Ultibro Breezhaler Mechanism of Action

Pharmacotherapeutic group: adrenergics in combination with anticholinergics. ATC code: R03AL04.
Pharmacology: Pharmacodynamics: Mechanism of action: Ultibro Breezhaler: When indacaterol and glycopyrronium are administered together in Ultibro Breezhaler, they are expected to provide additive efficacy due to their different mode of action targeting different receptors and pathways to achieve smooth muscle relaxation. Due to the differential density of beta₂-adrenoceptors and M3-receptors in central versus smaller airways, beta₂-agonists should be more effective in relaxing small airways whilst an anti-cholinergic compound may be more effective in large airways. Thus for optimal bronchodilation in all regions of the human lung, a combination of a beta₂-adrenergic agonist and a muscarinic antagonist may be beneficial.
Indacaterol: Indacaterol is an 'ultra' long-acting beta₂-adrenergic agonist for once-daily administration. The pharmacological effects of beta₂-adrenoceptor agonists, including indacaterol, are at least in part attributable to stimulation of intracellular adenyl cyclase, the enzyme that catalyzes the conversion of adenosine triphosphate (ATP) to cyclic-3', 5'-adenosine monophosphate (cyclic monophosphate). Increased cyclic AMP levels cause relaxation of bronchial smooth muscle. In vitro studies have shown that indacaterol has more than 24-fold greater agonist activity at beta₂-receptors compared to beta₁-receptors and 20-fold greater agonist activity compared to beta₃-receptors. This selectivity profile is similar to formoterol.
When inhaled, indacaterol acts locally in the lung as a bronchodilator. Indacaterol is a nearly full agonist at the human beta₂-adrenergic receptor with nanomolar potency. In isolated human bronchus, indacaterol has a rapid onset of action and a long duration of action.
Although beta₂-adrenergic receptors are the predominant adrenergic receptors in bronchial smooth muscle and beta₁-adrenergic receptors are the predominant receptors in the human heart, there are also beta₂-adrenergic receptors in the human heart comprising 10% to 50% of the total adrenergic receptors. The precise function of beta₂-adrenergic receptors in the heart is not known, but their presence raises the possibility that even highly selective beta₂-adrenergic agonists may have cardiac effects.
Glycopyrronium: Glycopyrronium is an inhaled long-acting muscarinic receptor antagonist (anti-cholinergic) for once-daily maintenance bronchodilator treatment of COPD. Parasympathetic nerves are the major bronchoconstrictive neural pathway in airways, and cholinergic tone is the key reversible component of airflow obstruction in COPD. Glycopyrronium works by blocking the bronchoconstrictor action of acetylcholine on airway smooth muscle cells, thereby dilating the airways.
Of the five known muscarinic receptor subtypes (M1-5), only subtypes M1-3 have a defined physiological function in the human lung. Glycopyrronium bromide is a high affinity muscarinic receptor antagonist of these three receptor subtypes. It demonstrated 4- to 5-fold selectivity for the human M3 and M1 receptors over the human M2 receptor in competition binding studies. It has a rapid onset of action as evidenced by observed receptor association/dissociation kinetic parameters and the onset of action after inhalation in clinical studies.
The long duration of action can be partly attributed to sustained drug concentrations in the lungs as reflected by the prolonged terminal elimination half-life of glycopyrronium after inhalation via the glycopyrronium inhaler in contrast to the half-life after i.v. administration (see Pharmacokinetics as follows). Lung pharmacokinetic data in rats following inhalation of glycopyrronium bromide provides further evidence for this.
Pharmacodynamic effects: Primary Pharmacodynamic Effects: The combination of indacaterol and glycopyrronium in Ultibro Breezhaler showed a rapid onset of action within 5 minutes after dosing (see Table 3 under Clinical Trials as follows). The effect remains constant over the whole 24 h dosing interval (see Figures 1 and 2 under Clinical Trials as follows).
The mean bronchodilator effect derived from serial FEV₁ measurements over 24 h was 0.32 L after 26 weeks of treatment when compared to placebo. The effect was significantly greater for Ultibro Breezhaler, when compared to indacaterol, glycopyrronium or tiotropium alone (difference 0.11 L, for each comparison), (serial spirometry subset).
There was no evidence for tachyphylaxis to the effect of Ultibro Breezhaler over time when compared to placebo or its monotherapy components.
Primary Pharmacodynamic Effects: The systemic side effects of inhaled beta₂-adrenergic agonists and inhaled muscarinic receptor antagonists are the result of activation of systemic beta₂-adrenergic receptors and blockade of muscarinic receptors after systemic absorption of the drugs. The side effect profile of Ultibro Breezhaler was explored in healthy subjects) and in COPD patients.
Effects on heart rate: Heart rate effects in healthy volunteers were investigated after a single dose of ULTIBRO BREEZHALER 440/200 microgram administered in four dose steps separated by one hour and compared to the effects of placebo, 600 microgram indacaterol, 200 microgram glycopyrronium and 200 microgram salmeterol.
The largest time matched heart rate increase for Ultibro Breezhaler compared to placebo was +5.69 bpm, the largest decrease was -2.51 bpm. Overall the effect on heart rate over time did not show a consistent PD-effect of Ultibro Breezhaler.
There were no significant effects when Ultibro Breezhaler was compared with indacaterol and glycopyrronium alone. Heart rate in COPD patients at supratherapeutic dose levels was investigated in Ultibro Breezhaler up to doses of 150/100, 300/100 and 600/100 microgram. There were no relevant effects of Ultibro Breezhaler on mean heart rate over 24 h and heart rate assessed after 30 min, 4 h and 24 h.
QT-interval: A thorough QT (TQT)-study in healthy volunteers with doses of inhaled indacaterol up to 600 micrograms did not demonstrate a clinically relevant effect on the QT-interval. Also for glycopyrronium, no QT-prolongation has been observed in a TQT study after an inhaled dose of 400 microgram.
The effects of Ultibro Breezhaler on QTc-interval were investigated in healthy volunteers after inhalation of ULTIBRO BREEZHALER 440/200 microgram in four dose steps separated by one hour. The largest time matched difference versus placebo was 4.62 ms (90% CI 0.40, 8.85 ms), the largest time matched decrease was -2.71 ms (90% CI -6.97, 1.54 ms), indicating that Ultibro Breezhaler had no relevant impact on the QT-interval as was expected by the properties of its components.
In COPD patients, doses up to 600/100 microgram of ULTIBRO BREEZHALER also had no apparent influence on the QTc-interval in repeated ECG assessments executed between 15 min and 24 h after dosing. A slightly higher proportion of patients had QTc-prolongations above 450 ms at the ULTIBRO BREEZHALER 600/100 microgram group. The number of notable QTcF changes versus baseline (>30 ms) was similar across all active treatment groups (ULTIBRO BREEZHALER 600/100 microgram, 300/100 microgram, 150/100 microgram and indacaterol 300 microgram), but was lower with placebo.
Serum potassium and blood glucose: In healthy volunteers, after administration of ULTIBRO BREEZHALER 440/200 microgram, the effect on serum potassium was very small (maximal difference -0.14 mmol/L when compared to placebo). The maximal effect on blood glucose was 0.67 mmol/L. When ULTIBRO BREEZHALER 440/200 microgram was compared with 200 microgram salmeterol, the effect on serum potassium (maximum difference 0.21 mmol/L) and blood glucose was smaller (maximum difference 0.21 and 1.19 mmol/L, respectively).
Clinical trials: The Ultibro Breezhaler Phase III clinical development program [IGNITE] included six studies (Table 1) in which over 8,000 patients were enrolled: one 26-week placebo- and active-controlled (indacaterol 150 microgram once daily, glycopyrronium 50 microgram once daily, open-label tiotropium 18 microgram once daily) study [SHINE]; one 26-week active-controlled (fluticasone/salmeterol 500/50 microgram twice daily) study [ILLUMINATE]; a 64-week active controlled (glycopyrronium 50 microgram once daily, open-label tiotropium 18 microgram once daily) study [SPARK]; a 52-week placebo-controlled study [ENLIGHTEN]; a 3-week placebo- and active-controlled (tiotropium once daily) exercise tolerance study [BRIGHT]; and a 52-week active-controlled (fluticasone/salmeterol 500/50 microgram twice daily) study [FLAME].
These studies enrolled patients with a clinical diagnosis of moderate to very severe COPD, who were 40 years old or older, and had a smoking history of at least 10 pack years. Of these 5 studies, the [SHINE] and [ENLIGHTEN] studies had a post-bronchodilator FEV₁ <80% and ≥30% of the predicted normal value and a post-bronchodilator FEV1/FVC ratio of less than 70%. The 26-week active-controlled study, [ILLUMINATE], enrolled patients with a post-bronchodilator FEV₁ of <80% and ≥40% of the predicted normal value. In comparison, the 64-week [SPARK] study enrolled patients with severe to very severe COPD, with a history of ≥1 moderate or severe COPD exacerbation in the previous year, and a post-bronchodilator FEV₁ <50% of the predicted normal value. Patients with significant concomitant illnesses including Type 1 or uncontrolled Type 2 diabetes, significantly abnormal ECG (including QTc prolongation), narrow angle glaucoma, urinary retention, severe renal failure, patients requiring long-term oxygen therapy, patients with recent acute COPD exacerbations or URTI, patients with other significant pulmonary disease including asthma, patients with atopy or intermittent allergic rhinitis were excluded from the COPD trials. Patients with unstable ischemic heart disease, left ventricular failure (NYHA Class III & IV), history of myocardial infarction, arrhythmia (excluding chronic stable atrial fibrillation) were also excluded. The 52-week active-controlled study, [FLAME], enrolled moderate (33.4%), severe (58.1%) and very severe (7.6%) COPD patients with a history of ≥1 moderate or severe COPD exacerbation (19% had a history of ≥2 exacerbations) in the previous year, and a post-bronchodilator FEV₁ of ≥25 and <60% of the predicted normal value. At screening, over half of the patients (56.3%) were using ICS and over two-thirds of the patients (67.1%) were treated with a LABA, whereas 60.6% were treated by a LAMA and 46.5% were treated by ICS/LABA. (See Table 1.)

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Effects on lung function: Ultibro Breezhaler administered at 110/50 microgram once daily showed clinically meaningful improvements in lung function (as measured by the forced expiratory volume in one second, FEV₁), in a number of clinical studies. In Phase III studies, bronchodilator effects were seen within 5 minutes after the first dose and were maintained over the 24-hour dosing interval from the first dose. Within the 26-week [SHINE] and 52-week [ENLIGHTEN] studies, there was no attenuation of the bronchodilator effect over time.
Trough FEV₁: In the [SHINE] study, Ultibro Breezhaler increased post-dose trough FEV₁ by 200 mL compared to placebo at the 26-week primary endpoint (p<0.001) and showed significant increases compared to each monotherapy component treatment arm (indacaterol and glycopyrronium) as well as the tiotropium treatment arm (see Table 2).

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The mean pre-dose FEV₁ (average of the values taken at -45 and -15 min prior to the morning dose of study drug) was clinically meaningful and statistically significant in favor of Ultibro Breezhaler at Week 26 compared to fluticasone/salmeterol (100 mL, p<0.001) [ILLUMINATE], at Week 52 compared to placebo (189 mL, p<0.001) [ENLIGHTEN] and at all visits up to Week 64 compared to glycopyrronium (70-80 mL, p-value <0.001) and tiotropium (60-80 mL, p-value <0.001) [SPARK]. In the [FLAME] study, the mean pre-dose FEV₁ was a secondary efficacy endpoint which showed clinically meaningful and statistically significant result in favor of Ultibro Breezhaler at all visits up to Week 52 compared to fluticasone/salmeterol (62-86 ml, p<0.001).
Peak FEV₁: Ultibro Breezhaler produced statistically significant improvement in peak FEV₁ compared to placebo in the first 4 hours post-dose on Day 1 (210 mL, p<0.001), at Week 26 (330 mL, p<0.001), and compared to indacaterol (120 mL), glycopyrronium (130 mL), tiotropium (130 mL) at Week 26 (p<0.001 for all comparisons) [SHINE], and compared to fluticasone/salmeterol on Day 1 (70 mL, p<0.001) and Week 26 (150 mL, p<0.001) [ILLUMINATE].
FEV₁ AUC: Ultibro Breezhaler increased post-dose FEV₁ AUC_0-12 (primary endpoint) by 140 mL at 26 weeks (p<0.001) in the active-controlled [ILLUMINATE] study compared to fluticasone/salmeterol.
Onset of action: In the [SHINE and ILLUMINATE] studies, Ultibro Breezhaler demonstrated a statistically significant rapid onset of bronchodilator effect on Day 1 and at Week 26. (See Table 3.)

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Serial spirometry subset: In the 26-week, placebo-controlled [SHINE] study, 12-hour serial spirometry was performed on Day 1 (Figure 1) and 24-hour serial spirometry at Week 26 (Figure 2) in a subset of 294 patients. Serial FEV₁ values over 12 hours at Day 1 and trough FEV₁ values at Day 2 are shown in Figure 1, and at Week 26 in Figure 2. Improvement of lung function was maintained for 24 hours after the first dose and consistently maintained over the 26-week treatment period with no evidence of tolerance. (See Figures 1 and 2.)

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In the [SHINE] serial spirometry subset, ULTIBRO BREEZHALER demonstrated a statistically significant improvement in FEV₁ compared to placebo (400 mL, p<0.001) and tiotropium (160 mL, p<0.001) at 2 hours post-dose at Week 26.
Ultibro Breezhaler also had clinically meaningful and statistically significant improvements in FEV₁ compared to fluticasone/salmeterol across all time points from 5 minutes post-dose up to 12 hours post-dose at both Week 12 (p<0.001) and Week 26 (p<0.001) [ILLUMINATE] (see Figure 3).

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In the [ILLUMINATE] study, Ultibro Breezhaler demonstrated significant overall improvements in lung function compared with fluticasone/salmeterol, across all key subgroups, including age, gender, smoking history, disease severity, and reversibility.
Symptomatic benefit: Breathlessness: Ultibro Breezhaler significantly reduced breathlessness as evaluated by the Transitional Dyspnoea Index (TDI). Ultibro Breezhaler demonstrated a clinically meaningful and statistically significant improvement in the TDI focal score at Week 26 as compared to placebo (1.09, p<0.001), tiotropium (0.51, p=0.007) [SHINE], and fluticasone/salmeterol (0.76, p=0.003) [ILLUMINATE].
A significantly higher percentage of patients receiving Ultibro Breezhaler responded with a 1 point or greater improvement in the TDI focal score at Week 26 compared to placebo (68.1% and 57.5% respectively, p=0.004). A higher proportion of patients demonstrated clinically meaningful response at Week 26 on Ultibro Breezhaler as compared to tiotropium (68.1% ULTIBRO BREEZHALER vs. 59.2% tiotropium, p=0.016) [SHINE] and fluticasone/salmeterol (65.1% Ultibro Breezhaler vs. 55.5% fluticasone/salmeterol, p=0.088) [ILLUMINATE].
Health related quality of life: Ultibro Breezhaler once daily has also shown a statistically significant effect on health related quality of life measured using the St. George's Respiratory Questionnaire (SGRQ) at 26 weeks as indicated by a reduction in SGRQ total score compared to placebo (-3.01, p=0.002) and tiotropium (-2.13, p=0.009) [SHINE] and at 64 weeks compared to tiotropium (-2.69, p<0.001) [SPARK], and at 52 weeks compared to fluticasone/salmeterol (-1.3, p=0.003) [FLAME]. In addition, improvements of the domains of the SGRQ score "symptoms", "activity" and "impact of daily life" were all statistically significant versus tiotropium at Week 64 ("symptoms": -3.06, p=0.003, "activity": -3.14, p<0.001, "impact of daily life": -2.24, p=0.008) [SPARK].
A higher percentage of patients receiving Ultibro Breezhaler responded with a clinically meaningful improvement in SGRQ score (defined as a decrease of at least 4 units from baseline) at Week 26 compared to placebo (63.7% and 56.6% respectively, p=0.088) and tiotropium (63.7% Ultibro Breezhaler vs. 56.4% tiotropium, p=0.047) [SHINE] , and at Week 64 compared to glycopyrronium and tiotropium (57.3% Ultibro Breezhaler vs. 51.8% glycopyrronium, p=0.055; vs. 50.8% tiotropium, p=0.051, respectively) [SPARK], and at Week 52 compared to fluticasone/salmeterol (49.2% Ultibro Breezhaler vs. 43.7% fluticasone/salmeterol, OR: 1.30, p<0.001) [FLAME].
Daily activities: Ultibro Breezhaler demonstrated a statistically superior improvement versus tiotropium in the percentage of 'days able to perform usual daily activities' over 26 weeks (8.45%, p<0.001) [SHINE] and showed numerical improvement over glycopyrronium (1.87; p=0.195) and statistical improvement over tiotropium (4.95; p=0.001) [SPARK].
COPD exacerbations: In the 64-week [SPARK] study comparing Ultibro Breezhaler 110/50 (n=729), glycopyrronium (n=739) and tiotropium (n=737), Ultibro Breezhaler 110/50 reduced the annualised rate of moderate or severe COPD exacerbations by 12% (95%CI -23%, -1%) compared to glycopyrronium and by 10% (95%CI -21%, 102%) compared to tiotropium. The number of moderate or severe COPD exacerbations/patient-years was 0.94 for Ultibro Breezhaler 110/50, 1.07 for glycopyrronium and 1.06 for tiotropium. The number of all COPD exacerbations/patient-years was 3.34 for Ultibro Breezhaler 110/50, 3.92 for glycopyrronium and 3.89 for tiotropium.
In a 52-week active-controlled [FLAME] study, Ultibro Breezhaler once daily (n=1,675) met the primary study objective of non-inferiority in rate of all COPD exacerbations (mild, moderate, or severe) compared to fluticasone/salmeterol (n=1,679). The number of all COPD exacerbations per patient-years was 3.59 for Ultibro Breezhaler and 4.03 for fluticasone/salmeterol. Ultibro Breezhaler further showed superiority in reducing the annualised rate of all exacerbations by 11% (95% CI: 4-17%) versus fluticasone/salmeterol (p=0.003) and prolonged time-to-first exacerbation with a 16% reduction in risk of an exacerbation (95% CI: 9-22%); median time: 71 days for Ultibro Breezhaler vs. 51 days for fluticasone/salmeterol, p<0.001).
Ultibro Breezhaler reduced the annualised rate of moderate or severe exacerbations by 17% (95% CI: 9-25%) versus fluticasone/salmeterol (p<0.001). The number of moderate or severe COPD exacerbations per patient-years was 0.98 for Ultibro Breezhaler and 1.19 for fluticasone/salmeterol. Ultibro Breezhaler prolonged time-to-first moderate or severe exacerbation with a 22% reduction in risk of an exacerbation (95% CI: 14-30%; 25th percentile: 127 days for Ultibro Breezhaler vs. 87 days for fluticasone/salmeterol, p<0.001). Less than 50% of patients in the Ultibro Breezhaler group had an exacerbation, therefore the time to the first moderate or severe exacerbation in the first quartile of patients was calculated instead.
Ultibro Breezhaler numerically reduced the annualised rate of severe exacerbations by 13% versus fluticasone/salmeterol (95% CI: -9 to 31%, p=0.231). The number of severe COPD exacerbations per patient-years was 0.15 for Ultibro Breezhaler and 0.17 for fluticasone/salmeterol. Ultibro Breezhaler prolonged time-to-first severe exacerbation with a 19% reduction in risk of an exacerbation (95% CI: 0-34%, p=0.046).
The incidence of pneumonia (as confirmed by radiographic imaging i.e. chest x-ray or CT scan) was 3.2% in the Ultibro Breezhaler arm compared to 4.8% in the fluticasone/salmeterol arm (p=0.017). Time to first pneumonia was prolonged with Ultibro Breezhaler compared to fluticasone/salmeterol (p=0.013).
Use of rescue medication: Over 26 weeks, Ultibro Breezhaler once daily significantly reduced the use of rescue medication (salbutamol) by 0.96 puffs per day (p<0.001) compared to placebo and 0.54 puffs/day (p<0.001) compared to tiotropium in the [SHINE] study, as well as 0.39 puffs per day (p=0.019) compared to fluticasone/salmeterol in the [ILLUMINATE] study.
Over 64 weeks, Ultibro Breezhaler reduced the use of rescue medication (salbutamol) by 0.76 puffs per day (p<0.001) compared to tiotropium in the [SPARK] study.
Over 52 weeks, Ultibro Breezhaler reduced the use of rescue medication by 1.01 puffs per day from baseline and fluticasone/salmeterol had a reduction of 0.76 puffs per day from baseline in the [FLAME] study. The difference of 0.25 puffs per day was statistically significant (p<0.001).
Exercise tolerance: In a 3-week study [BRIGHT] where exercise tolerance was tested via cycle ergometry at submaximal (75%) workload (submaximal exercise tolerance test), Ultibro Breezhaler, dosed in the morning, reduced dynamic hyperinflation and improved the length of time exercise could be maintained from the first dose onwards. On the first day of treatment, inspiratory capacity under exercise was significant improved (250 mL, p<0.001) compared to placebo. After three weeks of treatment, the improvement in inspiratory capacity with Ultibro Breezhaler was greater (320 mL, p<0.001) and exercise endurance time increased (59.5 seconds, p=0.006) compared to placebo. Similar findings were seen with tiotropium.
Whole-Body Plethysmography measurements of Residual volume (RV) and Functional Residual Capacity (FRC) give insights on airway closure and reflects the presence of gas trapping, considered a hallmark of COPD. On the first day of treatment, 60 min post-dose, Ultibro Breezhaler reduced RV by 380 mL (p<0.001) compared to placebo and FRC by 350 mL p<0.001) compared to placebo. On day 21, 60 min post-dose, further reductions were seen with RV by 520 mL (p<0.001) and FRC by 520 mL (p<0.001).
Pharmacokinetics: Absorption: Indacaterol/glycopyrronium: Following inhalation of Ultibro Breezhaler, the median time to reach peak plasma concentrations of indacaterol and glycopyrronium was approximately 15 minutes and 5 minutes, respectively.
Based on the in vitro performance data, the dose of indacaterol delivered to the lung is expected to be similar for Ultibro Breezhaler microgram and indacaterol 150 microgram monotherapy product. The steady-state exposure to indacaterol after Ultibro Breezhaler microgram inhalation was either similar or slightly lower than systemic exposure after indacaterol 150 microgram monotherapy product inhalation.
Absolute bioavailability of indacaterol after Ultibro Breezhaler microgram inhalation ranged from 47% to 66% whereas that of glycopyrronium was about 40%.
The steady-state exposure to glycopyrronium after Ultibro Breezhaler microgram inhalation was similar to systemic exposure after glycopyrronium 50 microgram monotherapy product inhalation.
Indacaterol: The median time to reach peak serum concentrations of indacaterol was approximately 15 min after single or repeated inhaled doses.
Indacaterol serum concentrations increased with repeated once-daily administration. Steady-state was achieved within 12 to 15 days. The mean accumulation ratio of indacaterol, i.e., AUC over the 24-h dosing interval on Day 14 or Day 15 compared to Day 1, was in the range of 2.9 to 3.8 for once-daily inhaled doses between 75 microgram and 600 microgram.
Glycopyrronium: Following oral inhalation using the glycopyrronium inhaler, glycopyrronium was rapidly absorbed and reached peak plasma levels at 5 minutes post dose.
About 90% of systemic exposure following inhalation is due to lung absorption and 10% is due to gastrointestinal absorption. The absolute bioavailability of orally administered glycopyrronium was estimated to be about 5%.
Following repeated once-daily inhalation in patients with COPD, PK steady-state of glycopyrronium was reached within one week of treatment. The steady-state mean peak and trough plasma concentrations of glycopyrronium for a 50 microgram once-daily dosing regimen were 166 pg/mL and 8 pg/mL, respectively. With once-daily doses of 100 and 200 microgram, steady-state exposure to glycopyrronium (AUC over the dosing interval) was about 1.4- to 1.7-fold higher than after the first dose. Urinary excretion data at steady-state compared to the first dose suggest that systemic accumulation is independent of dose in the dose range of 25 to 200 microgram.
Distribution: Indacaterol: After intravenous infusion the volume of distribution (V_z) of indacaterol was 2,361 to 2,557 L indicating an extensive distribution. The in vitro human serum and plasma protein binding was 94.1 to 95.3% and 95.1 to 96.2%, respectively.
Glycopyrronium: After i.v. dosing, the steady-state volume of distribution (Vss) of glycopyrronium was 83 L and the volume of distribution in the terminal phase (Vz) was 376 L. The apparent volume of distribution in the terminal phase following inhalation (Vz/F) was 7310 L, which reflects the much slower elimination after inhalation. The in vitro human plasma protein binding of glycopyrronium was 38% to 41% at concentrations of 1 to 10 ng/mL. These concentrations were at least 6-fold higher than the steady state mean peaks levels achieved in plasma for a 50 micrograms once-daily dosing regimen.
Metabolism: Indacaterol: After oral administration of radiolabelled indacaterol in a human ADME (absorption, distribution, metabolism, excretion) study, unchanged indacaterol was the main component in serum, accounting for about one third of total drug-related AUC over 24 h. A hydroxylated derivative was the most prominent metabolite in serum. Phenolic O-glucuronides of indacaterol and hydroxylated indacaterol were further prominent metabolites. A diastereomer of the hydroxylated derivative, a N-glucuronide of indacaterol, and C- and N-dealkylated products were further metabolites identified.
In vitro investigations indicated that UGT1A1 is the only UGT isoform that metabolised indacaterol to the phenolic O-glucuronide. The oxidative metabolites were found in incubations with recombinant CYP1A1, CYP2D6, and CYP3A4. CYP3A4 is concluded to be the predominant isoenzyme responsible for hydroxylation of indacaterol. In vitro investigations further indicated that indacaterol is a low affinity substrate for the efflux pump P-gp.
Glycopyrronium: In vitro metabolism studies showed consistent metabolic pathways for glycopyrronium bromide between animals and humans. No human specific metabolites were found. Hydroxylation resulting in a variety of mono- and bis-hydroxylated metabolites and direct hydrolysis resulting in the formation of a carboxylic acid derivative (M9) were seen.
In vitro investigations showed that multiple CYP isoenzymes contribute to the oxidative biotransformation of glycopyrronium. The hydrolysis to M9 is likely to be catalysed by members from the cholinesterase family.
After inhalation, systemic exposure to M9 was on average in the same order of magnitude as the exposure to the parent drug. Since in vitro studies did not show lung metabolism and M9 was of minor importance in the circulation (about 4% of parent drug C_max and AUC) after i.v. administration, it is assumed that M9 is formed from the swallowed dose fraction of orally inhaled glycopyrronium bromide by pre-systemic hydrolysis and/or via first pass metabolism. After inhalation as well as i.v. administration, only minimal amounts of M9 were found in the urine (i.e. ≤0.5% of dose). Glucuronide and/or sulfate conjugates of glycopyrronium were found in urine of humans after repeated inhalation, accounting for about 3% of the dose.
In vitro inhibition studies demonstrated that glycopyrronium bromide has no relevant capacity to inhibit CYP1A2, CYP2A6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1 or CYP3A4/5, the efflux transporters MDR1, MRP2 or MXR, and the uptake transporters OATP1B1, OATP1B3, OAT1, OAT3, OCT1 or OCT2. In vitro enzyme induction studies did not indicate a clinically relevant induction by glycopyrronium bromide for any of the cytochrome P450 isoenzymes tested as well as for UGT1A1 and the transporters MDR1 and MRP2.
Excretion: Indacaterol: In clinical studies which included urine collection, the amount of indacaterol excreted unchanged via urine was generally lower than 2% of the dose. Renal clearance of indacaterol was, on average, between 0.46 and 1.20 L/h. When compared with the serum clearance of indacaterol of 18.8 to 23.3 L/h, it is evident that renal clearance plays a minor role (about 2 to 6% of systemic clearance) in the elimination of systemically available indacaterol.
In a human ADME study where indacaterol was given orally, the fecal route of excretion was dominant over the urinary route. Indacaterol was excreted into human feces primarily as unchanged parent drug (54% of the dose) and, to a lesser extent, hydroxylated indacaterol metabolites (23% of the dose). Mass balance was complete with ≥90% of the dose recovered in the excreta.
Indacaterol serum concentrations declined in a multi-phasic manner with an average terminal half-life ranging from 45.5 to 126 hours. The effective half-life, calculated from the accumulation of indacaterol after repeated dosing ranged from 40 to 56 hours which is consistent with the observed time to steady state of approximately 12 to 15 days.
Glycopyrronium: After i.v. administration of [³H]-labelled glycopyrronium bromide to humans, the mean urinary excretion of radioactivity in 48 h amounted to 85% of the dose. A further 5% of the dose was found in the bile. Thus, mass balance was almost complete.
Renal elimination of parent drug accounts for about 60 to 70% of total clearance of systemically available glycopyrronium whereas non-renal clearance processes account for about 30 to 40%. Biliary clearance contributes to the non-renal clearance, but the majority of non-renal clearance is thought to be due to metabolism.
Following inhalation of single and repeated once-daily doses between 50 and 200 microgram glycopyrronium by healthy volunteers and patients with COPD mean renal clearance of glycopyrronium was in the range of 17.4 and 24.4 L/h. Active tubular secretion contributes to the renal elimination of glycopyrronium. Up to 20% of the dose was found in urine as parent drug.
Glycopyrronium plasma concentrations declined in a multi-phasic manner. The mean terminal elimination half-life was much longer after inhalation (33 to 57 hours) than after intravenous (6.2 hours) and oral (2.8 hours) administration. The elimination pattern suggests a sustained lung absorption and/or transfer of glycopyrronium into the systemic circulation at and beyond 24 h after inhalation.
Linearity/non-linearity: Indacaterol: Systemic exposure to indacaterol increased with increasing dose (150 microgram to 600 microgram) in a dose proportional manner. Systemic exposure results from a composite of pulmonary and intestinal absorption.
Glycopyrronium: In COPD patients' systemic exposure as well as total urinary excretion of glycopyrronium at pharmacokinetic steady state increased about dose-proportionally over the dose range of 50 microgram to 200 microgram.
Pharmacokinetics in special patient groups: Ultibro Breezhaler: A population PK analysis in COPD patients after inhalation of Ultibro Breezhaler indicated no significant effect of age, gender and (lean body) weight on the systemic exposure to indacaterol and glycopyrronium. Lean body weight (which is a function of weight and height) was identified as a covariate. A negative correlation between systemic exposure and lean body-weight (or body weight) was observed; however, no dose adjustment is recommended due to the magnitude of the change or the predictive precision of lean body weight.
Smoking status and baseline FEV₁ had no apparent effect on systemic exposure to indacaterol and glycopyrronium after inhalation of Ultibro Breezhaler.
Indacaterol: A population analysis of the effect of age, gender and weight on systemic exposure in COPD patients after inhalation indicated that indacaterol can be used at the recommended dose in all age and weight groups and regardless of gender.
The pharmacokinetics of indacaterol was investigated in two different UGT1A1 genotypes - the fully functional [(TA)₆, (TA)₆] genotype and the low activity [(TA)₇, (TA)₇] genotype (Gilbert's syndrome genotype). The study demonstrated that steady-state AUC and C_max of indacaterol were 1.2-fold higher in the [(TA)₇, (TA)₇] genotype, indicating that systemic exposure to indacaterol is only insignificantly affected by this UGT1A1 genotypic variation.
Glycopyrronium: A population PK analysis of data in COPD patients identified body weight and age as factors contributing to inter-patient variability in systemic exposure. Glycopyrronium 50 microgram once-daily can be used at the recommended dose in all age and body weight groups.
Gender, smoking status and baseline FEV₁ had no apparent effect on systemic exposure.
Hepatic impairment: Based on the clinical PK characteristics of its monotherapy components, Ultibro Breezhaler can be used at the recommended dose in patients with mild and moderate hepatic impairment. No data are available for subjects with severe hepatic impairment.
Patients with mild and moderate hepatic impairment showed no relevant changes in C_max or AUC of indacaterol, nor did protein binding differ between mild and moderate hepatic impaired subjects and their healthy controls. Studies in subjects with severe hepatic impairment were not performed.
Clinical studies in patients with hepatic impairment have not been conducted. Glycopyrronium is cleared predominantly from the systemic circulation by renal excretion (see Pharmacokinetics). Impairment of the hepatic metabolism of glycopyrronium is not thought to result in a clinically relevant increase of systemic exposure.
Renal impairment: Based on the clinical PK characteristics of its monotherapy components, Ultibro Breezhaler can be used at the recommended dose in patients with mild to moderate renal impairment. In patients with severe renal impairment or end-stage renal disease requiring dialysis Ultibro Breezhaler should be used only if the expected benefit outweighs the potential risk.
Indacaterol: Due to the very low contribution of the urinary pathway to total body elimination of indacaterol, a study in renally impaired subjects was not performed.
Glycopyrronium: Renal impairment has an impact on the systemic exposure to glycopyrronium. A moderate mean increase in total systemic exposure (AUC last) of up to 1.4-fold was seen in subjects with mild and moderate renal impairment and up to 2.2-fold in subjects with severe renal impairment and end stage renal disease. Using a population PK analysis, it was concluded that in COPD patients with mild and moderate renal impairment (estimated glomerular filtration rate eGFR ≥30 mL/min/1.73 m²) glycopyrronium can be used at the recommended dose.
Race/Ethnicity: Ultibro Breezhaler: When corrected by lean body weight, no statistically significant effect of ethnicity (Japanese versus non-Japanese) on exposure for both compounds was found.
Slightly higher total systemic exposures to indacaterol and glycopyrronium (on average 11% to 34% and 19% to 39%, respectively) were observed in Japanese compared to Caucasian healthy subjects after ULTIBRO BREEZHALER inhalation (at doses of 110/50 and 220/100 micrograms), which were not considered clinically relevant and did not raise any safety concerns.
Indacaterol: No difference between ethnic subgroups was identified. Limited treatment experience is available for the black population.
Glycopyrronium: There were no major differences in total systemic exposure (AUC) between Japanese and Caucasian subjects. Insufficient PK data is available for other ethnicities or races.
Toxicology: Preclinical Safety Data: Genotoxicity: Refer to Precautions.
Carcinogenicity: Refer to Precautions.