Alendronate (alendronic acid; 4-amino-1-hydroxybutylidene bisphosphonate) h
as demonstrated effectiveness orally in the treatment and prevention of pos
tmenopausal osteoporosis, corticosteroid-induced osteoporosis and Paget's d
isease of the bone. Its primary mechanism of action involves the inhibition
of osteoclastic bone resorption. The pharmacokinetics and pharmacodynamics
of alendronate must be interpreted in the context of its unique properties
, which include targeting to the skeleton and incorporation into the skelet
al matrix.
Preclinically, alendronate is not metabolised in animals and is cleared fro
m the plasma by uptake into bone and elimination via renal excretion. Altho
ugh soon after administration the drug distributes widely in the body, this
transient state is rapidly followed by a nonsaturable redistribution to sk
eletal tissues. Oral bioavailability is about 0.9 to 1.8%, and food markedl
y inhibits oral absorption. Removal of the drug from bone reflects the unde
rlying rate of turnover of the skeleton. Renal clearance appears to involve
both glomerular filtration and a specialised secretory pathway.
Clinically, the pharmacokinetics of alendronate have been characterised alm
ost exclusively based on urinary excretion data because of the extremely lo
w concentrations achieved after oral administration. After intravenous admi
nistration of radiolabelled alendronate to women, no metabolites of the dru
g were detectable and urinary excretion was the sole means of elimination.
About 40 to 60% of the dose is retained for a long time in the body, presum
ably in the skeleton, with no evidence of saturation or influence of one in
travenous dose on the pharmacokinetics of subsequent doses.
The oral bioavailability of alendronate in the fasted state is about 0.7%,
with no significant difference between men and women. Absorption and dispos
ition appear independent of dose. Food substantially reduces the bioavailab
ility of oral alendronate; otherwise, no substantive drug interactions have
been identified.
The pharmacokinetic properties of alendronate are evident pharmacodynamical
ly. Alendronate treatment results in an early and dose-dependent inhibition
of skeletal resorption, which can be followed clinically with biochemical
markers, and which ultimately reaches a plateau and is slowly reversible up
on discontinuation of the drug. These findings reflect the uptake of the dr
ug into bone, where it exerts its pharmacological activity, and a time cour
se that results from the long residence time in the skeleton. The net resul
t is that alendronate corrects the underlying imbalance in skeletal turnove
r characteristic of several disease states. In women with postmenopausal os
teoporosis, for example, alendronate treatment results in increases in bone
mass and a reduction in fracture incidence, including at the hip.