FOSAMAX PLUS D (Page 5 of 9)

12.2 Pharmacodynamics

Alendronate Sodium

Alendronate is a bisphosphonate that binds to bone hydroxyapatite and specifically inhibits the activity of osteoclasts, the bone-resorbing cells. Alendronate reduces bone resorption with no direct effect on bone formation, although the latter process is ultimately reduced because bone resorption and formation are coupled during bone turnover.

Daily oral doses of alendronate (5, 20, and 40 mg for six weeks) in postmenopausal women produced biochemical changes indicative of dose-dependent inhibition of bone resorption, including decreases in urinary calcium and urinary markers of bone collagen degradation (such as deoxypyridinoline and cross-linked N-telopeptides of type I collagen). These biochemical changes tended to return toward baseline values as early as 3 weeks following the discontinuation of therapy with alendronate and did not differ from placebo after 7 months.

Long-term treatment of osteoporosis with FOSAMAX 10 mg/day (for up to five years) reduced urinary excretion of markers of bone resorption, deoxypyridinoline and cross-linked N-telopeptides of type l collagen, by approximately 50% and 70%, respectively, to reach levels similar to those seen in healthy premenopausal women. The decrease in the rate of bone resorption indicated by these markers was evident as early as one month and at three to six months reached a plateau that was maintained for the entire duration of treatment with FOSAMAX. In osteoporosis treatment studies FOSAMAX 10 mg/day decreased the markers of bone formation, osteocalcin and bone specific alkaline phosphatase by approximately 50%, and total serum alkaline phosphatase by approximately 25 to 30% to reach a plateau after 6 to 12 months. Similar reductions in the rate of bone turnover were observed in postmenopausal women during one-year studies with once weekly FOSAMAX 70 mg for the treatment of osteoporosis. These data indicate that the rate of bone turnover reached a new steady-state, despite the progressive increase in the total amount of alendronate deposited within bone.

As a result of inhibition of bone resorption, asymptomatic reductions in serum calcium and phosphate concentrations were also observed following treatment with FOSAMAX. In the long-term studies, reductions from baseline in serum calcium (approximately 2%) and phosphate (approximately 4 to 6%) were evident the first month after the initiation of FOSAMAX 10 mg. No further decreases in serum calcium were observed for the five-year duration of treatment; however, serum phosphate returned toward prestudy levels during years three through five. In one-year studies with once weekly FOSAMAX 70 mg, similar reductions were observed at 6 and 12 months. The reduction in serum phosphate may reflect not only the positive bone mineral balance due to FOSAMAX but also a decrease in renal phosphate reabsorption.

Osteoporosis in Men

Treatment of men with osteoporosis with FOSAMAX 10 mg/day for two years reduced urinary excretion of cross-linked N-telopeptides of type I collagen by approximately 60% and bone-specific alkaline phosphatase by approximately 40%. Similar reductions were observed in a one-year study in men with osteoporosis receiving once weekly FOSAMAX 70 mg.

Cholecalciferol

Vitamin D is required for normal bone formation. Vitamin D insufficiency is associated with negative calcium balance, leading to increased parathyroid hormone levels and worsening of bone loss associated with osteoporosis. When taken without vitamin D, alendronate is also associated with a reduction in serum calcium concentrations and increased parathyroid hormone levels. In a 15-week trial, 717 postmenopausal women and men, mean age 67 years, with osteoporosis (lumbar spine bone mineral density [BMD] of at least 2.5 standard deviations below the premenopausal mean) were randomized to receive either weekly FOSAMAX PLUS D 70 mg/2800 international units vitamin D or weekly FOSAMAX 70 mg alone with no vitamin D supplementation. Patients who were vitamin D deficient (25-hydroxyvitamin D less than 9 ng/mL) at baseline were excluded. Treatment with FOSAMAX PLUS D 70 mg/2800 international units resulted in a smaller reduction in serum calcium levels (-0.9%) when compared to FOSAMAX 70 mg alone (-1.4%). As well, treatment with FOSAMAX PLUS D 70 mg/2800 international units resulted in a significantly smaller increase in parathyroid hormone levels when compared to FOSAMAX 70 mg alone (14% and 24%, respectively).

The sufficiency of patients’ vitamin D status is best assessed by measuring 25-hydroxyvitamin D levels. In the 15-week trial mentioned above, baseline 25-hydroxyvitamin D levels were 22.2 ng/mL in the FOSAMAX PLUS D group and 22.1 ng/mL in the FOSAMAX only group. After 15 weeks of treatment, the mean levels were 23.1 ng/mL and 18.4 ng/mL in the FOSAMAX PLUS D and FOSAMAX only groups, respectively. The final levels of 25-hydroxyvitamin D at Week 15 are summarized in Table 4.

Table 4: 25-hydroxyvitamin D Levels after Treatment with FOSAMAX PLUS D (70 mg/2800 international units) or FOSAMAX 70 mg at Week 15*
Number (%) of Patients
*
Patients who were vitamin D deficient (25-hydroxyvitamin D less than 9 ng/mL) at baseline were excluded.
25-hydroxyvitamin D Ranges (ng/mL) <9 9-14 15-19 20-24 25-29 30-62
FOSAMAX PLUS D(70 mg/2800 international units)(N=357) 4 (1.1) 37 (10.4) 87 (24.4) 84 (23.5) 82 (23.0) 63 (17.7)
FOSAMAX 70 mg(N=351) 46 (13.1) 66 (18.8) 108 (30.8) 58 (16.5) 37 (10.5) 36 (10.3)

Patients (n=652) who completed the above 15-week trial continued in a 24-week extension in which all received FOSAMAX PLUS D (70 mg/2800 international units) and were randomly assigned to receive either additional once weekly vitamin D3 2800 international units (Vitamin D3 5600 international units group) or matching placebo (Vitamin D3 2800 international units group). After 24 weeks of extended treatment (Week 39 from original baseline), the mean levels of 25-hydroxyvitamin D were 27.9 ng/mL and 25.6 ng/mL in the vitamin D3 5600 international units group and vitamin D3 2800 international units group, respectively. The percentage of patients with hypercalciuria at Week 39 was not statistically different between treatment groups.

The distribution of the final levels of 25-hydroxyvitamin D at Week 39 is summarized in Table 5.

Table 5: 25-hydroxyvitamin D Levels after Treatment with FOSAMAX PLUS D at Week 39
Number (%) of Patients
*
Patients received FOSAMAX 70 mg or FOSAMAX PLUS D (70 mg/2800 international units) for the 15-week base study followed by FOSAMAX PLUS D (70 mg/2800 international units) and 2800 international units additional vitamin D3 for the 24-week extension study.
Patients received FOSAMAX 70 mg or FOSAMAX PLUS D (70 mg/2800 international units) for 15-week base study followed by FOSAMAX PLUS D (70 mg/2800 international units) and placebo for the additional vitamin D3 for 24-week extension study.
25-hydroxyvitamin D Ranges (ng/mL) <9 9-14 15-19 20-24 25-29 30-59
FOSAMAX PLUS D (Vitamin D3 5600 international units group)* (N=321) 0 10 (3.1) 29 (9.0) 79 (24.6) 87 (27.1) 116 (36.1)
FOSAMAX PLUS D (Vitamin D3 2800 international units group) (N=320) 1 (0.3) 17 (5.3) 56 (17.5) 80 (25.0) 74 (23.1) 92 (28.8)

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