Document: Alendronat Orifarm Veckotablett tablet ENG SmPC change

• Alendronat Orifarm Veckotablett 70 mg tablet SmPC
• Alendronat Orifarm Veckotablett tablet ENG SmPC

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Summary of product characteristics

Alendronat Orifarm Veckotablett 70 mg tablets

One tablet contains alendronate sodium trihydrate equivalent to 70 mg alendronate sodium.

For the full list of excipients, see section 6.1.

Tablet.

Oval, white, biconvex tablets marked APO on one side and ALE 70 on the other.

Treatment of post-menopausal osteoporosis. Alendronat Orifarm Veckotablett reduces the risk of vertebral and hip fractures.

Posology

The recommended dose is one 70 mg tablet once a week.

The optimal duration of bisphosphonate treatment for osteoporosis has not been established. The need for continued treatment should be re-evaluated periodically based on the benefits and potential risks of alendronate on an individual patient basis, particularly after 5 or more years of use.

Use in the elderly: Clinical studies showed no age-related difference in the efficacy or safety profiles of alendronate. Therefore no dose adjustment is necessary in the elderly.

Use in renal impairment: No dose adjustment is necessary in patients with glomerular filtration rates (GFR) of over 35 ml/min. Alendronate is not recommended in patients with renal impairment with a GFR of less than 35 ml/min, as there is insufficient experience.

Paediatric population

Alendronate sodium is not recommended for use in children under the age of 18 years due to insufficient data on safety and efficacy in conditions associated with paediatric osteoporosis (also see section 5.1).

Alendronat Orifarm Veckotablett has not been investigated in the treatment of corticosteroid-induced osteoporosis.

Method of administration

To obtain satisfactory absorption of alendronate:

Alendronat Orifarm Veckotablett should only be taken with plain water at least 30 minutes before the first food, drink or other medication of the day. Other drinks (including mineral water), food and certain medications are likely to reduce absorption of alendronate (see section 4.5).

To facilitate transport to the stomach and hence reduce the risk of irritation/side effects locally and in the oesophagus (see section 4.4):

• Alendronat Orifarm Veckotablett should only be swallowed whole with a full glass of water (no less than 200 ml) upon rising.

• Patients must not crush or chew the tablet or allow the tablet to dissolve in the mouth because of the risk of ulcers of the mouth/throat.

• Patients must not lie down before the first meal of the day, which should be at least 30 minutes after taking the tablet.

• Patients should not lie down for at least 30 minutes after taking their Alendronat Orifarm Veckotablett.

• The Alendronat Orifarm Veckotablett should not be taken at bedtime or before rising for the day.

• Patients should take calcium or vitamin D supplements if dietary intake is inadequate (see section 4.4).

• Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

• Oesophageal changes and other factors that delay oesophageal emptying, such as stricture or achalasia.

• Inability to sit or stand upright for a minimum of 30 minutes.

• Hypocalcaemia

• See also section 4.4.

Alendronate can cause local irritation of the mucous membranes in the upper gastrointestinal tract. Since there is a risk that the underlying disorder can become worse, caution should be exercised when alendronate is given to patients with active problems of the upper gastrointestinal tract, such as dysphagia, oesophageal disease, gastritis, duodenitis, ulcers or newly developed (within the past year) serious gastrointestinal disease such as stomach ulcers, active gastrointestinal bleeding or gastrointestinal surgery other than pyloroplasty (see section 4.3). In patients with known Barrett’s oesophagus, prescribers should consider the benefits and potential risks of alendronate on an individual patient basis.

Oesophageal side effects (in some cases serious or which require hospital admission) such as oesophagitis, oesophageal ulcers and oesophageal erosions, in rare cases followed by oesophageal stricture, have been reported in patients on alendronate treatment. Doctors should therefore watch out for any signs or symptoms of an oesophageal reaction. Patients should be told to stop taking alendronate and seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, pain on swallowing, retrosternal pain or new or worsening heartburn.

The risk of oesophageal side effects is thought to be greater in patients who are taking alendronate incorrectly and/or continue to take alendronate (70 mg weekly tablet) after developing symptoms suggestive of oesophageal irritation. It is very important that complete dosage instructions are given to and understood by patients (see section 4.2). Patients should be informed that the risk of oesophageal problems may increase if they do not follow these instructions.

Despite the fact that no increased risk was observed in extensive clinical trials, there have been rare reports of gastric and duodenal ulcers, some severe and with complications. A causal connection cannot be ruled out.

If patients forget to take one Alendronat Orifarm Veckotablett, they should be told to take the 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. Causes of osteoporosis other than oestrogen deficiency and ageing should be considered.

Hypocalcaemia must be corrected before initiating treatment with alendronate (see section 4.3). Other disorders of mineral metabolism (such as vitamin D deficiency and hypoparathyroidism) should also be effectively treated. In patients with these conditions serum calcium and symptoms of hypocalcaemia should be monitored during treatment with alendronate.

Due to the positive effects of alendronate in increasing bone mineral, decreases in serum calcium and phosphate may occur. These are usually small and asymptomatic. However, there have been rare reports of symptomatic hypocalcaemia, which have occasionally been severe and often occurred in patients with predisposing conditions (e.g. hypoparathyroidism, vitamin D deficiency and calcium malabsorption). Therefore ensuring adequate calcium and vitamin D intake is particularly important in patients receiving corticosteroids.

Alendronate is not recommended in patients with impaired renal function with a GFR of less than 35 ml/min (see section 4.2).

Osteonecrosis of the jaw, generally associated with tooth extraction and/or local infection (including osteomyelitis) has been reported in patients with cancer receiving treatment regimens including primarily intravenously administered bisphosphonates. Many of these patients were also receiving chemotherapy and corticosteroids. Osteonecrosis of the jaw has also been reported in patients with osteoporosis receiving oral bisphosphonates.

The following risk factors should be considered when evaluating an individual’s risk of developing osteonecrosis of the jaw:

• Potency of the bisphosphonate (highest for zoledronic acid), route of administration (see above) and cumulative dose

• Cancer, chemotherapy, radiotherapy, corticosteroids, smoking

• A history of dental disease, poor oral hygiene, periodontal disease, invasive dental procedures and poorly fitting dentures.

A dental examination with appropriate preventive dentistry should be considered prior to treatment with bisphosphonates in patients with poor dental status.

While on treatment, these patients should avoid invasive dental procedures if possible. For patients who develop osteonecrosis of the jaw while on bisphosphonate therapy, dental surgery may exacerbate the condition. For patients requiring dental procedures, there are no data available to suggest whether discontinuation of bisphosphonate treatment reduces the risk of osteonecrosis of the jaw. Clinical judgement of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment.

During bisphosphonate treatment, all patients should be encouraged to maintain good oral hygiene, receive routine dental check-ups, and report any oral symptoms such as dental mobility, pain, or swelling.

Bone, joint, and/or muscle pain has been reported in patients taking bisphosphonates. In post-marketing experience, these symptoms have rarely been severe and/or incapacitating (see section 4.8). The time onset of symptoms varied from one day to several months after starting treatment. Most patients had relief of symptoms after stopping. A subset had recurrence of symptoms when rechallenged with the same drug or another bisphosphonate.

Osteonecrosis of the external auditory canal has been reported with bisphosphonates, mainly in association with long-term therapy. Possible risk factors for osteonecrosis of the external auditory canal include steroid use and chemotherapy and/or local risk factors such as infection or trauma. The possibility of osteonecrosis of the external auditory canal should be considered in patients receiving bisphosphonates who present with ear symptoms including chronic ear infections.

In post-marketing experience, there have been rare reports of severe skin reactions including Stevens Johnson syndrome and toxic epidermal necrolysis.

Atypical fractures of the femur

Atypical subtrochanteric and diaphyseal femoral fractures have been reported with bisphosphonate therapy, primarily in patients receiving long-term treatment for osteoporosis. These transverse or short oblique fractures can occur anywhere along the femur from just below the lesser trochanter to just above the supracondylar flare. These fractures occur after minimal or no trauma and some patients experience thigh or groin pain, often associated with

imaging features of stress fractures, weeks to months before presenting with a completed femoral fracture. Fractures are often bilateral; therefore the contralateral femur should be examined in bisphosphonate-treated patients who have sustained a femoral shaft fracture. Poor healing of these fractures has also been reported. Discontinuation of bisphosphonate therapy in patients suspected to have an atypical femur fracture should be considered pending evaluation of the patient, based on an individual benefit risk assessment.

During bisphosphonate treatment patients should be advised to report any thigh, hip or groin pain and any patient presenting with such symptoms should be evaluated for an incomplete femur fracture.

If taken at the same time, it is likely that food and drink (including mineral water), calcium supplements, antacids and some oral medicinal products will interfere with absorption of alendronate. Therefore patients must wait at least 30 minutes after taking alendronate before taking any other oral medicinal product (see sections 4.2 and 5.2).

No other interactions of clinical significance are anticipated. A number of patients in the clinical studies received oestrogen (intravaginal, transdermal or oral) while taking alendronate. No side effects attributable to their concomitant use were identified.

Since NSAID use is associated with gastrointestinal irritation, caution should be used during concomitant use with alendronate.

Although specific interaction studies were not performed, in clinical studies alendronate was used concomitantly with a wide range of commonly prescribed medicinal products without evidence of adverse clinical interactions.

Pregnancy

There are no adequate data from the use of alendronate in pregnant women. Animal studies do not indicate direct harmful effects with respect to pregnancy, embryonal/foetal development or postnatal development. Alendronate given to pregnant rats caused dystocia related to hypocalcaemia (see section 5.3). Given the indication, alendronate should not be used during pregnancy.

Breastfeeding

It is not known whether alendronate is excreted into human breast milk. Given the indication, alendronate should not be used by breast-feeding women.

No effects have been reported on ability to drive or operate machinery. However, certain adverse reactions that have been reported with alendronate may affect some patients’ ability to drive or operate machinery. Individual responses to alendronate may vary (see section 4.8).

In a one-year study in post-menopausal women with osteoporosis, the overall safety profiles of alendronate 70 mg once weekly tablet (n=519) and alendronate10 mg daily (n=370) were similar.

In two three-year studies of almost identical design in post-menopausal women (alendronate 10 mg: n=196, placebo: n=397) the overall safety profiles of alendronate 10 mg daily and placebo were similar.

Side effects reported by the investigators as possibly, probably or definitely drug-related are presented below if they occurred in ≥1% in either treatment group in the one-year study, or in >1% of patients treated with alendronate10 mg per day and at a greater incidence than in patients given placebo in the three-year studies.

	One-year study		Three-year studies
	Alendronate 70 mg weekly tablet (n=519) %	Alendronate 10 mg daily (n=370) %	Alendronate 10 mg daily (n=196) %	Placebo (n=397) %
Gastrointestinal
Abdominal pain	3.7	3.0	6.6	4.8
Dyspepsia	2.7	2.2	3.6	3.5
Acid regurgitation	1.9	2.4	2.0	4.3
Nausea	1.9	2.4	3.6	4.0
Abdominal distension	1.0	1.4	1.0	0.8
Constipation	0.8	1.6	3.1	1.8
Diarrhoea	0.6	0.5	3.1	1.8
Dysphagia	0.4	0.5	1.0	0.0
Flatulence	0.4	1.6	2.6	0.5
Gastritis	0.2	1.1	0.5	1.3
Gastric ulcer	0.0	1.1	0.0	0.0
Oesophageal ulcer	0.0	0.0	1.5	0.0
Musculoskeletal
Musculoskeletal pain (bone, muscle or joint)	2.9	3.2	4.1	2.5
Muscle cramp	0.2	1.1	0.0	1.0
Neurological
Headache	0.4	0.3	2.6	1.5

The following side effects have also been reported during clinical studies and/or post-authorisation:

[Very common (1/10),Common(>1/100 to <1/10), Uncommon (>1/1,000 to <1/100), Rare (>1/10,000 to <1/1,000), Very rare <1/10,000), not known (cannot be estimated from the available data)]

Immune system disorders

Rare: Hypersensitivity reactions including urticaria and angiooedema.

Metabolism and nutrition disorders

Rare: Symptomatic hypocalcaemia, often in association with predisposing conditions (see section 4.4).

Nervous system disorders

Common: Headache, dizziness.

Uncommon: Dysgeusia^†.

Eye disorders

Uncommon: Eye inflammation (Uveitis, scleritis, episcleritis).

Ear and labyrinth disorders

Common: Vertigo^†.

Very rare: Osteonecrosis of the external auditory canal (bisphosphonate class adverse reaction).

Gastrointestinal disorders

Common: Abdominal pain, dyspepsia, constipation, diarrhoea, flatulence, oesophageal ulcer*, dysphagia*, abdominal distension, acid regurgitation.

Uncommon: Nausea, vomiting, gastritis, oesophagitis*, oesophageal erosions*, melena.

Rare: Oesophageal stricture*, oropharyngeal ulcers*, upper gastrointestinal PUBs (perforations, ulcers, bleeding) (see section 4.4).

Skin and subcutaneous tissue disorders

Common: Alopecia^†, pruritus^†

Uncommon: Rash, pruritis, erythema.

Rare: Rash with photosensitivity, severe skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis.

Musculoskeletal and connective tissue disorders

Very common: Musculoskeletal pain (bone, muscle or joint) which is sometimes severe^† (see section 4.4).

Common: Joint swelling^†.

Rare: Osteonecrosis of the jaw^‡(see section 4.4), atypical subtrochanteric and diaphyseal femoral fractures (bisphosphonate class adverse reaction).

General disorders and administration site conditions

Common: Asthenia^†, peripheral oedema^†.

Uncommon: Transient symptoms as in an acute-phase response (myalgia, general malaise and in rare cases fever), usually in association with initiation of treatment^†.

* See sections 4.2 and 4.4.

^†Frequency in clinical trials was similar in the drug and placebo group.

^‡This adverse reaction was identified through post-marketing surveillance. The frequency of rare was estimated based on relevant clinical trials.

^┴Identified in post-marketing experience.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.

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

Pharmacotherapeutic group: Bisphosphonate, for the treatment of bone disease

ATC code: M05BA04

The active substance in Alendronat Orifarm Veckotablett, alendronate sodium trihydrate, is a bisphosphonate that inhibits osteoclastic bone resorption with no direct effect on bone formation.

Preclinical studies have shown preferential localisation of alendronate to sites of active resorption. Activity of osteoclasts is inhibited, but formation or binding of osteoclasts is not affected. The bone formed during treatment with alendronate is of normal quality.

Treatment of post-menopausal osteoporosis

Osteoporosis is defined as bone density of the spine or hip 2.5 standard deviations below the mean value of a normal young population or as a previous fragility fracture, irrespective of bone density.

The therapeutic equivalence of alendronate (70 mg once weekly tablet) (n=519) and alendronate 10 mg daily (n=370) was demonstrated in a one-year multicentre study on post-menopausal women with osteoporosis. The mean increases from baseline in lumbar spine bone density at one year were 5.1% (95% confidence interval: 4.8, 5.4%) in the group receiving 70 mg once weekly tablet and 5.4% (95% confidence interval: 5.0, 5.8%) in the group receiving 10 mg daily. The mean bone density increases were 2.3% and 2.9% at the femoral neck and 2.9% and 3.1% at the total hip in the 70 mg once weekly tablet and 10 mg daily groups respectively. The two treatment groups were also similar with regard to bone density increases at other skeletal sites.

The effects of alendronate on bone density and fracture incidence in post-menopausal women were examined in two initial efficacy studies of identical design (n=994), as well as in the Fracture Intervention Trial (FIT: n = 6,459).

In the initial efficacy studies, the mean bone density increases with alendronate10 mg daily compared with placebo at three years were 8.8%, 5.9% and 7.8% at the spine, the femoral neck and trochanter respectively. Total body bone density also increased significantly. There was a 48% reduction (alendronate 3.2% compared with placebo 6.2%) in the proportion of patients treated with alendronate experiencing one or more vertebral fractures relative to those treated with placebo. In the two-year extension to these studies, bone density at the spine and trochanter continued to increase and bone density at the femoral neck and total body were maintained.

FIT studies consisted of two placebo-controlled studies where alendronate was administered daily (5 mg daily for two years and 10 mg daily for either one or two additional years).

• FIT 1: A three-year study of 2,027 patients who had at least one vertebral (compression) fracture before the start of the study. In this study daily alendronate reduced the incidence of >1 new vertebral fracture by 47% (alendronate 7.9% compared with placebo 15.0%). In addition, a statistically significant reduction was found in the incidence of hip fractures (1.1% compared with 2.2%, a 51% reduction).

• FIT 2: A four-year study of 4,432 patients with a low bone mass but no vertebral fracture before the start of the study. In this study a significant difference was observed in the analysis of the subgroup of osteoporotic women (37% of the global population who comply with the above definition of osteoporosis) in the incidence of hip fractures (alendronate 1.0% compared with placebo 2.2%, a 56% reduction) and in the incidence of >1 vertebral fracture (2.9% compared with 5.8%, a 50% reduction).

Paediatric population

Alendronate sodium has been studied in a small number of patients with osteogenesis imperfecta under the age of 18 years. Results are insufficient to support the use of alendronate sodium in paediatric patients with osteogenesis imperfecta.

Absorption

Relative to an intravenous reference dose, the oral mean 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. Bioavailability was decreased similarly to an estimated 0.46% and 0.39% when alendronate was administered one hour or half an hour before a standardised breakfast. In osteoporosis studies, alendronate was effective when administered at least 30 minutes before the first food or drink 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 healthy subjects, oral prednisolone (20 mg three times daily for five days) did not produce a clinically significant change in oral bioavailability of alendronate (a mean increase ranging from 20% to 44%).

Distribution

Studies in rats show that alendronate is initially distributed to soft tissues following 1 mg/kg intravenous administration but is then rapidly redistributed to bone or excreted in the urine. The mean steady state volume of distribution, exclusive of bone, is at least 28 litres in humans. Concentrations of drug in plasma following therapeutic oral doses are too low for analytical detection (<5 ng/ml). Protein binding in human plasma is approximately 78%.

Biotransformation

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

Elimination

Following a single intravenous 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. Following a single 10 mg intravenous dose, the renal clearance of alendronate was 71 ml/min, and systemic clearance did not exceed 200 ml/min. Plasma concentrations fell by more than 95% within six hours following intravenous administration. The terminal half-life in humans is estimated to exceed ten years, reflecting release of alendronate from the skeleton. Alendronate is not excreted through the acidic or basic transport systems of the kidney in rats, and thus is not anticipated to interfere with the excretion of other medicinal products by these systems in humans.

Patient characteristics

Preclinical studies show that the drug that is not deposited in bone is rapidly excreted in the urine. No evidence of saturation of bone uptake was found after chronic dosing with cumulative intravenous doses up to 35 mg/kg in animals. Although no clinical information is available, it is likely that, as in animals, elimination of alendronate via the kidneys 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. (se 4.2 Posology and method of administration).

Current studies with regard to general toxicity, genotoxicity and carcinogenicity reveal no special hazard to humans. Studies in female rats have shown that treatment with alendronate during pregnancy was associated with dystocia during parturition which was related to hypocalcaemia. Studies in which rats were given high doses showed an increased incidence of incomplete bone formation in foetuses. The relevance to humans is unknown.

Magnesium stearate

Mannitol (E421)

Microcrystalline cellulose

Not applicable.

3 years

This medicinal product does not require any special storage conditions.

Clear PVC/PVDC/aluminium blisters

Pack sizes: 1, 4, 12 and 24 tablets

HDPE container with PP cap:

Pack sizes: 100 tablets

Not all pack sizes may be marketed.

No special requirements.

Orifarm Generics A/S

Energivej 15

5260 Odense S

Denmark

[To be completed nationally]

Date of first authorisation: 19 December 2007

Date of latest renewal: 19 December 2012

18 February 2016