ther warfarin derivatives, prothrombin time should be monitored more closely when starting or stopping therapy with raloxifene hydrochloride tablets [see clinical pharmacology (12.3) ]. 7.3 other highly protein-bound drugs raloxifene hydrochloride tablets should be used with caution with certain other highly protein-bound drugs such as diazepam, diazoxide, and lidocaine. although not examined, raloxifene hydrochloride tablets might affect the protein binding of other drugs. raloxifene is more than 95% bound to plasma proteins [see clinical pharmacology (12.3) ]. 7.4 systemic estrogens the safety of concomitant use of raloxifene hydrochloride tablets with systemic estrogens has not been established and its use is not recommended. 7.5 other concomitant medications raloxifene hydrochloride tablets can be concomitantly administered with ampicillin, amoxicillin, antacids, corticosteroids, and digoxin [see clinical pharmacology (12.3) ]. the concomitant use of raloxifene hydrochloride tablets and lipid-lowering agents has not been studied.

the reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis [see clinical studies (14.3) ] . 1.3 reduction in the risk of invasive breast cancer in postmenopausal women at high risk of invasive breast cancer raloxifene hydrochloride tablets are indicated for the reduction in risk of invasive breast cancer in postmenopausal women at high risk of invasive breast cancer [see clinical studies (14.4) ] . the effect in the reduction in the incidence of breast cancer was shown in a study of postmenopausal women at high risk for breast cancer with a 5-year planned duration with a median follow-up of 4.3 years [see clinical studies (14.4) ] . twenty-seven percent of the participants received drug for 5 years. the long-term effects and the recommended length of treatment are not known. high risk of breast cancer is defined as at least one breast biopsy showing lobular carcinoma in situ (lcis) or atypical hyperplasia, one or more first-degree relatives with breast cancer, or a 5-year predicted risk of breast cancer ≥1.66% (based on the modified gail model). among the factors included in the modified gail model are the following: current age, number of first-degree relatives with breast cancer, number of breast biopsies, age at menarche, nulliparity or age of first live birth. healthcare professionals can obtain a gail model risk assessment tool by dialing 1-800-545-5979. currently, no single clinical finding or test result can quantify risk of breast cancer with certainty. after an assessment of the risk of developing breast cancer, the decision regarding therapy with raloxifene hydrochloride tablets should be based upon an individual assessment of the benefits and risks. raloxifene hydrochloride does not eliminate the risk of breast cancer. patients should have breast exams and mammograms before starting raloxifene hydrochloride tablets and should continue regular breast exams and mammograms in keeping with good medical practice after beginning treatment with raloxifene hydrochloride. important limitations of use for breast cancer risk reduction there are no data available regarding the effect of raloxifene hydrochloride on invasive breast cancer incidence in women with inherited mutations (brca1, brca2) to be able to make specific recommendations on the effectiveness of raloxifene hydrochloride. raloxifene hydrochloride tablets are not indicated for the treatment of invasive breast cancer or reduction of the risk of recurrence. raloxifene hydrochloride tablets are not indicated for the reduction in the risk of noninvasive breast cancer.

nous thromboembolism in clinical trials, raloxifene hydrochloride-treated women had an increased risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism). other venous thromboembolic events also could occur. a less serious event, superficial thrombophlebitis, also has been reported more frequently with raloxifene hydrochloride tablets than with placebo. the greatest risk for deep vein thrombosis and pulmonary embolism occurs during the first 4 months of treatment, and the magnitude of risk appears to be similar to the reported risk associated with use of hormone therapy. because immobilization increases the risk for venous thromboembolic events independent of therapy, raloxifene hydrochloride tablets should be discontinued at least 72 hours prior to and during prolonged immobilization (e.g., post-surgical recovery, prolonged bed rest), and raloxifene hydrochloride tablets therapy should be resumed only after the patient is fully ambulatory. in addition, women taking raloxifene hydrochloride tablets should be advised to move about periodically during prolonged travel. the risk-benefit balance should be considered in women at risk of thromboembolic disease for other reasons, such as congestive heart failure, superficial thrombophlebitis, and active malignancy [see contraindications (4.1) and adverse reactions (6.1) ]. 5.2 death due to stroke in a clinical trial of postmenopausal women with documented coronary heart disease or at increased risk for coronary events, an increased risk of death due to stroke was observed after treatment with raloxifene hydrochloride tablets. during an average follow-up of 5.6 years, 59 (1.2%) raloxifene hydrochloride tablets -treated women died due to a stroke compared to 39 (0.8%) placebo-treated women (22 versus 15 per 10,000 women-years; hazard ratio 1.49; 95% confidence interval, 1.00 to 2.24; p=0.0499). there was no statistically significant difference between treatment groups in a incidence of stroke (249 in raloxifene hydrochloride tablets [4.9%] versus 224 placebo [4.4%]). raloxifene hydrochloride tablets had no significant effect on all-cause mortality. the risk-benefit balance should be considered in women at risk for stroke, such as prior stroke or transient ischemic attack (tia), atrial fibrillation, hypertension, or cigarette smoking [see clinical studies (14.5) ]. 5.3 cardiovascular disease raloxifene hydrochloride tablets should not be used for the primary or secondary prevention of cardiovascular disease. in a clinical trial of postmenopausal women with documented coronary heart disease or at increased risk for coronary events, no cardiovascular benefit was demonstrated after treatment with raloxifene for 5 years [see clinical studies (14.5) ]. 5.4 premenopausal use there is no indication for premenopausal use of raloxifene hydrochloride tablets. safety of raloxifene hydrochloride tablets in premenopausal women has not been established and its use is not recommended. additionally, there is concern regarding inadvertent drug exposure in pregnancy in women of reproductive potential who become pregnant, due to risk of fetal harm [see use in specific populations (8.1) ]. 5.5 hepatic impairment raloxifene hydrochloride tablets should be used with caution in patients with hepatic impairment. safety and efficacy have not been established in patients with hepatic impairment [see clinical pharmacology (12.3) ]. 5.6 concomitant estrogen therapy the safety of concomitant use of raloxifene hydrochloride tablets with systemic estrogens has not been established and its use is not recommended. 5.7 history of hypertriglyceridemia when treated with estrogens limited clinical data suggest that some women with a history of marked hypertriglyceridemia (>5.6 mmol/l or >500 mg/dl) in response to treatment with oral estrogen or estrogen plus progestin may develop increased levels of triglycerides when treated with raloxifene hydrochloride tablets. women with this medical history should have serum triglycerides monitored when taking raloxifene hydrochloride tablets. 5.8 renal impairment raloxifene hydrochloride tablets should be used with caution in patients with moderate or severe renal impairment. safety and efficacy have not been established in patients with moderate or severe renal impairment [see clinical pharmacology (12.3) ]. 5.9 history of breast cancer raloxifene hydrochloride tablets have not been adequately studied in women with a prior history of breast cancer. 5.10 use in men there is no indication for the use of raloxifene hydrochloride tablets in men. raloxifene hydrochloride tablets have not been adequately studied in men and its use is not recommended. 5.11 unexplained uterine bleeding any unexplained uterine bleeding should be investigated as clinically indicated. raloxifene hydrochloride tablets-treated and placebo-treated groups had similar incidences of endometrial proliferation [see clinical studies (14.1 , 14.2 )] 5.12 breast abnormalities any unexplained breast abnormality occurring during raloxifene hydrochloride tablets therapy should be investigated. raloxifene hydrochloride does not eliminate the risk of breast cancer [see clinical studies (14.4 )].

risk for vitamin d insufficiency (e.g., over the age of 70 years, nursing home bound, or chronically ill) may need additional vitamin d supplements. patients with gastrointestinal malabsorption syndromes may require higher doses of vitamin d supplementation and measurement of 25-hydroxyvitamin d should be considered.

d trial. duration of treatment was 36 months, and 5129 postmenopausal women were exposed to raloxifene hydrochloride (2557 received 60 mg/day, and 2572 received 120 mg/day). the incidence of all-cause mortality was similar among groups: 23 (0.9%) placebo, 13 (0.5%) raloxifene hydrochloride tablets-treated (raloxifene hcl 60 mg), and 28 (1.1%) raloxifene hcl 120 mg women died. therapy was discontinued due to an adverse reaction in 10.9% of raloxifene hydrochloride tablets-treated women and 8.8% of placebo-treated women. venous thromboembolism: the most serious adverse reaction related to raloxifene hydrochloride tablets was vte (deep venous thrombosis, pulmonary embolism, and retinal vein thrombosis). during an average of study-drug exposure of 2.6 years, vte occurred in about 1 out of 100 patients treated with raloxifene hydrochloride tablets. twenty-six raloxifene hydrochloride tablets-treated women had a vte compared to 11 placebo-treated women, the hazard ratio was 2.4 (95% confidence interval, 1.2, 4.5), and the highest vte risk was during the initial months of treatment. common adverse reactions considered to be related to raloxifene hydrochloride tablets therapy were hot flashes and leg cramps. hot flashes occurred in about one in 10 patients on raloxifene hydrochloride tablets and were most commonly reported during the first 6 months of treatment and were not different from placebo thereafter. leg cramps occurred in about one in 14 patients on raloxifene hydrochloride tablets. placebo-controlled osteoporosis prevention clinical trials — the safety of raloxifene has been assessed primarily in 12 phase 2 and phase 3 studies with placebo, estrogen, and estrogen-progestin therapy control groups. the duration of treatment ranged from 2 to 30 months, and 2036 women were exposed to raloxifene hcl (371 patients received 10 to 50 mg/day, 828 received 60 mg/day, and 837 received from 120 to 600 mg/day). therapy was discontinued due to an adverse reaction in 11.4% of 581 raloxifene hydrochloride-treated women and 12.2% of 584 placebo-treated women. discontinuation rates due to hot flashes did not differ significantly between raloxifene hydrochloride and placebo groups (1.7% and 2.2%, respectively). common adverse reactions considered to be drug-related were hot flashes and leg cramps. hot flashes occurred in about one in four patients on raloxifene hydrochloride versus about one in six on placebo. the first occurrence of hot flashes was most commonly reported during the first 6 months of treatment. table 1 lists adverse reactions occurring in either the osteoporosis treatment or in five prevention placebo-controlled clinical trials at a frequency ≥2.0% in either group and in more raloxifene hydrochloride-treated women than in placebo-treated women. adverse reactions are shown without attribution of causality. the majority of adverse reactions occurring during the studies were mild and generally did not require discontinuation of therapy. table 1: adverse reactions occurring in placebo–controlled osteoporosis clinical trials at a frequency ≥2.0% and in more raloxifene hydrochloride tablets-treated (60 mg once daily) women than placebo-treated women a treatment prevention raloxifene hydrochloride tablets (n=2557) % placebo (n=2576) % raloxifene hydrochloride tablets (n=581) % placebo (n=584) % a a: placebo incidence greater than or equal to raloxifene hydrochloride tablets incidence; b: less than 2% incidence and more frequent with raloxifene hydrochloride tablets. b includes only patients with an intact uterus: prevention trials: raloxifene hydrochloride tablets, n=354, placebo,n=364; treatment trial: raloxifene hydrochloride tablets, n=1948, placebo, n=1999. c actual terms most frequently referred to endometrial fluid. body as a whole infection a a 15.1 14.6 flu syndrome 13.5 11.4 14.6 13.5 headache 9.2 8.5 a a leg cramps 7 3.7 5.9 1.9 chest pain a a 4 3.6 fever 3.9 3.8 3.1 2.6 cardiovascular system hot flashes 9.7 6.4 24.6 18.3 migraine a a 2.4 2.1 syncope 2.3 2.1 b b varicose vein 2.2 1.5 a a digestive system nausea 8.3 7.8 8.8 8.6 diarrhea 7.2 6.9 a a dyspepsia a a 5.9 5.8 vomiting 4.8 4.3 3.4 3.3 flatulence a a 3.1 2.4 gastrointestinal disorder a a 3.3 2.1 gastroenteritis b b 2.6 2.1 metabolic and nutritional weight gain a a 8.8 6.8 peripheral edema 5.2 4.4 3.3 1.9 musculoskeletal system arthralgia 15.5 14 10.7 10.1 myalgia a a 7.7 6.2 arthritis a a 4 3.6 tendon disorder 3.6 3.1 a a nervous system depression a a 6.4 6 insomnia a a 5.5 4.3 vertigo 4.1 3.7 a a neuralgia 2.4 1.9 b b hypesthesia 2.1 2 b b respiratory system sinusitis 7.9 7.5 10.3 6.5 rhinitis 10.2 10.1 a a bronchitis 9.5 8.6 a a pharyngitis 5.3 5.1 7.6 7.2 cough increased 9.3 9.2 6 5.7 pneumonia a a 2.6 1.5 laryngitis b b 2.2 1.4 skin and appendages rash a a 5.5 3.8 sweating 2.5 2 3.1 1.7 special senses conjunctivitis 2.2 1.7 a a urogenital system vaginitis a a 4.3 3.6 urinary tract infection a a 4 3.9 cystitis 4.6 4.5 3.3 3.1 leukorrhea a a 3.3 1.7 uterine disorder b,c 3.3 2.3 a a endometrial disorder b b b 3.1 1.9 vaginal hemorrhage 2.5 2.4 a a urinary tract disorder 2.5 2.1 a a comparison of raloxifene hydrochloride and hormone therapy — raloxifene hydrochloride tablets were compared with estrogen-progestin therapy in three clinical trials for prevention of osteoporosis. table 2 shows adverse reactions occurring more frequently in one treatment group and at an incidence ≥ 2.0% in any group. adverse reactions are shown without attribution of causality. table 2: adverse reactions reported in the clinical trials for osteoporosis prevention with raloxifene hydrochloride tablets (60 mg once daily) and continuous combined or cyclic estrogen plus progestin (hormone therapy) at an incidence ≥2.0% in any treatment group a raloxifene hydrochloride tablets (n=317) % hormone therapy-continuous combined b (n=96) % hormone therapy-cyclic c (n=219) % a these data are from both blinded and open-label studies. b continuous combined hormone therapy = 0.625 mg conjugated estrogens plus 2.5 mg medroxyprogesterone acetate. c cyclic hormone therapy = 0.625 mg conjugated estrogens for 28 days with concomitant 5 mg medroxyprogesterone acetate or 0.15 mg norgestrel on days 1 through 14 or 17 through 28. d includes only patients with an intact uterus: raloxifene hydrochloride tablets, n=290; hormone therapy-continuous combined, n=67; hormone therapy-cyclic, n=217. urogenital breast pain 4.4 37.5 29.7 vaginal bleeding d 6.2 64.2 88.5 digestive flatulence 1.6 12.5 6.4 cardiovascular hot flashes 28.7 3.1 5.9 body as a whole infection 11 0 6.8 abdominal pain 6.6 10.4 18.7 chest pain 2.8 0 0.5 breast pain — across all placebo-controlled trials, raloxifene was indistinguishable from placebo with regard to frequency and severity of breast pain and tenderness. raloxifene was associated with less breast pain and tenderness than reported by women receiving estrogens with or without added progestin. gynecologic cancers — raloxifene-treated and placebo-treated groups had similar incidences of endometrial cancer and ovarian cancer. placebo-controlled trial of postmenopausal women at increased risk for major coronary events (ruth) — the safety of raloxifene (60 mg once daily) was assessed in a placebo-controlled multinational trial of 10,101 postmenopausal women (age range 55 to 92) with documented coronary heart disease (chd) or multiple chd risk factors. median study drug exposure was 5.1 years for both treatment groups [see clinical studies ( 14.3 )].. therapy was discontinued due to an adverse reaction in 25% of 5044 raloxifene-treated women and 24% of 5057 placebo-treated women. the incidence per year of all-cause mortality was similar between the raloxifene (2.07%) and placebo (2.25%) groups. adverse reactions reported more frequently in raloxifene-treated women than in placebo-treated women included peripheral edema (14.1% raloxifene versus 11.7% placebo), muscle spasms/leg cramps (12.1% raloxifene versus 8.3% placebo), hot flashes (7.8% raloxifene versus 4.7% placebo) venous thromboembolic events (2.0% raloxifene versus 1.4% placebo), and cholelithiasis (3.3% raloxifene versus 2.6% placebo) [see clinical studies (14.3 , 14.5) ]. tamoxifen-controlled trial of postmenopausal women at increased risk for invasive breast cancer (star) -the safety of raloxifene hydrochloride 60 mg/day versus tamoxifen 20 mg/day over 5 years was assessed in 19,747 postmenopausal women (age range 35-83 years) in a randomized, double-blind trial. as of 31 december 2005, the median follow-up was 4.3 years. the safety profile of raloxifene was similar to that in the placebo-controlled raloxifene trials [see clinical studies (14.4) ]. 6.2 postmarketing 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. adverse reactions reported very rarely since market introduction include retinal vein occlusion, stroke, and death associated with venous thromboembolism (vte).

ther warfarin derivatives, prothrombin time should be monitored more closely when starting or stopping therapy with raloxifene hydrochloride tablets [see clinical pharmacology (12.3) ]. 7.3 other highly protein-bound drugs raloxifene hydrochloride tablets should be used with caution with certain other highly protein-bound drugs such as diazepam, diazoxide, and lidocaine. although not examined, raloxifene hydrochloride tablets might affect the protein binding of other drugs. raloxifene is more than 95% bound to plasma proteins [see clinical pharmacology (12.3) ]. 7.4 systemic estrogens the safety of concomitant use of raloxifene hydrochloride tablets with systemic estrogens has not been established and its use is not recommended. 7.5 other concomitant medications raloxifene hydrochloride tablets can be concomitantly administered with ampicillin, amoxicillin, antacids, corticosteroids, and digoxin [see clinical pharmacology (12.3) ]. the concomitant use of raloxifene hydrochloride tablets and lipid-lowering agents has not been studied.

animal data in the developmental and reproductive toxicity studies conducted with raloxifene hydrochloride, numerous adverse effects were observed in multiple animal species. in rabbits dosed during organogenesis, abortion and a low rate of fetal heart anomalies (ventricular septal defects) occurred at doses ≥0.1 mg/kg (≥0.04 times the human dose based on surface area, mg/m 2 ). in rats dosed during organogenesis, retardation of fetal growth and developmental abnormalities (wavy ribs, kidney cavitation) occurred at doses ≥1 mg/kg (≥0.2 times the human dose based on surface area, mg/m 2 ). treatment of rats during gestation and lactation with doses of 0.1 to 10 mg/kg (0.02 to 1.6 times the human dose based on surface area, mg/m 2 ) produced effects that included delayed and disrupted parturition, decreased neonatal survival and altered physical development, sex- and age-specific reductions in growth and changes in pituitary hormone content, and decreased lymphoid compartment size in offspring. at 10 mg/kg, the disruption of parturition resulted in maternal and progeny morbidity and death. effects in adult offspring (4 months of age) included uterine hypoplasia and reduced fertility; however, no ovarian or vaginal pathology was observed. 8.2 lactation risk summary raloxifene hydrochloride tablets are not indicated for use in females of reproductive potential. there is no information on the presence of raloxifene in human milk, the effects on the breastfed child, or the effects on milk production. however, based on mechanism of action, raloxifene hydrochloride may block the important functions that estrogen has in mammary tissue during lactation [see clinical pharmacology (12.1) ] . 8.4 pediatric use safety and effectiveness in pediatric patients have not been established. 8.5 geriatric use of the total number of patients in placebo-controlled clinical studies of raloxifene hydrochloride tablets, 61% were 65 and over, while 15.5% were 75 and over. no overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. based on clinical trials, there is no need for dose adjustment for geriatric patients [see clinical pharmacology (12.3) ]. 8.6 renal impairment raloxifene hydrochloride tablets should be used with caution in patients with moderate or severe renal impairment [see warnings and precautions (5.8) and clinical pharmacology (12.3) ]. 8.7 hepatic impairment raloxifene hydrochloride tablets should be used with caution in patients with hepatic impairment [see warnings and precautions (5.5) and clinical pharmacology (12.3) ].

drochloride, numerous adverse effects were observed in multiple animal species. in rabbits dosed during organogenesis, abortion and a low rate of fetal heart anomalies (ventricular septal defects) occurred at doses ≥0.1 mg/kg (≥0.04 times the human dose based on surface area, mg/m 2 ). in rats dosed during organogenesis, retardation of fetal growth and developmental abnormalities (wavy ribs, kidney cavitation) occurred at doses ≥1 mg/kg (≥0.2 times the human dose based on surface area, mg/m 2 ). treatment of rats during gestation and lactation with doses of 0.1 to 10 mg/kg (0.02 to 1.6 times the human dose based on surface area, mg/m 2 ) produced effects that included delayed and disrupted parturition, decreased neonatal survival and altered physical development, sex- and age-specific reductions in growth and changes in pituitary hormone content, and decreased lymphoid compartment size in offspring. at 10 mg/kg, the disruption of parturition resulted in maternal and progeny morbidity and death. effects in adult offspring (4 months of age) included uterine hypoplasia and reduced fertility; however, no ovarian or vaginal pathology was observed.

uterus and breast tissue. 12.2 pharmacodynamics decreases in estrogen levels after oophorectomy or menopause lead to increases in bone resorption and accelerated bone loss. bone is initially lost rapidly because the compensatory increase in bone formation is inadequate to offset resorptive losses. in addition to loss of estrogen, this imbalance between resorption and formation may be due to age-related impairment of osteoblasts or their precursors. in some women, these changes will eventually lead to decreased bone mass, osteoporosis, and increased risk for fractures, particularly of the spine, hip, and wrist. vertebral fractures are the most common type of osteoporotic fracture in postmenopausal women. in both the osteoporosis treatment and prevention trials, raloxifene hydrochloride tablets therapy resulted in consistent, statistically significant suppression of bone resorption and bone formation, as reflected by changes in serum and urine markers of bone turnover (e.g., bone-specific alkaline phosphatase, osteocalcin, and collagen breakdown products). the suppression of bone turnover markers was evident by 3 months and persisted throughout the 36-month and 24-month observation periods. in a 31-week, open-label, radiocalcium kinetics study, 33 early postmenopausal women were randomized to treatment with once-daily raloxifene hydrochloride tablets 60 mg, cyclic estrogen/progestin (0.625 mg conjugated estrogens daily with 5 mg medroxyprogesterone acetate daily for the first 2 weeks of each month [hormone therapy]), or no treatment. treatment with either raloxifene hydrochloride tablets or hormone therapy was associated with reduced bone resorption and a positive shift in calcium balance (-82 mg ca/day and +60 mg ca/day, respectively, for raloxifene hydrochloride tablets and –162 mg ca/day and +91 mg ca/day, respectively, for hormone therapy). there were small decreases in serum total calcium, inorganic phosphate, total protein, and albumin, which were generally of lesser magnitude than decreases observed during estrogen or hormone therapy. platelet count was also decreased slightly and was not different from estrogen therapy. 12.3 pharmacokinetics the disposition of raloxifene has been evaluated in more than 3000 postmenopausal women in selected raloxifene osteoporosis treatment and prevention clinical trials, using a population approach. pharmacokinetic data also were obtained in conventional pharmacology studies in 292 postmenopausal women. raloxifene exhibits high within-subject variability (approximately 30% coefficient of variation) of most pharmacokinetic parameters. table 3 summarizes the pharmacokinetic parameters of raloxifene. absorption — raloxifene is absorbed rapidly after oral administration. approximately 60% of an oral dose is absorbed, but presystemic glucuronide conjugation is extensive. absolute bioavailability of raloxifene is 2%. the time to reach average maximum plasma concentration and bioavailability are functions of systemic interconversion and enterohepatic cycling of raloxifene and its glucuronide metabolites. administration of raloxifene hcl with a standardized, high-fat meal increases the absorption of raloxifene (c max 28% and auc 16%), but does not lead to clinically meaningful changes in systemic exposure. raloxifene hydrochloride tablets can be administered without regard to meals. distribution — following oral administration of single doses ranging from 30 to 150 mg of raloxifene hcl, the apparent volume of distribution is 2348 l/kg and is not dose dependent. raloxifene and the monoglucuronide conjugates are highly (95%) bound to plasma proteins. raloxifene binds to both albumin and α1-acid glycoprotein, but not to sex-steroid binding globulin. metabolism — biotransformation and disposition of raloxifene in humans have been determined following oral administration of 14 c-labeled raloxifene. raloxifene undergoes extensive first-pass metabolism to the glucuronide conjugates: raloxifene-4´-glucuronide, raloxifene-6-glucuronide, and raloxifene-6, 4´-diglucuronide. no other metabolites have been detected, providing strong evidence that raloxifene is not metabolized by cytochrome p450 pathways. unconjugated raloxifene comprises less than 1% of the total radiolabeled material in plasma. the terminal log-linear portions of the plasma concentration curves for raloxifene and the glucuronides are generally parallel. this is consistent with interconversion of raloxifene and the glucuronide metabolites. following intravenous administration, raloxifene is cleared at a rate approximating hepatic blood flow. apparent oral clearance is 44.1 l/kg•hr. raloxifene and its glucuronide conjugates are interconverted by reversible systemic metabolism and enterohepatic cycling, thereby prolonging its plasma elimination half-life to 27.7 hours after oral dosing. results from single oral doses of raloxifene predict multiple-dose pharmacokinetics. following chronic dosing, clearance ranges from 40 to 60 l/kg•hr. increasing doses of raloxifene hcl (ranging from 30 to 150 mg) result in slightly less than a proportional increase in the area under the plasma time concentration curve (auc). excretion — raloxifene is primarily excreted in feces, and less than 0.2% is excreted unchanged in urine. less than 6% of the raloxifene dose is eliminated in urine as glucuronide conjugates. table 3: summary of raloxifene pharmacokinetic parameters in a healthy postmenopausal woman c max a,b (ng/ml)/ (mg/kg) t 1/2 (hr) a auc 0-∞ a,b (ng•hr/ml)/ (mg/kg) cl/f a (l/kg•hr) v/f a (l/kg) a abbreviations: c max = maximum plasma concentration, t 1/2 = half-life, auc = area under the curve, cl = clearance, v = volume of distribution, f = bioavailability, cv = coefficient of variation. b data normalized for dose in mg and body weight in kg. c range of observed half–life single dose mean 0.5 27.7 27.2 44.1 2348 cv a (%) 52 10.7 to 273 c 44 46 52 multiple dose mean 1.36 32.5 24.2 47.4 2853 cv a (%) 37 15.8 to 86.6 c 36 41 56 special populations pediatric — the pharmacokinetics of raloxifene has not been evaluated in a pediatric population [see use in specific populations (8.4) ]. geriatric — no differences in raloxifene pharmacokinetics were detected with regard to age (range 42 to 84 years) [see use in specific populations (8.5) ]. gender — total extent of exposure and oral clearance, normalized for lean body weight, are not significantly different between age-matched female and male volunteers. race — pharmacokinetic differences due to race have been studied in 1712 women, including 97.5% white, 1.0% asian, 0.7% hispanic, and 0.5% black in a osteoporosis treatment trial and in 1053 women, including 93.5% white, 4.3% hispanic, 1.2% asian, and 0.5% black in a osteoporosis prevention trials.. there were no discernible differences in raloxifene plasma concentrations among these groups; however, the influence of race cannot be conclusively determined. renal impairment — in a osteoporosis treatment and prevention trials, raloxifene concentrations in women with mild renal impairment are similar to women with normal creatinine clearance. when a single dose of 120 mg raloxifene hcl was administered to 10 renally impaired males [7 moderate impairment (crcl = 31 – 50 ml/min); 3 severe impairment (crcl ≤30 ml/min)] and to 10 healthy males (crcl >80 ml/min), plasma raloxifene concentrations were 122% (auc 0-∞ ) higher in renally impaired patients than those of healthy volunteers. raloxifene should be used with caution in patients with moderate or severe renal impairment [see warnings and precautions (5.8) and use in specific populations (8.6) ]. hepatic impairment — the disposition of raloxifene was compared in 9 patients with mild (child-pugh class a) hepatic impairment (total bilirubin ranging from 0.6 to 2 mg/dl) to 8 subjects with normal hepatic function following a single dose of 60 mg raloxifene hcl. apparent clearance of raloxifene was reduced 56% and the half-life of raloxifene was not altered in patients with mild hepatic impairment. plasma raloxifene concentrations were approximately 150% higher than those in healthy volunteers and correlated with total bilirubin concentrations. the pharmacokinetics of raloxifene has not been studied in patients with moderate or severe hepatic impairment. raloxifene should be used with caution in patients with hepatic impairment [see warnings and precautions (5.5) and use in specific populations (8.7) ]. drug interactions cholestyramine — cholestyramine, an anion exchange resin, causes a 60% reduction in the absorption and enterohepatic cycling of raloxifene after a single dose. although not specifically studied, it is anticipated that other anion exchange resins would have a similar effect [see drug interactions (7.1) ]. warfarin — in vitro, raloxifene did not interact with the binding of warfarin. the concomitant administration of raloxifene hydrochloride tablets and warfarin, a coumarin derivative, has been assessed in a single-dose study. in this study, raloxifene had no effect on the pharmacokinetics of warfarin. however, a 10% decrease in prothrombin time was observed in a single-dose study. in a osteoporosis treatment trial, there were no clinically relevant effects of warfarin co-administration on plasma concentrations of raloxifene [see drug interactions (7.2) ]. other highly protein-bound drugs — in a osteoporosis treatment trial, there were no clinically relevant effects of co-administration of other highly protein-bound drugs (e.g., gemfibrozil) on plasma concentrations of raloxifene. in vitro, raloxifene did not interact with the binding of phenytoin, tamoxifen, or warfarin (see above) [see drug interactions (7.3) ]. ampicillin and amoxicillin — peak concentrations of raloxifene and the overall extent of absorption are reduced 28% and 14%, respectively, with co-administration of ampicillin. these reductions are consistent with decreased enterohepatic cycling associated with antibiotic reduction of enteric bacteria. however, the systemic exposure and the elimination rate of raloxifene were not affected. in a osteoporosis treatment trial, co-administration of amoxicillin had no discernible differences in plasma raloxifene concentrations [see drug interactions (7.5) ]. antacids — concomitant administration of calcium carbonate or aluminum and magnesium hydroxide-containing antacids does not affect the systemic exposure of raloxifene [see drug interactions (7.5) ]. corticosteroids — the chronic administration of raloxifene in postmenopausal women has no effect on the pharmacokinetics of methylprednisolone given as a single oral dose [see drug interactions (7.5) ]. digoxin — raloxifene has no effect on the pharmacokinetics of digoxin [see drug interactions (7.5) ]. cyclosporine — concomitant administration of raloxifene hydrochloride tablets with cyclosporine has not been studied. lipid-lowering agents — concomitant administration of raloxifene hydrochloride tablets with lipid-lowering agents has not been studied.

their reproductive lives when their ovaries were functional and responsive to hormonal stimulation. mutagenesis — raloxifene hcl was not genotoxic in any of the following test systems: the ames test for bacterial mutagenesis with and without metabolic activation, the unscheduled dna synthesis assay in rat hepatocytes, the mouse lymphoma assay for mammalian cell mutation, the chromosomal aberration assay in chinese hamster ovary cells, the in vivo sister chromatid exchange assay in chinese hamsters, and the in vivo micronucleus test in mice. impairment of fertility — when male and female rats were given daily doses ≥5 mg/kg (≥0.8 times the human dose based on surface area, mg/m 2 ) prior to and during mating, no pregnancies occurred. in male rats, daily doses up to 100 mg/kg (16 times the human dose based on surface area, mg/m 2 ) for at least 2 weeks did not affect sperm production or quality or reproductive performance. in female rats, at doses of 0.1 to 10 mg/kg/day (0.02 to 1.6 times the human dose based on surface area, mg/m 2 ), raloxifene disrupted estrous cycles and inhibited ovulation. these effects of raloxifene were reversible. in another study in rats in which raloxifene was given during the preimplantation period at doses ≥0.1 mg/kg (≥0.02 times the human dose based on surface area, mg/m 2 ), raloxifene delayed and disrupted embryo implantation, resulting in prolonged gestation and reduced litter size. the reproductive and developmental effects observed in animals are consistent with the estrogen receptor activity of raloxifene. 13.2 animal toxicology and/or pharmacology the skeletal effects of raloxifene treatment were assessed in ovariectomized rats and monkeys. in rats, raloxifene prevented increased bone resorption and bone loss after ovariectomy. there were positive effects of raloxifene on bone strength, but the effects varied with time. cynomolgus monkeys were treated with raloxifene or conjugated estrogens for 2 years. in terms of bone cycles, this is equivalent to approximately 6 years in humans. raloxifene and estrogen suppressed bone turnover and increased bmd in the lumbar spine and in the central cancellous bone of the proximal tibia. in this animal model, there was a positive correlation between vertebral compressive breaking force and bmd of the lumbar spine. histologic examination of bone from rats and monkeys treated with raloxifene showed no evidence of woven bone, marrow fibrosis, or mineralization defects. these results are consistent with data from human studies of radiocalcium kinetics and markers of bone metabolism, and are consistent with the action of raloxifene hydrochloride tablets as a skeletal antiresorptive agent.

ncreased spine and hip bmd by 2 to 3%. raloxifene hydrochloride tablets decreased the incidence of the first vertebral fracture from 4.3% for placebo to 1.9% for raloxifene hydrochloride tablets (relative risk reduction = 55%) and subsequent vertebral fractures from 20.2% for placebo to 14.1% for raloxifene hydrochloride tablets (relative risk reduction = 30%) (see table 4). all women in a study received calcium (500 mg/day) and vitamin d (400 to 600 iu/day). raloxifene hydrochloride tablets reduced the incidence of vertebral fractures whether or not patients had a vertebral fracture upon study entry. the decrease in incidence of vertebral fracture was greater than could be accounted for by increase in bmd alone. table 4: effect of raloxifene hydrochloride tablets on risk of vertebral fractures a includes all patients with baseline and at least one follow-up radiograph. number of patients absolute risk reduction (arr) relative risk reduction (95% ci) raloxifene hydrochloride tablets placebo fractures diagnosed radiographically patients with no baseline fracture a n=1401 n=1457 number (%) of patients with ≥1 new vertebral fracture 27 (1.9%) 62 (4.3%) 2.4% 55% (29%, 71%) patients with ≥1 baseline fracture a n=858 n=835 number (%) of patients with ≥1 new vertebral fracture 121 (14.1%) 169 (20.2%) 6.1% 30% (14%, 44%) symptomatic vertebral fractures all randomized patients n=2557 n=2576 number (%) of patients with ≥1 new clinical (painful) vertebral fracture 47 (1.8%) 81 (3.1%) 1.3% 41% (17%, 59%) the mean percentage change in bmd from baseline for raloxifene hydrochloride tablets was statistically significantly greater than for placebo at each skeletal site (see table 5). table 5: raloxifene hcl tablets - (60 mg once daily) related increases in bmd a for the osteoporosis treatment study expressed as mean percentage increase vs. placebo b ,c a note: all bmd increases were significant (p<0.001). b intent-to-treat analysis; last observation carried forward. c all patients received calcium and vitamin d. d nd = not done (total body and radius bmd were measured only at 24 months). site time 12 months % 24 months % 36 months % lumbar spine 2 2.6 2.6 femoral neck 1.3 1.9 2.1 ultradistal radius nd d 2.2 nd d distal radius nd d 0.9 nd d total body nd d 1.1 nd d discontinuation from the study was required when excessive bone loss or multiple incident vertebral fractures occurred. such discontinuation was statistically significantly more frequent in the placebo group (3.7%) than in the raloxifene hydrochloride tablets group (1.1%). bone histology bone biopsies for qualitative and quantitative histomorphometry were obtained at baseline and after 2 years of treatment. there were 56 paired biopsies evaluable for all indices. in raloxifene hydrochloride tablets-treated patients, there were statistically significant decreases in bone formation rate per tissue volume, consistent with a reduction in bone turnover. normal bone quality was maintained; specifically, there was no evidence of osteomalacia, marrow fibrosis, cellular toxicity, or woven bone after 2 years of treatment. effect on endometrium endometrial thickness was evaluated annually in a subset of the study population (1781 patients) for 3 years. placebo-treated women had a 0.27 mm mean decrease from baseline in endometrial thickness over 3 years, whereas the raloxifene hydrochloride tablets-treated women had a 0.06 mm mean increase. patients in a osteoporosis treatment study were not screened at baseline or excluded for pre-existing endometrial or uterine disease. this study was not specifically designed to detect endometrial polyps. over the 36 months of the study, clinically or histologically benign endometrial polyps were reported in 17 of 1999 placebo-treated women, 37 of 1948 raloxifene hydrochloride tablets-treated women, and in 31 of 2010 women treated with raloxifene hcl 120 mg/day. there was no difference between raloxifene hydrochloride tablets- and placebo-treated women in the incidences of endometrial carcinoma, vaginal bleeding, or vaginal discharge. 14.2 prevention of postmenopausal osteoporosis the effects of raloxifene hydrochloride on bmd in postmenopausal women were examined in three randomized, placebo-controlled, double-blind osteoporosis prevention trials: (1) a north american trial enrolled 544 women; (2) a european trial, 601 women; and (3) an international trial, 619 women who had undergone hysterectomy. in these trials, all women received calcium supplementation (400 to 600 mg/day). women enrolled in these trials had a median age of 54 years and a median time since menopause of 5 years (less than 1 year up to 15 years postmenopause). the majority of the women were white (93.5%). women were included if they had spine bmd between 2.5 standard deviations below and 2 standard deviations above the mean value for healthy young women. the mean t scores (number of standard deviations above or below the mean in healthy young women) for the three trials ranged from -1.01 to -0.74 for spine bmd and included women both with normal and low bmd. raloxifene hydrochloride, 60 mg administered once daily, produced increases in bone mass versus calcium supplementation alone, as reflected by dual-energy x-ray absorptiometric (dxa) measurements of hip, spine, and total body bmd. effect on bone mineral density compared with placebo, the increases in bmd for each of the three studies were statistically significant at 12 months and were maintained at 24 months ( see table 6). the placebo groups lost approximately 1% of bmd over 24 months. table 6: raloxifene hydrochloride- (60 mg once daily) related increases in bmd a for the three osteoporosis prevention studies expressed as mean percentage increase vs. placebo b at 24 months c site study na d % eu d % int d,e % a note: all bmd increases were significant (p≤0.001). b all patients received calcium. c intent-to-treat analysis; last observation carried forward. d abbreviations: na = north american, eu = european, int = international. e all women in the study had previously undergone hysterectomy. total hip 2 2.4 1.3 femoral neck 2.1 2.5 1.6 trochanter 2.2 2.7 1.3 intertrochanter 2.3 2.4 1.3 lumbar spine 2 2.4 1.8 raloxifene hydrochloride also increased bmd compared with placebo in the total body by 1.3% to 2.0% and in ward’s triangle (hip) by 3.1% to 4.0%. the effects of raloxifene hydrochloride tablets on forearm bmd were inconsistent between studies. in study eu, raloxifene hydrochloride tablets prevented bone loss at the ultradistal radius, whereas in study na, it did not ( see figure 1). effect on endometrium in placebo-controlled osteoporosis prevention trials, endometrial thickness was evaluated every 6 months (for 24 months) by transvaginal ultrasonography (tvu). a total of 2978 tvu measurements were collected from 831 women in all dose groups. placebo-treated women had a 0.04 mm mean increase from baseline in endometrial thickness over 2 years, whereas the raloxifene hydrochloride tablets-treated women had a 0.09 mm mean increase. endometrial thickness measurements in raloxifene-treated women were indistinguishable from placebo. there were no differences between the raloxifene and placebo groups with respect to the incidence of reported vaginal bleeding. image 14.3 reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis more trial the effect of raloxifene hydrochloride on the incidence of breast cancer was assessed as a secondary safety endpoint in a randomized, placebo-controlled, double-blind, multinational osteoporosis treatment trial in postmenopausal women [see clinical studies (14.1) ] . after 4 years, raloxifene hydrochloride, 60 mg administered once daily, reduced the incidence of all breast cancers by 62%, compared with placebo (hr 0.38, 95% ci 0.22-0.67). raloxifene hydrochloride reduced the incidence of invasive breast cancer by 71%, compared with placebo (arr 3.1 per 1000 women-years); this was primarily due to an 80% reduction in the incidence of er-positive invasive breast cancer in the raloxifene hydrochloride group compared with placebo. table 7 presents efficacy and selected safety outcomes. core trial the effect of raloxifene hydrochloride on the incidence of invasive breast cancer was evaluated for 4 additional years in a follow-up study conducted in a subset of postmenopausal women originally enrolled in the more osteoporosis treatment trial. women were not re-randomized; the treatment assignment from the osteoporosis treatment trial was carried forward to this study. raloxifene hydrochloride, 60 mg administered once daily, reduced the incidence of invasive breast cancer by 56%, compared with placebo (arr 3.0 per 1000 women-years); this was primarily due to a 63% reduction in the incidence of er-positive invasive breast cancer in the raloxifene hydrochloride group compared with placebo. there was no reduction in the incidence of er-negative breast cancer. in the osteoporosis treatment trial and the follow-up study, there was no difference in incidence of noninvasive breast cancer between the raloxifene hydrochloride and placebo groups. table 7 presents efficacy and selected safety outcomes. in a subset of postmenopausal women followed for up to 8 years from randomization in more to the end of core, raloxifene hydrochloride, 60 mg administered once daily, reduced the incidence of invasive breast cancer by 60% in women assigned raloxifene hydrochloride (n=1355) compared with placebo (n=1286) (hr 0.40, 95% ci 0.21, 0.77; arr 1.95 per 1000 women-years); this was primarily due to a 65% reduction in the incidence of er-positive invasive breast cancer in the raloxifene hydrochloride group compared with placebo. table 7: raloxifene hydrochloride (60 mg once daily) vs. placebo on outcomes in postmenopausal women with osteoporosis a core was a follow-up study conducted in a subset of 4011 postmenopausal women who originally enrolled in more. women were not re-randomized; the treatment assignment from more was carried forward to this study. at core enrollment, the raloxifene group included 2725 total patients with 1355 patients who were originally assigned to raloxifene hcl 60 mg once daily and 1370 patients who were originally assigned to raloxifene hcl 120 mg at more randomization. b abbreviations: ci = confidence interval; er = estrogen receptor; hr = hazard ratio; ir = annual incidence rate per 1000 women; n/a = not applicable. c included 1274 patients in placebo and 2716 patients in raloxifene who were not diagnosed with breast cancer prior to core enrollment. d p<0.05, obtained from the log-rank test, and not adjusted for multiple comparisons in more. e all cases were ductal carcinoma in situ. f only patients with an intact uterus were included (more: placebo = 1999, raloxifene = 1950; core: placebo = 1008, raloxifene = 2138). more 4 years core a 4 years outcomes placebo (n=2576) raloxifene hydrochloride (n=2557) hr (95% ci) b placebo (n=1286) raloxifene hydrochloride (n=2725) hr (95% ci) b n ir b n ir b n ir b n ir b invasive c breast cancer 38 4.36 11 1.26 0.29 (0.15, 0.56) d 20 5.41 19 2.43 0.44 (0.24, 0.83) d er b,c positive 29 3.33 6 0.69 0.2 (0.08, 0.49) 15 4.05 12 1.54 0.37 (0.17, 0.79) er b,c negative 4 0.46 5 0.57 1.23 (0.33, 4.6) 3 0.81 6 0.77 0.95 (0.24, 3.79) er b,c unknown 5 0.57 0 0 n/a b 2 0.54 1 0.13 n/a b noninvasive c, e breast cancer 5 0.57 3 0.34 0.59 (0.14, 2.47) 2 0.54 5 0.64 1.18 (0.23, 6.07) clinical vertebral fractures 107 12.27 62 7.08 0.57 (0.42, 0.78) n/a b n/a b n/a b n/a b n/a b death 36 4.13 23 2.63 0.63 (0.38, 1.07) 29 7.76 47 5.99 0.77 (0.49, 1.23) death due to stroke 6 0.69 3 0.34 0.49 (0.12, 1.98) 1 0.27 6 0.76 2.87 (0.35, 23.8) stroke 56 6.42 43 4.91 0.76 (0.51, 1.14) 14 3.75 49 6.24 1.67 (0.92, 3.03) deep vein thrombosis 8 0.92 20 2.28 2.5 (1.1, 5.68) 4 1.07 17 2.17 2.03 (0.68, 6.03) pulmonary embolism 4 0.46 11 1.26 2.76 (0.88, 8.67) 0 0 9 1.15 n/a b endometrial and uterine cancer f 5 0.74 5 0.74 1.01 (0.29, 3.49) 3 1.02 4 0.65 0.64 (0.14, 2.85) ovarian cancer 6 0.69 3 0.34 0.49 (0.12, 1.95) 2 0.54 2 0.25 0.47 (0.07, 3.36) hot flashes 151 17.31 237 27.06 1.61 (1.31, 1.97) 11 2.94 26 3.31 1.12 (0.55, 2.27) peripheral edema 134 15.36 164 18.73 1.23 (0.98, 1.54) 30 8.03 61 7.77 0.96 (0.62, 1.49) cholelithiasis 45 5.16 53 6.05 1.18 (0.79, 1.75) 12 3.21 35 4.46 1.39 (0.72, 2.67) ruth trial the effect of raloxifene hydrochloride on the incidence of invasive breast cancer was assessed in a randomized, placebo-controlled, double-blind, multinational study in 10,101 postmenopausal women at increased risk of coronary events. women in this study had a median age of 67.6 years (range 55 to 92) and were followed for a median of 5.6 years (range 0.01 to 7.1). eighty-four percent were white, 9.8% of women reported a first-degree relative with a history of breast cancer, and 41.4% of the women had a 5-year predicted risk of invasive breast cancer ≥1.66%, based on the modified gail model. raloxifene hydrochloride, 60 mg administered once daily, reduced the incidence of invasive breast cancer by 44% compared with placebo [absolute risk reduction (arr) 1.2 per 1000 women-years]; this was primarily due to a 55% reduction in estrogen receptor (er)-positive invasive breast cancer in the raloxifene hydrochloride group compared with placebo (arr 1.2 per 1000 women-years). there was no reduction in er-negative invasive breast cancer. table 8 presents efficacy and selected safety outcomes. table 8: raloxifene hydrochloride (60 mg once daily) vs. placebo on outcomes in postmenopausal women at increased risk for major coronary events a note: there were a total of 76 breast cancer cases in the placebo group and 52 in the raloxifene hydrochloride group. for two cases, one in each treatment group, invasive status was unknown. b abbreviations: ci = confidence interval; er = estrogen receptor; hr = hazard ratio; ir = annual incidence rate per 1000 women. c p<0.05, obtained from the log-rank test, after adjusting for the co-primary endpoint of major coronary events. d all cases were ductal carcinoma in situ. e only patients with an intact uterus were included (placebo = 3882, raloxifene hydrochloride = 3900).. f only patients with at least one ovary were included (placebo = 4606, raloxifene hydrochloride = 4559). g only patients with an intact gallbladder at baseline were included (placebo = 4111, raloxifene hydrochloride =4144). outcomes placebo a (n=5057) raloxifene hydrochloride a (n=5044) hr (95% ci) b n ir b n ir b invasive breast cancer 70 2.66 40 1.5 0.56 (0.38, 0.83) c er b positive 55 2.09 25 0.94 0.45 (0.28, 0.72) er b negative 9 0.34 13 0.49 1.44 (0.61, 3.36) er b unknown 6 0.23 2 0.07 0.33 (0.07, 1.63) noninvasive d breast cancer 5 0.19 11 0.41 2.17 (0.75, 6.24) clinical vertebral fractures 97 3.7 64 2.4 0.65 (0.47, 0.89) death 595 22.45 554 20.68 0.92 (0.82, 1.03) death due to stroke 39 1.47 59 2.2 1.49 (1, 2.24) stroke 224 8.6 249 9.46 1.1 (0.92, 1.32) deep vein thrombosis 47 1.78 65 2.44 1.37 (0.94, 1.99) pulmonary embolism 24 0.91 36 1.35 1.49 (0.89, 2.49) endometrial and uterine cancer e 17 0.83 21 1.01 1.21 (0.64 to 2.3) ovarian cancer f 10 0.41 17 0.7 1.69 (0.78, 3.7) hot flashes 241 9.09 397 14.82 1.68 (1.43, 1.97) peripheral edema 583 22 706 26.36 1.22 (1.09, 1.36) cholelithiasis g 131 6.2 168 7.83 1.26 (1.01, 1.59) the effect of raloxifene hydrochloride in reducing the incidence of invasive breast cancer was consistent among women above or below age 65 or with a 5-year predicted invasive breast cancer risk, based on the modified gail model, <1.66%, or ≥1.66%. 14.4 reduction in risk of invasive breast cancer in postmenopausal women at high risk of invasive breast cancer star trial the effects of raloxifene hydrochloride 60 mg/day versus tamoxifen 20 mg/day over 5 years on reducing the incidence of invasive breast cancer were assessed in 19,747 postmenopausal women in a randomized, double-blind trial conducted in north america by the national surgical adjuvant breast and bowel project and sponsored by the national cancer institute. women in this study had a mean age of 58.5 years (range 35 to 83), a mean 5-year predicted invasive breast cancer risk of 4.03% (range 1.66 to 23.61%), and 9.1% had a history of lobular carcinoma in situ (lcis). more than 93% of participants were white. as of 31 december 2005, the median time of follow-up was 4.3 years (range 0.07 to 6.50 years). raloxifene hydrochloride was not superior to tamoxifen in reducing the incidence of invasive breast cancer. the observed incidence rates of invasive breast cancer were raloxifene hydrochloride 4.4 and tamoxifen 4.3 per 1000 women per year. the results from a noninferiority analysis are consistent with raloxifene hydrochloride potentially losing up to 35% of the tamoxifen effect on reduction of invasive breast cancer. the effect of each treatment on invasive breast cancer was consistent when women were compared by baseline age, history of lcis, history of atypical hyperplasia, 5-year predicted risk of breast cancer by the modified gail model, or the number of relatives with a history of breast cancer. fewer noninvasive breast cancers occurred in the tamoxifen group compared to the raloxifene hydrochloride group. table 9 presents efficacy and selected safety outcomes. table 9: raloxifene hydrochloride (60 mg once daily) vs. tamoxifen (20 mg once daily) on outcomes in postmenopausal women at increased risk for invasive breast cancer a abbreviations: ci = confidence interval; dcis = ductal carcinoma in situ; er = estrogen receptor; ir = annual incidence rate per 1000 women; lcis = lobular carcinoma in situ; rr = risk ratio for women in the raloxifene group compared with those in the tamoxifen group. b of the 60 noninvasive breast cases in the tamoxifen group, 5 were mixed types. of the 83 noninvasive breast cancers in the raloxifene group, 7 were mixed types. c only patients with an intact uterus at baseline were included (tamoxifen = 4739, raloxifene =4715). d only patients with at least one intact ovary at baseline were included (tamoxifen = 6813, raloxifene = 6787). e defined as myocardial infarction, severe angina, or acute ischemic syndromes. f only patients who were free of cataracts at baseline were included (tamoxifen = 8342, raloxifene = 8333). g peripheral edema events are included in the term edema. outcomes raloxifene hydrochloride (n=9751) tamoxifen (n=9736) rr (95% ci) a n ir a n ir a invasive breast cancer 173 4.4 168 4.3 1.02 (0.82, 1.27) er a positive 115 2.93 120 3.07 0.95 (0.73, 1.24) er a negative 52 1.32 46 1.18 1.12 (0.74, 1.71) er a unknown 6 0.15 2 0.05 2.98 (0.53, 30.21) noninvasive breast cancer b 83 2.12 60 1.54 1.38 (0.98, 1.95) dcis a 47 1.2 32 0.82 1.46 (0.91, 2.37) lcis a 29 0.74 23 0.59 1.26 (0.7, 2.27) uterine cancer c 23 1.21 37 1.99 0.61 (0.34, 1.05) endometrial hyperplasia c 17 0.9 100 5.42 0.17 (0.09, 0.28) hysterectomy c 92 4.84 246 13.25 0.37 (0.28, 0.47) ovarian cancer d 18 0.66 14 0.52 1.27 (0.6, 2.76) ischemic heart disease e 138 3.5 125 3.19 1.1 (0.86, 1.41) stroke 54 1.36 56 1.42 0.96 (0.65, 1.42) deep vein thrombosis 67 1.69 92 2.35 0.72 (0.52, 1) pulmonary embolism 38 0.96 58 1.47 0.65 (0.42, 1) clinical vertebral fractures 58 1.46 58 1.47 0.99 (0.68, 1.46) cataracts f 343 10.34 435 13.19 0.78 (0.68, 0.91) cataract surgery f 240 7.17 295 8.85 0.81 (0.68, 0.96) death 104 2.62 109 2.76 0.95 (0.72, 1.25) edema g 741 18.66 664 16.83 1.11 (1, 1.23) hot flashes 6748 169.91 7170 181.71 0.94 (0.9, 0.97) 14.5 effects on cardiovascular disease in a randomized, placebo-controlled, double-blind, multinational clinical trial (ruth) of 10,101 postmenopausal women with documented coronary heart disease or at increased risk for coronary events, no cardiovascular benefit was demonstrated after treatment with raloxifene hydrochloride tablets 60 mg once daily for a median follow-up of 5.6 years. no significant increase or decrease was observed for coronary events (death from coronary causes, nonfatal myocardial infarction, or hospitalization for an acute coronary syndrome). an increased risk of death due to stroke after treatment with raloxifene hydrochloride tablets was observed: 59 (1.2%) raloxifene hydrochloride tablets-treated women died due to a stroke compared to 39 (0.8%) placebo-treated women (2.2 versus 1.5 per 1000 women-years; hazard ratio 1.49; 95% confidence interval, 1.00-2.24; p=0.0499). the incidence of stroke did not differ significantly between treatment groups (249 with raloxifene hydrochloride tablets [4.9%] versus 224 with placebo [4.4%]; hazard ratio 1.10; 95% confidence interval 0.92-1.32; p=0.30; 9.5 versus 8.6 per 1000 women-years) [see warnings and precautions (5.2 , 5.3) ].

least 72 hours prior to and during prolonged immobilization (e.g., post-surgical recovery, prolonged bed rest), and patients should be advised to avoid prolonged restrictions of movement during travel because of the increased risk of venous thromboembolic events [see warnings and precautions (5.1) ]. 17.3 hot flashes or flushes raloxifene hydrochloride tablets may increase the incidence of hot flashes and is not effective in reducing hot flashes or flushes associated with estrogen deficiency. in some asymptomatic patients, hot flashes may occur upon beginning raloxifene hydrochloride tablets therapy. 17.4 reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis or at high risk of invasive breast cancer use of raloxifene hydrochloride is associated with the reduction of the risk of invasive breast cancer in postmenopausal women. raloxifene hydrochloride has not been shown to reduce the risk of noninvasive breast cancer. when considering treatment, physicians need to discuss the potential benefits and risks of raloxifene hydrochloride treatment with the patient. raloxifene hydrochloride is not indicated for the treatment of invasive breast cancer or reduction of the risk of recurrence. patients should have breast exams and mammograms before starting raloxifene hydrochloride and should continue regular breast exams and mammograms in keeping with good medical practice after beginning treatment with raloxifene hydrochloride. rev: 05/2020