- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
COPDTiotropium is indicated as a maintenance bronchodilator treatment to relieve symptoms of patients with chronic obstructive pulmonary disease (COPD).
AsthmaSpiriva Respimat is indicated as an add-on maintenance bronchodilator treatment in adult patients with asthma who are currently treated with the maintenance combination of inhaled corticosteroids (≥800 µg budesonide/day or equivalent) and long-acting β2 agonists and who experienced one or more severe exacerbations in the previous year.
PosologyThe medicinal product is intended for inhalation use only. The cartridge can only be inserted and used in the Respimat inhaler (see 4.2).Two puffs from the Respimat inhaler comprise one medicinal dose.The recommended dose for adults is 5 microgram tiotropium given as two puffs from the Respimat inhaler once daily, at the same time of the day.The recommended dose should not be exceeded.In the treatment of asthma the full benefit will be apparent after several doses of the medicinal product.
Special populationsGeriatric patients can use tiotropium bromide at the recommended dose. Renally impaired patients can use tiotropium bromide at the recommended dose. For patients with moderate to severe impairment (creatinine clearance ≤ 50 ml/min, see 4.4 and 5.2).Hepatically impaired patients can use tiotropium bromide at the recommended dose (see 5.2).Paediatric population
COPDThere is no relevant use of Spiriva Respimat in children and adolescents below 18 years
Cystic fibrosisThe efficacy and safety of Spiriva Respimat has not been established (see sections 4.4 and 5.1).
AsthmaThe efficacy and safety of Spiriva Respimat in children and adolescents has not yet been established.
Method of administrationTo ensure proper administration of the medicinal product, the patient should be shown how to use the inhaler by a physician or other health professionals.
Patient's instructions for use and handling
Spiriva Respimat inhaler and Spiriva Respimat cartridge
1) Inserting the cartridgeThe following steps 1-6 are necessary before first use:
|1 With the green cap (A) closed, press the safety catch (E) while pulling off the clear base (G).|
|2 Take the cartridge (H) out of the box. Push the narrow end of the cartridge into the inhaler until it clicks into place. The cartridge should be pushed firmly against a firm surface to ensure that it has gone all the way in (2b). The cartridge will not be flush with the inhaler, you will still see the silver ring of the lower end of the cartridge. Do not remove the cartridge once it has been inserted into the inhaler.|
|3 Replace the clear base (G). Do not remove the clear base again.|
2) To prepare the Spiriva Respimat inhaler for first-time use
|4 Hold the Spiriva Respimat inhaler upright, with the green cap (A) closed. Turn the base (G) in the direction of the black arrows on the label until it clicks (half a turn).|
|5 Open the green cap (A) until it snaps fully open.|
|6 Point the Spiriva Respimat inhaler towards the ground. Press the dose release button (D). Close the green cap (A). Repeat steps 4, 5 and 6 until a cloud is visible. Then repeat steps 4, 5 and 6 three more times to ensure the inhaler is prepared for use. Your Spiriva Respimat inhaler is now ready to use.These steps will not affect the number of doses available. After preparation your Spiriva Respimat inhaler will be able to deliver your 60 puffs (30 medicinal doses).|
Daily use of your Spiriva Respimat inhaler
You will need to use this inhaler ONLY ONCE A DAY.
Each time you use it take TWO PUFFS.
|I Hold the Spiriva Respimat inhaler upright, with the green cap (A) closed, to avoid accidental release of dose. Turn the base (G) in the direction of the black arrows on the label until it clicks (half a turn).|
|II Open the green cap (A) until it snaps fully open. Breathe out slowly and fully, and then close your lips around the end of the mouthpiece without covering the air vents (C). Point your Spiriva Respimat inhaler to the back of your throat. While taking in a slow, deep breath through your mouth, press the dose release button (D) and continue to breathe in slowly for as long as you can. Hold your breath for 10 seconds or for as long as comfortable. III Repeat steps I and II so that you get the full dose.You will need to use this inhaler only ONCE A DAY.Close the green cap until you use your Spiriva Respimat inhaler again.If Spiriva Respimat inhaler has not been used for more than 7 days release one puff towards the ground. If Spiriva Respimat inhaler has not been used for more than 21 days repeat steps 4 to 6 until a cloud is visible. Then repeat steps 4 to 6 three more times.|
When to get a new Spiriva Respimat inhaler
|The Spiriva Respimat inhaler contains 60 puffs (30 medicinal doses). The dose indicator shows approximately how much medication is left. When the pointer enters the red area of the scale, there is, approximately, medication for 7 days left (14 puffs). This is when you need to get a new Spiriva Respimat inhaler prescription. Once the dose indicator has reached the end of the red scale (i.e. all 30 doses have been used), the Spiriva Respimat inhaler locks automatically - no more doses can be released. At this point, the base cannot be turned any further. At the latest, three months after use the Spiriva Respimat inhaler should be discarded even if not all medication has been used.|
How to care for your inhalerClean the mouthpiece including the metal part inside the mouthpiece with a damp cloth or tissue only, at least once a week.Any minor discoloration in the mouthpiece does not affect your Spiriva Respimat inhaler performance.If necessary, wipe the outside of your Spiriva Respimat inhaler with a damp cloth.
PregnancyThere is a very limited amount of data from the use of tiotropium in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity at clinically relevant doses (see 5.3). As a precautionary measure, it is preferable to avoid the use of Spiriva Respimat during pregnancy.
Breast-feedingIt is unknown whether tiotropium bromide is excreted in human breast milk. Despite studies in rodents which have demonstrated that excretion of tiotropium bromide in breast milk occurs only in small amounts, use of Spiriva Respimat is not recommended during breast-feeding. Tiotropium bromide is a long-acting compound. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Spiriva Respimat should be made taking into account the benefit of breast-feeding to the child and the benefit of Spiriva Respimat therapy to the woman.
FertilityClinical data on fertility are not available for tiotropium. A non-clinical study performed with tiotropium showed no indication of any adverse effect on fertility (see 5.3).
Summary of the safety profileMany of the listed undesirable effects can be assigned to the anticholinergic properties of tiotropium bromide.
Tabulated summary of adverse reactionsThe frequencies assigned to the undesirable effects listed below are based on crude incidence rates of adverse drug reactions (i.e. events attributed to tiotropium) observed in the tiotropium group pooled from 7 placebo-controlled clinical trials in COPD (3,282 patients) and 6 placebo-controlled clinical trials in asthma (1,256 patients) with treatment periods ranging from four weeks to one year. Frequency is defined using the following convention:Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data)
|System Organ Class / MedDRA Preferred Term||FrequencyCOPD||FrequencyAsthma|
|Metabolism and nutrition disorders|
|Dehydration||Not known||Not known|
|Nervous system disorders|
|Intraocular pressure increased||Rare||Not known|
|Vision blurred||Rare||Not known|
|Atrial fibrillation||Rare||Not known|
|Supraventricular tachycardia||Rare||Not known|
|Respiratory, thoracic and mediastinal disorders|
|Sinusitis||Not known||Not known|
|Gastrooesophageal reflux disease||Rare||Not known|
|Dental caries||Rare||Not known|
|Intestinal obstruction, including ileus paralytic||Not known||Not known|
|Nausea||Not known||Not known|
|Skin and subcutaneous tissue disorders, immune system disorders|
|Skin infection/skin ulcer||Rare||Not known|
|Dry skin||Rare||Not known|
|Hypersensitivity (including immediate reactions)||Not known||Rare|
|Anaphylactic reaction||Not known||Not known|
|Musculoskeletal and connective tissue disorders|
|Joint swelling||Not known||Not known|
|Renal and urinary disorders|
|Urinary retention||Uncommon||Not known|
|Urinary tract infection||Rare||Not known|
Description of selected adverse reactionsIn controlled clinical studies in COPD, the commonly observed undesirable effects were anticholinergic undesirable effects such as dry mouth which occurred in approximately 2.9 % of patients. In asthma the incidence of dry mouth was 1.2%.In 7 clinical trials in COPD, dry mouth led to discontinuation in 3 of 3,282 tiotropium treated patients (0.1 %). No discontinuations due to dry mouth were reported in 6 clinical trials in asthma (1,256 patients).Serious undesirable effects consistent with anticholinergic effects include glaucoma, constipation, intestinal obstruction including ileus paralytic and urinary retention.
Other special populationAn increase in anticholinergic effects may occur with increasing age.
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard
Mechanism of actionTiotropium bromide is a long-acting, specific antagonist at muscarinic receptors. It has similar affinity to the subtypes, M1 to M5. In the airways, tiotropium bromide competitively and reversibly binds to the M3 receptors in the bronchial smooth musculature, antagonising the cholinergic (bronchoconstrictive) effects of acetylcholine, resulting in bronchial smooth muscle relaxation. The effect was dose dependent and lasted longer than 24h. As an N-quaternary anticholinergic, tiotropium bromide is topically (broncho-) selective when administered by inhalation, demonstrating an acceptable therapeutic range before systemic anticholinergic effects may occur. Pharmacodynamic effectsThe dissociation of tiotropium from especially M3-receptors is very slow, exhibiting a significantly longer dissociation half-life than ipratropium. Dissociation from M2-receptors is faster than from M3, which in functional in vitro studies, elicited (kinetically controlled) receptor subtype selectivity of M3 over M2. The high potency, very slow receptor dissociation and topical inhaled selectivity found its clinical correlate in significant and long-acting bronchodilation in patients with COPD and asthma.
Clinical efficacy and safety in COPDThe clinical Phase III development programme included two 1-year, two 12-weeks and two 4-weeks randomised, double-blind studies in 2901 COPD patients (1038 receiving the 5 µg tiotropium dose). The 1-year programme consisted of two placebo-controlled trials. The two 12-week trials were both active (ipratropium) - and placebo-controlled. All six studies included lung function measurements. In addition, the two 1-year studies included health outcome measures of dyspnoea, health-related quality of life and effect on exacerbations.
Lung functionTiotropium inhalation solution, administered once daily, provided significant improvement in lung function (forced expiratory volume in one second and forced vital capacity) within 30 minutes following the first dose, compared to placebo (FEV1 mean improvement at 30 minutes: 0.113 litres; 95% confidence interval (CI): 0.102 to 0.125 litres, p< 0.0001). Improvement of lung function was maintained for 24 hours at steady state compared to placebo (FEV1 mean improvement: 0.122 litres; 95% CI: 0.106 to 0.138 litres, p< 0.0001).Pharmacodynamic steady state was reached within one week.Spiriva Respimat significantly improved morning and evening PEFR (peak expiratory flow rate) as measured by patient's daily recordings compared to placebo (PEFR mean improvement: mean improvement in the morning 22 L/min; 95% CI: 18 to 55 L/min, p< 0.0001; evening 26 L/min; 95% CI: 23 to 30 L/min, p<0.0001). The use of Spiriva Respimat resulted in a reduction of rescue bronchodilator use compared to placebo (mean reduction in rescue use 0.66 occasions per day, 95% CI: 0.51 to 0.81 occasions per day, p<0.0001). The bronchodilator effects of Spiriva Respimat were maintained throughout the 1-year period of administration with no evidence of tolerance.
Dyspnoea, Health-related Quality of Life, COPD Exacerbations in long term 1 year studiesDyspnoeaSpiriva Respimat significantly improved dyspnoea (as evaluated using the Transition Dyspnoea Index) compared to placebo (mean improvement 1.05 units; 95% CI: 0.73 to 1.38 units, p<0.0001). An improvement was maintained throughout the treatment period.Health-related Quality of LifeThe improvement in mean total score of patient's evaluation of their Quality of Life (as measured using the St. George's Respiratory Questionnaire) between Spiriva Respimat versus placebo at the end of the two 1-year studies was 3.5 units (95% CI: 2.1 to 4.9, p<0.0001). A 4-unit decrease is considered clinically relevant.COPD Exacerbations In three one-year, randomised, double-blind, placebo-controlled clinical trials Spiriva Respimat treatment resulted in a significantly reduced risk of a COPD exacerbation in comparison to placebo. Exacerbations of COPD were defined as a complex of at least two respiratory events/symptoms with a duration of three days or more requiring a change in treatment (prescription of antibiotics and/or systemic corticosteroids and/or a significant change of the prescribed respiratory medication). Spiriva Respimat treatment resulted in a reduced risk of a hospitalisation due to a COPD exacerbation (significant in the appropriately powered large exacerbation trial). The pooled analysis of two Phase III trials and separate analysis of an additional exacerbation trial is displayed in Table 1. All respiratory medications except anticholinergics and long-acting beta-agonists were allowed as concomitant treatment, i.e. rapidly acting beta-agonists, inhaled corticosteroids and xanthines. Long-acting beta-agonists were allowed in addition in the exacerbation trial.Table 1: Statistical Analysis of Exacerbations of COPD and Hospitalized COPD Exacerbations in Patients with Moderate to Very Severe COPD
|Study (NSpiriva, Nplacebo)||Endpoint||Spiriva Respimat||Placebo||% Risk Reduction (95% CI)a||p-value|
|1-year Ph III studies, pooled analysisd (670, 653)||Days to first COPD exacerbation||160a||86a||29 (16 to 40)b||<0.0001b|
|Mean exacerbation incidence rate per patient year||0.78c||1.00c||22 (8 to 33)c||0.002c|
|Time to first hospitalised COPD exacerbation||25 (-16 to 51)b||0.20b|
|Mean hospitalised exacerbation incidence rate per patient year||0.09 c||0.11 c||20 (-4 to 38) c||0.096 c|
|1-year Ph IIIb exacerbation study (1939, 1953)||Days to first COPD exacerbation||169a||119a||31 (23 to 37)b||<0.0001b|
|Mean exacerbation incidence rate per patient year||0.69c||0.87c||21 (13 to 28)c||<0.0001c|
|Time to first hospitalised COPD exacerbation||27 (10 to 41)b||0.003b|
|Mean hospitalised exacerbation incidence rate per patient year||0.12c||0.15c||19 (7 to 30)c||0.004c|
Long-term tiotropium active- controlled studyA long-term large scale randomised, double-blind, active-controlled study with an observation period up to 3 years has been performed to compare the efficacy and safety of Spiriva Respimat and Spiriva HandiHaler (5,711 patients receiving Spiriva Respimat; 5,694 patients receiving Spiriva HandiHaler). The primary endpoints were time to first COPD exacerbation, time to all-cause mortality and in a sub-study (906 patients) trough FEV1 (pre-dose). The time to first COPD exacerbation was numericallysimilar during the study with Spiriva Repimat and Spiriva HandiHaler (hazard ratio (Spiriva Respimat/Spiriva HandiHaler) 0.98 with a 95% CI of 0.93 to 1.03). The median number of days to the first COPD exacerbation was 756 days for Spiriva Respimat and 719 days for Spiriva HandiHaler. The bronchodilator effect of Spiriva Respimat was sustained over 120 weeks, and was similar to Spiriva HandiHaler. The mean difference in trough FEV1 for Spiriva Respimat versus Spiriva HandiHaler was -0.010 L (95% CI -0.038 to 0.018 L). In the post-marketing TIOSPIR study comparing Spiriva Respimat and Spiriva HandiHaler, all-cause mortality (including vital status follow up) was similar with hazard ratio (Spiriva Respimat/Spiriva HandiHaler) = 0.96 , 95% CI 0.84 -1.09). Respective treatment exposure was 13,135 and 13,050 patient-years. In the placebo-controlled studies with vital status follow-up to the end of the intended treatment period, Spiriva Respimat showed a numerical increase in all-cause mortality compared to placebo (rate ratio (95% confidence interval) of 1.33 (0.93, 1.92) with treatment exposure to Spiriva Respimat of 2,574 patient years; the excess in mortality was observed in patients with known rhythm disorders. Spiriva HandiHaler showed a 13 % reduction in the risk of death ((hazard ratio including vital status follow-up (tiotropium/placebo) = 0.87; 95% CI, 0.76 to 0.99)). Treatment exposure to Spiriva HandiHaler was 10,927 patient-years. No excess mortality risk was observed in the subgroup of patients with known rhythm disorders in the placebo controlled Spiriva HandiHaler study as well as in the TIOSPIR Spiriva Respimat to HandiHaler comparison.
Clinical efficacy and safety in asthmaThe clinical Phase III programme for persistent asthma included two 1-year randomised, double-blind, placebo-controlled studies in a total of 907 asthma patients (453 receiving Spiriva Respimat) on a combination of ICS (≥800 µg budesonide/day or equivalent) with a LABA. The studies included lung function measurements and severe exacerbations as primary endpoints.PrimoTinA-asthma studiesIn the two 1-year studies in patients who were symptomatic on maintenance treatment of at least ICS (≥800 µg budesonide/day or equivalent) plus LABA, Spiriva Respimat showed clinically relevant improvements in lung function over placebo when used as add-on to background treatment. At week 24, mean improvements in peak and trough FEV1 were 0.110 litres (95% CI: 0.063 to 0.158 litres, p<0.0001) and 0.093 litres (95% CI: 0.050 to 0.137 litres, p<0.0001), respectively. The improvement of lung function compared to placebo was maintained for 24 hours. In the PrimoTinA-asthma studies, treatment of symptomatic patients (N=453) with ICS plus LABA plus tiotropium reduced the risk of severe asthma exacerbations by 21% as compared to treatment of symptomatic patients (N=454) with ICS plus LABA plus placebo. The risk reduction in the mean number of severe asthma exacerbations/patient year was 20%.This was supported by a reduction of 31% in risk for asthma worsening and 24% risk reduction in the mean number of asthma worsenings/patient year (see Table 2).Table 2: Exacerbations in Patients Symptomatic on ICS (≥800 µg budesonide/day or equivalent) plus LABA (PrimoTinA-asthma studies)
|Study||Endpoint||Spiriva Respimat, added-on to at least ICSa/LABA (N=453)||Placebo, added-on to at least ICSa/LABA (N=454)||% Risk Reduction (95% CI)||p-value|
|two 1-year Phase III studies, pooled analysis||Days to 1st severe asthma exacerbation||282c||226c||21b (0, 38)||0.0343|
|Mean number of severe asthma exacerbations / patient year||0.530||0.663||20d (0, 36)||0.0458|
|Days to 1st worsening of asthma||315c||181c||31b (18, 42)||<0.0001|
|Mean number of asthma worsenings / patient year||2.145||2.835||24d (9, 37)||0.0031|
Paediatric populationCOPDThe European Medicines Agency has waived the obligation to submit the results of studies with Spiriva Respimat in all subsets of the paediatric population in COPD (see section 4.2 for information on paediatric use).AsthmaThe European Medicines Agency has deferred the obligation to submit the results of studies with Spiriva Respimat in one or more subsets of the paediatric population in the treatment of asthma (see section 4.2 for information on paediatric use).
Clinical efficacy and safety in cystic fibrosis (CF):The clinical development programme in CF included 3 multicentre studies in 959 patients aged 5 months and above. Patients below 5 years used a spacer (AeroChamber Plus®) with face mask and were included for safety assessment only. The two pivotal studies (a dose finding Phase II study and a confirmatory Phase III study) compared lung function effects (percent predicted FEV1 AUC 0-4h and trough FEV1) of Spiriva Respimat (tiotropium 5 µg: 469 patients) versus placebo (315 patients) in 12-weeks randomised, double-blind periods; the Phase III study also included a long term open label extension, up to 12 months. In these studies, all respiratory medications, except anticholinergics, were allowed as concomitant treatment, e.g. long acting beta agonists, mucolytics and antibiotics.Effects on lung function are displayed in Table 3. No significant improvement in symptoms and health status (exacerbations by Respiratory and Systemic Symptoms Questionnaire and quality of life by Cystic Fibrosis Questionnaire) have been observed. Table 3: Adjusted mean difference from placebo for absolute changes from baseline after 12 weeks
|Phase II||Phase III|
|All patients (NSpiriva = 176, Nplacebo = 168)||All patients (NSpiriva = 293, Nplacebo = 147)||≤11 years(NSpiriva = 95, Nplacebo = 47)||≥12 years(NSpiriva = 198, Nplacebo = 100)|
|mean(95% CI)||p-value||mean(95% CI)||p-value||mean(95% CI)||mean(95% CI)|
|FEV1AUC0-4h (% predicted) aabsolute changes||3.39(1.67, 5.12)||<0.001||1.64(-0.27, 3.55)||0.092||-0.63(-4.58, 3.32)||2.58(0.50, 4.65)|
|FEV1AUC0-4h (litres) absolute changes||0.09(0.05, 0.14)||<0.001||0.07(0.02, 0.12)||0.010||0.01(-0.07, 0.08)||0.10(0.03, 0.17)|
|Trough FEV1(% predicted) aabsolute changes||2.22(0.38, 4.06)||0.018||1.40-0.50, 3.30||0.150||-1.24(-5.20, - 271)||2.56(0.49, 4.62)|
|Trough FEV1 (litres) absolute changes||0.06(0.01, 0.11)||0.028||0.07(0.02, 0.12)||0.012||-0.01(-0.08, 0.06)||0.10(0.03, 0.17)|
|≤11 years||≥12 years|
|Nplacebo = 96||NSpiriva = 158||Nplacebo = 215||NSpiriva = 307|
|Distal intestinal obstruction syndrome||0.0||0.0||1.4||1.3|
|Respiratory tract infections||34.4||36.7||28.4||28.3|
a) General IntroductionTiotropium bromide is a non-chiral quaternary ammonium compound and is sparingly soluble in water. Tiotropium bromide is available as inhalation solution administered by the Respimat inhaler. Approximately 40% of the inhaled dose is deposited in the lungs, the target organ, the remaining amount being deposited in the gastrointestinal tract. Some of the pharmacokinetic data described below were obtained with higher doses than recommended for therapy.
b) General Characteristics of the Active Substance after Administration of the Medicinal ProductAbsorption: Following inhalation by young healthy volunteers, urinary excretion data suggests that approximately 33% of the inhaled dose reaches the systemic circulation. Oral solutions of tiotropium bromide have an absolute bioavailability of 2-3%. Food is not expected to influence the absorption of this quaternary ammonium compound.Maximum tiotropium plasma concentrations were observed 5-7 minutes after inhalation.At steady state, peak tiotropium plasma levels in COPD patients of 10.5 pg/ml were achieved and decreased rapidly in a multi-compartmental manner. Steady state trough plasma concentrations were 1.60 pg/ml. A steady state tiotropium peak plasma concentration of 5.15 pg/ml was attained 5 minutes after the administration of the same dose to patients with asthma. Systemic exposure to tiotropium following the inhalation of tiotropium via the Respimat inhaler was similar to tiotropium inhaled via the HandiHaler device.Distribution: The drug has a plasma protein binding of 72% and shows a volume of distribution of 32 l/kg. 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 penetrate the blood-brain barrier to any relevant extent.Biotransformation: The extent of biotransformation is small. This is evident from a urinary excretion of 74% of unchanged substance after an intravenous dose to young healthy volunteers. The ester tiotropium bromide is nonenzymatically cleaved to the alcohol (N-methylscopine) and acid compound (dithienylglycolic acid) that are inactive on muscarinic receptors. In-vitro experiments with human liver microsomes and human hepatocytes suggest that some further drug (< 20% of dose after intravenous administration) is metabolised by cytochrome P450 (CYP) dependent oxidation and subsequent glutathion conjugation to a variety of Phase II-metabolites.In vitro studies in liver microsomes reveal that the enzymatic pathway can be inhibited by the CYP 2D6 (and 3A4) inhibitors, quinidine, ketoconazole and gestodene. Thus CYP 2D6 and 3A4 are involved in metabolic pathway that is responsible for the elimination of a smaller part of the dose.Tiotropium bromide even in supra-therapeutic concentrations does not inhibit CYP 1A1, 1A2, 2B6, 2C9, 2C19, 2D6, 2E1 or 3A in human liver microsomes.Elimination: The effective half-life of tiotropium ranges between 27 45 h following inhalation by healthy volunteers and COPD patients. The effective half-life was 34 hours in patients with asthma. Total clearance was 880 ml/min after an intravenous dose in young healthy volunteers. Intravenously administered tiotropium is mainly excreted unchanged in urine (74%). After inhalation of the solution by COPD patients to steady-state, urinary excretion is 18.6 % (0.93 µg) of the dose, the remainder being mainly non-absorbed drug in gut that is eliminated via the faeces. After inhalation of the solution by healthy volunteers urinary excretion is 20.1-29.4 % of the dose, the remainder being mainly non-absorbed drug in gut that is eliminated via the faeces. In patients with asthma, 11.9% (0.595 µg) of the dose is excreted unchanged in the urine over 24 hours post dose at steady state. The renal clearance of tiotropium exceeds the creatinine clearance, indicating secretion into the urine. After chronic once daily inhalation by COPD patients, pharmacokinetic steady-state was reached by day 7 with no accumulation thereafter.Linearity / Nonlinearity: Tiotropium demonstrates linear pharmacokinetics in the therapeutic range independent of the formulation.
c) Characteristics in PatientsGeriatric Patients: As expected for all predominantly renally excreted drugs, advancing age was associated with a decrease of tiotropium renal clearance (347 ml/min in COPD patients < 65 years to 275 ml/min in COPD patients ≥ 65 years). This did not result in a corresponding increase in AUC0-6,ss or Cmax,ss values. Exposure to tiotropium was not found to differ with age in patients with asthma.Renally Impaired Patients: Following once daily inhaled administrations of tiotropium to steady-state in COPD patients, mild renal impairment (CLCR 50 - 80 ml/min) resulted in slightly higher AUC0-6,ss (between 1.8 - 30% higher) and similar Cmax,ss values compared to patients with normal renal function(CLCR >80 ml/min). In COPD patients with moderate to severe renal impairment (CLCR < 50 ml/min), the intravenous administration of a single dose of tiotropium resulted in doubling of the total exposure (82% higher AUC0-4h) and 52% higher Cmax) compared to COPD patients with normal renal function, which was confirmed by plasma concentrations after dry powder inhalation. In asthma patients with mild renal impairment (CLCR 50-80 ml/min) inhaled tiotropium did not result in relevant increases in exposure compared to patients with normal renal function.Hepatically Impaired Patients: Liver insufficiency is not expected to have any relevant influence on tiotropium pharmacokinetics. Tiotropium is predominantly cleared by renal elimination (74% in young healthy volunteers) and simple non-enzymatic ester cleavage to pharmacologically inactive products.Japanese COPD Patients: In cross trial comparison, mean peak tiotropium plasma concentrations 10 minutes post-dosing at steady-state were 20% to 70% higher in Japanese compared to Caucasian COPD patients following inhalation of tiotropium but there was no signal for higher mortality or cardiac risk in Japanese patients compared to Caucasian patients. Insufficient pharmacokinetic data is available for other ethnicities or races.Paediatric Patients: There were no paediatric patients in the COPD programme (see 4.2). Paediatric patients were studied as part of the CF clinical programme also covering adults. Following inhalation of 5 µg tiotropium, the tiotropium plasma level in CF patients ≥5 years was 10.1 pg/ml 5 minutes post-dosing at steady-state and decreased rapidly thereafter. The fraction of the dose available in CF patients <5 years old who used the spacer and mask was approximately 3- to 4-fold lower than that observed in CF patients 5 years and older. Tiotropium exposure was related to body-weight in CF patients <5 years.
d) Pharmacokinetic / Pharmacodynamic Relationship(s)There is no direct relationship between pharmacokinetics and pharmacodynamics.
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