Zoledronic Acid for Injection Concentrate: Indications, Dosage, Precautions, Adverse Effects
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Zoledronic Acid for Injection Concentrate - Product Information

Manufacture: Dr. Reddy's Laboratories Inc
Country: India
Condition: Bone Metastases (Osteolytic Bone Metastases of Solid Tumors), Bone Metastases of Breast Cancer (Breast Cancer, Bone Metastases), Hypercalcemia, Myeloma, Multiple (Multiple Myeloma), Osteolytic Bone Metastases of Solid Tumors, Osteolytic Bone Lesions of Multiple Myeloma, Prostate Cancer
Class: Bisphosphonates
Form: Liquid solution, Intravenous (IV)
Ingredients: mannitol, USP, as bulking agent, water for injection, and sodium citrate, USP, as buffering agent

4 mg/5 mL zoledronic acid (as zoledronic acid monohydrate)

Summary Product Information

Route of
Administration
Dosage Form / StrengthAll Nonmedicinal
Ingredients
Intravenous injection- Concentrate: 4 mg zoledronic acid/5 mL
0.8 mg/mL
mannitol, sodium citrate dihydrate and water for injection.

This corresponds to 4.264 mg zoledronic acid monohydrate

Indications and Clinical Use

Tumour-Induced Hypercalcaemia (TIH)

Zoledronic acid for injection concentrate is indicated for the treatment of Tumour-Induced Hypercalcaemia, defined as albumin-corrected serum calcium (cCa) ≥ 12.0 mg/dL (3.0 mmol/L), following adequate saline rehydration. Prior to treatment with zoledronic acid for injection Concentrate, renal excretion of excess calcium should be promoted by restoring and maintaining adequate fluid balance and urine output.

Bone Metastases of Solid Tumours and Osteolytic Lesions of Multiple Myeloma

Zoledronic acid for injection concentrate is indicated for the treatment of patients with documented bone metastases from solid tumours (including prostate cancer, breast cancer, lung cancer, renal cell carcinoma and other solid tumours) and patients with osteolytic lesions of multiple myeloma in conjunction with standard care in order to prevent or delay potential complications from the bone lesions (see Warnings and Precautions, Deteriorationin renal function).

Zoledronic acid for injection concentrate must only be administered to patients by healthcare professionals experienced in the administration of intravenous bisphosphonates.

Contraindications

  • Hypersensitivity to zoledronic acid or other bisphosphonates, or any of the excipients in the formulation of zoledronic acid for injection concentrate (see Dosage Forms, Composition and Packaging).
  • Non-corrected hypocalcaemia at the time of infusion (see Warnings and Precautions, Hypocalcaemia)
  • Pregnancy and breastfeeding women (see Warnings and Precautions, Special Populations)

Warnings and Precautions

Serious Warnings and Precautions

  • Osteonecrosis of the jaw (ONJ), (See, General, Osteonecrosis of the Jaw below)
  • Deterioration in renal function (See Renal below)
  • The use of zoledronic acid for injection concentrate is not recommended in patients withsevere renal impairment (See Special Populations below)
  • Hypocalcaemia (See General, Hypocalcaemia below)
  • Single doses of zoledronic acid for injection concentrate should not exceed 4 mg and the duration of the infusion should be no less than 15 minutes. (See Renal and Dosage and Administration below)

General

Drug Interactions

Patients being treated with zoledronic acid for injection concentrate should not be treated with other drugs containing zoledronic acid concomitantly.

Zoledronic acid for injection concentrate should not be given together with other bisphosphonates since the combined effects of these agents are unknown.

Zoledronic acid for injection concentrate is eliminated by renal excretion. Caution is indicated when zoledronic acid is administered in conjunction with drugs that are potentially nephrotoxic (e.g. aminoglycosides, other antineoplastic agents, ASA, NSAIDs), or that can significantly impact renal function (e.g. diuretics, ACE inhibitors, leading to dehydration).

Caution is advised when zoledronic acid for injection concentrate is administered with anti-angiogenic drugs, as the incidence of ONJ is increased when these drugs are used concomitantly (see Osteonecrosis of the Jaw, DRUG INTERACTIONS/Drug-Drug Interactions).

Caution is advised when zoledronic acid for injection concentrate is administered with loop diuretics (particularly in patients treated for TIH) with aminoglycosides or with calcitonin, since there may be an additive effect on the risk of developing hypocalcaemia.

Zoledronic acid for injection concentrate should be used with extreme caution in conjunction with other antineoplastic agents that are known to produce renal dysfunction (it is advised that renal function be monitored); or where the dose depends upon renal function (for example platinum- containing agents).

Zoledronic acid for injection concentrate should not be mixed with calcium-containing intravenous infusions.

Effects on ability to drive or use machines

In rare cases, somnolence and/or dizziness may occur, in which case the patient should not drive, operate potentially dangerous machinery or engage in other activities that may be hazardous.

Musculoskeletal Pain

In post-marketing experience, severe and occasionally incapacitating bone, joint, and/or muscle pain have been reported in patients taking bisphosphonates, including zoledronic acid for injection (see Adverse Reactions). The time to onset of symptoms varied from one day to several months after starting treatment. Zoledronic acid for injection concentrate should be discontinued if symptoms are severe. Most patients had relief of symptoms after stopping treatment. A subset had recurrence of symptoms when re-challenged with the same drug or another bisphosphonate.

Osteonecrosis of the Jaw

Osteonecrosis of the jaw (ONJ), has been reported in cancer patients treated with bisphosphonates, including zoledronic acid for injection. Although no causal relationship has been established, there is an association between bisphosphonate use and the development of ONJ. Post-marketing experience suggests a greater frequency of reports of ONJ based on tumour type (advanced breast cancer, multiple myeloma) and dental status (dental extractions, periodontal disease and local trauma including poorly fitting dentures); these are associated with a greater risk of developing ONJ. Cancer patients also receive other treatments that may play a role in the development of ONJ, such as chemotherapy and glucocorticosteroids. Many patients had signs of local infection including osteomyelitis.

Presentation of ONJ may include altered local sensation (hyperaesthesia or numbness), maxillofacial pain, “toothaches”, denture sore spots, loose teeth, exposed bone in the oral cavity, impaired healing, recurrent or persistent soft tissue infection in the oral cavity and marked oral odour. The onset can be from months to years after commencing bisphosphonate therapy. Cancer patients should maintain good oral hygiene; it is recommended that advanced cancer patients be encouraged to have an oral examination of both hard and soft tissues, with preventive dentistry prior to treatment with bisphosphonates, and that such assessments continue at regularly scheduled intervals after bisphosphonate therapy is initiated. While on bisphosphonate treatment, these patients should avoid invasive dental procedures if possible. Biopsies are not recommended unless metastasis to the jaw is suspected. For patients who develop ONJ while on bisphosphonate therapy, dental surgery may exacerbate the condition. For patients requiring dental procedures, there is no data available to suggest whether discontinuation of bisphosphonate treatment reduces the risk of ONJ. Clinical judgment of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment.

Caution is advised when zoledronic acid injection concentrate is administered with anti-angiogenic drugs, as the incidence of ONJ is increased when these drugs are used concomitantly (see Drug Interactions, Drug-Drug Interactions).

Atypical fractures of the femur

Atypical subtrochanteric and diaphyseal femoral fractures have been reported in patients receiving bisphosphonate therapy, primarily in patients receiving long-term treatment for osteoporosis. Reports of atypical femoral fracture have also been received in patients treated with zoledronic acid for injection concentrate. These transverse or short oblique fractures can occur anywhere along the femur from just below the lesser trochanter to just above the supracondylar flare. These fractures occur after minimal or no trauma and some patients experience thigh or groin pain, often associated with imaging features of stress fractures, weeks to months before presenting with a completed femoral fracture. Fractures are often bilateral; therefore, the contralateral femur should be examined in zoledronic acid for injection concentrate - treated patients who have sustained a femoral shaft fracture. Poor healing of these fractures has also been reported. Discontinuation of zoledronic acid for injection concentrate therapy in patients suspected to have an atypical femur fracture should be considered pending evaluation of the patient, based on an individual benefit risk assessment.

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

Hypocalcaemia

Hypocalcaemia has been reported in patients treated with zoledronic acid for injection. QTc prolongation and neurologic adverse events (tonic-clonic seizures, tetany and numbness) have been reported secondary to cases of severe hypocalcaemia. In some instances, the hypocalcaemia required hospitalization and/or was life-threatening.

Caution is advised when zoledronic acid for injection concentrate is administered with other hypocalcaemia-causing drugs (including aminoglycosides, calcitonin, or loop diuretics), as they may have an additive effect resulting in severe hypocalcaemia (see also Drug Interactions).

Patients who have undergone thyroid surgery may be particularly susceptible to develop hypocalcaemia due to relative hypoparathyroidism.

Serum albumin-corrected calcium should be measured prior to each dose and during therapy with zoledronic acid for injection concentrate (see Monitoring and Laboratory Tests). Zoledronic acid for injection concentrate is contraindicated in patients who have non-corrected hypocalcaemia at the time of infusion (see Contraindications).

Tumour-Induced Hypercalcaemia

It is essential in the initial treatment of tumour-induced hypercalcaemia that intravenous rehydration be instituted to restore urine output. All patients, including patients with mild to moderate renal impairment, should be hydrated adequately throughout treatment, but overhydration must be avoided.

In patients with cardiac disease, especially in the elderly, additional saline overload may precipitate cardiac failure (left ventricular failure or congestive heart failure). Fever (influenza-like symptoms) may also contribute to this deterioration.

Carcinogenesis and Mutagenesis

In carcinogenicity studies, zoledronic acid was administered orally (gavage) to rats and mice for at least 104 weeks without evidence of carcinogenic potential. Chronic parenteral administration was not feasible given the potential of the compound to cause severe local irritation. The pharmacological bone changes (nonproliferative hyperostosis) typically observed following long term bisphosphonate administration to young animals with growing skeletons gave clear evidence of systemic exposure to zoledronic acid in both species at all doses.

Six mutagenicity studies were conducted with zoledronic acid: three Ames Assays (using E. coli and/or S. typhimurium), a gene mutation assay using V79 hamster cells, a cytogenetics test with Chinese hamster cells and an in vivo micronucleus assay in rats. There was no evidence of mutagenic potential.

Cardiovascular

In a 3-year, randomized, double-blind controlled trial that evaluated the efficacy and safety of zoledronic acid 5 mg dose once yearly vs. placebo in the treatment of post menopausal osteoporosis (PMO), the overall incidence of atrial fibrillation was 2.5% (96 out of 3,862) and 1.9% (75 out of 3,852) in patients receiving zoledronic acid 5 mg and placebo, respectively. The rate of atrial fibrillation serious adverse events was 1.3% (51 out of 3,862) and 0.6% (22 out of 3,852) in patients receiving zoledronic acid 5 mg and placebo, respectively. The imbalance observed in this trial has not been observed in other trials with zoledronic acid, including those with zoledronic acid 4 mg administered every 3-4 weeks in oncology patients. The mechanism behind the increased incidence of atrial fibrillation in this single clinical trial is unknown.

Hepatic/Biliary/Pancreatic

Hepatic Impairment

As only limited clinical data are available for patients with hepatic impairment, dosage recommendations cannot be given for this group.

Ophthalmologic

Ocular disturbances (conjunctivitis, uveitis, episcleritis, scleritis and orbital inflammation) have been reported with zoledronic acid for injection therapy. Patients with ocular events other than uncomplicated conjunctivitis should be referred to an ophthalmologist for evaluation. Treatment may need to be discontinued.

Peri-Operative Considerations

Patients treated with zoledronic acid for injection concentrate should avoid invasive dental procedures if possible. Biopsies are not recommended unless metastasis to the jaw is suspected. For patients who develop ONJ while on bisphosphonate therapy, dental surgery may exacerbate the condition. For patients requiring dental procedures, there is no data available to suggest whether discontinuation of bisphosphonate treatment reduces the risk of ONJ. Clinical judgment of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment. (See also General, Osteonecrosis of the Jaw)

Renal

Assessment of renal function is recommended in all patients prior to the administration of each dose and during therapy with zoledronic acid for injection concentrate.

Deterioration in Renal Function

DUE TO THE RISK OF CLINICALLY SIGNIFICANT DETERIORATION IN RENAL FUNCTION, WHICH MAY PROGRESS TO RENAL FAILURE, SINGLE DOSES OF ZOLEDRONIC ACID FOR INJECTION CONCENTRATE SHOULD NOT EXCEED 4 MG AND THE DURATION OF THE INFUSION SHOULD BE NO LESS THAN 15 MINUTES. (See also Dosage and Administration)

Bisphosphonates, including zoledronic acid for injection, have been associated with reports of renal function deterioration. Factors that may increase the potential for deterioration in renalfunction include dehydration, pre-existing renal impairment, multiple cycles of zoledronic acid for injection concentrate or other bisphosphonates or using a shorter infusion time than currently recommended (the 4-mg dose is given as a single-dose intravenous infusion over not less than 15 minutes in not less than 100 mL diluent). Concomitant use of potentially nephrotoxic drugs (i.e. ASA, NSAIDS, diuretics, ACE inhibitors etc.) may also increase the potential for renal function deterioration. Renal function should be monitored appropriately during therapy with zoledronic acid for injection concentrate. Renal deterioration, progression to renal failure (some with fatal outcome) and dialysis have been reported very rarely in cancer patients (e.g., those with hypercalcaemia of malignancy and/or pre-existing renal disease) after the initial dose or a single dose of zoledronic acid for injection. Increases in serum creatinine may occur in some patients with chronic administration of zoledronic acid for injection concentrate at recommended doses. Patients with evidence of deterioration in renal function should be appropriately evaluated with consideration given as to whether the potential benefit of continued treatment with zoledronic acid for injection concentrate outweighs the possible risk (see also Dosage and Administration).

Zoledronic acid for injection concentrate should be used with extreme caution in conjunction with other antineoplastic agents that are either known to produce renal impairment (it is advised that renal function be monitored); or where the dose depends upon renal function (for example platinum- containing agents).

Respiratory

Patients with Asthma

While not observed in clinical trials with zoledronic acid for injection, administration of other bisphosphonates has been associated with bronchoconstriction in acetylsalicylic acid (ASA)-sensitive asthmatic patients. Zoledronic acid for injection concentrate should be used with caution in patients with aspirin-sensitive asthma.

Special Populations

Renal Impairment

Zoledronic acid for injection is excreted exclusively via the kidney and the risk of adverse reactions may be greater in patients with impaired renal function. The use of zoledronic acidfor injection concentrate is not recommended in patients with severe renal impairment due to the potential impact of bisphosphonates, including zoledronic acid for injection concentrate, on renal function and the lack of extensive clinical safety data in these patients. Patients with severe renal impairment were excluded from clinical trials (defined as serum creatinine > 400 μmol/L or > 4.5 mg/dL in patients with tumour-induced hypercalcaemia and serum creatinine > 265 μmol/L or > 3.0 mg/dL in patients with bone metastases of solid tumours and osteolytic lesions of multiple myeloma) and from limited pharmacokinetic studies (defined as creatinine clearance [CrCl] < 30 mL/min) with zoledronic acid for injection.

Close monitoring of renal function is necessary in patients who are receiving concomitant drugs with nephrotoxic potential.

Patients should have their serum creatinine levels assessed prior to each dose of zoledronic acid for injection concentrate.

Upon initiation of treatment in patients with bone metastases of solid tumours and osteolytic lesions of multiple myeloma, with mild-to-moderate renal impairment, lower doses of zoledronic acid for injection concentrate are recommended. In patients who show evidence of renal deterioration during treatment, appropriate evaluation should be carried out and consideration should be given as to whether the potential benefit outweighs the possible risk. If zoledronic acid for injection concentrate. treatment is to be continued in these patients, zoledronic acid for injection concentrate should only be resumed when serum creatinine returns to within 10% of baseline (see Dosage and Administration).

Women of child-bearing potential

Women of child-bearing potential should be advised to avoid becoming pregnant and advised of the potential hazard to the foetus while receiving zoledronic acid injection concentrate. There may be a risk of foetal harm (e.g. skeletal and other abnormalities) if a woman becomes pregnant while receiving zoledronic acid injection concentrate (see Contraindications). The impact of variables such as time between cessation of zoledronic acid injection concentrate therapy to conception on this risk has not been established.

Pregnant Women

Zoledronic acid for injection concentrate should not be administered during pregnancy (see Contraindications). There is no clinical evidence to support the use of zoledronic acid for injection in pregnant women, and animal studies suggest zoledronic acid for injection may cause foetal harm when administered to a pregnant woman.

In animal reproduction studies zoledronic acid was administered subcutaneously to rats and rabbits. Teratogenicity manifested by external, visceral and skeletal malformations was observed in the rat at doses ≥ 0.2 mg/kg (2.4 fold the systemic human exposure at 4 mg based on AUC comparison). There was also evidence of maternal toxicity at ≥ 0.2 mg/kg as well as foetal toxicity at 0.4 mg/kg (2.4 and 4.8 fold respectively the human exposure). In the rabbit, maternal toxicity was marked at ≥ 0.1 mg/kg due to decreased serum calcium. Zoledronic acid readily crosses the placental barrier and is taken up into the developing foetal skeleton. The potential risk in humans is unknown (see also Detailed Pharmacology, Reproductive ToxicityStudies).

Nursing Women

Zoledronic acid for injection concentrate should not be administered to breast-feeding women (see Contraindications ). There is no clinical experience with zoledronic acid for injection in lactating women and it is not known whether zoledronic acid for injection passes into breast milk. A study in lactating rats has shown that another bisphosphonate pamidronate disodium for injection passes into the milk. Mothers treated with zoledronic acid for injection concentrate should therefore not breast feed their infants.

Fertility

The fertility was decreased in rats dosed subcutaneously with 0.01 mg/kg/day of zoledronic acid, with systemic exposures of 0.12 times the human systemic exposure following an intravenous dose of 4 mg (based on AUC). The effects observed included an increase in pre-implantation losses and a decrease in the number of implantations and live foetuses. There are no data available in humans.

Pediatrics (< 18 years of age)

The safety and efficacy of zoledronic acid for injection in children have not been established. No toxicology studies have been conducted in juvenile animals. The most frequent finding in growing animals during repeat-dose studies consisted of increased primary spongiosa (non-proliferative hyperostosis) in the metaphysis of long bones. Zoledronic acid injection concentrate is not recommended for use in pediatric patients.

Paediatric Osteogenesis Imperfecta (OI)

In a one-year, active-controlled trial which compared zoledronic acid for injection concentrate and pamidronate in osteogenesis imperfecta (OI), zoledronic acid for injection concentrate was studied in 74 children aged 1 year to 17 years. Of the patients with type I OI, fracture adverse events of long bones in the lower extremities were reported in approximately 26% (femur) and 11% (tibia) of patients treated with zoledronic acid vs. 0% and 3%, respectively, of patients treated with pamidronate.

Geriatrics (> 65 years of age)

Controlled clinical studies of zoledronic acid for injection in TIH do not provide a sufficient number of geriatric subjects to determine whether patients 65 years and older respond differently. The median age in the two controlled clinical trials in patients with tumour-induced hypercalcaemia was 61 years old (range: 21-87 years old).

Controlled clinical studies of zoledronic acid for injection in the treatment of bone metastases of solid tumours and osteolytic lesions of multiple myeloma in patients over age 65 revealed similar efficacy and safety compared to younger patients. The proportion of patients experiencing SREs is lower in the zoledronic acid for injection treatment group when compared to placebo and similar to pamidronate disodium for injection 90 mg. Older patients generally had adverse events similar to those of the overall population. However, because of the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy in elderly patients, zoledronic acid for injection concentrate should be administered with caution in this patient population.

Race

Japanese female subjects had substantially higher systemic exposure, i.e., 47% higher AUC0-24h and 39% higher Cmax than the North American population (see Action and ClinicalPharmacology, Special Populations and Conditions, Race).

Monitoring and Laboratory Tests

Serum electrolytes, creatinine, phosphate, magnesium and calcium, and CBC with differential must be closely monitored in all patients treated with zoledronic acid for injection concentrate. Renal function should be assessed prior to the administration of each dose and should be monitored appropriately during therapy with of zoledronic acid for injection concentrate (see Warnings and Precautions,Renal). Serum albumin corrected calcium should be measured prior to each dose and should be monitored during therapy with zoledronic acid for injection concentrate (see Contraindications and Warnings and Precautions, Hypocalcaemia).

Patients with anaemia, leukopenia or thrombocytopenia should have regular haematology assessments.

In tumour-induced hypercalcaemia, either ionized calcium or total serum calcium corrected (adjusted) for albumin should be monitored during treatment with zoledronic acid for injection concentrate. Serum calcium levels in patients who have hypercalcaemia of malignancy may not reflect the severity of hypercalcaemia, since hypoalbuminaemia is commonly present. Corrected serum calcium values should be calculated using established algorithms, such as: Albumin-corrected serum calcium (CSC, mmol/L) = tCa + 0.02 (mid-range albumin-measured albumin).

Adverse Reactions

Adverse Drug Reaction Overview

The most serious adverse drug reactions reported in patients receiving zoledronic acid for injection are: anaphylactic reaction, ocular adverse events, osteonecrosis of the jaw, atypical femoral fracture, atrial fibrillation, renal function deterioration, acute phase reaction and hypocalcaemia.

Adverse reactions to zoledronic acid for injection are usually mild and transient and similar to those reported for other bisphosphonates. Intravenous administration has been most commonly associated with fever. Within three days after zoledronic acid for injection administration, an acute phase reaction has been reported commonly, with symptoms including pyrexia, fatigue, bone pain and/or arthralgias, myalgias, chills, influenza-like illness, arthritis and joint swelling; these symptoms usually resolve within a few days.

Gastrointestinal reactions such as nausea and vomiting have been reported commonly following intravenous infusion of zoledronic acid for injection. Local reactions at the infusion site, such as redness or swelling, and/or pain, were observed infrequently.

Rash or pruritis and chest pain have been reported uncommonly following treatment with zoledronic acid for injection.

As with other bisphosphonates, isolated cases of hypomagnesaemia have been reported. Isolated cases of episcleritis have been reported, uveitis has been reported rarely, blurred vision has been reported uncommonly and cases of conjunctivitis have been reported commonly.

Cardiac arrhythmias associated with hypocalcaemia have been reported rarely following treatment with zoledronic acid injection concentrate. Atrial fibrillation not associated with hypocalcaemia has been reported following treatment with zoledronic acid.

Cases of interstitial lung disease have been reported rarely following treatment with zoledronic acid injection concentrate.

Clinical Trial Adverse Drug Reactions

Tumour-Induced Hypercalcaemia Clinical Trials

Patients with tumour-induced hypercalcaemia may have numerous confounding medical conditions that make causality of adverse events difficult to assess due to the prevalence and wide variety of symptoms related to the underlying disease, its progression, and the side effects of cytotoxic chemotherapy.

In patients treated with zoledronic acid for injection concentrate, serum calcium may fall to asymptomatic hypocalcemic levels. This frequently leads to a reduction in renal calcium excretion which is accompanied by a fall in serum phosphate levels that does not require treatment.

Grade 3 [Common Toxicity Criteria (CTC)] serum creatinine was reported in 2.3% and 3.0% of patients receiving zoledronic acid for injection 4mg and pamidronate disodium for injection 90 mg, respectively in the clinical trials in tumour-induced hypercalcaemia. Grade 4 (CTC) serum creatinine was reported in 0% and 1.0% in patients receiving zoledronic acid for injection 4 mg and pamidronate disodium for injection 90 mg, respectively.

Table 1 lists the adverse events considered to be treatment-related in the tumour-induced hypercalcaemia trials.

Table 1 - Treatment-Related Adverse Events Reported in Tumour-Induced Hypercalcaemia Clinical Trials
Zoledronic Acid
for Injection
4 mg
% (N= 86)
Pamidronate
Disodium for
Injection
90 mg
Fever7.09.7
Hypocalcaemia5.81.9
Hypophosphataemia3.51.0
Nausea1.21.0
Pruritus1.20
Skeletal pain1.21.0
Hypomagnesaemia1.20
Taste perversion1.20
Thirst1.20
Pancytopenia1.20
Arthralgia1.20
Bradycardia1.20
Confusion1.20
Fatigue1.20
Hallucination1.20
Vomiting1.20
Chest pain1.20

Bone Metastases of Solid Tumours and Osteolytic Lesions of Multiple Myeloma Clinical Trials

The adverse event data pertaining to bone metastases of solid tumours and osteolytic lesions of multiple myeloma are based upon the core and extension phases of the three pivotal controlled trials in this indication (see Drtailed Pharmacology and Clinical Studies). These trials included 2042 safety evaluable patients treated with either zoledronic acid for injection 4 mg, pamidronate disodium for injection 90 mg, or placebo. Of these 2042 patients who entered the core phase of the trials; 969 completed the core phase, 619 entered the safety extension phase, and 347 completed the extension phase. The median duration of exposure to zoledronic acid for injection 4 mg (core plus extension phases) was 10.5 months for patients with prostate cancer, 12.8 months for patients with breast cancer and multiple myeloma, and 4.0 months for patients with lung cancer and other solid tumours. The mean duration of exposure to zoledronic acid for injection 4 mg (core plus extension phases) was 11.8 months for patients with prostate cancer, 13.9 months for patients with breast cancer and multiple myeloma, and 5.7 months for patients with lung cancer and other solid tumours (see Clinical Studies).

In general, zoledronic acid for injection was well tolerated across all studies for various tumour types in patients with bone metastases and in patients with multiple myeloma. The proportion of patients experiencing Grade 3 and Grade 4 laboratory abnormalities and adverse events were similar in patients treated with zoledronic acid for injection and pamidronate disodium for injection.

Grade 3 [Common Toxicity Criteria (CTC)] serum creatinine was reported in 1.3%, 1.5% and 1.7% of patients receiving zoledronic acid for injection 4mg, pamidronate disodium for injection 90 mg and placebo, respectively. Grade 4 (CTC) serum creatinine was reported in 0.4%, 0.4% and 0% of patients receiving zoledronic acid for injection 4 mg, pamidronate disodium for injection 90 mg and placebo, respectively.

The most commonly reported (>15%) adverse events occurred with similar frequencies in the zoledronic acid for injection, pamidronate disodium for injection and placebo treatment groups, and most of these events may have been related to the underlying disease state or cancer therapy. Table 2 lists the events which occurred in ≥ 15% of patients regardless of study drug relationship by preferred term and treatment group, in the bone metastases trials.

Table 2 -Commonly Reported Events in Three Bone Metastases Clinical Trials
Zoledronic Acid for
Injection 4 mg
n (%)
Pamidronate
Disodium for
Injection
90 mg
n (%)
Placebo
n (%)
Patients studied
Total no. of patients studied1031 (100)556 (100)455 (100)
Total no. of patients with an AE1015 (98.4)548 (98.6)445 (97.8)
Adverse events (preferred term)
Bone pain55.2%56.8%62.4%
Nausea46.2%47.8%37.6%
Fatigue38.6%43.2%28.6%
Anaemia33.4%31.5%28.1%
Vomiting32.3%32.9%26.8%
Pyrexia31.8%30.9%19.6%
Constipation31.0%29.1%38.2%
Dyspnoea NOS27.4%27.9%23.5%
Weakness24.4%19.4%25.1%
Diarrhoea NOS24.2%29.1%18.2%
Myalgia23.2%25.7%16.3%
Anorexia22.4%14.6%23.1%
Cough21.7%23.2%14.3%
Arthralgia21.0%23.6%16.0%
Oedema lower limb20.9%22.7%18.5%
Malignant neoplasm aggravated19.9%17.4%19.6%
Headache NOS18.5%26.8%11.0%
Dizziness (excl. vertigo)17.5%16.4%12.7%
Insomnia NEC16.1%20.0%16.0%
Weight decreased15.9%9.0%13.4%
Back pain15.1%19.1%8.8%
Paresthesia NEC14.5%15.3%7.7%
Depression NEC14.2%17.1%10.8%
Pain in limb13.9%15.1%11.4%

NOS: Not otherwise specified NEC: Not elsewhere classified

The adverse events occurring during the studies were generally of a type and frequency expected in patients with cancer and bone metastases, many of whom were undergoing antineoplastic therapy. Except for pyrexia, the absolute difference in the proportions of patients in the zoledronic acid for injection 4 mg group compared with the placebo group for any of the common adverse events did not exceed 10%. Pyrexia, or fever, may occur as part of an acute phase reaction with bisphosphonate administration.

Among less commonly occurring adverse events (< 15% of patients in any group), hypocalcemia was reported in 4.7%, 2.5%, and 0.7% of patients in the zoledronic acid for injection 4 mg, pamidronate disodium for injection and placebo groups, respectively. Hypokalemia was reported in 9.7%, 9.0%, and 4.8% of patients in the zoledronic acid for injection 4 mg, pamidronate disodium for injection and placebo groups, respectively. Arthritis was reported in 2.42%, 4.32% and 3.08% of patients and joint swelling was reported in 1.55%, 2.88% and 1.32% of patients in the zoledronic acid for injection 4 mg, pamidronate disodium for injection and placebo groups, respectively.

Hypotension

Based on the clinical trial experience, the frequency of non-serious hypotensive events is uncommon (between 0.1% and 1.0%).

Deterioration in Renal Function

In a pooled analysis of the laboratory data from the three registration trials of zoledronic acid for injection for the treatment of multiple myeloma and bone metastases from breast, prostate, lung and other solid tumours, renal deterioration was defined as an increase of 44.2 μmol/L (0.5 mg/dL) for patients with normal baseline creatinine (< 123.76 µmol/L or < 1.4 mg/dL) or an increase of 88.4 µmol/L (1.0 mg/dL) for patients with an abnormal baseline creatinine (≥ 123.76 µmol/L or ≥ 1.4 mg/dL). The following are data on the incidence of renal deterioration in patients receiving zoledronic acid for injection 4 mg over 15 minutes in these trials (see Table 3).

Table 3 -Percentage of Patients with Renal Function Deterioration Who Were Randomized Following the 15-Minute Infusion Amendment
Patient Population/Baseline Creatinine
Multiple Myeloma and Breast
Cancer
Zoledronic Acid
for Injection 4 mg
Pamidronate Disodium
for Injection 90 mg
n/N(%)n/N(%)
Normal27/246(11.0%)23/246(9.3%)
Abnormal2/26(7.7%)2/22(9.1%)
Total29/272(10.7%)25/268(9.3%)
Solid TumoursZoledronic Acid
For Injection 4 mg
Placebo
n/N(%)n/N(%)
Normal17/154(11.0%)10/143(7.0%)
Abnormal1/11(9.1%)1/20(5.0%)
Total18/165(10.9%)11/163(6.7%)
Prostate CancerZoledronic Acid
For Injection 4 mg
Placebo
n/N(%)n/N(%)
Normal12/82(14.6%)8/68(11.8%)
Abnormal4/10(40.0%)2/10(20.0%)
Total16/92(17.4%)10/78(12.8%)

The risk of deterioration in renal function appeared to be related to time on study, whether patients were receiving zoledronic acid for injection (4 mg over 15 minutes), placebo, or pamidronate disodium for injection.

In a pooled analysis of safety data from the three registration trials of zoledronic acid for injection for the treatment of multiple myeloma and bone metastases from breast, prostate, lung and other solid tumours, the frequency of renal function adverse events (adverse reactions) suspected to be related to zoledronic acid for injection was as follows: multiple myeloma (3.2%), prostate cancer (3.1%), breast cancer (4.3%), lung and other solid tumours (3.2%).

The frequency distribution of chemotherapy-associated adverse events by chemotherapy, renal involvement and treatment group for patients in the primary safety population is provided in Table 4. This includes patients who were administered at least one chemotherapeutic agent during the study (i.e., patients treated with only hormonal agents are not included). Each chemotherapeutic agent is classified in one of the three categories: renally excreted, nephrotoxic, or no renal involvement (see Tables 4-1 and 4-2). For a chemotherapy that is both renally excreted and nephrotoxic, the agent is classified as nephrotoxic.

Patients receiving renally excreted drugs that were not nephrotoxic had a similar incidence of nausea for the zoledronic acid for injection and placebo treatment groups when compared to the nephrotoxic agents. Nausea was higher for the pamidronate disodium for injection treatment group for the nephrotoxic agents when compared to the agents that were not nephrotoxic and renally excreted. Vomiting, stomatitis and anorexia were similar for all of the treatment groups whether or not the agent was renally excreted or nephrotoxic. Alopecia was higher in all groups treated with nephrotoxic drugs when compared to renally excreted drugs.

Table 4 -Frequency distribution of chemotoxicities (>1%) by renal involvement and treatment group for patients who were treated with at least one chemotherapy agent (Safety evaluable patients)
Renal involvement Zoledronic Acid
for Injection 4 mg
Pamidronate
Disodium for
Injection 90 mg
Placebo
Renally excreted
Number of patients22116376
Total with chemotoxicity161 (72.9%)100 (61.3%)54 (71.1%)
Nausea113 (51.1%)68 (41.7%)37 (48.7%
Vomiting NOS175 (33.9%)48 (29.4%)23 (30.3%)
Anorexia55 (24.9%)23 (14.1%)28 (36.8%)
Appetite decreased NOS39 (17.6%)16 (9.8%)7 (9.2%)
Stomatitis25 (11.3%)21 (12.9%)6 (7.9%)
Alopecia24 (10.9%)18 (11.0%)9 (11.8%)
Malaise6 (2.7%)3 (1.8%)5 (6.6%)
Cachexia4 (1.8%)1 (0.6%)3 (3.9%)
Gingivitis3 (1.4%)3 (1.8%)0 (0.0%)
Mouth ulceration3 (1.4%)2 (1.2%)0 (0.0%)
Gingival disorder NOS0 (0.0%)0 (0.0%)1 (1.3%)
Malnutrition NOS0 (0.0%)2 (1.2%)0 (0.0%)
Pallor0 (0.0%)0 (0.0%)1 (1.3%)
Nephrotoxic
Number of patients471248164
Total with chemotoxicity345 (73.2%)191 (77.0%)116 (70.7%)
Nausea249 (52.9%)136 (54.8%)73 (44.5%)
Vomiting NOS194 (41.2%)99 (39.9)%58 (35.4%)
Anorexia117 (24.8%)46 (18.5%)48 (29.3%)
Alopecia93 (19.7%)54 (21.8%)24 (14.6%)
Appetite decreased NOS63 (13.4%)23 (9.3%)17 (10.4%)
Stomatitis59 (12.5%)36 (14.5%)7 (4.3%)
Malaise18 (3.8%)10 (4.0%)8 (4.9%)
Mouth ulceration13 (2.8%)5 (2.0%)1 (0.6%)
Malnutrition NOS6 (1.3%)2 (0.8%)1 (0.6%)
Pallor6 (1.3%)2 (0.8%)2 (1.2%)
Gingivitis5 (1.1%)2 (0.8%)0 (0.0%)
Cachexia3 (0.6%)0 (0.0%)4 (2.4%)
No renal involvement
Number of patients010
Total with chemotoxicity0 (0%)1 (100%)0 (0%)
Nausea0 (0%)1 (100%)0 (0%)

1 NOS: Not otherwise specified.
Each chemotherapeutic agent is classified in one of the three categories: renally excreted, nephrotoxic, or no renal involvement (See Tables 4-1 and 4-2)

Table 4-1 - Listing of chemotherapy agents by renal involvement
Preferred termRenal toxic
Preferred term
Adriamycin + CyclophosphamideMethotrexate
Adriamycin + Vincristine + MTXMethotrexate sodium
AldesleukinMitomycin
BCG VaccineOxaliplatin
CarboplatinPaclitaxel
CisplatinRaltitrexed
CyclophosphamideStreptozocin
Cyclophosphamide + 5-FU + MethotrexateStrontium-89
Cyclophosphamide + 5-FU + PrednisoloneTaxol + Carboplatin
Cyclophosphamide + Doxorubicin + 5-FUTegafur
Cyclophosphamide + EpirubicinTegafur Uracil
DacarbazineTeniposide
EtanerceptThalidomide
Gallium NitrateThiotepa
GemcitabineTopotecan Hydrochloride
Gemcitabine HydrochlorideTrastuzumab
HydroxycarbamideCarboplatin + Etoposide
IfosfamideCMF + Dexamethasone
InterferonCMF + Tamoxifen
Interferon AlfaFAC + Tamoxifen Citrate
Interferon BetaTopotecan
Interferon GammaEVCMF
Interferon NOS1(Epirubicine+Vincri.+Cycloph.+MTX+5FU)
Interleukin-2
M - VAC

1NOS: Not otherwise specified. 
David S. Fischer, M.Tish Knobf, Henry J. Durivage. The Cancer Chemotherapy Handbook, 5th 1997.

Table 4-2 - Listing of chemotherapy agents by renal involvement
Preferred termRenally excreted
Preferred term
5-FU + Calcium folinateFloxuridine
Adriamycin + 5-FUFlurouracil
BetamethasoneFormestane
Betamethasone Sodium PhosphateIrinotecan
BleomycinIrinitecan Hydrochloride
Bleomycin SulfateLomustine
BusulfanMelphalan
CapecitabineMelphalan + Prednisolone
CarmustineMitoxantrone
CytarabineMitoxantrone Hydrochloride
DaunorubicinTropisetron Hydrochloride
Dexrazoxane HydrochlorideVinblastine
DocetaxelVinblastine Sulfate
DoxorubicinVincristine
Doxorubicin HydrochlorideVincristine Sulfate
EpirubicinVindesine
Epirubicin HydrochlorideVinorelbine
EtoposideVinorelbine Bitartrate
ExemestaneVinorelbine Ditartrate
Pirarubicin

David S. Fischer, M.Tish Knobf, Henry J. Durivage. The Cancer Chemotherapy Handbook, 5th edition. 1997.

Bone Metastases From Breast Cancer: Placebo-controlled Trial in Japanese Patients

In a placebo-controlled clinical study in breast cancer patients with bone metastases, 227 patients were evaluated for safety (114 zoledronic acid for injection and 113 placebo) (see Clinical Trials). Table 5 below illustrates AEs that occurred more frequently in the zoledronic acid for injection arm compared to placebo. The adverse events occurring during the study were generally of a type and frequency expected in patients with cancer and bone metastases, many of whom were undergoing concurrent antineoplastic therapy.

Table 5 -Most Commonly Reported AEs (incidence >10 %) occurring more frequently in the zoledronic acid for injection arm compared to Placebo
Zoledronic Acid
for Injection 4 mg
(n=114)
Placebo
(n=113)
n (%)n (%)
Pyrexia63 (55.3)37 (32.7)
Malaise51 (44.7)36 (31.9)
Headache NOS34 (29.8)32 (28.3)
Hypoaesthesia28 (24.6)22 (19.5)
Arthralgia24 (21.1)18 (15.9)
Dyspnoea NOS21 (18.4)15 (13.3)
Epigastric pain19 (16.7)8 (7.1)
Leukopenia NOS17 (14.9)16 (14.2)
Myalgia15 (13.2)13 (11.5)
Pruritus NOS13 (11.4)12 (10.6)
Oedema lower limb13 (11.4)4 (3.5)
Anaemia NOS12 (10.5)7 (6.2)
Pain NOS12 (10.5)11 (9.7)

Shows no. of subjects experiencing at least 1 AE in category in question

Post-Market Adverse Drug Reactions

Cases of ONJ are uncommon. However, a large retrospective study of the frequency and risk factors for ONJ in cancer patients receiving intravenous bisphosphonates (Hoff, A. et al., 2008) indicated a higher proportion of reported cases in certain cancers, such as advanced breast cancer (1.2%) and multiple myeloma (2.4%), compared to the overall study population (0.72%). The majority of reported cases of ONJ are associated with invasive dental procedures (such as tooth extraction or dental surgery and local trauma including poorly fitting dentures) or periodontal disease (see Warnings and Precautions, Osteonecrosis of the Jaw). Many patients reporting ONJ also had signs of local infection, including osteomyelitis.

Cases of anaphylactic reactions/shock, atrial fibrillation, hypotension leading to syncope or circulatory collapse (primarily in patients with underlying risk factors), somnolence, uveitis, episcleritis, scleritis and orbital inflammation as well as hypersensitivity reactions including cases of severe allergic reactions, bronchospasm, interstitial lung disease (ILD) and urticaria, severe and occasionally incapacitating bone, joint, and/or muscle pain, atypical subtrochanteric and diaphyseal femoral fractures have also been reported. There were reports that had ocular events, bone, joint, and/or muscle pain, and ILD with a bisphosphonate, including zoledronic acid for injection, and had a re-occurrence when re-challenged.

Post marketing events of arthritis and joint swelling, likely occurring as part of an acute phase reaction, have been reported with zoledronic acid for injection administration.

In clinical trials and from post-market surveillance, hypocalcaemia has been reported in patients treated with zoledronic acid for injection. QTc prolongation and neurologic adverse events (including seizures, numbness and tetany) have been reported secondary to cases of severe hypocalcaemia. In addition, cardiac arrhythmias have been reported with cases of severe hypocalcaemia. Cases of severe hypocalcaemia requiring hospitalisation have been reported. In some instances, the hypocalcaemia was life-threatening. Time from the first injection of zoledronic acid to the initial hypocalcaemia-related neurologic or cardiac adverse events ranged from 1 day to several months. Evidence supports a causal relationship between hypocalcaemia and zoledronic acid therapy based on temporal relationship and the secondary QTc prolongation and neurological events as sequelae of the hypocalcaemia.

Spontaneously reported adverse drug reactions are presented above. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or clearly establish a causal relationship to zoledronic acid for injection exposure.

Drug Interactions

Zoledronic acid is not systemically metabolized and does not affect human cytochrome P450 enzymes in vitro. Zoledronic acid is not highly bound to plasma proteins (approximately 55%) and therefore, interactions resulting from displacement of highly protein-bound drugs are unlikely.

Drug-Drug Interactions

Co-administration of thalidomide (100 mg once daily for 14 days and then 200 mg thereafter) with zoledronic acid for injection (4 mg given as a 15-minute infusion) in a phase III study did not significantly change the pharmacokinetics of zoledronic acid or creatinine clearance in patients with multiple myeloma.

Caution is indicated when zoledronic acid injection concentrate is used with other potentially nephrotoxic drugs (see also Warnings and Precautions, General).

Caution is advised when zoledronic acid injection concentrate is administered with aminoglycosides, calcitonin, or loop diuretics, since these agents may have an additive effect on the risk of developing hypocalcaemia (see also Warnings and Precautions, General,Drug Interactions).

A drug interaction with zoledronic acid injection concentrate therapy and the concomitant use of anti-angiogenic drugs has been established in cases of ONJ. Retrospective analyses indicate that the incidence of ONJ is increased in patients treated with bisphosphonates and anti-angiogenic drugs concomitantly.

Dosage and Administration

Dosing Considerations

Renal function should be assessed in all patients prior to the administration of each dose of zoledronic acid for injection concentrate. Patients with mild to moderate renal impairment require a reduction in dose (see Dosage and Administration, Recommended Dose and Dosage Adjustment). Zoledronic acid for injection concentrate is not recommended in patients with severe renal impairment (see Warnings and Precautions).

Serum calcium should be measured prior to each dose of zoledronic acid for injection concentrate. Zoledronic acid for injection concentrate is contraindicated in patients who have non-corrected hypocalcaemia at the time of infusion (see Contraindications).

Patients must be maintained in a well hydrated state prior to and following administration of Zoledronic acid for injection concentrate.

Renal Impairment

Zoledronic acid for injection is excreted exclusively via the kidney and the risk of adverse reactions may be greater in patients with impaired renal function.

Zoledronic acid for injection has not been tested in patients with severe renal impairment (defined in clinical trials as serum creatinine > 400 μmol/L or > 4.5 mg/dL in patients with tumour-induced hypercalcaemia; and serum creatinine > 265 μmol/L or > 3.0 mg/dL in patients with bone metastases of solid tumours and osteolytic lesions of multiple myeloma defined in pharmacokinetic studies as baseline creatinine clearance <30 mL/min). Therefore, its use is not recommended in this patient population (see Action and Clinical Pharmacology,Special Populations and Conditions).

Hepatic Impairment

As only limited clinical data are available for patients with hepatic impairment, dosage recommendations cannot be given for this group.

Recommended Dose and Dosage Adjustment

Tumour-Induced Hypercalcaemia

The recommended dose of zoledronic acid for injection concentrate in hypercalcaemia (albumin-corrected serum calcium > 3.0 mmol/L (12 mg/dL)) is 4 mg given as a single- dose intravenous infusion over no less than 15 minutes following standard rehydration procedures.

Albumin-corrected serum calcium (CSC, mmol/L) = tCa + 0.02 (mid-range albumin-measured albumin).

Prior to treatment with zoledronic acid for injection concentrate renal excretion of excess calcium should be promoted by restoring and maintaining adequate fluid balance and urine output.

Patients who show complete or partial response initially may be retreated with zoledronic acid for injection concentrate 4 mg if serum calcium does not return to normal or does not remain normal after initial treatment although retreatment with zoledronic acid for injection 4 mg in TIH patients has not been assessed for efficacy and safety in prospective studies. It is recommended that at least one week must elapse before retreatment to allow for a full response to the initial dose. In addition, retreatment should be given to only those patients who can tolerate the standard rehydration procedures (i.e., 3 to 5 litres of fluids per day and more than 400 meq of sodium chloride per day). In any patient requiring repeated administration, serum BUN and creatinine must be evaluated and possible deterioration in renal function must be assessed prior to each re-administration (see Warnings and Precautions).

Dosage Adjustment: Mild to Moderate Renal Impairment

Dose reduction in patients with tumour-induced hypercalcaemia with mild to moderate renal impairment is not recommended.

Bone Metastases of Solid Tumours and Osteolytic Lesions of Multiple Myeloma

The recommended dose of zoledronic acid for injection concentrate in patients with documented metastatic bone lesions from solid tumours and patients with osteolytic lesions of multiple myeloma for patients with CrCl > 60 mL/min is 4 mg, given as a single dose intravenous infusion over no less than 15 minutes every 3 to 4 weeks. In patients requiring antineoplastic therapy, zoledronic acid for injection concentrate should be administered either prior to or after this treatment. Patients will be required to take an oral calcium supplement of 500 mg and a multivitamin containing at least 400 IU of Vitamin D daily. If a patient has a prior history of hypercalcaemia or develops hypercalcaemia during treatment with calcium and Vitamin D supplementation, the patient is advised to discontinue taking calcium and Vitamin D.

Zoledronic acid for injection has been used with cyclophosphamide, doxorubicin, paclitaxel, anastrozole, melphalan and tamoxifen.It has been given less frequently with docetaxel, dexamethasone, prednisone, carboplatin, letrozole, vinorelbine, cisplatin and gemcitabine.

Dosage Adjustment: Mild to Moderate Renal Impairment

Zoledronic acid for injection has been used in patients with bone metastases of solid tumours and osteolytic lesions of multiple myeloma with mild to moderate renal impairment in clinical trials; their risk of renal deterioration was increased compared to that of patients with normal renal function. Therefore, if zoledronic acid for injection concentrate is to be administered to patients with mild to moderate renal impairment (defined as baseline CrCl 30 mL/min to 60 mL/min), doses should be reduced. The following dosing recommendations are based on data from pharmacokinetic studies, however, the efficacy and safety of adjusted dosing has not been prospectively assessed in clinical trials.

Upon treatment initiation, the recommended zoledronic acid for injection concentrate doses for patients with reduced renal function (mild and moderate renal impairment) are listed in the following table. These doses are calculated based on pharmacokinetic data in order to achieve the same AUC as that achieved in patients with CrCl of 75 mL/min (see Action and Clinical Pharmacology - Special Populations and Conditions and Renal Impairment). Creatinine clearance is calculated using the Cockcroft-Gault formula.

CrCl (mL/min) = 1.2 [140-age (years)] x [total body weight (kg)]{multiply by 0.85 for females} serum creatinine (μmol/L)

Baseline Creatinine Clearance (mL/min)Zoledronic Acid for Injection
Recommended Dose‡
> 604.0 mg
50-603.5 mg
40-493.3 mg
30-393.0 mg

Doses calculated assuming target AUC of 0.66 (mg.hr/L) (CrCl = 75 mL/min)

During treatment, serum creatinine should be measured before each zoledronic acid for injection concentrate dose and treatment should be withheld if renal function has deteriorated. In the clinical studies, renal deterioration was defined as follows:

For patients with normal baseline creatinine (< 123 µmol/L or < 1.4 mg/dL), an increase of 44 µmol/L or 0.5 mg/dL 
For patients with abnormal baseline creatinine (> 123 µmol/L or >1.4 mg/dL), an increase of 88 µmol/L or 1.0 mg/dL

In the clinical studies, zoledronic acid for injection treatment was resumed only when the creatinine returned to within 10% of the baseline value. Zoledronic acid for injection concentrate should be re-initiated at the same dose as that prior to treatment interruption.

Renal function should be monitored appropriately during therapy with zoledronic acid for injection concentrate. Patients with evidence of renal function deterioration should be appropriately evaluated and consideration should be given as to whether the potential benefit outweighs the possible risk.

Administration Reconstitution

Method of Preparation

Zoledronic Acid For Injection Concentrate

Vials of zoledronic acid for injection concentrate contain overfill allowing for the withdrawal of 5 mL of concentrate (equivalent to 4 mg zoledronic acid for injection). The content of the vials is withdrawn using a sterile syringe. This concentrate should immediately be diluted in 100 mL of sterile 0.9% w/v Sodium Chloride Injection, USP, or 5% w/v Dextrose Injection, USP. Do not store undiluted concentrate in a syringe, to avoid inadvertent injection. Any unused portion of zoledronic acid for injection concentrate should be discarded.

Reduced Doses for Patients with Baseline CrCl ≤ 60 mL/min:

Withdraw an appropriate volume of the 5 mL - zoledronic acid for injection concentrate as needed:

  • 4 mL for 3.5 mg dose
  • 1 mL for 3.3 mg dose
  • 8 mL for 3.0 mg dose

The withdrawn concentrate must be diluted in 100 mL of sterile 0.9% w/v Sodium Chloride Injection, USP, or 5% w/v Dextrose Injection, USP. The dose must be given as a single intravenous injection over no less than 15 minutes.

Incompatibilities

Zoledronic acid for injection concentrate must not be mixed or come into contact with calcium- or other divalent cation-containing infusion solutions, such as Lactated Ringer’s solution, and should be administered as a single intravenous solution in a line separate from all other drugs over no less than 15 minutes.

Studies with glass bottles, as well as several types of infusion bags and infusion lines made from polyvinylchloride, polyethylene and polypropylene (pre-filled with 0.9 % w/v sodium chloride solution or 5 % w/v glucose solution), showed no incompatibility with zoledronic acid for injection.

Stability of Diluted Zoledronic Acid for Injection Solutions

After aseptic reconstitution and dilution, it is preferable to use the product immediately. If not used immediately after dilution with infusion media, for microbiological integrity, the solution should be stored at 2°C – 8°C. If refrigerated, the solution should be equilibrated to room temperature prior to administration. The total time between dilution, storage at 2°C – 8°C, and end of administration must not exceed 24 hours.

Strict adherence to the intravenous route is recommended for the parenteral administration of zoledronic acid for injection.

Note: Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Store zoledronic acid for injection concentrate at 15°C – 30°C.

Overdosage

Clinical experience of acute overdose with zoledronic acid for injection is limited. There have been two patients who received maladministration of 32 mg of zoledronic acid for injection given over 5 minutes. Neither patient experienced any clinical nor laboratory toxicity. Clinically relevant hypocalcaemia should be corrected by intravenous administration of calcium gluconate.

In an open label study of zoledronic acid for injection 4 mg in breast cancer patients, a female patient received a single 48 mg dose of zoledronic acid in error. Two days after the overdose the patient experienced a single episode of hyperthermia (38°C), which resolved after treatment. All other evaluations were normal and the patient was discharged seven days after the overdose.

A patient with Non-Hodgkin’s Lymphoma received zoledronic acid for injection 4 mg daily on four successive days for a total dose of 16 mg. The patient developed paraesthesia and abnormal liver function tests with increased GGT (nearly 100U/L, exact value unknown). The outcome of this case is not known.

Patients who have received doses higher than those recommended should be carefully monitored, since renal function impairment (including renal failure) and serum electrolyte (including calcium, phosphorus and magnesium) abnormalities have been observed.

For management of a suspected drug overdose, contact your regional poison centre.

Action and Clinical Pharmacology

Mechanism of Action

The principal pharmacologic action of zoledronic acid is inhibition of bone resorption. Although the antiresorptive mechanism is not completely understood, several factors are thought to contribute to this action. Zoledronic acid accumulates in bone, where it blocks the resorption of mineralized bone and cartilage. In vitro, zoledronic acid has a very large ratio between the desired inhibition of bone resorption and the adverse effects on bone mineralization. In vitro, zoledronic acid inhibits osteoclastic activity and induces apoptosis in osteoclasts, as well as reducing the formation and recruitment of osteoclasts into bone. Zoledronic acid inhibits the osteoclastic hyperactivity and accelerated bone resorption induced by various stimulatory factors released by tumours. In long-term animal studies, doses of zoledronic acid similar to those recommended for the treatment of hypercalcaemia inhibit bone resorption without adversely affecting the formation, mineralization, or mechanical properties of bone.

In addition to inhibiting osteoclastic bone resorption, zoledronic acid exerts direct anti-tumour effects on cultured human myeloma and breast cancer cells, inhibiting their proliferation and inducing apoptosis. Zoledronic acid also inhibits the proliferation of human endothelial cells invitro and is anti-angiogenic in animal tumour models. In vitro zoledronic acid reduces the invasion of human breast cancer cells into the extracellular matrix.

Preclinical data suggest that low micromolar concentrations of zoledronic acid are cytostatic and pro-apoptotic in vitro to a range of human cancer cell lines (breast, prostate, lung, bladder, myeloma). This anti-tumour efficacy may be enhanced when used in combination with other anti-cancer drugs. Preclinical data suggest that zoledronic acid is also anti-proliferative for human foetal osteoblasts and promotes their differentiation, a property that may be potentially relevant for the treatment of bone metastases in prostate cancer. Zoledronic acid has been shown to inhibit the proliferation of human endothelial cells in vitro and is anti -angiogenic in vivo. Zoledronic acid at picomolar concentrations has been shown to inhibit tumour cell invasion through extracellular matrix in preclinical cancer models.

Pharmacodynamics

Clinical studies in TIH demonstrated that the effect of zoledronic acid for injection is characterized by decreases in serum calcium and urinary calcium excretion. Normalization of serum calcium by day 4 was greater for the zoledronic acid for injection 4 mg and 8 mg doses (45% and 56%, respectively) compared with pamidronate disodium for injection 90 mg (33%).

Tumour-Induced Hypercalcaemia

Osteoclastic hyperactivity resulting in excessive bone resorption is the underlying pathophysiologic derangement in tumour-induced hypercalcaemia (TIH, hypercalcaemia of malignancy) and metastatic bone disease. Excessive release of calcium into the blood as bone is resorbed results in polyuria and gastrointestinal disturbances, with progressive dehydration and decreasing glomerular filtration rate. This results in increased renal resorption of calcium, setting up a cycle of worsening systemic hypercalcaemia. Correction of excessive bone resorption and adequate fluid administration to correct volume deficits are, therefore, essential to the management of hypercalcaemia.

Most cases of hypercalcaemia associated with malignancy occur in patients who have breast cancer, squamous-cell tumours of the lung or head and neck, renal cell carcinoma, and certain haematologic malignancies, such as multiple myeloma and some types of lymphomas. A few less common malignancies, including vasoactive intestinal-peptide-producing tumours and cholangiocarcinoma, have a high incidence of hypercalcaemia as a metabolic complication. Patients who have tumour-induced hypercalcaemia can generally be divided into two groups according to the pathophysiologic mechanism involved.

In humoral hypercalcaemia, osteoclasts are activated and bone resorption is stimulated by factors such as parathyroid-hormone-related protein, which are elaborated by the tumour and circulate systemically. Humoral hypercalcaemia usually occurs in squamous-cell malignancies of the lung or head and neck or in genitourinary tumours such as renal cell carcinoma or ovarian cancer. Skeletal metastases may be absent or minimal in these patients.

Extensive invasion of bone by tumour cells can also result in hypercalcaemia due to local tumour products that stimulate bone resorption by osteoclasts. Tumours commonly associated with locally mediated hypercalcaemia include breast cancer and multiple myeloma.

Total serum calcium levels in patients who have tumour-induced hypercalcaemia may not reflect the severity of hypercalcaemia, since concomitant hypoalbuminemia is commonly present. Ideally, ionized calcium levels should be used to diagnose and follow hypercalcaemic conditions; however, these are not commonly or rapidly available in many clinical situations. Therefore, adjustment of the total serum calcium value for differences in albumin levels is often used in place of measurement of ionized calcium; several nomograms are in use for this type of calculation (see Dosage and Administration).

Bone Metastases of Solid Tumours and Osteolytic Lesions of Multiple Myeloma

Osteolytic bone lesions and metastases commonly occur in patients with multiple myeloma, breast cancer, non-small cell lung cancer, renal cell carcinoma and a variety of other solid tumours. Bone lesions associated with bone metastases from prostate carcinoma classically are osteoblastic in contrast to those from other carcinomas, which are usually osteolytic or mixed osteolytic/osteoblastic. Adenocarcinoma of the prostate spreads most commonly to the well vascularized areas of the skeleton such as the vertebral column, ribs, skull, and the proximal ends of the long bones. Prostate carcinoma cells have long been believed to gain access to the vertebral column and ribs via the Batson venous plexus, which is a low pressure, high volume plexus of vertebral veins that join the intercostal veins.

These bone changes in patients with evidence of osteolytic and osteoblastic skeletal destruction may cause severe bone pain that requires either radiation therapy or narcotic analgesics (or both) for symptomatic relief. These changes also cause pathologic fractures of bone in both the axial and appendicular skeleton. Axial skeletal fractures of the vertebral bodies may lead to spinal cord compression or vertebral body collapse with significant neurologic complications. Patients may also experience episode(s) of hypercalcaemia.

Pharmacokinetics

Summary

Single or multiple (q 28 days) 5-minute or 15-minute infusions of 2, 4, 8 or 16 mg zoledronic acid for injection were given to 64 cancer patients with bone metastases. The post infusion decline of zoledronic acid concentrations in plasma was consistent with a triphasic process showing a rapid decrease from peak concentrations at end-of-infusion to <1% of Cmax after 24 hours post infusion with population half-lives of t ½α 0.24 hours and t½β 1.87 hours for the early disposition phases of the drug, followed by a prolonged period of very low concentrations in plasma between days 2 and 28 post infusion, with a terminal elimination half-life t½γ of 146 hours. The area under the plasma concentration versus time curve (AUC0-24h) of zoledronic acid was linearly related to dose. The accumulation of zoledronic acid following a 28-day dosing schedule over 3 cycles was low, with mean AUC0-24h ratios cycles 2 and 3 versus 1 of 1.13 ± 0.30 and 1.16 ± 0.36, respectively.

Distribution

In vitro and ex vivo studies showed no affinity of zoledronic acid for the cellular components of human blood, with a mean blood to plasma concentration ratio of 0.59 in a concentration range of 30 ng/mL to 5000 ng/mL. The plasma protein binding was low (with the unbound fraction ranging from 60% at 2 ng/mL to 77% at 2000 ng/mL of zoledronic acid).

Biotransformation/Metabolism

Zoledronic acid does not inhibit human P-450 enzymes invitro. Zoledronic acid does not experience biotransformation.

Excretion

In animal studies <3% of the administered intravenous dose was found in the faeces, with the balance either recovered in the urine or taken up by bone, indicating that the drug is eliminated intact via the kidney. Following an intravenous dose of 20 nCi 14C-zoledronic acid in a cancer patient with bone metastases, the radioactivity excreted in the urine consisted solely of intact drug.

In 64 cancer patients with bone metastases on average (± s.d.) 39 ± 16% of the administered dose was recovered in the urine within 24 hours, with only trace amounts of drug found in urine post day 2. The cumulative percent of drug excreted in the urine over 0-24 hours was independent of dose. The balance of drug not recovered in urine over 0-24 hours, representing drug presumably bound to bone tissue, is slowly released back into the systemic circulation, giving rise to the observed prolonged low plasma concentrations days 2 to 28 post dose. The 0–24 h renal clearance of zoledronic acid was on average (±s.d.) 3.7 ± 2.0 L/h.

Linearity/Non-linearity

Zoledronic acid clearance was reasonably independent of dose and demographic variables, with effects of body weight, gender and race on clearance being within the bounds of the inter-patient variability of clearance, which was 36%.

Increasing the infusion time from 5 minutes to 15 minutes caused a 30% decrease in the zoledronic acid concentration at the end of the infusion, but had no effect on the area under the plasma concentration versus time curve.

Special Populations and Conditions

There are no pharmacokinetic data in patients with hypercalcaemia.

Pediatrics

There are no pharmacokinetic data in pediatric patients (see Warnings and Precautions).

Geriatrics

The pharmacokinetics of zoledronic acid for injection were not affected by age in cancer patients with bone metastases aged 38 years to 84 years.

Race

The pharmacokinetics of 2 mg, 4 mg and 8 mg zoledronic acid have been evaluated in a Phase I study of Japanese patients with cancer and bone metastasis.

Japanese female subjects had substantially higher systemic exposure, i.e., 47% higher AUC0-24h and 39% higher Cmax than the North American population (see the Table below) following a single dose intravenous of zoledronic acid for injection (4 mg over 15 minutes). The exposure of Japanese males were comparable to that of the North American population based on the limited data (n=4 and 1 for AUC and Cmax, respectively).

Comparative PK between Japanese and North American Population (mean ± SD)
JapanNorth America
Female
(n=14)
Male
(n=4 or 1)
Female
(n=16)
Male
(n=29)
AUC0-24h, ng-h/m154 ± 38118 ± 40114 ± 22100 ± 32
Cmax, ng-h/mL111 ± 226487 ± 2077 ± 28

Hepatic Impairment

There are no pharmacokinetic data in patients with impaired liver function. Zoledronic acid is not cleared by the liver, therefore impaired liver function may not affect the pharmacokinetics of zoledronic acid for injection.

Renal Impairment

Limited pharmacokinetic data are available for zoledronic acid for injection in patients with severe renal impairment (CrCl <30 mL/min). The pharmacokinetic studies were conducted in cancer patients (n=64) typical of the target clinical population, showing renal function mainly in the range of normal to moderately impaired [mean (± s.d.) CrCl 84 ± 29 mL/min, range 22 - 143 mL/min]. In these 64 patients the renal clearance of zoledronic acid was found to closely correlate with CrCl, representing in the mean (± s.d.) 75 ± 33% of the CrCl. Creatinine clearance is calculated by the Cockcroft- Gault formula (see Dosage and Administration):

CrCl (mL/min) = 1.2 [140-age (years)] x [total body weight (kg)] {multiply by 0.85 for females} serum creatinine (μmol/L)

Patients with mild renal impairment (CrCl 50 - 80 mL/min) showed increases in plasma AUC of 26% to 36%, whereas patients with moderate renal impairment (CrCl 30 - 50 mL/min) showed increases in plasma AUC of 27 - 41%, compared to patients with normal renal function (CrCl> 80 mL/min). However, there were no further increases in the systemic exposure after multiple doses in patients with impaired renal function (see Warnings and Precautions).

The population-derived relationship of zoledronic acid for injection clearance with CrCl offers an algorithm for dose reduction in renal impairment. Zoledronic acid for injection systemic clearance (CL) in individual patients can be calculated from the population clearance of zoledronic acid for injection and that individual’s CrCl, as CL (L/h) = 6.5 x (CrCl/90)0.4. This formula can be used to predict zoledronic acid for injection AUC in patients, where CL=Dose/AUC0-∞. The average AUC0-24 in patients with normal renal function was 0.42 mg•h/L and the calculated AUC 0-∞ for a patient with CrCl of 75 mL/min was 0.66 mg•h/L following a 4 mg dose of zoledronic acid for injection.

Storage and Stability

Store zoledronic acid for injection concentrate at room temperature (15°C – 30°C).

After aseptic reconstitution and dilution, it is preferable to use the product immediately. If not used immediately after dilution with infusion media, the solution should be stored at 2°C - 8°C. If refrigerated, the solution should be equilibrated to room temperature prior to administration. The total time between dilution, storage at 2 – 8°C, and end of administration must not exceed 24 hours. Any unused solution should be discarded. Only clear solution free from particles and discoloration should be used (see Dosage and Administration, Administration).

Zoledronic acid for injection concentrate must be kept out of the reach and sight of children and pets.

Dosage Forms, Composition and Packaging

Zoledronic acid for injection concentrate is available as a concentrate in vials. Each vial of zoledronic acid for injection concentrate delivers 4 mg of zoledronic acid corresponding to 4.264 mg zoledronic acid monohydrate.

Zoledronic acid for injection concentrate is available as a concentrate i.e. 5 mL sterile solution is packaged in 10 mL/20 mm glass vials, closed with 20 mm grey butyl rubber closure and aluminum seal with a red top.

Available in cartons containing 1 vial.

Composition

Zoledronic acid for injection concentrate:

Each 5 mL vial of zoledronic acid for injection concentrate contains 4 mg zoledronic acid sterile liquid concentrate. This corresponds to 4.264 mg of zoledronic acid monohydrate.

Inactive Ingredients

220 mg mannitol per vial, as bulking agent and sodium citrate dihydrate 24 mg per vial as buffering agent, and water for injection