Tiopronin Delayed-release Tablets

Tiopronin Delayed-Release Tablets 100mg

NDC 44523-054-01

Tiopronin is released faster from Tiopronin Delayed-Release Tablets in the presence of alcohol and the risk for

adverse events associated with Tiopronin Delayed-Release Tablets when taken with alcohol is unknown. Avoid

alcohol consumption 2 hours before and 3 hours after taking Tiopronin Delayed-Release Tablets [see Clinical

Pharmacology (12.3)].

There is no information on overdosage with tiopronin.

Risk Summary

Available published case report data with tiopronin have not identified a drug-associated risk for major birth

defects, miscarriage, or adverse maternal or fetal outcomes. Renal stones in pregnancy may result in adverse

pregnancy outcomes (see Clinical Considerations). In animal reproduction studies, there were no adverse

developmental outcomes with oral administration of tiopronin to pregnant mice and rats during organogenesis

at doses up to 2 times a 2 grams/day human dose (based on mg/m2). The estimated background risk of major

birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background

risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background

risk of major birth defects and miscarriage in clinically recognized pregnancies are 2% to 4% and 15% to

20%, respectively.

Clinical Considerations

Disease-associated maternal and/or embryo/fetal risk

Renal stones in pregnancy may increase the risk of adverse pregnancy outcomes, such as preterm birth and

low birth weight.

Data

Animal Data

No findings of fetal malformations could be attributed to the drug in reproduction studies in mice and rats at

doses up to 2 times the highest recommended human dose of 2 grams/day (based on mg/m2).

Risk Summary

There are no data on the presence of tiopronin in either human or animal milk or on the effects of the

breastfed child. A published study suggests that tiopronin may suppress milk production. Because of the

potential for serious adverse reactions, including nephrotic syndrome, advise patients that breastfeeding is not

recommended during treatment with Tiopronin Delayed-Release Tablets.

Tiopronin Delayed-Release Tablets are a reducing and cystine-binding thiol drug (CBTD) for oral use. Tiopronin

is N-(2-Mercaptopropionyl) glycine and has the following structure:

Tiopronin is a white crystalline powder, which is freely soluble in water.

Each Tiopronin Delayed-Release Tablet contains 100 or 300 mg of tiopronin. The inactive ingredients in

Tiopronin Delayed-Release Tablets include lactose monohydrate, hydroxypropyl cellulose, hydroxypropyl

cellulose (low substitute), magnesium stearate, hydroxypropyl methylcellulose E5, methacrylic acid: ethyl

acrylate copolymer (Eudragit L 100-55), talc, triethyl citrate.

Measure urinary cystine 1 month after starting Tiopronin Delayed-Release Tablets and every 3 months

thereafter. Adjust Tiopronin Delayed-Release Tablets dosage to maintain urinary cystine concentration less

than 250 mg/L.

Assess for proteinuria before treatment and every 3 to 6 months during treatment [see Warnings and

Precautions (5.1)].

Discontinue Tiopronin Delayed-Release Tablets in patients who develop proteinuria, and monitor urinary

protein and renal function. Consider restarting Tiopronin Delayed-Release Tablets treatment at a lower dosage

after resolution of proteinuria.

Proteinuria, including nephrotic syndrome, and membranous nephropathy, have been reported with tiopronin

use. Pediatric patients receiving greater than 50 mg/kg of tiopronin per day may be at increased risk for

proteinuria [see Dosage and Administration (2.3), Adverse Reactions (6.1, 6.2), Use in Specific Populations

(8.4)]. Monitor patients for the development of proteinuria and discontinue therapy in patients who develop

proteinuria [see Dosage and Administration (2.3)].

Tiopronin Delayed-Release Tablets are indicated in pediatric patients weighing 20 kg or more with severe

homozygous cystinuria, in combination with high fluid intake, alkali, and diet modification, for the prevention

of cystine stone formation who are not responsive to these measures alone. This indication is based on

safety and efficacy data from a trial in patients 9 years to 68 years of age and clinical experience. Proteinuria,

including nephrotic syndrome, has been reported in pediatric patients. Pediatric patients receiving greater

than 50 mg/kg tiopronin per day may be at greater risk [see Dosage and Administration (2.1, 2.3), Warnings

and Precautions (5.1) and Adverse Reactions (6.1)].

Tiopronin Delayed-Release Tablets are not approved for use in pediatric patients weighing less than 20 kg

[see Dosage and Administration (2.1)].

This drug is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug

may be greater in patients with impaired renal function. Because elderly patients are more likely to have

decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal

function.

Tiopronin Delayed-Release Tablets are contraindicated in patients with hypersensitivity to tiopronin or any other components of Tiopronin Delayed-Release Tablets [see Warnings and Precautions (5.2)].

The following adverse reactions are discussed in greater detail in other sections of the labeling:

• Proteinuria [see Warnings and Precautions (5.1)]

• Hypersensitivity [see Warnings and Precautions (5.2)]

The decrement in urinary cystine produced by tiopronin is generally proportional to the dose. A reduction in

urinary cystine of 250-350 mg/day at tiopronin dosage of 1 g/day, and a decline of approximately 500 mg/day

at a dosage of 2 g/day, might be expected. Tiopronin has a rapid onset and offset of action, showing a fall in

cystine excretion on the first day of administration and a rise on the first day of drug withdrawal.

Absorption

Tiopronin Delayed-Release Tablets

When Tiopronin Tablets and Tiopronin Delayed-Release Tablets single doses were given to fasted healthy

subjects, the median time to peak plasma levels (T _max) was 1 (range: 0.5 to 2.1) and 3 (range: 1.0 to 6.0)

hours, respectively. The peak exposure (C _max) and total exposure (AUC _0-t) of tiopronin from Tiopronin Delayed-

Release Tablets were decreased by 22% and 7% respectively compared to Tiopronin Tablets.

When Tiopronin Delayed-Release Tablets were administered crushed in applesauce, the median time to peak

plasma levels of tiopronin (T _max) was 1 hour (range: 0.5 to 2.0) compared to 3.1 hours (range: 1.5 to 4.0) when

administered as intact Tiopronin Delayed-Release Tablets.

When Tiopronin Delayed-Release Tablets were administered crushed in applesauce, the maximum

concentration (C _max) and exposure (AUC _0-t) to tiopronin were increased by 38% and 14%, respectively,

compared to Tiopronin Delayed-Release Tablets administered intact.

Food Effects

Administration of the Tiopronin Delayed-Release Tablet with food decreases C _max of tiopronin by 13% and

AUC _0-t by 25% compared to Tiopronin Delayed-Release Tablets administered in a fasted state.

Since the drug is dosed to effect, the study results support administration of Tiopronin Delayed-Release Tablets

with or without food; administer at the same time each day with a routine pattern with regard to meals.

Elimination

Excretion

When tiopronin is given orally, up to 48% of dose appears in urine during the first 4 hours and up to 78% by

72 hours.

Drug Interactions

Alcohol

An in vitro dissolution study was conducted to evaluate the impact of alcohol (5, 10, 20, and 40%) on the dose

dumping of Tiopronin Delayed-Release Tablets. The study results showed that the addition of alcohol to the

dissolution media increases the dissolution rate of Tiopronin Delayed-Release Tablets in the acidic media of

0.1N HCl [see Drug Interactions (7.1)].

Adults: The recommended initial dosage in adult patients is 800 mg/day. In clinical studies, the average

dosage was about 1,000 mg/day.

Pediatrics: The recommended initial dosage in pediatric patients weighing 20 kg and greater is 15 mg/kg/day.

Avoid dosages greater than 50 mg/kg per day in pediatric patients [see Warnings and Precautions (5.1), Use in

Specific Populations (8.4)].

Administer Tiopronin Delayed-Release Tablets in 3 divided doses at the same times each day, with or without

food. Maintain a routine pattern with regard to meals.

Consider starting Tiopronin Delayed-Release Tablets at a lower dosage in patients with history of severe

toxicity to d-penicillamine.

Tiopronin Delayed-Release Tablets are indicated, in combination with high fluid intake, alkali, and diet modification, for the prevention of cystine stone formation in adults and pediatric patients 20 kg and greater with severe homozygous cystinuria, who are not responsive to these measures alone.

The goal of therapy is to reduce urinary cystine concentration below its solubility limit. Tiopronin is an active

reducing agent which undergoes thiol-disulfide exchange with cystine to form a mixed disulfide of tiopronincysteine.

From this reaction, a water-soluble mixed disulfide is formed and the amount of sparingly soluble

cystine is reduced.

5.1 Proteinuria

Proteinuria, including nephrotic syndrome, and membranous nephropathy, have been reported with tiopronin

use. Pediatric patients receiving greater than 50 mg/kg of tiopronin per day may be at increased risk for

proteinuria [see Dosage and Administration (2.3), Adverse Reactions (6.1, 6.2), Use in Specific Populations

(8.4)]. Monitor patients for the development of proteinuria and discontinue therapy in patients who develop

proteinuria [see Dosage and Administration (2.3)].

5.2 Hypersensitivity Reactions

Hypersensitivity reactions (drug fever, rash, fever, arthralgia and lymphadenopathy) have been reported [see

Contraindications (4)].

2.1 Recommended Dosage

Adults: The recommended initial dosage in adult patients is 800 mg/day. In clinical studies, the average dosage was about 1,000 mg/day.

Pediatrics: The recommended initial dosage in pediatric patients weighing 20 kg and greater is 15 mg/kg/day. Avoid dosages greater than 50 mg/kg per day in pediatric patients [see Warnings and Precautions (5.1), Use in Specific Populations (8.4)].

Administer Tiopronin Delayed-Release Tablets in 3 divided doses at the same times each day, with or without

food. Maintain a routine pattern with regard to meals.

Consider starting Tiopronin Delayed-Release Tablets at a lower dosage in patients with history of severe

toxicity to d-penicillamine.

2.2 Preparation and Administration Instructions

For patients who cannot swallow the tablet whole, Tiopronin Delayed-Release Tablets can be crushed and mixed with applesauce. Administration of Tiopronin Delayed-Release Tablets with other liquids or foods has not been studied and is not recommended.

Preparation and Administration of Tiopronin Delayed-Release Tablets Mixed in Applesauce

For patients who can swallow semi-solid food, Tiopronin Delayed-Release Tablets can be crushed and mixed

with applesauce:

1. Crush the Tiopronin Delayed-Release Tablet in a clean pill crusher or mortar and pestle. Always crush one tablet at a time.

2. Measure approximately one tablespoon of applesauce and transfer it into a container with the crushed Tiopronin Delayed-Release Tablet.

3. Mix the crushed Tiopronin Delayed-Release Tablet in the applesauce until the powder is well dispersed.

4. Administer the entire Tiopronin Delayed-Release Tablets-applesauce mixture to the patient’s mouth immediately. (However, if this is not possible, the mixture can be stored in a refrigerator for up to 2 hours after adding the crushed tablet to the applesauce. Discard any mixture that has not been given within 2 hours.)

5. To assure that any leftover applesauce mixture from the container is recovered, add tap water to the same

container, mix, and have the patient drink the water.

2.3 Monitoring

Measure urinary cystine 1 month after starting Tiopronin Delayed-Release Tablets and every 3 months thereafter. Adjust Tiopronin Delayed-Release Tablets dosage to maintain urinary cystine concentration less than 250 mg/L.

Assess for proteinuria before treatment and every 3 to 6 months during treatment [see Warnings and Precautions (5.1)].

Discontinue Tiopronin Delayed-Release Tablets in patients who develop proteinuria, and monitor urinary protein and renal function. Consider restarting Tiopronin Delayed-Release Tablets treatment at a lower dosage after resolution of proteinuria.

Tablets for oral use:

100 mg tablets: round, white to off-white and imprinted in red with “T1” on one side

300 mg tablets: round, white to off-white and imprinted in red with “T3” on one side

Adverse reactions have been reported from the literature, as well as during post-approval use of Tiopronin

Tablets. Because the post-approval 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 Tiopronin Tablets

exposure.

Adverse reactions reported during the postmarketing use of Tiopronin Tablets are listed by body system in

Table 2.

• Lactation: Breastfeeding is not recommended. (8.2)
• Geriatric: Choose dose carefully and monitor renal function in the elderly. (8.5)

See 17 for PATIENT COUNSELING INFORMATION.

Revised: 07/2021

Hypersensitivity reactions (drug fever, rash, fever, arthralgia and lymphadenopathy) have been reported [see

Contraindications (4)].

Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of the drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adverse reactions occurring at an incidence of ≥5% in an uncontrolled trial in 66 patients with cystinuria age 9 to 68 years are shown in the table below. Patients in group 1 had previously been treated with d-penicillamine; those in group 2 had not. Of those patients who had stopped taking d-penicillamine due to toxicity (34 out of 49 patients in group 1), 22 were able to continue treatment with Tiopronin Tablets. In those without prior history of d-penicillamine treatment, 6% developed reactions of sufficient severity to require Tiopronin Tablets withdrawal.

Table 1 presents adverse reactions ≥5% in either treatment group occurring in this trial.

Taste Disturbance

A reduction in taste perception may develop. It is believed to be the result of chelation of trace metals by tiopronin. Hypogeusia is often self-limited.

Administration Instructions

For patients who cannot swallow the tablet whole, the Tiopronin Delayed-Release Tablets can be crushed and

mixed with applesauce. See Dosage and Administration (2.2) for preparation and administration instructions.

Lactation

Advise women that breastfeeding is not recommended during treatment with Tiopronin Delayed-Release

Tablets [see Use in Specific Populations (8.2)].

100 mg delayed-release, round, white to off-white tablet imprinted with “T1” on one side with red ink and

blank on the other side: Bottles of 300 NDC 44523-054-01.

300 mg delayed-release, round, white to off-white tablet imprinted with “T3” on one side with red ink and

blank on the other side: Bottles of 90 NDC 44523-055-01.

Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature].

For patients who cannot swallow the tablet whole, Tiopronin Delayed-Release Tablets can be crushed and

mixed with applesauce. Administration of Tiopronin Delayed-Release Tablets with other liquids or foods has

not been studied and is not recommended.

Preparation and Administration of Tiopronin Delayed-Release Tablets Mixed in Applesauce

For patients who can swallow semi-solid food, Tiopronin Delayed-Release Tablets can be crushed and mixed

with applesauce:

1. Crush the Tiopronin Delayed-Release Tablet in a clean pill crusher or mortar and pestle. Always crush one

tablet at a time.

2. Measure approximately one tablespoon of applesauce and transfer it into a container with the crushed

Tiopronin Delayed-Release Tablet.

3. Mix the crushed Tiopronin Delayed-Release Tablet in the applesauce until the powder is well dispersed.

4. Administer the entire Tiopronin Delayed-Release Tablets-applesauce mixture to the patient’s mouth

immediately. (However, if this is not possible, the mixture can be stored in a refrigerator for up to 2 hours

after adding the crushed tablet to the applesauce. Discard any mixture that has not been given within 2

hours.)

5. To assure that any leftover applesauce mixture from the container is recovered, add tap water to the same

container, mix, and have the patient drink the water.

Carcinogenesis

Long-term carcinogenicity studies in animals have not been performed.

Mutagenesis

Tiopronin was not genotoxic in the chromosomal aberration, sister chromatid exchange, and in vivo

micronucleus assays.

Impairment of Fertility

High doses of tiopronin in experimental animals have been shown to interfere with maintenance of pregnancy

and viability of the fetus. In 2 published male fertility studies in rats, tiopronin at 20 mg/kg/day intramuscular

(IM) for 60 days induced reductions in testis, epididymis, vas deferens, and accessory sex glands weights and

in the count and motility of cauda epididymal sperm.

Tiopronin Delayed-Release Tablets 100mg

NDC 44523-054-01

Tiopronin is released faster from Tiopronin Delayed-Release Tablets in the presence of alcohol and the risk for

adverse events associated with Tiopronin Delayed-Release Tablets when taken with alcohol is unknown. Avoid

alcohol consumption 2 hours before and 3 hours after taking Tiopronin Delayed-Release Tablets [see Clinical

Pharmacology (12.3)].

There is no information on overdosage with tiopronin.

Risk Summary

Available published case report data with tiopronin have not identified a drug-associated risk for major birth

defects, miscarriage, or adverse maternal or fetal outcomes. Renal stones in pregnancy may result in adverse

pregnancy outcomes (see Clinical Considerations). In animal reproduction studies, there were no adverse

developmental outcomes with oral administration of tiopronin to pregnant mice and rats during organogenesis

at doses up to 2 times a 2 grams/day human dose (based on mg/m2). The estimated background risk of major

birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background

risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background

risk of major birth defects and miscarriage in clinically recognized pregnancies are 2% to 4% and 15% to

20%, respectively.

Clinical Considerations

Disease-associated maternal and/or embryo/fetal risk

Renal stones in pregnancy may increase the risk of adverse pregnancy outcomes, such as preterm birth and

low birth weight.

Data

Animal Data

No findings of fetal malformations could be attributed to the drug in reproduction studies in mice and rats at

doses up to 2 times the highest recommended human dose of 2 grams/day (based on mg/m2).

Risk Summary

There are no data on the presence of tiopronin in either human or animal milk or on the effects of the

breastfed child. A published study suggests that tiopronin may suppress milk production. Because of the

potential for serious adverse reactions, including nephrotic syndrome, advise patients that breastfeeding is not

recommended during treatment with Tiopronin Delayed-Release Tablets.

Tiopronin Delayed-Release Tablets are a reducing and cystine-binding thiol drug (CBTD) for oral use. Tiopronin

is N-(2-Mercaptopropionyl) glycine and has the following structure:

Tiopronin is a white crystalline powder, which is freely soluble in water.

Each Tiopronin Delayed-Release Tablet contains 100 or 300 mg of tiopronin. The inactive ingredients in

Tiopronin Delayed-Release Tablets include lactose monohydrate, hydroxypropyl cellulose, hydroxypropyl

cellulose (low substitute), magnesium stearate, hydroxypropyl methylcellulose E5, methacrylic acid: ethyl

acrylate copolymer (Eudragit L 100-55), talc, triethyl citrate.

Measure urinary cystine 1 month after starting Tiopronin Delayed-Release Tablets and every 3 months

thereafter. Adjust Tiopronin Delayed-Release Tablets dosage to maintain urinary cystine concentration less

than 250 mg/L.

Assess for proteinuria before treatment and every 3 to 6 months during treatment [see Warnings and

Precautions (5.1)].

Discontinue Tiopronin Delayed-Release Tablets in patients who develop proteinuria, and monitor urinary

protein and renal function. Consider restarting Tiopronin Delayed-Release Tablets treatment at a lower dosage

after resolution of proteinuria.

Proteinuria, including nephrotic syndrome, and membranous nephropathy, have been reported with tiopronin

use. Pediatric patients receiving greater than 50 mg/kg of tiopronin per day may be at increased risk for

proteinuria [see Dosage and Administration (2.3), Adverse Reactions (6.1, 6.2), Use in Specific Populations

(8.4)]. Monitor patients for the development of proteinuria and discontinue therapy in patients who develop

proteinuria [see Dosage and Administration (2.3)].

Tiopronin Delayed-Release Tablets are indicated in pediatric patients weighing 20 kg or more with severe

homozygous cystinuria, in combination with high fluid intake, alkali, and diet modification, for the prevention

of cystine stone formation who are not responsive to these measures alone. This indication is based on

safety and efficacy data from a trial in patients 9 years to 68 years of age and clinical experience. Proteinuria,

including nephrotic syndrome, has been reported in pediatric patients. Pediatric patients receiving greater

than 50 mg/kg tiopronin per day may be at greater risk [see Dosage and Administration (2.1, 2.3), Warnings

and Precautions (5.1) and Adverse Reactions (6.1)].

Tiopronin Delayed-Release Tablets are not approved for use in pediatric patients weighing less than 20 kg

[see Dosage and Administration (2.1)].

This drug is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug

may be greater in patients with impaired renal function. Because elderly patients are more likely to have

decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal

function.

Tiopronin Delayed-Release Tablets are contraindicated in patients with hypersensitivity to tiopronin or any other components of Tiopronin Delayed-Release Tablets [see Warnings and Precautions (5.2)].

The following adverse reactions are discussed in greater detail in other sections of the labeling:

• Proteinuria [see Warnings and Precautions (5.1)]

• Hypersensitivity [see Warnings and Precautions (5.2)]

The decrement in urinary cystine produced by tiopronin is generally proportional to the dose. A reduction in

urinary cystine of 250-350 mg/day at tiopronin dosage of 1 g/day, and a decline of approximately 500 mg/day

at a dosage of 2 g/day, might be expected. Tiopronin has a rapid onset and offset of action, showing a fall in

cystine excretion on the first day of administration and a rise on the first day of drug withdrawal.

Absorption

Tiopronin Delayed-Release Tablets

When Tiopronin Tablets and Tiopronin Delayed-Release Tablets single doses were given to fasted healthy

subjects, the median time to peak plasma levels (T _max) was 1 (range: 0.5 to 2.1) and 3 (range: 1.0 to 6.0)

hours, respectively. The peak exposure (C _max) and total exposure (AUC _0-t) of tiopronin from Tiopronin Delayed-

Release Tablets were decreased by 22% and 7% respectively compared to Tiopronin Tablets.

When Tiopronin Delayed-Release Tablets were administered crushed in applesauce, the median time to peak

plasma levels of tiopronin (T _max) was 1 hour (range: 0.5 to 2.0) compared to 3.1 hours (range: 1.5 to 4.0) when

administered as intact Tiopronin Delayed-Release Tablets.

When Tiopronin Delayed-Release Tablets were administered crushed in applesauce, the maximum

concentration (C _max) and exposure (AUC _0-t) to tiopronin were increased by 38% and 14%, respectively,

compared to Tiopronin Delayed-Release Tablets administered intact.

Food Effects

Administration of the Tiopronin Delayed-Release Tablet with food decreases C _max of tiopronin by 13% and

AUC _0-t by 25% compared to Tiopronin Delayed-Release Tablets administered in a fasted state.

Since the drug is dosed to effect, the study results support administration of Tiopronin Delayed-Release Tablets

with or without food; administer at the same time each day with a routine pattern with regard to meals.

Elimination

Excretion

When tiopronin is given orally, up to 48% of dose appears in urine during the first 4 hours and up to 78% by

72 hours.

Drug Interactions

Alcohol

An in vitro dissolution study was conducted to evaluate the impact of alcohol (5, 10, 20, and 40%) on the dose

dumping of Tiopronin Delayed-Release Tablets. The study results showed that the addition of alcohol to the

dissolution media increases the dissolution rate of Tiopronin Delayed-Release Tablets in the acidic media of

0.1N HCl [see Drug Interactions (7.1)].

Adults: The recommended initial dosage in adult patients is 800 mg/day. In clinical studies, the average

dosage was about 1,000 mg/day.

Pediatrics: The recommended initial dosage in pediatric patients weighing 20 kg and greater is 15 mg/kg/day.

Avoid dosages greater than 50 mg/kg per day in pediatric patients [see Warnings and Precautions (5.1), Use in

Specific Populations (8.4)].

Administer Tiopronin Delayed-Release Tablets in 3 divided doses at the same times each day, with or without

food. Maintain a routine pattern with regard to meals.

Consider starting Tiopronin Delayed-Release Tablets at a lower dosage in patients with history of severe

toxicity to d-penicillamine.

Tiopronin Delayed-Release Tablets are indicated, in combination with high fluid intake, alkali, and diet modification, for the prevention of cystine stone formation in adults and pediatric patients 20 kg and greater with severe homozygous cystinuria, who are not responsive to these measures alone.

The goal of therapy is to reduce urinary cystine concentration below its solubility limit. Tiopronin is an active

reducing agent which undergoes thiol-disulfide exchange with cystine to form a mixed disulfide of tiopronincysteine.

From this reaction, a water-soluble mixed disulfide is formed and the amount of sparingly soluble

cystine is reduced.

5.1 Proteinuria

Proteinuria, including nephrotic syndrome, and membranous nephropathy, have been reported with tiopronin

use. Pediatric patients receiving greater than 50 mg/kg of tiopronin per day may be at increased risk for

proteinuria [see Dosage and Administration (2.3), Adverse Reactions (6.1, 6.2), Use in Specific Populations

(8.4)]. Monitor patients for the development of proteinuria and discontinue therapy in patients who develop

proteinuria [see Dosage and Administration (2.3)].

5.2 Hypersensitivity Reactions

Hypersensitivity reactions (drug fever, rash, fever, arthralgia and lymphadenopathy) have been reported [see

Contraindications (4)].

2.1 Recommended Dosage

Adults: The recommended initial dosage in adult patients is 800 mg/day. In clinical studies, the average dosage was about 1,000 mg/day.

Pediatrics: The recommended initial dosage in pediatric patients weighing 20 kg and greater is 15 mg/kg/day. Avoid dosages greater than 50 mg/kg per day in pediatric patients [see Warnings and Precautions (5.1), Use in Specific Populations (8.4)].

Administer Tiopronin Delayed-Release Tablets in 3 divided doses at the same times each day, with or without

food. Maintain a routine pattern with regard to meals.

Consider starting Tiopronin Delayed-Release Tablets at a lower dosage in patients with history of severe

toxicity to d-penicillamine.

2.2 Preparation and Administration Instructions

For patients who cannot swallow the tablet whole, Tiopronin Delayed-Release Tablets can be crushed and mixed with applesauce. Administration of Tiopronin Delayed-Release Tablets with other liquids or foods has not been studied and is not recommended.

Preparation and Administration of Tiopronin Delayed-Release Tablets Mixed in Applesauce

For patients who can swallow semi-solid food, Tiopronin Delayed-Release Tablets can be crushed and mixed

with applesauce:

1. Crush the Tiopronin Delayed-Release Tablet in a clean pill crusher or mortar and pestle. Always crush one tablet at a time.

2. Measure approximately one tablespoon of applesauce and transfer it into a container with the crushed Tiopronin Delayed-Release Tablet.

3. Mix the crushed Tiopronin Delayed-Release Tablet in the applesauce until the powder is well dispersed.

4. Administer the entire Tiopronin Delayed-Release Tablets-applesauce mixture to the patient’s mouth immediately. (However, if this is not possible, the mixture can be stored in a refrigerator for up to 2 hours after adding the crushed tablet to the applesauce. Discard any mixture that has not been given within 2 hours.)

5. To assure that any leftover applesauce mixture from the container is recovered, add tap water to the same

container, mix, and have the patient drink the water.

2.3 Monitoring

Measure urinary cystine 1 month after starting Tiopronin Delayed-Release Tablets and every 3 months thereafter. Adjust Tiopronin Delayed-Release Tablets dosage to maintain urinary cystine concentration less than 250 mg/L.

Assess for proteinuria before treatment and every 3 to 6 months during treatment [see Warnings and Precautions (5.1)].

Discontinue Tiopronin Delayed-Release Tablets in patients who develop proteinuria, and monitor urinary protein and renal function. Consider restarting Tiopronin Delayed-Release Tablets treatment at a lower dosage after resolution of proteinuria.

Tablets for oral use:

100 mg tablets: round, white to off-white and imprinted in red with “T1” on one side

300 mg tablets: round, white to off-white and imprinted in red with “T3” on one side

Adverse reactions have been reported from the literature, as well as during post-approval use of Tiopronin

Tablets. Because the post-approval 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 Tiopronin Tablets

exposure.

Adverse reactions reported during the postmarketing use of Tiopronin Tablets are listed by body system in

Table 2.

• Lactation: Breastfeeding is not recommended. (8.2)
• Geriatric: Choose dose carefully and monitor renal function in the elderly. (8.5)

See 17 for PATIENT COUNSELING INFORMATION.

Revised: 07/2021

Hypersensitivity reactions (drug fever, rash, fever, arthralgia and lymphadenopathy) have been reported [see

Contraindications (4)].

Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of the drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adverse reactions occurring at an incidence of ≥5% in an uncontrolled trial in 66 patients with cystinuria age 9 to 68 years are shown in the table below. Patients in group 1 had previously been treated with d-penicillamine; those in group 2 had not. Of those patients who had stopped taking d-penicillamine due to toxicity (34 out of 49 patients in group 1), 22 were able to continue treatment with Tiopronin Tablets. In those without prior history of d-penicillamine treatment, 6% developed reactions of sufficient severity to require Tiopronin Tablets withdrawal.

Table 1 presents adverse reactions ≥5% in either treatment group occurring in this trial.

Taste Disturbance

A reduction in taste perception may develop. It is believed to be the result of chelation of trace metals by tiopronin. Hypogeusia is often self-limited.

Administration Instructions

For patients who cannot swallow the tablet whole, the Tiopronin Delayed-Release Tablets can be crushed and

mixed with applesauce. See Dosage and Administration (2.2) for preparation and administration instructions.

Lactation

Advise women that breastfeeding is not recommended during treatment with Tiopronin Delayed-Release

Tablets [see Use in Specific Populations (8.2)].

100 mg delayed-release, round, white to off-white tablet imprinted with “T1” on one side with red ink and

blank on the other side: Bottles of 300 NDC 44523-054-01.

300 mg delayed-release, round, white to off-white tablet imprinted with “T3” on one side with red ink and

blank on the other side: Bottles of 90 NDC 44523-055-01.

Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature].

For patients who cannot swallow the tablet whole, Tiopronin Delayed-Release Tablets can be crushed and

mixed with applesauce. Administration of Tiopronin Delayed-Release Tablets with other liquids or foods has

not been studied and is not recommended.

Preparation and Administration of Tiopronin Delayed-Release Tablets Mixed in Applesauce

For patients who can swallow semi-solid food, Tiopronin Delayed-Release Tablets can be crushed and mixed

with applesauce:

1. Crush the Tiopronin Delayed-Release Tablet in a clean pill crusher or mortar and pestle. Always crush one

tablet at a time.

2. Measure approximately one tablespoon of applesauce and transfer it into a container with the crushed

Tiopronin Delayed-Release Tablet.

3. Mix the crushed Tiopronin Delayed-Release Tablet in the applesauce until the powder is well dispersed.

4. Administer the entire Tiopronin Delayed-Release Tablets-applesauce mixture to the patient’s mouth

immediately. (However, if this is not possible, the mixture can be stored in a refrigerator for up to 2 hours

after adding the crushed tablet to the applesauce. Discard any mixture that has not been given within 2

hours.)

5. To assure that any leftover applesauce mixture from the container is recovered, add tap water to the same

container, mix, and have the patient drink the water.

Carcinogenesis

Long-term carcinogenicity studies in animals have not been performed.

Mutagenesis

Tiopronin was not genotoxic in the chromosomal aberration, sister chromatid exchange, and in vivo

micronucleus assays.

Impairment of Fertility

High doses of tiopronin in experimental animals have been shown to interfere with maintenance of pregnancy

and viability of the fetus. In 2 published male fertility studies in rats, tiopronin at 20 mg/kg/day intramuscular

(IM) for 60 days induced reductions in testis, epididymis, vas deferens, and accessory sex glands weights and

in the count and motility of cauda epididymal sperm.