DRUG INTERACTIONS SECTION.

Drug Interactions. CYP3A4 Inhibitors. Ketoconazole, an inhibitor of the drug metabolizing enzyme CYP3A4, significantly increased plasma concentrations of tolterodine when coadministered to subjects who were poor metabolizers (see CLINICAL PHARMACOLOGY, Variability in Metabolism and Drug-Drug Interactions). For patients receiving ketoconazole or other potent CYP3A4 inhibitors such as other azole antifungals (e.g., itraconazole, miconazole) or macrolide antibiotics (e.g., erythromycin, clarithromycin) or cyclosporine or vinblastine, the recommended dose of tolterodine tartrate is mg twice daily (see DOSAGE AND ADMINISTRATION).

WARNINGS SECTION.

WARNINGS. Anaphylaxis and angioedema requiring hospitalization and emergency medical treatment have occurred with the first or subsequent doses of tolterodine tartrate tablets. In the event of difficulty in breathing, upper airway obstruction, or fall in blood pressure, tolterodine tartrate tablets should be discontinued and appropriate therapy promptly provided.

DOSAGE & ADMINISTRATION SECTION.

DOSAGE AND ADMINISTRATION. The initial recommended dose of tolterodine tartrate tablets is mg twice daily. The dose may be lowered to mg twice daily based on individual response and tolerability. For patients with significantly reduced hepatic or renal function or who are currently taking drugs that are potent inhibitors of CYP3A4, the recommended dose of tolterodine tartrate is mg twice daily (see PRECAUTIONS, General PRECAUTIONS, Reduced Hepatic and Renal Function and PRECAUTIONS, Drug Interactions).

ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. The Phase and clinical trial program for tolterodine tartrate tablets included 3071 patients who were treated with tolterodine tartrate (N=2133) or placebo (N=938). The patients were treated with 1, 2, 4, or mg/day for up to 12 months. No differences in the safety profile of tolterodine were identified based on age, gender, race, or metabolism.The data described below reflect exposure to tolterodine tartrate mg bid in 986 patients and to placebo in 683 patients exposed for 12 weeks in five Phase 3, controlled clinical studies. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The adverse reaction information from clinical trials does, however, provide basis for identifying the adverse events that appear to be related to drug use and approximating rates.Sixty-six percent of patients receiving tolterodine tartrate mg bid reported adverse events versus 56% of placebo patients. The most common adverse events reported by patients receiving tolterodine tartrate were dry mouth, headache, constipation, vertigo/dizziness, and abdominal pain. Dry mouth, constipation, abnormal vision (accommodation abnormalities), urinary retention, and xerophthalmia are expected side effects of antimuscarinic agents.Dry mouth was the most frequently reported adverse event for patients treated with tolterodine tartrate mg bid in the Phase clinical studies, occurring in 34.8% of patients treated with tolterodine tartrate and 9.8% of placebo-treated patients. One percent of patients treated with tolterodine tartrate discontinued treatment due to dry mouth.The frequency of discontinuation due to adverse events was highest during the first weeks of treatment. Seven percent of patients treated with tolterodine tartrate mg bid discontinued treatment due to adverse events versus 6% of placebo patients. The most common adverse events leading to discontinuation of tolterodine tartrate were dizziness and headache.Three percent of patients treated with tolterodine tartrate mg bid reported serious adverse event versus 4% of placebo patients. Significant ECG changes in QT and QTc have not been demonstrated in clinical-study patients treated with tolterodine tartrate mg bid. Table lists the adverse events reported in 1% or more of the patients treated with tolterodine tartrate mg bid in the 12-week studies. The adverse events are reported regardless of causality.Table 5. Incidence (%) of Adverse Events Exceeding Placebo Rate and Reported in >1% of Patients Treated with Tolterodine tartrate tablets (2 mg bid) in 12-week, Phase Clinical StudiesBody SystemAdverse Event% Tolterodine tartrate N=986 PlaceboN=683 Autonomic Nervousaccommodation abnormal21dry mouth3510Generalchest pain21fatigue43headache75influenza-like symptoms32Central/Peripheral Nervousvertigo/dizziness53Gastrointestinalabdominal pain53constipation74diarrhea43dyspepsia41Urinarydysuria21Skin/Appendagesdry skin10Musculoskeletalarthralgia21Visionxerophthalmia32Psychiatricsomnolence32Metabolic/Nutritionalweight gain10Resistance Mechanisminfection10in nearest integer.. Post-marketing Surveillance. The following events have been reported in association with tolterodine use in worldwide post-marketing experience: General: anaphylaxis and angioedema; Cardiovascular: tachycardia, palpitations, peripheral edema; Central/Peripheral Nervous: confusion, disorientation, memory impairment, hallucinations. Reports of aggravation of symptoms of dementia (e.g., confusion, disorientation, delusion) have been reported after tolterodine therapy was initiated in patients taking cholinesterase inhibitors for the treatment of dementia.Because these spontaneously reported events are from the worldwide post-marketing experience, the frequency of events and the role of tolterodine in their causation cannot be reliably determined.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

Carcinogenesis, Mutagenesis, Impairment of Fertility. Carcinogenicity studies with tolterodine were conducted in mice and rats. At the maximum tolerated dose in mice (30 mg/kg/day), female rats (20 mg/kg/day), and male rats (30 mg/kg/day), AUC values obtained for tolterodine were 355, 291, and 462 ugh/L, respectively. In comparison, the human AUC value for 2-mg dose administered twice daily is estimated at 34 ugh/L. Thus, tolterodine exposure in the carcinogenicity studies was 9- to 14-fold higher than expected in humans. No increase in tumors was found in either mice or rats.No mutagenic effects of tolterodine were detected in battery of in vitro tests, including bacterial mutation assays (Ames test) in strains of Salmonella typhimurium and in strains of Escherichia coli, gene mutation assay in L5178Y mouse lymphoma cells, and chromosomal aberration tests in human lymphocytes. Tolterodine was also negative in vivo in the bone marrow micronucleus test in the mouse. In female mice treated for weeks before mating and during gestation with 20 mg/kg/day (corresponding to AUC value of about 500 ugh/L), neither effects on reproductive performance or fertility were seen. Based on AUC values, the systemic exposure was about 15-fold higher in animals than in humans. In male mice, dose of 30 mg/kg/day did not induce any adverse effects on fertility.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. Tolterodine is competitive muscarinic receptor antagonist. Both urinary bladder contraction and salivation are mediated via cholinergic muscarinic receptors.After oral administration, tolterodine is metabolized in the liver, resulting in the formation of the 5-hydroxymethyl derivative, major pharmacologically active metabolite. The 5-hydroxymethyl metabolite, which exhibits an antimuscarinic activity similar to that of tolterodine, contributes significantly to the therapeutic effect. Both tolterodine and the 5-hydroxymethyl metabolite exhibit high specificity for muscarinic receptors, since both show negligible activity or affinity for other neurotransmitter receptors and other potential cellular targets, such as calcium channels.Tolterodine has pronounced effect on bladder function. Effects on urodynamic parameters before and and hours after single 6.4 mg dose of tolterodine immediate release were determined in healthy volunteers. The main effects of tolterodine at and hours were an increase in residual urine, reflecting an incomplete emptying of the bladder, and decrease in detrusor pressure. These findings are consistent with an antimuscarinic action on the lower urinary tract.. Pharmacokinetics. Absorption. In study with 14C-tolterodine solution in healthy volunteers who received 5-mg oral dose, at least 77% of the radiolabeled dose was absorbed. Tolterodine immediate release is rapidly absorbed, and maximum serum concentrations (C max) typically occur within to hours after dose administration. max and area under the concentration-time curve (AUC) determined after dosage of tolterodine immediate release are dose-proportional over the range of to mg. Effect of Food. Food intake increases the bioavailability of tolterodine (average increase 53%), but does not affect the levels of the 5-hydroxymethyl metabolite in extensive metabolizers. This change is not expected to be safety concern and adjustment of dose is not needed.. Distribution. Tolterodine is highly bound to plasma proteins, primarily 1-acid glycoprotein. Unbound concentrations of tolterodine average 3.7% +- 0.13% over the concentration range achieved in clinical studies. The 5-hydroxymethyl metabolite is not extensively protein bound, with unbound fraction concentrations averaging 36% +- 4.0%. The blood to serum ratio of tolterodine and the 5-hydroxymethyl metabolite averages 0.6 and 0.8, respectively, indicating that these compounds do not distribute extensively into erythrocytes. The volume of distribution of tolterodine following administration of 1.28-mg intravenous dose is 113 +- 26.7 L.. Metabolism. Tolterodine is extensively metabolized by the liver following oral dosing. The primary metabolic route involves the oxidation of the 5-methyl group and is mediated by the cytochrome P450 2D6 (CYP2D6) and leads to the formation of pharmacologically active 5-hydroxymethyl metabolite. Further metabolism leads to formation of the 5-carboxylic acid and N-dealkylated 5-carboxylic acid metabolites, which account for 51% +- 14% and 29% +- 6.3% of the metabolites recovered in the urine, respectively.. Variability in Metabolism. subset (about 7%) of the population is devoid of CYP2D6, the enzyme responsible for the formation of the 5-hydroxymethyl metabolite of tolterodine. The identified pathway of metabolism for these individuals (poor metabolizers) is dealkylation via cytochrome P450 3A4 (CYP3A4) to N-dealkylated tolterodine. The remainder of the population is referred to as extensive metabolizers. Pharmacokinetic studies revealed that tolterodine is metabolized at slower rate in poor metabolizers than in extensive metabolizers; this results in significantly higher serum concentrations of tolterodine and in negligible concentrations of the 5-hydroxymethyl metabolite. Excretion. Following administration of 5-mg oral dose of 14C-tolterodine solution to healthy volunteers, 77% of radioactivity was recovered in urine and 17% was recovered in feces in days. Less than 1% (<2.5% in poor metabolizers) of the dose was recovered as intact tolterodine, and 5% to 14% (<1% in poor metabolizers) was recovered as the active 5-hydroxymethyl metabolite. summary of mean (+- standard deviation) pharmacokinetic parameters of tolterodine immediate release and the 5-hydroxymethyl metabolite in extensive (EM) and poor (PM) metabolizers is provided in Table 1. These data were obtained following single and multiple doses of tolterodine mg administered twice daily to 16 healthy male volunteers (8 EM, PM).Table 1. Summary of Mean (+-SD) Pharmacokinetic Parameters of Tolterodine and its Active Metabolite (5-hydroxymethyl metabolite) in Healthy VolunteersTolterodine5-Hydroxymethyl MetabolitePhenotype(CYP2D6)tmax(h)Cmax(ug/L)Cavg(ug/L)t1/2(h)CL/F (L/h)tmax(h)Cmax(ug/L)Cavg(ug/L)t1/2(h)Single-dose EM PM 1.6+-1.5 1.4+-0.5 1.6+-1.2 10+-4.9 0.50+-0.35 8.3+-4.3 2.0+-0.7 6.5+-1.6 534+-697 17+-7.3 1.8+-1.4 1.8+-0.7 0.62+-0.26 3.1+-0.7 Multiple-dose EM PM 1.2+-0.5 1.9+-1.0 2.6+-2.8 19+-7.5 0.58+-0.54 12+-5.1 2.2+-0.4 9.6+-1.5 415+-377 11+-4.2 1.2+-0.5 2.4+-1.3 0.92+-0.46 .9+-0.4 C max Maximum plasma concentration; m ax Time of occurrence of m ax; Cavg Average plasma concentration; t1/2 Terminal elimination half-life; CL/F Apparent oralclearance.EM Extensive metabolizers; PM Poor metabolizers. Parameter was dose-normalized from mg to mg.+ not applicable.. Pharmacokinetics in Special Populations. Age. In Phase 1, multiple-dose studies in which tolterodine immediate release mg (2 mg bid) was administered, serum concentrations of tolterodine and of the 5-hydroxymethyl metabolite were similar in healthy elderly volunteers (aged 64 through 80 years) and healthy young volunteers (aged less than 40 years). In another Phase study, elderly volunteers (aged 71 through 81 years) were given tolterodine immediate release or mg (1 or mg bid). Mean serum concentrations of tolterodine and the 5-hydroxymethyl metabolite in these elderly volunteers were approximately 20% and 50% higher, respectively, than reported in young healthy volunteers. However, no overall differences were observed in safety between older and younger patients on tolterodine in Phase 3, 12-week, controlled clinical studies; therefore, no tolterodine dosage adjustment for elderly patients is recommended (see PRECAUTIONS, Geriatric Use) . Pediatric. The pharmacokinetics of tolterodine have not been established in pediatric patients.. Gender. The pharmacokinetics of tolterodine immediate release and the 5-hydroxymethyl metabolite are not influenced by gender. Mean max of tolterodine (1.6 ug/L in males versus 2.2 ug/L in females) and the active 5-hydroxymethyl metabolite (2.2 ug/L in males versus 2.5 ug/L in females) are similar in males and females who were administered tolterodine immediate release mg. Mean AUC values of tolterodine (6.7 ugh/L in males versus 7.8 ugh/L in females) and the 5-hydroxymethyl metabolite (10 ugh/L in males versus 11 ugh/L in females) are also similar. The elimination half-life of tolterodine for both males and females is 2.4 hours, and the half-life of the 5-hydroxymethyl metabolite is 3.0 hours in females and 3.3 hours in males. Race. Pharmacokinetic differences due to race have not been established.. Renal Insufficiency. Renal impairment can significantly alter the disposition of tolterodine immediate release and its metabolites. In study conducted in patients with creatinine clearance between 10 and 30 mL/min, tolterodine immediate release and the 5-hydroxymethyl metabolite levels were approximately 2-3 fold higher in patients with renal impairment than in healthy volunteers. Exposure levels of other metabolites of tolterodine (e.g., tolterodine acid, N-dealkylated tolterodine acid, N-dealkylated tolterodine, and N-dealkylated hydroxylated tolterodine) were significantly higher (10-30 fold) in renally impaired patients as compared to the healthy volunteers. The recommended dosage for patients with significantly reduced renal function is tolterodine mg twice daily (see PRECAUTIONS, General and DOSAGE AND ADMINISTRATION). Hepatic Insufficiency. Liver impairment can significantly alter the disposition of tolterodine immediate release. In study conducted in cirrhotic patients, the elimination half-life of tolterodine immediate release was longer in cirrhotic patients (mean, 7.8 hours) than in healthy, young, and elderly volunteers (mean, to hours). The clearance of orally administered tolterodine was substantially lower in cirrhotic patients (1.0 +- 1.7 L/h/kg) than in the healthy volunteers (5.7 +- 3.8 L/h/kg). The recommended dose for patients with significantly reduced hepatic function is tolterodine mg twice daily (see PRECAUTIONS, General and DOSAGE AND ADMINISTRATION ). Drug-Drug Interactions. Fluoxetine. Fluoxetine is selective serotonin reuptake inhibitor and potent inhibitor of CYP2D6 activity. In study to assess the effect of fluoxetine on the pharmacokinetics of tolterodine immediate release and its metabolites, it was observed that fluoxetine significantly inhibited the metabolism of tolterodine immediate release in extensive metabolizers, resulting in 4.8-fold increase in tolterodine AUC. There was 52% decrease in max and 20% decrease in AUC of the 5-hydroxymethyl metabolite. Fluoxetine thus alters the pharmacokinetics in patients who would otherwise be extensive metabolizers of tolterodine immediate release to resemble the pharmacokinetic profile in poor metabolizers. The sums of unbound serum concentrations of tolterodine immediate release and the 5-hydroxymethyl metabolite are only 25% higher during the interaction. No dose adjustment is required when tolterodine and fluoxetine are coadministered. Other Drugs Metabolized by Cytochrome P450 Isoenzymes. Tolterodine immediate release does not cause clinically significant interactions with other drugs metabolized by the major drug metabolizing CYP enzymes. In vivo drug-interaction data show that tolterodine immediate release does not result in clinically relevant inhibition of CYP1A2, 2D6, 2C9, 2C19, or 3A4 as evidenced by lack of influence on the marker drugs caffeine, debrisoquine, S-warfarin, and omeprazole. In vitro data show that tolterodine immediate release is competitive inhibitor of CYP2D6 at high concentrations (Ki 1.05 uM), while tolterodine immediate release as well as the 5-hydroxymethyl metabolite are devoid of any significant inhibitory potential regarding the other isoenzymes.. CYP3A4 Inhibitors. The effect of 200 mg daily dose of ketoconazole on the pharmacokinetics of tolterodine immediate release was studied in healthy volunteers, all of whom were poor metabolizers (see Pharmacokinetics ,Variability in Metabolism for discussion of poor metabolizers). In the presence of ketoconazole, the mean max and AUC of tolterodine increased by and 2.5 fold, respectively. Based on these findings, other potent CYP3A inhibitors such as other azole antifungals (eg, itraconazole, miconazole) or macrolide antibiotics (eg, erythromycin, clarithromycin) or cyclosporine or vinblastine may also lead to increases of tolterodine plasma concentrations (see PRECAUTIONS and DOSAGE AND ADMINISTRATION ). Warfarin. In healthy volunteers, coadministration of tolterodine immediate release mg (2 mg bid) for days and single dose of warfarin 25 mg on day had no effect on prothrombin time, Factor VII suppression, or on the pharmacokinetics of warfarin.. Oral Contraceptives. Tolterodine immediate release mg (2 mg bid) had no effect on the pharmacokinetics of an oral contraceptive (ethinyl estradiol 30 ug/levonorgestrel 150 ug) as evidenced by the monitoring of ethinyl estradiol and levonorgestrel over 2-month cycle in healthy female volunteers.. Diuretics. Coadministration of tolterodine immediate release up to mg (4 mg bid) for up to 12 weeks with diuretic agents, such as indapamide, hydrochlorothiazide, triamterene, bendroflumethiazide, chlorothiazide, methylchlorothiazide, or furosemide, did not cause any adverse electrocardiographic (ECG) effects.. Cardiac Electrophysiology. The effect of mg BID and mg BID of tolterodine immediate release (IR) on the QT interval was evaluated in 4-way crossover, double-blind, placebo- and active-controlled (moxifloxacin 400 mg QD) study in healthy male (N=25) and female (N=23) volunteers aged 18-55 years. Study subjects [approximately equal representation of CYP2D6 extensive metabolizers (EMs) and poor metabolizers (PMs)] completed sequential 4-day periods of dosing with moxifloxacin 400 mg QD, tolterodine mg BID, tolterodine mg BID, and placebo. The mg BID dose of tolterodine IR (two times the highest recommended dose) was chosen because this dose results in tolterodine exposure similar to that observed upon coadministration of tolterodine mg BID with potent CYP3A4 inhibitors in patients who are CYP2D6 poor metabolizers (see PRECAUTIONS, Drug Interactions). QT interval was measured over 12-hour period following dosing, including the time of peak plasma concentration (T max) of tolterodine and at steady state (Day of dosing). Table summarizes the mean change from baseline to steady state in corrected QT interval (QTc) relative to placebo at the time of peak tolterodine (1 hour) and moxifloxacin (2 hour) concentrations. Both Fridericias (QTcF) and population-specific (QTcP) method were used to correct QT interval for heart rate. No single QT correction method is known to be more valid than others. QT interval was measured manually and by machine, and data from both are presented. The mean increase of heart rate associated with 4 mg/day dose of tolterodine in this study was 2.0 beats/minute and 6.3 beats/minute with mg/day tolterodine. The change in heart rate with moxifloxacin was 0.5 beats/minute.Table 2. Mean (CI) change in QTc from baseline to steady state (Day of dosing)at Tmax (relative to placebo)Drug/DoseNQTcF (msec) (manual)QTcF (msec) (machine)QTcP (msec) (manual)QTcP (msec) (machine)Tolterodine2 mg BID 485.01 (0.28, 9.74) 1.16 (-2.99, 5.30) 4.45 (-0.37, 9.26) 2.00 (-1.81, 5.81) Tolterodine4 mg BID 4811.84 (7.11, 16.58) 5.63 (1.48, 9.77) 10.31 (5.49, 15.12) 8.34 (4.53, 12.15) Moxifloxacin400 mg QD 4519.26 (15.49, 23.03) 8.90 (4.77, 13.03) 19.10 (15.32, 22.89) 9.29 (5.34, 13.24) 1At max of hr; 95% Confidence Interval 2At max of hr; 90% Confidence Interval 3The effect on QT interval with days of moxifloxacin dosing in this QT trial may be greater than typically observed in QT trials of other drugs. The reason for the difference between machine and manual read of QT interval is unclear.The QT effect of tolterodine immediate release tablets appeared greater for mg/day (two times the therapeutic dose) compared to mg/day. The effect of tolterodine mg/day was not as large as that observed after four days of therapeutic dosing with the active control moxifloxacin. However, the confidence intervals overlapped.Tolterodines effect on QT interval was found to correlate with plasma concentration of tolterodine. There appeared to be greater QTc interval increase in CYP2D6 poor metabolizers than in CYP2D6 extensive metabolizers after tolterodine treatment in this study.This study was not designed to make direct statistical comparisons between drugs or dose levels. There has been no association of Torsade de Pointes in the international post-marketing experience with tolterodine tartrate tablets or tolterodine extended-release capsules (see PRECAUTIONS, Patients with Congenital or Acquired QT Prolongation).

CLINICAL STUDIES SECTION.

CLINICAL STUDIES. Tolterodine tartrate tablets were evaluated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in four randomized, double-blind, placebo-controlled, 12-week studies. total of 853 patients received tolterodine tartrate mg twice daily and 685 patients received placebo. The majority of patients were Caucasian (95%) and female (78%), with mean age of 60 years (range, 19 to 93 years). At study entry, nearly all patients perceived they had urgency and most patients had increased frequency of micturitions and urge incontinence. These characteristics were well balanced across treatment groups for the studies.The efficacy endpoints for study 007 (see Table 3) included the change from baseline for:Number of incontinence episodes per week Number of micturitions per 24 hours (averaged over days) Volume of urine voided per micturition (averaged over days)The efficacy endpoints for studies 008, 009, and 010 (see Table 4) were identical to the above endpoints with the exception that the number of incontinence episodes was per 24 hours (averaged over days).Table 3. 95% Confidence Intervals (CI) for the Difference between Tolterodine tartrate (2 mg bid) and Placebo for the Mean Change at Week 12 from Baseline in Study 007Tolterodine tartrate(SD) N=514 Placebo (SD) N=508 Difference (95% CI) Number of Incontinence Episodes per Week Mean baseline23.223.3 Mean change from baseline-10.6 (17)-6.9 (15)-3.7 (-5.7, -1.6)Number of Micturitions per 24 Hours Mean baseline11.111.3 Mean change from baseline-1.7 (3.3)-1.2 (2.9)-0.5 (-0.9, -0.1)Volume Voided per Micturition (mL) Mean baseline137136 Mean change from baseline29 (47)14 (41)15 (9, 21)SD Standard Deviation. The difference between tolterodine tartrate and placebo was statistically significant.Table 4. 95% Confidence Intervals (CI) for the Difference between Tolterodine tartrate (2 mg bid) and Placebo for the Mean Change at Week 12 from Baseline in Studies 008, 009, 010StudyTolterodine tartrate(SD) Placebo(SD) Difference(95% CI) Number of Incontinence Episodes per 24 Hours008Number of patients9340Mean baseline2.93.3Mean change from baseline-1.3 (3.2)-0.9 (1.5)0.5 (-1.3,0.3)009Number of patients11655Mean baseline3.63.5Mean change from baseline-1.7 (2.5)-1.3 (2.5)-0.4 (-1.0,0.2)010Number of patients9050Mean baseline3.73.5Mean change from baseline-1.6 (2.4)-1.1 (2.1)-0.5 (-1.1,0.1)Number of Micturitions per 24 Hours008Number of patients11856Mean baseline11.511.7Mean change from baseline-2.7 (3.8)-1.6 (3.6)-1.2 (-2.0,-0.4)009Number of patients12864Mean baseline11.211.3Mean change from baseline-2.3 (2.1)-1.4 (2.8)-0.9 (-1.5,-0.3)010Number of patients10856Mean baseline11.611.6Mean change from baseline-1.7 (2.3)-1.4 (2.8)-0.38 (-1.1,0.3)Volume Voided per Micturition (mL)008Number of patients11856Mean baseline166157Mean change from baseline38 (54)6 (42)32(18,46)009Number of patients12964Mean baseline155158Mean change from baseline36 (50)10 (47)26(14,38)010Number of patients10856Mean baseline155160Mean change from baseline31 (45)13 (52)18(4,32)SD Standard Deviation. The difference between tolterodine tartrate and placebo was statistically significant. Number of incontinence episodes per week Number of micturitions per 24 hours (averaged over days) Volume of urine voided per micturition (averaged over days).

CONTRAINDICATIONS SECTION.

CONTRAINDICATIONS. Tolterodine tartrate tablets are contraindicated in patients with urinary retention, gastric retention, or uncontrolled narrow-angle glaucoma. Tolterodine tartrate is also contraindicated in patients who have demonstrated hypersensitivity to the drug or its ingredients, or to fesoterodine fumarate extended-release tablets which, like tolterodine tartrate, are metabolized to 5-hydroxymethyl tolterodine.

DESCRIPTION SECTION.

DESCRIPTION. Tolterodine tartrate tablets contain tolterodine tartrate. The active moiety, tolterodine, is muscarinic receptor antagonist. The chemical name of tolterodine tartrate is (R)-2-[3-[bis(1-methylethyl)-amino]1-phenylpropyl]-4-methylphenol [R-(R,R)]-2,3dihydroxybutanedioate (1:1) (salt). The empirical formula of tolterodine tartrate is 26H 37NO 7, and its molecular weight is 475.6. The structural formula of tolterodine tartrate is represented below: Tolterodine tartrate is white, crystalline powder. The pKa value is 9.87 and the solubility in water is 12 mg/mL. It is soluble in methanol, slightly soluble in ethanol, and practically insoluble in toluene. The partition coefficient (Log D) between n-octanol and water is 1.83 at pH 7.3.Each tolterodine tartrate tablets for oral administration contains or mg of tolterodine tartrate. The inactive ingredients are colloidal silicon dioxide, dibasic calcium phosphate dihydrate, hypromellose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, sodium starch glycolate, and titanium dioxide. Tolterodine tartrate tablets contain tolterodine tartrate. The active moiety, tolterodine, is muscarinic receptor antagonist. The chemical name of tolterodine tartrate is (R)-2-[3-[bis(1-methylethyl.

GENERAL PRECAUTIONS SECTION.

General. Risk of Urinary Retention and Gastric Retention. Tolterodine tartrate tablets should be administered with caution to patients with clinically significant bladder outflow obstruction because of the risk of urinary retention and to patients with gastrointestinal obstructive disorders, such as pyloric stenosis, because of the risk of gastric retention (see CONTRAINDICATIONS). Decreased Gastrointestinal Motility. Tolterodine tartrate, like other antimuscarinic drugs, should be used with caution in patients with decreased gastrointestinal motility.. Controlled Narrow-Angle Glaucoma. Tolterodine tartrate should be used with caution in patients being treated for narrow-angle glaucoma.. Central Nervous System (CNS) Effects. Tolterodine tartrate is associated with anticholinergic central nervous system (CNS) effects including dizziness and somnolence (see Adverse Reactions). Patients should be monitored for signs of anticholinergic CNS effects, particularly after beginning treatment or increasing the dose. Advise patients not to drive or operate heavy machinery until the drugs effects have been determined. If patient experiences anticholinergic CNS effects, dose reduction or drug discontinuation should be considered.. Reduced Hepatic and Renal Function. For patients with significantly reduced hepatic function or renal function, the recommended dose of tolterodine is mg twice daily (see CLINICAL PHARMACOLOGY, Pharmacokinetics in Special Populations). Myasthenia Gravis. Tolterodine tartrate should be used with caution in patients with myasthenia gravis, disease characterized by decreased cholinergic activity at the neuromuscular junction.

GERIATRIC USE SECTION.

Geriatric Use. Of the 1120 patients who were treated in the four Phase 3, 12-week clinical studies of tolterodine tartrate, 474 (42%) were 65 to 91 years of age. No overall differences in safety were observed between the older and younger patients (see CLINICAL PHARMACOLOGY, Pharmacokinetics in Special Populations).

HOW SUPPLIED SECTION.

HOW SUPPLIED. Tolterodine tartrate tablets mg (White to off white, round biconvex film coated tablets, debossed IT 89 on one side, other side is plain.) and olterodine tartrate ablets mg (White to off white, round biconvex film coated tablets, debossed IT 90 on one side, other side is plain.) are supplied as follows: Bottles of 60 mg NDC 10135-0706-60 mg NDC 10135-0707-60 Bottles of 500 mg NDC 10135-0706-05 mg NDC 10135-0707-05 Store at 25C (77F); excursions permitted to 15-30C (59-86F) [see USP Controlled Room Temperature] (DTL).Manufactured for and Distributed by: Marlex Pharmaceuticals, Inc.New Castle, DE 19720 Rev. 7/20 IT.

INDICATIONS & USAGE SECTION.

INDICATIONS AND USAGE. Tolterodine tartrate tablets are indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency.

INFORMATION FOR PATIENTS SECTION.

Information for Patients. Patients should be informed that antimuscarinic agents such as tolterodine tartrate may produce the following effects: blurred vision, dizziness, or drowsiness. Patients should be advised to exercise caution in decisions to engage in potentially dangerous activities until the drugs effects have been determined.

NURSING MOTHERS SECTION.

Nursing Mothers. Tolterodine is excreted into the milk in mice. Offspring of female mice treated with tolterodine 20 mg/kg/day during the lactation period had slightly reduced body weight gain. The offspring regained the weight during the maturation phase. It is not known whether tolterodine is excreted in human milk; therefore, tolterodine tartrate should not be administered during nursing. decision should be made whether to discontinue nursing or to discontinue tolterodine tartrate in nursing mothers.

OVERDOSAGE SECTION.

OVERDOSAGE. 27-month-old child who ingested to tolterodine tartrate tablets mg was treated with suspension of activated charcoal and was hospitalized overnight with symptoms of dry mouth. The child fully recovered.. Management of Overdosage. Overdosage with tolterodine tartrate can potentially result in severe central anticholinergic effects and should be treated accordingly.ECG monitoring is recommended in the event of overdosage. In dogs, changes in the QT interval (slight prolongation of 10% to 20%) were observed at suprapharmacologic dose of 4.5 mg/kg, which is about 68 times higher than the recommended human dose. In clinical trials of normal volunteers and patients, QT interval prolongation was observed with tolterodine immediate release at doses up to mg (4 mg bid) and higher doses were not evaluated (see PRECAUTIONS, Patients with Congenital or Acquired QT Prolongation).

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PACKAGE LABEL PRINCIPAL DISPLAY PANEL 1 mg StrengthNDC 10135-0706-60 60 Tablets Tolterodine Tartrate Tablets mg Rx only. PACKAGE LABEL PRINCIPAL DISPLAY PANEL 1 mg StrengthNDC 10135-0706-6060 Tablets Tolterodine Tartrate Tablets mg Rx only.

PEDIATRIC USE SECTION.

Pediatric Use. Efficacy in the pediatric population has not been demonstrated.Two pediatric phase randomized, placebo-controlled, double-blind, 12-week studies were conducted using tolterodine extended release capsules. total of 710 pediatric patients (486 on tolterodine extended-release capsules and 224 on placebo) aged 5-10 years with urinary frequency and urge urinary incontinence were studied. The percentage of patients with urinary tract infections was higher in patients treated with tolterodine extended-release capsules (6.6%) compared to patients who received placebo (4.5%). Aggressive, abnormal and hyperactive behavior and attention disorders occurred in 2.9% of children treated with tolterodine extended-release capsules compared to 0.9% of children treated with placebo.

PHARMACOKINETICS SECTION.

Pharmacokinetics. Absorption. In study with 14C-tolterodine solution in healthy volunteers who received 5-mg oral dose, at least 77% of the radiolabeled dose was absorbed. Tolterodine immediate release is rapidly absorbed, and maximum serum concentrations (C max) typically occur within to hours after dose administration. max and area under the concentration-time curve (AUC) determined after dosage of tolterodine immediate release are dose-proportional over the range of to mg. Effect of Food. Food intake increases the bioavailability of tolterodine (average increase 53%), but does not affect the levels of the 5-hydroxymethyl metabolite in extensive metabolizers. This change is not expected to be safety concern and adjustment of dose is not needed.. Distribution. Tolterodine is highly bound to plasma proteins, primarily 1-acid glycoprotein. Unbound concentrations of tolterodine average 3.7% +- 0.13% over the concentration range achieved in clinical studies. The 5-hydroxymethyl metabolite is not extensively protein bound, with unbound fraction concentrations averaging 36% +- 4.0%. The blood to serum ratio of tolterodine and the 5-hydroxymethyl metabolite averages 0.6 and 0.8, respectively, indicating that these compounds do not distribute extensively into erythrocytes. The volume of distribution of tolterodine following administration of 1.28-mg intravenous dose is 113 +- 26.7 L.. Metabolism. Tolterodine is extensively metabolized by the liver following oral dosing. The primary metabolic route involves the oxidation of the 5-methyl group and is mediated by the cytochrome P450 2D6 (CYP2D6) and leads to the formation of pharmacologically active 5-hydroxymethyl metabolite. Further metabolism leads to formation of the 5-carboxylic acid and N-dealkylated 5-carboxylic acid metabolites, which account for 51% +- 14% and 29% +- 6.3% of the metabolites recovered in the urine, respectively.. Variability in Metabolism. subset (about 7%) of the population is devoid of CYP2D6, the enzyme responsible for the formation of the 5-hydroxymethyl metabolite of tolterodine. The identified pathway of metabolism for these individuals (poor metabolizers) is dealkylation via cytochrome P450 3A4 (CYP3A4) to N-dealkylated tolterodine. The remainder of the population is referred to as extensive metabolizers. Pharmacokinetic studies revealed that tolterodine is metabolized at slower rate in poor metabolizers than in extensive metabolizers; this results in significantly higher serum concentrations of tolterodine and in negligible concentrations of the 5-hydroxymethyl metabolite. Excretion. Following administration of 5-mg oral dose of 14C-tolterodine solution to healthy volunteers, 77% of radioactivity was recovered in urine and 17% was recovered in feces in days. Less than 1% (<2.5% in poor metabolizers) of the dose was recovered as intact tolterodine, and 5% to 14% (<1% in poor metabolizers) was recovered as the active 5-hydroxymethyl metabolite. summary of mean (+- standard deviation) pharmacokinetic parameters of tolterodine immediate release and the 5-hydroxymethyl metabolite in extensive (EM) and poor (PM) metabolizers is provided in Table 1. These data were obtained following single and multiple doses of tolterodine mg administered twice daily to 16 healthy male volunteers (8 EM, PM).Table 1. Summary of Mean (+-SD) Pharmacokinetic Parameters of Tolterodine and its Active Metabolite (5-hydroxymethyl metabolite) in Healthy VolunteersTolterodine5-Hydroxymethyl MetabolitePhenotype(CYP2D6)tmax(h)Cmax(ug/L)Cavg(ug/L)t1/2(h)CL/F (L/h)tmax(h)Cmax(ug/L)Cavg(ug/L)t1/2(h)Single-dose EM PM 1.6+-1.5 1.4+-0.5 1.6+-1.2 10+-4.9 0.50+-0.35 8.3+-4.3 2.0+-0.7 6.5+-1.6 534+-697 17+-7.3 1.8+-1.4 1.8+-0.7 0.62+-0.26 3.1+-0.7 Multiple-dose EM PM 1.2+-0.5 1.9+-1.0 2.6+-2.8 19+-7.5 0.58+-0.54 12+-5.1 2.2+-0.4 9.6+-1.5 415+-377 11+-4.2 1.2+-0.5 2.4+-1.3 0.92+-0.46 .9+-0.4 C max Maximum plasma concentration; m ax Time of occurrence of m ax; Cavg Average plasma concentration; t1/2 Terminal elimination half-life; CL/F Apparent oralclearance.EM Extensive metabolizers; PM Poor metabolizers. Parameter was dose-normalized from mg to mg.+ not applicable.

PRECAUTIONS SECTION.

PRECAUTIONS. General. Risk of Urinary Retention and Gastric Retention. Tolterodine tartrate tablets should be administered with caution to patients with clinically significant bladder outflow obstruction because of the risk of urinary retention and to patients with gastrointestinal obstructive disorders, such as pyloric stenosis, because of the risk of gastric retention (see CONTRAINDICATIONS). Decreased Gastrointestinal Motility. Tolterodine tartrate, like other antimuscarinic drugs, should be used with caution in patients with decreased gastrointestinal motility.. Controlled Narrow-Angle Glaucoma. Tolterodine tartrate should be used with caution in patients being treated for narrow-angle glaucoma.. Central Nervous System (CNS) Effects. Tolterodine tartrate is associated with anticholinergic central nervous system (CNS) effects including dizziness and somnolence (see Adverse Reactions). Patients should be monitored for signs of anticholinergic CNS effects, particularly after beginning treatment or increasing the dose. Advise patients not to drive or operate heavy machinery until the drugs effects have been determined. If patient experiences anticholinergic CNS effects, dose reduction or drug discontinuation should be considered.. Reduced Hepatic and Renal Function. For patients with significantly reduced hepatic function or renal function, the recommended dose of tolterodine is mg twice daily (see CLINICAL PHARMACOLOGY, Pharmacokinetics in Special Populations). Myasthenia Gravis. Tolterodine tartrate should be used with caution in patients with myasthenia gravis, disease characterized by decreased cholinergic activity at the neuromuscular junction.. Patients with Congenital or Acquired QT Prolongation. In study of the effect of tolterodine immediate release tablets on the QT interval (see CLINICAL PHARMACOLOGY, Cardiac Electrophysiology), the effect on the QT interval appeared greater for mg/day (two times the therapeutic dose) compared to mg/day and was more pronounced in CYP2D6 poor metabolizers (PM) than extensive metabolizers (EMs). The effect of tolterodine mg/day was not as large as that observed after four days of therapeutic dosing with the active control moxifloxacin. However, the confidence intervals overlapped. These observations should be considered in clinical decisions to prescribe tolterodine for patients with known history of QT prolongation or patients who are taking Class IA (e.g., quinidine, procainamide) or Class III (e.g., amiodarone, sotalol) antiarrhythmic medications (see PRECAUTIONS, Drug Interactions). There has been no association of Torsade de Pointes in the international post-marketing experience with Tolterodine tartrate tablets or tolterodine extended-release capsules. Information for Patients. Patients should be informed that antimuscarinic agents such as tolterodine tartrate may produce the following effects: blurred vision, dizziness, or drowsiness. Patients should be advised to exercise caution in decisions to engage in potentially dangerous activities until the drugs effects have been determined.. Drug Interactions. CYP3A4 Inhibitors. Ketoconazole, an inhibitor of the drug metabolizing enzyme CYP3A4, significantly increased plasma concentrations of tolterodine when coadministered to subjects who were poor metabolizers (see CLINICAL PHARMACOLOGY, Variability in Metabolism and Drug-Drug Interactions). For patients receiving ketoconazole or other potent CYP3A4 inhibitors such as other azole antifungals (e.g., itraconazole, miconazole) or macrolide antibiotics (e.g., erythromycin, clarithromycin) or cyclosporine or vinblastine, the recommended dose of tolterodine tartrate is mg twice daily (see DOSAGE AND ADMINISTRATION). Drug-Laboratory-Test Interactions. Interactions between tolterodine and laboratory tests have not been studied.. Carcinogenesis, Mutagenesis, Impairment of Fertility. Carcinogenicity studies with tolterodine were conducted in mice and rats. At the maximum tolerated dose in mice (30 mg/kg/day), female rats (20 mg/kg/day), and male rats (30 mg/kg/day), AUC values obtained for tolterodine were 355, 291, and 462 ugh/L, respectively. In comparison, the human AUC value for 2-mg dose administered twice daily is estimated at 34 ugh/L. Thus, tolterodine exposure in the carcinogenicity studies was 9- to 14-fold higher than expected in humans. No increase in tumors was found in either mice or rats.No mutagenic effects of tolterodine were detected in battery of in vitro tests, including bacterial mutation assays (Ames test) in strains of Salmonella typhimurium and in strains of Escherichia coli, gene mutation assay in L5178Y mouse lymphoma cells, and chromosomal aberration tests in human lymphocytes. Tolterodine was also negative in vivo in the bone marrow micronucleus test in the mouse. In female mice treated for weeks before mating and during gestation with 20 mg/kg/day (corresponding to AUC value of about 500 ugh/L), neither effects on reproductive performance or fertility were seen. Based on AUC values, the systemic exposure was about 15-fold higher in animals than in humans. In male mice, dose of 30 mg/kg/day did not induce any adverse effects on fertility.. Pregnancy. Pregnancy Category C. At oral doses of 20 mg/kg/day (approximately 14 times the human exposure), no anomalies or malformations were observed in mice. When given at doses of 30 to 40 mg/kg/day, tolterodine has been shown to be embryolethal, reduce fetal weight, and increase the incidence of fetal abnormalities (cleft palate, digital abnormalities, intra-abdominal hemorrhage, and various skeletal abnormalities, primarily reduced ossification) in mice. At these doses, the AUC values were about 20- to 25-fold higher than in humans. Rabbits treated subcutaneously at dose of 0.8 mg/kg/day achieved an AUC of 100 ugh/L, which is about 3-fold higher than that resulting from the human dose. This dose did not result in any embryotoxicity or teratogenicity. There are no studies of tolterodine in pregnant women. Therefore, tolterodine tartrate should be used during pregnancy only if the potential benefit for the mother justifies the potential risk to the fetus.. Nursing Mothers. Tolterodine is excreted into the milk in mice. Offspring of female mice treated with tolterodine 20 mg/kg/day during the lactation period had slightly reduced body weight gain. The offspring regained the weight during the maturation phase. It is not known whether tolterodine is excreted in human milk; therefore, tolterodine tartrate should not be administered during nursing. decision should be made whether to discontinue nursing or to discontinue tolterodine tartrate in nursing mothers.. Pediatric Use. Efficacy in the pediatric population has not been demonstrated.Two pediatric phase randomized, placebo-controlled, double-blind, 12-week studies were conducted using tolterodine extended release capsules. total of 710 pediatric patients (486 on tolterodine extended-release capsules and 224 on placebo) aged 5-10 years with urinary frequency and urge urinary incontinence were studied. The percentage of patients with urinary tract infections was higher in patients treated with tolterodine extended-release capsules (6.6%) compared to patients who received placebo (4.5%). Aggressive, abnormal and hyperactive behavior and attention disorders occurred in 2.9% of children treated with tolterodine extended-release capsules compared to 0.9% of children treated with placebo.. Geriatric Use. Of the 1120 patients who were treated in the four Phase 3, 12-week clinical studies of tolterodine tartrate, 474 (42%) were 65 to 91 years of age. No overall differences in safety were observed between the older and younger patients (see CLINICAL PHARMACOLOGY, Pharmacokinetics in Special Populations).

PREGNANCY SECTION.

Pregnancy. Pregnancy Category C. At oral doses of 20 mg/kg/day (approximately 14 times the human exposure), no anomalies or malformations were observed in mice. When given at doses of 30 to 40 mg/kg/day, tolterodine has been shown to be embryolethal, reduce fetal weight, and increase the incidence of fetal abnormalities (cleft palate, digital abnormalities, intra-abdominal hemorrhage, and various skeletal abnormalities, primarily reduced ossification) in mice. At these doses, the AUC values were about 20- to 25-fold higher than in humans. Rabbits treated subcutaneously at dose of 0.8 mg/kg/day achieved an AUC of 100 ugh/L, which is about 3-fold higher than that resulting from the human dose. This dose did not result in any embryotoxicity or teratogenicity. There are no studies of tolterodine in pregnant women. Therefore, tolterodine tartrate should be used during pregnancy only if the potential benefit for the mother justifies the potential risk to the fetus.

SPL UNCLASSIFIED SECTION.

Tolterodine tartrate tablet, film coated Marlex Pharmaeuticals, Inc. ----------.