Tiotropium

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# Overview
Tiotropium is a cholinergic muscarinic agonist that is FDA approved for the treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD) including chronic bronchitis and emphysema.   Common adverse reactions include constipation, xerostomia, pharyngitis, sinusitis, upper respiratory infection.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

### Bronchospasm
- Dosing information
- DO NOT SWALLOW Tiotropium CAPSULES
- FOR USE WITH HANDIHALER DEVICE ONLY
- FOR ORAL INHALATION ONLY
- Tiotropium capsules must not be swallowed as the intended effects on the lungs will not be obtained. The contents of the Tiotropium capsules are only for oral inhalation and should only be used with the HandiHaler device
- Recommended dosage: two inhalations of the powder contents of one Tiotropium capsule, once-daily, with the HandiHaler device
- For administration of Tiotropium HandiHaler, a Tiotropium capsule is placed into the center chamber of the HandiHaler device. The Tiotropium capsule is pierced by pressing and releasing the green piercing button on the side of the HandiHaler device. The tiotropium formulation is dispersed into the air stream when the patient inhales through the mouthpiece.
- No dosage adjustment is required for geriatric, hepatically-impaired, or renally-impaired patients. However, patients with moderate to severe renal impairment given Tiotropium HandiHaler should be monitored closely for anticholinergic effects

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Tiotropium  in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Tiotropium  in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
The safety and effectiveness of Tiotropium HandiHaler in pediatric patients have not been established.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Tiotropium  in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Tiotropium  in pediatric patients.

# Contraindications
Tiotropium HandiHaler is contraindicated in patients with a hypersensitivity to tiotropium, ipratropium, or any components of Tiotropium capsules . In clinical trials and postmarketing experience with Tiotropium HandiHaler, immediate hypersensitivity reactions, including angioedema (including swelling of the lips, tongue, or throat), itching, or rash have been reported.

# Warnings

## Not for Acute Use
Tiotropium HandiHaler is intended as a once-daily maintenance treatment for COPD and is not indicated for the initial treatment of acute episodes of bronchospasm (i.e., rescue therapy).

## Immediate Hypersensitivity Reactions
Immediate hypersensitivity reactions, including urticaria, angioedema (including swelling of the lips, tongue, or throat), rash, bronchospasm, anaphylaxis, or itching, may occur after administration of Tiotropium HandiHaler. If such a reaction occurs, therapy with Tiotropium HandiHaler should be stopped at once and alternative treatments should be considered. Given the similar structural formula of atropine to tiotropium, patients with a history of hypersensitivity reactions to atropine should be closely monitored for similar hypersensitivity reactions to Tiotropium HandiHaler. In addition, Tiotropium HandiHaler should be used with caution in patients with severe hypersensitivity to milk proteins.

## Paradoxical Bronchospasm
Inhaled medicines, including Tiotropium HandiHaler, can produce paradoxical bronchospasm. If this occurs, treatment with Tiotropium HandiHaler should be stopped and other treatments considered.

## Worsening of Narrow-Angle Glaucoma
Tiotropium HandiHaler should be used with caution in patients with narrow-angle glaucoma.  Prescribers and patients should be alert for signs and symptoms of acute narrow-angle glaucoma (e.g., eye pain or discomfort, blurred vision, visual halos or colored images in association with red eyes from conjunctival congestion and corneal edema). Instruct patients to consult a physician immediately should any of these signs or symptoms develop.

## Worsening of Urinary Retention
Tiotropium HandiHaler should be used with caution in patients with urinary retention.  Prescribers and patients should be alert for signs and symptoms of prostatic hyperplasia or bladder-neck obstruction (e.g., difficulty passing urine, painful urination).  Instruct patients to consult a physician immediately should any of these signs or symptoms develop.

## Renal Impairment
As a predominantly renally excreted drug, patients with moderate to severe renal impairment (creatinine clearance of 50 mL/min) treated with Tiotropium HandiHaler should be monitored closely for anticholinergic side effects .

# Adverse Reactions

## Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
6-Month to 1-Year Trials
The data described below reflect exposure to Tiotropium HandiHaler in 2663 patients. Tiotropium HandiHaler 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, 1308 patients were treated with Tiotropium HandiHaler at the recommended dose 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 (FEV1) 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 HandiHaler in patients with COPD. Table 1 shows all adverse reactions that occurred with a frequency of 3% in the Tiotropium HandiHaler group in the 1-year placebo-controlled trials where the rates in the Tiotropium HandiHaler group exceeded placebo by 1%.  The frequency of corresponding reactions in the ipratropium-controlled trials is included for comparison.
Arthritis, coughing, and influenza-like symptoms occurred at a rate of 3% in the Tiotropium HandiHaler treatment group, but were <1% in excess of the placebo group.
Other reactions that occurred in the Tiotropium HandiHaler 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 .
Two multicenter, 6-month, controlled studies evaluated Tiotropium HandiHaler 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 HandiHaler in 5992 COPD patients in a 4-year placebo-controlled trial.  In this trial, 2986 patients were treated with Tiotropium HandiHaler at the recommended dose 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 FEV1 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 HandiHaler group where the rates in the Tiotropium HandiHaler group exceeded placebo by 1%, adverse reactions included (Tiotropium HandiHaler, 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 HandiHaler than placebo include: dehydration, skin ulcer, stomatitis, gingivitis, oropharyngeal candidiasis, dry skin, skin infection, and joint swelling.

## Postmarketing Experience
Adverse reactions have been identified during worldwide post-approval use of Tiotropium HandiHaler. 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.

# Drug Interactions

## Sympathomimetics, Methylxanthines, Steroids
Tiotropium HandiHaler has been used concomitantly with short-acting and long-acting sympathomimetic (beta-agonists) bronchodilators, methylxanthines, and oral and inhaled steroids without increases in adverse drug reactions.

## Anticholinergics
There is potential for an additive interaction with concomitantly used anticholinergic medications. Therefore, avoid coadministration of Tiotropium HandiHaler with other anticholinergic-containing drugs as this may lead to an increase in anticholinergic adverse effects .

## Cimetidine, Ranitidine
No clinically significant interaction occurred between tiotropium and cimetidine or ranitidine

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
There are no adequate and well-controlled studies in pregnant women.  Tiotropium HandiHaler should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
No evidence of structural alterations was observed in rats and rabbits at inhalation tiotropium doses of up to approximately 660 and 6 times the recommended human daily inhalation dose (RHDID) on a mg/m2 basis, respectively. However, in rats, tiotropium caused fetal resorption, litter loss, decreases in the number of live pups at birth and the mean pup weights, and a delay in pup sexual maturation at inhalation tiotropium doses of approximately 35 times the RHDID on a mg/m2 basis. In rabbits, tiotropium caused an increase in post-implantation loss at an inhalation dose of approximately 360 times the RHDID on a mg/m2 basis. Such effects were not observed at inhalation doses of approximately 4 and 80 times the RHDID on a mg/m2 basis in rats and rabbits, respectively. These dose multiples may be over-estimated due to difficulties in measuring deposited doses in animal inhalation studies.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Tiotropium in women who are pregnant.

### Labor and Delivery
The safety and effectiveness of Tiotropium HandiHaler has not been studied during labor and delivery.

### Nursing Mothers
Clinical data from nursing women exposed to tiotropium are not available. Based on lactating rodent studies, tiotropium is excreted into breast milk. It is not known whether tiotropium is excreted in human milk, but because many drugs are excreted in human milk and given these findings in rats, caution should be exercised if Tiotropium HandiHaler is administered to a nursing woman.

### Pediatric Use
Tiotropium HandiHaler is approved for use in the maintenance treatment of bronchospasm associated with COPD and for the reduction of COPD exacerbations. COPD does not normally occur in children. The safety and effectiveness of Tiotropium HandiHaler in pediatric patients have not been established.

### Geriatic Use
Of the total number of patients who received Tiotropium HandiHaler in the 1-year clinical trials, 426 were <65 years, 375 were 65 to 74 years, and 105 were 75 years of age. Within each age subgroup, there were no differences between the proportion of patients with adverse events in the Tiotropium HandiHaler and the comparator groups for most events. Dry mouth increased with age in the Tiotropium HandiHaler group (differences from placebo were 9.0%, 17.1%, and 16.2% in the aforementioned age subgroups). A higher frequency of constipation and urinary tract infections with increasing age was observed in the Tiotropium HandiHaler group in the placebo-controlled studies. The differences from placebo for constipation were 0%, 1.8%, and 7.8% for each of the age groups. The differences from placebo for urinary tract infections were 0.6%, 4.6%, and 4.5%. No overall differences in effectiveness were observed among these groups. Based on available data, no adjustment of Tiotropium HandiHaler dosage in geriatric patients is warranted

### Gender
There is no FDA guidance on the use of Tiotropium with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Tiotropium with respect to specific racial populations.

### Renal Impairment
Patients with moderate to severe renal impairment (creatinine clearance of 50 mL/min) treated with Tiotropium HandiHaler should be monitored closely for anticholinergic side effects

### Hepatic Impairment
The effects of hepatic impairment on the pharmacokinetics of tiotropium were not studied.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Tiotropium in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Tiotropium in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- DO NOT SWALLOW Tiotropium CAPSULES
- FOR USE WITH HANDIHALER DEVICE ONLY
- FOR ORAL INHALATION ONLY

### Monitoring
FDA Package Insert for Tiotropium contains no information regarding drug monitoring.

# IV Compatibility
There is limited information about the IV Compatibility.

# Overdosage
High doses of tiotropium may lead to anticholinergic signs and symptoms. However, there were no systemic anticholinergic adverse effects following a single inhaled dose of up to 282 mcg tiotropium in 6 healthy volunteers. In a study of 12 healthy volunteers, bilateral conjunctivitis and dry mouth were seen following repeated once-daily inhalation of 141 mcg of tiotropium.
Accidental Ingestion
Acute intoxication by inadvertent oral ingestion of Tiotropium capsules is unlikely since it is not well-absorbed systemically.
A case of overdose has been reported from postmarketing experience. A female patient was reported to have inhaled 30 capsules over a 2.5 day period, and developed altered mental status, tremors, abdominal pain, and severe constipation. The patient was hospitalized, Tiotropium HandiHaler was discontinued, and the constipation was treated with an enema. The patient recovered and was discharged on the same day.
No mortality was observed at inhalation tiotropium doses up to 32.4 mg/kg in mice, 267.7 mg/kg in rats, and 0.6 mg/kg in dogs. These doses correspond to 7300, 120,000, and 850 times the recommended human daily inhalation dose on a mg/m2 basis, respectively. These dose multiples may be over-estimated due to difficulties in measuring deposited doses in animal inhalation studies.

# Pharmacology

## Mechanism of Action
Tiotropium is a long-acting, antimuscarinic agent, which is often referred to as an anticholinergic. It has similar affinity to the subtypes of muscarinic receptors, M1 to M5. In the airways, it exhibits pharmacological effects through inhibition of M3-receptors at the smooth muscle leading to bronchodilation. The competitive and reversible nature of antagonism was shown with human and animal origin receptors and isolated organ preparations. In preclinical in vitro as well as in vivo studies, prevention of methacholine-induced bronchoconstriction effects was dose-dependent and lasted longer than 24 hours. The bronchodilation following inhalation of tiotropium is predominantly a site-specific effect.

## Structure
Tiotropium HandiHaler consists of a capsule dosage form containing a dry powder formulation of tiotropium intended for oral inhalation only with the HandiHaler device.
Each light green, hard gelatin Tiotropium capsule contains 18 mcg tiotropium (equivalent to 22.5 mcg tiotropium bromide monohydrate) blended with lactose monohydrate (which may contain milk proteins) as the carrier.
The dry powder formulation within the Tiotropium capsule is intended for oral inhalation only.
The active component of Tiotropium HandiHaler is tiotropium. The drug substance, tiotropium bromide monohydrate, is an anticholinergic with specificity for muscarinic receptors. It is chemically described as (1, 2, 4 , 5, 7)-7--9,9-dimethyl-3-oxa-9-azoniatricyclononane 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 C19H22NO4S2Br - H2O.
The HandiHaler device is an inhalation device used to inhale the dry powder contained in the Tiotropium capsule. The dry powder is delivered from the HandiHaler device at flow rates as low as 20 L/min. Under standardized in vitro testing, the HandiHaler 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 , the median peak inspiratory flow (PIF) through the HandiHaler 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 HandiHaler device, which may vary from patient to patient, and may vary with the exposure time of the Tiotropium capsule outside the blister pack.

## Pharmacodynamics
Cardiovascular Effects
In a multicenter, randomized, double-blind trial that enrolled 198 patients with COPD, the number of subjects with changes from baseline-corrected QT interval of 30 to 60 msec was higher in the Tiotropium HandiHaler group as compared with placebo. This difference was apparent using both the Bazett (QTcB)  and Fredericia (QTcF)  corrections of QT for heart rate. No patients in either group had either QTcB or QTcF of >500 msec. Other clinical studies with Tiotropium HandiHaler did not detect an effect of the drug on QTc intervals.
The effect of Tiotropium HandiHaler on QT interval was also evaluated in a randomized, placebo- and positive-controlled crossover study in 53 healthy volunteers. Subjects received Tiotropium HandiHaler 18 mcg, 54 mcg (3 times the recommended dose), or placebo for 12 days. ECG assessments were performed at baseline and throughout the dosing interval following the first and last dose of study medication. Relative to placebo, the maximum mean change from baseline in study-specific QTc interval was 3.2 msec and 0.8 msec for Tiotropium HandiHaler 18 mcg and 54 mcg, respectively. No subject showed a new onset of QTc >500 msec or QTc changes from baseline of 60 msec.

## Pharmacokinetics
Tiotropium is administered by dry powder inhalation. In common with other inhaled drugs, the majority of the delivered dose is deposited in the gastrointestinal tract and, to a lesser extent, in the lung, the intended organ. Many of the pharmacokinetic data described below were obtained with higher doses than recommended for therapy.
Absorption 
Following dry powder inhalation by young healthy volunteers, the absolute bioavailability of 19.5% suggests that the fraction reaching the lung is highly bioavailable. It is expected from the chemical structure of the compound (quaternary ammonium compound) that tiotropium is poorly absorbed from the gastrointestinal tract. The effect of food on tiotropium's bioavailability has not been studied.  Oral solutions of tiotropium have an absolute bioavailability of 2% to 3%. Maximum tiotropium plasma concentrations were observed 5 minutes after inhalation.
Distribution 
Tiotropium shows a volume of distribution of 32 L/kg indicating that the drug binds extensively to tissues. The human plasma protein binding for tiotropium is 72%. At steady state, peak tiotropium plasma levels in COPD patients were 17 to 19 pg/mL when measured 5 minutes after dry powder inhalation of an 18 mcg dose and decreased in a multi-compartmental manner. Steady-state trough plasma concentrations were 3 to 4 pg/mL. Local concentrations in the lung are not known, but the mode of administration suggests substantially higher concentrations in the lung. Studies in rats have shown that tiotropium does not readily penetrate the blood-brain barrier.
Metabolism 
The extent of metabolism appears to be small. This is evident from a urinary excretion of 74% of unchanged substance after an intravenous dose to young healthy volunteers. Tiotropium, an ester, is nonenzymatically cleaved to the alcohol N-methylscopine and dithienylglycolic acid, neither of which binds to muscarinic receptors.
In vitro experiments with human liver microsomes and human hepatocytes suggest that a fraction of the administered dose (74% of an intravenous dose is excreted unchanged in the urine, leaving 25% for metabolism) is metabolized by cytochrome P450-dependent oxidation and subsequent glutathione conjugation to a variety of Phase II metabolites. This enzymatic pathway can be inhibited by CYP450 2D6 and 3A4 inhibitors, such as quinidine, ketoconazole, and gestodene. Thus, CYP450 2D6 and 3A4 are involved in the metabolic pathway that is responsible for the elimination of a small part of the administered dose. In vitro studies using human liver microsomes showed that tiotropium in supra-therapeutic concentrations did not inhibit CYP450 1A1, 1A2, 2B6, 2C9, 2C19, 2D6, 2E1, or 3A4.
Elimination 
The terminal elimination half-life of tiotropium was between 5 and 6 days following inhalation. Total clearance was 880 mL/min after an intravenous dose in young healthy volunteers with an inter-individual variability of 22%. Intravenously administered tiotropium was mainly excreted unchanged in urine (74%). After dry powder inhalation, urinary excretion was 14% of the dose, the remainder being mainly non-absorbed drug in the gut which was eliminated via the feces. The renal clearance of tiotropium exceeds the creatinine clearance, indicating active secretion into the urine. After chronic once-daily inhalation by COPD patients, pharmacokinetic steady state was reached after 2 to 3 weeks with no accumulation thereafter.
Drug Interactions 
An interaction study with tiotropium (14.4 mcg intravenous infusion over 15 minutes) and cimetidine 400 mg three times daily or ranitidine 300 mg once daily was conducted. Concomitant administration of cimetidine with tiotropium resulted in a 20% increase in the AUC0-4h, a 28% decrease in the renal clearance of tiotropium and no significant change in the Cmax and amount excreted in urine over 96 hours. Co-administration of tiotropium with ranitidine did not affect the pharmacokinetics of tiotropium.
Specific Populations 
Geriatric Patients 
As expected for drugs predominantly excreted renally, advanced age was associated with a decrease of tiotropium renal clearance (326 mL/min in COPD patients 70 years), which may be explained by decreased renal function. Tiotropium excretion in urine after inhalation decreased from 14% (young healthy volunteers) to about 7% (COPD patients). Plasma concentrations were numerically increased with advancing age within COPD patients (43% increase in AUC0-4 after dry powder inhalation), which was not significant when considered in relation to inter- and intra-individual variability .
Renal Impairment 
Since tiotropium is predominantly renally excreted, renal impairment was associated with increased plasma drug concentrations and reduced drug clearance after both intravenous infusion and dry powder inhalation. Mild renal impairment (creatinine clearance of 50 to 80 mL/min), which is often seen in elderly patients, increased tiotropium plasma concentrations (39% increase in AUC0-4 after intravenous infusion). In COPD patients with moderate to severe renal impairment (creatinine clearance of <50 mL/min), the intravenous administration of tiotropium resulted in doubling of the plasma concentrations (82% increase in AUC0-4), which was confirmed by plasma concentrations after dry powder inhalation.  Patients with moderate to severe renal impairment (creatinine clearance of 50 mL/min) treated with Tiotropium HandiHaler should be monitored closely for anticholinergic side effects .
Hepatic Impairment 
The effects of hepatic impairment on the pharmacokinetics of tiotropium were not studied.

## Nonclinical Toxicology

## Carcinogenesis, Mutagenesis, Impairment of Fertility
No evidence of tumorigenicity was observed in a 104-week inhalation study in rats at tiotropium doses up to 0.059 mg/kg/day, in an 83-week inhalation study in female mice at doses up to 0.145 mg/kg/day, and in a 101-week inhalation study in male mice at doses up to 0.002 mg/kg/day. These doses correspond to approximately 25, 35, and 0.5 times the recommended human daily inhalation dose (RHDID) on a mg/m2 basis, respectively. These dose multiples may be over-estimated due to difficulties in measuring deposited doses in animal inhalation studies.
Tiotropium bromide demonstrated no evidence of mutagenicity or clastogenicity in the following assays: the bacterial gene mutation assay, the V79 Chinese hamster cell mutagenesis assay, the chromosomal aberration assays in human lymphocytes in vitro and mouse micronucleus formation in vivo, and the unscheduled DNA synthesis in primary rat hepatocytes in vitro assay.
In rats, decreases in the number of corpora lutea and the percentage of implants were noted at inhalation tiotropium doses of 0.078 mg/kg/day or greater (approximately 35 times the RHDID on a mg/m2 basis). No such effects were observed at 0.009 mg/kg/day (approximately 4 times than the RHDID on a mg/m2 basis). The fertility index, however, was not affected at inhalation doses up to 1.689 mg/kg/day (approximately 760 times the RHDID on a mg/m2 basis). These dose multiples may be over-estimated due to difficulties in measuring deposited doses in animal inhalation studies.

## Animal Toxicology and Pharmacology
Reproductive Toxicology Studies
No evidence of fetal structural alteration was observed in rats and rabbits at inhalation tiotropium doses of up to 1.471 and 0.007 mg/kg/day, respectively. These doses correspond to approximately 660 and 6 times the RHDID on a mg/m2 basis, respectively. However, in rats, fetal resorption, litter loss, decreases in the number of live pups at birth and the mean pup weights, and a delay in pup sexual maturation were observed at inhalation tiotropium doses of 0.078 mg/kg (approximately 35 times the RHDID on a mg/m2 basis). In rabbits, an increase in post-implantation loss was observed at an inhalation dose of 0.4 mg/kg/day (approximately 360 times the RHDID on a mg/m2 basis). Such effects were not observed at inhalation doses of 0.009 and up to 0.088 mg/kg/day in rats and rabbits, respectively. These doses correspond to approximately 4 and 80 times the RHDID on a mg/m2 basis, respectively. These dose multiples may be over-estimated due to difficulties in measuring deposited doses in animal inhalation studies.

# Clinical Studies
The Tiotropium HandiHaler (tiotropium bromide inhalation powder) clinical development program consisted of six Phase 3 studies in 2663 patients with COPD (1308 receiving Tiotropium HandiHaler): two 1-year, placebocontrolled studies, two 6-month, placebo-controlled studies and two 1-year, ipratropium-controlled studies. These studies enrolled patients who had a clinical diagnosis of COPD, were 40 years of age or older, had a history of smoking greater than 10 pack-years, had a forced expiratory volume in one second (FEV1) less than or equal to 60% or 65% of predicted, and a ratio of FEV1/FVC of less than or equal to 0.7.
In these studies, Tiotropium HandiHaler, administered once-daily in the morning, provided improvement in lung function (FEV1), with peak effect occurring within 3 hours following the first dose.
Two additional trials evaluated exacerbations: a 6-month, randomized, double-blind, placebo-controlled, multicenter clinical trial of 1829 COPD patients in a US Veterans Affairs setting and a 4-year, randomized, double-blind, placebo-controlled, multicenter, clinical trial of 5992 COPD patients. Long-term effects on lung function and other outcomes were also evaluated in the 4-year multicenter trial.
6-Month to 1-Year Effects on Lung Function 
In the 1-year, placebo-controlled trials, the mean improvement in FEV1 at 30 minutes was 0.13 liters (13%) with a peak improvement of 0.24 liters (24%) relative to baseline after the first dose (Day 1). Further improvements in FEV1 and forced vital capacity (FVC) were observed with pharmacodynamic steady state reached by Day 8 with once-daily treatment. The mean peak improvement in FEV1, relative to baseline, was 0.28 to 0.31 liters (28% to 31%), after 1 week (Day 8) of once-daily treatment. Improvement of lung function was maintained for 24 hours after a single dose and consistently maintained over the 1-year treatment period with no evidence of tolerance.
In the two 6-month, placebo-controlled trials, serial spirometric evaluations were performed throughout daytime hours in Trial A (12 hours) and limited to 3 hours in Trial B. The serial FEV1 values over 12 hours (Trial A) are displayed in Figure 1. These trials further support the improvement in pulmonary function (FEV1) with Tiotropium HandiHaler, which persisted over the spirometric observational period. Effectiveness was maintained for 24 hours after administration over the 6-month treatment period.
Results of each of the 1-year ipratropium-controlled trials were similar to the results of the 1-year placebo-controlled trials. The results of one of these trials are shown in Figure 2.
A randomized, placebo-controlled clinical study in 105 patients with COPD demonstrated that bronchodilation was maintained throughout the 24-hour dosing interval in comparison to placebo, regardless of whether Tiotropium HandiHaler was administered in the morning or in the evening.
Throughout each week of the one-year treatment period in the two placebo-controlled trials, patients taking Tiotropium HandiHaler had a reduced requirement for the use of rescue short-acting beta2-agonists. Reduction in the use of rescue short-acting beta2-agonists, as compared to placebo, was demonstrated in one of the two 6-month studies.
4-Year Effects on Lung Function
A 4-year, randomized, double-blind, placebo-controlled, multicenter clinical trial involving 5992 COPD patients was conducted to evaluate the long-term effects of Tiotropium HandiHaler on disease progression (rate of decline in FEV1). Patients were permitted to use all respiratory medications (including short-acting and long-acting beta-agonists, inhaled and systemic steroids, and theophyllines) other than inhaled anticholinergics. The patients were 40 to 88 years of age, 75% male, and 90% Caucasian with a diagnosis of COPD and a mean pre-bronchodilator FEV1 of 39% predicted (range = 9% to 76%) at study entry.  There was no difference between the groups in either of the co-primary efficacy endpoints, yearly rate of decline in pre- and post-bronchodilator FEV1, as demonstrated by similar slopes of FEV1 decline over time (Figure 3).
Tiotropium HandiHaler maintained improvements in trough (pre-dose) FEV1 (adjusted means over time: 87 to 103 mL) throughout the 4 years of the study (Figure 3).
Repeated measure ANOVA was used to estimate means. Means are adjusted for baseline measurements. Baseline trough FEV1 (observed mean) = 1.12. Patients with 3 acceptable pulmonary function tests after Day 30 and non-missing baseline value were included in the analysis.
Exacerbations
The effect of Tiotropium HandiHaler on COPD exacerbations was evaluated in two clinical trials: a 4-year clinical trial described above and a 6-month clinical trial of 1829 COPD patients in a Veterans Affairs setting. In the 6-month trial, COPD exacerbations were defined as a complex of respiratory symptoms (increase or new onset) of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least 3 days requiring treatment with antibiotics, systemic steroids, or hospitalization.  The population had an age ranging from 40 to 90 years with 99% males, 91% Caucasian, and had COPD with a mean pre-bronchodilator FEV1 percent predicted of 36% (range = 8% to 93%).  Patients were permitted to use respiratory medications (including short-acting and long-acting beta-agonists, inhaled and systemic steroids, and theophyllines) other than inhaled anticholinergics. In the 6-month trial, the co-primary endpoints were the proportion of patients with COPD exacerbation and the proportion of patients with hospitalization due to COPD exacerbation.  Tiotropium HandiHaler significantly reduced the proportion of COPD patients who experienced exacerbations compared to placebo (27.9% vs 32.3%, respectively; Odds Ratio (OR) (tiotropium/placebo) = 0.81; 95% CI = 0.66, 0.99; p = 0.037).  The proportion of patients with hospitalization due to COPD exacerbations in patients who used Tiotropium HandiHaler compared to placebo was 7.0% vs 9.5%, respectively; OR = 0.72; 95% CI = 0.51, 1.01; p = 0.056.
Exacerbations were evaluated as a secondary outcome in the 4-year multicenter trial. In this trial, COPD exacerbations were defined as an increase or new onset of more than one of the following respiratory symptoms (cough, sputum, sputum purulence, wheezing, dyspnea) with a duration of three or more days requiring treatment with antibiotics and/or systemic (oral, intramuscular, or intravenous) steroids.  Tiotropium HandiHaler significantly reduced the risk of an exacerbation by 14% (Hazard Ratio (HR) = 0.86; 95% CI = 0.81, 0.91; p<0.001) and reduced the risk of exacerbation-related hospitalization by 14% (HR = 0.86; 95% CI = 0.78, 0.95; p<0.002) compared to placebo.  The median time to first exacerbation was delayed from 12.5 months (95% CI = 11.5, 13.8) in the placebo group to 16.7 months (95% CI = 14.9, 17.9) in the Tiotropium HandiHaler group.

# How Supplied
Tiotropium HandiHaler consists of Tiotropium capsules and the HandiHaler device. Tiotropium capsules contain 18 mcg of tiotropium and are light green, with the Boehringer Ingelheim company logo on the Tiotropium capsule cap and TI 01 on the Tiotropium capsule body, or vice versa.
The HandiHaler device is gray colored with a green piercing button. It is imprinted with Tiotropium HandiHaler (tiotropium bromide inhalation powder), the Boehringer Ingelheim company logo, and the Pfizer company logo. It is also imprinted to indicate that Tiotropium capsules should not be stored in the HandiHaler device and that the HandiHaler device is only to be used with Tiotropium capsules.
Tiotropium capsules are packaged in an aluminum/aluminum blister card and joined along a perforated-cut line. Tiotropium capsules should always be stored in the blister and only removed immediately before use. The drug should be used immediately after the packaging over an individual Tiotropium capsule is opened.
The following packages are available:
- carton containing 5 Tiotropium capsules (1 unit-dose blister card) and 1 HandiHaler inhalation device (NDC 0597-0075-75)
- carton containing 30 Tiotropium capsules (3 unit-dose blister cards) and 1 HandiHaler inhalation device (NDC 0597-0075-41)
- carton containing 90 Tiotropium capsules (9 unit-dose blister cards) and 1 HandiHaler inhalation device (NDC 0597-0075-47)

## Storage
Store at 25C (77F); excursions permitted to 15 to 30C (59 to 86F) .
The Tiotropium capsules should not be exposed to extreme temperature or moisture. Do not store Tiotropium capsules in the HandiHaler device.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information

# Precautions with Alcohol
Alcohol-Tiotropium interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
Tiotropium

# Look-Alike Drug Names
Tiotropium - Inspra

# Drug Shortage Status

# Price