5.1 Deterioration of Disease and Acute Episodes

YUPELRI should not be initiated in patients during acutely deteriorating or potentially life-threatening episodes of COPD. YUPELRI has not been studied in subjects with acutely deteriorating COPD. The initiation of YUPELRI in this setting is not appropriate.

YUPELRI is intended as a once-daily maintenance treatment for COPD and should not be used for relief of acute symptoms, i.e. as rescue therapy for the treatment of acute episodes of bronchospasm, and extra doses should not be used for that purpose. Acute symptoms should be treated with an inhaled, short-acting beta2-agonist.

COPD may deteriorate acutely over a period of hours or chronically over several days or longer. If YUPELRI no longer controls symptoms of bronchoconstriction, the patient's inhaled, short-acting beta2-agonist becomes less effective, or the patient needs more inhalations of a short-acting beta2-agonist than usual, these may be markers of deterioration of disease. In this setting, a re-evaluation of the patient and the COPD treatment regimen should be undertaken at once. Increasing the daily dose of YUPELRI beyond the recommended dose is not appropriate in this situation.

5.2 Paradoxical Bronchospasm

As with other inhaled medicines, YUPELRI can produce paradoxical bronchospasm that may be life-threatening. If paradoxical bronchospasm occurs following dosing with YUPELRI, it should be treated immediately with an inhaled, short-acting bronchodilator; YUPELRI should be discontinued immediately and alternative therapy should be instituted.

5.3 Worsening of Narrow-Angle Glaucoma

YUPELRI should be used with caution in patients with narrow-angle glaucoma. Prescribers and patients should be alert for signs and symptoms of acute narrow-angle glaucoma (e.g. eye pain or discomfort, blurred vision, visual halos or colored images in association with red eyes from conjunctival congestion and corneal edema). Instruct patients to consult a physician immediately if any of these signs or symptoms develops.

5.4 Worsening of Urinary Retention

YUPELRI should be used with caution in patients with urinary retention. Prescribers and patients should be alert for signs and symptoms of urinary retention (e.g. difficulty passing urine, painful urination), especially in patients with prostatic hyperplasia or bladder-neck obstruction. Instruct patients to consult a healthcare provider immediately if any of these signs or symptoms develops.

5.5 Immediate Hypersensitivity Reactions

Immediate hypersensitivity reactions may occur after administration of YUPELRI. If such a reaction occurs, therapy with YUPELRI should be stopped at once and alternative treatments should be considered.

6.1 Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The YUPELRI safety database included 2,285 subjects with COPD in two 12-week efficacy studies and one 52-week long-term safety study. A total of 730 subjects received treatment with YUPELRI 175 mcg once daily. The safety data described below are based on the two 12-week trials and the one 52-week trial.

12-Week Trials

YUPELRI was studied in two 12-week replicate placebo-controlled trials in patients with moderate to very severe COPD (Trials 1 and 2). In these trials, 395 patients were treated with YUPELRI at the recommended dose of 175 mcg once daily.

The population had a mean age of 64 years (range from 41 to 88 years), with 50% males, 90% Caucasian, and had COPD with a mean post-bronchodilator forced expiratory volume in one second (FEV1) percent predicted of 55%. Of subjects enrolled in the two 12-week trials, 37% were taking concurrent LABA or ICS/LABA therapy. Patients with unstable cardiac disease, narrow-angle glaucoma, or symptomatic prostatic hypertrophy or bladder outlet obstruction were excluded from these trials.

Table 1 shows the most common adverse reactions that occurred with a frequency of greater than or equal to 2% in the YUPELRI group and higher than placebo in the two 12‑week placebo-controlled trials.

The proportion of subjects who discontinued treatment due to adverse reactions was 13% for the YUPELRI-treated subjects and 19% for placebo-treated subjects.

Other adverse reactions defined as events with an incidence of ≥1.0%, less than 2.0%, and more common than with placebo included the following: hypertension, dizziness, oropharyngeal pain, and bronchitis.

52-Week Trial

YUPELRI was studied in one 52-week, open-label, active-control (tiotropium 18 mcg once daily) trial in 1,055 patients with COPD. In this trial, 335 patients were treated with YUPELRI 175 mcg once daily and 356 patients with tiotropium. The demographic and baseline characteristics of the long-term safety trial were similar to those of the placebo-controlled 12-week studies described, with the exception that concurrent LABA or LABA/ICS therapy was used in 50% of patients. The adverse reactions reported in the long-term safety trial for YUPELRI were consistent with those observed in the placebo-controlled studies of 12-weeks.

6.2 Postmarketing Experience

The following adverse reaction has been reported during post-approval use of YUPELRI. Because this reaction was reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate the frequency or establish a causal relationship to drug exposure.

Gastrointestinal Disorders: Dry mouth

7.1 Anticholinergics

There is potential for an additive interaction with concomitantly used anticholinergic medicines. Therefore, avoid coadministration of YUPELRI with other anticholinergic-containing drugs as this may lead to an increase in anticholinergic adverse effects [see Warnings and Precautions (5.3, 5.4)].

7.2 Transporter-Related Drug Interactions

OATP1B1 and OATP1B3 inhibitors (e.g. rifampicin, cyclosporine, etc.) could lead to an increase in systemic exposure of the active metabolite. Therefore, coadministration with YUPELRI is not recommended [see Clinical Pharmacology (12.3)].

8.1 Pregnancy

8.2 Lactation

8.4 Pediatric Use

The safety and effectiveness of YUPELRI have not been established in pediatric patients. YUPELRI is not indicated for use in children.

8.5 Geriatric Use

Based on available data, no adjustment of the dosage of YUPELRI in geriatric patients is necessary.

Clinical trials of YUPELRI included 441 subjects aged 65 years and older, and of those, 101 subjects were aged 75 years and older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

8.6 Hepatic Impairment

The systemic exposure of revefenacin is unchanged while that of its active metabolite is increased in subjects with moderate hepatic impairment. The safety of YUPELRI has not been evaluated in COPD patients with mild-to-severe hepatic impairment. YUPELRI is not recommended in patients with any degree of hepatic impairment. [see Clinical Pharmacology (12.3)].

8.7 Renal Impairment

No dosage adjustment is required in patients with renal impairment. Monitor for systemic antimuscarinic side effects in COPD patients with severe renal impairment. [see Clinical Pharmacology (12.3)].

12.1 Mechanism of Action

Revefenacin is a long-acting muscarinic antagonist, which is often referred to as an anticholinergic. It has similar affinity to the subtypes of muscarinic receptors M1 to M5. In the airways, it exhibits pharmacological effects through inhibition of M3 receptor at the smooth muscle leading to bronchodilation. The competitive and reversible nature of antagonism was shown with human and animal origin receptors and isolated organ preparations. In preclinical in vitro as well as in vivo models, prevention of methacholine- and acetylcholine-induced bronchoconstrictive effects was dose-dependent and lasted longer than 24 hours. The clinical relevance of these findings is unknown. The bronchodilation following inhalation of revefenacin is predominantly a site-specific effect.

12.2 Pharmacodynamics

12.3 Pharmacokinetics

Revefenacin pharmacokinetic parameters are presented as the mean [standard deviation (SD)] unless otherwise specified. Following repeat dosing of inhaled YUPELRI, steady-state was achieved within 7 days with <1.6‑fold accumulation. Revefenacin exposure (Cmax and AUC) in COPD patients is approximately 60% lower as compared to healthy subjects. Exposure (Cmax and AUC) of the active metabolite in COPD patients is approximately 2-fold higher as compared to healthy subjects. Revefenacin Cmax was 0.16 ng/mL (0.11) and AUC was 0.22 ng·hr/mL (0.20) at steady-state after inhaled YUPELRI 175 mcg dose in COPD patients. Cmax of the active metabolite was 0.20 ng/mL (0.13) and AUC was 0.69 ng·hr/mL (0.53) at steady-state after inhaled YUPELRI 175 mcg dose in COPD patients.

Revefenacin and its active metabolite exposure increased in a slightly greater than dose proportional manner with increasing revefenacin dose. After single or multiple once-daily dosing of YUPELRI, both AUC and Cmax of revefenacin and its active metabolite increased by approximately 11-fold over the 88 to 700 mcg (8‑fold) dose range.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Two-year inhalation studies in Sprague-Dawley rats and CD1 mice were conducted to assess the carcinogenic potential of revefenacin. No evidence of tumorigenicity was observed in male and female rats at inhaled doses up to 338 mcg/kg/day (approximately 35 times the MRHD based upon summed AUCs for revefenacin and its active metabolite). No evidence of tumorigenicity was observed in male and female mice at inhaled doses up to 326 mcg/kg/day (approximately 40 times the MRHD based on summed AUCs for revefenacin and its active metabolite).

Revefenacin and its active metabolite were negative for mutagenicity in the Ames test for bacterial gene mutation. Revefenacin was negative for genotoxicity in the in vitro mouse lymphoma assay and in vivo rat bone marrow micronucleus assay.

There were no effects on male or female fertility and reproductive performance in rats at subcutaneous revefenacin doses up to 500 mcg/kg/day (approximately 30 times the MRHD on an mg/m2 basis for revefenacin).

14.1 Dose-Ranging Trials

Dose selection for YUPELRI was supported by a 28-day, randomized, double-blind, placebo-controlled, parallel-group trial of 355 subjects diagnosed with moderate to severe COPD, which was conducted to evaluate four doses of YUPELRI. YUPELRI 44, 88, 175, and 350 mcg, or matching placebo were taken once daily in the morning via a standard jet nebulizer (PARI LC® Sprint Reusable Nebulizer) and evaluated using the primary efficacy endpoint of change from baseline in trough (predose) FEV1 measured on Day 29. The LS mean differences in change from baseline in trough FEV1 compared to placebo for the 44 mcg, 88 mcg, 175 mcg, and 350 mcg once-daily doses were 52 mL [95% CI: -17.3, 121.0], 187 mL [95% CI: 118.8, 256.1], 167 mL [95% CI: 97.3, 236.0], and 171 mL [95% CI: 101.9, 239.3], respectively.

Evaluations of the dosing interval by comparing once- and twice-daily dosing of YUPELRI in a 7-day, randomized, double-blind, placebo-controlled, crossover trial in 64 patients supported selection of the once-daily dosing interval for further evaluation in the confirmatory COPD trials.

The dose-ranging results supported the evaluation of two doses of YUPELRI, 88 mcg and 175 mcg once daily, in the confirmatory COPD trials.

14.2 Confirmatory Trials

The clinical development program for YUPELRI included two 12-week, randomized, double-blind, placebo-controlled, multiple-dose, parallel-group, confirmatory trials in subjects with moderate to very severe COPD designed to evaluate the efficacy of once-daily YUPELRI’s effect on lung function (Trial 1: NCT02459080 and Trial 2: NCT02512510). To be enrolled, subjects needed to be 40 years of age or older, have a clinical diagnosis of COPD, a history of smoking greater than or equal to 10 pack-years, moderate to very severe COPD (post‑ipratropium FEV1 less than or equal to 80% of predicted normal values but at least 700 mL), and an FEV1/FVC ratio of 0.7 or less. Trials 1 and 2 included 1,229 subjects of which 395 received the 175 mcg dose administered via a standard jet nebulizer (PARI LC® Sprint Reusable Nebulizer). The study population had a mean age of 64 years (range: 41 to 88) and mean smoking history of 53 pack-years, with 48% identified as current smokers. At screening, the mean post-bronchodilator percent predicted FEV1 was 55% (range: 10% to 90%), and the post-bronchodilator FEV1/FVC ratio was 0.54 (range: 0.3 to 0.7). In addition, of the subjects enrolled, 37% were taking LABA or ICS/LABA therapy at study entry and remained on this concomitant therapy throughout the study.

Trials 1 and 2 evaluated YUPELRI 175 mcg once daily and placebo once daily. The primary endpoint was change from baseline in trough (predose) FEV1 at Day 85. In both trials, YUPELRI 175 mcg demonstrated significant improvement in lung function (mean change from baseline in trough (predose) FEV1) compared to placebo.

Table 2 presents the results from Trial 1 and Trial 2. The change from baseline in trough FEV1 over time from Trial 1 is depicted in Figure 1.

In Trial 1, serial spirometry over 24 hours was performed in a subset of patients (n=44 placebo, n=45 YUPELRI 175 mcg) on Day 84. In Trial 2, similar testing was also performed (n=39 placebo, n=44 YUPELRI 175 mcg). That data for Trial 1 is shown in Figure 2.

Peak FEV1 was defined as the highest postdose FEV1 within the first 2 hours after dosing on Day 1. The mean peak FEV1 improvement on Day 1 relative to placebo was 133 mL and 129 mL in Trials 1 and 2, respectively.

The St. Georges Respiratory Questionnaire (SGRQ) was assessed in Trials 1 and 2. In Trial 1, the SGRQ responder rate (defined as an improvement in score of 4 or more as threshold) for the YUPELRI treatment arm on Day 85 was 49% compared to 34% for placebo [Odds Ratio: 2.11; 95% CI: 1.14, 3.92]. In Trial 2, the SGRQ responder rate for the YUPELRI treatment arm was 45% compared to 39% for placebo [Odds Ratio: 1.31; 95% CI: 0.72, 2.38].