During bisphosphonate treatment patients should be advised to report any thigh, hip or groin pain and any patient presenting with such symptoms should be eva luated for an incomplete femur fracture.

4.5 Interaction with other medicinal products and other forms of interaction

 In clinical studies, Zometa has been administered concomitantly with commonly used anticancer agents, diuretics, antibiotics and analgesics without clinically apparent interactions occurring. Zoledronic acid shows no appreciable binding to plasma proteins and does not inhibit human P450 enzymes in vitro (see section 5.2), but no formal clinical interaction studies have been performed.

Caution is advised when bisphosphonates are administered with aminoglycosides, since both agents may have an additive effect, resulting in a lower serum calcium level for longer periods than required.

Caution is indicated when Zometa is used with other potentially nephrotoxic medicinal products. Attention should also be paid to the possibility of hypomagnesaemia developing during treatment.

In multiple myeloma patients, the risk of renal dysfunction may be increased when Zometa is used in combination with thalidomide.

4.6 Pregnancy and lactation

 Pregnancy

There are no adequate data on the use of zoledronic acid in pregnant women. Animal reproduction studies with zoledronic acid have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. Zometa should not be used during pregnancy.

Breast-feeding

It is not known whether zoledronic acid is excreted into human milk. Zometa is contraindicated in breast-feeding women (see section 4.3).

Fertility

Zoledronic acid was eva luated in rats for potential adverse effects on fertility of the parental and F1 generation. This resulted in exaggerated pharmacological effects considered to be related to the compound's inhibition of skeletal calcium metabolisation, resulting in periparturient hypocalcaemia, a bisphosphonate class effect, dystocia and early termination of the study. Thus these results precluded determining a definitive effect of zoledronic acid on fertility in humans.

4.7 Effects on ability to drive and use machines

 Adverse reactions, such as dizziness and somnolence, may have influence on the ability to drive or use machines, therefore caution should be exercised with the use of Zometa along with driving and operating of machinery.

4.8 Undesirable effects

 Summary of the safety profile

Within three days after Zometa administration, an acute phase reaction has commonly been reported, with symptoms including bone pain, fever, fatigue, arthralgia, myalgia and rigors; these symptoms usually resolve within a few days (see description of selected adverse reactions).

The following are the important identified risks with Zometa in the approved indications:

Renal function impairment, osteonecrosis of the jaw, acute phase reaction, hypocalcaemia, ocular adverse events, atrial fibrillation, anaphylaxis. The frequencies for each of these identified risks are shown in Table 2.

Tabulated list of adver