TIOTROPIUM BROMIDE

Tiotropium bromide inhalation powder consists of tiotropium bromide inhalation powder capsules and a LupinHaler device. Each white opaque, hypromellose tiotropium bromide inhalation powder capsule contains a dry powder consisting of 18 mcg tiotropium (equivalent to 22.5 mcg tiotropium bromide monohydrate USP) blended with lactose monohydrate (which may contain milk proteins). The contents of tiotropium bromide inhalation powder capsules are intended for oral inhalation only, and are intended for administration only with the LupinHaler device. The active component of tiotropium bromide inhalation powder is tiotropium. The drug substance, tiotropium bromide monohydrate, is an anticholinergic with specificity for muscarinic receptors. It is chemically described as (1α, 2β, 4β, 5α, 7β)-7-[(Hydroxydi-2-thienylacetyl)oxy]-9,9-dimethyl-3-oxa-9-azoniatricyclo [3.3.1.0 2,4 ] nonane bromide monohydrate. It is a synthetic, non-chiral, quaternary ammonium compound. Tiotropium bromide is a white or yellowish white powder. It is sparingly soluble in water and soluble in methanol. The structural formula is: Tiotropium bromide (monohydrate) has a molecular mass of 490.4 and a molecular formula of C 19 H 22 NO 4 S 2 Br • H 2 O. The LupinHaler device is an inhalation device used to inhale the dry powder contained in the tiotropium bromide inhalation powder capsule. The dry powder is delivered from the LupinHaler device at flow rates as low as 20 L/min. Under standardized in vitro testing, the LupinHaler device delivers a mean of 10.4 mcg tiotropium when tested at a flow rate of 39 L/min for 3.1 seconds (2 L total). In a study of 26 adult patients with COPD and severely compromised lung function [mean FEV 1 1.02 L (range 0.45 to 2.24 L); 37.6% of predicted (range 16% to 65%)], the median peak inspiratory flow (PIF) through the LupinHaler device was 30.0 L/min (range 20.4 to 45.6 L/min). The amount of drug delivered to the lungs will vary depending on patient factors such as inspiratory flow and peak inspiratory flow through the LupinHaler device, which may vary from patient to patient, and may vary with the exposure time of the tiotropium bromide inhalation powder capsule outside the blister pack. Image

Tiotropium bromide inhalation powder is indicated for the long-term, once-daily, maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. Tiotropium bromide inhalation powder is indicated to reduce exacerbations in COPD patients. Tiotropium bromide inhalation powder is an anticholinergic indicated for the long-term, once-daily, maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), and for reducing COPD exacerbations ( 1 )

For oral inhalation only. Do not swallow tiotropium bromide inhalation powder capsules, as the intended effects on the lungs will not be obtained. The contents of the tiotropium bromide inhalation powder capsules should only be used with the LupinHaler ® device [see Overdosage ( 10 )] . The recommended dosage of tiotropium bromide inhalation powder is two inhalations of the powder contents of one tiotropium bromide inhalation powder capsule, once-daily, with the LupinHaler device [see Patient Counseling Information ( 17 )]. Do not take more than one dose in 24 hours. For administration of tiotropium bromide inhalation powder, a tiotropium bromide inhalation powder capsule is placed into the center chamber of the LupinHaler device. The tiotropium bromide inhalation powder capsule is pierced by pressing and releasing the green piercing button on the side of the LupinHaler device. The tiotropium formulation is dispersed into the air stream when the patient inhales through the mouthpiece [see Patient Counseling Information ( 17 )]. No dosage adjustment is required for geriatric, hepatically-impaired, or renally-impaired patients. However, patients with moderate to severe renal impairment given tiotropium bromide inhalation powder should be monitored closely for anticholinergic effects [see Warnings and Precautions ( 5.6 ), Use in Specific Populations ( 8.5 , 8.6 , 8.7 ), and Clinical Pharmacology ( 12.3 )]. For oral inhalation only. DO NOT swallow tiotropium bromide inhalation powder capsules. Only use tiotropium bromide inhalation powder capsules with the LupinHaler ® device ( 2 ) Two inhalations of the powder contents of a single tiotropium bromide inhalation powder capsule (18 mcg) once daily ( 2 )

Tiotropium bromide inhalation powder is contraindicated in patients with a hypersensitivity to tiotropium, ipratropium, or any components of this product [see Warnings and Precautions ( 5.2 )] . In clinical trials and postmarketing experience with tiotropium bromide inhalation powder, immediate hypersensitivity reactions, including angioedema (including swelling of the lips, tongue, or throat), itching, or rash have been reported [see Warnings and Precautions ( 5.2 )] . Hypersensitivity to tiotropium, ipratropium, or any components of tiotropium bromide inhalation powder capsules ( 4 )

The following adverse reactions are described, or described in greater detail, in other sections: Immediate hypersensitivity reactions [see Warnings and Precautions ( 5.2 )] Paradoxical bronchospasm [see Warnings and Precautions ( 5.3 )] Worsening of narrow-angle glaucoma [see Warnings and Precautions ( 5.4 )] Worsening of urinary retention [see Warnings and Precautions ( 5.5 )] The most common adverse reactions (>5% incidence in the 1-year placebo- controlled trials) were upper respiratory tract infection, dry mouth, sinusitis, pharyngitis, non-specific chest pain, urinary tract infection, dyspepsia, and rhinitis ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Lupin Pharmaceuticals, Inc. at 1-800-399-2561 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, the incidence of adverse reactions observed in the clinical trials of a drug cannot be directly compared to the incidences in the clinical trials of another drug and may not reflect the incidences observed in practice. 6-Month to 1-Year Trials The data described below reflect exposure to tiotropium bromide inhalation powder in 2,663 patients. Tiotropium bromide inhalation powder was studied in two 1-year placebo-controlled trials, two 1-year active-controlled trials, and two 6-month placebo-controlled trials in patients with COPD. In these trials, 1,308 patients were treated with tiotropium bromide inhalation powder at the recommended dosage of 18 mcg once a day. The population had an age ranging from 39 to 87 years with 65% to 85% males, 95% Caucasian, and had COPD with a mean pre-bronchodilator forced expiratory volume in one second (FEV 1 ) percent predicted of 39% to 43%. Patients with narrow-angle glaucoma, or symptomatic prostatic hypertrophy or bladder outlet obstruction were excluded from these trials. An additional 6-month trial conducted in a Veteran's Affairs setting is not included in this safety database because only serious adverse events were collected. The most commonly reported adverse drug reaction was dry mouth. Dry mouth was usually mild and often resolved during continued treatment. Other reactions reported in individual patients and consistent with possible anticholinergic effects included constipation, tachycardia, blurred vision, glaucoma (new onset or worsening), dysuria, and urinary retention. Four multicenter, 1-year, placebo-controlled and active-controlled trials evaluated tiotropium bromide inhalation powder in patients with COPD. Table 1 shows all adverse reactions that occurred with a frequency of ≥3% in the tiotropium bromide inhalation powder group in the 1-year placebo-controlled trials where the rates in the tiotropium bromide inhalation powder group exceeded placebo by ≥1%. The frequency of corresponding reactions in the ipratropium-controlled trials is included for comparison. Table 1: Adverse Reactions (% Patients) in One-Year COPD Clinical Trials Body System (Event) Placebo-Controlled Trials Ipratropium-Controlled Trials Tiotropium Bromide Inhalation Powder (n = 550) Placebo (n = 371) Tiotropium Bromide Inhalation Powder (n = 356) Ipratropium (n = 179) Body as a Whole Chest Pain (non-specific) 7 5 5 2 Edema, Dependent 5 4 3 5 Gastrointestinal System Disorders Dry Mouth 16 3 12 6 Dyspepsia 6 5 1 1 Abdominal Pain 5 3 6 6 Constipation 4 2 1 1 Vomiting 4 2 1 2 Musculoskeletal System Myalgia 4 3 4 3 Resistance Mechanism Disorders Infection 4 3 1 3 Moniliasis 4 2 3 2 Respiratory System (Upper) Upper Respiratory Tract Infection 41 37 43 35 Sinusitis 11 9 3 2 Pharyngitis 9 7 7 3 Rhinitis 6 5 3 2 Epistaxis 4 2 1 1 Skin and Appendage Disorders Rash 4 2 2 2 Urinary System Urinary Tract Infection 7 5 4 2 Arthritis, coughing, and influenza-like symptoms occurred at a rate of ≥3% in the tiotropium bromide inhalation powder treatment group, but were <1% in excess of the placebo group. Other reactions that occurred in the tiotropium bromide inhalation powder group at a frequency of 1% to 3% in the placebo-controlled trials where the rates exceeded that in the placebo group include: Body as a Whole : allergic reaction, leg pain; Central and Peripheral Nervous System : dysphonia, paresthesia; Gastrointestinal System Disorders : gastrointestinal disorder not otherwise specified (NOS), gastroesophageal reflux, stomatitis (including ulcerative stomatitis); Metabolic and Nutritional Disorders : hypercholesterolemia, hyperglycemia; Musculoskeletal System Disorders : skeletal pain; Cardiac Events : angina pectoris (including aggravated angina pectoris); Psychiatric Disorder : depression; Infections : herpes zoster; Respiratory System Disorder (Upper): laryngitis; Vision Disorder : cataract. In addition, among the adverse reactions observed in the clinical trials with an incidence of <1% were atrial fibrillation, supraventricular tachycardia, angioedema, and urinary retention. In the 1-year trials, the incidence of dry mouth, constipation, and urinary tract infection increased with age [see Use in Specific Populations ( 8.5 )]. Two multicenter, 6-month, controlled studies evaluated tiotropium bromide inhalation powder in patients with COPD. The adverse reactions and the incidence rates were similar to those seen in the 1-year controlled trials. 4-Year Trial The data described below reflect exposure to tiotropium bromide inhalation powder in 5,992 COPD patients in a 4-year placebo-controlled trial. In this trial, 2,986 patients were treated with tiotropium bromide inhalation powder at the recommended dosage of 18 mcg once a day. The population had an age range from 40 to 88 years, was 75% male, 90% Caucasian, and had COPD with a mean pre-bronchodilator FEV 1 percent predicted of 40%. Patients with narrow-angle glaucoma, or symptomatic prostatic hypertrophy or bladder outlet obstruction were excluded from these trials. When the adverse reactions were analyzed with a frequency of ≥3% in the tiotropium bromide inhalation powder group where the rates in the tiotropium bromide inhalation powder group exceeded placebo by ≥1%, adverse reactions included (tiotropium bromide inhalation powder, placebo): pharyngitis (12.5%, 10.8%), sinusitis (6.5%, 5.3%), headache (5.7%, 4.5%), constipation (5.1%, 3.7%), dry mouth (5.1%, 2.7%), depression (4.4%, 3.3%), insomnia (4.4%, 3.0%), and arthralgia (4.2%, 3.1%). Additional Adverse Reactions Other adverse reactions not previously listed that were reported more frequently in COPD patients treated with tiotropium bromide inhalation powder than placebo include: dehydration, skin ulcer, stomatitis, gingivitis, oropharyngeal candidiasis, dry skin, skin infection, and joint swelling. 6.2 Postmarketing Experience Adverse reactions have been identified during worldwide post-approval use of tiotropium bromide inhalation powder. 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. These adverse reactions are: application site irritation (glossitis, mouth ulceration, and pharyngolaryngeal pain), dizziness, dysphagia, hoarseness, intestinal obstruction including ileus paralytic, intraocular pressure increased, oral candidiasis, palpitations, pruritus, tachycardia, throat irritation, and urticaria.

Anticholinergics: May interact additively with concomitantly used anticholinergic medications. Avoid administration of tiotropium bromide inhalation powder with other anticholinergic-containing drugs. ( 7.2 ) 7.1 Sympathomimetics, Methylxanthines, Steroids Tiotropium bromide inhalation powder has been used concomitantly with short-acting and long-acting sympathomimetic (beta-agonists) bronchodilators, methylxanthines, and oral and inhaled steroids without increases in adverse reactions. 7.2 Anticholinergics There is potential for an additive interaction with concomitantly used anticholinergic medications. Therefore, avoid coadministration of tiotropium bromide inhalation powder with other anticholinergic-containing drugs as this may lead to an increase in anticholinergic adverse effects [see Warnings and Precautions ( 5.4 , 5.5 ) and Adverse Reactions ( 6 )].