Provocholine, used in a methacholine challenge test, is indicated for the diagnosis of bronchial airway hyperreactivity in adults and pediatric patients five years of age and older who do not have clinically apparent asthma.

{ "type": "p", "children": [], "text": "Provocholine, used in a methacholine challenge test, is indicated for the diagnosis of bronchial airway hyperreactivity in adults and pediatric patients five years of age and older who do not have clinically apparent asthma." }

The recommended dosage of Provocholine powder for inhalation solution (require reconstitution and dilution) or inhalation solution (in a ready-to-use kit) used in the methacholine challenge test administered via nebulization in adult and pediatric patients (5 years or older) is increasing concentrations of methacholine chloride solutions using either doubling or quadrupling dosing concentrations. Please refer to Table 3 for the doubling or quadrupling dosing concentrations.

{ "type": "p", "children": [], "text": "The recommended dosage of Provocholine powder for inhalation solution (require reconstitution and dilution) or inhalation solution (in a ready-to-use kit) used in the methacholine challenge test administered via nebulization in adult and pediatric patients (5 years or older) is increasing concentrations of methacholine chloride solutions using either doubling or quadrupling dosing concentrations. Please refer to Table 3 for the doubling or quadrupling dosing concentrations." }

1. Provocholine Powder for Inhalation Solution requires reconstitution before use (see Tables 1 and 2):

{ "type": "p", "children": [], "text": "1. Provocholine Powder for Inhalation Solution requires reconstitution before use (see Tables 1 and 2):" }

Add 6.25 mL of 0.9% Sodium Chloride Injection (0.9% saline) or 0.9% Sodium Chloride Injection with 0.4% phenol (0.9% saline with 0.4% phenol) to the supplied vials containing 100 mg of Provocholine powder. Shake the vial to obtain a clear solution.

{ "type": "p", "children": [], "text": "Add 6.25 mL of 0.9% Sodium Chloride Injection (0.9% saline) or 0.9% Sodium Chloride Injection with 0.4% phenol (0.9% saline with 0.4% phenol) to the supplied vials containing 100 mg of Provocholine powder. Shake the vial to obtain a clear solution." }

2. Dilute the reconstituted Provocholine solution:

{ "type": "p", "children": [], "text": "2. Dilute the reconstituted Provocholine solution:" }

Using sterile, empty USP Type 1 borosilicate glass vials, dilute the reconstituted Provocholine solution with 0.9% saline or 0.9% saline with 0.4% phenol either by doubling the concentration (see Table 1) or quadrupling the concentration (see Table 2). After adding the diluent, shake each vial to obtain a clear solution. Use the same diluent to prepare all concentrations

{ "type": "p", "children": [], "text": "Using sterile, empty USP Type 1 borosilicate glass vials, dilute the reconstituted Provocholine solution with 0.9% saline or 0.9% saline with 0.4% phenol either by doubling the concentration (see Table 1) or quadrupling the concentration (see Table 2). After adding the diluent, shake each vial to obtain a clear solution. Use the same diluent to prepare all concentrations" }

3. Use a sterile bacterial-retentive filter (porosity 0.22 µm) when transferring the reconstituted or diluted solution from each vial (at least 2 mL) to a nebulizer.

{ "type": "p", "children": [], "text": "3. Use a sterile bacterial-retentive filter (porosity 0.22 µm) when transferring the reconstituted or diluted solution from each vial (at least 2 mL) to a nebulizer." }

4. Refrigerate the reconstituted and diluted solutions at 36oF to 46oF (2oC to 8oC) for up to 2 weeks. Since the temperature of the solution affects nebulizer output, solutions should be taken out of the refrigerator and allowed to equilibrate to room temperature (approximately 30 minutes) before use.

{ "type": "p", "children": [], "text": "4. Refrigerate the reconstituted and diluted solutions at 36oF to 46oF (2oC to 8oC) for up to 2 weeks. Since the temperature of the solution affects nebulizer output, solutions should be taken out of the refrigerator and allowed to equilibrate to room temperature (approximately 30 minutes) before use." }

Table 1: Reconstitution and Dilution of Supplied Provocholine powder for inhalation solution:  Doubling Concentrations

{ "type": "p", "children": [], "text": "\nTable 1: Reconstitution and Dilution of Supplied Provocholine powder for inhalation solution:  Doubling Concentrations\n" }

<div class="scrollingtable"><table border="1" cellpadding="0" cellspacing="0" width="677px"> <tbody class="Headless"> <tr class="First"> <td> <p class="First First PIHeading1"> <span class="Bold">TAKE</span> </p> </td><td> <p class="First First PIHeading1"> <span class="Bold">ADD 0.9% Saline or 0.9% Saline with 0.4% Phenol</span> </p> </td><td> <p class="First First PIHeading1"> <span class="Bold">Concentration (Total Volume) after reconstitution or dilution</span> </p> </td> </tr> <tr> <td> <p class="First First PIHeading1">100 mg of Provocholine Powder in one supplied vial</p> </td><td> <p class="First First PIHeading1">6.25 mL</p> </td><td> <p class="First First PIHeading1">16 mg/mL (6.25 mL) (Solution A)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution A</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">8 mg/mL (6 mL) (Solution B)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution B</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">4 mg/mL (6 mL) (Solution C)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution C</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">2 mg/mL (6 mL) (Solution D)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution D</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">1 mg/mL (6 mL) (Solution E)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution E</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">0.5 mg/mL (6 mL) (Solution F)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution F</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">0.25 mg/mL (6 mL) (Solution G)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution G</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">0.125 mg/mL (6 mL) (Solution H)</p> </td> </tr> <tr class="Last"> <td> <p class="First First PIHeading1">3 mL of Solution H</p> </td><td> <p class="First First PIHeading1">3 mL</p> </td><td> <p class="First First PIHeading1">0.0625 mg/mL (6 mL) (Solution I)</p> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"677px\">\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td>\n<p class=\"First First PIHeading1\">\n<span class=\"Bold\">TAKE</span>\n</p>\n</td><td>\n<p class=\"First First PIHeading1\">\n<span class=\"Bold\">ADD 0.9% Saline or 0.9% Saline with 0.4% Phenol</span>\n</p>\n</td><td>\n<p class=\"First First PIHeading1\">\n<span class=\"Bold\">Concentration (Total Volume) after reconstitution or dilution</span>\n</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">100 mg of Provocholine Powder in one supplied vial</p>\n</td><td>\n<p class=\"First First PIHeading1\">6.25 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">16 mg/mL (6.25 mL) (Solution A)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution A</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">8 mg/mL (6 mL) (Solution B)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution B</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">4 mg/mL (6 mL) (Solution C)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution C</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">2 mg/mL (6 mL) (Solution D)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution D</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">1 mg/mL (6 mL) (Solution E)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution E</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">0.5 mg/mL (6 mL) (Solution F)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution F</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">0.25 mg/mL (6 mL) (Solution G)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution G</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">0.125 mg/mL (6 mL) (Solution H)</p>\n</td>\n</tr>\n<tr class=\"Last\">\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution H</p>\n</td><td>\n<p class=\"First First PIHeading1\">3 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">0.0625 mg/mL (6 mL) (Solution I)</p>\n</td>\n</tr>\n</tbody>\n</table></div>" }

Table 2: Reconstitution and Dilution of Supplied Provocholine powder for inhalation solution:  Quadrupling Concentrations

{ "type": "p", "children": [], "text": "\nTable 2: Reconstitution and Dilution of Supplied Provocholine powder for inhalation solution:  Quadrupling Concentrations\n" }

<div class="scrollingtable"><table border="1" cellpadding="0" cellspacing="0" width="677px"> <tbody class="Headless"> <tr class="First"> <td> <p class="First First PIHeading1"> <span class="Bold">TAKE</span> </p> </td><td> <p class="First First PIHeading1"> <span class="Bold">ADD 0.9% Saline or 0.9% Saline with 0.4% Phenol</span> </p> </td><td> <p class="First First PIHeading1"> <span class="Bold">Concentration (Total Volume) after reconstitution or dilution</span> </p> </td> </tr> <tr> <td> <p class="First First PIHeading1">100 mg of Provocholine Powder in one supplied vial</p> </td><td> <p class="First First PIHeading1">6.25 mL</p> </td><td> <p class="First First PIHeading1">16 mg/mL (6.25 mL) (Solution 1)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution 1</p> </td><td> <p class="First First PIHeading1">9 mL</p> </td><td> <p class="First First PIHeading1">4 mg/mL (12 mL) (Solution 2)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution 2</p> </td><td> <p class="First First PIHeading1">9 mL</p> </td><td> <p class="First First PIHeading1">1 mg/mL (12 mL) (Solution 3)</p> </td> </tr> <tr> <td> <p class="First First PIHeading1">3 mL of Solution 3</p> </td><td> <p class="First First PIHeading1">9 mL</p> </td><td> <p class="First First PIHeading1">0.25 mg/mL (12 mL) (Solution 4)</p> </td> </tr> <tr class="Last"> <td> <p class="First First PIHeading1">3 mL of Solution 4</p> </td><td> <p class="First First PIHeading1">9 mL</p> </td><td> <p class="First First PIHeading1">0.0625 mg/mL (12 mL) (Solution 5)</p> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"677px\">\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td>\n<p class=\"First First PIHeading1\">\n<span class=\"Bold\">TAKE</span>\n</p>\n</td><td>\n<p class=\"First First PIHeading1\">\n<span class=\"Bold\">ADD 0.9% Saline or 0.9% Saline with 0.4% Phenol</span>\n</p>\n</td><td>\n<p class=\"First First PIHeading1\">\n<span class=\"Bold\">Concentration (Total Volume) after reconstitution or dilution</span>\n</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">100 mg of Provocholine Powder in one supplied vial</p>\n</td><td>\n<p class=\"First First PIHeading1\">6.25 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">16 mg/mL (6.25 mL) (Solution 1)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution 1</p>\n</td><td>\n<p class=\"First First PIHeading1\">9 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">4 mg/mL (12 mL) (Solution 2)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution 2</p>\n</td><td>\n<p class=\"First First PIHeading1\">9 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">1 mg/mL (12 mL) (Solution 3)</p>\n</td>\n</tr>\n<tr>\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution 3</p>\n</td><td>\n<p class=\"First First PIHeading1\">9 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">0.25 mg/mL (12 mL) (Solution 4)</p>\n</td>\n</tr>\n<tr class=\"Last\">\n<td>\n<p class=\"First First PIHeading1\">3 mL of Solution 4</p>\n</td><td>\n<p class=\"First First PIHeading1\">9 mL</p>\n</td><td>\n<p class=\"First First PIHeading1\">0.0625 mg/mL (12 mL) (Solution 5)</p>\n</td>\n</tr>\n</tbody>\n</table></div>" }

Prior to administering the Provocholine dose(s), determine the post-diluent FEV1 value required for the methacholine challenge test.

{ "type": "p", "children": [], "text": "Prior to administering the Provocholine dose(s), determine the post-diluent FEV1 value required for the methacholine challenge test." }

Administration of the Diluent or Base to Obtain Post-Diluent FEV1 Value

{ "type": "p", "children": [], "text": "\nAdministration of the Diluent or Base to Obtain Post-Diluent FEV1 Value\n" }

1. For the Provocholine powder for inhalation solution:

{ "type": "p", "children": [], "text": "1. For the Provocholine powder for inhalation solution:" }

    Using a 3 mL syringe and needle, draw up 2 to 3 mL of the same diluent used to reconstitute the Provocholine Powder (0.9% saline or 0.9%        saline with 0.4% phenol) and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm).

{ "type": "p", "children": [], "text": "    Using a 3 mL syringe and needle, draw up 2 to 3 mL of the same diluent used to reconstitute the Provocholine Powder (0.9% saline or 0.9%        saline with 0.4% phenol) and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm)." }

   For the Provocholine inhalation solution:

{ "type": "p", "children": [], "text": "\n   For the Provocholine inhalation solution:\n" }

   Dispense the contents of a vial containing the base solution (contains no methacholine chloride) into the nebulizer.

{ "type": "p", "children": [], "text": "   Dispense the contents of a vial containing the base solution (contains no methacholine chloride) into the nebulizer." }

2. Instruct the patient to hold the nebulizer upright with the mouthpiece in his/her mouth. The patient should wear a nose clip while inhaling from the nebulizer. 3. At the end of exhalation during tidal breathing (functional residual capacity), instruct the patient to inhale slowly and deeply through the mouthpiece. Trigger the dosimeter soon after oral inhalation begins. Encourage the patient to continue inhaling slowly (about 5 seconds to complete the inhalation) and to hold the breath at total lung capacity (TLC) for another 5 seconds.

{ "type": "p", "children": [], "text": "2. Instruct the patient to hold the nebulizer upright with the mouthpiece in his/her mouth. The patient should wear a nose clip while inhaling from the nebulizer.\n3. At the end of exhalation during tidal breathing (functional residual capacity), instruct the patient to inhale slowly and deeply through the mouthpiece. Trigger the dosimeter soon after oral inhalation begins. Encourage the patient to continue inhaling slowly (about 5 seconds to complete the inhalation) and to hold the breath at total lung capacity (TLC) for another 5 seconds." }

4. Repeat Step 3 for a total of five inspiratory capacity inhalations. Take no more than 2 minutes to perform these 5 inhalations. 5. Perform spirometry and measure the FEV1 30 and 90 seconds after the fifth inhalation from the nebulizer to obtain the post-diluent FEV1 value. These values may be left at ambient (spirometer) temperature pressure saturated (ATPS). If the FEV1 value is not of acceptable quality, repeat the procedure.  If the post-diluent FEV1 falls by ≥ 20% from baseline FEV1, do not give further inhalations and proceed to Step 8. If the post-diluent FEV1 falls by < 20% from baseline FEV1, continue to Step 6.

{ "type": "p", "children": [], "text": "4. Repeat Step 3 for a total of five inspiratory capacity inhalations. Take no more than 2 minutes to perform these 5 inhalations.\n5. Perform spirometry and measure the FEV1 30 and 90 seconds after the fifth inhalation from the nebulizer to obtain the post-diluent FEV1 value. These values may be left at ambient (spirometer) temperature pressure saturated (ATPS). If the FEV1 value is not of acceptable quality, repeat the procedure.  If the post-diluent FEV1 falls by ≥ 20% from baseline FEV1, do not give further inhalations and proceed to Step 8. If the post-diluent FEV1 falls by < 20% from baseline FEV1, continue to Step 6." }

Administration of Provocholine in a Methacholine Challenge Test

{ "type": "p", "children": [], "text": "\nAdministration of Provocholine in a Methacholine Challenge Test\n" }

6. For the Provocholine powder for inhalation:

{ "type": "p", "children": [], "text": "\n6. For the Provocholine powder for inhalation:\n" }

Using a 3 mL syringe and needle, draw up the recommended Provocholine concentration (see Table 3) that was prepared using either the doubling or quadrupling dose method and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm).  See Tables 1 and 2 for preparation of the Provocholine powder for inhalation solution.

{ "type": "p", "children": [], "text": "Using a 3 mL syringe and needle, draw up the recommended Provocholine concentration (see Table 3) that was prepared using either the doubling or quadrupling dose method and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm).  See Tables 1 and 2 for preparation of the Provocholine powder for inhalation solution." }

Table 3: Recommended Provocholine Dose(s) By Nebulization [Doubling Dose(s) or Quadrupling Dose(s)]

{ "type": "p", "children": [], "text": "\nTable 3: Recommended Provocholine Dose(s) By Nebulization [Doubling Dose(s) or Quadrupling Dose(s)]\n" }

<div class="scrollingtable"><table width="40%"> <tbody class="Headless"> <tr class="First"> <td align="center" class="Botrule Lrule Rrule Toprule" colspan="2"><span class="Bold"> Doubling Dose Increments</span></td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Provocholine Concentration</span></td><td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Provocholine Dose*</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 0.0625 mg/mL (Solution I)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 1.484 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 0.125 mg/mL (Solution H)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 2.969 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 0.25 mg/mL (Solution G)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 5.938 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 0.5 mg/mL (Solution F)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 11.875 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 1 mg/mL (Solution E)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 23.75 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 2 mg/mL (Solution D)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 47.5 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 4 mg/mL (Solution C)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 95 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 8 mg/mL (Solution B)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 190 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 16 mg/mL (Solution A)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 380 mcg</td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule Toprule" colspan="2"><span class="Bold">Quadrupling Dose Increments </span></td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold"> Provocholine Concentration</span></td><td class="Botrule Lrule Rrule Toprule"><span class="Bold"> Provocholine Dose*</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 0.0625 mg/mL (Solution 5)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 1.484 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 0.25 mg/mL (Solution 4)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 5.938 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 1 mg/mL (Solution 3)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 23.75 mcg</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule Toprule"> 4 mg/mL (Solution 2)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 95 mcg</td> </tr> <tr class="Last"> <td align="right" class="Botrule Lrule Rrule Toprule"> 16 mg/mL (Solution 1)</td><td align="right" class="Botrule Lrule Rrule Toprule"> 380 mcg</td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"40%\">\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td align=\"center\" class=\"Botrule Lrule Rrule Toprule\" colspan=\"2\"><span class=\"Bold\"> Doubling Dose Increments</span></td>\n</tr>\n<tr>\n<td align=\"center\" class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\"> Provocholine Concentration</span></td><td align=\"center\" class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\"> Provocholine Dose*</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 0.0625 mg/mL (Solution I)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 1.484 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 0.125 mg/mL (Solution H)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 2.969 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 0.25 mg/mL (Solution G)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 5.938 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 0.5 mg/mL (Solution F)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 11.875 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 1 mg/mL (Solution E)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 23.75 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 2 mg/mL (Solution D)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 47.5 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 4 mg/mL (Solution C)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 95 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 8 mg/mL (Solution B)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 190 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 16 mg/mL (Solution A)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 380 mcg</td>\n</tr>\n<tr>\n<td align=\"center\" class=\"Botrule Lrule Rrule Toprule\" colspan=\"2\"><span class=\"Bold\">Quadrupling Dose Increments </span></td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\"> Provocholine Concentration</span></td><td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\"> Provocholine Dose*</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 0.0625 mg/mL (Solution 5)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 1.484 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 0.25 mg/mL (Solution 4)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 5.938 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 1 mg/mL (Solution 3)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 23.75 mcg</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 4 mg/mL (Solution 2)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 95 mcg</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 16 mg/mL (Solution 1)</td><td align=\"right\" class=\"Botrule Lrule Rrule Toprule\"> 380 mcg</td>\n</tr>\n</tbody>\n</table></div>" }

  * Dose delivered based on the drug output of the English Wright Nebulizer and the duration of inhalation (2 minutes).

{ "type": "p", "children": [], "text": "  * Dose delivered based on the drug output of the English Wright Nebulizer and the duration of inhalation (2 minutes)." }

For the Provocholine inhalation solution:

{ "type": "p", "children": [], "text": "\nFor the Provocholine inhalation solution:\n" }

Dispense the contents of a vial of the appropriate Provocholine concentration, starting with the lowest dose, into the nebulizer. The Provocholine solution concentrations, 0.0625 mg/mL, 0.25 mg/mL, 1 mg/mL, 4 mg/mL, and 16 mg/mL, provided in the kit are ready-to-use. No further dilution is required.

{ "type": "p", "children": [], "text": "Dispense the contents of a vial of the appropriate Provocholine concentration, starting with the lowest dose, into the nebulizer. The Provocholine solution concentrations, 0.0625 mg/mL, 0.25 mg/mL, 1 mg/mL, 4 mg/mL, and 16 mg/mL, provided in the kit are ready-to-use. No further dilution is required." }

7. Repeat steps 2 through 5 for each Provocholine concentration, emptying the nebulizer between each concentration. To keep the cumulative effect of Provocholine relatively constant, the time interval between the commencement of two subsequent concentrations should be kept to 5 minutes.

{ "type": "p", "children": [], "text": "\n7. Repeat steps 2 through 5 for each Provocholine concentration, emptying the nebulizer between each concentration. To keep the cumulative effect of Provocholine relatively constant, the time interval between the commencement of two subsequent concentrations should be kept to 5 minutes." }

8. Stop dosing if the FEV1 has fallen by ≥ 20% from the post-diluent FEV1, or the highest Provocholine concentration (16 mg/mL) has been administered (whichever comes first). Do not administer additional Provocholine concentrations if severe bronchoconstriction occurs [see Warnings and Precautions (5.1)].

{ "type": "p", "children": [], "text": "8. Stop dosing if the FEV1 has fallen by ≥ 20% from the post-diluent FEV1, or the highest Provocholine concentration (16 mg/mL) has been administered (whichever comes first). Do not administer additional Provocholine concentrations if severe bronchoconstriction occurs [see Warnings and Precautions (5.1)]." }

9. After the test is completed, administer an inhaled β-agonist to the patient to expedite the return of the FEV1 to within 90% of baseline and to relieve any discomfort (the majority of patients revert to normal pulmonary function within 5 minutes after β-agonist administration; in contrast the majority of patients revert to normal pulmonary function within 30-45 minutes without β-agonist administration). Wait 10 minutes and measure the FEV1 and Vital Capacity. Patients should not be allowed to leave the laboratory until their FEV1 has returned to within 90% of baseline.

{ "type": "p", "children": [], "text": "9. After the test is completed, administer an inhaled β-agonist to the patient to expedite the return of the FEV1 to within 90% of baseline and to relieve any discomfort (the majority of patients revert to normal pulmonary function within 5 minutes after β-agonist administration; in contrast the majority of patients revert to normal pulmonary function within 30-45 minutes without β-agonist administration). Wait 10 minutes and measure the FEV1 and Vital Capacity. Patients should not be allowed to leave the laboratory until their FEV1 has returned to within 90% of baseline." }

10. After the test, wash and clean reusable nebulizers thoroughly according to manufacturer’s recommendations.

{ "type": "p", "children": [], "text": "10. After the test, wash and clean reusable nebulizers thoroughly according to manufacturer’s recommendations." }

Administer the diluent and the Provocholine dose(s) using the English Wright nebulizer or other suitable nebulizer as long as the device output and particle size are characterized.Prior to administering the Provocholine dose(s), determine the post-diluent FEV1 required for the methacholine challenge test.

{ "type": "p", "children": [], "text": "Administer the diluent and the Provocholine dose(s) using the English Wright nebulizer or other suitable nebulizer as long as the device output and particle size are characterized.Prior to administering the Provocholine dose(s), determine the post-diluent FEV1 required for the methacholine challenge test." }

Administration of the Diluent or Base Solution to Obtain Post-Diluent FEV1 Value

{ "type": "p", "children": [], "text": "\n\nAdministration of the Diluent or Base Solution to Obtain Post-Diluent FEV1 Value\n" }

1. For the Provocholine powder for inhalation solution:

{ "type": "p", "children": [], "text": "1. For the Provocholine powder for inhalation solution:\n" }

Using a 3 mL syringe and needle, draw up 2 to 3 mL of the same diluent used to reconstitute the Provocholine powder (0.9% saline or 0.9% saline with 0.4% phenol) and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm).

{ "type": "p", "children": [], "text": "Using a 3 mL syringe and needle, draw up 2 to 3 mL of the same diluent used to reconstitute the Provocholine powder (0.9% saline or 0.9% saline with 0.4% phenol) and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm)." }

For the Provocholine inhalation solution:

{ "type": "p", "children": [], "text": "\nFor the Provocholine inhalation solution:\n" }

Dispense the contents of a vial containing the base solution (contains no methacholine chloride) into the nebulizer.

{ "type": "p", "children": [], "text": "Dispense the contents of a vial containing the base solution (contains no methacholine chloride) into the nebulizer." }

2. Instruct the patient to relax and breathe the aerosol quietly (tidal breathing) for 2 minutes of inhalation time.

{ "type": "p", "children": [], "text": "2. Instruct the patient to relax and breathe the aerosol quietly (tidal breathing) for 2 minutes of inhalation time." }

3. Place the face mask loosely over the nose and mouth or the mouthpiece in the mouth (with a nose clip) of the patient. The patient should hold the nebulizer to avoid warming the solution. Nebulizer should be kept upright and vertical.

{ "type": "p", "children": [], "text": "3. Place the face mask loosely over the nose and mouth or the mouthpiece in the mouth (with a nose clip) of the patient. The patient should hold the nebulizer to avoid warming the solution. Nebulizer should be kept upright and vertical." }

4. Start the nebulizer by adjusting the flow meter so that the nebulizer is operating at the calibrated output (0.13 mL/minute for the English Wright nebulizer). Start the stopwatch immediately.

{ "type": "p", "children": [], "text": "4. Start the nebulizer by adjusting the flow meter so that the nebulizer is operating at the calibrated output (0.13 mL/minute for the English Wright nebulizer). Start the stopwatch immediately." }

5. After exactly 2 minutes, turn off the flow meter, remove the face mask (or the mouthpiece from the mouth), and discard any remaining solution.

{ "type": "p", "children": [], "text": "5. After exactly 2 minutes, turn off the flow meter, remove the face mask (or the mouthpiece from the mouth), and discard any remaining solution." }

6. Perform spirometry and measure the FEV1 30 and 90 seconds after the end of the inhalation to obtain the post-diluent FEV1. These values may be left at ambient (spirometer) temperature pressure saturated (ATPS). If the FEV1 value is not of acceptable quality, repeat the procedure. If the post-diluent FEV1 falls by ≥ 20% from baseline FEV1, do not give further inhalations and proceed to Step 9. If the post-diluent FEV1 falls by < 20% from baseline FEV1, continue to Step 7.

{ "type": "p", "children": [], "text": "6. Perform spirometry and measure the FEV1 30 and 90 seconds after the end of the inhalation to obtain the post-diluent FEV1. These values may be left at ambient (spirometer) temperature pressure saturated (ATPS). If the FEV1 value is not of acceptable quality, repeat the procedure. If the post-diluent FEV1 falls by ≥ 20% from baseline FEV1, do not give further inhalations and proceed to Step 9. If the post-diluent FEV1 falls by < 20% from baseline FEV1, continue to Step 7." }

Administration of Provocholine in a Methacholine Challenge Test

{ "type": "p", "children": [], "text": "\nAdministration of Provocholine in a Methacholine Challenge Test\n" }

7. For the Provocholine powder for inhalation solution:

{ "type": "p", "children": [], "text": "7. For the Provocholine powder for inhalation solution:" }

Using a 3 mL syringe and needle, draw up the recommended Provocholine dose (see Table 3) using either the doubling or quadrupling dose method and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm). See Tables 1 and 2 for preparation of the Provocholine powder for inhalation.

{ "type": "p", "children": [], "text": "Using a 3 mL syringe and needle, draw up the recommended Provocholine dose (see Table 3) using either the doubling or quadrupling dose method and dispense into the nebulizer using a sterile bacterial-retentive filter (porosity 0.22 µm). See Tables 1 and 2 for preparation of the Provocholine powder for inhalation." }

For the Provocholine inhalation solution:

{ "type": "p", "children": [], "text": "For the Provocholine inhalation solution:" }

Dispense the contents of a vial of the appropriate Provocholine concentration, starting with the lowest dose, into the nebulizer. The Provocholine solution concentrations, 0.0625 mg/mL, 0.25 mg/mL, 1 mg/mL, 4 mg/mL, and 16 mg /mL, provided in the kit are ready-to-use. No further dilution is required.

{ "type": "p", "children": [], "text": "Dispense the contents of a vial of the appropriate Provocholine concentration, starting with the lowest dose, into the nebulizer. The Provocholine solution concentrations, 0.0625 mg/mL, 0.25 mg/mL, 1 mg/mL, 4 mg/mL, and 16 mg /mL, provided in the kit are ready-to-use. No further dilution is required." }

8. Repeat steps 2 through 6 for each Provocholine dose, emptying the nebulizer between each dose. However, stop dosing if the FEV1 has fallen by ≥ 20% from the post-diluent FEV1 or the highest Provocholine concentration (16 mg/mL) has been administered (whichever comes first). Do not administer additional Provocholine doses if severe bronchoconstriction occurs [see Warnings and Precautions (5.1)].

{ "type": "p", "children": [], "text": "8. Repeat steps 2 through 6 for each Provocholine dose, emptying the nebulizer between each dose. However, stop dosing if the FEV1 has fallen by ≥ 20% from the post-diluent FEV1 or the highest Provocholine concentration (16 mg/mL) has been administered (whichever comes first). Do not administer additional Provocholine doses if severe bronchoconstriction occurs [see Warnings and Precautions (5.1)]." }

9. After the test is completed, administer an inhaled β-agonist to the patient to expedite the return of the FEV1 to within 90% of baseline and to relieve any discomfort (the majority of patients revert to normal pulmonary function within 5 minutes after β-agonist administration; in contrast the majority of patients revert to normal pulmonary function within 30-45 minutes without β-agonist administration). Wait 10 minutes and measure the FEV1 and Vital Capacity. Patients should not be allowed to leave the laboratory until their FEV1 has returned to within 90% of baseline.

{ "type": "p", "children": [], "text": "9. After the test is completed, administer an inhaled β-agonist to the patient to expedite the return of the FEV1 to within 90% of baseline and to relieve any discomfort (the majority of patients revert to normal pulmonary function within 5 minutes after β-agonist administration; in contrast the majority of patients revert to normal pulmonary function within 30-45 minutes without β-agonist administration). Wait 10 minutes and measure the FEV1 and Vital Capacity. Patients should not be allowed to leave the laboratory until their FEV1 has returned to within 90% of baseline." }

10. After the test, wash and clean reusable nebulizers thoroughly according to manufacturer’s recommendations and discard disposable nebulizers appropriately.

{ "type": "p", "children": [], "text": "10. After the test, wash and clean reusable nebulizers thoroughly according to manufacturer’s recommendations and discard disposable nebulizers appropriately." }

A positive methacholine challenge test is a ≥ 20% reduction in the FEV1 (after Provocholine oral inhalation) compared with the mean post-diluent FEV1. Calculate and record post-diluent FEV1 value before the methacholine challenge test is started. Express airway hyperreactivity as the provocative Provocholine concentration (mg/mL) providing a fall in FEV1 of ≥ 20% (PC20) when the methacholine challenge test is dosed using either the 5-breath dosimeter method or the 2-minute tidal breathing method, or as the provocative Provocholine dose (mcg) providing a fall in FEV1 of ≥ 20% (PD20) when using the 2-minute tidal breathing method.

{ "type": "p", "children": [], "text": "A positive methacholine challenge test is a ≥ 20% reduction in the FEV1 (after Provocholine oral inhalation) compared with the mean post-diluent FEV1. Calculate and record post-diluent FEV1 value before the methacholine challenge test is started. Express airway hyperreactivity as the provocative Provocholine concentration (mg/mL) providing a fall in FEV1 of ≥ 20% (PC20) when the methacholine challenge test is dosed using either the 5-breath dosimeter method or the 2-minute tidal breathing method, or as the provocative Provocholine dose (mcg) providing a fall in FEV1 of ≥ 20% (PD20) when using the 2-minute tidal breathing method." }

Calculation of PC20

{ "type": "p", "children": [], "text": "\nCalculation of PC20\n" }

Calculate PC20 using one of the following methods. Determine the percent decrease in FEV1 using the mean post-diluent FEV1 and the lowest FEV1 post-dose, as shown below:

{ "type": "p", "children": [], "text": "\nCalculate PC20 using one of the following methods. Determine the percent decrease in FEV1 using the mean post-diluent FEV1 and the lowest FEV1 post-dose, as shown below:" }

% fall in FEV1 = mean post-diluent FEV1 - lowest FEV1 post-Provocholine x 100                                                  mean post-diluent FEV1

{ "type": "p", "children": [], "text": "\n% fall in FEV1 = mean post-diluent FEV1 - lowest FEV1 post-Provocholine x 100\n                                                 mean post-diluent FEV1\n" }

Method #1

{ "type": "p", "children": [], "text": "\nMethod #1\n" }

Plot the percent decrease in FEV1 against the increasing methacholine concentration using a log scale and obtain the PC20 by linear interpolation between the last two points, as shown in Figure 1.

{ "type": "p", "children": [], "text": "\nPlot the percent decrease in FEV1 against the increasing methacholine concentration using a log scale and obtain the PC20 by linear interpolation between the last two points, as shown in Figure 1." }

Method #2

{ "type": "p", "children": [], "text": "\nMethod #2\n" }

Alternatively, calculate the PC20 as follows:

{ "type": "p", "children": [], "text": "\nAlternatively, calculate the PC20 as follows:" }

PC20 = antilog [log C1+ (log C2 - log C1)(20 - R1)]                                                (R2- R1)

{ "type": "p", "children": [], "text": "\nPC20 = antilog [log C1+ (log C2 - log C1)(20 - R1)]                                                (R2- R1)" }

Where:• C1 = second last methacholine concentration (< 20% FEV1 decrease)• C2 = last methacholine concentration (≥ 20% FEV1 decrease)• R1 = % fall FEV1 after C1• R2 = % fall FEV1 after C2

{ "type": "p", "children": [], "text": "Where:• C1 = second last methacholine concentration (< 20% FEV1 decrease)• C2 = last methacholine concentration (≥ 20% FEV1 decrease)• R1 = % fall FEV1 after C1• R2 = % fall FEV1 after C2" }

Calculation of PD20 (2-minute tidal breathing method only)

{ "type": "p", "children": [], "text": "\nCalculation of PD20 (2-minute tidal breathing method only)\n" }

Calculate the PD20 as follows:

{ "type": "p", "children": [], "text": "\nCalculate the PD20 as follows:" }

PD20 = antilog [log D1+ (log D2 - log D1)(20 - R1)]                                                   (R2- R1)

{ "type": "p", "children": [], "text": "\nPD20 = antilog [log D1+ (log D2 - log D1)(20 - R1)]                                                   (R2- R1)" }

Where:• D1 = second last Provocholine dose (< 20% FEV1 decrease)• D2 = last Provocholine dose (≥ 20% FEV1 decrease)• R1 = % FEV1 decrease after D1• R2 = % FEV1 decrease after D2

{ "type": "p", "children": [], "text": "Where:• D1 = second last Provocholine dose (< 20% FEV1 decrease)• D2 = last Provocholine dose (≥ 20% FEV1 decrease)• R1 = % FEV1 decrease after D1• R2 = % FEV1 decrease after D2" }

When using the English Wright nebulizer, refer to Table 2 for D1 and D2.

{ "type": "p", "children": [], "text": "When using the English Wright nebulizer, refer to Table 2 for D1 and D2." }

Interpretation of Results

{ "type": "p", "children": [], "text": "\nInterpretation of Results\n" }

A negative (normal) methacholine challenge result is defined as FEV1 reduction of < 20% after all the doses (doubling or quadrupling dose increments) in Table 1 (for 5-breath dosimeter method) or Table 2 (for the 2-minute tidal breathing method) have been administered.

{ "type": "p", "children": [], "text": "\nA negative (normal) methacholine challenge result is defined as FEV1 reduction of < 20% after all the doses (doubling or quadrupling dose increments) in Table 1 (for 5-breath dosimeter method) or Table 2 (for the 2-minute tidal breathing method) have been administered." }

If asthma drugs are discontinued prior to the methacholine challenge test, consider the possibility of rebound airway hyperreactivity in the interpretation of the test results. The methacholine challenge test may occasionally be falsely positive after an influenza infection or upper respiratory infection, immunizations, in very young or very old patients, in patients with chronic lung disease (e.g., cystic fibrosis, sarcoidosis, tuberculosis, chronic obstructive pulmonary disease), in patients with allergic rhinitis without asthma symptoms, in smokers, or in patients after exposure to air pollutants.

{ "type": "p", "children": [], "text": "If asthma drugs are discontinued prior to the methacholine challenge test, consider the possibility of rebound airway hyperreactivity in the interpretation of the test results. The methacholine challenge test may occasionally be falsely positive after an influenza infection or upper respiratory infection, immunizations, in very young or very old patients, in patients with chronic lung disease (e.g., cystic fibrosis, sarcoidosis, tuberculosis, chronic obstructive pulmonary disease), in patients with allergic rhinitis without asthma symptoms, in smokers, or in patients after exposure to air pollutants." }

• For inhalation solution: 100 mg of white to off-white crystalline powder in amber glass vials (powder is reconstituted and then diluted prior to administration)

{ "type": "p", "children": [], "text": "• For inhalation solution: 100 mg of white to off-white crystalline powder in amber glass vials (powder is reconstituted and then diluted prior to administration)" }

• Inhalation solution:   o base solution (contains no methacholine chloride/3 mL)   o 0.0625 mg/mL (0.1875 mg/3 mL)   o 0.25 mg/mL (0.75 mg/3 mL)   o 1 mg/mL (3 mg/3 mL)   o 4 mg/mL (12 mg/3 mL)   o 16 mg/mL (48 mg/3 mL)

{ "type": "p", "children": [], "text": "• Inhalation solution:   o base solution (contains no methacholine chloride/3 mL)   o 0.0625 mg/mL (0.1875 mg/3 mL)   o 0.25 mg/mL (0.75 mg/3 mL)   o 1 mg/mL (3 mg/3 mL)   o 4 mg/mL (12 mg/3 mL)   o 16 mg/mL (48 mg/3 mL)" }

Provocholine is contraindicated in the following:

{ "type": "p", "children": [], "text": "Provocholine is contraindicated in the following:" }

{ "type": "ul", "children": [ "Hypersensitivity to methacholine or other parasympathomimetic agents. Reactions have included rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.", "Baseline FEV1 < 60% predicted (adults or pediatric patients) or <1.5 L (adults)" ], "text": "" }

Severe bronchoconstriction can result from Provocholine administration (including the lowest dose). The use of Provocholine is contraindicated in pediatric and adult patients with baseline FEV1 < 60% predicted or adults with FEV1 < 1.5 L. Emergency equipment and medication should be immediately available to treat acute respiratory distress. Because of the potential for severe bronchoconstriction, the use of Provocholine in patients with clinically apparent asthma or wheezing is not recommended. If severe bronchoconstriction occurs, reverse immediately by the administration of a rapid-acting inhaled β-agonist.

If baseline spirometry is not performed or is measured inaccurately, the initial FEV1 may be underestimated. In this situation, decreases in FEV1 may not be detected after escalating Provocholine doses, which may result in administration of unnecessary higher doses and an increase in the risk for excessive bronchoconstriction.

The supplied Provocholine powder or the Provocholine nebulized aerosol may cause bronchoconstriction in healthcare providers administering Provocholine in a methacholine challenge test. Healthcare providers and any other personnel involved in the administration of Provocholine should take the following precautionary steps:

Provocholine is not recommended for patients with uncontrolled hypertension, aortic aneurysm, or history of myocardial infarction or stroke diseases. Patients with epilepsy, vagotonia, peptic ulcer disease, thyroid disease, urinary tract obstruction or other condition that could be adversely affected by a cholinergic agent should undergo methacholine challenge only if the healthcare practitioner considers the benefit to the individual outweighs the potential risks.

The following adverse reactions associated with the use of Provocholine were identified in clinical studies or post marketing reports. Because some of these reactions were reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

{ "type": "p", "children": [], "text": "The following adverse reactions associated with the use of Provocholine were identified in clinical studies or post marketing reports. Because some of these reactions were reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure." }

Bronchospasm (includes symptoms such as chest tightness, cough or wheezing).

{ "type": "p", "children": [], "text": "Bronchospasm (includes symptoms such as chest tightness, cough or wheezing)." }

Adverse reactions less commonly associated with Provocholine include headache, throat irritation, light-headedness and itching.

{ "type": "p", "children": [], "text": "Adverse reactions less commonly associated with Provocholine include headache, throat irritation, light-headedness and itching." }

Beta-Adrenergic Blockers

{ "type": "p", "children": [], "text": "\nBeta-Adrenergic Blockers\n" }

The use of beta-adrenergic blockers may impair reversal of Provocholine-caused bronchoconstriction.

{ "type": "p", "children": [], "text": "The use of beta-adrenergic blockers may impair reversal of Provocholine-caused bronchoconstriction." }

Beta-Agonists, Anticholinergics, and Theophylline Beta-agonists, anticholinergics, and theophylline inhibit the response of airways to Provocholine; therefore, hold these drugs before Provocholine use for the following duration:

{ "type": "p", "children": [], "text": "\nBeta-Agonists, Anticholinergics, and Theophylline\nBeta-agonists, anticholinergics, and theophylline inhibit the response of airways to Provocholine; therefore, hold these drugs before Provocholine use for the following duration:" }

• Short-acting β-agonists (e.g., albuterol): 6 hours• Long-acting β-agonists (e.g., salmeterol): 36 hours• Short-acting anti-cholinergics (e.g., ipratropium): 12 hours• Long-acting anti-cholinergics (e.g., tiotropium): ≥168 hours• Oral theophylline: 12-48 hours

{ "type": "p", "children": [], "text": "• Short-acting β-agonists (e.g., albuterol): 6 hours• Long-acting β-agonists (e.g., salmeterol): 36 hours• Short-acting anti-cholinergics (e.g., ipratropium): 12 hours• Long-acting anti-cholinergics (e.g., tiotropium): ≥168 hours• Oral theophylline: 12-48 hours" }

Oral or Inhaled Corticosteroids, and Inhaled Cromoglycate

{ "type": "p", "children": [], "text": "\nOral or Inhaled Corticosteroids, and Inhaled Cromoglycate\n" }

Regular use of oral or inhaled corticosteroids and inhaled cromoglycate may acutely decrease bronchial responsiveness to Provocholine. However, these drugs may be continued with Provocholine use.

{ "type": "p", "children": [], "text": "Regular use of oral or inhaled corticosteroids and inhaled cromoglycate may acutely decrease bronchial responsiveness to Provocholine. However, these drugs may be continued with Provocholine use." }

Risk Summary The available data from published literature on Provocholine use in pregnant women are insufficient to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Animal reproduction studies evaluating effects of methacholine chloride on embryofetal development have not been conducted. Diagnosis of bronchial airway hyperreactivity with bronchoprovocation challenge is not recommended for pregnant women because of the potential for hypoxia in the fetus. If bronchial airway hyperreactivity is suspected, consider trial of empiric treatment.

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 United States general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Risk Summary There are no available data on the presence of methacholine chloride in human milk, the effect on the breastfed infant, or the effect on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Provocholine and any potential adverse effects on the breastfed infant from Provocholine or from the underlying maternal condition.

Provocholine is used in a methacholine challenge test for the diagnosis of bronchial airway hyperreactivity in pediatric patients 5 years of age and older who do not have clinically apparent asthma. The safety and effectiveness of Provocholine have not been established in pediatric patients below the age of 5 years.

The diagnosis of bronchial airway hyperreactivity is largely performed in pediatric and younger adult patients. Clinical studies of Provocholine did not include patients 65 years of age or older.

Methacholine chloride, the active ingredient of Provocholine, is a parasympathomimetic (cholinergic) bronchoconstrictor agent. Provocholine (methacholine chloride) powder for solution is administered by oral inhalation.

{ "type": "p", "children": [], "text": "Methacholine chloride, the active ingredient of Provocholine, is a parasympathomimetic (cholinergic) bronchoconstrictor agent. Provocholine (methacholine chloride) powder for solution is administered by oral inhalation." }

Chemically, methacholine chloride (the active ingredient) is 1-propanaminium, 2-(acetyloxy)-N,N,N,-trimethyl-, chloride. It is a white to practically white deliquescent compound, soluble in water, alcohol and chloroform and insoluble in ether. Aqueous solutions are neutral to litmus.

{ "type": "p", "children": [], "text": "Chemically, methacholine chloride (the active ingredient) is 1-propanaminium, 2-(acetyloxy)-N,N,N,-trimethyl-, chloride. It is a white to practically white deliquescent compound, soluble in water, alcohol and chloroform and insoluble in ether. Aqueous solutions are neutral to litmus." }

Methacholine chloride has an empirical formula of C8H18ClNO2, a molecular weight of 195.69, and the following structural formula:

{ "type": "p", "children": [], "text": "Methacholine chloride has an empirical formula of C8H18ClNO2, a molecular weight of 195.69, and the following structural formula:" }

Provocholine Powder for Solution: Each vial of Provocholine contains 100 mg of methacholine chloride powder.

{ "type": "p", "children": [], "text": "\nProvocholine Powder for Solution: Each vial of Provocholine contains 100 mg of methacholine chloride powder." }

Provocholine Solution for Inhalation Kit (Sterile): Each kit is packaged in a carton with six plastic vials with twist-off cap each containing 3 mL of the following concentrations of methacholine chloride solution.   Each solution also contains: Sodium Acetate Trihydrate, Sodium Chloride, glacial acetic acid as pH adjuster.

{ "type": "p", "children": [], "text": "\nProvocholine Solution for Inhalation Kit (Sterile):\nEach kit is packaged in a carton with six plastic vials with twist-off cap each containing 3 mL of the following concentrations of methacholine chloride solution.   Each solution also contains: Sodium Acetate Trihydrate, Sodium Chloride, glacial acetic acid as pH adjuster." }

a) base solution (contains no methacholine chloride)b) 0.0625 mg/mL (0.1875 mg/3 mL)c) 0.25 mg/mL (0.75 mg/3 mL)d) 1 mg/mL (3 mg/3 mL)e) 4 mg/mL (12 mg/3 mL)f) 16 mg/mL (48 mg/3 mL)

{ "type": "p", "children": [], "text": "a) base solution (contains no methacholine chloride)b) 0.0625 mg/mL (0.1875 mg/3 mL)c) 0.25 mg/mL (0.75 mg/3 mL)d) 1 mg/mL (3 mg/3 mL)e) 4 mg/mL (12 mg/3 mL)f) 16 mg/mL (48 mg/3 mL)" }

Methacholine chloride is a cholinergic agonist. Bronchial smooth muscle contains significant parasympathetic (cholinergic) innervation. Methacholine chloride agonizes the muscarinic receptors which eventually induce bronchoconstriction.

After oral inhalation of Provocholine, patients with asthma are more sensitive to Provocholine-induced bronchoconstriction than are healthy subjects. This difference in response is the pharmacological basis for Provocholine in the methacholine challenge test.

There are no metabolic and pharmacokinetic data available on methacholine chloride.

There have been no studies with methacholine chloride that would permit an evaluation of its carcinogenic or mutagenic potential or of its effect on fertility.

How Supplied

{ "type": "p", "children": [], "text": "\nHow Supplied\n" }

{ "type": "ul", "children": [ "Provocholine (methacholine chloride) Powder for Inhalation Solution: in amber glass vials that contain 100 mg of methacholine chloride powder, white to off-white in color. Cartons have 6 vials (NDC 64281-100-06)." ], "text": "" }

{ "type": "ul", "children": [ "Provocholine (methacholine chloride) Inhalation Solution Kit (Sterile):" ], "text": "" }

Each kit (NDC: 64281-110-05) contains six (6) plastic vials with twist-off cap each containing 3 mL of different concentrations of methacholine chloride as shown below. Cartons have six (6) kits (NDC 64281-110-06).

{ "type": "p", "children": [], "text": "Each kit (NDC: 64281-110-05) contains six (6) plastic vials with twist-off cap each containing 3 mL of different concentrations of methacholine chloride as shown below. Cartons have six (6) kits (NDC 64281-110-06)." }

a) base solution (contains no methacholine chloride) (NDC: 64281-111-00)b) 0.0625 mg/mL (0.1875 mg/3 mL) (NDC:64281-112-00)c) 0.25 mg/mL (0.75 mg/3 mL) (NDC:64281-113-00)d) 1 mg/mL (3 mg/3 mL) (NDC:64281-114-00)e) 4 mg/mL (12 mg/3 mL) (NDC:64281-115-00)f) 16 mg/mL (48 mg/3 mL) (NDC:64281-116-00)

{ "type": "p", "children": [], "text": "a) base solution (contains no methacholine chloride) (NDC: 64281-111-00)b) 0.0625 mg/mL (0.1875 mg/3 mL) (NDC:64281-112-00)c) 0.25 mg/mL (0.75 mg/3 mL) (NDC:64281-113-00)d) 1 mg/mL (3 mg/3 mL) (NDC:64281-114-00)e) 4 mg/mL (12 mg/3 mL) (NDC:64281-115-00)f) 16 mg/mL (48 mg/3 mL) (NDC:64281-116-00)" }

Storage and Handling

{ "type": "p", "children": [], "text": "\nStorage and Handling\n" }

{ "type": "ul", "children": [ "Powder for inhalation solution: Store the supplied powder at 59oF to 86oF (15oC to 30oC). Refrigerate the reconstituted and diluted solutions at 36oF to 46oF (2oC to 8oC) for up to 2 weeks [see Dosage and Administration (2.3)].\n" ], "text": "" }

{ "type": "ul", "children": [ "Provocholine inhalation solution kit:  Store between 59oF to 86oF (15°C to 30°C). Use immediately upon opening the vial." ], "text": "" }

Risk of Severe Bronchoconstriction Inform the patient or caregiver that severe bronchoconstriction can result from Provocholine administration [see Warnings and Precautions (5.1)].

{ "type": "p", "children": [], "text": "\nRisk of Severe Bronchoconstriction\nInform the patient or caregiver that severe bronchoconstriction can result from Provocholine administration [see Warnings and Precautions (5.1)]." }

Cough, Chest Tightness, or Shortness of Breath Inform the patient or caregiver that Provocholine may produce mild cough, chest tightness or shortness of breath.

{ "type": "p", "children": [], "text": "\nCough, Chest Tightness, or Shortness of Breath\nInform the patient or caregiver that Provocholine may produce mild cough, chest tightness or shortness of breath." }

Manufactured for:Methapharm, Inc.11772 West Sample Road, Suite 101Coral Springs, FL,USA 33065

{ "type": "p", "children": [], "text": "Manufactured for:Methapharm, Inc.11772 West Sample Road, Suite 101Coral Springs, FL,USA 33065" }

For more information visit www.methapharmrespiratory.com,email ussales@methapharm.comor call 1-833-887-7686.

{ "type": "p", "children": [], "text": "For more information visit www.methapharmrespiratory.com,email ussales@methapharm.comor call 1-833-887-7686." }

®Provocholine is a registered trademark of Methapharm Inc.

{ "type": "p", "children": [], "text": "\n\n®Provocholine is a registered trademark of Methapharm Inc." }

Revision: December 2022

{ "type": "p", "children": [], "text": "Revision: December 2022" }