TUDORZ ( PRESSAIR)
(ACLIDINIUM BROMIDE) INHALATION POWDER
DRUG DESCRIPTION
TUDORZA PRESSAIR CONSISTS OF A DRY POWDER FORMULATION OF ACLIDINIUM BROMIDE FOR ORAL INHALATION ONLY.
ACLIDINIUM BROMIDE, THE ACTIVE COMPONENT OF TUDORZA PRESSAIR IS AN ANTICHOLINERGIC WITH SPECIFICITY FOR MUSCARINIC RECEPTORS. ACLIDINIUM BROMIDE IS A SYNTHETIC, QUATERNARY AMMONIUM COMPOUND, CHEMICALLY DESCRIBED AS L-AZONIABICYCLO[2.2.2]OCTANE, 3-[(HYDROXYDI-2-THIENYLACETYL)OXY]-L-(3-PHENOXYPROPYL)-, BROMIDE, (3R)-. THE STRUCTURAL FORMULA IS:
ACLIDINIUM BROMIDE IS A WHITE POWDER WITH A MOLECULAR FORMULA OF C26H30 NO4S2BR AND A MOLECULAR MASS OF 564.56. IT IS VERY SLIGHTLY SOLUBLE IN WATER AND ETHANOL AND SPARINGLY SOLUBLE IN METHANOL.
TUDORZA PRESSAIR IS A BREATH-ACTUATED MULTI-DOSE DRY POWDER INHALER. EACH ACTUATION OF TUDORZA PRESSAIR PROVIDES A METERED DOSE OF 13 MG OF THE FORMULATION WHICH CONTAINS LACTOSE MONOHYDRATE (WHICH MAY CONTAIN MILK PROTEINS) AS THE CARRIER AND 400 MCG OF ACLIDINIUM BROMIDE. THIS RESULTS IN DELIVERY OF 375 MCG ACLIDINIUM BROMIDE FROM THE MOUTHPIECE, BASED ON IN VITRO TESTING AT AN AVERAGE FLOW RATE OF 63 L/MIN WITH CONSTANT VOLUME OF 2 L. THE AMOUNT OF DRUG DELIVERED TO THE LUNGS WILL VARY DEPENDING ON PATIENT FACTORS SUCH AS INSPIRATORY FLOW RATE AND INSPIRATORY TIME. THE PRESSAIR INHALER DELIVERS THE TARGET DOSE AT FLOW RATES AS LOW AS 35 L/MIN. BASED ON A STUDY IN ADULT PATIENTS WITH MODERATE (N=24) AND SEVERE (N=24) COPD THE MEAN PEAK INSPIRATORY FLOW (PIF) WAS 95.3 L/MIN (RANGE: 54.6 TO 129.4 L/MIN) AND 88.7 L/MIN (RANGE: 72.0 TO 106.4 L/MIN) RESPECTIVELY.
INDICATIONS
TUDORZAā¢ PRESSAIRā¢ (ACLIDINIUM BROMIDE INHALATION POWDER) IS INDICATED FOR THE LONG-TERM, MAINTENANCE TREATMENT OF BRONCHOSPASM ASSOCIATED WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), INCLUDING CHRONIC BRONCHITIS AND EMPHYSEMA.
DOSAGE AND ADMINISTRATION
THE RECOMMENDED DOSE OF TUDORZA PRESSAIR IS ONE ORAL INHALATION OF 400 MCG, TWICE DAILY.
HOW SUPPLIED
DOSAGE FORMS AND STRENGTHS
INHALATION POWDER. TUDORZA PRESSAIR IS A BREATH-ACTUATED MULTI-DOSE DRY POWDER INHALER METERING 400 MCG OF ACLIDINIUM BROMIDE PER ACTUATION. EACH ACTUATION DELIVERS 375 MCG OF ACLIDINIUM BROMIDE FROM THE MOUTHPIECE.
TUDORZAā¢ PRESSAIRā¢ (ACLIDINIUM BROMIDE INHALATION POWDER) 400 MCG IS SUPPLIED IN A SEALED LABELED ALUMINUM POUCH AND IS AVAILABLE IN 60 METERED DOSES (NDC 0456-0800-60).
THE ACTIVE INGREDIENT IS ADMINISTERED USING A MULTI-DOSE DRY POWDER INHALER, PRESSAIRā¢, WHICH DELIVERS 60 DOSES OF ACLIDINIUM BROMIDE POWDER FOR ORAL INHALATION. THE PRESSAIR INHALER IS A WHITE AND GREEN COLORED DEVICE AND IS COMPRISED OF AN ASSEMBLED PLASTIC DOSING MECHANISM WITH A DOSE INDICATOR, A DRUG-PRODUCT STORAGE UNIT CONTAINING THE DRUG-PRODUCT FORMULATION, AND A MOUTHPIECE COVERED BY A GREEN PROTECTIVE CAP. THE INHALER SHOULD BE DISCARDED WHEN THE MARKING "0" WITH A RED BACKGROUND SHOWS IN THE MIDDLE OF THE DOSE INDICATOR OR WHEN THE DEVICE LOCKS OUT, WHICHEVER COMES FIRST.
STORAGE AND HANDLING
STORE TUDORZA PRESSAIR IN A DRY PLACE AT 25Ā°C (77Ā°F); EXCURSIONS PERMITTED TO 15-30Ā°C (59-86Ā°F) [SEE USP CONTROLLED ROOM TEMPERATURE].
THE PRESSAIR INHALER SHOULD BE STORED INSIDE THE SEALED POUCH AND ONLY BE OPENED IMMEDIATELY BEFORE USE.
DISCARD THE PRESSAIR INHALER 45 DAYS AFTER OPENING THE POUCH, AFTER THE MARKING "0" WITH A RED BACKGROUND SHOWS IN THE MIDDLE OF THE DOSE INDICATOR, OR WHEN THE DEVICE LOCKS OUT, WHICHEVER COMES FIRST.
KEEP OUT OF REACH OF CHILDREN.
DISTRIBUTED BY: FOREST PHARMACEUTICALS, INC. SUBSIDIARY OF FOREST LABORATORIES, INC. ST. LOUIS, MO 63045. REVISED: 07/2012
SIDE EFFECTS
THE FOLLOWING ADVERSE REACTIONS ARE DESCRIBED IN GREATER DETAIL IN OTHER SECTIONS:
PARADOXICAL BRONCHOSPASM [SEE WARNINGS AND PRECAUTIONS]
WORSENING OF NARROW-ANGLE GLAUCOMA [SEE WARNINGS AND PRECAUTIONS]
WORSENING OF URINARY RETENTION [SEE WARNINGS AND PRECAUTIONS]
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.
3-MONTH AND 6-MONTH TRIALS
TUDORZA PRESSAIR WAS STUDIED IN TWO 3-MONTH (TRIALS B AND C) AND ONE 6-MONTH (TRIAL D) PLACEBO-CONTROLLED TRIALS IN PATIENTS WITH COPD. IN THESE TRIALS, 636 PATIENTS WERE TREATED WITH TUDORZA PRESSAIR AT THE RECOMMENDED DOSE OF 400 MCG TWICE DAILY.
THE POPULATION HAD A MEAN AGE OF 64 YEARS (RANGING FROM 40 TO 89 YEARS), WITH 58% MALES, 94% CAUCASIAN, AND HAD COPD WITH A MEAN PRE-BRONCHODILATOR FORCED EXPIRATORY VOLUME IN ONE SECOND (FEV1) PERCENT PREDICTED OF 48%. PATIENTS WITH UNSTABLE CARDIAC DISEASE, NARROW-ANGLE GLAUCOMA, OR SYMPTOMATIC PROSTATIC HYPERTROPHY OR BLADDER OUTLET OBSTRUCTION WERE EXCLUDED FROM THESE TRIALS.
TABLE 1 SHOWS ALL ADVERSE REACTIONS THAT OCCURRED WITH A FREQUENCY OF GREATER THAN OR EQUAL TO 1% IN THE TUDORZA PRESSAIR GROUP IN THE TWO 3-MONTH AND ONE 6-MONTH PLACEBO-CONTROLLED TRIALS WHERE THE RATES IN THE TUDORZA PRESSAIR GROUP EXCEEDED PLACEBO.
TABLE 1: ADVERSE REACTIONS (Ā°/O PATIENTS) IN PLACEBO-CONTROLLED CLINICAL TRIALS
ADVERSE REACTIONS
PREFERRED TERM
TREATMENT
TUDORZA
PRESSAIR
PLACEBO
(N=636)
(N=640)
N (%)
N (%)
HEADACHE
42 (6.6)
32 (5.0)
NASOPHARYNGITIS
35(5.5)
25 (3.9)
COUGH
19 (3.0)
14 (2.2)
DIARRHEA
17 (2.7)
9(1.4)
SINUSITIS
11(1.7)
5 (0.8)
RHINITIS
10(1.6)
8(1.2)
TOOTHACHE
7(1.1)
5 (0.8)
FALL
7(1.1)
3(0.5)
VOMITING
7(1.1)
3(0.5)
IN ADDITION, AMONG THE ADVERSE REACTIONS OBSERVED IN THE CLINICAL TRIALS WITH AN INCIDENCE OF LESS THAN 1% WERE DIABETES MELLITUS, DRY MOUTH, 1ST DEGREE AV BLOCK, OSTEOARTHRITIS, CARDIAC FAILURE, AND CARDIO-RESPIRATORY ARREST.
LONG-TERM SAFETY TRIALS
TUDORZA PRESSAIR WAS STUDIED IN THREE LONG TERM SAFETY TRIALS, TWO DOUBLE BLIND AND ONE OPEN LABEL, RANGING FROM 40 TO 52 WEEKS IN PATIENTS WITH MODERATE TO SEVERE COPD. TWO OF THESE TRIALS WERE EXTENSIONS OF THE 3-MONTH TRIALS, AND ONE WAS A DEDICATED LONG TERM SAFETY TRIAL. IN THESE TRIALS, 891 PATIENTS WERE TREATED WITH TUDORZA PRESSAIR AT THE RECOMMENDED DOSE OF 400 MCG TWICE DAILY. THE DEMOGRAPHIC AND BASELINE CHARACTERISTICS OF THE LONG TERM SAFETY TRIALS WERE SIMILAR TO THOSE OF THE PLACEBO-CONTROLLED TRIALS. THE ADVERSE EVENTS REPORTED IN THE LONG TERM SAFETY TRIALS WERE SIMILAR TO THOSE OCCURRING IN THE PLACEBO-CONTROLLED TRIALS OF 3 TO 6 MONTHS. NO NEW SAFETY FINDINGS WERE REPORTED COMPARED TO THE PLACEBO CONTROLLED TRIALS.
READ THE TUDORZA PRESSAIR (ACLIDINIUM BROMIDE) SIDE EFFECTS CENTER FOR A COMPLETE GUIDE TO POSSIBLE SIDE EFFECTS
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DRUG INTERACTIONS
IN VITRO STUDIES SUGGEST LIMITED POTENTIAL FOR CYP450-RELATED METABOLIC DRUG INTERACTIONS, THUS NO FORMAL DRUG INTERACTION STUDIES HAVE BEEN PERFORMED WITH TUDORZA PRESSAIR [SEE CLINICAL PHARMACOLOGY].
SYMPATHOMIMETICS, METHYLXANTHINES, STEROIDS
IN CLINICAL STUDIES, CONCURRENT ADMINISTRATION OF ACLIDINIUM BROMIDE AND OTHER DRUGS COMMONLY USED IN THE TREATMENT OF COPD INCLUDING SYMPATHOMIMETICS (SHORT-ACTING BETA2 AGONISTS), METHYLXANTHINES, AND ORAL AND INHALED STEROIDS SHOWED NO INCREASES IN ADVERSE DRUG REACTIONS.
ANTICHOLINERGICS
THERE IS A POTENTIAL FOR AN ADDITIVE INTERACTION WITH CONCOMITANTLY USED ANTICHOLINERGIC MEDICATIONS. THEREFORE, AVOID COADMINISTRATION OF TUDORZA PRESSAIR WITH OTHER ANTICHOLINERGIC-CONTAINING DRUGS AS THIS MAY LEAD TO AN INCREASE IN ANTICHOLINERGIC EFFECTS.
WARNINGS
INCLUDED AS PART OF THE PRECAUTIONS SECTION.
PRECAUTIONS
NOT FOR ACUTE USE
TUDORZA PRESSAIR IS INTENDED AS A TWICE-DAILY MAINTENANCE TREATMENT FOR COPD AND IS NOT INDICATED FOR THE INITIAL TREATMENT OF ACUTE EPISODES OF BRONCHOSPASM (I.E., RESCUE THERAPY).
PARADOXICAL BRONCHOSPASM
INHALED MEDICINES, INCLUDING TUDORZA PRESSAIR, MAY CAUSE PARADOXICAL BRONCHOSPASM. IF THIS OCCURS, TREATMENT WITH TUDORZA PRESSAIR SHOULD BE STOPPED AND OTHER TREATMENTS CONSIDERED.
WORSENING OF NARROW-ANGLE GLAUCOMA
TUDORZA PRESSAIR 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
TUDORZA PRESSAIR 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.
IMMEDIATE HYPERSENSITIVITY REACTIONS
IMMEDIATE HYPERSENSITIVITY REACTIONS MAY OCCUR AFTER ADMINISTRATION OF TUDORZA PRESSAIR. IF SUCH A REACTION OCCURS, THERAPY WITH TUDORZA PRESSAIR SHOULD BE STOPPED AT ONCE AND ALTERNATIVE TREATMENTS SHOULD BE CONSIDERED. GIVEN THE SIMILAR STRUCTURAL FORMULA OF ATROPINE TO ACLIDINIUM, PATIENTS WITH A HISTORY OF HYPERSENSITIVITY REACTIONS TO ATROPINE SHOULD BE CLOSELY MONITORED FOR SIMILAR HYPERSENSITIVITY REACTIONS TO TUDORZA PRESSAIR. IN ADDITION, TUDORZA PRESSAIR SHOULD BE USED WITH CAUTION IN PATIENTS WITH SEVERE HYPERSENSITIVITY TO MILK PROTEINS.
PATIENT COUNSELING INFORMATION
SEE FDA-APPROVED PATIENT LABELING (PATIENT INFORMATION AND INSTRUCTIONS FOR USE)
INSTRUCTIONS FOR ADMINISTERING TUDORZA PRESSAIR
IT IS IMPORTANT FOR PATIENTS TO UNDERSTAND HOW TO CORRECTLY USE TUDORZA PRESSAIR.
INFORM PATIENTS THAT IF THEY MISS A DOSE, THEY SHOULD TAKE THEIR NEXT DOSE AT THE USUAL TIME; THEY SHOULD NOT TAKE 2 DOSES AT ONE TIME.
ACUTE BRONCHOSPASM
INSTRUCT PATIENTS THAT TUDORZA PRESSAIR IS A TWICE DAILY MAINTENANCE BRONCHODILATOR AND SHOULD NOT BE USED FOR IMMEDIATE RELIEF OF BREATHING PROBLEMS (I.E., AS A RESCUE MEDICATION) [SEE WARNINGS AND PRECAUTIONS].
PARADOXICAL BRONCHOSPASM
INFORM PATIENTS THAT TUDORZA PRESSAIR CAN CAUSE PARADOXICAL BRONCHOSPASM. ADVISE PATIENTS THAT IF PARADOXICAL BRONCHOSPASM OCCURS, PATIENTS SHOULD DISCONTINUE TUDORZA PRESSAIR [SEE WARNINGS AND PRECAUTIONS].
VISUAL EFFECTS
EYE PAIN OR DISCOMFORT, BLURRED VISION, VISUAL HALOS OR COLORED IMAGES IN ASSOCIATION WITH RED EYES FROM CONJUNCTIVAL CONGESTION AND CORNEAL EDEMA MAY BE SIGNS OF ACUTE NARROW-ANGLE GLAUCOMA. INFORM PATIENTS TO CONSULT A PHYSICIAN IMMEDIATELY SHOULD ANY OF THESE SIGNS AND SYMPTOMS DEVELOP. ADVISE PATIENTS THAT MIOTIC EYE DROPS ALONE ARE NOT CONSIDERED TO BE EFFECTIVE TREATMENT [SEE WARNINGS AND PRECAUTIONS].
INFORM PATIENTS THAT CARE MUST BE TAKEN NOT TO ALLOW THE POWDER TO ENTER INTO THE EYES AS THIS MAY CAUSE BLURRING OF VISION AND PUPIL DILATION.
URINARY RETENTION
DIFFICULTY PASSING URINE AND DYSURIA MAY BE SYMPTOMS OF NEW OR WORSENING PROSTATIC HYPERPLASIA OR BLADDER OUTLET OBSTRUCTION. PATIENTS SHOULD BE INSTRUCTED TO CONSULT A PHYSICIAN IMMEDIATELY SHOULD ANY OF THESE SIGNS OR SYMPTOMS DEVELOP [SEE WARNINGS AND PRECAUTIONS].
NONCLINICAL TOXICOLOGY
CARCINOGENESIS, MUTAGENESIS, IMPAIRMENT OF FERTILITY
TWO-YEAR INHALATION STUDIES WERE CONDUCTED IN MICE AND RATS TO ASSES THE CARCINOGENIC POTENTIAL OF ACLIDINIUM BROMIDE. NO EVIDENCE OF TUMORIGENICITY WAS OBSERVED IN RATS AND MICE AT ACLIDINIUM DOSES UP TO 0.20 AND 2.4 MG/KG/DAY, RESPECTIVELY [APPROXIMATELY 10 AND 80 TIMES THE RECOMMENDED HUMAN DAILY DOSE (RHDD), RESPECTIVELY, BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES].
ACLIDINIUM BROMIDE WAS POSITIVE IN THE IN VITRO BACTERIAL GENE MUTATION ASSAY AND THE IN VITRO THYMIDINE LOCUS MOUSE LYMPHOMA ASSAY. HOWEVER, ACLIDINIUM BROMIDE WAS NEGATIVE IN THE IN VIVO MOUSE MICRONUCLEUS ASSAY AND THE IN VIVO/IN VITRO UNSCHEDULED DNA SYNTHESIS ASSAY WITH RAT LIVER.
ACLIDINIUM BROMIDE IMPAIRED SEVERAL FERTILITY AND REPRODUCTIVE PERFORMANCE INDICES (INCREASED NUMBER OF DAYS TO MATE, DECREASED CONCEPTION RATE, DECREASED NUMBER OF CORPORA LUTEA, INCREASED PRE-IMPLANTATION LOSS WITH CONSEQUENT DECREASED NUMBER OF IMPLANTATIONS AND LIVE EMBRYOS) IN BOTH MALE AND FEMALE RATS ADMINISTERED INHALED DOSES GREATER THAN OR EQUAL TO 0.8 MG/KG/DAY [APPROXIMATELY 15 TIMES THE RHDD BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES]. THESE ADVERSE FERTILITY EFFECTS WERE OBSERVED IN THE PRESENCE OF PATERNAL TOXICITY AS EVIDENCED BY MORTALITY AND DECREASED BODY WEIGHT GAIN. HOWEVER, THERE WERE NO EFFECTS ON MATING INDEX AND SPERM NUMBER AND MORPHOLOGY. IN THE SEPARATE FERTILITY ASSESSMENTS (TREATED MALES MATED WITH UNTREATED FEMALES; TREATED FEMALES MATED WITH UNTREATED MALES), NO EFFECT WAS OBSERVED IN MALE AND FEMALE RATS AT INHALED DOSE OF 1.9 AND 0.8 MG/KG/DAY, RESPECTIVELY [APPROXIMATELY 30 AND 15 TIMES THE RHDD, RESPECTIVELY, BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES].
USE IN SPECIFIC POPULATIONS
PREGNANCY
TERATOGENIC EFFECTS
PREGNANCY CATEGORY C: THERE ARE NO ADEQUATE AND WELL CONTROLLED STUDIES IN PREGNANT WOMEN. ADVERSE DEVELOPMENT EFFECTS WERE OBSERVED IN RATS AND RABBITS EXPOSED TO ACLIDINIUM BROMIDE. TUDORZA PRESSAIR SHOULD BE USED DURING PREGNANCY ONLY IF THE POTENTIAL BENEFIT JUSTIFIES THE POTENTIAL RISK TO THE FETUS.
EFFECTS OF ACLIDINIUM BROMIDE ON EMBRYO-FETAL DEVELOPMENT WERE EXAMINED IN RATS AND RABBITS. NO EVIDENCE OF STRUCTURAL ALTERATIONS WAS OBSERVED IN RATS EXPOSED DURING THE PERIOD OF ORGANOGENESIS AT APPROXIMATELY 15 TIMES THE RECOMMENDED HUMAN DAILY DOSE (RHDD) [BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES AT INHALED DOSES LESS THAN OR EQUAL TO 5.0 MG/KG/DAY]. HOWEVER, DECREASED PUP WEIGHTS WERE OBSERVED FROM DAMS EXPOSED DURING THE LACTATION PERIOD AT APPROXIMATELY 5 TIMES THE RHDD [BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES AT INHALED DOSES GREATER THAN OR EQUAL TO 0.2 MG/KG/DAY]. MATERNAL TOXICITY WAS ALSO OBSERVED AT INHALED DOSES GREATER THAN OR EQUAL TO 0.2 MG/KG/DAY.
NO EVIDENCE OF STRUCTURAL ALTERATIONS WAS OBSERVED IN HIMALAYAN RABBITS EXPOSED DURING THE PERIOD OF ORGANOGENESIS AT APPROXIMATELY 20 TIMES THE RHDD [BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES AT INHALED DOSES LESS THAN OR EQUAL TO 3.6 MG/KG/DAY]. HOWEVER, INCREASED INCIDENCES OF ADDITIONAL LIVER LOBES (3-5%), AS COMPARED TO 0% IN THE CONTROL GROUP, WERE OBSERVED AT APPROXIMATELY 1,400 TIMES THE RHDD [BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES AT ORAL DOSES GREATER THAN OR EQUAL TO 150 MG/KG/DAY], AND DECREASED FETAL BODY WEIGHTS WERE OBSERVED AT APPROXIMATELY 2,300 TIMES THE RHDD [BASED ON SUMMED AUCS OF ACLIDINIUM BROMIDE AND ITS METABOLITES AT ORAL DOSES GREATER THAN OR EQUAL TO 300 MG/KG/DAY]. THESE FETAL FINDINGS WERE OBSERVED IN THE PRESENCE OF MATERNAL TOXICITY.
LABOR AND DELIVERY
THE EFFECT OF TUDORZA PRESSAIR ON LABOR AND DELIVERY IS UNKNOWN. TUDORZA PRESSAIR SHOULD BE USED DURING LABOR AND DELIVERY ONLY IF THE POTENTIAL BENEFIT TO THE PATIENT JUSTIFIES THE POTENTIAL RISK TO THE FETUS.
NURSING MOTHERS
ACLIDINIUM BROMIDE IS EXCRETED INTO THE MILK OF LACTATING FEMALE RATS, AND DECREASED PUP WEIGHTS WERE OBSERVED. EXCRETION OF ACLIDINIUM INTO HUMAN MILK IS PROBABLE. THERE ARE NO HUMAN STUDIES THAT HAVE INVESTIGATED THE EFFECTS OF TUDORZA PRESSAIR ON BREAST-FED INFANTS. CAUTION SHOULD BE EXERCISED WHEN TUDORZA PRESSAIR IS ADMINISTERED TO NURSING WOMEN.
PEDIATRIC USE
TUDORZA PRESSAIR IS APPROVED FOR USE IN THE MAINTENANCE TREATMENT OF BRONCHOSPASM ASSOCIATED WITH COPD. COPD DOES NOT NORMALLY OCCUR IN CHILDREN. THE SAFETY AND EFFECTIVENESS OF TUDORZA PRESSAIR IN PEDIATRIC PATIENTS HAVE NOT BEEN ESTABLISHED.
GERIATRIC USE
OF THE 636 COPD PATIENTS EXPOSED TO TUDORZA PRESSAIR 400 MCG TWICE DAILY FOR UP TO 24 WEEKS IN THREE PLACEBO-CONTROLLED CLINICAL TRIALS, 197 WERE LESS THAN 60 YEARS, 272 WERE GREATER THAN OR EQUAL TO 60 TO LESS THAN 70 YEARS, AND 167 WERE GREATER THAN OR EQUAL TO 70 YEARS OF AGE. NO OVERALL DIFFERENCES IN SAFETY OR EFFECTIVENESS WERE OBSERVED BETWEEN THESE SUBJECTS AND YOUNGER SUBJECTS. OTHER REPORTED CLINICAL EXPERIENCE HAS NOT IDENTIFIED DIFFERENCES IN RESPONSES BETWEEN THE ELDERLY AND YOUNGER PATIENTS, BUT GREATER SENSITIVITY OF SOME OLDER INDIVIDUALS CANNOT BE RULED OUT. BASED ON AVAILABLE DATA FOR TUDORZA PRESSAIR, NO ADJUSTMENT OF DOSAGE IN GERIATRIC PATIENTS IS WARRANTED [SEE CLINICAL PHARMACOLOGY].
RENAL IMPAIRMENT
THE PHARMACOKINETICS OF TUDORZA PRESSAIR WERE INVESTIGATED IN SUBJECTS WITH NORMAL RENAL FUNCTION AND IN SUBJECTS WITH MILD, MODERATE AND SEVERE RENAL IMPAIRMENT [SEE CLINICAL PHARMACOLOGY]. NO CLINICALLY SIGNIFICANT DIFFERENCES IN ACLIDINIUM PHARMACOKINETICS WERE NOTED BETWEEN THESE POPULATIONS. BASED ON AVAILABLE DATA FOR TUDORZA PRESSAIR, NO ADJUSTMENT OF DOSAGE IN RENALLY IMPAIRED SUBJECTS IS WARRANTED.
HEPATIC IMPAIRMENT
THE EFFECTS OF HEPATIC IMPAIRMENT ON THE PHARMACOKINETICS OF TUDORZA PRESSAIR WERE NOT STUDIED [SEE CLINICAL PHARMACOLOGY].
OVERDOSE
HUMAN EXPERIENCE
NO CASE OF OVERDOSE HAS BEEN REPORTED IN CLINICAL STUDIES WITH TUDORZA PRESSAIR. THERE WERE NO SYSTEMIC ANTICHOLINERGIC OR OTHER ADVERSE EFFECTS FOLLOWING A SINGLE INHALED DOSE OF UP TO 6,000 MCG ACLIDINIUM BROMIDE (7.5 TIMES THE RHDD) IN 16 HEALTHY VOLUNTEERS.
CONTRAINDICATIONS
NONE.
CLINICAL PHARMACOLOGY
MECHANISM OF ACTION
ACLIDINIUM BROMIDE 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 RECEPTOR 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 ACETYLCHOLINE-INDUCED BRONCHONCONSTRICTION EFFECTS WAS DOSE-DEPENDENT AND LASTED LONGER THAN 24 HOURS. THE CLINICAL RELEVANCE OF THESE FINDINGS IS UNKNOWN. THE BRONCHODILATION FOLLOWING INHALATION OF ACLIDINIUM BROMIDE IS PREDOMINANTLY A SITE-SPECIFIC EFFECT.
PHARMACODYNAMICS
CARDIOVASCULAR EFFECTS
IN A THOROUGH QT STUDY, 200 MCG AND 800 MCG TUDORZA PRESSAIR WAS ADMINISTERED TO HEALTHY VOLUNTEERS ONCE DAILY FOR 3 DAYS; NO EFFECTS ON PROLONGATION OF QT INTERVAL WERE OBSERVED USING QTCF HEART-RATE CORRECTION METHODS.
ADDITIONALLY, THE EFFECT OF TUDORZA PRESSAIR ON CARDIAC RHYTHM WAS ASSESSED IN 336 COPD PATIENTS, 164 PATIENTS RECEIVED ACLIDINIUM BROMIDE 400 MCG TWICE DAILY AND 172 PATIENTS RECEIVED PLACEBO, USING 24-HR HOLTER MONITORING. NO CLINICALLY SIGNIFICANT EFFECTS ON CARDIAC RHYTHM WERE OBSERVED.
PHARMACOKINETICS
ABSORPTION
THE ABSOLUTE BIOAVAILABILITY OF ACLIDINIUM BROMIDE IS APPROXIMATELY 6% IN HEALTHY VOLUNTEERS. FOLLOWING TWICE-DAILY ORAL INHALATION ADMINISTRATION OF 400 MCG ACLIDINIUM BROMIDE IN HEALTHY SUBJECTS, PEAK STEADY STATE PLASMA LEVELS WERE OBSERVED WITHIN 10 MINUTES AFTER INHALATION.
DISTRIBUTION
ACLIDINIUM BROMIDE SHOWS A VOLUME OF DISTRIBUTION OF APPROXIMATELY 300 L FOLLOWING INTRAVENOUS ADMINISTRATION OF 400 MCG IN HUMANS.
METABOLISM
CLINICAL PHARMACOKINETICS STUDIES, INCLUDING A MASS BALANCE STUDY, INDICATE THAT THE MAJOR ROUTE OF METABOLISM OF ACLIDINIUM BROMIDE IS HYDROLYSIS, WHICH OCCURS BOTH CHEMICALLY AND ENZYMATICALLY BY ESTERASES. ACLIDINIUM BROMIDE IS RAPIDLY AND EXTENSIVELY HYDROLYZED TO ITS ALCOHOL AND DITHIENYLGLYCOLIC ACID DERIVATIVES, NEITHER OF WHICH BINDS TO MUSCARINIC RECEPTORS AND ARE DEVOID OF PHARMACOLOGIC ACTIVITY.
THEREFORE, DUE TO THE LOW PLASMA LEVELS ACHIEVED AT THE CLINICALLY RELEVANT DOSES, ACLIDINIUM BROMIDE AND ITS METABOLITES ARE NOT EXPECTED TO ALTER THE DISPOSITION OF DRUGS METABOLIZED BY THE HUMAN CYP450 ENZYMES.
ELIMINATION
TOTAL CLEARANCE WAS APPROXIMATELY 170 L/H AFTER AN INTRAVENOUS DOSE OF ACLIDINIUM BROMIDE IN YOUNG HEALTHY VOLUNTEERS WITH AN INTER-INDIVIDUAL VARIABILITY OF 36%. INTRAVENOUSLY ADMINISTERED RADIOLABELLED ACLIDINIUM BROMIDE WAS ADMINISTERED TO HEALTHY VOLUNTEERS AND WAS EXTENSIVELY METABOLIZED WITH 1% EXCRETED AS UNCHANGED ACLIDINIUM. APPROXIMATELY 54% TO 65% OF THE RADIOACTIVITY WAS EXCRETED IN URINE AND 20% TO 33% OF THE DOSE WAS EXCRETED IN FECES. THE COMBINED RESULTS INDICATED THAT ALMOST THE ENTIRE ACLIDINIUM BROMIDE DOSE WAS ELIMINATED BY HYDROLYSIS. AFTER DRY POWDER INHALATION, URINARY EXCRETION OF ACLIDINIUM IS ABOUT 0.09% OF THE DOSE AND THE ESTIMATED EFFECTIVE HALF-LIFE IS 5 TO 8 HOURS.
DRUG INTERACTIONS
FORMAL DRUG INTERACTION STUDIES WERE NOT PERFORMED. IN VITRO STUDIES USING HUMAN LIVER MICROSOMES INDICATED THAT ACLIDINIUM BROMIDE AND ITS MAJOR METABOLITES DO NOT INHIBIT CYP450, 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, 3A4/5 OR 4A9/11 AT CONCENTRATIONS UP TO 1,000-FOLD HIGHER THAN THE MAXIMUM PLASMA CONCENTRATION THAT WOULD BE EXPECTED TO BE ACHIEVED AT THE THERAPEUTIC DOSE. THEREFORE, IT IS UNLIKELY THAT ACLIDINIUM BROMIDE CAUSES CYP450 RELATED DRUG INTERACTIONS [SEE DRUG INTERACTIONS].
SPECIFIC POPULATIONS
ELDERLY PATIENTS
THE PHARMACOKINETIC PROFILE OF ACLIDINIUM BROMIDE AND ITS MAIN METABOLITES WAS ASSESSED IN 12 ELDERLY COPD PATIENTS (AGED 70 YEARS OR OLDER) COMPARED TO A YOUNGER COHORT OF 12 COPD PATIENTS (40-59 YEARS) THAT WERE ADMINISTERED 400 MCG ACLIDINIUM BROMIDE ONCE DAILY FOR 3 DAYS VIA INHALATION. NO CLINICALLY SIGNIFICANT DIFFERENCES IN SYSTEMIC EXPOSURE (AUC AND CMAX) WERE OBSERVED WHEN THE TWO GROUPS WERE COMPARED. NO DOSAGE ADJUSTMENT IS NECESSARY IN ELDERLY PATIENTS [USE IN SPECIFIC POPULATIONS].
RENAL IMPAIRMENT
THE IMPACT OF RENAL DISEASE UPON THE PHARMACOKINETICS OF ACLIDINIUM BROMIDE WAS STUDIED IN 18 SUBJECTS WITH MILD, MODERATE, OR SEVERE RENAL IMPAIRMENT. SYSTEMIC EXPOSURE (AUC AND CMAX) TO ACLIDINIUM BROMIDE AND ITS MAIN METABOLITES FOLLOWING SINGLE DOSES OF 400 MCG ACLIDINIUM BROMIDE WAS SIMILAR IN RENALLY IMPAIRED PATIENTS COMPARED WITH 6 MATCHED HEALTHY CONTROL SUBJECTS. NO DOSE ADJUSTMENT IS NECESSARY IN RENALLY IMPAIRED PATIENTS [SEE USE IN SPECIFIC POPULATIONS].
HEPATIC IMPAIRMENT
THE EFFECTS OF HEPATIC IMPAIRMENT ON THE PHARMACOKINETICS OF ACLIDINIUM BROMIDE WERE NOT STUDIED. HOWEVER, HEPATIC INSUFFICIENCY IS NOT EXPECTED TO HAVE RELEVANT INFLUENCE ON ACLIDINIUM BROMIDE PHARMACOKINETICS, SINCE IT IS PREDOMINANTLY METABOLIZED BY CHEMICAL AND ENZYMATIC HYDROLYSIS TO PRODUCTS THAT DO NOT BIND TO MUSCARINIC RECEPTORS [SEE USE IN SPECIFIC POPULATIONS].
CLINICAL STUDIES
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
THE TUDORZA PRESSAIR CLINICAL DEVELOPMENT PROGRAM INCLUDED A DOSE-RANGING TRIAL (TRIAL A) FOR NOMINAL DOSE SELECTION AND THREE CONFIRMATORY TRIALS (TRIALS B, C, AND D).
DOSE-RANGING TRIAL
TRIAL A WAS A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, ACTIVE-CONTROLLED, CROSS-OVER TRIAL WITH 7-DAY TREATMENT PERIODS SEPARATED BY 5-DAY WASHOUT PERIODS. TRIAL A ENROLLED 79 PATIENTS WHO HAD A CLINICAL DIAGNOSIS OF COPD, WERE 40 YEARS OF AGE OR OLDER, HAD A HISTORY OF SMOKING AT LEAST 10 PACK-YEARS, HAD A FORCED EXPIRATORY VOLUME IN ONE SECOND (FEV1) OF AT LEAST 30% AND LESS THAN 80% OF PREDICTED NORMAL VALUE, AND A RATIO OF FEV1 OVER FORCED VITAL CAPACITY (FEV1/FVC) OF LESS THAN 0.7. TRIAL A INCLUDED TUDORZA PRESSAIR DOSES OF 400 MCG, 200 MCG AND 100 MCG TWICE DAILY, FORMOTEROL ACTIVE CONTROL, AND PLACEBO. TRIAL A DEMONSTRATED THAT THE EFFECT ON TROUGH FEV1 AND SERIAL FEV1 IN PATIENTS TREATED WITH THE TUDORZA PRESSAIR 100 MCG TWICE DAILY AND 200 MCG TWICE DAILY DOSES WAS LOWER COMPARED TO PATIENTS TREATED WITH THE TUDORZA PRESSAIR 400 MCG TWICE DAILY DOSE (FIGURE 1).
FIGURE 1. CHANGE FROM BASELINE IN FEV1 OVER TIME (PRIOR TO AND AFTER ADMINISTRATION OF STUDY DRUG) AT WEEK 1 IN TRIAL A
CONFIRMATORY TRIALS
TRIALS B, C, AND D WERE THREE RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIALS IN PATIENTS WITH COPD. TRIALS B AND C WERE 3 MONTHS IN DURATION, AND TRIAL D WAS 6 MONTHS IN DURATION. THESE TRIALS ENROLLED 1,276 PATIENTS WHO HAD A CLINICAL DIAGNOSIS OF COPD, WERE 40 YEARS OF AGE OR OLDER, HAD A HISTORY OF SMOKING AT LEAST 10 PACK-YEARS, HAD AN FEV1 OF AT LEAST 30% AND LESS THAN 80% OF PREDICTED NORMAL VALUE, AND A RATIO OF FEV1/FVC OF LESS THAN 0.7; 59% WERE MALE, AND 93% WERE CAUCASIAN.
THESE CLINICAL TRIALS EVALUATED TUDORZA PRESSAIR 400 MCG TWICE DAILY (636 PATIENTS) AND PLACEBO (640 PATIENTS). TUDORZA PRESSAIR 400 MCG RESULTED IN STATISTICALLY SIGNIFICANTLY GREATER BRONCHODILATION AS MEASURED BY CHANGE FROM BASELINE IN MORNING PRE-DOSE FEV1 AT 12 WEEKS (THE PRIMARY EFFICACY ENDPOINT) COMPARED TO PLACEBO IN ALL THREE TRIALS (TABLE 2).
TABLE 2: CHANGE FROM BASELINE IN TROUGH FEV1 (L) AT WEEK 12
TREATMENT ARM
BASELINE
CHANGE FROM BASELINE LS MEAN (SE)
TREATMENT DIFFERENCE
LS MEAN (95% CI)
TRIAL B (N=375)
Ā Ā ACLIDINIUM 400 MCG
1.33
0.10(0.01)
0.12(0.08,0.16)
Ā Ā PLACEBO
1.38
-0.02 (0.02)
Ā
TRIAL C (N=359)
Ā Ā ACLIDINIUM 400 MCG
1.25
0.06(0.02)
0.07(0.03,0.12)
Ā Ā PLACEBO
1.46
-0.01 (0.02)
Ā
TRIAL D* (N=542)
Ā Ā ACLIDINIUM 400 MCG
1.51
0.06(0.02)
0.11 (0.07,0.14)
Ā Ā PLACEBO
1.50
-0.05 (0.02)
Ā
SE=STANDARD ERROR, AND LS MEAN=LEAST SQUARE MEAN. LS MEAN, AND 95% CONFIDENCE INTERVAL WERE OBTAINED FROM AN ANCOVA MODEL WITH CHANGE FROM BASELINE IN TROUGH FEV1 AS RESPONSE, WITH TREATMENT GROUP AND SEX AS FACTORS AND BASELINE TROUGH FEV1 AND AGE AS COVARIATES.
*IN THE 6-MONTH TRIAL D, PLACEBO ADJUSTED CHANGE FROM BASELINE IN TROUGH FEV1 AT 24 WEEKS WAS 0.13 (0.09, 0.17).
SERIAL SPIROMETRIC EVALUATIONS WERE PERFORMED THROUGHOUT DAYTIME HOURS IN A SUBSET OF PATIENTS IN THE THREE TRIALS. THE SERIAL FEV1 VALUES OVER 12 HOURS FOR ONE OF THE 3-MONTH TRIALS (TRIAL B) ARE DISPLAYED IN FIGURE 2. RESULTS FOR THE OTHER TWO PLACEBO-CONTROLLED TRIALS WERE SIMILAR TO THE RESULTS FOR TRIAL B. IMPROVEMENT OF LUNG FUNCTION WAS MAINTAINED FOR 12 HOURS AFTER A SINGLE DOSE AND WAS CONSISTENT OVER THE 3- OR 6-MONTH TREATMENT PERIOD.
FIGURE 2. MEAN FEV1 OVER TIME (PRIOR TO AND AFTER ADMINISTRATION OF STUDY DRUG) ON DAY 1 AND WEEK 12 IN SUBSET OF PATIENTS PARTICIPATING IN THE 12 HOURS SERIAL SPIROMETRY SUBSTUDY FOR TRIAL B (A 3-MONTH PLACEBO-CONTROLLED STUDY)
MEAN PEAK IMPROVEMENTS IN FEV1, FORTUDORZA PRESSAIR RELATIVE TO BASELINE WERE ASSESED IN ALL PATIENTS IN TRIALS B, C AND D AFTER THE FIRST DOSE ON DAY 1 AND WERE SIMILAR AT WEEK 12. IN TRIALS B AND D BUT NOT IN TRIAL C, PATIENTS TREATED WITH TUDORZA PRESSAIR USED LESS DAILY RESCUE ALBUTEROL DURING THE TRIAL COMPARED TO PATIENTS TREATED WITH PLACEBO.