ZOLEDRONIC ACID

Zoledronic acid injection contains zoledronic acid, a bisphosphonic acid which is an inhibitor of osteoclastic bone resorption. Zoledronic acid is designated chemically as (1-Hydroxy-2-imidazol-1-yl-phosphonoethyl) phosphonic acid monohydrate and its structural formula is: Zoledronic acid monohydrate is a white crystalline powder. Its molecular formula is C 5 H 10 N 2 O 7 P 2 • H 2 O and a molar mass of 290.1 g/Mol. Zoledronic acid is sparingly soluble in 0.1N sodium hydroxide solution and slightly soluble in water. The pH of the zoledronic acid injection solution for infusion is approximately 6.0 to 7.0. Zoledronic acid injection is available as a sterile solution in a ready-to-infuse bag for intravenous infusion. One ready-to-infuse bag with 100 mL solution contains 5.330 mg of zoledronic acid monohydrate, equivalent to 5 mg zoledronic acid on an anhydrous basis. Inactive Ingredients : 4950 mg of mannitol, USP; and 30 mg of sodium citrate, USP. image01

Zoledronic acid injection is a bisphosphonate indicated for: • Treatment and prevention of postmenopausal osteoporosis ( 1.1 , 1.2 ) • Treatment to increase bone mass in men with osteoporosis ( 1.3 ) • Treatment and prevention of glucocorticoid-induced osteoporosis ( 1.4 ) • Treatment of Paget’s disease of bone in men and women ( 1.5 ) Limitations of Use Optimal duration of use has not been determined. For patients at low-risk for fracture, consider drug discontinuation after 3 to 5 years of use ( 1.6 ) 1.1 Treatment of Osteoporosis in Postmenopausal Women Zoledronic acid injection is indicated for treatment of osteoporosis in postmenopausal women. In postmenopausal women with osteoporosis, diagnosed by bone mineral density (BMD) or prevalent vertebral fracture, zoledronic acid injection reduces the incidence of fractures (hip, vertebral and non-vertebral osteoporosis-related fractures). In patients at high risk of fracture, defined as a recent low-trauma hip fracture, zoledronic acid injection reduces the incidence of new clinical fractures [ see Clinical Studies (14.1) ]. 1.2 Prevention of Osteoporosis in Postmenopausal Women Zoledronic acid injection is indicated for prevention of osteoporosis in postmenopausal women [ see Clinical Studies (14.2) ]. 1.3 Osteoporosis in Men Zoledronic acid injection is indicated for treatment to increase bone mass in men with osteoporosis [ see Clinical Studies (14.3) ]. 1.4 Glucocorticoid-Induced Osteoporosis Zoledronic acid injection is indicated for the treatment and prevention of glucocorticoid-induced osteoporosis in men and women who are either initiating or continuing systemic glucocorticoids in a daily dosage equivalent to 7.5 mg or greater of prednisone and who are expected to remain on glucocorticoids for at least 12 months [ see Clinical Studies (14.4) ]. 1.5 Paget's Disease of Bone Zoledronic acid injection is indicated for treatment of Paget's disease of bone in men and women. Treatment is indicated in patients with Paget’s disease of bone with elevations in serum alkaline phosphatase of two times or higher than the upper limit of the age-specific normal reference range, or those who are symptomatic, or those at risk for complications from their disease [ see Clinical Studies (14.5) ]. 1.6 Important Limitations of Use The safety and effectiveness of zoledronic acid injection for the treatment of osteoporosis is based on clinical data of three years duration. The optimal duration of use has not been determined. All patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis. Patients at low-risk for fracture should be considered for drug discontinuation after 3 to 5 years of use. Patients who discontinue therapy should have their risk for fracture re-evaluated periodically.

Infusion given intravenously over no less than 15 minutes: • Treatment of postmenopausal osteoporosis ( 2.2 ); treatment to increase bone mass in men with osteoporosis ( 2.4 ): treatment and prevention of glucocorticoid-induced osteoporosis ( 2.5 ): 5 mg once a year • Prevention of postmenopausal osteoporosis: 5 mg once every 2 years ( 2.3 ) • Treatment of Paget’s disease of bone: a single 5 mg infusion. Patients should receive 1500 mg elemental calcium and 800 international units vitamin D daily ( 2.6 ) 2.1 Important Administration Instructions Zoledronic acid injection must be administered as an intravenous infusion over no less than 15 minutes. • Patients must be appropriately hydrated prior to administration of zoledronic acid injection [ see Warnings and Precautions (5.3) ]. • Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. • Intravenous infusion should be followed by a 10 mL normal saline flush of the intravenous line. • Administration of acetaminophen following zoledronic acid injection administration may reduce the incidence of acute-phase reaction symptoms. 2.2 Treatment of Osteoporosis in Postmenopausal Women The recommended regimen is a 5 mg infusion once a year given intravenously over no less than 15 minutes. 2.3 Prevention of Osteoporosis in Postmenopausal Women The recommended regimen is a 5 mg infusion given once every 2 years intravenously over no less than 15 minutes. 2.4 Osteoporosis in Men The recommended regimen is a 5 mg infusion once a year given intravenously over no less than 15 minutes. 2.5 Treatment and Prevention of Glucocorticoid-Induced Osteoporosis The recommended regimen is a 5 mg infusion once a year given intravenously over no less than 15 minutes. 2.6 Treatment of Paget's Disease of Bone The recommended dose is a 5 mg infusion. The infusion time must not be less than 15 minutes given over a constant infusion rate. Re-treatment of Paget's Disease After a single treatment with zoledronic acid injection in Paget’s disease an extended remission period is observed. Specific re-treatment data are not available. However, re-treatment with zoledronic acid injection may be considered in patients who have relapsed, based on increases in serum alkaline phosphatase, or in those patients who failed to achieve normalization of their serum alkaline phosphatase, or in those patients with symptoms, as dictated by medical practice. 2.7 Laboratory Testing and Oral Examination Prior to Administration • Prior to administration of each dose of zoledronic acid injection, obtain a serum creatinine and creatinine clearance should be calculated based on actual body weight using Cockcroft-Gault formula before each zoledronic acid injection dose. Zoledronic acid injection is contraindicated in patients with creatinine clearance less than 35 mL/min and in those with evidence of acute renal impairment. A 5 mg dose of zoledronic acid injection administered intravenously is recommended for patients with creatinine clearance greater than or equal to 35 mL/min. There are no safety or efficacy data to support the adjustment of the zoledronic acid injection dose based on baseline renal function. Therefore, no dose adjustment is required in patients with CrCl greater than or equal to 35 mL/min [ see Contraindications ( 4 ), Warnings and Precautions (5.3 )]. • A routine oral examination should be performed by the prescriber prior to initiation of zoledronic acid injection treatment [ see Warnings and Precautions (5.4 )]. 2.8 Calcium and Vitamin D Supplementation • Instruct patients being treated for Paget’s disease of bone on the importance of calcium and vitamin D supplementation in maintaining serum calcium levels, and on the symptoms of hypocalcemia. All patients should take 1500 mg elemental calcium daily in divided doses (750 mg two times a day, or 500 mg three times a day) and 800 international units vitamin D daily, particularly in the 2 weeks following zoledronic acid injection administration [ see Warnings and Precautions (5.2 )]. • Instruct patients being treated for osteoporosis to take supplemental calcium and vitamin D if their dietary intake is inadequate. An average of at least 1200 mg calcium and 800 to 1000 international units vitamin D daily is recommended. 2.9 Method of Administration The zoledronic acid injection infusion time must not be less than 15 minutes given over a constant infusion rate. The intravenous infusion should be followed by a 10 mL normal saline flush of the intravenous line. Zoledronic acid injection solution for infusion must not be allowed to come in contact with any calcium or other divalent cation-containing solutions, and should be administered as a single intravenous solution through a separate infusion line. If refrigerated, allow the refrigerated solution to reach room temperature before administration. After opening, the solution is stable for 24 hours at 2° to 8°C (36° to 46°F) [ see How Supplied/Storage and Handling (16 )].

Zoledronic acid injection is contraindicated in patients with the following conditions: • Hypocalcemia [ see Warnings and Precautions ( 5.2 ) ] • Creatinine clearance less than 35 mL/min and in those with evidence of acute renal impairment due to an increased risk of renal failure [ see Warnings and Precautions ( 5.3 ) ]. • Known hypersensitivity to zoledronic acid or any components of zoledronic acid injection. Hypersensitivity reactions including urticaria, angioedema, and anaphylactic reaction/shock have been reported [ see Adverse Reactions ( 6.2 ) ]. • Hypocalcemia ( 4 ) • Patients with creatinine clearance less than 35 mL/min and in those with evidence of acute renal impairment ( 4 , 5.3 ) • Hypersensitivity to any component of zoledronic acid injection ( 4 , 6.2 )

The most common adverse reactions (greater than 10%) were pyrexia, myalgia, headache, arthralgia, pain in extremity ( 6.1 ). Other important adverse reactions were flu-like illness, nausea, vomiting, diarrhea ( 6.2 ), and eye inflammation ( 6.1 ). To report SUSPECTED ADVERSE REACTIONS, contact Gland Pharma at 864-879-9994 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Treatment of Osteoporosis in Postmenopausal Women The safety of zoledronic acid injection in the treatment of postmenopausal osteoporosis was assessed in Study 1, a large, randomized, double-blind, placebo-controlled, multinational study of 7736 postmenopausal women aged 65 to 89 years with osteoporosis, diagnosed by bone mineral density or the presence of a prevalent vertebral fracture. The duration of the trial was three years with 3862 patients exposed to zoledronic acid injection and 3852 patients exposed to placebo administered once annually as a single 5 mg dose in 100 mL solution infused over at least 15 minutes, for a total of three doses. All women received 1000 to 1500 mg of elemental calcium plus 400 to 1200 international units of vitamin D supplementation per day. The incidence of all-cause mortality was similar between groups: 3.4% in the zoledronic acid injection group and 2.9% in the placebo group. The incidence of serious adverse events was 29.2% in the zoledronic acid injection group and 30.1% in the placebo group. The percentage of patients who withdrew from the study due to adverse events was 5.4% and 4.8% for the zoledronic acid injection and placebo groups, respectively. The safety of zoledronic acid injection in the treatment of osteoporosis patients with a recent (within 90 days) low-trauma hip fracture was assessed in Study 2, a randomized, double-blind, placebo-controlled, multinational endpoint-driven study of 2127 men and women aged 50 to 95 years; 1065 patients were randomized to zoledronic acid injection and 1062 patients were randomized to placebo. Zoledronic acid injection was administered once annually as a single 5 mg dose in 100 mL solution infused over at least 15 minutes. The study continued until at least 211 patients had a confirmed clinical fracture in the study population who were followed for an average of approximately 2 years on study drug. Vitamin D levels were not routinely measured but a loading dose of vitamin D (50,000 to 125,000 international units orally or IM) was given to patients and they were started on 1000 to 1500 mg of elemental calcium plus 800 to 1200 international units of vitamin D supplementation per day for at least 14 days prior to the study drug infusions. The incidence of all-cause mortality was 9.6% in the zoledronic acid injection group and 13.3% in the placebo group. The incidence of serious adverse events was 38.3% in the zoledronic acid injection group and 41.3% in the placebo group. The percentage of patients who withdrew from the study due to adverse events was 5.3% and 4.7% for the zoledronic acid injection and placebo groups, respectively. Adverse reactions reported in at least 2% of patients with osteoporosis and more frequently in the zoledronic acid injection-treated patients than placebo-treated patients in either osteoporosis trial are shown below in Table 1. Table 1: Adverse Reactions Occurring in greater than or equal to 2.0% of Patients with Osteoporosis and More Frequently than in Placebo-Treated Patients System Organ Class Study 1 Study 2 5 mg IV zoledronic acid injection once per year % (N = 3862) Placebo once per year % (N = 3852) 5 mg IV zoledronic acid injection once per year % (N = 1054) Placebo once per year % (N = 1057) Blood and the Lymphatic System Disorders Anemia 4.4 3.6 5.3 5.2 Metabolism and Nutrition Disorders Dehydration 0.6 0.6 2.5 2.3 Anorexia 2.0 1.1 1.0 1.0 Nervous System Disorders Headache 12.4 8.1 3.9 2.5 Dizziness 7.6 6.7 2.0 4.0 Ear and Labyrinth Disorders Vertigo 4.3 4.0 1.3 1.7 Cardiac Disorders Atrial Fibrillation 2.4 1.9 2.8 2.6 Vascular Disorders Hypertension 12.7 12.4 6.8 5.4 Gastrointestinal Disorders Nausea 8.5 5.2 4.5 4.5 Diarrhea 6.0 5.6 5.2 4.7 Vomiting 4.6 3.2 3.4 3.4 Abdominal Pain Upper 4.6 3.1 0.9 1.5 Dyspepsia 4.3 4.0 1.7 1.6 Musculoskeletal, Connective Tissue and Bone Disorders Arthralgia 23.8 20.4 17.9 18.3 Myalgia 11.7 3.7 4.9 2.7 Pain in Extremity 11.3 9.9 5.9 4.8 Shoulder Pain 6.9 5.6 0.0 0.0 Bone Pain 5.8 2.3 3.2 1.0 Neck Pain 4.4 3.8 1.4 1.1 Muscle Spasms 3.7 3.4 1.5 1.7 Osteoarthritis 9.1 9.7 5.7 4.5 Musculoskeletal Pain 0.4 0.3 3.1 1.2 General Disorders and Administrative Site Conditions Pyrexia 17.9 4.6 8.7 3.1 Influenza-like Illness 8.8 2.7 0.8 0.4 Fatigue 5.4 3.5 2.1 1.2 Chills 5.4 1.0 1.5 0.5 Asthenia 5.3 2.9 3.2 3.0 Peripheral Edema 4.6 4.2 5.5 5.3 Pain 3.3 1.3 1.5 0.5 Malaise 2.0 1.0 1.1 0.5 Hyperthermia 0.3 <0.1 2.3 0.3 Chest Pain 1.3 1.1 2.4 1.8 Investigations Creatinine Renal Clearance Decreased 2.0 2.4 2.1 1.7 Renal Impairment Treatment with intravenous bisphosphonates, including zoledronic acid, has been associated with renal impairment manifested as deterioration in renal function (i.e., increased serum creatinine) and in rare cases, acute renal failure. In the clinical trial for postmenopausal osteoporosis, patients with baseline creatinine clearance less than 30 mL/min (based on actual body weight), urine dipstick greater than or equal to 2+ protein or increase in serum creatinine of greater than 0.5 mg/dL during the screening visits were excluded. The change in creatinine clearance (measured annually prior to dosing) and the incidence of renal failure and impairment was comparable for both the zoledronic acid injection and placebo treatment groups over 3 years, including patients with creatinine clearance between 30 to 60 mL/min at baseline. Overall, there was a transient increase in serum creatinine observed within 10 days of dosing in 1.8% of zoledronic acid injection-treated patients versus 0.8% of placebo-treated patients which resolved without specific therapy [ see Warnings and Precautions ( 5.3 )]. Acute Phase Reaction The signs and symptoms of acute phase reaction occurred in Study 1 following zoledronic acid injection infusion including fever (18%), myalgia (9%), flu-like symptoms (8%), headache (7%), and arthralgia (7%). The majority of these symptoms occurred within the first 3 days following the dose of zoledronic acid injection and usually resolved within 3 days of onset but resolution could take up to 7 to 14 days. In Study 2, patients without a contraindication to acetaminophen were provided with a standard oral dose at the time of the IV infusion and instructed to use additional acetaminophen at home for the next 72 hours as needed. Zoledronic acid injection was associated with fewer signs and symptoms of a transient acute phase reaction in this trial: fever (7%) and arthralgia (3%). The incidence of these symptoms decreased with subsequent doses of zoledronic acid injection. Laboratory Findings In Study 1, in women with postmenopausal osteoporosis, approximately 0.2% of patients had notable declines of serum calcium levels (less than 7.5 mg/dL) following zoledronic acid injection administration. No symptomatic cases of hypocalcemia were observed. In Study 2, following pre-treatment with vitamin D, no patients had treatment emergent serum calcium levels below 7.5 mg/dL. Injection Site Reactions In the osteoporosis trials, local reactions at the infusion site such as itching, redness and/or pain have been reported in 0% to 0.7% of patients following the administration of zoledronic acid injection and 0% to 0.5% of patients following administration of placebo. Osteonecrosis of the Jaw In the postmenopausal osteoporosis trial, Study 1, in 7736 patients, after initiation of therapy, symptoms consistent with ONJ occurred in one patient treated with placebo and one patient treated with zoledronic acid injection. Both cases resolved after appropriate treatment [ see Warnings and Precautions ( 5.4 )]. No reports of osteonecrosis of the jaw were reported in either treatment group in Study 2. Atrial Fibrillation In the postmenopausal osteoporosis trial, Study 1, adjudicated serious adverse events of atrial fibrillation in the zoledronic acid treatment group occurred in 1.3% of patients (50 out of 3862) compared to 0.4% (17 out of 3852) in the placebo group. The overall incidence of all atrial fibrillation adverse events in the zoledronic acid treatment group was reported in 2.5% of patients (96 out of 3862) in the zoledronic acid injection group vs. 1.9% of patients (75 out of 3852) in the placebo group. Over 90% of these events in both treatment groups occurred more than a month after the infusion. In an ECG sub-study, ECG measurements were performed on a subset of 559 patients before and 9 to 11 days after treatment. There was no difference in the incidence of atrial fibrillation between treatment groups suggesting these events were not related to the acute infusions. In Study 2, adjudicated serious adverse events of atrial fibrillation in the zoledronic acid treatment group occurred in 1.0% of patients (11 out of 1054) compared to 1.2% (13 out of 1057) in the placebo group demonstrating no difference between treatment groups. Ocular Adverse Events Cases of iritis/uveitis/episcleritis/conjunctivitis have been reported in patients treated with bisphosphonates, including zoledronic acid. In the osteoporosis trials, 1 (less than 0.1%) to 9 (0.2%) patients treated with zoledronic acid injection and 0 (0%) to 1 (less than 0.1%) patient treated with placebo developed iritis/uveitis/episcleritis. Prevention of Osteoporosis in Postmenopausal Women The safety of zoledronic acid injection in postmenopausal women with osteopenia (low bone mass) was assessed in a 2-year randomized, multi-center, double-blind, placebo-controlled study of 581 postmenopausal women aged greater than or equal to 45 years. Patients were randomized to one of three treatment groups: (1) zoledronic acid injection given at randomization and Month 12 (n = 198); (2) zoledronic acid injection given at randomization and placebo at Month 12 (n = 181); and (3) placebo given at randomization and Month 12 (n = 202). Zoledronic acid injection was administered as a single 5 mg dose in 100 mL solution infused over at least 15 minutes. All women received 500 to 1200 mg elemental calcium plus 400 to 800 international units vitamin D supplementation per day. The incidence of serious adverse events was similar for subjects given (1) zoledronic acid injection at randomization and at Month 12 (10.6%), (2) zoledronic acid injection at randomization and placebo given at Month 12 (9.4%), and (3) placebo at randomization and at Month 12 (11.4%). The percentages of patients who withdrew from the study due to adverse events were 7.1%, 7.2%, and 3.0% in the two zoledronic acid injection groups and placebo group, respectively. Adverse reactions reported in at least 2% of patients with osteopenia and more frequently in the zoledronic acid injection-treated patients than placebo-treated patients are shown in Table 2. Table 2: Adverse Reactions Occurring in greater than or equal to 2% of Patients with Osteopenia and More Frequently than in Placebo-Treated Patients System Organ Class 5 mg IV zoledronic acid injection once per year % (n = 198) 5 mg IV zoledronic acid injection once % (n = 181) Placebo once per year % (n = 202) Metabolism and Nutrition Disorders Anorexia 2.0 0.6 0.0 Nervous System Disorders Headache 14.6 20.4 11.4 Dizziness 7.6 6.1 3.5 Hypoesthesia 5.6 2.2 2.0 Ear and Labyrinth Disorders Vertigo 2.0 1.7 1.0 Vascular Disorders Hypertension 5.1 8.3 6.9 Gastrointestinal Disorders Nausea 17.7 11.6 7.9 Diarrhea 8.1 6.6 7.9 Vomiting 7.6 5.0 4.5 Dyspepsia 7.1 6.6 5.0 Abdominal Pain* 8.6 6.6 7.9 Constipation 6.6 7.2 6.9 Abdominal Discomfort 2.0 1.1 0.5 Abdominal Distension 2.0 0.6 0.0 Skin and Subcutaneous Tissue Disorders Rash 3.0 2.2 2.5 Musculoskeletal and Connective Tissue Disorders Arthralgia 27.3 18.8 19.3 Myalgia 19.2 22.7 6.9 Back Pain 18.2 16.6 11.9 Pain in Extremity 11.1 16.0 9.9 Muscle Spasms 5.6 2.8 5.0 Musculoskeletal Pain** 8.1 7.2 7.9 Bone Pain 5.1 3.3 1.0 Neck Pain 5.1 6.6 5.0 Arthritis 4.0 2.2 1.5 Joint Stiffness 3.5 1.1 2.0 Joint Swelling 3.0 0.6 0.0 Flank Pain 2.0 0.6 0.0 Pain in Jaw 2.0 3.9 2.5 General Disorders and Administration Site Conditions Pain 24.2 14.9 3.5 Pyrexia 21.7 21.0 4.5 Chills 18.2 18.2 3.0 Fatigue 14.6 9.9 4.0 Asthenia 6.1 2.8 1.0 Peripheral Edema 5.6 3.9 3.5 Non-cardiac Chest Pain 3.5 7.7 3.0 Influenza-like Illness 1.5 3.3 2.0 Malaise 1.0 2.2 0.5 * Combined abdominal pain, abdominal pain upper, and abdominal pain lower as one ADR ** Combined musculoskeletal pain and musculoskeletal chest pain as one ADR Ocular Adverse Events Cases of iritis/uveitis/episcleritis/conjunctivitis have been reported in patients treated with bisphosphonates, including zoledronic acid. In the osteoporosis prevention trial, 4 (1.1%) patients treated with zoledronic acid injection and 0 (0%) patients treated with placebo developed iritis/uveitis. Acute Phase Reaction In patients given zoledronic acid injection at randomization and placebo at Month 12, zoledronic acid injection was associated with signs and symptoms of an acute phase reaction: myalgia (20.4%), fever (19.3%), chills (18.2%), pain (13.8%), headache (13.3%), fatigue (8.3%), arthralgia (6.1%), pain in extremity (3.9%), influenza-like illness (3.3%), and back pain (1.7%), which occurred within the first 3 days following the dose of zoledronic acid injection. The majority of these symptoms were mild to moderate and resolved within 3 days of the event onset but resolution could take up to 7 to 14 days. Osteoporosis in Men The safety of zoledronic acid injection in men with osteoporosis or osteoporosis secondary to hypogonadism was assessed in a two year randomized, multicenter, double-blind, active controlled group study of 302 men aged 25 to 86 years. One hundred fifty three (153) patients were exposed to zoledronic acid injection administered once annually with a 5 mg dose in 100 mL infused over 15 minutes for up to a total of two doses, and 148 patients were exposed to a commercially-available oral weekly bisphosphonate (active control) for up to two years. All participants received 1000 mg of elemental calcium plus 800 to 1000 international units of vitamin D supplementation per day. The incidence of all-cause mortality (one in each group) and serious adverse events were similar between the zoledronic acid injection and active control treatment groups. The percentage of patients experiencing at least one adverse event was comparable between the zoledronic acid injection and active control groups, with the exception of a higher incidence of post-dose symptoms in the zoledronic acid injection group that occurred within 3 days after infusion. The overall safety and tolerability of zoledronic acid injection was similar to the active control. Adverse reactions reported in at least 2% of men with osteoporosis and more frequently in the zoledronic acid injection-treated patients than the active control-treated patients and either (1) not reported in the postmenopausal osteoporosis treatment trial or (2) reported more frequently in the trial of osteoporosis in men are presented in Table 3. Therefore, Table 3 should be viewed in conjunction with Table 1. Table 3: Adverse Reactions Occurring in greater than or equal to 2% of Men with Osteoporosis and More Frequently in the Zoledronic Acid Injection-Treated Patients than the Active Control-Treated Patients and either (1) Not Reported in the Postmenopausal Osteoporosis Treatment Trial or (2) Reported More Frequently in this Trial System Organ Class 5 mg IV zoledronic acid injection once per year % (N = 153) Active Control once weekly % (N = 148) Nervous System Disorders Headache 15.0 6.1 Lethargy 3.3 1.4 Eye Disorders Eye Pain 2.0 0.0 Cardiac Disorders Atrial Fibrillation 3.3 2.0 Palpitations 2.6 0.0 Respiratory, Thoracic and Mediastinal Disorders Dyspnea 6.5 4.7 Abdominal Pain* 7.9 4.1 Skin and Subcutaneous Tissue Disorders Hyperhidrosis 2.6 2.0 Musculoskeletal, Connective Tissue and Bone Disorders Myalgia 19.6 6.8 Musculoskeletal Pain** 12.4 10.8 Musculoskeletal Stiffness 4.6 0.0 Renal and Urinary Disorders Blood Creatinine Increased 2.0 0.7 General Disorders and Administrative Site Conditions Fatigue 17.6 6.1 Pain 11.8 4.1 Chills 9.8 2.7 Influenza-like Illness 9.2 2.0 Malaise 7.2 0.7 Acute Phase Reaction 3.9 0.0 Investigations C-reactive Protein Increased 4.6 1.4 * Combined abdominal pain, abdominal pain upper, and abdominal pain lower as one ADR ** Combined musculoskeletal pain and musculoskeletal chest pain as one ADR Renal Impairment Creatinine clearance was measured annually prior to dosing and changes in long-term renal function over 24 months were comparable in the zoledronic acid injection and active control groups [ see Warnings and Precautions ( 5.3 )]. Acute Phase Reaction Zoledronic acid injection was associated with signs and symptoms of an acute phase reaction: myalgia (17.1%), fever (15.7%), fatigue (12.4%), arthralgia (11.1%), pain (10.5%), chills (9.8%), headache (9.8%), influenza-like illness (8.5%), malaise (5.2%), and back pain (3.3%), which occurred within the first 3 days following the dose of zoledronic acid injection. The majority of these symptoms were mild to moderate and resolved within 3 days of the event onset but resolution could take up to 7 to 14 days. The incidence of these symptoms decreased with subsequent doses of zoledronic acid injection. Atrial Fibrillation The incidence of all atrial fibrillation adverse events in the zoledronic acid injection treatment group was 3.3% (5 out of 153) compared to 2.0% (3 out of 148) in the active control group. However, there were no patients with adjudicated serious adverse events of atrial fibrillation in the zoledronic acid injection treatment group. Laboratory Findings There were no patients who had treatment emergent serum calcium levels below 7.5 mg/dL. Injection Site Reactions There were 4 patients (2.6%) on zoledronic acid injection vs. 2 patients (1.4%) on active control with local site reactions. Osteonecrosis of the Jaw In this trial there were no cases of osteonecrosis of the jaw [ see Warnings and Precautions ( 5.4 )]. Glucocorticoid-Induced Osteoporosis The safety of zoledronic acid injection in men and women in the treatment and prevention of glucocorticoid-induced osteoporosis was assessed in a randomized, multicenter, double-blind, active controlled, stratified study of 833 men and women aged 18 to 85 years treated with greater than or equal to 7.5 mg/day oral prednisone (or equivalent). Patients were stratified according to the duration of their pre-study corticosteroid therapy: less than or equal to 3 months prior to randomization (prevention subpopulation), and greater than 3 months prior to randomization (treatment subpopulation). The duration of the trial was one year with 416 patients exposed to zoledronic acid injection administered once as a single 5 mg dose in 100 mL infused over 15 minutes, and 417 patients exposed to a commercially-available oral daily bisphosphonate (active control) for one year. All participants received 1000 mg of elemental calcium plus 400 to 1000 international units of vitamin D supplementation per day. The incidence of all–cause mortality was similar between treatment groups: 0.9% in the zoledronic acid injection group and 0.7% in the active control group. The incidence of serious adverse events was similar between the zoledronic acid injection treatment and prevention groups, 18.4% and 18.1%, respectively, and the active control treatment and prevention groups, 19.8% and 16.0%, respectively. The percentage of subjects who withdrew from the study due to adverse events was 2.2% in the zoledronic acid injection group vs. 1.4% in the active control group. The overall safety and tolerability were similar between zoledronic acid injection and active control groups with the exception of a higher incidence of post-dose symptoms in the zoledronic acid injection group that occurred within 3 days after infusion. The overall safety and tolerability profile of zoledronic acid injection in glucocorticoid-induced osteoporosis was similar to the adverse events reported in the zoledronic acid injection postmenopausal osteoporosis clinical trial. Adverse reactions reported in at least 2% of patients that were either not reported in the postmenopausal osteoporosis treatment trial or reported more frequently in the treatment and prevention of glucocorticoid-induced osteoporosis trial included the following: abdominal pain (zoledronic acid injection 7.5%; active control 5.0%), and musculoskeletal pain (zoledronic acid injection 3.1%; active control 1.7%). Other musculoskeletal events included back pain (zoledronic acid injection 4.3%, active control 6.2%), bone pain (zoledronic acid injection 3.1%, active control 2.2%), and pain in the extremity (zoledronic acid injection 3.1%, active control 1.2%). In addition, the following adverse events occurred more frequently than in the postmenopausal osteoporosis trial: nausea (zoledronic acid injection 9.6%; active control 8.4%), and dyspepsia (zoledronic acid injection 5.5%; active control 4.3%). Renal Impairment Renal function measured prior to dosing and at the end of the 12 month study was comparable in the zoledronic acid injection and active control groups [ see Warnings and Precautions ( 5.3 )]. Acute Phase Reaction Zoledronic acid injection was associated with signs and symptoms of a transient acute phase reaction that was similar to that seen in the zoledronic acid injection postmenopausal osteoporosis clinical trial. Atrial Fibrillation The incidence of atrial fibrillation adverse events was 0.7% (3 of 416) in the zoledronic acid injection group compared to no adverse events in the active control group. All subjects had a prior history of atrial fibrillation and no cases were adjudicated as serious adverse events. One patient had atrial flutter in the active control group. Laboratory Findings There were no patients who had treatment emergent serum calcium levels below 7.5 mg/dL. Injection Site Reactions There were no local reactions at the infusion site. Osteonecrosis of the Jaw In this trial there were no cases of osteonecrosis of the jaw [ see Warnings and Precautions ( 5.4 )]. Paget's Disease of Bone In the Paget’s disease trials, two 6-month, double-blind, comparative, multinational studies of 349 men and women aged greater than 30 years with moderate to severe disease and with confirmed Paget’s disease of bone, 177 patients were exposed to zoledronic acid injection and 172 patients exposed to risedronate. Zoledronic acid injection was administered once as a single 5 mg dose in 100 mL solution infused over at least 15 minutes. Risedronate was given as an oral daily dose of 30 mg for 2 months. The incidence of serious adverse events was 5.1% in the zoledronic acid injection group and 6.4% in the risedronate group. The percentage of patients who withdrew from the study due to adverse events was 1.7% and 1.2% for the zoledronic acid injection and risedronate groups, respectively. Adverse reactions occurring in at least 2% of the Paget’s patients receiving zoledronic acid injection (single 5 mg intravenous infusion) or risedronate (30 mg oral daily dose for 2 months) over a 6-month study period are listed by system organ class in Table 4. Table 4: Adverse Reactions Reported in at Least 2% of Paget’s Patients Receiving Zoledronic Acid Injection (Single 5 mg intravenous Infusion) or Risedronate (Oral 30 mg Daily for 2 Months) Over a 6-Month Follow-Up Period System Organ Class 5 mg IV zoledronic acid injection % (N = 177) 30 mg/day × 2 Months risedronate % (N = 172) Infections and Infestations Influenza 7 5 Metabolism and Nutrition Disorders Hypocalcemia 3 1 Anorexia 2 2 Nervous System Disorders Headache 11 10 Dizziness 9 4 Lethargy 5 1 Paresthesia 2 0 Respiratory, Thoracic and Mediastinal Disorders Dyspnea 5 1 Gastrointestinal Disorders Nausea 9 6 Diarrhea 6 6 Constipation 6 5 Dyspepsia 5 4 Abdominal Distension 2 1 Abdominal Pain 2 2 Vomiting 2 2 Abdominal Pain Upper 1 2 Skin and Subcutaneous Tissue Disorders Rash 3 2 Musculoskeletal, Connective Tissue and Bone Disorders Arthralgia 9 11 Bone Pain 9 5 Myalgia 7 4 Back Pain 4 7 Musculoskeletal Stiffness 2 1 General Disorders and Administrative Site Conditions Influenza-like Illness 11 6 Pyrexia 9 2 Fatigue 8 4 Rigors 8 1 Pain 5 4 Peripheral Edema 3 1 Asthenia 2 1 Laboratory Findings In the Paget’s disease trials, early, transient decreases in serum calcium and phosphate levels were observed. Approximately 21% of patients had serum calcium levels less than 8.4 mg/dL 9 to 11 days following zoledronic acid injection administration. Renal Impairment In clinical trials in Paget’s disease there were no cases of renal deterioration following a single 5 mg 15-minute infusion [ see Warnings and Precautions ( 5.3 )]. Acute Phase Reaction The signs and symptoms of acute phase reaction (influenza-like illness, pyrexia, myalgia, arthralgia, and bone pain) were reported in 25% of patients in the zoledronic acid injection-treated group compared to 8% in the risedronate-treated group. Symptoms usually occur within the first 3 days following zoledronic acid injection administration. The majority of these symptoms resolved within 4 days of onset. Osteonecrosis of the Jaw Osteonecrosis of the jaw has been reported with zoledronic acid [ see Warnings and Precautions ( 5.4 )]. 6.2 Post-Marketing Experience Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The following adverse reactions have been identified during post approval use of zoledronic acid injection: Acute Phase Reactions Fever, headache, flu-like symptoms, nausea, vomiting, diarrhea, arthralgia, and myalgia. Symptoms may be significant and lead to dehydration. Acute Renal Failure Acute renal failure requiring hospitalization and/or dialysis or with a fatal outcome have been rarely reported. Increased serum creatinine was reported in patients with 1) underlying renal disease, 2) dehydration secondary to fever, sepsis, gastrointestinal losses, or diuretic therapy, or 3) other risk factors such as advanced age, or concomitant nephrotoxic drugs in the post-infusion period. Transient rise in serum creatinine can be correctable with intravenous fluids. Allergic Reactions Allergic reactions with intravenous zoledronic acid including anaphylactic reaction/shock, urticaria, angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis, and bronchoconstriction have been reported. Asthma Exacerbations Asthma exacerbations have been reported. Hypocalcemia Hypocalcemia has been reported. Hypophosphatemia Hypophosphatemia has been reported. Osteonecrosis of the Jaw Osteonecrosis of the jaw has been reported. Osteonecrosis of other bones Cases of osteonecrosis of other bones (including femur, hip, knee, ankle, wrist and humerus) have been reported; causality has not been determined in the population treated with zoledronic acid injection. Ocular Adverse Events Cases of the following events have been reported: conjunctivitis, iritis, iridocyclitis, uveitis, episcleritis, scleritis and orbital inflammation/edema. Other Hypotension in patients with underlying risk factors has been reported.

No in vivo drug interaction studies have been performed for zoledronic acid injection. In vitro and ex vivo studies showed low affinity of zoledronic acid for the cellular components of human blood. In vitro mean zoledronic acid protein binding in human plasma ranged from 28% at 200 ng/mL to 53% at 50 ng/mL. In vivo studies showed that zoledronic acid is not metabolized, and is excreted into the urine as the intact drug. • Aminoglycosides: May lower serum calcium for prolonged periods ( 7.1 ) • Loop diuretics: May increase risk of hypocalcemia ( 7.2 ) • Nephrotoxic drugs: Use with caution ( 7.3 ) • Drugs primarily excreted by the kidney: Exposure may be increased with renal impairment. Monitor serum creatinine in patients at risk ( 7.4 ) 7.1 Aminoglycosides Caution is advised when bisphosphonates, including zoledronic acid, are administered with aminoglycosides, since these agents may have an additive effect to lower serum calcium level for prolonged periods. This effect has not been reported in zoledronic acid clinical trials. 7.2 Loop Diuretics Caution should also be exercised when zoledronic acid injection is used in combination with loop diuretics due to an increased risk of hypocalcemia. 7.3 Nephrotoxic Drugs Caution is indicated when zoledronic acid injection is used with other potentially nephrotoxic drugs such as nonsteroidal anti-inflammatory drugs. 7.4 Drugs Primarily Excreted by the Kidney Renal impairment has been observed following the administration of zoledronic acid in patients with pre-existing renal compromise or other risk factors [ see Warnings and Precautions ( 5.3 )]. In patients with renal impairment, the exposure to concomitant medications that are primarily renally excreted (e.g., digoxin) may increase. Consider monitoring serum creatinine in patients at risk for renal impairment who are taking concomitant medications that are primarily excreted by the kidney.