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Fosavance, inn-alendronic acid as alendronate sodium trihydrate/colecalciferol
NAME OF THE MEDICINAL PRODUCT
FOSAVANCE 70 mg/5600 IU tablets 2.
QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains 70 mg alendronic acid as alendronate sodium trihydrate and 140 micrograms (5600 IU) colecalciferol (vitamin D3).
Each tablet contains 63 mg lactose anhydrous and 16 mg sucrose.
For a full list of excipients, see section 6.1. 3. PHARMACEUTICAL
Modified rectangle-shaped, white to off-white tablets, marked with an outline of a bone image on one
side, and '270' on the other. 4. CLINICAL
FOSAVANCE is indicated for the treatment of postmenopausal osteoporosis in patients who are not
receiving vitamin D supplementation and are at risk of vitamin D insufficiency.
FOSAVANCE reduces the risk of vertebral and hip fractures. 4.2
Posology and method of administration
The recommended dose is one FOSAVANCE tablet once weekly.
Patients should be instructed that if they miss a dose of FOSAVANCE 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.
Due to the nature of the disease process in osteoporosis, FOSAVANCE is intended for long-term use.
Patients should receive supplemental calcium if intake from diet is inadequate (see section 4.4). The
equivalence of intake of 5600 IU of vitamin D3 weekly in FOSAVANCE to daily dosing of vitamin D
800 IU has not been studied. Elderly population:
In clinical studies there was no age-related difference in the efficacy or safety profiles of alendronate. Therefore no dose adjustment is necessary for the elderly.
FOSAVANCE is not recommended for patients with renal impairment where GFR is less than
35 ml/min, due to lack of experience. No dose adjustment is necessary for patients with a glomerular
filtration rate (GFR) greater than 35 ml/min. Paediatric population:
The safety and efficacy of FOSAVANCE in children less than 18 years of age has not been
established. FOSAVANCE should not be used in children less than 18 years of age because no data
Method of administration
To permit adequate absorption of alendronate:
FOSAVANCE must be taken with water only (not mineral water) at least 30 minutes before the first
food, beverage, or medicinal product (including antacids, calcium supplements and vitamins) of the
day. Other beverages (including mineral water), food and some medicinal products are likely to reduce
the absorption of alendronate (see section 4.5).
The following instructions should be followed exactly in order to minimize the risk of oesophageal
irritation and related adverse reactions (see section 4.4):
FOSAVANCE should only be swallowed after getting up for the day with a full glass of water (not less than 200 ml or 7 fl.oz.).
Patients should only swallow FOSAVANCE whole. Patients should not crush or chew the tablet or allow the tablet to dissolve in their mouths because of a potential for oropharyngeal ulceration.
Patients should not lie down until after their first food of the day.
Patients should not lie down for at least 30 minutes after taking FOSAVANCE.
FOSAVANCE should not be taken at bedtime or before arising for the day.
Hypersensitivity to the active substances or to any of the excipients.
Abnormalities of the oesophagus and other factors which delay oesophageal emptying such as stricture or achalasia.
Inability to stand or sit upright for at least 30 minutes.
Special warnings and precautions for use
Alendronate Upper gastrointestinal adverse reactions
Alendronate can cause local irritation of the upper gastrointestinal mucosa. Because there is a potential for worsening of the underlying disease, caution should be used when alendronate is given to patients with active upper gastrointestinal problems, such as dysphagia, oesophageal disease, gastritis, duodenitis, ulcers, or with a recent history (within the previous year) of major gastrointestinal disease
such as peptic ulcer, or active gastrointestinal bleeding, or surgery of the upper gastrointestinal tract
other than pyloroplasty (see 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 reactions (sometimes severe and requiring hospitalisation), such as oesophagitis,
oesophageal ulcers and oesophageal erosions, rarely followed by oesophageal stricture, have been
reported in patients receiving alendronate. Physicians should therefore be alert to any signs or
symptoms signalling a possible oesophageal reaction and patients should be instructed to discontinue
alendronate and seek medical attention if they develop symptoms of oesophageal irritation such as
dysphagia, pain on swallowing or retrosternal pain or new or worsening heartburn (see section 4.8).
The risk of severe oesophageal adverse reactions appears to be greater in patients who fail to take
alendronate properly and/or who continue to take alendronate after developing symptoms suggestive
of oesophageal irritation. It is very important that the full dosing instructions are provided to, and are
understood by the patient (see section 4.2). Patients should be informed that failure to follow these
instructions may increase their risk of oesophageal problems.
While no increased risk was observed in extensive clinical trials with alendronate, there have been rare
(post-marketing) reports of gastric and duodenal ulcers, some of which were severe and with
complications (see section 4.8). Osteonecrosis of the jaw
Osteonecrosis of the jaw, generally associated with tooth extraction and/or local infection (including
osteomyelitis) has been reported in patients with cancer who are 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, periodontal disease).
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.
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 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 medicinal product or another bisphosphonate. Stress fractures
Stress fractures (also known as insufficiency fractures) of the proximal femoral shaft have been
reported in patients treated long-term with alendronic acid (time to onset in the majority of cases
ranged from 18 months to 10 years). The fractures occurred after minimal or no trauma and some
patients experienced thigh pain, often associated with imaging features of stress fractures, weeks to
months before presenting with a completed femoral fracture. Fractures were 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 was also reported. Discontinuation of
bisphosphonate therapy in patients with stress fracture is advisable pending evaluation of the patient,
based on an individual benefit risk assessment.
FOSAVANCE is not recommended for patients with renal impairment where GFR is less than 35 ml/min (see section 4.2). Bone and mineral metabolism
Causes of osteoporosis other than oestrogen deficiency and ageing should be considered. Hypocalcaemia must be corrected before initiating therapy with FOSAVANCE (see section 4.3). Other disorders affecting mineral metabolism (such as vitamin D deficiency and hypoparathyroidism) should also be effectively treated before starting FOSAVANCE. The content of vitamin D in FOSAVANCE is not suitable for correction of vitamin D deficiency. In patients with these conditions, serum calcium and symptoms of hypocalcaemia should be monitored during therapy with FOSAVANCE. Due to the positive effects of alendronate in increasing bone mineral, decreases in serum calcium and phosphate may occur especially in patients taking glucocorticoids in whom calcium absorption may be decreased. These are usually small and asymptomatic. However, there have been rare reports of symptomatic hypocalcaemia, which have occasionally been severe and often occurred in patients with predisposing conditions (e.g. hypoparathyroidism, vitamin D deficiency and calcium malabsorption) (see section 4.8). Colecalciferol
Vitamin D3 may increase the magnitude of hypercalcaemia and/or hypercalciuria when administered to
patients with disease 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.
This medicinal product contains lactose and sucrose. Patients with rare hereditary problems of fructose
intolerance, galactose intolerance, the Lapp lactase deficiency, glucose-galactose malabsorption or
sucrase-isomaltase insufficiency should not take this medicinal product.
Interaction with other medicinal products and other forms of interaction
If taken at the same time, it is likely that food and beverages (including mineral water), calcium
supplements, antacids, and some oral medicinal products will interfere with absorption of alendronate.
Therefore, patients must wait at least 30 minutes after taking alendronate before taking any other oral
medicinal product (see sections 4.2 and 5.2).
Since Non Steroidal 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. Additional vitamin D supplements may be considered on an individual basis. 4.6
Fertility, pregnancy and lactation
FOSAVANCE is only intended for use in postmenopausal women and therefore it should not be used during pregnancy or in breast-feeding women.
There are no adequate data from the use of FOSAVANCE in pregnant women. Animal studies with
alendronate do not indicate direct harmful effects with respect to pregnancy, embryonal/foetal
development, or postnatal development. Alendronate given during pregnancy in rats caused dystocia
related to hypocalcaemia (see section 5.3). Studies in animals have shown hypercalcaemia and
reproductive toxicity with high doses of vitamin D (see section 5.3). Breastfeeding
It is not known whether alendronate is excreted into human breast milk. Colecalciferol and some of its
active metabolites pass into breast milk. Fertility
Bisphosphonates are incorporated into the bone matrix, from which they are gradually released over a
period of years. The amount of bisphosphonate incorporated into adult bone, and hence, the amount
available for release back into the systemic circulation, is directly related to the dose and duration of
bisphosphonate use (see section 5.2). There are no data on fetal risk in humans. However, there is a
theoretical risk of fetal harm, predominantly skeletal, if a woman becomes pregnant after completing a
course of bisphosphonate therapy. The impact of variables such as time between cessation of
bisphosphonate therapy to conception, the particular bisphosphonate used, and the route of
administration (intravenous versus oral) on the risk has not been studied. 4.7
Effects on ability to drive and use machines
Certain adverse reactions that have been reported with FOSAVANCE may affect some patients' ability
to drive or operate machinery. Individual responses to FOSAVANCE may vary (see section 4.8). 4.8 Undesirable
The most commonly reported adverse reactions are upper gastrointestinal adverse reactions including
abdominal pain, dyspepsia, oesophageal ulcer, dysphagia, abdominal distension and acid regurgitation
(≥ 1/100 to < 1/10).
The following adverse reactions have been reported during clinical studies and/or post-marketing use
No additional adverse reactions have been identified for FOSAVANCE.
Frequencies are defined as: 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
hypersensitivity reactions including urticaria and angioedema
Metabolism and nutrition
symptomatic hypocalcaemia, often in association with
predisposing conditions. (see section 4.4)
uveitis, scleritis, episcleritis
abdominal pain, dyspepsia, constipation, diarrhoea, flatulence,
oesophageal ulcer*, dysphagia*, abdominal distension, acid regurgitation Uncommon:
nausea, vomiting, gastritis, oesophagitis*,oesophageal erosions*, melena Rare:
oesophageal stricture*, oropharyngeal ulceration*, upper gastrointestinal PUBs (perforation, ulcers, bleeding)(see section 4.4). *See sections 4.2 and 4.4
Skin and subcutaneous
rash, pruritus, erythema
rash with photosensitivity Very rare:
severe skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis
musculoskeletal (bone, muscle or joint) pain
severe musculoskeletal (bone, muscle or joint) pain (see
General disorders and
transient symptoms as in an acute-phase response (myalgia,
malaise and rarely, fever), typically in association with initiation of
During post-marketing experience the following reactions have been reported (frequency not known):
disorders: Ear and labyrinth
Skin and subcutaneous
Osteonecrosis of the jaw has been reported in patients treated by
connective tissue and
bisphosphonates. The majority of the reports refer to cancer patients, but
such cases have also been reported in patients treated for osteoporosis. Osteonecrosis of the jaw is generally associated with tooth extraction and / or local infection (including osteomyelitis). Diagnosis of cancer, chemotherapy, radiotherapy, corticosteroids and poor oral hygiene are also deemed as risk factors (see section 4.4); joint swelling; stress fractures of the proximal femoral shaft (see section 4.4)
General disorders and
Hypocalcaemia, hypophosphataemia and upper gastrointestinal adverse reactions, such as upset
stomach, heartburn, oesophagitis, gastritis, or ulcer, may result from oral overdose.
No specific information is available on the treatment of overdose with alendronate. In case of overdose
with FOSAVANCE, 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. 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 4,000 IU daily dose of vitamin D3
for up to five months was not associated with hypercalciuria or hypercalcaemia. 5. PHARMACOLOGICAL
Drugs for treatment of bone diseases,
Bisphosphonates, combinations, ATC code: M05BB03 FOSAVANCE is a combination tablet containing the two active substances alendronate sodium trihydrate and colecalciferol (vitamin D3).
Alendronate sodium 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 recruitment or attachment of osteoclasts is
not affected. The bone formed during treatment with alendronate is of normal quality.
Colecalciferol (vitamin D3)
Vitamin D3 is produced in the skin by conversion of 7-dehydrocholesterol to vitamin D3 by ultraviolet
light. In the absence of adequate sunlight exposure, vitamin D3 is an essential dietary nutrient.
Vitamin D3 is converted to 25-hydroxyvitamin D3 in the liver, and stored until needed. Conversion to
the active calcium-mobilizing hormone 1,25-dihydroxyvitamin D3 (calcitriol) in the kidney is tightly
regulated. 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. 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 reduces these risks and their consequences. Osteoporosis is defined as bone mineral density (BMD) of the spine or hip 2.5 standard deviations (SD) below the mean value of a normal young population or as a previous fragility fracture, irrespective of BMD. FOSAVANCE studies
The effect of the lower dose of FOSAVANCE (alendronate 70 mg/vitamin D3 2800 IU) on vitamin D
status was demonstrated in a 15-week, multinational study that enrolled 682 osteoporotic post-menopausal women (serum 25-hydroxyvitamin D at baseline: mean, 56 nmol/l [22.3 ng/ml]; range, 22.5-225 nmol/l [9-90 ng/ml]). Patients received the lower strength (70 mg/2800 IU) of FOSAVANCE (n=350) or FOSAMAX (alendronate) 70 mg (n=332) once a week; additional vitamin D supplements were prohibited. After 15 weeks of treatment, the mean serum 25-hydroxyvitamin D levels were significantly higher (26 %) in the FOSAVANCE (70 mg/2800 IU) group (56 nmol/l [23 ng/ml]) than in the alendronate-only group (46 nmol/l [18.2 ng/ml]). The percentage of patients with vitamin D insufficiency (serum 25-hydroxyvitamin D < 37.5 nmol/l [< 15 ng/ml]) was significantly reduced by 62.5 % with FOSAVANCE (70 mg/2800 IU) vs. alendronate-only (12 % vs. 32 %, respectively), through week 15. The percentage of patients with vitamin D deficiency (serum 25-hydroxyvitamin D < 22.5 nmol/l [< 9 ng/ml]) was significantly reduced by 92 % with FOSAVANCE (70 mg/2800 IU) vs. alendronate-only (1 % vs 13 %, respectively). In this study, mean 25-hydroxyvitamin D levels in patients with vitamin D insufficiency at baseline (25-hydroxyvitamin D, 22.5 to 37.5 nmol/l [9 to < 15 ng/ml]) increased from 30 nmol/l (12.1 ng/ml) to 40 nmol/l (15.9 ng/ml) at week 15 in the FOSAVANCE (70 mg/2800 IU) group (n=75) and decreased from 30 nmol/l (12.0 ng/ml) at baseline to 26 nmol/l (10.4 ng/ml) at week 15 in the alendronate-only group (n=70). There were no differences in mean serum calcium, phosphate, or 24-hour urine calcium between treatment groups. The effect of the lower dose of FOSAVANCE (alendronate 70 mg/vitamin D3 2800 IU) plus an
additional 2800 IU Vitamin D3 for a total of 5600 IU (the amount of vitamin D3 in the higher dose of
FOSAVANCE) once weekly was demonstrated in a 24-week, extension study that enrolled 619 osteoporotic post-menopausal women. Patients in the Vitamin D3 2800 group received
FOSAVANCE (70 mg/2800 IU) (n=299) and patients in the Vitamin D3 5600 group received
FOSAVANCE (70 mg/2800 IU) plus an additional 2800 IU vitamin D3 (n=309) once a week;
additional vitamin D supplements were allowed. After 24-weeks of treatment, the mean serum 25-hydroxyvitamin D levels were significantly higher in the Vitamin D3 5600 group (69 nmol/l
[27.6 ng/ml]) than in the Vitamin D3 2800 group (64 nmol/l [25.5 ng/ml]). The percentage of patients
with vitamin D insufficiency was 5.4 % in the Vitamin D3 2800 group vs. 3.2 % in the Vitamin D3 Renewal
5600 group through the 24-week extension. The percentage of patients with vitamin D deficiency was 0.3 % in the Vitamin D3 2800 group vs. zero in the Vitamin D3 5600 group. There were no differences
in mean serum calcium, phosphate, or 24-hour urine calcium between treatment groups. The
percentage of patients with hypercalciuria at the end of the 24-week extension was not statistically
different between treatment groups. Alendronate studies
The therapeutic equivalence of alendronate once weekly 70 mg (n=519) and alendronate 10 mg daily
(n=370) was demonstrated in a one-year multicentre study of post-menopausal women with
osteoporosis. The mean increases from baseline in lumbar spine BMD at one year were 5.1 % (95 %
CI: 4.8, 5.4 %) in the 70 mg once-weekly group and 5.4 % (95 % CI: 5.0, 5.8 %) in the 10 mg daily
group. The mean BMD 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 and 10 mg daily groups, respectively. The two treatment groups
were also similar with regard to BMD increases at other skeletal sites.
The effects of alendronate on bone mass and fracture incidence in post-menopausal women were
examined in two initial efficacy studies of identical design (n=994) as well as in the Fracture
Intervention Trial (FIT: n=6,459).
In the initial efficacy studies, the mean BMD increases with alendronate 10 mg/day relative to placebo
at three years were 8.8 %, 5.9 % and 7.8 % at the spine, femoral neck and trochanter, respectively.
Total body BMD also increased significantly. There was a 48 % reduction (alendronate 3.2 % vs
placebo 6.2 %) in the proportion of patients treated with alendronate experiencing one or more
vertebral fractures relative to those treated with placebo. In the two-year extension of these studies
BMD at the spine and trochanter continued to increase and BMD at the femoral neck and total body
FIT consisted of two placebo-controlled studies using alendronate daily (5 mg daily for two years and
10 mg daily for either one or two additional years):
FIT 1: A three-year study of 2,027 patients who had at least one baseline vertebral (compression) fracture. In this study alendronate daily reduced the incidence of ≥ 1 new vertebral fracture by 47 % (alendronate 7.9 % vs. placebo 15.0 %). In addition, a statistically significant reduction was found in the incidence of hip fractures (1.1 % vs. 2.2 %, a reduction of 51 %).
FIT 2: A four year study of 4,432 patients with low bone mass but without a baseline vertebral fracture. In this study, a significant difference was observed in the analysis of the subgroup of osteoporotic women (37 % of the global population who correspond with the above definition of osteoporosis) in the incidence of hip fractures (alendronate 1.0 % vs. placebo 2.2 %, a reduction of 56 %) and in the incidence of ≥ 1 vertebral fracture (2.9 % vs. 5.8 %, a reduction of 50 %).
Laboratory test findings
In clinical studies, asymptomatic, mild and transient decreases in serum calcium and phosphate were
observed in approximately 18 % and 10 %, respectively, of patients taking alendronate 10 mg/day
versus approximately 12 % and 3 % of those taking placebo. However, the incidences of decreases in
serum calcium to < 8.0 mg/dl (2.0 mmol/l) and serum phosphate to ≤ 2.0 mg/dl (0.65 mmol/l) were
similar in both treatment groups.
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 Renewal
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 beverage of the day. The alendronate component in the FOSAVANCE (70 mg/5600 IU) combination tablet is bioequivalent to the alendronate 70 mg tablet. 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 prednisone (20 mg three times daily for five days) did not produce a clinically meaningful change in oral bioavailability of alendronate (a mean increase ranging from 20 % to 44 %). Distribution
Studies in rats show that alendronate transiently distributes 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 alendronate 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 it is not anticipated to interfere with the excretion of other medicinal products by those systems in humans. Colecalciferol Absorption
In healthy adult subjects (males and females), following administration of FOSAVANCE 70 mg/5600 IU after an overnight fast and two hours before a meal, the mean area under the serum-concentration-time curve (AUC0-80 hrs) for vitamin D3 (unadjusted for endogenous vitamin D3 levels) was 490.2 ng•hr/ml. The mean maximal serum concentration (Cmax) of vitamin D3 was 12.2 ng/ml and
the median time to maximal serum concentration (Tmax) was 10.6 hours. The bioavailability of the
5600 IU vitamin D3 in FOSAVANCE is similar to 5600 IU vitamin D3 administered alone.
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
Vitamin D3 is rapidly metabolized by hydroxylation in the liver to 25-hydroxyvitamin D3, and
subsequently metabolized 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.
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 4 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 FOSAVANCE
(70 mg/2800 IU) is approximately 24 hours. Characteristics in patients
Preclinical studies show that alendronate 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 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 section 4.2). 5.3
Preclinical safety data
Non-clinical studies with the combination of alendronate and colecalciferol have not been conducted. Alendronate
Non-clinical data reveal no special hazard for humans based on conventional studies of safety
pharmacology, repeated dose toxicity, genotoxicity and carcinogenic potential. Studies in rats have
shown that treatment with alendronate during pregnancy was associated with dystocia in dams during
parturition which was related to hypocalcaemia. In studies, rats given high doses showed an increased
incidence of incomplete foetal ossification. The relevance to humans is unknown.
At doses far higher than the human therapeutic range, reproductive toxicity has been observed in
animal studies. 6. PHARMACEUTICAL
List of excipients
Microcrystalline cellulose (E460)
Medium chain triglycerides
Silica, colloidal anhydrous
Magnesium stearate (E572)
Butyl hydroxytoluene (E321)
Modified starch (maize)
Sodium aluminium silicate (E554) 6.2 Incompatibilities
Not applicable. 6.3 Shelf
Special precautions for storage
Store in the original blister in order to protect from moisture and light. 6.5
Nature and contents of container
Wallet with sealed aluminium/aluminium blisters, in cartons containing 2 (1 wallet x 2 tablets), 4
(1 wallet x 4 tablets), 12 (3 wallets x 4 tablets) or 40 (10 wallets x 4 tablets) tablets.
Not all pack sizes may be marketed.
Special precautions for disposal
No special requirements. 7. MARKETING
Merck Sharp & Dohme Ltd.
Hertford Road, Hoddesdon
Hertfordshire EN11 9BU
United Kingdom 8. MARKETING
DATE OF FIRST AUTHORISATION/RENEWAL OF AUTHORISATION
24 August 2005 10.
DATE OF REVISION OF THE TEXT
Detailed information on this medicine is available on the website of the European Medicines Agency
Thresholds for therapies: highlights of the St GallenInternational Expert Consensus on the Primary Therapyof Early Breast Cancer 2009A. Goldhirsch1,2*, J. N. Ingle3, R. D. Gelber4, A. S. Coates5, B. Thu¨rlimann6, H.-J. Senn7& Panel members 1International Breast Cancer Study Group, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; 2European Institute of Oncology, Milan, It
Browsable and searchable archive of 2009 Kansas Statutes Annotated (K.S.A.) : Schools : Technology Education And Virtual Schools Statute 72-3715: Same; determining full-time equivalent enrollment; state aid; virtual school fund. (a) In order to be included in the ful -time equivalent enrol ment of a virtual school, a pupil shal be in attendance at the virtual school on (1) a single sch