Alendronate 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 drugs by those systems in humans.
Preclinical studies show that the alendronate that is not deposited in bone is rapidly excreted in the urine. No evidence of saturation of bone uptake was found over three weeks in rats with a cumulative IV dose of 35 mg/kg. Although no clinical information is available, it is likely that, as in animals, elimination of alendronate via the kidney will be reduced in patients with impaired renal function. Therefore, somewhat greater accumulation of alendronate in bone might be expected in patients with impaired renal function (see Dosage and Administration).

Colecalciferol.

When radioactive vitamin D3 was administered to healthy subjects, the mean urinary excretion of radioactivity after 48 hours was 2.4% and the mean faecal excretion of radioactivity after four days was 4.9%. In both cases, the excreted radioactivity was almost exclusively as metabolites of the parent. The mean half-life of vitamin D3 in the serum following an oral dose of alendronate 70 mg/ colecalciferol 70 is approximately 24 hours.

Calcium.

Calcium is eliminated through renal excretion.

Pharmacodynamic properties.

Alendronate sodium.

Alendronate is a bisphosphonate that, in animal studies, localises preferentially to sites of bone resorption, specifically under osteoclasts, and inhibits osteoclastic bone resorption with no direct effect on bone formation. Since bone formation and bone resorption are coupled, bone formation is also reduced, but less so than resorption, leading to progressive gains in bone mass (see Clinical Trials). Following exposure to alendronate, normal bone is formed that incorporates alendronate into its matrix, where it is pharmacologically inactive.
The relative inhibitory activities on bone resorption and mineralisation of alendronate and etidronate were compared in growing rats. The lowest dose of alendronate that interfered with bone mineralisation (leading to osteomalacia) was 6000-fold the antiresorptive dose. The corresponding safety margin for etidronate was one to one. These data indicate that, unlike etidronate, alendronate administered in therapeutic doses is highly unlikely to induce osteomalacia.

Colecalciferol.

Vitamin D3 is produced in the skin by photochemical conversion of 7-dehydrocholesterol to previtamin D3 by ultraviolet light. This is followed by nonenzymatic isomerisation to vitamin D3. In the absence of adequate sunlight exposure, vitamin D3 is an essential dietary nutrient. Vitamin D3 in skin and dietary vitamin D3 (absorbed into chylomicrons) is converted to 25-hydroxyvitamin D3 in the liver. Conversion to the active calcium mobilising hormone 1,25-dihydroxyvitamin D3 (calcitriol) in the kidney is stimulated by both parathyroid hormone and hypophosphataemia. The principal action of 1,25-dihydroxyvitamin D3 is to increase intestinal absorption of both calcium and phosphate as well as regulate serum calcium, renal calcium and phosphate excretion, bone formation and bone resorption.
Vitamin D3 is required for normal bone formation. Optimal serum levels of 25-hydroxyvitamin D are unknown. Vitamin D insufficiency may be seen with serum levels below 30 to 50 nanomol/L. Severe vitamin D deficiency is commonly associated with levels < 12.5 nanomol/L. Vitamin D insufficiency develops when both sunlight exposure and dietary intake are inadequate. Insufficiency is associated with negative calcium balance, bone loss and increased risk of skeletal fracture. In severe cases, deficiency results in secondary hyperparathyroidism, hypophosphataemia, proximal muscle weakness and osteomalacia, further increasing the risk of falls and fractures in osteoporotic individuals. Supplemental vitamin D is associated with reduced risk of vitamin D insufficiency as defined by serum hydroxyvitamin D of < 37.5 nanomol/L.

Osteoporosis.

The WHO utilises the definition of osteoporosis as a disease characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. The diagnosis may be confirmed by the finding of low bone mass (for example at least 2 standard deviations below the gender specific mean for young adults) or by the presence or history of osteoporotic fracture. It occurs in both males and females but is most common among women following the menopause, when bone turnover increases and the rate of bone resorption exceeds that of bone formation, leading to loss of bone mass.

Osteoporosis in postmenopausal women.

Daily oral doses of alendronate in postmenopausal women produced biochemical changes indicative of dose dependent inhibition of bone resorption, including decreases in urinary calcium and urinary markers of bone collagen degradation (such as hydroxyproline, deoxypyridinoline and cross linked N-telopeptides of type I collagen). These biochemical changes returned toward baseline values as early as three weeks following the discontinuation of alendronate despite the long retention of alendronate in the skeleton.
Long-term treatment of osteoporosis with Fosamax 10 mg/day (for up to five years) reduced urinary excretion of markers of bone resorption, deoxypyridinoline and cross linked N-telopeptides of type I collagen by approximately 50% and 70%, respectively, to reach levels similar to those seen in healthy premenopausal women. Similar decreases were seen in patients in osteoporosis prevention studies who received Fosamax 5 mg/day. The decrease in the rate of bone resorption indicated by these markers was evident as early as one month and at three to six months reached a plateau that was maintained for the entire duration of treatment with Fosamax. In osteoporosis treatment studies Fosamax 10 mg/day decreased the markers of bone formation, osteocalcin and total serum alkaline phosphatase, by approximately 50% and 25-30%, respectively, to reach a plateau after 6 to 12 months. Similar though slightly lower reductions in the rate of bone turnover were observed in postmenopausal women during one year studies with Fosamax Once Weekly 70 mg for the treatment of osteoporosis. In osteoporosis prevention studies Fosamax 5 mg/day decreased these markers by approximately 40% and 15%, respectively.

Osteoporosis in men.

Even though osteoporosis is less prevalent in men than in postmenopausal women, a significant proportion of osteoporotic fractures occur in men. The prevalence of vertebral deformities appears to be similar in men and women. All men with osteoporosis should be investigated for hypogonadism and, if necessary, treated for this condition. Treatment of men with osteoporosis with Fosamax 10 mg/day for two years reduced urinary excretion of cross linked N-telopeptides of type I collagen by approximately 60% and bone specific alkaline phosphatase by approximately 40%. Similar reductions in cross linked N-telopeptides of type I collagen were seen in men receiving Fosamax 70 mg once weekly.

Clinical Trials

Treatment of osteoporosis.

Fosamax Plus studies.

The effect of alendronate 70 mg/ colecalciferol 70 microgram on vitamin D status was demonstrated in a 15 week, double blind, multinational study of 717 osteoporotic postmenopausal women and men (serum 25-hydroxyvitamin D at baseline: mean, 22.2 nanogram/mL (56 nanomol/L); range, 9-90 nanogram/mL (22.5 to 225 nanomol/L)). Patients received alendronate 70 mg/ colecalciferol 70 microgram (2800 IU)) (n = 350 women, 10 men) or Fosamax (alendronate) 70 mg (n = 332 women, 25 men) once a week; additional vitamin D supplements were prohibited. Patients who were vitamin D deficient (defined as serum 25-hydroxyvitamin D < 9 nanogram/mL (22.5 nanomol/L)) at baseline were excluded. Patients with vitamin D insufficiency at baseline were defined as having serum 25-hydroxyvitamin D levels between 9 nanogram/mL (22.5 nanomol/L) and 15 nanogram/mL (37.5 nanomol/L).
The percentage of patients with serum 25-hydroxyvitamin D ≥ 15 nanogram/mL (37.5 nanomol/L) was significantly higher with alendronate 70 mg/ colecalciferol 70 microgram vs. alendronate only (89 vs. 68%, respectively). The percentage of patients with serum 25-hydroxyvitamin D ≥ 9 nanogram/mL (22.5 nanomol/L) was significantly higher with alendronate 70 mg/ colecaliferol 70 microgram vs. alendronate only (99 vs. 87%, respectively). There were no differences in mean serum calcium, phosphate or 24 hour urine calcium between treatment groups. The final levels of 25-hydroxyvitamin D at week 15 are summarised in Table 1.
The effect of alendronate 70 mg/ colecalciferol 70 microgram with an additional 70 microgram colecalciferol (2800 IU vitamin D3) for a total of 140 microgram colecalciferol (5600 IU vitamin D3) once weekly was compared to 70 mg/ colecalciferol 70 microgram weekly in a 24 week, extension study that enrolled 652 osteoporotic men and postmenopausal women who completed the above 15 week study. Patients in the colecalciferol 70 microgram group received alendronate 70 mg/ colecalciferol 70 microgram (n = 305 women, 21 men) and those in the colecalciferol 140 microgram group received alendronate 70 mg/ colecalciferol 70 microgram with an additional 70 microgram colecalciferol (n = 314 women, 12 men) once a week; additional vitamin D supplements were allowed. The primary endpoint was incidence of hypercalciuria, defined as an increase of greater than 25% from baseline in 24 hour urine calcium and to a value greater than the upper limit of normal (300 mg in women, 350 mg in men). The rate of hypercalciuria was 13/311 (4.2%) for the colecalciferol 140 microgram group and 9/317 (2.8%) for the colecalciferol 70 microgram group, relative risk 1.48 (95% CI 0.64, 3.40).
Secondary endpoints included 25 hydroxyvitamin D levels. The proportions of patients with vitamin D insufficiency (< 37.5 nanomol/L) after 39 weeks was 10/321 (3.1%) in the colecalciferol 140 microgram group and 18/320 (5.6%) in the colecalciferol 70 microgram group.
The percentage of patients with serum 25-hydroxyvitamin D ≥ 15 nanogram/mL (37.5 nanomol/L) was higher with the colecalciferol 140 microgram group vs. the colecalciferol 70 microgram group (96.9 vs. 94.4%, respectively), although not statistically significant.
There were no differences detected between mean serum calcium, mean serum phosphate, or mean 24 hour urine calcium between groups. The distribution of the final levels of 25-hydroxyvitamin D at week 39 is summarised in Table 2.

Fosamax studies.

Postmenopausal women.

Effect on bone mineral density.

The efficacy of Fosamax 10 mg once daily in postmenopausal women with osteoporosis was demonstrated in two large three year multicentre studies of virtually identical design, one performed in the United States and the other in 15 different countries (multinational), which enrolled 478 and 516 patients, respectively. Figure 1 shows the mean increases in bone mineral density (BMD) of the lumbar spine, femoral neck and trochanter in patients receiving Fosamax 10 mg/day relative to placebo treated patients at three years for each of these studies.
These increases were highly significant relative both to baseline and placebo at each measurement site in each study. Increases in BMD were evident as early as three months and continued throughout the entire three years of treatment. See Figure 2 for lumbar spine results. In the two year extension of these studies, treatment with Fosamax 10 mg/day resulted in continued increases in BMD at the lumbar spine and trochanter (absolute additional increases between years 3 and 5: lumbar spine 0.94%; trochanter 0.88%). BMD at the femoral neck, forearm and total body were maintained. Thus, Fosamax appears to reverse the progression of osteoporosis as assessed by increased bone mineral density. Fosamax was similarly effective regardless of age, race, baseline rate of bone turnover, renal function and use of concomitant medications.
In patients with postmenopausal osteoporosis treated with Fosamax 10 mg/day for one or two years the effects of treatment withdrawal were assessed. Following discontinuation, there were no further increases in bone mass and the rates of bone loss were similar to those in the placebo groups. These data indicate that continuous treatment with Fosamax is required to produce progressive increases in bone mass.
The therapeutic equivalence of Fosamax Once Weekly 70 mg (n = 519) and Fosamax 10 mg daily (n = 370) was demonstrated in a one year, double blind, multicentre study of postmenopausal women with osteoporosis. The mean increases from baseline in lumbar spine BMD at one year were 5.1% (4.8, 5.4%; 95% CI) in the 70 mg once weekly group and 5.4% (5.0, 5.8%; 95% CI) in the 10 mg daily group. The two treatment groups were also similar with regard to BMD increases at other skeletal sites. While there are no placebo controlled fracture data for the once weekly 70 mg tablet, the increases in bone density support the expectation that Fosamax Once Weekly 70 mg will have effects to reduce the incidence of fractures similar to those of the 10 mg daily treatment (see below). The study was not designed to evaluate the relative compliance of Fosamax once weekly 70 mg and 10 mg daily.

Effect on fracture incidence.

Although the US and multinational studies (see above) were not designed to assess fracture rates as the primary endpoint, preplanned analysis of the data pooled across once daily doses at three years revealed a statistically significant and clinically meaningful 48% reduction in the proportion of patients treated with Fosamax experiencing one or more vertebral fractures (3.2%) relative to those treated with placebo (6.2%). Furthermore, of patients who sustained any vertebral fracture, those treated with Fosamax experienced less height loss (5.9 mm vs. 23.3 mm) due to a reduction in both the number and severity of fractures.
The Fracture Intervention Trial (FIT) consisted of two studies in postmenopausal women: the three year study of patients who had at least one baseline vertebral (compression) fracture and the four year study of patients with low bone mass but without baseline vertebral fracture.

Fracture Intervention Trial: three year study (patients with at least one baseline vertebral fracture).

This randomised, double blind, placebo controlled 2027 patient study, (Fosamax n = 1022; placebo n = 1005) demonstrated that treatment with Fosamax resulted in clinically significant reductions in fracture incidence at three years as shown in Table 3. Data also showed statistically significant reductions in painful vertebral fractures and clinical fractures at other sites. Similar reductions of hip and wrist fractures were seen in five pooled osteoporosis treatment studies of two or three years duration.
Furthermore, in this population of patients with baseline vertebral fracture, treatment with Fosamax significantly reduced the incidence of hospitalisations resulting from any cause (25.0% vs. 30.7%, a 20% relative risk reduction). This difference appears to be related, at least in part, to the reduction in fracture incidence.

Fracture Intervention Trial: four year study (patients with low bone mass but without a baseline vertebral fracture).

This randomised, double blind, placebo controlled, 4,432 patient study (Fosamax, n = 2,214; placebo, n = 2,218) further demonstrated the reduction in fracture incidence due to Fosamax. The intent of the study was to recruit women with osteoporosis, i.e. with a baseline femoral neck BMD at least two standard deviations below the mean for young adult women. However, due to subsequent revisions to the normative values for femoral neck BMD, 31% of patients were found not to meet this entry criterion and thus this study included both osteoporotic and nonosteoporotic women. The results are shown in Table 4 for the patients with osteoporosis.

Consistency of fracture results.

The reductions in the incidence of vertebral fractures (Fosamax vs. placebo) in the three and four year studies of FIT were consistent with that in the combined US and multinational (US/Mult) treatment studies (see above), in which 80% of the women did not have a vertebral fracture at baseline. During these studies, treatment with Fosamax reduced the proportion of women experiencing at least one new vertebral fracture by approximately 50% (three year FIT: 47% reduction, p < 0.001; four year FIT: 44% reduction, p = 0.001; US/Mult, 48% reduction, p = 0.034). In addition, Fosamax reduced the proportion of women experiencing multiple (two or more) new vertebral fractures by approximately 90% in the US/Mult and three year FIT studies (p < 0.001). Thus, Fosamax reduced the incidence of vertebral fractures whether or not patients had experienced a previous vertebral fracture.
Overall, these results demonstrate the consistent efficacy of Fosamax in reducing the incidence of fractures, including those of the spine and hip, which are the sites of osteoporotic fracture associated with greatest morbidity.

Bone histology.

Bone histology in 270 postmenopausal patients with osteoporosis treated with Fosamax at doses ranging from 1 to 20 mg/day for one, two or three years revealed normal mineralisation and structure, as well as the expected decrease in bone turnover relative to placebo. These data, together with the normal bone histology and increased bone strength observed in ovariectomised rats and baboons exposed to long-term alendronate treatment, indicate that bone formed during therapy with Fosamax is of normal quality.

Concomitant use with oestrogen/ hormone replacement therapy.

The effects on BMD of treatment with Fosamax 10 mg once daily and conjugated oestrogen (0.625 mg/day) either alone or in combination were assessed in a two year, double blind, placebo controlled study of hysterectomised postmenopausal osteoporotic women (n = 425). At two years, the increases in lumbar spine BMD from baseline were significantly greater with the combination (8.3%) than with either oestrogen or Fosamax alone (both 6.0%).
The effects on BMD when Fosamax was added to stable doses (for at least one year) of HRT (oestrogen ± progestin) were assessed in a one year, double blind, placebo controlled study in postmenopausal osteoporotic women (n = 428). The addition of Fosamax 10 mg once daily to HRT produced, at one year, significantly greater increases in lumbar spine BMD (3.7%) vs. HRT alone (1.1%).
In these studies, significant increases or favourable trends in BMD for combined therapy compared with HRT alone were seen at the total hip, femoral neck and trochanter. No significant effect was seen for total body BMD.

Men.

The efficacy of Fosamax 10 mg once daily in men with osteoporosis was demonstrated in a two year, double blind, placebo controlled, multicentre study, which enrolled 241 osteoporotic men between the ages of 31 and 87 years. All patients in the study (97.5% of whom were Caucasian) had either: 1) a BMD T score ≤ -2 at the femoral neck and ≤ -1 at the lumbar spine or 2) a baseline osteoporotic fracture and a BMD T score of ≤ -1 at the femoral neck. At two years the mean increases relative to placebo in BMD in men receiving Fosamax 10 mg daily were: lumbar spine 5.3%; femoral neck 2.6%; trochanter 3.1%; and total body 1.6% (all p ≤ 0.001). Fosamax was effective regardless of age, gonadal function, baseline rate of bone turnover, or baseline BMD. Consistent with the much larger studies in postmenopausal women, in these men Fosamax 10 mg daily reduced the incidence of new vertebral fracture (posthoc analysis; assessment by quantitative radiography) relative to placebo (0.8% vs 7.1%, respectively; p = 0.017) and, correspondingly, also reduced height loss (-0.6 vs -2.4 mm, respectively; p = 0.022).
The effects of discontinuation of Fosamax treatment have not been studied in this population.

Prevention of osteoporosis.

For the prevention of osteoporosis, Fosamax may be considered in postmenopausal women who are at risk of developing osteoporosis and for whom the desired clinical outcome is to maintain bone mass and to reduce the risk of future fracture.
Bone loss is particularly rapid in postmenopausal women younger than age 60. Risk factors often associated with the development of postmenopausal osteoporosis include early menopause; moderately low bone mass (for example, at least 1 standard deviation below the mean for healthy young adult women); thin body build and family history of osteoporosis. The presence of such risk factors may be important when considering the use of Fosamax for prevention of osteoporosis.
Prevention of bone loss was demonstrated in both a two year (n = 1609) and a three year (n = 447) study of women 40-60 years of age who were at least 6 months postmenopausal. In these studies, Fosamax or matching placebo was administered once daily to nonosteoporotic women (overall baseline spine BMD approximately one SD lower that the premenopausal mean BMD).
As expected, in the placebo treated patients BMD losses of approximately 1% per year were seen at the spine, hip (femoral neck and trochanter) and total body. In contrast, Fosamax 5 mg/day effectively prevented bone loss, and induced highly significant increases in bone mass at each of these sites. The mean percent increase in BMD from baseline at the lumbar spine, femoral neck, trochanter and total body at the end of the two year study were 3.46%, 1.27%, 2.98% and 0.67%, respectively, and those at the end of the three year study were 2.89%, 1.10%, 2.71% and 0.32%, respectively (see Figure 3).
In addition, Fosamax 5 mg/day reduced the rate of bone loss in the forearm by approximately half relative to placebo. Fosamax 5 mg/day was similarly effective in this population regardless of age, time since menopause, race and baseline rate of bone turnover.
In the two year study (n = 1609), of 435 women willing to be randomised to an open label oestrogen/ progestin therapy subgroup, 55 in the US centres received conjugated equine oestrogens 0.625 mg daily (Premarin) in combination with medroxyprogesterone acetate 5 mg daily (Provera), whilst 55 in the European centres received higher doses of oestrogen given as 17β-oestradiol 2 mg daily in combination with norethisterone acetate 1 mg daily (10 days per 28 day cycle) (Trisequens). Only women in the European centres using Trisequens experienced increases in BMD at the spine, hip and total body that were different from those in women using Fosamax 5 mg. At these centres, two year increases in BMD at the lumbar spine were 5.1% and 3.3%, femoral neck 2.4% and 1.4%, trochanter 4.8% and 2.8%, and total body 2.6% and 0.6% in the Trisequens and Fosamax 5 mg groups, respectively. Increases with Premarin and Provera in the US centres were not statistically different to those obtained with Fosamax 5 mg. Both Fosamax 5 mg and oestrogen/ progestin therapy prevented bone loss in these nonosteoporotic women.
Bone histology was normal in the 28 patients biopsied at the end of three years who received Fosamax doses of up to 10 mg/day.

Glucocorticoid induced osteoporosis.

Sustained use of glucocorticoids is commonly associated with development of osteoporosis and resulting fractures (especially vertebral, hip and rib). It occurs both in males and females of all ages. Bone loss occurs as a result of a lower rate of bone formation relative to that of bone resorption. Alendronate decreases bone resorption without directly inhibiting bone formation.
In clinical studies of one year's duration, Fosamax 5 and 10 mg/day reduced cross linked N-telopeptides of type 1 collagen (a marker of bone resorption) by approximately 60% and reduced bone specific alkaline phosphatase and total serum alkaline phosphatase (markers of bone formation) by approximately 25 to 30% and 12 to 15%, respectively. As a result of inhibition of bone resorption, Fosamax 5 and 10 mg/day induced asymptomatic decreases in serum calcium (approximately 1%) and serum phosphate (approximately 2 to 7%).
The efficacy of Fosamax 5 and 10 mg once daily in men and women receiving glucocorticoids (at least 7.5 mg/day of prednisone or equivalent) was demonstrated in two one year placebo controlled double blind, multicentre studies (n total = 560, males = 176) of virtually identical design. Most of the patients were ambulant, Caucasian and nonsmokers. The study population included patients with rheumatoid arthritis, polymyalgia rheumatica, systemic lupus erythematosus, pemphigus, asthma, myositis, inflammatory bowel disease, giant cell arteritis, sarcoidosis, myasthenia gravis, chronic obstructive pulmonary disease and nephrotic syndrome. The range and duration of prior corticosteroid use in the studies was 0 to 538 months with a mean of 43.6 months and a median of 12 months. The range of prednisone dose at study commencement was 5 to 135 mg/day with a mean of 18.4 mg and a median of 10 mg daily. Fifty seven percent of patients had osteopenia/ osteoporosis at study commencement. Patients received supplemental calcium and vitamin D. At one year, the mean increases relative to placebo in BMD in patients receiving Fosamax 5 mg/day from the combined studies were: lumbar spine, 2.41%; femoral neck, 2.19%; and trochanter, 1.65%. These increases were significant at each site. Total body BMD was maintained with Fosamax 5 mg/day indicating that the increase in bone mass of the spine and hip did not occur at the expense of other sites. The increases in BMD with Fosamax 10 mg/day were similar to those with Fosamax 5 mg/day in all patients except for postmenopausal women not receiving oestrogen therapy. In these women, the increases (relative to placebo) with Fosamax 10 mg/day were greater than those with Fosamax 5 mg/day at the lumbar spine (4.11% vs. 1.56%) and trochanter (2.84% vs 1.67%), but not at other sites. Fosamax was effective regardless of dose or duration of glucocorticoid use. In addition, Fosamax was similarly effective regardless of age (< 65 vs ≥ 65 years), race (Caucasian vs other races), gender, baseline BMD, baseline bone turnover, and use with a variety of common medications.
Bone histology was normal in the 49 patients biopsied at the end of one year who received Fosamax at doses of up to 10 mg/day.

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 osteoblastic new bone formation, leading to the replacement of the normal bone architecture by disorganised, enlarged and weakened bone structure.
Fosamax decreases the rate of bone resorption directly, which leads to an indirect decrease in bone formation. Fosamax 40 mg once daily for six months produced highly significant decreases in serum alkaline phosphatase, an objective measure of disease severity. Furthermore, normal lamellar bone was produced during treatment with Fosamax, even where pre-existing bone was woven and disorganised.
As a result of the inhibition of bone resorption, Fosamax induced generally mild, transient and asymptomatic decreases in serum calcium and phosphate.
The efficacy of Fosamax 40 mg once daily for six months was demonstrated in two double blind clinical studies of male and female patients with moderate to severe Paget's disease (alkaline phosphatase at least twice the upper limit of normal): a placebo controlled multinational study and a US comparative study with etidronate disodium 400 mg/day. Figure 4 shows the mean percent changes from baseline in serum alkaline phosphatase for up to six months of randomised treatment.
At six months, the mean percent suppression from baseline in serum alkaline phosphatase in patients treated with Fosamax (-79% and -73% in the two studies) was significantly greater than that achieved with etidronate disodium 400 mg/day (-44%) and contrasted with the complete lack of response in placebo treated patients (+8.0%). Response (defined as either normalisation of serum alkaline phosphatase or decrease from baseline ≥ 60%) occurred in approximately 85% of patients treated with Fosamax in the combined studies versus 30% in the etidronate group and 0% in the placebo group. Fosamax was similarly effective irrespective of age, gender, race, renal function, concomitant medications, prior use of other bisphosphonates or baseline alkaline phosphatase.

Indications

Fosamax.

Fosamax is indicated for the treatment of the following.
Osteoporosis*, including glucocorticoid induced osteoporosis.
Paget's disease of bone.
Fosamax is indicated for the prevention of the following.
Osteoporosis in postmenopausal women with low bone mass (at least 1 standard deviation below the mean for young adults).
Glucocorticoid induced osteoporosis in those patients on long-term corticosteroid therapy (see Clinical Trials).

Fosamax Plus Once Weekly.

Fosamax Plus Once Weekly Tablet and Fosamax Plus 70 mg/140 microgram are indicated for the treatment of osteoporosis* in select patients where vitamin D supplementation is recommended.

Fosamax Plus D-Cal.

Fosamax Plus D-Cal is indicated for the treatment of osteoporosis* in select patients where vitamin D and calcium supplementation is recommended.
*Prior to treatment, osteoporosis must be confirmed by the finding of low bone mass of at least 2 standard deviations below the gender specific mean for young adults, or by the presence of osteoporotic fracture.

Contraindications

Fosamax, Fosamax Plus (including the Fosamax Plus component of Fosamax Plus D-Cal).

Abnormalities of the oesophagus which delay oesophageal emptying, such as stricture or achalasia.
Inability to stand or sit upright for at least 30 minutes.
Hypersensitivity to any component of this product.
Hypocalcaemia (see Precautions).

BoneCal component of Fosamax Plus D-Cal.

Hypercalcaemia.
Severe hypercalciuria.
Hypersensitivity to any component of this product.

Precautions

Severe oesophageal unlceration has been reported in patients taking alendronate. (See Dosage and Administration.) Physicians should therefore be alert to any signs or symptoms signaling a possible oesophageal reaction. Patients should be instructed to discontinue Fosamax, Fosamax Plus or the Fosamax Plus component of Fosamax Plus D-Cal and seek medical attention if they develop dysphagia, odynophagia or retrosternal pain.

General.

Causes of osteoporosis other than hypogonadism, aging and glucocorticoid use should be considered.
If there are clinical reasons to suspect hypocalcaemia and/or vitamin D deficiency (serum levels 25-hydroxyvitamin D < 9 nanomol/L), the appropriate diagnostic tests should be performed. Hypocalcaemia must be corrected before initiating therapy with Fosamax, Fosamax Plus or the Fosamax Plus component of Fosamax Plus D-Cal (see Contraindications). Other disturbances of mineral metabolism (such as vitamin D deficiency) should also be effectively treated. In patients with these conditions, serum calcium and symptoms of hypocalcaemia should be monitored during therapy with Fosamax, Fosamax Plus or the Fosamax Plus component of Fosamax Plus D-Cal. The content of vitamin D in Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) is not suitable for correction of vitamin D deficiency.
Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) should not be used as sole treatment for osteoporotic patients with a vitamin D deficiency (defined as serum 25-hydroxyvitamin D < 9 nanogram/mL (22.5 nanomol/L)) (see Clinical Trials, Fosamax Plus study). Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) should not be used to treat osteomalacia. Vitamin D should be used to treat osteomalacia. Fosamax Plus Once Weekly (70 mg/70 microgram or 70 mg/140 microgram) has not been studied in patients with vitamin D deficiency.
Small, asymptomatic decreases in serum calcium and phosphate may occur, especially in patients with Paget's disease, in whom the pretreatment rate of bone turnover may be greatly elevated, and in patients receiving glucocorticoids, in whom calcium absorption may be decreased.
Ensuring adequate calcium and vitamin D intake is especially important in patients with Paget's disease of bone and in patients receiving glucocorticoids.

Alendronate.

Alendronate, like other bisphosphonates, may cause local irritation of the upper gastrointestinal mucosa.
Oesophageal adverse experiences, such as oesophagitis, oesophageal ulcers and oesophageal erosions, rarely followed by oesophageal stricture or perforation, have been reported in patients receiving treatment with alendronate. In some cases these have been severe and required hospitalisation.
The risk of severe oesophageal adverse experiences appears to be greater in patients who lie down after taking Fosamax, Fosamax Plus or the Fosamax Plus component of Fosamax Plus D-Cal and/or who fail to swallow it with the recommended amount of water, and/or who continue to take Fosamax, Fosamax Plus or the Fosamax Plus component of Fosamax Plus D-Cal after developing symptoms suggestive of oesophageal irritation. Therefore, it is very important that the full dosing instructions are provided to, and understood by, the patient (see Dosage and Administration).
While no increased risk was observed in extensive clinical trials, there have been rare (postmarketing) reports of gastric and duodenal ulcers, some severe and with complications.
Because of possible irritant effects of alendronate on the upper gastrointestinal mucosa and a potential for worsening of the underlying disease, caution should be used when Fosamax, Fosamax Plus or the Fosamax Plus component of Fosamax Plus D-Cal is given to patients with active upper gastrointestinal problems, such as dysphagia, oesophageal diseases (including known Barrett's oesophagus), gastritis, duodenitis or ulcers.

Colecalciferol.

Vitamin D3 may increase the magnitude of hypercalcemia and/or hypercalciuria when administered to patients with diseases associated with unregulated overproduction of calcitriol (e.g. leukaemia, lymphoma, sarcoidosis). Urine and serum calcium should be monitored in these patients.
Patients with malabsorption may not adequately absorb vitamin D3.

Dental.

Localised osteonecrosis of the jaw (ONJ), generally associated with tooth extraction and/or local infection (including osteomyelitis) with delayed healing, has been reported rarely with oral bisphosphonates including Fosamax (see Adverse Effects, Postmarketing experience). As of May 2004, ONJ after bisphosphonate treatment has been described in a total of 99 cases in two large case series, 7 of which were taking oral bisphosphonates. As of 3 November 2006, the Australian Adverse Drug Reactions Advisory Committee has received 25 reports of ONJ in patients receiving alendronate. Most reported cases of bisphosphonate associated ONJ have been in cancer patients treated with intravenous bisphosphonates. Known risk factors for ONJ include a diagnosis of cancer, concomitant therapies (e.g. chemotherapy, radiotherapy, corticosteroids, angiogenesis inhibitors), poor oral hygiene, comorbid disorders (e.g. periodontal and/or other pre-existing dental disease, anaemia, coagulopathy, infection) and smoking.
Prior to treatment with bisphosphonates, a dental examination with appropriate preventative dentistry should be considered in patients with possible risk factors.
Before commencing invasive dental procedures, patients and their dentist should be advised of the risks and reports of osteonecrosis of the jaw so that dental symptoms, including toothache, developing during treatment can be fully assessed for cause before treatment of the tooth commences.
For patients requiring invasive dental surgery (e.g. tooth extraction, dental implants), there are no definitive data available to establish whether discontinuation of bisphosphonate treatment reduces the risk of ONJ. Therefore, clinical judgment of the treating physician and/or oral surgeon should guide the management plan, including discontinuation of bisphosphonate treatment, of each patient based on individual benefit/ risk assessment.
In patients who develop ONJ while on bisphosphonate therapy, the clinical judgment of the treating physician should guide the management plan to include appropriate care by an oral surgeon and discontinuation of bisphosphonate therapy should be based on individual benefit/ risk assessment. Surgery at the affected area may exacerbate the condition.

Atypical stress fractures.

A small number of long-term (usually longer than three years) alendronate treated patients developed stress fractures of the proximal femoral shaft (also known as insufficiency fractures), some of which occurred in the absence of apparent trauma. Some patients experienced prodromal pain in the affected area, often associated with imaging features of stress fracture, weeks to months before a complete fracture occurred. Approximately one third of these fractures were bilateral; therefore the contralateral femur should be examined in patients who have sustained a femoral shaft stress fracture. The number of reported cases of this condition is very low (some 40 reported cases worldwide in connection with alendronate as of 2008). Patients with suspected stress fractures should be evaluated, including evaluation for known causes and risk factors (e.g. vitamin D deficiency, malabsorption, glucocorticoid use, previous stress fracture, lower extremity arthritis or fracture, extreme or increased exercise, diabetes mellitus, chronic alcohol abuse) and receive appropriate orthopaedic care. Discontinuation of bisphosphonate therapy in patients with stress fractures is advisable pending evaluation of the patient, based on individual benefit/ risk assessment. A cause and effect relationship between bisphosphonate use and stress fractures has not been excluded.

Musculoskeletal pain.

Bone, joint, and/or muscle pain has been reported in patients taking bisphosphonates. In postmarketing experience, these symptoms have rarely been severe and/or incapacitating (see Adverse Effects, Postmarketing experience). The time to onset of symptoms varied from one day to several months after starting treatment. Most patients had relief of symptoms after stopping treatment. A subset had recurrence of symptoms when rechallenged with the same drug or another bisphosphonate.

Renal insufficiency.

Fosamax and Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram or D-Cal) are not recommended for patients with creatinine clearance < 35 mL/min (see Dosage and Administration).

Nephrolithiasis and hypercalciuria.

Patients with a history of either nephrolithiasis or hypercalciuria may require special diets that limit their calcium intake. The calcium content of BoneCal should be considered when these diets are prescribed.

Dosing instructions for patients.

Fosamax, Fosamax Plus tablets (including the Fosamax Plus component of Fosamax Plus D-Cal).

To facilitate delivery to the stomach and thus reduce the potential for oesophageal irritation, patients should be instructed to swallow each tablet of Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal with a full glass of water. Patients should be instructed not to lie down for at least 30 minutes and until after their first food of the day. Patients should not chew or suck on the tablet because of a potential for oropharyngeal ulceration. Patients should be specifically instructed not to take Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal at bedtime or before arising for the day. Patients should be informed that failure to follow these instructions may increase their risk of oesophageal problems. Patients should be instructed that if they develop symptoms of oesophageal disease, (such as difficulty or pain upon swallowing, retrosternal pain or new or worsening heartburn), they should stop taking Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal and consult their physician.
Patients should be instructed that if they miss a dose of Fosamax Once Weekly (70 mg), Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal, 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.

Additional instructions for Fosamax Plus D-Cal.

Fosamax Plus D-Cal is a combination pack consisting of 4 once weekly tablets of Fosamax Plus 70 mg/140 microgram and 48 tablets of BoneCal. One tablet of Fosamax Plus 70 mg/140 microgram should be taken on the first day. Beginning on the next day, one or two BoneCal tablets should be taken daily for 6 days. This 7 day cycle should be repeated each week. With this regimen Fosamax Plus and BoneCal are not taken on the same day.
The Fosamax Plus component should always be taken on the same day each week, in accordance with the directions as described above. Patients should be instructed to commence the BoneCal component on the day after the Fosamax Plus tablet is taken. Patients should be instructed to take one or two tablets each day with food for the next 6 days, depending on their need for calcium supplementation.
Patients should be instructed that if they miss a dose of Fosamax Plus 70 mg/140 microgram, 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. On the following day, they should take their next dose of BoneCal.
Patients should be instructed that if they miss a dose of BoneCal, they should omit that dose and continue taking the tablets on the day that they remember.

Effects on fertility.

Alendronate sodium.

Alendronate sodium had no effect on fertility in male and female rats at oral doses of up to 9 and 15 mg/kg/day.
No studies on the effects on fertility have been carried out using the alendronate and colecalciferol combination.

Use in pregnancy.

(Category B3)

Alendronate sodium.

Alendronate has not been studied in pregnant women and should not be given to them. In studies with pregnant rats, oral alendronate doses of 2 mg/kg/day and above resulted in dystocia due to maternal hypocalcaemia. Foetal weight was reduced in rats at maternal doses greater than 5 mg/kg/day. No teratogenic effects were seen in rats or rabbits at oral doses up to 25 and 35 mg/kg/day, respectively.

Colecalciferol.

No data are available for colecalciferol (vitamin D3). Intramuscular administration of high doses (≥ 10,000 IU/every other day) of ergocalciferol (vitamin D2) to pregnant rabbits resulted in higher incidence of foetal aortic stenosis compared to controls. Administration of vitamin D2 (40,000 IU/day) to pregnant rats resulted in neonatal death, decreased foetal weight and impaired osteogenesis of long bones postnatally.
No studies on the reproductive toxicity potential of the alendronate and colecalciferol combination have been carried out in animals.

Use in lactation.

Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) and the Fosamax Plus component of Fosamax Plus D-Cal have not been studied in breastfeeding women and should not be given to them. No studies using the combination of alendronate and colecalciferol have been carried out in lactating animals.

Paediatric use.

Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) and the Fosamax Plus component of Fosamax Plus D-Cal have not been studied in children and should not be given to them.

Use in the elderly.

In controlled trials, there was no age related difference in the efficacy or safety profiles of Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal.

Carcinogenicity.

Alendronate sodium.

No evidence of carcinogenic effect was observed in a 105 week study in rats receiving oral doses up to 3.75 mg/kg/day and in a 92 week study in mice receiving oral doses up to 10 mg/kg/day.
The carcinogenic potential of colecalciferol alone or the alendronate and colecalciferol combination has not been studied.

Genotoxicity.

Alendronate sodium.

Alendronate did not cause gene mutations in bacteria or in mammalian cells in vitro, nor did it cause DNA damage in rat hepatocytes in vitro (alkaline elution assay). In assays of chromosomal damage, alendronate was weakly positive in an in vitro assay using Chinese hamster ovary cells at cytotoxic concentrations (≥ 5 microM) but was negative at IV doses up to 25 mg/kg/day (75 mg/m2) in an in vivo assay (chromosomal aberrations in mouse bone marrow).

Colecalciferol.

Calcitriol, the active hormonal metabolite of colecalciferol, was not genotoxic in the microbial mutagenesis assay with or without metabolic activation, or in an in vivo micronucleus assay in mice.
No studies on the genotoxic potential have been carried out using the alendronate and colecalciferol combination.

Interactions

Alendronate sodium.

If taken at the same time, it is likely that calcium supplements, antacids and other oral medications will interfere with absorption of alendronate. Therefore, patients must wait at least one half hour after taking Fosamax or Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal before taking any other oral medication.
No other drug interactions of clinical significance are anticipated though the concomitant medication with two or more bisphosphonates cannot be recommended because of the lack of clinical data.
Concomitant use of HRT (oestrogen ± progestin) and Fosamax was assessed in two clinical studies of one or two years' duration in postmenopausal osteoporotic women. Combined use of Fosamax and HRT resulted in greater increases in bone mass, together with greater decreases in bone turnover, than seen with either treatment alone. In these studies, the safety and tolerability profile of the combination was consistent with those of the individual treatments (see Adverse Effects, Clinical studies, Concomitant use with oestrogen/ hormone replacement therapy).
Specific interaction studies were not performed. Fosamax (10 mg and 5 mg/day) was used in studies of treatment and prevention of osteoporosis in postmenopausal women, men and glucocorticoid users, with a wide range of commonly prescribed drugs without evidence of clinical adverse interactions. In clinical studies, the incidence of upper gastrointestinal adverse events was increased in patients receiving daily therapy with dosages of Fosamax greater than 10 mg and aspirin containing products. However, this was not observed in studies with Fosamax Once Weekly 70 mg.
Since nonsteroidal anti-inflammatory drug (NSAID) use is associated with gastrointestinal irritation, caution should be used during concomitant use with alendronate.

Colecalciferol.

Olestra, mineral oils, orlistat and bile acid sequestrants (e.g. cholestyramine, colestipol) may impair the absorption of vitamin D. Anticonvulsants, cimetidine and thiazides may increase the catabolism of vitamin D.

Calcium carbonate.

Calcium carbonate may interfere with the absorption of some concomitantly administered medications (e.g. tetracycline preparations). For this reason, the effect of calcium on the absorption of concomitantly administered medications should be reviewed.
Thiazide diuretics may reduce the urinary excretion of calcium.
Systemic glucocorticoids may reduce calcium absorption. During concomitant use with the BoneCal component of Fosamax Plus D-Cal, it may be necessary to increase the amount of calcium supplementation.

Effect on ability to drive or use machinery.

No studies on the effects on the ability to drive and use machines have been performed. However, certain adverse reactions that have been reported with Fosamax or Fosamax Plus may affect some patients' ability to drive or operate machinery. Individual responses to Fosamax or Fosamax Plus may vary (see Adverse Effects).

Effect on laboratory tests.

In double-blind, multicentre, controlled studies, asymptomatic, mild and transient decreases in serum calcium and phosphate were observed in approximately 18 and 10%, respectively, of patients taking Fosamax versus approximately 12 and 3% of those taking placebo. However, the incidences of decreases in serum calcium to < 8.0 mg/dL (2.0 mM) and serum phosphate to ≤ 2.0 mg P/dL (0.65 mM) were similar in both treatment groups.

Adverse Effects

Clinical studies.

Fosamax.

In clinical studies Fosamax was generally well tolerated. In studies of up to five years in duration, side effects, which usually were mild, generally did not require discontinuation of therapy.

Treatment of osteoporosis.

Postmenopausal women.

Fosamax has been evaluated for safety in clinical studies in approximately 5000 postmenopausal patients. In two three year placebo controlled double blind multicentre studies, discontinuation of therapy due to any clinical adverse experience occurred in 4.1% of 196 patients treated with Fosamax 10 mg/day and 6.0% of 397 patients treated with placebo. Adverse experiences reported by the investigators as possibly, probably or definitely drug related in ≥ 1% of patients treated with either Fosamax 10 mg/day or placebo are presented in Table 5.
Rarely, rash and erythema have occurred.
In the two year extension (treatment years 4 and 5) of the above studies, the overall safety profile of Fosamax 10 mg/day was similar to that observed during the three year placebo controlled period. Additionally, the proportion of patients who discontinued Fosamax 10 mg/day due to any clinical adverse experience was similar to that during the first three years of the study.
In the Fracture Intervention Trial, discontinuation of therapy due to any clinical adverse experience occurred in 9.1% of 3236 patients treated with Fosamax 5 mg/day for 2 years and 10 mg/day for either one or two additional years and 10.1% of 3223 patients treated with placebo. Discontinuations due to upper gastrointestinal adverse experiences were: Fosamax 3.2%; placebo 2.7%. The overall adverse experience profile was similar to that seen in other studies with Fosamax 5 or 10 mg/day.
In a one year, double blind, multicentre study, the overall safety and tolerability profiles of Fosamax Once Weekly 70 mg (n = 519) and Fosamax 10 mg daily (n = 370) were similar. Adverse experiences reported by the investigators as possibly, probably or definitely drug related in ≥ 1% of patients treated with either patient group are presented in Table 6.

Concomitant use with oestrogen/ hormone replacement therapy.

In two studies (of one and two years duration) of postmenopausal osteoporotic women (total n = 853), the safety and tolerability profile of combined treatment with Fosamax 10 mg once daily and oestrogen ± progestin (n = 354) was consistent with those of the individual treatments.

Men.

In a two year, placebo controlled, double blind, multicentre study, the safety profile of Fosamax 10 mg daily in 146 men was generally similar to that seen in postmenopausal women.

Other studies in men and women.

In a ten week endoscopy study in men and women (n = 277; mean age 55 years) no difference was seen in upper gastrointestinal tract lesions between Fosamax Once Weekly 70 mg and placebo.
In an additional one year study in men and women (n = 335; mean age 50 years) the overall safety and tolerability profiles of Fosamax Once Weekly 70 mg were similar to that of placebo and no difference was seen between men and women.

Prevention of osteoporosis.

The safety of Fosamax in postmenopausal women 40 to 60 years of age has been evaluated in three double blind, placebo controlled studies involving over 1,400 patients randomised to receive Fosamax for either two or three years. In these studies, the safety and tolerability profile of Fosamax 5 mg/day (n = 642) was similar to that of placebo (n = 648). The only adverse experience reported by the investigators as possibly, probably or definitely drug related in ≥ 1% of patients treated with Fosamax 5 mg/day and at a greater incidence than placebo was dyspepsia (Fosamax 1.9% vs. placebo 1.7%).

Treatment and prevention of glucocorticoid induced osteoporosis.

In two, one year, placebo controlled, double blind, multicentre studies in patients receiving glucocorticoid treatment, the overall safety and tolerability profiles of Fosamax 5 and 10 mg/day were generally similar to that of placebo. Adverse experiences reported by the investigators as possibly, probably or definitely drug related in ≥ 1% of patients treated with either Fosamax 5 mg/day, 10 mg/day or placebo are presented in Table 7.

Paget's disease of bone.

In clinical studies (Paget's disease and osteoporosis), adverse experiences reported in patients taking Fosamax 40 mg/day for 3-12 months were similar to those in postmenopausal women treated with Fosamax 10 mg/day. However, there was an apparent increased incidence of upper gastrointestinal adverse experiences in patients taking Fosamax 40 mg/day. Isolated cases of oesophagitis and gastritis resulted in discontinuation of treatment.
Additionally, musculoskeletal pain (bone, muscle or joint), which has been described in patients with Paget's disease treated with other bisphosphonates, was reported by the investigators as possibly, probably or definitely drug related in approximately 6% of patients treated with Fosamax 40 mg/day versus approximately 1% of patients treated with placebo, but rarely resulted in discontinuation of therapy.

Fosamax Plus.

In a 15 week, double blind, multinational study in osteoporotic postmenopausal women (n = 682) and men (n = 35), the safety profile of once weekly alendronate 70 mg/ colecalciferol 70 microgram was similar to that of Fosamax Once Weekly 70 mg. In the 24 week double blind extension study in women (n = 619) and men (n = 33), the safety profile of alendronate 70 mg/ colecalciferol 70 microgram (vitamin D3 2800 IU) administered with an additional colecalciferol 70 microgram for a total of colecalciferol 140 microgram (5600 IU vitamin D3) was similar to that of alendronate 70 mg/ colecalciferol 70 microgram (2800 IU vitamin D3). The primary endpoint was the proportion of patients who developed hypercalciuria at week 39, with 4.2% noted in the colecalciferol 140 microgram group and 2.8% in the colecalciferol 70 microgram group, which was not statistically significant. Overall, the safety profile of alendronate 70 mg/ colecalciferol 70 microgram administered with 70 microgram additional colecalciferol for a total of colecaciferol 140 microgram was similar to that of alendronate/ colecalciferol 70 microgram.

Fosamax, Fosamax Plus (including the Fosamax Plus component of Fosamax Plus D-Cal) postmarketing experience.

The following adverse reactions have been reported in postmarketing use with alendronate.

Body as a whole.

Hypersensitivity reactions including urticaria and, rarely, angioedema. Transient symptoms as in an acute phase response (myalgia, malaise, asthenia and, rarely, fever) have been reported with alendronate, typically in association with initiation of treatment. Rarely, symptomatic hypocalcaemia has occurred, generally in association with predisposing conditions. Rarely, peripheral oedema.

Gastrointestinal.

Nausea, vomiting, oesophagitis, oesophageal erosions, oesophageal ulcers, rarely oesophageal stricture or perforation, and oropharyngeal ulceration and/or stomatitis; rarely, gastric or duodenal ulcers, some severe and with complications (see Precautions and Dosage and Administration). Localised osteonecrosis of the jaw, generally associated with tooth extraction and/or local infection (including osteomyelitis), often with delayed healing, has been reported rarely.

Musculoskeletal.

Bone, joint and/or muscle pain, rarely severe and/or incapacitating (see Precautions, Instructions to patients); joint swelling, atypical stress fracture (see Precautions).

Nervous system.

Dizziness, vertigo, dysgeusia.

Skin.

Rash (occasionally with photosensitivity), pruritus, alopecia, rarely severe skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis.

Special senses.

Rarely uveitis; scleritis or episcleritis. Cholesteatoma of the external auditory canal (focal osteonecrosis) has been reported rarely.

BoneCal component of Fosamax Plus D-Cal.

The following adverse reactions have been described with calcium carbonate: constipation, flatulence, nausea, abdominal pain, hypercalcaemia, hypercalciuria, nephrolithiasis.

Dosage and Administration

Fosamax and Fosamax Plus brands (70 mg/70 microgram or 70 mg/140 microgram) as well as the Fosamax Plus component of Fosamax Plus D-Cal must be taken at least 30 minutes before the first food, beverage or medication of the day with plain water only. Other beverages (including mineral water), food and some medications are likely to reduce the absorption of alendronate (see Interactions with Other Medicines).
Fosamax and Fosamax Plus brands (70 mg/70 microgram or 70 mg/140 microgram) as well as the Fosamax Plus component of Fosamax Plus D-Cal should only be taken upon arising for the day. To facilitate delivery to the stomach and thus reduce the potential for oesophageal irritation, Fosamax tablets and Fosamax Plus brands (70 mg/70 microgram or 70 mg/140 microgram) tablets should only be swallowed with a full glass of water.
Patients should not lie down for at least 30 minutes and until after their first food of the day. Fosamax and Fosamax Plus brands (70 mg/70 microgram or 70 mg/140 microgram) as well as the Fosamax Plus component of Fosamax Plus D-Cal should not be taken at bedtime or before arising for the day. Failure to follow these instructions may increase the risk of oesophageal adverse experiences (see Precautions).
Severe oesophageal ulceration has been reported in patients taking alendronate. (See Precautions.) Patients should be instructed that if they develop symptoms of oesophageal disease (such as difficulty or pain upon swallowing, retrosternal pain or new or worsening heartburn) they should stop taking Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal and consult their doctor.
In clinical trials, Fosamax was administered with appropriate calcium and vitamin D supplementation. The use of vitamin D as the sole treatment of osteoporosis has not been established.
Patients should receive supplemental calcium and/or vitamin D if intake is inadequate (see Precautions). Each tablet of BoneCal in Fosamax Plus D-Cal provides elemental calcium 500 mg.
Physicians should consider the vitamin D intake from vitamins and dietary supplements. Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) provides 2800 IU (70 microgram) of vitamin D in a single once weekly dose, which is equivalent to seven daily doses of 400 IU (10 microgram). Fosamax Plus (70 mg/140 microgram) provides 140 microgram colecalciferol (5600 IU of vitamin D3) in a single once weekly dose, which is equivalent to seven daily doses of 20 microgram colecalciferol (800 IU vitamin D3). Additional supplements should not be taken at the same time of day as Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) or the Fosamax Plus component of Fosamax Plus D-Cal (see above).
No dosage adjustment is necessary for the elderly or patients with mild to moderate renal insufficiency (creatinine clearance 35 to 60 mL/min). Fosamax, Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) and Fosamax Plus D-Cal are not recommended for patients with more severe renal insufficiency (creatinine clearance < 35 mL/min).
Although no specific studies have been conducted on the effects of switching patients on another therapy for osteoporosis to Fosamax or Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram), or on another therapy for Paget's disease to Fosamax, there are no known or theoretical safety concerns related to Fosamax or Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) in patients who previously received any other antiosteoporotic or antipagetic therapy.

Fosamax.

Treatment of osteoporosis.

The recommended dosage is one 70 mg tablet of Fosamax once weekly or one 10 mg tablet of Fosamax once daily.

Prevention of osteoporosis in postmenopausal women.

The recommended dosage is one 5 mg tablet of Fosamax once a day.

Treatment and prevention of glucocorticoid induced osteoporosis.

In selected patients, the recommended dosage is one 5 mg tablet of Fosamax once a day, except for postmenopausal women not receiving oestrogen, for whom the recommended dosage is one 10 mg tablet of Fosamax once a day (see Clinical Trials, Glucocorticoid induced osteoporosis).
The optimal duration of use has not been determined. All patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis (see Adverse Effects, Clinical studies).

Paget's disease of bone.

The recommended treatment regimen is one 40 mg tablet of Fosamax once a day for up to six months.

Retreatment of Paget's disease.

In clinical studies, during the twelve months following therapy, relapses occurred in only 9% (3 out of 32) of patients who responded to treatment with Fosamax. Specific retreatment data with Fosamax are not available, although responses to Fosamax were similar in patients who had received prior bisphosphonate therapy and those who had not. Retreatment with Fosamax may be considered, following a six month post-treatment evaluation period, in patients who have relapsed based on increases in serum alkaline phosphatase. Retreatment may also be considered in those who failed to normalise their serum alkaline phosphatase.

Fosamax Plus brands (70 mg/70 microgram or 70 mg/140 microgram).

Treatment of osteoporosis in patients where vitamin D supplementation is recommended.

The recommended dose is one tablet of Fosamax Plus (70 mg/70 microgram or 70 mg/140 microgram) once weekly.
The optimal duration of use has not been determined. All patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis (see Adverse Effects, Clinical studies).

Fosamax Plus D-Cal.

Treatment of osteoporosis in patients where vitamin D and calcium supplementation is recommended.

The recommended dose is one tablet of Fosamax Plus 70 mg/140 microgram taken once weekly. For the next six days, patients should take one or two BoneCal tablets daily depending on their need for calcium supplementation. This 7 day cycle should be repeated each week. With this regimen Fosamax Plus and BoneCal are not taken on the same day.
The optimal duration of use has not been determined. All patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis (see Adverse Effects, Clinical studies).
The Fosamax Plus component should always be taken on the same day each week, in accordance with the directions as described above. The BoneCal component should commence on the day after the Fosamax Plus tablet is taken, with one or two tablets taken each day with food for the next 6 days. The Fosamax Plus and BoneCal tablets should never be taken at the same time.

Overdosage

Alendronate sodium.

No specific information is available on the treatment of overdosage with alendronate. Hypocalcaemia, hypophosphataemia and upper gastrointestinal adverse events such as upset stomach, heartburn, oesophagitis, gastritis or ulcer may result from oral overdosage. Administration of milk or antacids to bind alendronate should be considered.

Colecalciferol.

Vitamin D toxicity has not been documented during chronic therapy in generally healthy adults at a dose less than 10,000 IU/day. In a clinical study of healthy adults, a 4000 IU daily dose of vitamin D3 for up to five months was not associated with hypercalciuria or hypercalcemia.

Calcium carbonate.

Adverse effects of overdosage with calcium carbonate is unlikely due to limited intestinal absorption. However, chronic excessive dosing can lead to hypercalcaemia or hypercalciuria.
Contact the Poisons Information Centre (telephone 131 126) for advice regarding management of overdose.

Presentation

Fosamax.

Tablets, 5 mg* (≡ alendronate sodium 6.53 mg; white, round, marked MSD 925, outline of bone image on reverse): 8's, 30's (blister pack); 10 mg (≡ alendronate sodium 13.05 mg; white to off white, polished oval, marked 936, plain on reverse): 8's*, 30's* (blister pack); 40 mg (≡ alendronate sodium 52.21 mg; white, triangular, marked MSD 212, FOSAMAX on reverse): 8's**, 30's (blister pack).

Fosamax Once Weekly.

Tablets, 70 mg (≡ alendronate sodium 91.4 mg; white, oval, marked 31, outline of bone image on reverse): 1's*, 2's*, 4's (blister pack).

Fosamax Plus Once Weekly.

Tablets (white to off white, outline of bone image on reverse), 70 mg/70 microgram (≡ alendronate sodium 91.4 mg/ vitamin D3 2,800 IU, modified capsule shaped, marked 710 on one side), 70 mg/140 microgram (≡ alendronate sodium 91.4 mg/ vitamin D3 5,600 IU, modified rectangle shaped, marked 270 on one side): 1's**, 4's (blister pack).

Fosamax Plus D-Cal.

Combination pack. Fosamax Plus Once Weekly tablets, 70 mg/140 microgram (≡ alendronate sodium 91.4 mg/ vitamin D3 5,600 IU, white to off white, modified rectangle shaped, marked 270 on one side, outline of bone image on reverse): 4's (blister pack); BoneCal tablets, calcium carbonate 1,250 mg (≡ elemental calcium 500 mg, green, film coated, capsule shaped): 24's*, 48's (bottle).
*Not currently marketed in Australia.
**Supplied as starter packs only.

Storage

Store below 30°C.
Protect Fosamax Plus (70 mg/70 microgram and 70 mg/140 microgram and D-Cal) tablets from moisture and light and store tablets in original blister package until use.

Poison Schedule

S4.