Avestra
SUMMARY OF PRODUCT CHARACTERISTICS
1. Name of the Medicinal Product
Avestra 75 mg film‑coated tablets.
2. Qualitative and Quantitative Composition
Each film‑coated tablet contains 75 mg risedronate sodium (equivalent to 69.6 mg risedronic acid).
For the full list of excipients, see section 6.1.
3. Pharmaceutical Form
Film‑coated tablet.
Oval pink 11.7 x 5.8 mm film‑coated tablet engraved with RSN on one side and 75 mg on the other.
4. Clinical Particulars
4.1 Therapeutic indications
Treatment of osteoporosis in postmenopausal women at increased risk of fractures (see section 5.1).
4.2 Posology and method of administration
Posology
The recommended dose in adults is one 75 mg tablet orally on two consecutive days a month. The first tablet should be taken on the same day each month, followed by the second tablet the next day.
Special populations
Elderly
No dosage adjustment is necessary since bioavailability, distribution and elimination were similar in elderly (>60 years of age) compared to younger subjects.
This has also been shown in the very elderly, 75 years old and above, postmenopausal population.
Renal Impairment
No dosage adjustment is required for those patients with mild to moderate renal impairment. The use of risedronate sodium is contraindicated in patients with severe renal impairment (creatinine clearance lower than 30 ml/min) (see sections 4.3 and 5.2).
Paediatric population
Risedronate sodium is not recommended for use in children below age 18 due to insufficient data on safety and efficacy (see section 5.1).
Method of administration
- The absorption of risedronate sodium is affected by food and polyvalent cations (see section 4.5), thus to ensure adequate absorption patients should take Avestra 75 mg before breakfast: at least 30 minutes before the first food, other medicinal product or drink (other than plain water) of the day. Plain water is the only drink that should be taken with Avestra 75 mg tablet. Please note that some mineral water may have a higher concentration of calcium and therefore should not be used (see section 5.2).
- Patients who miss a dose of Avestra 75 mg should be instructed to take one Avestra 75 mg tablet the morning after the day it is remembered, unless the time to the next month’s scheduled doses are within 7 days. Patients should then return to taking Avestra 75 mg tablet on two consecutive days a month on the day the tablet is normally taken.
- If the next month’s scheduled doses Avestra 75 mg are within 7 days, patients should wait until their next month’s scheduled doses and then continue taking Avestra 75 mg on two consecutive days each month as originally scheduled.
- Three tablets should not be taken in the same week.
The tablet must be swallowed whole and not sucked or chewed. To aid delivery of the tablet to the stomach Avestra 75 mg is to be taken while in an upright position with a glass of plain water (>120 ml).Patients should not lie down for 30 minutes after taking the tablet (see section 4.4).
Supplemental calcium and vitamin D should be considered if the dietary intake is inadequate.
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 risedronate on an individual patient basis, particularly after 5 or more years of use.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Hypocalcaemia (see section 4.4).
Pregnancy and lactation.
Severe renal impairment (creatinine clearance <30 ml/min).
4.4 Special warnings and precautions for use
Foods, drinks (other than plain water) and medicinal products containing polyvalent cations (such as calcium, magnesium, iron and aluminium) interfere with the absorption of bisphosphonates and should not be taken at the same time as Avestra 75 mg (see section 4.5). In order to achieve the intended efficacy, strict adherence to dosing recommendations is necessary (see section 4.2).
Efficacy of bisphosphonates in the treatment of osteoporosis is related to the presence of low bone mineral density and/or prevalent fracture.
High age or clinical risk factors for fracture alone are not reasons to initiate treatment of osteoporosis with a bisphosphonate.
The evidence to support efficacy of bisphosphonates including risedronate sodium in the very elderly (>80 years) is limited (see section 5.1).
Bisphosphonates have been associated with oesophagitis, gastritis, oesophageal ulcerations and gastroduodenal ulcerations. Thus caution should be used:
- In patients who have a history of oesophageal disorders which delay oesophageal transit or emptying e.g. stricture or achalasia.
- In patients who are unable to stay in the upright position for at least 30 minutes after taking the tablet.
- If risedronate is given to patients with active or recent oesophageal or upper gastrointestinal problems (including known Barrett’s oesophagus).
Prescribers should emphasise to patients the importance of paying attention to the dosing instructions and be alert to any signs or symptoms of possible oesophageal reaction. The patients should be instructed to seek timely medical attention if they develop symptoms of oesophageal irritation such as dysphagia, pain on swallowing, retrosternal pain or new/worsened heartburn.
Hypocalcaemia should be treated before starting Avestra 75 mg therapy.Other disturbances of bone and mineral metabolism (i.e. parathyroid dysfunction, hypovitaminosis D) should be treated at the time of starting Avestra 75 mg therapy.
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.
A dental examination with appropriate preventive dentistry should be considered prior to treatment with bisphosphonates in patients with concomitant risk factors (e.g. cancer, chemotherapy, radiotherapy, corticosteroids, poor oral hygiene).
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 judgment of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment.
Osteonecrosis of the external auditory canal has been reported with bisphosphonates, mainly in association with long-term therapy. Possible risk factors for osteonecrosis of the external auditory canal include steroid use and chemotherapy and/or local risk factors such as infection or trauma. The possibility of osteonecrosis of the external auditory canal should be considered in patients receiving bisphosphonates who present with ear symptoms including chronic ear infections.
Atypical fractures of the femur
Atypical subtrochanteric and diaphyseal femoral fractures have been reported 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.
4.5 Interaction with other medicinal products and other forms of interaction
No formal interaction studies have been performed, however no clinically relevant interactions with other medicinal products were found during clinical studies.
Concomitant ingestion of medications containing polyvalent cations (e.g. calcium, magnesium, iron and aluminium) will interfere with the absorption of risedronate sodium (see section 4.4).
Risedronate sodium is not systemically metabolised, does not induce cytochrome P450 enzymes, and has low protein binding.
In the risedronate sodium Phase III osteoporosis studies with daily dosing, acetyl salicylic acid or NSAID use was reported by 33% and 45% of patients respectively. In the Phase III study comparing 75 mg on 2 consecutive days a month and 5 mg daily in postmenopausal women, acetyl salicylic acid/NSAID use was reported by 54.8% of patients. Similar percentages of patients experienced upper gastrointestinal adverse events regardless of NSAIDs and aspirin use.
If considered appropriate risedronate sodium may be used concomitantly with oestrogen supplementation.
4.6 Fertility, pregnancy and lactation
There are no adequate data from the use of risedronate sodium in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. Studies in animals indicate that a small amount of risedronate sodium pass into breast milk.
Risedronate sodium must not be used during pregnancy or by breast‑feeding women.
4.7 Effects on ability to drive and use machines
Avestra has no or negligible influence on the ability to drive and use machines.
4.8 Undesirable effects
Risedronate sodium has been studied in phase III clinical studies involving more than 15,000 patients. The majority of undesirable effects observed in clinical studies was mild to moderate in severity and usually did not require cessation of therapy.
Adverse experiences reported in phase III clinical studies in postmenopausal women with osteoporosis treated for up to 36 months with risedronate sodium 5 mg/day (n=5020) or placebo (n=5048) and considered possibly or probably related to risedronate sodium are listed below using the following convention (incidences versus placebo are shown in brackets): very common (≥1/10); common (≥1/100; <1/10); uncommon (≥1/1,000; <1/100); rare (≥1/10,000; <1/1,000); very rare (<1/10,000).
Nervous system disorders
Common: headache (1.8% vs. 1.4%)
Eye disorders
Uncommon: iritis*
Gastrointestinal disorders
Common: constipation (5.0% vs. 4.8%), dyspepsia (4.5% vs. 4.1%), nausea (4.3% vs. 4.0%), abdominal pain (3.5% vs. 3.3%), diarrhoea (3.0% vs. 2.7%)
Uncommon: gastritis (0.9% vs. 0.7%), oesophagitis (0.9% vs. 0.9%), dysphagia (0.4% vs. 0.2%), duodenitis (0.2% vs. 0.1%), oesophageal ulcer (0.2% vs. 0.2%)
Rare: glossitis (<0.1% vs. 0.1%), oesophageal stricture (<0.1% vs. 0.0%),
Musculoskeletal and connective tissues disorders
Common: musculoskeletal pain (2.1% vs. 1.9%)
Investigations
Rare: abnormal liver function tests*
* No relevant incidences from Phase III osteoporosis studies; frequency based on adverse event/laboratory/rechallenge findings in earlier clinical studies.
In a 2‑year, double‑blind, multicentre study comparing risedronate sodium 5 mg daily (n=613) and risedronate sodium 75 mg tablets on two consecutive days a month (n=616) in postmenopausal women with osteoporosis, the overall safety profiles were similar. The following additional adverse experiences considered possibly or probably drug related by investigators have been reported (incidence greater in risedronate sodium 75 mg than in risedronate sodium 5 mg group).
Gastrointestinal disorders
Common: gastritis erosive (1.5% vs 0.8%), vomiting (1.3% vs 1.1%)
Musculoskeletal and connective tissues disorders
Common: arthralgia (1.5% vs. 1.0%) bone pain (1.1% vs 0.5%) and pain in extremity (1.1% vs 0.5%).
General disorders
Uncommon: acute phase reactions, such as fever and/or influenza-like illness (within 5 days of the first dose) (0.6% vs. 0.0%)
Laboratory findings
Early, transient, asymptomatic and mild decreases in serum calcium and phosphate levels have been observed in some patients.
The following additional adverse reactions have been reported during post‑marketing use (frequency unknown):
Eye disorders
iritis, uveitis
Musculoskeletal and connective tissues disorders
osteonecrosis of the jaw
Skin and
subcutaneous tissue disorders
hypersensitivity and skin reactions, including angioedema,
generalised rash, urticaria and bullous skin reactions, some severe
including isolated reports of Stevens‑Johnson syndrome toxic
epidermal necrolysis and leukocytoclastic vasculitis.
hair loss.
Immune system disorders
anaphylactic reaction
Hepatobiliary disorders
serious hepatic disorders. In most of the reported cases the patients were also treated with other products known to cause hepatic disorders.
During post‑marketing experience the following reactions have been reported:
Rare: Atypical subtrochanteric and diaphyseal femoral fractures (bisphosphonate class adverse reaction).
Very rare: Osteonecrosis of the external auditory canal (bisphosphonate class adverse reaction).
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.
4.9 Overdose
No specific information is available on the treatment of overdose with risedronate sodium.
Decreases in serum calcium following substantial overdose may be expected. Signs and symptoms of hypocalcaemia may also occur in some of these patients.
Milk or antacids containing magnesium, calcium or aluminium should be given to bind risedronate and reduce absorption of risedronate sodium. In cases of substantial overdose, gastric lavage may be considered to remove unabsorbed risedronate sodium.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Bisphosphonates, ATC Code: M05 BA07.
Mechanism of action
Risedronate sodium is a pyridinyl bisphosphonate that binds to bone hydroxyapatite and inhibits osteoclast-mediated bone resorption. The bone turnover is reduced while the osteoblast activity and bone mineralisation is preserved.
Pharmacodynamic effects
In preclinical studies risedronate sodium demonstrated potent anti‑osteoclast and antiresorptive activity, and dose dependently increased bone mass and biomechanical skeletal strength. The activity of risedronate sodium was confirmed by measuring biochemical markers for bone turnover during pharmacodynamic and clinical studies. In studies of post‑menopausal women, decreases in biochemical markers of bone turnover were observed within 1 month and reached a maximum in 3‑6 months. In a 2‑year study, decreases in biochemical markers of bone turnover (urinary collagen cross‑linked N telopeptide and serum bone specific alkaline phosphatase) were similar between risedronate sodium 75 mg tablets on two consecutive days a month and risedronate sodium 5 mg tablets daily at 24 months.
Clinical efficacy and safety
Treatment of Postmenopausal Osteoporosis
A number of risk factors are associated with postmenopausal osteoporosis including low bone mass, low bone mineral density, existence of previous fractures, early menopause, a history of smoking, alcohol consumption and a family history of osteoporosis. The clinical consequence of osteoporosis is fractures. The risk of fractures is increased with the number of risk factors.
Based on effects on mean percent change in lumbar spine BMD, risedronate sodium 75 mg (n=524) on two consecutive days a month was shown to be equivalent to risedronate sodium 5 mg (n=527) daily in a 2‑year, double‑blind, multicentre study of postmenopausal women with osteoporosis. Both groups had statistically significant mean percent increases from baseline to Month 6, 12, 24 and endpoint in lumbar spine BMD.
The clinical programme for risedronate sodium administered once daily studied the effect of risedronate sodium on the risk of hip and vertebral fractures and contained early and late postmenopausal women with and without fracture. Daily doses of 2.5 mg and 5 mg were studied and all groups, including the control groups, received calcium and vitamin D (if baseline levels were low). The absolute and relative risk of new vertebral and hip fractures was estimated by use of a time‑to‑first event analysis.
- Two placebo‑controlled studies (n=3.661) enrolled postmenopausal women under 85 years with vertebral fractures at baseline. Risedronate sodium 5 mg daily given for 3 years reduced the risk of new vertebral fractures relative to the control group. In women with respectively at least 2 or at least 1 vertebral fractures, the relative risk reduction was 49% and 41% respectively (incidence of new vertebral fractures with risedronate sodium 18.1% and 11.3%, with placebo 29.0% and 16.3%, respectively). The effect of treatment was seen as early as the end of the first year of treatment. Benefits were also demonstrated in women with multiple fractures at baseline. Risedronate sodium 5 mg daily also reduced the yearly height loss compared to the control group.
- Two further placebo controlled studies enrolled postmenopausal women above 70 years with or without vertebral fractures at baseline. Women 70‑79 years were enrolled with femoral neck BMD T‑score <-3 SD (manufacturer’s range, i.e. -2.5 SD using NHANES III (National Health and Nutrition Examination Survey)) and at least one additional risk factor. Women >80 years could be enrolled on the basis of at least one non‑skeletal risk factor for hip fracture or low bone mineral density at the femoral neck. Statistical significance of the efficacy of risedronate versus placebo is only reached when the two treatment groups 2.5 mg and 5 mg are pooled. The following results are only based on a‑posteriorianalysis of subgroups defined by clinical practise and current definitions of osteoporosis:
- In the subgroup of patients with femoral neck BMD T‑score <-2.5 SD (NHANES III) and at least one vertebral fracture at baseline, risedronate sodium given for 3 years reduced the risk of hip fractures by 46% relative to the control group (incidence of hip fractures in combined risedronate sodium 2.5 and 5 mg groups 3.8%, placebo 7.4%);
- Data suggest that a more limited protection than this may be observed in the very elderly (>80 years). This may be due to the increasing importance of non‑skeletal factors for hip fracture with increasing age;
- In these studies, data analysed as a secondary endpoint indicated a decrease in the risk of new vertebral fractures in patients with low femoral neck BMD without vertebral fracture and in patients with low femoral neck BMD with or without vertebral fracture.
- Risedronate sodium 5 mg daily given for 3 years increased bone mineral density (BMD) relative to control at the lumbar spine, femoral neck, trochanter and wrist and maintained bone density at the mid‑shaft radius.
- In a one‑year follow‑up off therapy after three years treatment with risedronate sodium 5 mg daily there was rapid reversibility of the suppressing effect of risedronate sodium on bone turnover rate.
- Bone biopsy samples from postmenopausal women treated with risedronate sodium 5 mg daily for 2 to 3 years, showed an expected moderate decrease in bone turnover. Bone formed during risedronate sodium treatment was of normal lamellar structure and bone mineralisation. These data together with the decreased incidence of osteoporosis related fractures at vertebral sites in women with osteoporosis appear to indicate no detrimental effect on bone quality.
Endoscopic findings from a number of patients with a number of moderate to severe gastrointestinal complaints in both risedronate sodium and control patients indicated no evidence of treatment related gastric, duodenal or oesophageal ulcers in either group, although duodenitis was uncommonly observed in the risedronate sodium group.
Paediatric population
The safety and efficacy of risedronate sodium has been investigated in a 3-year study (a randomized, double-blind, placebo-controlled, multicenter, parallel group study of one year duration followed by 2 years of open-label treatment) in paediatric patients aged 4 to less than 16 years with mild to moderate osteogenesis imperfecta. In this study, patients weighing 10-30 kg received risedronate 2.5 mg daily and patients weighing more than 30 kg received risedronate 5 mg daily.
After completion of its one-year randomized, double-blind, placebo-controlled phase, a statistically significant increase in lumbar spine BMD in the risedronate group versus placebo group was demonstrated; however an increased number of patients with at least 1 new morphometric (identified by x-ray) vertebral fracture was found in the risedronate group compared to placebo. During the one-year double-blind period, the percentage of patients who reported clinical fractures was 30.9% in the risedronate group and 49.0% in the placebo group. In the open-label period when all patients received risedronate (month 12 to month 36), clinical fractures were reported by 65.3% of patients initially randomized to the placebo group and by 52.9% of patients initially randomized to the risedronate group. Overall, results do not support the use of risedronate sodium in paediatric patients with mild to moderate osteogenesis imperfecta.
5.2 Pharmacokinetic properties
Absorption
Absorption after an oral dose is relatively rapid (tmax~1 hour) and is independent of dose over the range studied (single dose study, from 2.5 to 30 mg; multiple dose studies, from 2.5 to 5 mg daily and up to 75 mg on two consecutive days a month). Mean oral bioavailability of the tablet is 0.63% and is decreased when risedronate sodium is administered with food. Compared with a 4‑hour fast after dose, bioavailability decreased by about 50% and 30%, respectively, when breakfast was eaten 30 minutes or 1 hour after administration of a risedronate tablet. Swallowing the 75 mg tablet with hard water was shown to decrease bioavailability by about 60% compared with soft water. Bioavailability was similar in men and women.
Distribution
The mean steady state volume of distribution is 6.3 L/kg in humans.Plasma protein binding is about 24%.
Biotransformation
There is no evidence of systemic metabolism of risedronate sodium.
Elimination
Approximately half of the absorbed dose is excreted in urine within 24 hours, and 85% of an intravenous dose is recovered in the urine after 28 days. Mean renal clearance is 105 ml/min and mean total clearance is 122 ml/min, with the difference probably attributed to clearance due to adsorption to bone. The renal clearance is not concentration dependent, and there is a linear relationship between renal clearance and creatinine clearance. Unabsorbed risedronate sodium is eliminated unchanged in faeces. After oral administration the concentration-time profile shows three elimination phases with a terminal half‑life of 480 hours.
Special Populations
Elderly
No dosage adjustment is necessary.
Acetyl salicylic acid/NSAID users
Among regular acetyl salicylic acid or NSAID users (3 or more days per week) the incidence of upper gastrointestinal adverse events in risedronate sodium treated patients was similar to that in control patients (see section 4.5).
5.3 Preclinical safety data
In toxicological studies in rat and dog, dose dependent liver toxic effects of risedronate sodium were seen, primarily as enzyme increases with histological changes in rat. The clinical relevance of these observations is unknown. Testicular toxicity occurred in rat and dog at exposures considered in excess of the human therapeutic exposure. Dose related incidences of upper airway irritation were frequently noted in rodents. Similar effects have been seen with other bisphosphonates. Lower respiratory tract effects were also seen in longer term studies in rodents, although the clinical significance of these findings is unclear. In reproduction toxicity studies at exposures close to clinical exposure ossification changes were seen in sternum and/or skull of foetuses from treated rats and hypocalcemia and mortality in pregnant females allowed to deliver. There was no evidence of teratogenesis at 3.2 mg/kg/day in rat and 10 mg/kg/day in rabbit, although data are only available on a small number of rabbits. Maternal toxicity prevented testing of higher doses. Studies on genotoxicity and carcinogenesis did not show any particular risks for humans.
6. Pharmaceutical Particulars
6.1 List of excipients
Tablet core:
cellulose microcrystalline,
crospovidone A,
magnesium stearate.
Film coating:
hypromellose,
macrogol 400, macrogol 8000,
hydroxypropylcellulose,
colloidal anhydrous silica,
titanium dioxide (E171),
iron oxide red (E172).
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years.
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
Clear PVC/aluminium foil blisters in a cardboard carton.
Blisters in packs containing 2, 4, 6 or 8 tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements for disposal.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. Marketing Authorisation Holder
[To be completed nationally]
{Name and address}
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<{fax}>
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8. Marketing Authorisation Number(s)
[To be completed nationally]
9. Date of First Authorisation/Renewal of the Authorisation
<Date of first authorisation: {DD month YYYY}>
<Date of latest renewal: {DD month YYYY}>
<[To be completed nationally]>
10. Date of Revision of the Text
<{MM/YYYY}>
<{DD/MM/YYYY}>
<{DD month YYYY}>
14 January 2016
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