- ibandronic sodium monohydrate
POM: Prescription only medicine
This information is intended for use by health professionals
Prevention of skeletal events in patients with breast cancer and bone metastasesThe recommended dose for prevention of skeletal events in patients with breast cancer and bone metastases is 6 mg intravenous injection given every 3-4 weeks. The dose should be infused over at least 15 minutes. A shorter (i.e. 15 min) infusion time should only be used for patients with normal renal function or mild renal impairment. There are no data available characterising the use of a shorter infusion time in patients with creatinine clearance below 50 ml/min. Prescribers should consult the section Patients with Renal Impairment (see section 4.2) for recommendations on dosing and administration in this patient group.
Treatment of tumour-induced hypercalcaemiaPrior to treatment with Bondronat the patient should be adequately rehydrated with 9 mg/ml (0.9%) sodium chloride solution. Consideration should be given to the severity of the hypercalcaemia as well as the tumour type. In general patients with osteolytic bone metastases require lower doses than patients with the humoral type of hypercalcaemia. In most patients with severe hypercalcaemia (albumin-corrected serum calcium* ≥3 mmol/l or ≥12 mg/dl) 4 mg is an adequate single dose. In patients with moderate hypercalcaemia (albumin-corrected serum calcium <3 mmol/l or <12 mg/dl) 2 mg is an effective dose. The highest dose used in clinical trials was 6 mg but this dose does not add any further benefit in terms of efficacy.* Note albumin-corrected serum calcium concentrations are calculated as follows:
|Albumin-corrected serum calcium (mmol/l)||=||serum calcium (mmol/l) - [0.02 x albumin (g/l)] + 0.8|
|Albumin-corrected serum calcium (mg/dl)||=||serum calcium (mg/dl) + 0.8 x [4 - albumin (g/dl)]|
|To convert the albumin-corrected serum calcium in mmol/l value to mg/dl, multiply by 4.|
Patients with hepatic impairmentNo dose adjustment is required (see section 5.2).
Patients with renal impairmentFor patients with mild renal impairment (CLcr ≥50 and <80 mL/min) no dose adjustment is necessary. For patients with moderate renal impairment (CLcr ≥30 and <50 mL/min) or severe renal impairment (CLcr <30 mL/min) being treated for the prevention of skeletal events in patients with breast cancer and metastatic bone disease the following dosing recommendations should be followed (see section 5.2):
|Creatinine Clearance (ml/min)||Dosage||Infusion Volume 1 and Time 2|
|≥50 CLcr<80||6 mg (6 ml of concentrate for solution for infusion)||100 ml over 15 minutes|
|≥30 CLcr <50||4 mg (4 ml of concentrate for solution for infusion)||500 ml over 1 hour|
|<30||2 mg (2 ml of concentrate for solution for infusion)||500 ml over 1 hour|
Elderly population (> 65 years)No dose adjustment is required. (see section 5.2).
Paediatric populationThe safety and efficacy of Bondronat in children and adolescents below the age of 18 years have not been established. No data are available. (see section 5.1 and section 5.2).
Method of administrationFor intravenous administration.The content of the vial is to be used as follows:• Prevention of Skeletal Events - added to 100 ml isotonic sodium chloride solution or 100 ml 5% dextrose solution and infused over at least 15 minutes. See also dose section above for patients with renal impairment• Treatment of tumour-induced hypercalcaemia - added to 500 ml isotonic sodium chloride solution or 500 ml 5% dextrose solution and infused over 2 hoursFor single use only. Only clear solution without particles should be used.Bondronat concentrate for solution for infusion should be administered as an intravenous infusion. Care must be taken not to administer Bondronat concentrate for solution for infusion via intra-arterial or paravenous administration, as this could lead to tissue damage.
Patients with disturbances of bone and mineral metabolismHypocalcaemia and other disturbances of bone and mineral metabolism should be effectively treated before starting Bondronat therapy for metastatic bone disease. Adequate intake of calcium and vitamin D is important in all patients. Patients should receive supplemental calcium and/or vitamin D if dietary intake is inadequate.
Anaphylactic reaction/shockCases of anaphylactic reaction/shock, including fatal events, have been reported in patients treated with intravenous ibandronic acid.Appropriate medical support and monitoring measures should be readily available when Bondronat intravenous injection is administered. If anaphylactic or other severe hypersensitivity/allergic reactions occur, immediately discontinue the injection and initiate appropriate treatment. Osteonecrosis of the jaw Osteonecrosis of the jaw (ONJ) has been reported very rarely in the post marketing setting in patients receiving Bondronat for oncology indications (see section 4.8). The start of treatment or of a new course of treatment should be delayed in patients with unhealed open soft tissue lesions in the mouth. A dental examination with preventive dentistry and an individual benefit-risk assessment is recommended prior to treatment with Bondronat in patients with concomitant risk factors. The following risk factors should be considered when evaluating a patient's risk of developing ONJ: - Potency of the medicinal product that inhibit bone resorption (higher risk for highly potent compounds), route of administration (higher risk for parenteral administration) and cumulative dose of bone resorption therapy - Cancer, co-morbid conditions (e.g. anaemia, coagulopathies, infection), smoking - Concomitant therapies: corticosteroids, chemotherapy, angiogenesis inhibitors, radiotherapy to head and neck - Poor oral hygiene, periodontal disease, poorly fitting dentures, history of dental disease, invasive dental procedures e.g. tooth extractions All patients should be encouraged to maintain good oral hygiene, undergo routine dental check-ups, and immediately report any oral symptoms such as dental mobility, pain or swelling, or non-healing of sores or discharge during treatment with Bondronat. While on treatment, invasive dental procedures should be performed only after careful consideration and be avoided in close proximity to Bondronat administration. The management plan of the patients who develop ONJ should be set up in close collaboration between the treating physician and a dentist or oral surgeon with expertise in ONJ. Temporary interruption of Bondronat treatment should be considered until the condition resolves and contributing risk factors are mitigated where possible. Osteonecrosis of the external auditory canal Osteonecrosis of the external auditory canal has been reported with bisphosphonates, mainly in association with long-term therapy. Possible risk factors for osteonecrosis of the external auditory canal include steroid use and chemotherapy and/or local risk factors such as infection or trauma. The possibility of osteonecrosis of the external auditory canal should be considered in patients receiving bisphosphonates who present with ear symptoms including chronic ear infections.
Atypical fractures of the femurAtypical subtrochanteric and diaphyseal femoral fractures have been reported with bisphosphonate therapy, primarily in patients receiving long-term treatment for osteoporosis. These transverse or short oblique fractures can occur anywhere along the femur from just below the lesser trochanter to just above the supracondylar flare. These fractures occur after minimal or no trauma and some patients experience thigh or groin pain, often associated with imaging features of stress fractures, weeks to months before presenting with a completed femoral fracture. Fractures are often bilateral; therefore the contralateral femur should be examined in bisphosphonate-treated patients who have sustained a femoral shaft fracture. Poor healing of these fractures has also been reported. Discontinuation of bisphosphonate therapy in patients suspected to have an atypical femur fracture should be considered pending evaluation of the patient, based on an individual benefit risk assessment.During bisphosphonate treatment patients should be advised to report any thigh, hip or groin pain and any patient presenting with such symptoms should be evaluated for an incomplete femur fracture.
Patients with renal impairmentClinical studies have not shown any evidence of deterioration in renal function with long term Bondronat therapy. Nevertheless, according to clinical assessment of the individual patient, it is recommended that renal function, serum calcium, phosphate and magnesium should be monitored in patients treated with Bondronat (see section 4.2).
Patients with hepatic impairmentAs no clinical data are available, dose recommendations cannot be given for patients with severe hepatic insufficiency (see section 4.2).
Patients with cardiac impairmentOverhydration should be avoided in patients at risk of cardiac failure.
Patients with known hypersensitivity to other bisphosphonatesCaution is to be taken in patients with known hypersensitivity to other bisphosphonates.
Excipients with known effectBondronat is essentially sodium free.
PregnancyThere are no adequate data from the use of ibandronic acid in pregnant women. Studies in rats have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. Therefore, Bondronat should not be used during pregnancy.
Breast-feedingIt is not known whether ibandronic acid is excreted in human milk. Studies in lactating rats have demonstrated the presence of low levels of ibandronic acid in the milk following intravenous administration. Bondronat should not be used during breast-feeding.
FertilityThere are no data on the effects of ibandronic acid in humans. In reproductive studies in rats by the oral route, ibandronic acid decreased fertility. In studies in rats using the intravenous route, ibandronic acid decreased fertility at high daily doses (see section 5.3).
Summary of the safety profileThe most serious reported adverse reactions are anaphylactic reaction/shock, atypical fractures of the femur, osteonecrosis for the jaw, and ocular inflammation (see paragraph description of selected adverse reactions and section 4.4).Treatment of tumour induced hypercalcaemia is most frequently associated with a rise in body temperature. Less frequently, a decrease in serum calcium below normal range (hypocalcaemia) is reported. In most cases no specific treatment is required and the symptoms subside after a couple of hours/days.In the prevention of skeletal events in patients with breast cancer and bone metastases, treatment is most frequently associated with asthenia followed by rise in body temperature and headache.
Tabulated list of adverse reactionsTable 1 lists adverse drug reactions from the pivotal phase III studies (Treatment of tumour induced hypercalcaemia: 311 patients treated with Bondronat 2 mg or 4 mg; Prevention of skeletal events in patients with breast cancer and bone metastases: 152 patients treated with Bondronat 6 mg), and from post-marketing experience. Adverse reactions are listed according to MedDRA system organ class and frequency category. Frequency categories are defined using the following convention: very common (≥1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
Table 1 Adverse Reactions Reported for Intravenous Administration of Bondronat
|System Organ Class||Common||Uncommon||Rare||Very rare||Not known|
|Infections and infestations||Infection||Cystitis, vaginitis, oral candidiasis|
|Neoplasms benign, malignant and unspecified||Benign skin neoplasm|
|Blood and lymphatic system disorders||Anaemia, blood dyscrasia|
|Immune system disorders||Hypersensitivity, bronchospasm, angioedema, anaphylactic reaction/shock**||Asthma exacerbation|
|Endocrine disorders||Parathyroid disorder|
|Metabolism and nutrition disorders||Hypocalcaemia**||Hypophosphataemia|
|Psychiatric disorders||Sleep disorder, anxiety, affection lability|
|Nervous system disorders||Headache, dizziness, dysgeusia (taste perversion)||Cerebrovascular disorder, nerve root lesion, amnesia, migraine, neuralgia, hypertonia, hyperaestesia, paraesthesia circumoral, parosmia|
|Eye disorders||Cataract||Ocular inflammation**|
|Ear and labyrinth disorders||Deafness|
|Cardiac disorders||Bundle branch block||Myocardial ischaemia, cardiovascular disorder, palpitations|
|Respiratory, thoracic, and mediastinal disorders||Pharyngitis||Lung oedema, stridor|
|Gastrointestinal disorders||Diarrhoea, vomiting, dyspepsia, gastrointestinal pain, tooth disorder||Gastroenteritis, gastritis, mouth ulceration, dysphagia, cheilitis|
|Skin and subcutaneous tissue disorders||Skin disorder, ecchymosis||Rash, alopecia||Stevens-Johnson Syndrome, Erythema Multiforme, Dermatitis Bullous|
|Musculoskeletal and connective tissue disorders||Osteoarthritis, myalgia, arthralgia, joint disorder, bone pain||Atypical subtrochanteric and diaphyseal femoral fractures||Osteonecrosis of jaw** Osteonecrosis of the external auditory canal (bisphosphonate class adverse reaction)|
|Renal and urinary disorders||Urinary retention, renal cyst|
|Reproductive system and breast disorders||Pelvic pain|
|General disorders and administration site conditions||Pyrexia, influenza-like illness**, oedema peripheral, asthenia, thirst||Hypothermia|
|Investigations||Gamma-GT increased, creatinine increased||Blood alkaline phosphatase increase, weight decrease|
|Injury, poisoning and procedural complications||Injury, injection site pain|
Description of selected adverse reactions
HypocalcaemiaDecreased renal calcium excretion may be accompanied by a fall in serum phosphate levels not requiring therapeutic measures. The serum calcium level may fall to hypocalcaemic values.
Influenza-like illnessA flu-like syndrome consisting of fever, chills, bone and/or muscle ache-like pain has occurred. In most cases no specific treatment was required and the symptoms subsided after a couple of hours/days. Osteonecrosis of jaw Cases of osteonecrosis of the jaw have been reported, predominantly in cancer patients treated with medicinal products that inhibit bone resorption, such as ibandronic acid (see section 4.4.) Cases of ONJ have been reported in the post marketing setting for ibandronic acid.
Ocular inflammationOcular inflammation events such as uveitis, episcleritis and scleritis have been reported with ibandronic acid. In some cases, these events did not resolve until the ibandronic acid was discontinued.
Anaphylactic reaction/shockCases of anaphylactic reaction/shock, including fatal events, have been reported in patients treated with intravenous ibandronic acid.
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions (see details below).
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Clinical studies in the treatment of tumour-induced hypercalcaemiaClinical studies in hypercalcaemia of malignancy demonstrated that the inhibitory effect of ibandronic acid on tumour-induced osteolysis, and specifically on tumour-induced hypercalcaemia, is characterised by a decrease in serum calcium and urinary calcium excretion.In the dose range recommended for treatment, the following response rates with the respective confidence intervals have been shown in clinical trials for patients with baseline albumin-corrected serum calcium ≥ 3.0 mmol/l after adequate rehydration.
|Ibandronic acid dose||% of Patients with Response||90% Confidence Interval|
Clinical studies in the prevention of skeletal events in patients with breast cancer and bone metastasesClinical studies in patients with breast cancer and bone metastases have shown that there is a dose dependent inhibitory effect on bone osteolysis, expressed by markers of bone resorption, and a dose dependent effect on skeletal events.Prevention of skeletal events in patients with breast cancer and bone metastases with Bondronat 6 mg administered intravenously was assessed in one randomized placebo controlled phase III trial with duration of 96 weeks. Female patients with breast cancer and radiologically confirmed bone metastases were randomised to receive placebo (158 patients) or 6 mg Bondronat (154 patients). The results from this trial are summarised below.
Primary efficacy endpointsThe primary endpoint of the trial was the skeletal morbidity period rate (SMPR). This was a composite endpoint which had the following skeletal related events (SREs) as sub-components: - radiotherapy to bone for treatment of fractures/impending fractures - surgery to bone for treatment of fractures - vertebral fractures - non-vertebral fractures The analysis of the SMPR was time-adjusted and considered that one or more events occurring in a single 12 week period could be potentially related. Multiple events were therefore counted only once for the purposes of the analysis. Data from this study demonstrated a significant advantage for intravenous Bondronat 6 mg over placebo in the reduction in SREs measured by the time-adjusted SMPR (p=0.004). The number of SREs was also significantly reduced with Bondronat 6 mg and there was a 40% reduction in the risk of a SRE over placebo (relative risk 0.6, p = 0.003). Efficacy results are summarised in Table 2.
Table 2 Efficacy Results (Breast Cancer Patients with Metastatic Bone Disease)
|All Skeletal Related Events (SREs)|
|Placebo n=158||Bondronat 6 mg n=154||p-value|
|SMPR (per patient year)||1.48||1.19||p=0.004|
|Number of events (per patient)||3.64||2.65||p=0.025|
|SRE relative risk||-||0.60||p=0.003|
Secondary efficacy endpointsA statistically significant improvement in bone pain score was shown for intravenous Bondronat 6 mg compared to placebo. The pain reduction was consistently below baseline throughout the entire study and accompanied by a significantly reduced use of analgesics. The deterioration in Quality of Life was significantly less in Bondronat treated patients compared with placebo. A tabular summary of these secondary efficacy results is presented in Table 3.
Table 3 Secondary Efficacy Results (Breast cancer Patients with Metastatic Bone Disease)
|Placebo n=158||Bondronat 6 mg n=154||p-value|
|Bone pain *||0.21||-0.28||p<0.001|
|Analgesic use *||0.90||0.51||p=0.083|
|Quality of Life *||-45.4||-10.3||p=0.004|
Paediatric population (see section 4.2 and section 5.2)The safety and efficacy of Bondronat in children and adolescents below the age of 18 years have not been established. No data are available.
DistributionAfter initial systemic exposure, ibandronic acid rapidly binds to bone or is excreted into urine. In humans, the apparent terminal volume of distribution is at least 90 l and the amount of dose reaching the bone is estimated to be 40-50% of the circulating dose. Protein binding in human plasma is approximately 87% at therapeutic concentrations, and thus interaction with other medicinal products, due to displacement is unlikely.
BiotransformationThere is no evidence that ibandronic acid is metabolized in animals or humans.
EliminationThe range of observed apparent half-lives is broad and dependent on dose and assay sensitivity, but the apparent terminal half-life is generally in the range of 10-60 hours. However, early plasma levels fall quickly, reaching 10% of peak values within 3 and 8 hours after intravenous or oral administration respectively. No systemic accumulation was observed when ibandronic acid was administered intravenously once every 4 weeks for 48 weeks to patients with metastatic bone disease.Total clearance of ibandronic acid is low with average values in the range 84-160 ml/min. Renal clearance (about 60 ml/min in healthy postmenopausal females) accounts for 50-60% of total clearance and is related to creatinine clearance. The difference between the apparent total and renal clearances is considered to reflect the uptake by bone.The secretory pathway of renal elimination does not appear to include known acidic or basic transport systems involved in the excretion of other active substances. In addition, ibandronic acid does not inhibit the major human hepatic P450 isoenzymes and does not induce the hepatic cytochrome P450 system in rats.
Pharmacokinetics in special populations
GenderBioavailability and pharmacokinetics of ibandronic acid are similar in both men and women.
RaceThere is no evidence for clinically relevant interethnic differences between Asians and Caucasians in ibandronic acid disposition. There are only very few data available on patients with African origin.
Patients with renal impairmentExposure to ibandronic acid in patients with various degrees of renal impairment is related to creatinine clearance (CLcr). In subjects with severe renal impairment (mean estimated CLcr = 21.2 mL/min), dose-adjusted mean AUC0-24h was increased by 110% compared to healthy volunteers. In clinical pharmacology trial WP18551, after a single dose intravenous administration of 6 mg (15 minutes infusion), mean AUC0-24 increased by 14% and 86%, respectively, in subjects with mild (mean estimated CLcr=68.1 mL/min) and moderate (mean estimated CLcr=41.2 mL/min) renal impairment compared to healthy volunteers (mean estimated CLcr=120 mL/min). Mean Cmax was not increased in patients with mild renal impairment and increased by 12% in patients with moderate renal impairment. For patients with mild renal impairment (CLcr ≥50 and <80 mL/min) no dosage adjustment is necessary. For patients with moderate renal impairment (CLcr ≥30 and <50 mL/min) or severe renal impairment (CLcr <30 mL/min) being treated for the prevention of skeletal events in patients with breast cancer and metastatic bone disease an adjustment in the dose is recommended (see section 4.2).Patients with hepatic impairment (see section 4.2)There are no pharmacokinetic data for ibandronic acid in patients who have hepatic impairment. The liver has no significant role in the clearance of ibandronic acid since it is not metabolized but is cleared by renal excretion and by uptake into bone. Therefore dosage adjustment is not necessary in patients with hepatic impairment. Further, as protein binding of ibandronic acid is approximately 87% at therapeutic concentrations, hypoproteinaemia in severe liver disease is unlikely to lead to clinically significant increases in free plasma concentration.Elderly (see section 4.2)In a multivariate analysis, age was not found to be an independent factor of any of the pharmacokinetic parameters studied. As renal function decreases with age, this is the only factor that should be considered (see renal impairment section).Paediatric population (see section 4.2 and section 5.1)There are no data on the use of Bondronat in patients less than 18 years old.
Mutagenicity/Carcinogenicity:No indication of carcinogenic potential was observed. Tests for genotoxicity revealed no evidence of effects on genetic activity for ibandronic acid.
Reproductive toxicity:No evidence of direct foetal toxicity or teratogenic effects were observed for ibandronic acid in intravenously treated rats and rabbits. In reproductive studies in rats by the oral route, effects on fertility consisted of increased preimplantation losses at dose levels of 1 mg/kg/day and higher. In reproductive studies in rats by the intravenous route, ibandronic acid decreased sperm counts at doses of 0.3 and 1 mg/kg/day and decreased fertility in males at 1 mg/kg/day and in females at 1.2 mg/kg/day. Adverse effects of ibandronic acid in reproductive toxicity studies in the rat were those expected for this class of medicinal products (bisphosphonates). They include a decreased number of implantation sites, interference with natural delivery (dystocia), an increase in visceral variations (renal pelvis ureter syndrome) and teeth abnormalities in F1 offspring in rats.
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