Trokide 18 mcg Inhalation powder, hard capsules

Trokide is indicated as a maintenance bronchodilator treatment to relieve symptoms of patients with chronic obstructive pulmonary disease (COPD).

Posology

The recommended dosage of tiotropium is inhalation of the contents of one capsule once daily with the Vertical-Haler at the same time of day. Two inhalation manoeuvres are to be performed for each capsule.

The recommended dose should not be exceeded.

Tiotropium should only be inhaled with the Vertical-Haler device.

Special populations

Elderly

Elderly patients can use tiotropium at the recommended dose.

Renal impairment

Renally impaired patients can use tiotropium at the recommended dose. For patients with moderate to severe impairment (creatinine clearance ≤ 50 ml/min) see section 4.4 and section 5.2.

Hepatic impairment

Hepatically impaired patients can use tiotropium at the recommended dose (see section 5.2).

Paediatric population

COPD

There is no relevant use in the paediatric population (below 18 years) in the indication stated under section 4.1.

Cystic fibrosis

The safety and efficacy of Trokide in children and adolescents has not been established. No data are available.

Method of administration

For inhalation use only.

The capsules must not be swallowed.

The capsule should only be removed from the blister immediately before using the inhaler.

To ensure proper administration of the medicinal product the patient should be trained how to use the inhaler by the physician or by other healthcare professionals.

Instructions for handling and use

The patient must be advised to carefully follow the doctor's instructions for using Trokide. The Vertical-Haler is especially designed for Trokide. It must not be used to take any other medication. The Vertical-Haler can be used for up to 90 days to take the medication. It is a single patient device intended for multiple uses.

Trokide capsules contain only a small amount of powder so that the capsule is only partially filled.

Hypersensitivity to the active substance, milk proteins or to the excipients listed in section 6.1 or to atropine or its derivatives, e.g., ipratropium or oxitropium.

Tiotropium, as a once daily maintenance bronchodilator, should not be used for the initial treatment of acute episodes of bronchospasm, i.e., rescue therapy.

Immediate hypersensitivity reactions may occur after administration of tiotropium inhalation powder.

Consistent with its anticholinergic activity, tiotropium should be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder-neck obstruction. (see section 4.8).

Inhaled medicines may cause inhalation-induced bronchospasm.

Tiotropium should be used with caution in patients with recent myocardial infarction < 6 months; any unstable or life threatening cardiac arrhythmia or cardiac arrhythmia requiring intervention or a change in medicinal product therapy in the past year; hospitalisation of heart failure (NYHA Class III or IV) within the past year. These patients were excluded from the clinical trials and these conditions may be affected by the anticholinergic mechanism of action.

As plasma concentration increases with decreased renal function in patients with moderate to severe renal impairment (creatinine clearance ≤ 50 ml/min) tiotropium should be used only if the expected benefit outweighs the potential risk. There is no long-term experience in patients with severe renal impairment (see section 5.2).

Patients should be cautioned to avoid getting the inhalation powder into their eyes. They should be advised that this may result in precipitation or worsening of narrow-angle glaucoma, eye pain or discomfort, temporary blurring of vision, visual halos or coloured images in association with red eyes from conjunctival congestion and corneal oedema. Should any combination of these eye symptoms develop, patients should stop using tiotropium and consult a specialist immediately.

Dry mouth, which has been observed with anti-cholinergic treatment, may in the long term be associated with dental caries.

Tiotropium should not be used more frequently than once daily (see section 4.9).

Trokide contains lactose

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product. The excipient lactose monohydrate may contain small amounts of milk proteins which may cause allergic reactions.

Although no formal drug interaction studies have been performed, tiotropium inhalation powder has been used concomitantly with other medicinal products without clinical evidence of drug interactions. These include sympathomimetic bronchodilators, methylxanthines, oral and inhaled steroids, commonly used in the treatment of COPD.

Use of LABA or ICS was not found to alter the exposure to tiotropium.

The co-administration of tiotropium with other anticholinergic-containing medicinal products has not been studied and is therefore not recommended.

Pregnancy

There 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 section 5.3). As a precautionary measure, it is preferable to avoid the use of Trokide during pregnancy.

Breast-feeding

It is unknown whether tiotropium is excreted in human breast milk. Despite studies in rodents which have demonstrated that excretion of tiotropium in breast milk occurs only in small amounts, use of tiotropium is not recommended during breast-feeding. Tiotropium is a long-acting compound. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with tiotropium should be made taking into account the benefit of breast-feeding to the child and the benefit of tiotropium therapy to the woman.

Fertility

Clinical 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 section 5.3).

No studies on the effects on the ability to drive and use machines have been performed. The occurrence of dizziness, blurred vision, or headache may influence the ability to drive and use machinery.

Summary of the safety profile

Many of the listed undesirable effects can be assigned to the anticholinergic properties of Trokide.

Tabulated list of adverse reactions

The 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 (9647 patients) from 28 pooled placebo-controlled clinical trials with treatment periods ranging from four weeks to four years.

Adverse reactions are listed by System Organ Class and frequency. Frequencies are defined according to 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).

Description of selected adverse reactions

In controlled clinical studies, the commonly observed undesirable effects were anticholinergic undesirable effects such as dry mouth which occurred in approximately 4 % of patients.

In 28 clinical trials, dry mouth led to discontinuation in 18 of 9647 tiotropium treated patients (0.2 %).

Serious undesirable effects consistent with anticholinergic effects include glaucoma, constipation and intestinal obstruction including ileus paralytic as well as urinary retention.

Other special population

An increase in anticholinergic effects may occur with increasing age.

Reporting of suspected adverse reactions

Reporting 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 or search for MHRA Yellow Card in the Google Play or Apple App Store.

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 340 microgram tiotropium in healthy volunteers. Additionally, no relevant adverse effects, beyond dry mouth, were observed following 7 day dosing of up to 170 microgram tiotropium in healthy volunteers. In a multiple dose study in COPD patients with a maximum daily dose of 43 microgram tiotropium over four weeks no significant undesirable effects have been observed.

Acute intoxication by inadvertent oral ingestion of tiotropium capsules is unlikely due to low oral bioavailability.

Pharmacotherapeutic group: Drugs for obstructive airway diseases, anticholinergics; ATC code: R03BB04

Mechanism of action

Tiotropium is a long-acting, specific, muscarinic receptor antagonist, in clinical medicine often called an anticholinergic. By binding to the muscarinic receptors in the bronchial smooth musculature, tiotropium inhibits the cholinergic (bronchoconstrictive) effects of acetylcholine, released from parasympathetic nerve endings. It has similar affinity to the subtypes of muscarinic receptors, M₁ to M₅. In the airways, tiotropium competitively and reversibly antagonises the M₃ receptors, resulting in relaxation. The effect was dose dependent and lasted longer than 24 h. The long duration is probably due to the very slow dissociation from the M₃ receptor, exhibiting a significantly longer dissociation half-life than ipratropium. As an N-quaternary anticholinergic, tiotropium is topically (broncho-) selective when administered by inhalation, demonstrating an acceptable therapeutic range before systemic anticholinergic effects may occur.

Pharmacodynamic effects

The bronchodilation is primarily a local effect (on the airways), not a systemic one. 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 and slow receptor dissociation found its clinical correlate in significant and long-acting bronchodilation in patients with COPD.

Cardiac electrophysiology

Electrophysiology: In a dedicated QT study involving 53 healthy volunteers, tiotropium 18 microgram and 54 microgram (i.e. three times the therapeutic dose) over 12 days did not significantly prolong QT intervals of the ECG.

Clinical efficacy and safety

The clinical development programme included four one-year and two six-month randomised, double-blind studies in 2663 patients (1308 receiving tiotropium). The one-year programme consisted of two placebo-controlled trials and two trials with an active control (ipratropium). The two six-month trials were both, salmeterol and placebo controlled. These studies included lung function and health outcome measures of dyspnoea, exacerbations and health- related quality of life.

Lung function

Tiotropium, administered once daily, provided significant improvement in lung function (forced expiratory volume in one second, FEV₁ and forced vital capacity, FVC) within 30 minutes following the first dose which was maintained for 24 hours. Pharmacodynamic steady state was reached within one week with the majority of bronchodilation observed by the third day. Tiotropium significantly improved morning and evening PEFR (peak expiratory flow rate) as measured by patient's daily recordings. The bronchodilator effects of tiotropium were maintained throughout the one-year period of administration with no evidence of tolerance.

A randomised, placebo-controlled clinical study in 105 COPD patients demonstrated that bronchodilation was maintained throughout the 24 hour dosing interval in comparison to placebo regardless of whether the medicinal product was administered in the morning or in the evening.

Clinical trials (up to 12 months)

Dyspnoea, Exercise tolerance

Tiotropium significantly improved dyspnoea (as evaluated using the Transition Dyspnoea Index.). This improvement was maintained throughout the treatment period.

The impact of improvements in dyspnoea on exercise tolerance was investigated in two randomised, double-blind, placebo-controlled trials in 433 patients with moderate to severe COPD. In these trials, six weeks of treatment with tiotropium significantly improved symptom-limited exercise endurance time during cycle ergometry at 75 % of maximal work capacity by 19.7 % (Trial A) and 28.3 % (Trial B) compared with placebo.

Health-related Quality of Life

In a 9-month, randomised, double-blind, placebo-controlled clinical trial of 492 patients, tiotropium improved health-related quality of life as determined by the St. George's Respiratory Questionnaire (SGRQ) total score. The proportion of patients treated with tiotropium which achieved a meaningful improvement in the SGRQ total score (i.e., > 4 units) was 10.9 % higher compared with placebo (59.1 % in the tiotropium groups vs. 48.2 % in the placebo group (p=0.029). The mean difference between the groups was 4.19 units (p=0.001; confidence interval: 1.69 – 6.68). The improvements of the subdomains of the SGRQ-score were 8.19 units for “symptoms”, 3.91 units for “activity” and 3.61 units for “impact on daily life”. The improvements of all of these separate subdomains were statistically significant.

COPD exacerbations

In a randomised, double-blind, placebo controlled trial of 1829 patients with moderate to very severe COPD, tiotropium statistically significantly reduced the proportion of patients who experienced exacerbations of COPD (32.2 % to 27.8 %) and statistically significantly reduced the number of exacerbations by 19 % (1.05 to 0.85 events per patient year of exposure). In addition, 7.0 % of patients in the tiotropium group and 9.5% of patients in the placebo group were hospitalised due to a COPD exacerbation (p=0.056). The number of hospitalisations due to COPD was reduced by 30 % (0.25 to 0.18 events per patient year of exposure).

A one-year randomised, double-blind, double-dummy, parallel-group trial compared the effect of treatment with 18 microgram of tiotropium once daily with that of 50 microgram of salmeterol HFA pMDI twice daily on the incidence of moderate and severe exacerbations in 7376 patients with COPD and a history of exacerbations in the preceding year.

Table 1: Summary of exacerbation endpoints

¹ Time [days] refers to 1^st quartile of patients. Time to event analysis was done using Cox's proportional hazards regression model with (pooled) centre and treatment as covariate; ratio refers to hazard ratio.

² Time to event analysis was done using Cox's proportional hazards regression model with (pooled) centre and treatment as covariate; ratio refers to hazard ratio. Time [days] for the 1^st quartile of patients cannot be calculated, because proportion of patients with severe exacerbation is too low.

³ Number of patients with event were analysed using Cochran-Mantel-Haenszel test stratified by pooled centre; ratio refers to risk ratio

Compared with salmeterol, tiotropium increased the time to the first exacerbation (187 days vs. 145 days), with a 17 % reduction in risk (hazard ratio, 0.83; 95 % confidence interval [CI], 0.77 to 0.90; P<0.001). Tiotropium also increased the time to the first severe (hospitalised) exacerbation (hazard ratio, 0.72; 95 % CI, 0.61 to 0.85; P<0.001).

Long-term clinical trials (more than 1 year, up to 4 years)

In a 4-year, randomised, double-blind, placebo-controlled clinical trial of 5993 randomised patients (3006 receiving placebo and 2987 receiving tiotropium), the improvement in FEV₁ resulting from tiotropium, compared with placebo, remained constant throughout 4 years. A higher proportion of patients completed ≥ 45 months of treatment in the tiotropium group compared with the placebo group (63.8 % vs. 55.4 %, p<0.001). The annualized rate of decline of FEV₁ compared to placebo was similar between tiotropium and placebo. During treatment, there was a 16 % reduction in the risk of death. The incidence rate of death was 4.79 per 100 patient years in the placebo group vs. 4.10 per 100 patient years in the tiotropium group (hazard ratio (tiotropium/placebo) = 0.84, 95 % CI = 0.73, 0.97). Treatment with tiotropium reduced the risk of respiratory failure (as recorded through adverse event reporting) by 19 % (2.09 vs. 1.68 cases per 100 patient years, relative risk (tiotropium/placebo) = 0.81, 95 % CI = 0.65, 0.999).

Tiotropium active-controlled study

A 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 tiotropium inhalation powder and tiotropium inhalation solution (5694 patients receiving tiotropium inhalation powder; 5711 patients receiving tiotropium inhalation solution). 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 numerically similar during the study with tiotropium inhalation powder and tiotropium inhalation solution (hazard ratio (tiotropium inhalation powder/ tiotropium inhalation solution) 1.02 with a 95 % CI of 0.97 to 1.08). The median number of days to the first COPD exacerbation was 719 days for tiotropium inhalation powder and 756 days for tiotropium inhalation solution.

The bronchodilator effect of tiotropium inhalation powder was sustained over 120 weeks and was similar to tiotropium inhalation solution. The mean difference in trough FEV₁ for tiotropium inhalation powder versus tiotropium inhalation solution was 0.010 L (95 % CI - 0.018 to 0.038 L).

In the post-marketing TIOSPIR study comparing tiotropium soft mist inhaler and tiotropium inhalation powder, all-cause mortality including vital status follow up was similar during the study with tiotropium inhalation powder and tiotropium inhalation solution (hazard ratio (tiotropium inhalation powder/tiotropium inhalation solution) 1.04 with a 95 % CI of 0.91 to 1.19).

Paediatric population

The European Medicines Agency has waived the obligation to submit results of studies with tiotropium in all subsets of the paediatric population in COPD and cystic fibrosis (see section 4.2 for information on paediatric use).

General introduction

Tiotropium is a non-chiral quaternary ammonium compound and is sparingly soluble in water. Tiotropium is administered by dry powder inhalation. Generally, with the inhaled route of administration, the majority of the delivered dose is deposited in the gastro-intestinal tract, and to a lesser extent in the intended organ of the lung. Many of the pharmacokinetic data described below were obtained with higher doses than recommended for therapy.

General characteristics of the active substance after administration of the medicinal product

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. Oral solutions of tiotropium have an absolute bioavailability of 2-3 %. Maximum tiotropium plasma concentrations were observed 5-7 minutes after inhalation.

At steady state, peak tiotropium plasma levels in COPD patients were 12.9 pg/ml and decreased rapidly in a multicompartmental manner. Steady state trough plasma concentrations were 1.71 pg/ml. Systemic exposure following the inhalation of tiotropium inhalation powder was similar to tiotropium inhaled via the soft mist inhaler.

Distribution

Tiotropium 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 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 active substance (< 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 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 in COPD patients. 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 dry powder inhalation by COPD patients in steady-state, urinary excretion is 7 % (1.3 micrograms) of the unchanged active substance over 24 hours, the remainder being mainly non-absorbed drug in gut that is eliminated via the faeces. 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/non-linearity:

Tiotropium demonstrates linear pharmacokinetics in the therapeutic range independent of the formulation.

Special populations

Elderly: As expected for all predominantly renally excreted active substance, advancing age was associated with a decrease of tiotropium renal clearance (365 ml/min in COPD patients < 65 years to 271 ml/min in COPD patients ≥ 65 years). This did not result in a corresponding increase in AUC_{0-6, ss} or C_{max, ss} values.

Renal impairment: Following once daily inhaled administrations of tiotropium to steady-state in COPD patients, mild renal impairment (CL_CR 50-80 ml/min) resulted in slightly higher AUC_{0-6, ss} (between 1.8-30 % higher) and similar C_{max, ss} values compared to patients with normal renal function (CL_CR > 80 ml/min).

In COPD patients with moderate to severe renal impairment (CL_CR < 50 ml/min), the intravenous administration of tiotropium resulted in doubling of the total exposure (82 % higher AUC_0-4h) and 52 % higher C_max) compared to COPD patients with normal renal function, which was confirmed by plasma concentrations after dry powder inhalation.

Hepatic impairment: 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 population: See section 4.2

Pharmacokinetic / Pharmacodynamic relationship(s)

There is no direct relationship between pharmacokinetics and pharmacodynamics.

Many effects observed in conventional studies of safety pharmacology, repeated dose toxicity, and reproductive toxicity could be explained by the anticholinergic properties of tiotropium. Typically, in animals, reduced food consumption, inhibited body weight gain, dry mouth and nose, reduced lacrimation and salivation, mydriasis and increased heart rate were observed. Other relevant effects noted in repeated dose toxicity studies were: mild irritancy of the respiratory tract in rats and mice evinced by rhinitis and epithelial changes of the nasal cavity and larynx, and prostatitis along with proteinaceous deposits and lithiasis in the bladder in rats.

Harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development could only be demonstrated at maternally toxic dose levels. Tiotropium was not teratogenic in rats or rabbits. In a general reproduction and fertility study in rats, there was no indication of any adverse effect on fertility or mating performance of either treated parents or their offspring at any dosage.

The respiratory (irritation) and urogenital (prostatitis) changes and reproductive toxicity were observed at local or systemic exposures more than five-fold the therapeutic exposure. Studies on genotoxicity and carcinogenic potential revealed no special hazard for humans.

Capsule content:

Lactose monohydrate

Capsule shell:

Gelatin

Water

Polyethylene glycole 4000

Titanium Dioxide (E171)

Yellow Iron Oxide (E172)

FD&C Blue 1/ Brilliant Blue FCF

Not applicable.

2 years.

Discard the inhaler 90 days after first use.

The capsule should be used directly after opening the blister.

Do not store above 30 °C.

For storage conditions after first opening of the medicinal product, see section 6.3.

Heat-sealed Aluminium / Aluminium blister containing 5 or 10 capsules.

The Vertical-Haler is a single dose inhaler made from acrylonitrile butadiene styrene (ABS) plastic materials and stainless steel. Materials that come in direct contact with the product at the time of inhalation are: stainless steel 304 (needles that pierce the capsule), acrylonitrile butadiene styrene-ABS- (forming the mouthpiece through which the active substance flows and the capsule chamber).

Package size:

• Carton box containing Vertical-Haler device and 30 capsules

• Carton box containing Vertical-Haler device and 60 capsules

• Carton box containing Vertical-Haler device and 90 capsules

• Carton box containing 30 capsules

• Carton box containing 60 capsules

Not all pack sizes may be marketed.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.