rates. sixty-six percent of patients receiving tolterodine tartrate 2 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 2 mg bid in the phase 3 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 4 weeks of treatment. seven percent of patients treated with tolterodine tartrate 2 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 2 mg bid reported a 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 2 mg bid. table 5 lists the adverse events reported in 1% or more of the patients treated with tolterodine tartrate 2 mg bid in the 12-week studies. the adverse events are reported regardless of causality. table 5. incidence in nearest integer. (%) of adverse events exceeding placebo rate and reported in >1% of patients treated with tolterodine tartrate tablets (2 mg bid) in 12-week, phase 3 clinical studies body system adverse event % tolterodine tartrate n = 986 % placebo n = 683 autonomic nervous accommodation abnormal dry mouth 2 35 1 10 general chest pain fatigue headache influenza-like symptoms 2 4 7 3 1 3 5 2 central/peripheral nervous vertigo/dizziness 5 3 gastrointestinal abdominal pain constipation diarrhea dyspepsia 5 7 4 4 3 4 3 1 urinary dysuria 2 1 skin/appendages dry skin 1 0 musculoskeletal arthralgia 2 1 vision xerophthalmia 3 2 psychiatric somnolence 3 2 metabolic/nutritional weight gain 1 0 resistance mechanism infection 1 0 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.

of tolterodine at 1 and 5 hours were an increase in residual urine, reflecting an incomplete emptying of the bladder, and a decrease in detrusor pressure. these findings are consistent with an antimuscarinic action on the lower urinary tract. pharmacokinetics absorption: in a study with 14 c-tolterodine solution in healthy volunteers who received a 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 1 to 2 hours after dose administration. c max and area under the concentration-time curve (auc) determined after dosage of tolterodine immediate release are dose-proportional over the range of 1 to 4 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 a safety concern and adjustment of dose is not needed. distribution: tolterodine is highly bound to plasma proteins, primarily α 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 a 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 a 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 : a 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 a 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 a 5 mg oral dose of 14 c-tolterodine solution to healthy volunteers, 77% of radioactivity was recovered in urine and 17% was recovered in feces in 7 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. a 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 4 mg administered twice daily to 16 healthy male volunteers (8 em, 8 pm). table 1. summary of mean (±sd) pharmacokinetic parameters of tolterodine and its active metabolite (5-hydroxymethyl metabolite) in healthy volunteers * parameter was dose-normalized from 4 mg to 2 mg. † = not applicable cmax = maximum plasma concentration; t m a x = time of occurrence of c m a x ; c a v g = average plasma concentration; t 1 / 2 = terminal elimination half-life; cl/f = apparent oral clearance. em = extensive metabolizers; pm = poor metabolizers tolterodine 5 - hydroxymethyl metabolite phenotype t m a x c m a x * c a v g * t 1 / 2 cl / f t m a x c m a x * c a v g * t 1 / 2 ( cyp2d6 ) ( h ) ( μg / l ) ( μg / l ) ( h ) ( l / h ) ( h ) ( μg / l ) ( μg / l ) ( h ) single-dose em 1.6±1.5 1.6±1.2 0.50±0.35 2.0±0.7 534±697 1.8±1.4 1.8±0.7 0.62±0.26 3.1± 0.7 pm 1.4±0.5 10±4.9 8.3±4.3 6.5±1.6 17±7.3 † † † † multiple-dose em 1.2±0.5 2.6±2.8 0.58±0.54 2.2±0.4 415±377 1.2±0.5 2.4±1.3 0.92±0.46 2.9± 0.4 pm 1.9±1.0 19±7.5 12±5.1 9.6±1.5 11±4.2 † † † † pharmacokinetics in special populations age : in phase 1, multiple-dose studies in which tolterodine immediate release 4 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 1 study, elderly volunteers (aged 71 through 81 years) were given tolterodine immediate release 2 or 4 mg (1 or 2 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 c max of tolterodine (1.6 μg/l in males versus 2.2 μg/l in females) and the active 5-hydroxymethyl metabolite (2.2 μg/l in males versus 2.5 μg/l in females) are similar in males and females who were administered tolterodine immediate release 2 mg. mean auc values of tolterodine (6.7 μg·h/l in males versus 7.8 μg·h/l in females) and the 5-hydroxymethyl metabolite (10 μg·h/l in males versus 11 μg·h/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 a 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 tartrate tablets 1 mg twice daily (see precautions, general and dosage and administration ). hepatic insufficiency: liver impairment can significantly alter the disposition of tolterodine immediate release. in a 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, 2 to 4 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 tartrate tablets 1 mg twice daily (see precautions, general and dosage and administration ). drug-drug interactions fluoxetine : fluoxetine is a selective serotonin reuptake inhibitor and a potent inhibitor of cyp2d6 activity. in a 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 a 4.8-fold increase in tolterodine auc. there was a 52% decrease in c max and a 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 tartrate 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 a competitive inhibitor of cyp2d6 at high concentrations (ki 1.05 μm), 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 8 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 c max and auc of tolterodine increased by 2 and 2.5 fold, respectively. based on these findings, other potent cyp3a inhibitors such as other azole antifungals (e.g., itraconazole, miconazole) or macrolide antibiotics (e.g., 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 4 mg (2 mg bid) for 7 days and a single dose of warfarin 25 mg on day 4 had no effect on prothrombin time, factor vii suppression, or on the pharmacokinetics of warfarin. oral contraceptives: tolterodine immediate release 4 mg (2 mg bid) had no effect on the pharmacokinetics of an oral contraceptive (ethinyl estradiol 30 μg/levonorgestrel 150 μg) as evidenced by the monitoring of ethinyl estradiol and levonorgestrel over a 2 month cycle in healthy female volunteers. diuretics: coadministration of tolterodine immediate release up to 8 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 2 mg bid and 4 mg bid of tolterodine immediate release (ir) on the qt interval was evaluated in a 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 2 mg bid, tolterodine 4 mg bid, and placebo. the 4 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 2 mg bid with potent cyp3a4 inhibitors in patients who are cyp2d6 poor metabolizers (see precautions, drug interactions ). qt interval was measured over a 12-hour period following dosing, including the time of peak plasma concentration (t max ) of tolterodine and at steady state (day 4 of dosing). table 2 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 fridericia's (qtcf) and a 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 a 4 mg/day dose of tolterodine in this study was 2.0 beats/minute and 6.3 beats/minute with 8 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 4 of dosing) at t max (relative to placebo) 1 at t max of 1 hr; 95% confidence interval 2 at t max of 2 hr; 90% confidence interval 3 the effect on qt interval with 4 days of moxifloxacin dosing in this qt trial may be greater than typically observed in qt trials of other drugs. drug/dose (manual) n qtcf (msec) (manual) qtcf (msec) (machine) qtcp (msec) (manual) qtcp (msec) (machine) tolterodine 2 mg bid 1 48 5.01 (0.28, 9.74) 1.16 (-2.99, 5.30) 4.45 (-0.37, 9.26) 2.00 (-1.81, 5.81) tolterodine 4 mg bid 1 48 11.84 (7.11, 16.58) 5.63 (1.48, 9.77) 10.31 (5.49, 15.12) 8.34 (4.53, 12.15) moxifloxacin 400 mg qd 2 45 19.26 3 (15.49, 23.03) 8.90 (4.77, 13.03) 19.10 3 (15.32, 22.89) 9.29 (5.34, 13.24) 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 8 mg/day (two times the therapeutic dose) compared to 4 mg/day. the effect of tolterodine 8 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. tolterodine's effect on qt interval was found to correlate with plasma concentration of tolterodine. there appeared to be a 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 tartrate extended-release capsules (see precautions, patients with congenital or acquired qt prolongation ).

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 a 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 a 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 : a 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 a 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 a 5 mg oral dose of 14 c-tolterodine solution to healthy volunteers, 77% of radioactivity was recovered in urine and 17% was recovered in feces in 7 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. a 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 4 mg administered twice daily to 16 healthy male volunteers (8 em, 8 pm). table 1. summary of mean (±sd) pharmacokinetic parameters of tolterodine and its active metabolite (5-hydroxymethyl metabolite) in healthy volunteers * parameter was dose-normalized from 4 mg to 2 mg. † = not applicable cmax = maximum plasma concentration; t m a x = time of occurrence of c m a x ; c a v g = average plasma concentration; t 1 / 2 = terminal elimination half-life; cl/f = apparent oral clearance. em = extensive metabolizers; pm = poor metabolizers tolterodine 5 - hydroxymethyl metabolite phenotype t m a x c m a x * c a v g * t 1 / 2 cl / f t m a x c m a x * c a v g * t 1 / 2 ( cyp2d6 ) ( h ) ( μg / l ) ( μg / l ) ( h ) ( l / h ) ( h ) ( μg / l ) ( μg / l ) ( h ) single-dose em 1.6±1.5 1.6±1.2 0.50±0.35 2.0±0.7 534±697 1.8±1.4 1.8±0.7 0.62±0.26 3.1± 0.7 pm 1.4±0.5 10±4.9 8.3±4.3 6.5±1.6 17±7.3 † † † † multiple-dose em 1.2±0.5 2.6±2.8 0.58±0.54 2.2±0.4 415±377 1.2±0.5 2.4±1.3 0.92±0.46 2.9± 0.4 pm 1.9±1.0 19±7.5 12±5.1 9.6±1.5 11±4.2 † † † †

(see table 4) were identical to the above endpoints with the exception that the number of incontinence episodes was per 24 hours (averaged over 7 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 007 sd = standard deviation. *the difference between tolterodine tartrate and placebo was statistically significant. tolterodine tartrate ( sd ) n = 514 placebo ( sd ) n = 508 difference ( 95 % ci ) number of incontinence episodes per week mean baseline 23.2 23.3 mean change from baseline -10.6 (17) -6.9 (15) -3.7 (-5.7, -1.6) number of micturitions per 24 hours mean baseline 11.1 11.3 mean change from baseline -1.7 (3.3) -1.2 (2.9) -0.5* (-0.9, -0.1) volume voided per micturition (ml) mean baseline 137 136 mean change from baseline 29 (47) 14(41) 15*(9, 21) 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, 010 sd = standard deviation. *the difference between tolterodine tartrate and placebo was statistically significant. study tolterodine tartrate ( sd ) placebo ( sd ) difference ( 95 % ci ) number of incontinence episodes per 24 hours 008 number of patients 93 40 mean baseline 2.9 3.3 mean change from baseline -1.3 (3.2) -0.9 (1.5) 0.5 (-1.3,0.3) 009 number of patients 116 55 mean baseline 3.6 3.5 mean change from baseline -1.7 (2.5) -1.3 (2.5) -0.4 (-1.0, 0.2) 010 number of patients 90 50 mean baseline 3.7 3.5 mean change from baseline -1.6 (2.4) -1.1 (2.1) -0.5 (-1.1,0.1) number of micturitions per 24 hours 008 number of patients 118 56 mean baseline 11.5 11.7 mean change from baseline -2.7 (3.8) -1.6 (3.6) -1.2* (-2.0,-0.4) 009 number of patients 128 64 mean baseline 11.2 11.3 mean change from baseline -2.3 (2.1) -1.4 (2.8) -0.9* (-1.5,-0.3) 010 number of patients 108 56 mean baseline 11.6 11.6 mean change from baseline -1.7 (2.3) -1.4 (2.8) -0.38 (-1.1,0.3) volume voided per micturition ( ml ) 008 number of patients 118 56 mean baseline 166 157 mean change from baseline 38 (54) 6 (42) 32* (18,46) 009 number of patients 129 64 mean baseline 155 158 mean change from baseline 36 (50) 10 (47) 26* (14,38) 010 number of patients 108 56 mean baseline 155 160 mean change from baseline 31 (45) 13 (52) 18* (4,32)