1 INDICATIONS AND USAGE Tiotropium bromide inhalation powder is indicated for the long-term, once-daily, maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.

Tiotropium bromide inhalation powder is indicated to reduce exacerbations in COPD patients.

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

6 ADVERSE REACTIONS The following adverse reactions are described, or described in greater detail, in other sections: Immediate hypersensitivity reactions [see Warnings and Precautions ( 5.2 )] Paradoxical bronchospasm [see Warnings and Precautions ( 5.3 )] Worsening of narrow-angle glaucoma [see Warnings and Precautions ( 5.4 )] Worsening of urinary retention [see Warnings and Precautions ( 5.5 )] The most common adverse reactions (>5% incidence in the 1-year placebo- controlled trials) were upper respiratory tract infection, dry mouth, sinusitis, pharyngitis, non-specific chest pain, urinary tract infection, dyspepsia, and rhinitis ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Lupin Pharmaceuticals, Inc.

at 1-800-399-2561 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, the incidence of adverse reactions observed in the clinical trials of a drug cannot be directly compared to the incidences in the clinical trials of another drug and may not reflect the incidences observed in practice.

6-Month to 1-Year Trials The data described below reflect exposure to tiotropium bromide inhalation powder in 2,663 patients.

Tiotropium bromide inhalation powder was studied in two 1-year placebo-controlled trials, two 1-year active-controlled trials, and two 6-month placebo-controlled trials in patients with COPD.

In these trials, 1,308 patients were treated with tiotropium bromide inhalation powder at the recommended dosage of 18 mcg once a day.

The population had an age ranging from 39 to 87 years with 65% to 85% males, 95% Caucasian, and had COPD with a mean pre-bronchodilator forced expiratory volume in one second (FEV 1 ) percent predicted of 39% to 43%.

Patients with narrow-angle glaucoma, or symptomatic prostatic hypertrophy or bladder outlet obstruction were excluded from these trials.

An additional 6-month trial conducted in a Veteran's Affairs setting is not included in this safety database because only serious adverse events were collected.

The most commonly reported adverse drug reaction was dry mouth.

Dry mouth was usually mild and often resolved during continued treatment.

Other reactions reported in individual patients and consistent with possible anticholinergic effects included constipation, tachycardia, blurred vision, glaucoma (new onset or worsening), dysuria, and urinary retention.

Four multicenter, 1-year, placebo-controlled and active-controlled trials evaluated tiotropium bromide inhalation powder in patients with COPD.

Table 1 shows all adverse reactions that occurred with a frequency of ≥3% in the tiotropium bromide inhalation powder group in the 1-year placebo-controlled trials where the rates in the tiotropium bromide inhalation powder group exceeded placebo by ≥1%.

The frequency of corresponding reactions in the ipratropium-controlled trials is included for comparison.

Table 1: Adverse Reactions (% Patients) in One-Year COPD Clinical Trials Body System (Event) Placebo-Controlled Trials Ipratropium-Controlled Trials Tiotropium Bromide Inhalation Powder (n = 550) Placebo (n = 371) Tiotropium Bromide Inhalation Powder (n = 356) Ipratropium (n = 179) Body as a Whole Chest Pain (non-specific) 7 5 5 2 Edema, Dependent 5 4 3 5 Gastrointestinal System Disorders Dry Mouth 16 3 12 6 Dyspepsia 6 5 1 1 Abdominal Pain 5 3 6 6 Constipation 4 2 1 1 Vomiting 4 2 1 2 Musculoskeletal System Myalgia 4 3 4 3 Resistance Mechanism Disorders Infection 4 3 1 3 Moniliasis 4 2 3 2 Respiratory System (Upper) Upper Respiratory Tract Infection 41 37 43 35 Sinusitis 11 9 3 2 Pharyngitis 9 7 7 3 Rhinitis 6 5 3 2 Epistaxis 4 2 1 1 Skin and Appendage Disorders Rash 4 2 2 2 Urinary System Urinary Tract Infection 7 5 4 2 Arthritis, coughing, and influenza-like symptoms occurred at a rate of ≥3% in the tiotropium bromide inhalation powder treatment group, but were <1% in excess of the placebo group.

Other reactions that occurred in the tiotropium bromide inhalation powder group at a frequency of 1% to 3% in the placebo-controlled trials where the rates exceeded that in the placebo group include: Body as a Whole : allergic reaction, leg pain; Central and Peripheral Nervous System : dysphonia, paresthesia; Gastrointestinal System Disorders : gastrointestinal disorder not otherwise specified (NOS), gastroesophageal reflux, stomatitis (including ulcerative stomatitis); Metabolic and Nutritional Disorders : hypercholesterolemia, hyperglycemia; Musculoskeletal System Disorders : skeletal pain; Cardiac Events : angina pectoris (including aggravated angina pectoris); Psychiatric Disorder : depression; Infections : herpes zoster; Respiratory System Disorder (Upper): laryngitis; Vision Disorder : cataract.

In addition, among the adverse reactions observed in the clinical trials with an incidence of <1% were atrial fibrillation, supraventricular tachycardia, angioedema, and urinary retention.

In the 1-year trials, the incidence of dry mouth, constipation, and urinary tract infection increased with age [see Use in Specific Populations ( 8.5 )].

Two multicenter, 6-month, controlled studies evaluated tiotropium bromide inhalation powder in patients with COPD.

The adverse reactions and the incidence rates were similar to those seen in the 1-year controlled trials.

4-Year Trial The data described below reflect exposure to tiotropium bromide inhalation powder in 5,992 COPD patients in a 4-year placebo-controlled trial.

In this trial, 2,986 patients were treated with tiotropium bromide inhalation powder at the recommended dosage of 18 mcg once a day.

The population had an age range from 40 to 88 years, was 75% male, 90% Caucasian, and had COPD with a mean pre-bronchodilator FEV 1 percent predicted of 40%.

Patients with narrow-angle glaucoma, or symptomatic prostatic hypertrophy or bladder outlet obstruction were excluded from these trials.

When the adverse reactions were analyzed with a frequency of ≥3% in the tiotropium bromide inhalation powder group where the rates in the tiotropium bromide inhalation powder group exceeded placebo by ≥1%, adverse reactions included (tiotropium bromide inhalation powder, placebo): pharyngitis (12.5%, 10.8%), sinusitis (6.5%, 5.3%), headache (5.7%, 4.5%), constipation (5.1%, 3.7%), dry mouth (5.1%, 2.7%), depression (4.4%, 3.3%), insomnia (4.4%, 3.0%), and arthralgia (4.2%, 3.1%).

Additional Adverse Reactions Other adverse reactions not previously listed that were reported more frequently in COPD patients treated with tiotropium bromide inhalation powder than placebo include: dehydration, skin ulcer, stomatitis, gingivitis, oropharyngeal candidiasis, dry skin, skin infection, and joint swelling.

6.2 Postmarketing Experience Adverse reactions have been identified during worldwide post-approval use of tiotropium bromide inhalation powder.

Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

These adverse reactions are: application site irritation (glossitis, mouth ulceration, and pharyngolaryngeal pain), dizziness, dysphagia, hoarseness, intestinal obstruction including ileus paralytic, intraocular pressure increased, oral candidiasis, palpitations, pruritus, tachycardia, throat irritation, and urticaria.