Get your patient on Tiopronin - Tiopronin tablet, Delayed Release (Tiopronin)

Adults: The recommended initial dosage in adult patients is 800 mg/day. In clinical studies, the average
dosage was about 1,000 mg/day.

Pediatrics: The recommended initial dosage in pediatric patients weighing 20 kg and greater is 15 mg/kg/day.
Avoid dosages greater than 50 mg/kg per day in pediatric patients [see Warnings and Precautions (5.1), Use in
Specific Populations (8.4)].

Administer Tiopronin Delayed-Release Tablets in 3 divided doses at the same times each day, with or without
food. Maintain a routine pattern with regard to meals.

Consider starting Tiopronin Delayed-Release Tablets at a lower dosage in patients with history of severe
toxicity to d-penicillamine.

For patients who cannot swallow the tablet whole, Tiopronin Delayed-Release Tablets can be crushed and
mixed with applesauce. Administration of Tiopronin Delayed-Release Tablets with other liquids or foods has
not been studied and is not recommended.

Preparation and Administration of Tiopronin Delayed-Release Tablets Mixed in Applesauce
For patients who can swallow semi-solid food, Tiopronin Delayed-Release Tablets can be crushed and mixed
with applesauce:
1. Crush the Tiopronin Delayed-Release Tablet in a clean pill crusher or mortar and pestle. Always crush one
tablet at a time.
2. Measure approximately one tablespoon of applesauce and transfer it into a container with the crushed
Tiopronin Delayed-Release Tablet.
3. Mix the crushed Tiopronin Delayed-Release Tablet in the applesauce until the powder is well dispersed.
4. Administer the entire Tiopronin Delayed-Release Tablets-applesauce mixture to the patient’s mouth
immediately. (However, if this is not possible, the mixture can be stored in a refrigerator for up to 2 hours
after adding the crushed tablet to the applesauce. Discard any mixture that has not been given within 2
hours.)
5. To assure that any leftover applesauce mixture from the container is recovered, add tap water to the same
container, mix, and have the patient drink the water.

Measure urinary cystine 1 month after starting Tiopronin Delayed-Release Tablets and every 3 months
thereafter. Adjust Tiopronin Delayed-Release Tablets dosage to maintain urinary cystine concentration less
than 250 mg/L.

Assess for proteinuria before treatment and every 3 to 6 months during treatment [see Warnings and
Precautions (5.1)].

Discontinue Tiopronin Delayed-Release Tablets in patients who develop proteinuria, and monitor urinary
protein and renal function. Consider restarting Tiopronin Delayed-Release Tablets treatment at a lower dosage
after resolution of proteinuria.

Risk Summary
Available published case report data with tiopronin have not identified a drug-associated risk for major birth
defects, miscarriage, or adverse maternal or fetal outcomes. Renal stones in pregnancy may result in adverse
pregnancy outcomes (see Clinical Considerations). In animal reproduction studies, there were no adverse
developmental outcomes with oral administration of tiopronin to pregnant mice and rats during organogenesis
at doses up to 2 times a 2 grams/day human dose (based on mg/m2). The estimated background risk of major
birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background
risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background
risk of major birth defects and miscarriage in clinically recognized pregnancies are 2% to 4% and 15% to
20%, respectively.

Clinical Considerations
Disease-associated maternal and/or embryo/fetal risk
Renal stones in pregnancy may increase the risk of adverse pregnancy outcomes, such as preterm birth and
low birth weight.

Data
Animal Data
No findings of fetal malformations could be attributed to the drug in reproduction studies in mice and rats at
doses up to 2 times the highest recommended human dose of 2 grams/day (based on mg/m2).

Risk Summary
There are no data on the presence of tiopronin in either human or animal milk or on the effects of the
breastfed child. A published study suggests that tiopronin may suppress milk production. Because of the
potential for serious adverse reactions, including nephrotic syndrome, advise patients that breastfeeding is not
recommended during treatment with Tiopronin Delayed-Release Tablets.

Tiopronin Delayed-Release Tablets are indicated in pediatric patients weighing 20 kg or more with severe
homozygous cystinuria, in combination with high fluid intake, alkali, and diet modification, for the prevention
of cystine stone formation who are not responsive to these measures alone. This indication is based on
safety and efficacy data from a trial in patients 9 years to 68 years of age and clinical experience. Proteinuria,
including nephrotic syndrome, has been reported in pediatric patients. Pediatric patients receiving greater
than 50 mg/kg tiopronin per day may be at greater risk [see Dosage and Administration (2.1, 2.3), Warnings
and Precautions (5.1) and Adverse Reactions (6.1)].

Tiopronin Delayed-Release Tablets are not approved for use in pediatric patients weighing less than 20 kg
[see Dosage and Administration (2.1)].

This drug is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug
may be greater in patients with impaired renal function. Because elderly patients are more likely to have
decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal
function.

Proteinuria, including nephrotic syndrome, and membranous nephropathy, have been reported with tiopronin
use. Pediatric patients receiving greater than 50 mg/kg of tiopronin per day may be at increased risk for
proteinuria [see Dosage and Administration (2.3), Adverse Reactions (6.1, 6.2), Use in Specific Populations
(8.4)]. Monitor patients for the development of proteinuria and discontinue therapy in patients who develop
proteinuria [see Dosage and Administration (2.3)].

Hypersensitivity reactions (drug fever, rash, fever, arthralgia and lymphadenopathy) have been reported [see
Contraindications (4)].

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

Adverse reactions occurring at an incidence of ≥5% in an uncontrolled trial in 66 patients with cystinuria age 9 to 68 years are shown in the table below. Patients in group 1 had previously been treated with d-penicillamine; those in group 2 had not. Of those patients who had stopped taking d-penicillamine due to toxicity (34 out of 49 patients in group 1), 22 were able to continue treatment with Tiopronin Tablets. In those without prior history of d-penicillamine treatment, 6% developed reactions of sufficient severity to require Tiopronin Tablets withdrawal.

Table 1 presents adverse reactions ≥5% in either treatment group occurring in this trial.

Taste Disturbance
A reduction in taste perception may develop. It is believed to be the result of chelation of trace metals by tiopronin. Hypogeusia is often self-limited.

Adverse reactions have been reported from the literature, as well as during post-approval use of Tiopronin
Tablets. Because the post-approval reactions are reported voluntarily from a population of uncertain size, it is
not always possible to reliably estimate their frequency or establish a causal relationship to Tiopronin Tablets
exposure.

Adverse reactions reported during the postmarketing use of Tiopronin Tablets are listed by body system in
Table 2.

Tiopronin is released faster from Tiopronin Delayed-Release Tablets in the presence of alcohol and the risk for
adverse events associated with Tiopronin Delayed-Release Tablets when taken with alcohol is unknown. Avoid
alcohol consumption 2 hours before and 3 hours after taking Tiopronin Delayed-Release Tablets [see Clinical
Pharmacology (12.3)].

The goal of therapy is to reduce urinary cystine concentration below its solubility limit. Tiopronin is an active
reducing agent which undergoes thiol-disulfide exchange with cystine to form a mixed disulfide of tiopronincysteine.
From this reaction, a water-soluble mixed disulfide is formed and the amount of sparingly soluble
cystine is reduced.

The decrement in urinary cystine produced by tiopronin is generally proportional to the dose. A reduction in
urinary cystine of 250-350 mg/day at tiopronin dosage of 1 g/day, and a decline of approximately 500 mg/day
at a dosage of 2 g/day, might be expected. Tiopronin has a rapid onset and offset of action, showing a fall in
cystine excretion on the first day of administration and a rise on the first day of drug withdrawal.

Absorption
Tiopronin Delayed-Release Tablets
When Tiopronin Tablets and Tiopronin Delayed-Release Tablets single doses were given to fasted healthy
subjects, the median time to peak plasma levels (T _max ) was 1 (range: 0.5 to 2.1) and 3 (range: 1.0 to 6.0)
hours, respectively. The peak exposure (C _max ) and total exposure (AUC _0-t ) of tiopronin from Tiopronin Delayed-
Release Tablets were decreased by 22% and 7% respectively compared to Tiopronin Tablets.

When Tiopronin Delayed-Release Tablets were administered crushed in applesauce, the median time to peak
plasma levels of tiopronin (T _max ) was 1 hour (range: 0.5 to 2.0) compared to 3.1 hours (range: 1.5 to 4.0) when
administered as intact Tiopronin Delayed-Release Tablets.

When Tiopronin Delayed-Release Tablets were administered crushed in applesauce, the maximum
concentration (C _max ) and exposure (AUC _0-t ) to tiopronin were increased by 38% and 14%, respectively,
compared to Tiopronin Delayed-Release Tablets administered intact.

Food Effects
Administration of the Tiopronin Delayed-Release Tablet with food decreases C _max of tiopronin by 13% and
AUC _0-t by 25% compared to Tiopronin Delayed-Release Tablets administered in a fasted state.

Since the drug is dosed to effect, the study results support administration of Tiopronin Delayed-Release Tablets
with or without food; administer at the same time each day with a routine pattern with regard to meals.

Elimination
Excretion
When tiopronin is given orally, up to 48% of dose appears in urine during the first 4 hours and up to 78% by
72 hours.

Drug Interactions
Alcohol
An in vitro dissolution study was conducted to evaluate the impact of alcohol (5, 10, 20, and 40%) on the dose
dumping of Tiopronin Delayed-Release Tablets. The study results showed that the addition of alcohol to the
dissolution media increases the dissolution rate of Tiopronin Delayed-Release Tablets in the acidic media of
0.1N HCl [see Drug Interactions (7.1)].

Carcinogenesis
Long-term carcinogenicity studies in animals have not been performed.

Mutagenesis
Tiopronin was not genotoxic in the chromosomal aberration, sister chromatid exchange, and in vivo
micronucleus assays.

Impairment of Fertility
High doses of tiopronin in experimental animals have been shown to interfere with maintenance of pregnancy
and viability of the fetus. In 2 published male fertility studies in rats, tiopronin at 20 mg/kg/day intramuscular
(IM) for 60 days induced reductions in testis, epididymis, vas deferens, and accessory sex glands weights and
in the count and motility of cauda epididymal sperm.