Triova® 13mcg inhalation powder, hard capsules are indicated as a maintenance bronchodilator treatment to relieve symptoms in patients with chronic obstructive pulmonary disease (COPD).
Triova® 13mcg inhalation powder, hard capsules are indicated for use in adults.

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

Each capsule contains 18 mg lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine. The excipient lactose may contain trace amounts of milk proteins which may cause reactions in those with severe hypersensitivity or allergy to milk protein.

Although no formal drug interaction studies have been performed, tiotropium bromide inhalation powder has been used concomitantly with other drugs without clinical evidence of drug interactions. These include sympathomimetic bronchodilators, methylxanthines, oral and inhaled steroids, commonly used in the treatment of COPD.
Use of long-acting β2 agonists (LABA) or inhaled corticosteroids (ICS) was not found to alter the exposure to tiotropium.
The co-administration of tiotropium bromide with other anticholinergic drugs has not been studied and is therefore not recommended.

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.

High doses of tiotropium bromide 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 bromide in healthy volunteers. Additionally, no relevant adverse effects, beyond dry mouth, were observed following 7 day dosing of up to 170 microgram tiotropium bromide in healthy volunteers. In a multiple dose study in COPD patients with a maximum daily dose of 43 microgram tiotropium bromide over four weeks no significant undesirable effects have been observed.
Acute intoxication by inadvertent oral ingestion of tiotropium bromide capsules is unlikely due to low oral bioavailability.

Pharmacotherapeutic group: Other drugs for obstructive airway diseases, inhalants, anticholinergics ATC code: R03B B04
Mechanism of action
Tiotropium bromide 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 bromide 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 bromide competitively and reversibly antagonises the M3 receptors, resulting in relaxation. The effect was dose dependent and lasted longer

than 24 hours. 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 bromide 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 patients. These studies included lung function and health outcome measures of dyspnea, exacerbations and health-related quality of life.
Lung function
Tiotropium bromide, 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 bromide significantly improved morning and evening PEFR (peak expiratory flow rate) as measured by patient's daily recordings. The bronchodilator effects of tiotropium bromide were maintained throughout the one year period of administration with no evidence of tolerance.
A randomised, placebo-controlled clinical study in COPD patients demonstrated that bronchodilation was maintained throughout the 24 hour dosing interval in comparison to placebo regardless of whether the drug was administered in the morning or in the evening.
The following health outcome effect was demonstrated in the long term (6-month and one-year) trials:
Dyspnoea, Exercise tolerance
Tiotropium bromide significantly improved dyspnea (as evaluated using the Transition Dyspnea Index.). This improvement was maintained throughout the treatment period.

The impact of improvements in dyspnea on exercise tolerance was investigated in two randomised, double-blind, placebo-controlled trials in patients with moderate to severe COPD. In these trials, six weeks of treatment with tiotropium bromide 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, randomized, double-blind, placebo-controlled clinical trial of patients, tiotropium bromide 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 bromide 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 randomized, double-blind, placebo controlled trial of patients with moderate to very severe COPD, tiotropium bromide 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 bromide group and 9.5% of patients in the placebo group were hospitalized due to a COPD exacerbation (p=0.056). The number of hospitalizations 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 tiotropium once daily with that of 50 microgram salmeterol HFA pMDI twice daily on the incidence of moderate and severe exacerbations in patients with COPD and a history of exacerbations in the preceding year.

Table 1: Summary of exacerbation endpoints
Endpoint
Tiotropium
13 microgram inhalation powder4
Salmeterol 50 microgram HFA pMDI
Ratio (95% CI)
p-value
Time [days] to first exacerbation1
187
145
0.83
(0.77-0.90)
<0.001

Time to first severe
(hospitalised) exacerbation2
-
-
0.72
(0.61-0.85)
<0.001
Patients with ≥1 exacerbation, n (%)3
(34.4)
(38.5)
0.90
(0.85-0.95)
<0.001
Patients with ≥1 severe
(hospitalised) exacerbation, n (%)3
(7.1)
(9.2)
0.77
(0.66-0.89)
<0.001
1 Time [days] refers to 1st 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 1st quartile of patients cannot be calculated, because proportion of patients with severe exacerbation is too low.
3 Percentage of patients with event were analysed using Cochran-Mantel-Haenszel test stratified by pooled centre; ratio refers to risk ratio.
4 Tiotropium 13 microgram inhalation powder delivers 10 microgram tiotropium
Compared with salmeterol, tiotropium bromide 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 bromide 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 randomized, 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 bromide and placebo. During treatment, there was a 16% reduction in the risk of death. The incidence rate of death was 4.79% patients per years in the placebo group vs. 4.10% patient per 100 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 bromide inhalation powder and tiotropium bromide soft mist inhaler. The primary endpoints were time to first COPD exacerbation, time to all-cause mortality and in a sub-study trough FEV1 (pre-dose).
The time to first COPD exacerbation was numerically similar during the study with tiotropium bromide inhalation powder and tiotropium bromide soft mist inhaler (hazard ratio (tiotropium bromide inhalation powder/ tiotropium bromide soft mist inhaler) 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 bromide inhalation powder and 756 days for tiotropium bromide soft mist inhaler.
The bronchodilator effect of tiotropium bromide inhalation powder was sustained over 120 weeks, and was similar to tiotropium bromide soft mist inhaler. The mean difference in trough FEV1 for tiotropium bromide inhalation powder versus tiotropium bromide soft mist inhaler was 0.010 L (95% CI -0.018 to 0.038 L).
In the post-marketing study comparing tiotropium bromide soft mist inhaler and tiotropium bromide inhalation powder, all-cause mortality including vital status follow up was similar during the study with tiotropium bromide inhalation powder and tiotropium bromide soft mist inhaler (hazard ratio (tiotropium bromide inhalation powder/tiotropium bromide soft mist inhaler) 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 bromide in all subsets of the paediatric population in COPD and cystic fibrosis (see section 4.2 for information on paediatric use).

Tiotropium bromide is a non-chiral quaternary ammonium compound and is sparingly soluble in water. Tiotropium bromide 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. Food is not expected to influence the absorption of this quaternary ammonium compound.
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 bromide 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 bromide 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 glutathionconjugation 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 27-45h in COPD patients. Total clearance was 880 ml/min after an intravenous dose in young healthy volunteers. Intravenously administered tiotropiumis 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 drug 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.
Characteristics in Patients
271 mL/min in COPD patients ≥65 years). This does not result in a corresponding increase in AUC06,ss or Cmax,ss values.
Renal impairment: Following once daily inhaled administrations of tiotropium to steady-state 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 tiotropium resulted in doubling of the total exposure (82% higher AUC0-4h and 52% higher Cmax) compared to COPD patients with normal renal functions, 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 postdosing 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
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 bromide. 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 bromide 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.
6.

Lactose monohydrate (which contains milk protein)
Capsule composed of hydroxypropylmethylcellulose (HPMC), commonly known as Hypromellose.

Not applicable

Store below 30 °C.
Keep the bottle tightly closed. Store in the original packaging to protect from moisture.

Triova® is available in pack containing 30 capsules (2 bottles of 15) and a Zephir inhaler.
High density polyethylene (HDPE) bottles closed with polypropylene (PP) screw-caps with polyethylene (PE) safety ring and low density polyethylene (LDPE) desiccant capsule containing silica gel. Each bottle contains 15 capsules, supplied in a carton with a Zephir inhaler.
The Zephir inhaler is a single dose inhalation device with a green body and cap and a white push button, made from acrylonitrile butadiene styrene (ABS) plastic materials and stainless steel.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
 

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