9635610
9636810
FOSAMAX
®
(ALENDRONATE SODIUM) TABLETS AND ORAL SOLUTION
DESCRIPTION
FOSAMAX
*
(alendronate sodium) is a bisphosphonate that acts as a specific inhibitor of osteoclast-
mediated bone resorption. Bisphosphonates are synthetic analogs of pyrophosphate that bind to the
hydroxyapatite found in bone.
Alendronate sodium is chemically described as (4-amino-1-hydroxybutylidene) bisphosphonic acid
monosodium salt trihydrate.
The empirical formula of alendronate sodium is C
4
H
12
NNaO
7
P
2
•3H
2
O and its formula weight is
325.12. The structural formula is:
Alendronate sodium is a white, crystalline, nonhygroscopic powder. It is soluble in water, very slightly
soluble in alcohol, and practically insoluble in chloroform.
Tablets FOSAMAX for oral administration contain 6.53, 13.05, 45.68, 52.21 or 91.37 mg of
alendronate monosodium salt trihydrate, which is the molar equivalent of 5, 10, 35, 40 and 70 mg,
respectively, of free acid, and the following inactive ingredients: microcrystalline cellulose, anhydrous
lactose, croscarmellose sodium, and magnesium stearate. Tablets FOSAMAX 10 mg also contain
carnauba wax.
Each bottle of the oral solution contains 91.35 mg of alendronate monosodium salt trihydrate, which
is the molar equivalent to 70 mg of free acid. Each bottle also contains the following inactive ingredients:
sodium citrate dihydrate and citric acid anhydrous as buffering agents, sodium saccharin, artificial
raspberry flavor, and purified water. Added as preservatives are sodium propylparaben 0.0225% and
sodium butylparaben 0.0075%.
CLINICAL PHARMACOLOGY
Mechanism of Action
Animal studies have indicated the following mode of action. At the cellular level, alendronate shows
preferential localization to sites of bone resorption, specifically under osteoclasts. The osteoclasts adhere
normally to the bone surface but lack the ruffled border that is indicative of active resorption. Alendronate
*
Registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
Copyright ©1995, 1997, 2000 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved
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FOSAMAX
®
9635610
(alendronate sodium) Tablets and Oral Solution 9636810
does not interfere with osteoclast recruitment or attachment, but it does inhibit osteoclast activity. Studies
in mice on the localization of radioactive [
3
H]alendronate in bone showed about 10-fold higher uptake on
osteoclast surfaces than on osteoblast surfaces. Bones examined 6 and 49 days after [
3
H]alendronate
administration in rats and mice, respectively, showed that normal bone was formed on top of the
alendronate, which was incorporated inside the matrix. While incorporated in bone matrix, alendronate is
not pharmacologically active. Thus, alendronate must be continuously administered to suppress
osteoclasts on newly formed resorption surfaces. Histomorphometry in baboons and rats showed that
alendronate treatment reduces bone turnover (i.e., the number of sites at which bone is remodeled). In
addition, bone formation exceeds bone resorption at these remodeling sites, leading to progressive gains
in bone mass.
Pharmacokinetics
Absorption
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 standardized breakfast. Oral bioavailability of the 10 mg tablet in men (0.59%) was similar to that
in women when administered after an overnight fast and 2 hours before breakfast.
FOSAMAX 70 mg oral solution and FOSAMAX 70 mg tablet are equally bioavailable.
A study examining the effect of timing of a meal on the bioavailability of alendronate was performed in
49 postmenopausal women. Bioavailability was decreased (by approximately 40%) when 10 mg
alendronate was administered either 0.5 or 1 hour before a standardized breakfast, when compared to
dosing 2 hours before eating. In studies of treatment and prevention of osteoporosis, alendronate was
effective when administered at least 30 minutes before breakfast.
Bioavailability was negligible whether alendronate was administered with or up to two hours after a
standardized breakfast. Concomitant administration of alendronate with coffee or orange juice reduced
bioavailability by approximately 60%.
Distribution
Preclinical studies (in male rats) show that alendronate transiently distributes to soft tissues following
1 mg/kg IV 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 drug
in plasma following therapeutic oral doses are too low (less than 5 ng/mL) for analytical detection. Protein
binding in human plasma is approximately 78%.
Metabolism
There is no evidence that alendronate is metabolized in animals or humans.
Excretion
Following a single IV dose of [
14
C]alendronate, approximately 50% of the radioactivity was excreted
in the urine within 72 hours and little or no radioactivity was recovered in the feces. Following a single
10 mg IV dose, the renal clearance of alendronate was 71 mL/min (64, 78; 90% confidence interval [CI]),
and systemic clearance did not exceed 200 mL/min. Plasma concentrations fell by more than 95% within
6 hours following IV administration. The terminal half-life in humans is estimated to exceed 10 years,
probably reflecting release of alendronate from the skeleton. Based on the above, it is estimated that after
10 years of oral treatment with FOSAMAX (10 mg daily) the amount of alendronate released daily from
the skeleton is approximately 25% of that absorbed from the gastrointestinal tract.
Special Populations
Pediatric: The oral bioavailability in children was similar to that observed in adults; however,
FOSAMAX is not indicated for use in children (see PRECAUTIONS, Pediatric Use).
Gender: Bioavailability and the fraction of an IV dose excreted in urine were similar in men and
women.
Geriatric: Bioavailability and disposition (urinary excretion) were similar in elderly and younger
patients. No dosage adjustment is necessary (see DOSAGE AND ADMINISTRATION).
Race: Pharmacokinetic differences due to race have not been studied.
Renal Insufficiency: Preclinical studies show that, in rats with kidney failure, increasing amounts of
drug are present in plasma, kidney, spleen, and tibia. In healthy controls, drug that is not deposited in
bone is rapidly excreted in the urine. No evidence of saturation of bone uptake was found after 3 weeks
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FOSAMAX
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9635610
(alendronate sodium) Tablets and Oral Solution 9636810
dosing with cumulative IV doses of 35 mg/kg in young male rats. 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.
No dosage adjustment is necessary for patients with mild-to-moderate renal insufficiency (creatinine
clearance 35 to 60 mL/min). FOSAMAX is not recommended for patients with more severe renal
insufficiency (creatinine clearance <35 mL/min) due to lack of experience with alendronate in
renal failure.
Hepatic Insufficiency: As there is evidence that alendronate is not metabolized or excreted in the bile,
no studies were conducted in patients with hepatic insufficiency. No dosage adjustment is necessary.
Drug Interactions (also see PRECAUTIONS, Drug Interactions)
Intravenous ranitidine was shown to double the bioavailability of oral alendronate. The clinical
significance of this increased bioavailability and whether similar increases will occur in patients given oral
H
2
-antagonists is unknown.
In healthy subjects, oral prednisone (20 mg three times daily for five days) did not produce a clinically
meaningful change in the oral bioavailability of alendronate (a mean increase ranging from 20 to 44%).
Products containing calcium and other multivalent cations are likely to interfere with absorption of
alendronate.
Pharmacodynamics
Alendronate is a bisphosphonate that binds to bone hydroxyapatite and specifically inhibits the
activity of osteoclasts, the bone-resorbing cells. Alendronate reduces bone resorption with no direct effect
on bone formation, although the latter process is ultimately reduced because bone resorption and
formation are coupled during bone turnover.
Osteoporosis in postmenopausal women
Osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. The
diagnosis can be confirmed by the finding of low bone mass, evidence of fracture on x-ray, a history of
osteoporotic fracture, or height loss or kyphosis, indicative of vertebral (spinal) fracture. Osteoporosis
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. These changes
result in progressive bone loss and lead to osteoporosis in a significant proportion of women over age 50.
Fractures, usually of the spine, hip, and wrist, are the common consequences. From age 50 to age 90,
the risk of hip fracture in white women increases 50-fold and the risk of vertebral fracture 15- to 30-fold. It
is estimated that approximately 40% of 50-year-old women will sustain one or more osteoporosis-related
fractures of the spine, hip, or wrist during their remaining lifetimes. Hip fractures, in particular, are
associated with substantial morbidity, disability, and mortality.
Daily oral doses of alendronate (5, 20, and 40 mg for six weeks) 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
deoxypyridinoline and cross-linked N-telopeptides of type I collagen). These biochemical changes tended
to return toward baseline values as early as 3 weeks following the discontinuation of therapy with
alendronate and did not differ from placebo after 7 months.
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 l
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 bone specific alkaline phosphatase by
approximately 50%, and total serum alkaline phosphatase by approximately 25 to 30% to reach a plateau
after 6 to 12 months. In osteoporosis prevention studies FOSAMAX 5 mg/day decreased osteocalcin and
total serum alkaline phosphatase by approximately 40% and 15%, respectively. Similar reductions in the
rate of bone turnover were observed in postmenopausal women during one-year studies with once
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FOSAMAX
®
9635610
(alendronate sodium) Tablets and Oral Solution 9636810
weekly FOSAMAX 70 mg for the treatment of osteoporosis and once weekly FOSAMAX 35 mg for the
prevention of osteoporosis. These data indicate that the rate of bone turnover reached a new steady-
state, despite the progressive increase in the total amount of alendronate deposited within bone.
As a result of inhibition of bone resorption, asymptomatic reductions in serum calcium and phosphate
concentrations were also observed following treatment with FOSAMAX. In the long-term studies,
reductions from baseline in serum calcium (approximately 2%) and phosphate (approximately 4 to 6%)
were evident the first month after the initiation of FOSAMAX 10 mg. No further decreases in serum
calcium were observed for the five-year duration of treatment; however, serum phosphate returned
toward prestudy levels during years three through five. Similar reductions were observed with FOSAMAX
5 mg/day. In one-year studies with once weekly FOSAMAX 35 and 70 mg, similar reductions were
observed at 6 and 12 months. The reduction in serum phosphate may reflect not only the positive bone
mineral balance due to FOSAMAX but also a decrease in renal phosphate reabsorption.
Osteoporosis in men
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 were observed in a one-year study in
men with osteoporosis receiving once weekly FOSAMAX 70 mg.
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.
Osteoporosis occurs as a result of inhibited bone formation and increased bone resorption resulting in net
bone loss. Alendronate decreases bone resorption without directly inhibiting bone formation.
In clinical studies of up to two years’ duration, FOSAMAX 5 and 10 mg/day reduced cross-linked
N-telopeptides of type I 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 15 to 30% and 8 to 18%, respectively. As a result of inhibition of bone resorption,
FOSAMAX 5 and 10 mg/day induced asymptomatic decreases in serum calcium (approximately 1 to 2%)
and serum phosphate (approximately 1 to 8%).
Paget’s disease of bone
Paget’s disease of bone is a chronic, focal skeletal disorder characterized by greatly increased and
disorderly bone remodeling. Excessive osteoclastic bone resorption is followed by osteoblastic new bone
formation, leading to the replacement of the normal bone architecture by disorganized, enlarged, and
weakened bone structure.
Clinical manifestations of Paget’s disease range from no symptoms to severe morbidity due to bone
pain, bone deformity, pathological fractures, and neurological and other complications. Serum alkaline
phosphatase, the most frequently used biochemical index of disease activity, provides an objective
measure of disease severity and response to therapy.
FOSAMAX decreases the rate of bone resorption directly, which leads to an indirect decrease in
bone formation. In clinical trials, FOSAMAX 40 mg once daily for six months produced significant
decreases in serum alkaline phosphatase as well as in urinary markers of bone collagen degradation. As
a result of the inhibition of bone resorption, FOSAMAX induced generally mild, transient, and
asymptomatic decreases in serum calcium and phosphate.
Clinical Studies
Treatment of osteoporosis
Postmenopausal women
Effect on bone mineral density
The efficacy of FOSAMAX 10 mg once daily in postmenopausal women, 44 to 84 years of age, with
osteoporosis (lumbar spine bone mineral density [BMD] of at least 2 standard deviations below the
premenopausal mean) was demonstrated in four double-blind, placebo-controlled clinical studies of two
or three years’ duration. These included two three-year, multicenter studies of virtually identical design,
one performed in the United States (U.S.) and the other in 15 different countries (Multinational), which
enrolled 478 and 516 patients, respectively. The following graph shows the mean increases in BMD of
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FOSAMAX
®
9635610
(alendronate sodium) Tablets and Oral Solution 9636810
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.
At three years significant increases in BMD, relative both to baseline and placebo, were seen at each
measurement site in each study in patients who received FOSAMAX 10 mg/day. Total body BMD also
increased significantly in each study, suggesting that the increases in bone mass of the spine and hip did
not occur at the expense of other skeletal sites. Increases in BMD were evident as early as three months
and continued throughout the three years of treatment. (See figures below for lumbar spine results.) In
the two-year extension of these studies, treatment of 147 patients 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. FOSAMAX was similarly effective regardless of age, race, baseline rate of bone
turnover, and baseline BMD in the range studied (at least 2 standard deviations below the
premenopausal mean). Thus, overall FOSAMAX reverses the loss of bone mineral density, a central
factor in the progression of osteoporosis.
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 of the placebo groups.
These data indicate that continued treatment with FOSAMAX is required to maintain the effect of the
drug.
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FOSAMAX
®
9635610
(alendronate sodium) Tablets and Oral Solution 9636810
In the Three-Year Study of FIT, fractures of the hip occurred in 22 (2.2%) of 1005 patients on placebo
and 11 (1.1%) of 1022 patients on FOSAMAX, p=0.047. The figure below displays the cumulative
incidence of hip fractures in this study.
Cumulative Incidence of Hip Fractures in the
Three-Year Study of FIT
(patients with radiographic vertebral fracture at baseline)
Fracture Intervention Trial: Four-Year Study (patients with low bone mass but without a baseline
radiographic vertebral fracture)
This randomized, double-blind, placebo-controlled, 4432-patient study (FOSAMAX, n=2214; placebo,
n=2218) further investigated the reduction in fracture incidence due to FOSAMAX. The intent of the study
was to recruit women with osteoporosis, defined as 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 non-osteoporotic women. The results are shown in the
table below for the patients with osteoporosis.
Effect of FOSAMAX on Fracture Incidence in Osteoporotic
†
Patients in the Four-Year
Study of FIT
(patients without vertebral fracture at baseline)
Percent of Patients
Absolute Relative
Reduction Reduction
FOSAMAX Placebo in Fracture in Fracture
(n=1545) (n=1521) Incidence Risk (%)
Patients with:
Vertebral fractures (diagnosed by
X-ray)
††
≥ 1 new vertebral fracture
2.5 4.8 2.3 48***
≥ 2 new vertebral fractures
0.1 0.6 0.5 78*
Clinical (symptomatic) fractures
Any clinical (symptomatic) fracture 12.9 16.2 3.3 22**
≥ 1 clinical (symptomatic) vertebral
1.0 1.6 0.6 41 (NS)
†††
fracture
Hip fracture 1.0 1.4 0.4 29 (NS)
†††
NS
†††
Wrist (forearm) fracture 3.9 3.8 -0.1
†
Baseline femoral neck BMD at least 2 SD below the mean for young adult women
††
Number evaluable for vertebral fractures: FOSAMAX, n=1426; placebo, n=1428
†††
Not significant. This study was not powered to detect differences at these sites.
*p=0.035, ** p=0.01, ***p<0.001
Fracture results across studies
In the Three-Year Study of FIT, FOSAMAX reduced the percentage of women experiencing at least
one new radiographic vertebral fracture from 15.0% to 7.9% (47% relative risk reduction, p<0.001); in the
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Four-Year Study of FIT, the percentage was reduced from 3.8% to 2.1% (44% relative risk reduction,
p=0.001); and in the combined U.S./Multinational studies, from 6.2% to 3.2% (48% relative risk reduction,
p=0.034).
FOSAMAX reduced the percentage of women experiencing multiple (two or more) new vertebral
fractures from 4.2% to 0.6% (87% relative risk reduction, p<0.001) in the combined U.S./Multinational
studies and from 4.9% to 0.5% (90% relative risk reduction, p<0.001) in the Three-Year Study of FIT. In
the Four-Year Study of FIT, FOSAMAX reduced the percentage of osteoporotic women experiencing
multiple vertebral fractures from 0.6% to 0.1% (78% relative risk reduction, p=0.035).
Thus, FOSAMAX reduced the incidence of radiographic vertebral fractures in osteoporotic women
whether or not they had a previous radiographic vertebral fracture.
FOSAMAX, over a three- or four-year period, was associated with statistically significant reductions in
loss of height vs. placebo in patients with and without baseline radiographic vertebral fractures. At the
end of the FIT studies the between-treatment group differences were 3.2 mm in the Three-Year Study
and 1.3 mm in the Four-Year Study.
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 mineralization 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 rats and baboons exposed to long-term
alendronate treatment, support the conclusion that bone formed during therapy with FOSAMAX is of
normal quality.
Men
The efficacy of FOSAMAX in men with hypogonadal or idiopathic osteoporosis was demonstrated in
two clinical studies.
A two-year, double-blind, placebo-controlled, multicenter study of FOSAMAX 10 mg once daily
enrolled a total of 241 men between the ages of 31 and 87 (mean, 63). All patients in the trial 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 ≤-1 at the femoral neck. At two years, the mean increases relative to placebo
in BMD in men receiving FOSAMAX 10 mg/day were significant at the following sites: lumbar spine,
5.3%; femoral neck, 2.6%; trochanter, 3.1%; and total body, 1.6%. Treatment with FOSAMAX also
reduced height loss (FOSAMAX, -0.6 mm vs. placebo, -2.4 mm).
A one-year, double-blind, placebo-controlled, multicenter study of once weekly FOSAMAX 70 mg
enrolled a total of 167 men between the ages of 38 and 91 (mean, 66). Patients in the study had either: 1)
a BMD T-score ≤-2 at the femoral neck and ≤-1 at the lumbar spine, 2) a BMD T-score ≤-2 at the lumbar
spine and ≤-1 at the femoral neck, or 3) a baseline osteoporotic fracture and a BMD T-score ≤-1 at the
femoral neck. At one year, the mean increases relative to placebo in BMD in men receiving FOSAMAX
70 mg once weekly were significant at the following sites: lumbar spine, 2.8%; femoral neck, 1.9%;
trochanter, 2.0%; and total body, 1.2%. These increases in BMD were similar to those seen at one year in
the 10 mg once-daily study.
In both studies, BMD responses were similar regardless of age (≥65 years vs. <65 years), gonadal
function (baseline testosterone <9 ng/dL vs. ≥9 ng/dL), or baseline BMD (femoral neck and lumbar spine
T-score ≤-2.5 vs. >-2.5).
Prevention of osteoporosis in postmenopausal women
Prevention of bone loss was demonstrated in two double-blind, placebo-controlled studies of
postmenopausal women 40-60 years of age. One thousand six hundred nine patients (FOSAMAX
5 mg/day; n=498) who were at least six months postmenopausal were entered into a two-year study
without regard to their baseline BMD. In the other study, 447 patients (FOSAMAX 5 mg/day; n=88), who
were between six months and three years postmenopause, were treated for up to three years. 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 prevented bone loss in the majority
of patients and induced significant increases in mean bone mass at each of these sites (see figures
below). In addition, FOSAMAX 5 mg/day reduced the rate of bone loss at the forearm by approximately
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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.
The therapeutic equivalence of once weekly FOSAMAX 35 mg (n=362) and FOSAMAX 5 mg daily
(n=361) was demonstrated in a one-year, double-blind, multicenter study of postmenopausal women
without osteoporosis. In the primary analysis of completers, the mean increases from baseline in lumbar
spine BMD at one year were 2.9% (2.6, 3.2%; 95% CI) in the 35-mg once-weekly group (n=307) and
3.2% (2.9, 3.5%; 95% CI) in the 5-mg daily group (n=298). The two treatment groups were also similar
with regard to BMD increases at other skeletal sites. The results of the intention-to-treat analysis were
consistent with the primary analysis of completers.
Bone histology
Bone histology was normal in the 28 patients biopsied at the end of three years who received
FOSAMAX at doses of up to 10 mg/day.
Concomitant use with estrogen/hormone replacement therapy (HRT)
The effects on BMD of treatment with FOSAMAX 10 mg once daily and conjugated estrogen
(0.625 mg/day) either alone or in combination were assessed in a two-year, double-blind, placebo-
controlled study of hysterectomized 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 estrogen or FOSAMAX alone (both 6.0%).
The effects on BMD when FOSAMAX was added to stable doses (for at least one year) of HRT
(estrogen ± 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 favorable 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.
Histomorphometric studies of transiliac biopsies in 92 subjects showed normal bone architecture.
Compared to placebo there was a 98% suppression of bone turnover (as assessed by mineralizing
surface) after 18 months of combined treatment with FOSAMAX and HRT, 94% on FOSAMAX alone, and
78% on HRT alone. The long-term effects of combined FOSAMAX and HRT on fracture occurrence and
fracture healing have not been studied.
Glucocorticoid-induced osteoporosis
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, double-blind,
randomized, placebo-controlled, multicenter studies of virtually identical design, one performed in the
United States and the other in 15 different countries (Multinational [which also included FOSAMAX
2.5 mg/day]). These studies enrolled 232 and 328 patients, respectively, between the ages of 17 and
83 with a variety of glucocorticoid-requiring diseases. Patients received supplemental calcium and
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vitamin D. The following figure shows the mean increases relative to placebo in BMD of the lumbar spine,
femoral neck, and trochanter in patients receiving FOSAMAX 5 mg/day for each study.
Studies in Glucocorticoid - Treated Patients
Increase in BMD
FOSAMAX 5 mg/day at One Year
5
U.S.
Multinational
4
3
2
1
0
BMD (Mean % Increase
Relative to Placebo + SE)
Lumbar Spine Femoral Neck Trochanter
After one year, significant increases relative to placebo in BMD were seen in the combined studies at
each of these sites in patients who received FOSAMAX 5 mg/day. In the placebo-treated patients, a
significant decrease in BMD occurred at the femoral neck (-1.2%), and smaller decreases were seen at
the lumbar spine and trochanter. Total body BMD was maintained with FOSAMAX 5 mg/day. 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 estrogen 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 (4.1% vs. 1.6%) and trochanter (2.8% vs. 1.7%), 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,
underlying disease, 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.
Of the original 560 patients in these studies, 208 patients who remained on at least 7.5 mg/day of
prednisone or equivalent continued into a one-year double-blind extension. After two years of treatment,
spine BMD increased by 3.7% and 5.0% relative to placebo with FOSAMAX 5 and 10 mg/day,
respectively. Significant increases in BMD (relative to placebo) were also observed at the femoral neck,
trochanter, and total body.
After one year, 2.3% of patients treated with FOSAMAX 5 or 10 mg/day (pooled) vs. 3.7% of those
treated with placebo experienced a new vertebral fracture (not significant). However, in the population
studied for two years, treatment with FOSAMAX (pooled dosage groups: 5 or 10 mg for two years or
2.5 mg for one year followed by 10 mg for one year) significantly reduced the incidence of patients with a
new vertebral fracture (FOSAMAX 0.7% vs. placebo 6.8%).
Paget’s disease of bone
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 U.S.
comparative study with etidronate disodium 400 mg/day. The following figure shows the mean percent
changes from baseline in serum alkaline phosphatase for up to six months of randomized treatment.
10
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FOSAMAX
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At six months the suppression in alkaline phosphatase in patients treated with FOSAMAX was
significantly greater than that achieved with etidronate and contrasted with the complete lack of response
in placebo-treated patients. Response (defined as either normalization of serum alkaline phosphatase or
decrease from baseline ≥60%) occurred in approximately 85% of patients treated with FOSAMAX in the
combined studies vs. 30% in the etidronate group and 0% in the placebo group. FOSAMAX was similarly
effective regardless of age, gender, race, prior use of other bisphosphonates, or baseline alkaline
phosphatase within the range studied (at least twice the upper limit of normal).
Bone histology was evaluated in 33 patients with Paget’s disease treated with FOSAMAX 40 mg/day
for 6 months. As in patients treated for osteoporosis (see Clinical Studies, Treatment of osteoporosis in
postmenopausal women, Bone histology), FOSAMAX did not impair mineralization, and the expected
decrease in the rate of bone turnover was observed. Normal lamellar bone was produced during
treatment with FOSAMAX, even where preexisting bone was woven and disorganized. Overall, bone
histology data support the conclusion that bone formed during treatment with FOSAMAX is of normal
quality.
ANIMAL PHARMACOLOGY
The relative inhibitory activities on bone resorption and mineralization of alendronate and etidronate
were compared in the Schenk assay, which is based on histological examination of the epiphyses of
growing rats. In this assay, the lowest dose of alendronate that interfered with bone mineralization
(leading to osteomalacia) was 6000-fold the antiresorptive dose. The corresponding ratio for etidronate
was one to one. These data suggest that alendronate administered in therapeutic doses is highly unlikely
to induce osteomalacia.
INDICATIONS AND USAGE
FOSAMAX is indicated for:
• Treatment and prevention of osteoporosis in postmenopausal women
• For the treatment of osteoporosis, FOSAMAX increases bone mass and reduces the
incidence of fractures, including those of the hip and spine (vertebral compression fractures).
Osteoporosis may be confirmed by the finding of low bone mass (for example, at least
2 standard deviations below the premenopausal mean) or by the presence or history of
osteoporotic fracture. (See CLINICAL PHARMACOLOGY, Pharmacodynamics.)
11
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• 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; Caucasian or Asian race; and family
history of osteoporosis. The presence of such risk factors may be important when
considering the use of FOSAMAX for prevention of osteoporosis.
• Treatment to increase bone mass in men with osteoporosis
• Treatment of glucocorticoid-induced osteoporosis in men and women receiving glucocorticoids in
a daily dosage equivalent to 7.5 mg or greater of prednisone and who have low bone mineral
density (see PRECAUTIONS, Glucocorticoid-induced osteoporosis). Patients treated with
glucocorticoids should receive adequate amounts of calcium and vitamin D.
• Treatment of Paget’s disease of bone in men and women
• Treatment is indicated in patients with Paget's disease of bone having alkaline phosphatase
at least two times the upper limit of normal, or those who are symptomatic, or those at risk for
future complications from their disease.
CONTRAINDICATIONS
• Abnormalities of the esophagus which delay esophageal emptying such as stricture or achalasia
• Inability to stand or sit upright for at least 30 minutes (see WARNINGS)
• Patients at increased risk of aspiration should not receive FOSAMAX oral solution.
• Hypersensitivity to any component of this product
• Hypocalcemia (see PRECAUTIONS, General)
WARNINGS
FOSAMAX, like other bisphosphonates administered orally, may cause local irritation of the upper
gastrointestinal mucosa. Because of these possible irritant effects and a potential for worsening of the
underlying disease, caution should be used when FOSAMAX is given to patients with active upper
gastrointestinal problems (such as known Barrett's esophagus, dysphagia, other esophageal diseases,
gastritis, duodenitis, or ulcers).
Esophageal adverse experiences, such as esophagitis, esophageal ulcers and esophageal erosions,
occasionally with bleeding and rarely followed by esophageal stricture or perforation, have been reported
in patients receiving treatment with oral bisphosphonates including FOSAMAX. In some cases these
have been severe and required hospitalization. Physicians should therefore be alert to any signs or
symptoms signaling a possible esophageal reaction and patients should be instructed to discontinue
FOSAMAX and seek medical attention if they develop dysphagia, odynophagia, retrosternal pain or new
or worsening heartburn.
The risk of severe esophageal adverse experiences appears to be greater in patients who lie down
after taking oral bisphosphonates including FOSAMAX and/or who fail to swallow oral bisphosphonates
including FOSAMAX with the recommended full glass (6-8 oz) of water, and/or who continue to take oral
bisphosphonates including FOSAMAX after developing symptoms suggestive of esophageal irritation.
Therefore, it is very important that the full dosing instructions are provided to, and understood by, the
patient (see DOSAGE AND ADMINISTRATION). In patients who cannot comply with dosing instructions
due to mental disability, therapy with FOSAMAX should be used under appropriate supervision.
There have been post-marketing reports of gastric and duodenal ulcers with oral bisphosphonate
use, some severe and with complications, although no increased risk was observed in controlled clinical
trials.
12
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PRECAUTIONS
General
Causes of osteoporosis other than estrogen deficiency, aging, and glucocorticoid use should be
considered.
Hypocalcemia must be corrected before initiating therapy with FOSAMAX (see
CONTRAINDICATIONS). Other disorders affecting mineral metabolism (such as vitamin D deficiency)
should also be effectively treated. In patients with these conditions, serum calcium and symptoms of
hypocalcemia should be monitored during therapy with FOSAMAX.
Presumably due to the effects of FOSAMAX on increasing bone mineral, 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.
Musculoskeletal Pain
In post marketing experience, severe and occasionally incapacitating bone, joint, and/or muscle pain
has been reported in patients taking bisphosphonates that are approved for the prevention and treatment
of osteoporosis (see ADVERSE REACTIONS). This category of drugs includes FOSAMAX (alendronate).
Most of the patients were postmenopausal women. The time to onset of symptoms varied from one day
to several months after starting the drug. Discontinue use if severe symptoms develop. Most patients had
relief of symptoms after stopping. A subset had recurrence of symptoms when rechallenged with the
same drug or another bisphosphonate.
In placebo-controlled clinical studies of FOSAMAX, the percentages of patients with these symptoms
were similar in the FOSAMAX and placebo groups.
Dental
Osteonecrosis of the jaw (ONJ), which can occur spontaneously, is generally associated with tooth
extraction and/or local infection with delayed healing, and has been reported in patients taking
bisphosphonates, including FOSAMAX. Known risk factors for osteonecrosis of the jaw include invasive
dental procedures (e.g., tooth extraction, dental implants, boney surgery), diagnosis of cancer,
concomitant therapies (e.g., chemotherapy, corticosteroids), poor oral hygiene, and co-morbid disorders
(e.g., periodontal and/or other pre-existing dental disease, anemia, coagulopathy, infection, ill-fitting
dentures).
For patients requiring invasive dental procedures, discontinuation of bisphosphonate treatment may
reduce the risk for ONJ. Clinical judgment of the treating physician and/or oral surgeon should guide the
management plan of each patient based on individual benefit/risk assessment.
Patients who develop osteonecrosis of the jaw while on bisphosphonate therapy should receive care
by an oral surgeon. In these patients, extensive dental surgery to treat ONJ may exacerbate the
condition. Discontinuation of bisphosphonate therapy should be considered based on individual
benefit/risk assessment.
Renal insufficiency
FOSAMAX is not recommended for patients with renal insufficiency (creatinine clearance
<35 mL/min). (See DOSAGE AND ADMINISTRATION.)
Glucocorticoid-induced osteoporosis
The risk versus benefit of FOSAMAX for treatment at daily dosages of glucocorticoids less than
7.5 mg of prednisone or equivalent has not been established (see INDICATIONS AND USAGE). Before
initiating treatment, the hormonal status of both men and women should be ascertained and appropriate
replacement considered.
A bone mineral density measurement should be made at the initiation of therapy and repeated after
6 to 12 months of combined FOSAMAX and glucocorticoid treatment.
The efficacy of FOSAMAX for the treatment of glucocorticoid-induced osteoporosis has been shown
in patients with a median bone mineral density which was 1.2 standard deviations below the mean for
healthy young adults.
13
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The efficacy of FOSAMAX has been established in studies of two years’ duration. The greatest
increase in bone mineral density occurred in the first year with maintenance or smaller gains during the
second year. Efficacy of FOSAMAX beyond two years has not been studied.
The efficacy of FOSAMAX in respect to fracture prevention has been demonstrated for vertebral
fractures. However, this finding was based on very few fractures that occurred primarily in
postmenopausal women. The efficacy for prevention of non-vertebral fractures has not been
demonstrated.
Information for Patients
General
Physicians should instruct their patients to read the patient package insert before starting therapy
with FOSAMAX and to reread it each time the prescription is renewed.
Patients should be instructed to take supplemental calcium and vitamin D, if daily dietary intake is
inadequate. Weight-bearing exercise should be considered along with the modification of certain
behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, if these factors
exist.
Dosing Instructions
Patients should be instructed that the expected benefits of FOSAMAX may only be obtained when it
is taken with plain water the first thing upon arising for the day at least 30 minutes before the first food,
beverage, or medication of the day. Even dosing with orange juice or coffee has been shown to markedly
reduce the absorption of FOSAMAX (see CLINICAL PHARMACOLOGY, Pharmacokinetics, Absorption).
To facilitate delivery to the stomach and thus reduce the potential for esophageal irritation patients
should be instructed to swallow each tablet of FOSAMAX with a full glass of water (6-8 oz). To facilitate
gastric emptying patients should drink at least 2 oz (a quarter of a cup) of water after taking FOSAMAX
oral solution. 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 at bedtime or before arising
for the day. Patients should be informed that failure to follow these instructions may increase their risk of
esophageal problems. Patients should be instructed that if they develop symptoms of esophageal
disease (such as difficulty or pain upon swallowing, retrosternal pain or new or worsening heartburn) they
should stop taking FOSAMAX and consult their physician.
Patients should be instructed that if they miss a dose of once weekly FOSAMAX, they should take
one dose on the morning after they remember. They should not take two doses on the same day but
should return to taking one dose once a week, as originally scheduled on their chosen day.
Drug Interactions (also see CLINICAL PHARMACOLOGY, Pharmacokinetics, Drug Interactions)
Estrogen/hormone replacement therapy (HRT)
Concomitant use of HRT (estrogen ± progestin) and FOSAMAX was assessed in two clinical studies
of one or two years’ duration in postmenopausal osteoporotic women. In these studies, the safety and
tolerability profile of the combination was consistent with those of the individual treatments; however, the
degree of suppression of bone turnover (as assessed by mineralizing surface) was significantly greater
with the combination than with either component alone. The long-term effects of combined FOSAMAX
and HRT on fracture occurrence have not been studied (see CLINICAL PHARMACOLOGY, Clinical
Studies, Concomitant use with estrogen/hormone replacement therapy (HRT) and ADVERSE
REACTIONS, Clinical Studies, Concomitant use with estrogen/hormone replacement therapy).
Calcium Supplements/Antacids
It is likely that calcium supplements, antacids, and some oral medications will interfere with
absorption of FOSAMAX. Therefore, patients must wait at least one-half hour after taking FOSAMAX
before taking any other oral medications.
Aspirin
In clinical studies, the incidence of upper gastrointestinal adverse events was increased in patients
receiving concomitant therapy with daily doses of FOSAMAX greater than 10 mg and aspirin-containing
products.
14
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Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
FOSAMAX may be administered to patients taking NSAIDs. In a 3-year, controlled, clinical study
(n=2027) during which a majority of patients received concomitant NSAIDs, the incidence of upper
gastrointestinal adverse events was similar in patients taking FOSAMAX 5 or 10 mg/day compared to
those taking placebo. However, since NSAID use is associated with gastrointestinal irritation, caution
should be used during concomitant use with FOSAMAX.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Harderian gland (a retro-orbital gland not present in humans) adenomas were increased in high-dose
female mice (p=0.003) in a 92-week oral carcinogenicity study at doses of alendronate of 1, 3, and
10 mg/kg/day (males) or 1, 2, and 5 mg/kg/day (females). These doses are equivalent to 0.12
to 1.2 times a maximum recommended daily dose of 40 mg (Paget’s disease) based on surface area,
mg/m
2
. The relevance of this finding to humans is unknown.
Parafollicular cell (thyroid) adenomas were increased in high-dose male rats (p=0.003) in a 2-year
oral carcinogenicity study at doses of 1 and 3.75 mg/kg body weight. These doses are equivalent to 0.26
and 1 times a 40 mg human daily dose based on surface area, mg/m
2
. The relevance of this finding to
humans is unknown.
Alendronate was not genotoxic in the in vitro microbial mutagenesis assay with and without metabolic
activation, in an in vitro mammalian cell mutagenesis assay, in an in vitro alkaline elution assay in rat
hepatocytes, and in an in vivo chromosomal aberration assay in mice. In an in vitro chromosomal
aberration assay in Chinese hamster ovary cells, however, alendronate gave equivocal results.
Alendronate had no effect on fertility (male or female) in rats at oral doses up to 5 mg/kg/day
(1.3 times a 40 mg human daily dose based on surface area, mg/m
2
).
Pregnancy
Pregnancy Category C:
Reproduction studies in rats showed decreased postimplantation survival at 2 mg/kg/day and
decreased body weight gain in normal pups at 1 mg/kg/day. Sites of incomplete fetal ossification were
statistically significantly increased in rats beginning at 10 mg/kg/day in vertebral (cervical, thoracic, and
lumbar), skull, and sternebral bones. The above doses ranged from 0.26 times (1 mg/kg) to 2.6 times
(10 mg/kg) a maximum recommended daily dose of 40 mg (Paget’s disease) based on surface area,
mg/m
2
. No similar fetal effects were seen when pregnant rabbits were treated at doses up to
35 mg/kg/day (10.3 times a 40 mg human daily dose based on surface area, mg/m
2
).
Both total and ionized calcium decreased in pregnant rats at 15 mg/kg/day (3.9 times a 40 mg human
daily dose based on surface area, mg/m
2
) resulting in delays and failures of delivery. Protracted
parturition due to maternal hypocalcemia occurred in rats at doses as low as 0.5 mg/kg/day (0.13 times a
40 mg human daily dose based on surface area, mg/m
2
) when rats were treated from before mating
through gestation. Maternotoxicity (late pregnancy deaths) occurred in the female rats treated with
15 mg/kg/day for varying periods of time ranging from treatment only during pre-mating to treatment only
during early, middle, or late gestation; these deaths were lessened but not eliminated by cessation of
treatment. Calcium supplementation either in the drinking water or by minipump could not ameliorate the
hypocalcemia or prevent maternal and neonatal deaths due to delays in delivery; calcium
supplementation IV prevented maternal, but not fetal deaths.
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. 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.
There are no studies in pregnant women. FOSAMAX should be used during pregnancy only if the
potential benefit justifies the potential risk to the mother and fetus.
15
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Nursing Mothers
It is not known whether alendronate is excreted in human milk. Because many drugs are excreted in
human milk, caution should be exercised when FOSAMAX is administered to nursing women.
Pediatric Use
The efficacy and safety of FOSAMAX were examined in a randomized, double-blind, placebo-
controlled two-year study of 139 pediatric patients, aged 4-18 years, with severe osteogenesis
imperfecta. One-hundred-and-nine patients were randomized to 5 mg FOSAMAX daily (weight <40 kg) or
10 mg FOSAMAX daily (weight ≥40 kg) and 30 patients to placebo. The mean baseline lumbar spine
BMD Z-score of the patients was -4.5. The mean change in lumbar spine BMD Z-score from baseline to
Month 24 was 1.3 in the FOSAMAX-treated patients and 0.1 in the placebo-treated patients. Treatment
with FOSAMAX did not reduce the risk of fracture. Sixteen percent of the FOSAMAX patients who
sustained a radiologically-confirmed fracture by Month 12 of the study had delayed fracture healing
(callus remodeling) or fracture non-union when assessed radiographically at Month 24 compared with 9%
of the placebo-treated patients. In FOSAMAX-treated patients, bone histomorphometry data obtained at
Month 24 demonstrated decreased bone turnover and delayed mineralization time; however, there were
no mineralization defects. There were no statistically significant differences between the FOSAMAX and
placebo groups in reduction of bone pain.
FOSAMAX is not indicated for use in children.
(For clinical adverse experiences in children, see ADVERSE REACTIONS, Clinical Studies,
Osteogenesis Imperfecta.)
Geriatric Use
Of the patients receiving FOSAMAX in the Fracture Intervention Trial (FIT), 71% (n=2302) were
≥65 years of age and 17% (n=550) were ≥75 years of age. Of the patients receiving FOSAMAX in the
United States and Multinational osteoporosis treatment studies in women, osteoporosis studies in men,
glucocorticoid-induced osteoporosis studies, and Paget’s disease studies (see CLINICAL
PHARMACOLOGY, Clinical Studies), 45%, 54%, 37%, and 70%, respectively, were 65 years of age or
over. No overall differences in efficacy or safety were observed between these patients and younger
patients, but greater sensitivity of some older individuals cannot be ruled out.
ADVERSE REACTIONS
Clinical Studies
In clinical studies of up to five years in duration adverse experiences associated with FOSAMAX
usually were mild, and generally did not require discontinuation of therapy.
FOSAMAX has been evaluated for safety in approximately 8000 postmenopausal women in clinical
studies.
Treatment of osteoporosis
Postmenopausal women
In two identically designed, three-year, placebo-controlled, double-blind, multicenter studies (United
States and Multinational; n=994), 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. In the Fracture Intervention Trial (n=6459), 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%. In these study populations, 49-54% had a history of gastrointestinal disorders at baseline and 54-
89% used nonsteroidal anti-inflammatory drugs or aspirin at some time during the studies. Adverse
experiences from these studies considered by the investigators as possibly, probably, or definitely drug
related in ≥1% of patients treated with either FOSAMAX or placebo are presented in the following table.
16
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Osteoporosis Treatment Studies in Postmenopausal Women
Adverse Experiences Considered Possibly, Probably, or Definitely Drug Related by the Investigators and
Reported in ≥1% of Patients
United States/Multinational Studies Fracture Intervention Trial
FOSAMAX* Placebo FOSAMAX** Placebo
% % % %
(n=196) (n=397) (n=3236) (n=3223)
Gastrointestinal
abdominal pain
6.6
4.8
1.5
1.5
nausea
3.6
4.0
1.1
1.5
dyspepsia
3.6
3.5
1.1
1.2
constipation
3.1
1.8
0.0
0.2
diarrhea
3.1
1.8
0.6
0.3
flatulence
2.6
0.5
0.2
0.3
acid regurgitation
2.0
4.3
1.1
0.9
esophageal ulcer
1.5
0.0
0.1
0.1
vomiting
1.0
1.5
0.2
0.3
dysphagia
1.0
0.0
0.1
0.1
abdominal distention
1.0
0.8
0.0
0.0
gastritis
0.5
1.3
0.6
0.7
Musculoskeletal
musculoskeletal (bone,
muscle or joint) pain
4.1 2.5 0.4 0.3
muscle cramp
0.0 1.0 0.2 0.1
Nervous System/Psychiatric
headache
2.6 1.5 0.2 0.2
dizziness
0.0 1.0 0.0 0.1
Special Senses
taste perversion
0.5 1.0 0.1 0.0
* 10 mg/day for three years
** 5 mg/day for 2 years and 10 mg/day for either 1 or 2 additional years
Rarely, rash and erythema have occurred.
One patient treated with FOSAMAX (10 mg/day), who had a history of peptic ulcer disease and
gastrectomy and who was taking concomitant aspirin developed an anastomotic ulcer with mild
hemorrhage, which was considered drug related. Aspirin and FOSAMAX were discontinued and the
patient recovered.
The adverse experience profile was similar for the 401 patients treated with either 5 or 20 mg doses
of FOSAMAX in the United States and Multinational studies. The adverse experience profile for the
296 patients who received continued treatment with either 5 or 10 mg doses of FOSAMAX in the two-year
extension of these studies (treatment years 4 and 5) was similar to that observed during the three-year
placebo-controlled period. During the extension period, of the 151 patients treated with FOSAMAX
10 mg/day, the proportion of patients who discontinued therapy due to any clinical adverse experience
was similar to that during the first three years of the study.
In a one-year, double-blind, multicenter study, the overall safety and tolerability profiles of once
weekly FOSAMAX 70 mg and FOSAMAX 10 mg daily were similar. The adverse experiences considered
by the investigators as possibly, probably, or definitely drug related in ≥1% of patients in either treatment
group are presented in the following table.
17
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FOSAMAX
®
9635610
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Osteoporosis Treatment Studies in Postmenopausal Women
Adverse Experiences Considered Possibly, Probably, or Definitely Drug Related
by the Investigators and Reported in ≥1% of Patients
Once Weekly FOSAMAX FOSAMAX
70 mg 10 mg/day
% %
(n=519) (n=370)
Gastrointestinal
abdominal pain
3.7 3.0
dyspepsia
2.7 2.2
acid regurgitation
1.9 2.4
nausea
1.9 2.4
abdominal distention
1.0 1.4
constipation
0.8 1.6
flatulence
0.4 1.6
gastritis
0.2 1.1
gastric ulcer
0.0 1.1
Musculoskeletal
musculoskeletal (bone, muscle,
2.9 3.2
joint) pain
muscle cramp
0.2 1.1
Men
In two placebo-controlled, double-blind, multicenter studies in men (a two-year study of FOSAMAX
10 mg/day and a one-year study of once weekly FOSAMAX 70 mg) the rates of discontinuation of
therapy due to any clinical adverse experience were 2.7% for FOSAMAX 10 mg/day vs. 10.5% for
placebo, and 6.4% for once weekly FOSAMAX 70 mg vs. 8.6% for placebo. The adverse experiences
considered by the investigators as possibly, probably, or definitely drug related in ≥2% of patients treated
with either FOSAMAX or placebo are presented in the following table.
Osteoporosis Studies in Men
Adverse Experiences Considered Possibly, Probably, or
Definitely Drug Related by the Investigators and
Reported in ≥2% of Patients
Two-year Study One-year Study
Gastrointestinal
acid regurgitation
flatulence
gastroesophageal
reflux disease
dyspepsia
diarrhea
abdominal pain
nausea
FOSAMAX Placebo
10 mg/day %
% (n=95)
(n=146)
4.1 3.2 0.0 0.0
4.1 1.1 0.0 0.0
0.7 3.2 2.8 0.0
3.4 0.0 2.8 1.7
1.4 1.1 2.8 0.0
2.1 1.1 0.9 3.4
2.1 0.0 0.0 0.0
Once Weekly
FOSAMAX 70 mg Placebo
% %
(n=109) (n=58)
Prevention of osteoporosis in postmenopausal women
The safety of FOSAMAX 5 mg/day in postmenopausal women 40-60 years of age has been
evaluated in three double-blind, placebo-controlled studies involving over 1,400 patients randomized to
receive FOSAMAX for either two or three years. In these studies the overall safety profiles of FOSAMAX
5 mg/day and placebo were similar. Discontinuation of therapy due to any clinical adverse experience
occurred in 7.5% of 642 patients treated with FOSAMAX 5 mg/day and 5.7% of 648 patients treated with
placebo.
In a one-year, double-blind, multicenter study, the overall safety and tolerability profiles of once
weekly FOSAMAX 35 mg and FOSAMAX 5 mg daily were similar.
The adverse experiences from these studies considered by the investigators as possibly, probably, or
definitely drug related in ≥1% of patients treated with either once weekly FOSAMAX 35 mg, FOSAMAX
5 mg/day or placebo are presented in the following table.
18
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FOSAMAX
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9635610
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Osteoporosis Prevention Studies in Postmenopausal Women
Adverse Experiences Considered Possibly, Probably, or
Definitely Drug Related by the Investigators and
Reported in ≥1% of Patients
Two/Three-Year Studies
FOSAMA Placebo
X
5 mg/day %
% (n=648)
(n=642)
Gastrointestinal
dyspepsia
1.9 1.4
abdominal pain
1.7 3.4
acid regurgitation
1.4 2.5
nausea
1.4 1.4
diarrhea
1.1 1.7
constipation
0.9 0.5
abdominal distention
0.2 0.3
Musculoskeletal
musculoskeletal (bone,
0.8 0.9
muscle or joint)
pain
One-Year Study
Once Weekly
FOSAMAX FOSAMAX
5 mg/day 35 mg
% %
(n=361) (n=362)
2.2 1.7
4.2 2.2
4.2 4.7
2.5 1.4
1.1 0.6
1.7 0.3
1.4 1.1
1.9 2.2
Concomitant use with estrogen/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 estrogen ±
progestin (n=354) was consistent with those of the individual treatments.
Treatment of glucocorticoid-induced osteoporosis
In two, one-year, placebo-controlled, double-blind, multicenter 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. The adverse experiences considered by the investigators as possibly,
probably, or definitely drug related in ≥1% of patients treated with either FOSAMAX 5 or 10 mg/day or
placebo are presented in the following table.
One-Year Studies in Glucocorticoid-Treated Patients
Adverse Experiences Considered Possibly, Probably, or
Definitely Drug Related by the Investigators and
Reported in ≥1% of Patients
FOSAMAX FOSAMAX Placebo
10 mg/day 5 mg/day
% % %
(n=157) (n=161) (n=159)
Gastrointestinal
abdominal pain
3.2 1.9 0.0
acid regurgitation
2.5 1.9 1.3
constipation
1.3 0.6 0.0
melena
1.3 0.0 0.0
nausea
0.6 1.2 0.6
diarrhea
0.0 0.0 1.3
Nervous System/Psychiatric
headache
0.6 0.0 1.3
The overall safety and tolerability profile in the glucocorticoid-induced osteoporosis population that
continued therapy for the second year of the studies (FOSAMAX: n=147) was consistent with that
observed in the first year.
Paget’s disease of bone
In clinical studies (osteoporosis and Paget's disease), adverse experiences reported in 175 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 (17.7% FOSAMAX vs.
10.2% placebo). One case of esophagitis and two cases of gastritis resulted in discontinuation of
treatment.
19
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For current labeling information, please visit https://www.fda.gov/drugsatfda
FOSAMAX
®
9635610
(alendronate sodium) Tablets and Oral Solution 9636810
Additionally, musculoskeletal (bone, muscle or joint) pain, which has been described in patients with
Paget's disease treated with other bisphosphonates, was considered 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. Discontinuation of therapy due to any clinical adverse experience occurred in 6.4% of patients
with Paget's disease treated with FOSAMAX 40 mg/day and 2.4% of patients treated with placebo.
Osteogenesis Imperfecta
FOSAMAX is not indicated for use in children.
The overall safety profile of FOSAMAX in OI patients treated for up to 24 months was generally
similar to that of adults with osteoporosis treated with FOSAMAX. However, there was an increased
occurrence of vomiting in OI patients treated with FOSAMAX compared to placebo. During the 24-month
treatment period, vomiting was observed in 32 of 109 (29.4%) patients treated with FOSAMAX and 3 of
30 (10%) patients treated with placebo.
In a pharmacokinetic study, 6 of 24 pediatric OI patients who received a single oral dose of
FOSAMAX 35 or 70 mg developed fever, flu-like symptoms, and/or mild lymphocytopenia within 24 to 48
hours after administration. These events, lasting no more than 2 to 3 days and responding to
acetaminophen, are consistent with an acute-phase response that has been reported in patients
receiving bisphosphonates, including FOSAMAX. See ADVERSE REACTIONS, Post-Marketing
Experience, Body as a Whole.
Laboratory Test Findings
In double-blind, multicenter, 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/dL (0.65 mM)
were similar in both treatment groups.
Post-Marketing Experience
The following adverse reactions have been reported in post-marketing use:
Body as a Whole: hypersensitivity reactions including urticaria and rarely angioedema. Transient
symptoms of myalgia, malaise, asthenia and rarely, fever have been reported with FOSAMAX, typically in
association with initiation of treatment. Rarely, symptomatic hypocalcemia has occurred, generally in
association with predisposing conditions. Rarely, peripheral edema.
Gastrointestinal: esophagitis, esophageal erosions, esophageal ulcers, rarely esophageal stricture or
perforation, and oropharyngeal ulceration. Gastric or duodenal ulcers, some severe and with
complications have also been reported (see WARNINGS, PRECAUTIONS, Information for Patients, and
DOSAGE AND ADMINISTRATION).
Localized osteonecrosis of the jaw, generally associated with tooth extraction and/or local infection
with delayed healing, has been reported rarely (see PRECAUTIONS, Dental).
Musculoskeletal: bone, joint, and/or muscle pain, occasionally severe, and rarely incapacitating (see
PRECAUTIONS, Musculoskeletal Pain); joint swelling; low-energy femoral shaft and subtrochanteric
fractures.
Nervous system: dizziness and vertigo.
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.
OVERDOSAGE
Significant lethality after single oral doses was seen in female rats and mice at 552 mg/kg
(3256 mg/m
2
) and 966 mg/kg (2898 mg/m
2
), respectively. In males, these values were slightly higher,
626 and 1280 mg/kg, respectively. There was no lethality in dogs at oral doses up to 200 mg/kg
(4000 mg/m
2
).
No specific information is available on the treatment of overdosage with FOSAMAX. Hypocalcemia,
hypophosphatemia, and upper gastrointestinal adverse events, such as upset stomach, heartburn,
20
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For current labeling information, please visit https://www.fda.gov/drugsatfda
FOSAMAX
®
9635610
(alendronate sodium) Tablets and Oral Solution 9636810
esophagitis, gastritis, or ulcer, may result from oral overdosage. Milk or antacids should be given to bind
alendronate. Due to the risk of esophageal irritation, vomiting should not be induced and the patient
should remain fully upright.
Dialysis would not be beneficial.
DOSAGE AND ADMINISTRATION
FOSAMAX must be taken at least one-half hour before the first food, beverage, or medication of the
day with plain water only (see PRECAUTIONS, Information for Patients). Other beverages (including
mineral water), food, and some medications are likely to reduce the absorption of FOSAMAX (see
PRECAUTIONS, Drug Interactions). Waiting less than 30 minutes, or taking FOSAMAX with food,
beverages (other than plain water) or other medications will lessen the effect of FOSAMAX by decreasing
its absorption into the body.
FOSAMAX should only be taken upon arising for the day. To facilitate delivery to the stomach and
thus reduce the potential for esophageal irritation, a FOSAMAX tablet should be swallowed with a full
glass of water (6-8 oz). To facilitate gastric emptying FOSAMAX oral solution should be followed by at
least 2 oz (a quarter of a cup) of water. Patients should not lie down for at least 30 minutes and until after
their first food of the day. FOSAMAX should not be taken at bedtime or before arising for the day. Failure
to follow these instructions may increase the risk of esophageal adverse experiences (see WARNINGS,
PRECAUTIONS, Information for Patients).
Patients should receive supplemental calcium and vitamin D, if dietary intake is inadequate (see
PRECAUTIONS, General).
No dosage adjustment is necessary for the elderly or for patients with mild-to-moderate renal
insufficiency (creatinine clearance 35 to 60 mL/min). FOSAMAX is not recommended for patients with
more severe renal insufficiency (creatinine clearance <35 mL/min) due to lack of experience.
Treatment of osteoporosis in postmenopausal women (see INDICATIONS AND USAGE)
The recommended dosage is:
• one 70 mg tablet once weekly
or
• one bottle of 70 mg oral solution once weekly
or
• one 10 mg tablet once daily
Treatment to increase bone mass in men with osteoporosis
The recommended dosage is:
• one 70 mg tablet once weekly
or
• one bottle of 70 mg oral solution once weekly
or
• one 10 mg tablet once daily
Prevention of osteoporosis in postmenopausal women (see INDICATIONS AND USAGE)
The recommended dosage is:
• one 35 mg tablet once weekly
or
• one 5 mg tablet once daily
The safety of treatment and prevention of osteoporosis with FOSAMAX has been studied for up to
7 years.
Treatment of glucocorticoid-induced osteoporosis in men and women
The recommended dosage is one 5 mg tablet once daily, except for postmenopausal women not
receiving estrogen, for whom the recommended dosage is one 10 mg tablet once daily.
Paget’s disease of bone in men and women
The recommended treatment regimen is 40 mg once a day for six months.
21
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
FOSAMAX
®
9635610
(alendronate sodium) Tablets and Oral Solution 9636810
Retreatment of Paget’s disease
In clinical studies in which patients were followed every six months, relapses during the 12 months
following therapy occurred in 9% (3 out of 32) of patients who responded to treatment with FOSAMAX.
Specific retreatment data 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, which should be measured periodically.
Retreatment may also be considered in those who failed to normalize their serum alkaline phosphatase.
HOW SUPPLIED
No. 3759 — Tablets FOSAMAX, 5 mg, are white, round, uncoated tablets with an outline of a bone
image on one side and code MRK 925 on the other. They are supplied as follows:
NDC 0006-0925-31 unit-of-use bottles of 30
NDC 0006-0925-58 unit-of-use bottles of 100.
No. 3797 — Tablets FOSAMAX, 10 mg, are white, oval, wax-polished tablets with code MRK on one
side and 936 on the other. They are supplied as follows:
NDC 0006-0936-31 unit-of-use bottles of 30
NDC 0006-0936-58 unit-of-use bottles of 100
NDC 0006-0936-28 unit dose packages of 100
NDC 0006-0936-82 bottles of 1,000.
No. 3813 — Tablets FOSAMAX, 35 mg, are white, oval, uncoated tablets with code 77 on one side
and a bone image on the other. They are supplied as follows:
NDC 0006-0077-44 unit-of-use blister package of 4
NDC 0006-0077-21 unit dose packages of 20.
No. 8457 — Tablets FOSAMAX, 40 mg, are white, triangular-shaped, uncoated tablets with code
MSD 212 on one side and FOSAMAX on the other. They are supplied as follows:
NDC 0006-0212-31 unit-of-use bottles of 30.
No. 3814 — Tablets FOSAMAX, 70 mg, are white, oval, uncoated tablets with code 31 on one side
and an outline of a bone image on the other. They are supplied as follows:
NDC 0006-0031-44 unit-of-use blister package of 4
NDC 0006-0031-21 unit dose packages of 20.
No. 3833 — Oral Solution FOSAMAX, 70 mg, is a clear, colorless solution with a raspberry flavor and
is supplied as follows:
NDC 0006-3833-34 unit-of-use cartons of 4 single-dose bottles containing 75 mL each.
Storage
FOSAMAX Tablets:
Store in a well-closed container at room temperature, 15-30°C (59-86°F).
FOSAMAX Oral Solution:
Store at 25°C (77°F), excursions permitted to 15-30°C (59-86°F). [See USP Controlled Room
Temperature.] Do not freeze.
Issued March 2010
Printed in USA
22
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
Patient Information
Once Weekly FOSAMAX® (FOSS-ah-max)
(alendronate sodium)
Tablets and Oral Solution
Read this information before you start taking FOSAMAX
*
. Also, read the leaflet each time you refill your
prescription, just in case anything has changed. This leaflet does not take the place of discussions with
your doctor. You and your doctor should discuss FOSAMAX when you start taking your medicine and at
regular checkups.
What is the most important information I should know about once weekly FOSAMAX?
• You must take once weekly FOSAMAX exactly as directed to help make sure it works and to
help lower the chance of problems in your esophagus (the tube that connects your mouth and
stomach). (See “How should I take once weekly FOSAMAX?”).
• If you have chest pain, new or worsening heartburn, or have trouble or pain when you
swallow, stop taking FOSAMAX and call your doctor. (See “What are the possible side effects
of FOSAMAX?”).
What is FOSAMAX?
FOSAMAX is a prescription medicine for:
• The treatment or prevention of osteoporosis (thinning of bone) in women after menopause. It reduces
the chance of having a hip or spinal fracture (break).
• Treatment to increase bone mass in men with osteoporosis.
• FOSAMAX tablets are for treatment and prevention of osteoporosis.
• FOSAMAX oral solution is for treatment of osteoporosis.
Improvement in bone density may be observed as early as 3 months after you start taking FOSAMAX
even though you won’t see or feel a difference. For FOSAMAX to continue to work, you need to keep
taking it.
FOSAMAX is not a hormone.
There is more information about osteoporosis at the end of this leaflet.
Who should not take FOSAMAX?
Do not take FOSAMAX (tablets or oral solution) if you:
• Have certain problems with your esophagus, the tube that connects your mouth with your stomach
• Cannot stand or sit upright for at least 30 minutes
• Have low levels of calcium in your blood
• Are allergic to FOSAMAX or any of its ingredients. A list of ingredients is at the end of this leaflet.
*
Registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
Copyright © 2000 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
9635610
Do not take FOSAMAX oral solution if you have trouble swallowing liquids.
What should I tell my doctor before using FOSAMAX?
Tell your doctor about all of your medical or dental conditions, including if you:
• have problems with swallowing
• have stomach or digestive problems
• have kidney problems
• are pregnant or planning to become pregnant. It is not known if FOSAMAX can harm your unborn
baby.
• are breastfeeding. It is not known if FOSAMAX passes into your milk and if it can harm your baby.
Tell your doctor about all medicines you take, including prescription and non-prescription medicines,
vitamins, and herbal supplements.
Know the medicines you take. Keep a list of them and show it to your doctor and pharmacist each time
you get a new medicine.
How should I take once weekly FOSAMAX?
• Choose the day of the week that best fits your schedule.
• Take 1 dose of FOSAMAX every week on your chosen day after you get up for the day and before
taking your first food, drink, or other medicine
• Take FOSAMAX while you are sitting or standing.
• Take your FOSAMAX with plain water only as follows:
• TABLETS: Swallow one tablet with a full glass (6-8 oz) of plain water.
• ORAL SOLUTION: Drink one entire bottle of solution followed by at least 2 ounces (a quarter of a
cup) of plain water.
Do not take FOSAMAX with:
Mineral water
Coffee or tea
Juice
FOSAMAX works only if it is taken on an empty stomach.
Do not chew or suck on a tablet of FOSAMAX.
After taking your FOSAMAX, wait at least 30 minutes:
● before you lie down. You may sit, stand or walk, and do normal activities like reading.
● before you take your first food or drink except for plain water.
● before you take other medicines, including antacids, calcium, and other supplements and vitamins.
Do not lie down until after your first food of the day.
• It is important that you keep taking FOSAMAX for as long as your doctor says to take it. For
FOSAMAX to continue to work, you need to keep taking it.
2
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For current labeling information, please visit https://www.fda.gov/drugsatfda
9635610
What should I do if I miss a dose of FOSAMAX or if I take too many?
• If you miss a dose, take only 1 dose of FOSAMAX on the morning after you remember. Do not take 2
doses on the same day. Continue your usual schedule of 1 dose once a week on your chosen day.
• If you think you took more than the prescribed dose of FOSAMAX, drink a full glass of milk and call
your doctor right away. Do not try to vomit. Do not lie down.
What should I avoid while taking FOSAMAX?
• Do not eat, drink, or take other medicines or supplements before taking FOSAMAX.
• Wait for at least 30 minutes after taking FOSAMAX to eat, drink, or take other medicines or
supplements.
• Do not lie down for at least 30 minutes after taking FOSAMAX. Do not lie down until after your first
food of the day.
What are the possible side effects of FOSAMAX?
FOSAMAX may cause problems in your esophagus (the tube that connects the mouth and
stomach). (See “What is the most important information I should know about once weekly FOSAMAX?”.)
These problems include irritation, inflammation, or ulcers of the esophagus, which may sometimes bleed.
This may occur especially if you do not drink a full glass of water with FOSAMAX or if you lie down in less
than 30 minutes or before your first food of the day.
• Stop taking FOSAMAX and call your doctor right away if you get any of these signs of
possible serious problems of the esophagus:
• Chest pain
• New or worsening heartburn
• Trouble or pain when swallowing
• Esophagus problems may get worse if you continue to take FOSAMAX.
• Mouth sores (ulcers) may occur if the FOSAMAX tablet is chewed or dissolved in the mouth.
• You may get flu-like symptoms, typically at the start of treatment with FOSAMAX.
• You may get allergic reactions, such as hives or, in rare cases, swelling of your face, lips, tongue, or
throat.
• FOSAMAX may cause jaw-bone problems in some people. Jaw-bone problems may include
infection, and delayed healing after teeth are pulled.
• The most common side effect is stomach area (abdominal) pain. Less common side effects are
nausea, vomiting, a full or bloated feeling in the stomach, constipation, diarrhea, black or bloody
stools (bowel movements), gas, eye pain, rash that may be made worse by sunlight, hair loss,
headache, dizziness, a changed sense of taste, joint swelling or swelling in the hands or legs, and
bone, muscle, or joint pain.
3
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
9635610
• Call your doctor if you develop severe bone, muscle, or joint pain.
• Some patients have experienced fracture in a specific part of the thigh bone. Call your doctor if you
develop new or unusual pain in the hip or thigh.
Tell your doctor about any side effect that bothers you or that does not go away.
These are not all the side effects with FOSAMAX. Ask your doctor or pharmacist for more information.
How do I store FOSAMAX?
• Store at room temperature, 59 to 86°F (15 to 30°C).
• Safely discard FOSAMAX that is out-of-date or no longer needed.
• Keep FOSAMAX and all medicines out of the reach of children.
General information about using FOSAMAX safely and effectively
Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets.
Do not use FOSAMAX for a condition for which it was not prescribed. Do not give FOSAMAX to other
people, even if they have the same symptoms you have. It may harm them.
FOSAMAX is not indicated for use in children.
This leaflet is a summary of information about FOSAMAX. If you have any questions or concerns about
FOSAMAX or osteoporosis, talk to your doctor, pharmacist, or other health care provider. You can ask
your doctor or pharmacist for information about FOSAMAX written for health care providers. For more
information, call 1-877-408-4699 (toll-free) or visit the following website: www.fosamax.com.
What are the ingredients in FOSAMAX?
Tablets
FOSAMAX tablets contain alendronate sodium as the active ingredient and the following inactive
ingredients: cellulose, lactose, croscarmellose sodium and magnesium stearate.
Oral Solution
Fosamax oral solution contains alendronate sodium as the active ingredient and the following inactive
ingredients: sodium citrate, citric acid, sodium saccharin, artificial raspberry flavor, purified water, sodium
propylparaben and sodium butylparaben.
What should I know about osteoporosis?
Normally your bones are being rebuilt all the time. First, old bone is removed (resorbed). Then a similar
amount of new bone is formed. This balanced process keeps your skeleton healthy and strong.
Osteoporosis is a thinning and weakening of the bones. It is common in women after menopause, and
may also occur in men. In osteoporosis, bone is removed faster than it is formed, so overall bone mass is
lost and bones become weaker. Therefore, keeping bone mass is important to keep your bones healthy.
In both men and women, osteoporosis may also be caused by certain medicines called corticosteroids.
At first, osteoporosis usually has no symptoms, but it can cause fractures (broken bones). Fractures
usually cause pain. Fractures of the bones of the spine may not be painful, but over time they can make
4
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
9635610
you shorter. Eventually, your spine can curve and your body can become bent over. Fractures may
happen during normal, everyday activity, such as lifting, or from minor injury that would normally not
cause bones to break. Fractures most often occur at the hip, spine, or wrist. This can lead to pain, severe
disability, or loss of ability to move around (mobility).
Who is at risk for osteoporosis?
Many things put people at risk of osteoporosis. The following people have a higher chance of getting
osteoporosis:
Women who:
• Are going through or who are past menopause
Men who:
• Are elderly
People who:
• Are white (Caucasian) or oriental (Asian)
• Are thin
• Have family member with osteoporosis
• Do not get enough calcium or vitamin D
• Do not exercise
• Smoke
• Drink alcohol often
• Take bone thinning medicines (like prednisone or other corticosteroids) for a long time
What can I do to help prevent or treat osteoporosis?
In addition to FOSAMAX, your doctor may suggest one or more of the following lifestyle changes:
• Stop smoking. Smoking may increase your chance of getting osteoporosis.
• Reduce the use of alcohol. Too much alcohol may increase the risk of osteoporosis and injuries
that can cause fractures.
• Exercise regularly. Like muscles, bones need exercise to stay strong and healthy. Exercise
must be safe to prevent injuries, including fractures. Talk with your doctor before you begin any
exercise program.
• Eat a balanced diet. Having enough calcium in your diet is important. Your doctor can advise
you whether you need to change your diet or take any dietary supplements, such as calcium or
vitamin D.
Rx only
Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
Whitehouse Station, NJ 08889, USA
Issued March 2010
5
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
Patient Information
FOSAMAX® (FOSS-ah-max)
(alendronate sodium) Tablets
Read this information before you start taking FOSAMAX
*
. Also, read the leaflet each time you refill your
prescription, just in case anything has changed. This leaflet does not take the place of discussions with
your doctor. You and your doctor should discuss FOSAMAX when you start taking your medicine and at
regular checkups.
What is the most important information I should know about FOSAMAX?
• You must take FOSAMAX exactly as directed to help make sure it works and to help lower the
chance of problems in your esophagus (the tube that connects your mouth and stomach).
(See “How should I take FOSAMAX?”).
• If you have chest pain, new or worsening heartburn, or have trouble or pain when you swallow,
stop taking FOSAMAX and call your doctor. (See “What are the possible side effects of
FOSAMAX?”).
What is FOSAMAX?
FOSAMAX is a prescription medicine for:
• The treatment or prevention of osteoporosis (thinning of bone) in women after menopause. It reduces
the chance of having a hip or spinal fracture (break).
• Treatment to increase bone mass in men with osteoporosis.
• The treatment of osteoporosis in either men or women who are taking corticosteroid medicines (for
example, prednisone).
Improvement in bone density may be observed as early as 3 months after you start taking FOSAMAX
even though you won’t see or feel a difference. For FOSAMAX to continue to work, you need to keep
taking it.
FOSAMAX is not a hormone.
There is more information about osteoporosis at the end of this leaflet.
Who should not take FOSAMAX?
Do not take FOSAMAX if you:
• Have certain problems with your esophagus, the tube that connects your mouth with your stomach
• Cannot stand or sit upright for at least 30 minutes
• Have low levels of calcium in your blood
• Are allergic to FOSAMAX or any of its ingredients. A list of ingredients is at the end of this leaflet.
*
Registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
Copyright © 1995, 1997, 2000 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
9636810
What should I tell my doctor before using FOSAMAX?
Tell your doctor about all of your medical or dental conditions, including if you:
• have problems with swallowing
• have stomach or digestive problems
• have kidney problems
• are pregnant or planning to become pregnant. It is not known if FOSAMAX can harm your unborn
baby.
• are breastfeeding. It is not known if FOSAMAX passes into your milk and if it can harm your baby.
Tell your doctor about all medicines you take, including prescription and non-prescription medicines,
vitamins, and herbal supplements.
Know the medicines you take. Keep a list of them and show it to your doctor and pharmacist each time
you get a new medicine.
How should I take FOSAMAX?
• Take 1 FOSAMAX tablet once a day, every day after you get up for the day and before taking your
first food, drink, or other medicine.
• Take FOSAMAX while you are sitting or standing.
• Swallow your FOSAMAX tablet with a full glass (6-8 oz) of plain water only.
Do not take FOSAMAX with:
Mineral water
Coffee or tea
Juice
FOSAMAX works only if taken on an empty stomach.
Do not chew or suck on a tablet of FOSAMAX.
After swallowing your FOSAMAX tablet, wait at least 30 minutes:
● before you lie down. You may sit, stand or walk, and do normal activities like reading.
● before you take your first food or drink except for plain water.
● before you take other medicines, including antacids, calcium, and other supplements and vitamins.
Do not lie down until after first food of the day.
• It is important that you keep taking FOSAMAX for as long as your doctor says to take it. For
FOSAMAX to continue to work, you need to keep taking it.
What should I do if I miss a dose of FOSAMAX or if I take too many?
• If you miss a dose, do not take it later in the day. Continue your usual schedule of 1 tablet once a day
the next morning.
• If you think you took more than the prescribed dose of FOSAMAX, drink a full glass of milk and call
your doctor right away. Do not try to vomit. Do not lie down.
2
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
9636810
What should I avoid while taking FOSAMAX?
• Do not eat, drink, or take other medicines or supplements before taking FOSAMAX.
• Wait for at least 30 minutes after taking FOSAMAX to eat, drink, or take other medicines or
supplements.
• Do not lie down for at least 30 minutes after taking FOSAMAX. Do not lie down until after your first
food of the day.
What are the possible side effects of FOSAMAX?
FOSAMAX may cause problems in your esophagus (the tube that connects the mouth and
stomach). (See “What is the most important information I should know about FOSAMAX?”.) These
problems include irritation, inflammation, or ulcers of the esophagus, which may sometimes bleed. This
may occur especially if you do not drink a full glass of water with FOSAMAX or if you lie down in less than
30 minutes or before your first food of the day.
• Stop taking FOSAMAX and call your doctor right away if you get any of these signs of
possible serious problems of the esophagus:
• Chest pain
• New or worsening heartburn
• Trouble or pain when swallowing
• Esophagus problems may get worse if you continue to take FOSAMAX.
• Mouth sores (ulcers) may occur if the FOSAMAX tablet is chewed or dissolved in the mouth.
• You may get flu-like symptoms typically at the start of treatment with FOSAMAX.
• You may get allergic reactions, such as hives or, in rare cases, swelling of your face, lips, tongue, or
throat.
• FOSAMAX may cause jaw-bone problems in some people. Jaw-bone problems may include infection,
and delayed healing after teeth are pulled.
• The most common side effect is stomach area (abdominal) pain. Less common side effects are
nausea, vomiting, a full or bloated feeling in the stomach, constipation, diarrhea, black or bloody
stools (bowel movements), gas, eye pain, rash that may be made worse by sunlight, hair loss,
headache, dizziness, a changed sense of taste, joint swelling or swelling in the hands or legs, and
bone, muscle, or joint pain.
• Call your doctor if you develop severe bone, muscle, or joint pain.
• Some patients have experienced fracture in a specific part of the thigh bone. Call your doctor if you
develop new or unusual pain in the hip or thigh.
Tell your doctor about any side effect that bothers you or that does not go away.
These are not all the side effects with FOSAMAX. Ask your doctor or pharmacist for more information.
3
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
9636810
How do I store FOSAMAX?
• Store FOSAMAX at room temperature, 59 to 86°F (15 to 30°C).
• Safely discard FOSAMAX that is out-of-date or no longer needed.
• Keep FOSAMAX and all medicines out of the reach of children.
General information about using FOSAMAX safely and effectively
Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets.
Do not use FOSAMAX for a condition for which it was not prescribed. Do not give FOSAMAX to other
people, even if they have the same symptoms you have. It may harm them.
FOSAMAX is not indicated for use in children.
This leaflet is a summary of information about FOSAMAX. If you have any questions or concerns about
FOSAMAX or osteoporosis, talk to your doctor, pharmacist, or other health care provider. You can ask
your doctor or pharmacist for information about FOSAMAX written for health care providers. For more
information, call 1-877-408-4699 (toll-free) or visit the following website: www.fosamax.com.
What are the ingredients in FOSAMAX?
FOSAMAX contains alendronate sodium as the active ingredient and the following inactive ingredients:
cellulose, lactose, croscarmellose sodium and magnesium stearate. The 10 mg tablet also contains
carnauba wax.
What should I know about osteoporosis?
Normally your bones are being rebuilt all the time. First, old bone is removed (resorbed). Then a similar
amount of new bone is formed. This balanced process keeps your skeleton healthy and strong.
Osteoporosis is a thinning and weakening of the bones. It is common in women after menopause, and
may also occur in men. In osteoporosis, bone is removed faster than it is formed, so overall bone mass is
lost and bones become weaker. Therefore, keeping bone mass is important to keep your bones healthy.
In both men and women, osteoporosis may also be caused by certain medicines called corticosteroids.
At first, osteoporosis usually has no symptoms, but it can cause fractures (broken bones). Fractures
usually cause pain. Fractures of the bones of the spine may not be painful, but over time they can make
you shorter. Eventually, your spine can curve and your body can become bent over. Fractures may
happen during normal, everyday activity, such as lifting, or from minor injury that would normally not
cause bones to break. Fractures most often occur at the hip, spine, or wrist. This can lead to pain, severe
disability, or loss of ability to move around (mobility).
Who is at risk for osteoporosis?
Many things put people at risk of osteoporosis. The following people have a higher chance of getting
osteoporosis:
Women who:
• Are going through or who are past menopause
4
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda
9636810
Men who:
• Are elderly
People who:
• Are white (Caucasian) or oriental (Asian)
• Are thin
• Have family member with osteoporosis
• Do not get enough calcium or vitamin D
• Do not exercise
• Smoke
• Drink alcohol often
• Take bone thinning medicines (like prednisone or other corticosteroids) for a long time
What can I do to help prevent or treat osteoporosis?
In addition to FOSAMAX, your doctor may suggest one or more of the following lifestyle changes:
• Stop smoking. Smoking may increase your chance of getting osteoporosis.
• Reduce the use of alcohol. Too much alcohol may increase the risk of osteoporosis and injuries
that can cause fractures.
• Exercise regularly. Like muscles, bones need exercise to stay strong and healthy. Exercise
must be safe to prevent injuries, including fractures. Talk with your doctor before you begin any
exercise program.
• Eat a balanced diet. Having enough calcium in your diet is important. Your doctor can advise
you whether you need to change your diet or take any dietary supplements, such as calcium or
vitamin D.
Rx only
Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
Whitehouse Station, NJ 08889, USA
Issued March 2010
5
This label may not be the latest approved by FDA.
For current labeling information, please visit https://www.fda.gov/drugsatfda