Investigate the Impact of Early Treatment Initiation With Tiotropium in Patients Recovering From Hospitalization for an Acute COPD Exacerbation 1

• The primary endpoint is trough FEV1 (forced expiratory volume in 1 second) at 12 weeks on study medication. Trough FEV1 is defined as FEV1 measurement prior to the next dosing of study drug and approximately 24 hours after the last inhalation of drug. [ Time Frame: 12 weeks ] [ Designated as safety issue: No ]
• The primary endpoint for combined data from trials 205.477 and 205.478 will be time to the next adverse COPD outcome event defined as the combined endpoint of COPD exacerbations per BI definition, all-cause re-hospitalization, or all-cause mortality. [ Time Frame: Up to 2 years ] [ Designated as safety issue: No ]

• Lung function: Trough FVC at 12 weeks [ Time Frame: 12 weeks ] [ Designated as safety issue: Yes ]
• Time to event: Time to next adverse COPD outcome [ Time Frame: Up to 2 years ] [ Designated as safety issue: Yes ]

A randomized, placebo-controlled, double-blind, parallel group, multi center study to assess the safety and efficacy of tiotropium bromide (18 µg) delivered via the HandiHaler® in Chronic Obstructive Pulmonary Disease (COPD) subjects recovering from hospitalization for an acute exacerbation (Hospital Discharge 1)

• Drug: tiotropium bromide
  18 mcg QD
• Drug: Placebo
  QD

• Active Comparator: 18 mcg tiotropium
  Patient to receive one tiotropium bromide inhalation powder capsule daily (in the morning) via HandiHaler
  Intervention: Drug: tiotropium bromide
• Placebo Comparator: Placebo
  Patient to receive one placebo capsule daily (in the morning) identical to those containing tiotropium bromide inhalation powder via HandiHaler
  Intervention: Drug: Placebo

Inclusion criteria:

The following inclusion criteria apply at Visit 0:

1. All subjects must sign an informed consent consistent with the International Conference on Harmonization - Good Clinical Practice (ICH-GCP) guidelines prior to participation in the trial and conducting any study procedures.
2. Male or female subjects 40 years of age or older.
3. Hospitalization for a primary diagnosis of acute COPD exacerbation for =14 days. Determination of accuracy of admission diagnosis will be at the discretion of the investigator.

4. Patient reported hospital length of stay and discharge date (confirmed with hospital discharge summary/hospital records; however, medical record confirmation may occur following randomization).

   The following inclusion criteria apply at Visit 1:

5. Discharged from the hospital =10 days from date of randomization.
6. All subjects must have a diagnosis of COPD (P12-01205), and have documented airway obstruction with a post-bronchodilator FEV1/FVC <0.7(See Section 5.1.2, Pulmonary Function Testing). The diagnosis of COPD can be made at Visit 1 if no PFT data available within the past 12 months.

7. Subjects must be current or ex-smoker with a smoking history of =10 pack-years:

   Pack-years = Number of cigarettes/day x years of smoking 20 cigarettes/ pack

8. Subjects must be able to inhale medication in a competent manner from the HandiHaler® device (Appendix 10.1) and from a metered dose inhaler (MDI).

Exclusion criteria:

The following exclusion criterion applies at Visit 0:

1. Therapy with any long-acting inhaled anticholinergic 14 days prior to hospitalization or any other restricted concomitant medications.

   The following exclusion criteria apply at Visit 1:

2. Presence of a significant disease (in the opinion of the investigator) which may put the subject at risk because of participation in the study or may influence the subject's ability to participate in the study for up to 2 years.
3. A recent history (i.e., six months or less) of myocardial infarction. Subjects being stable with a history of cardiac stents prior to six months are permitted.
4. Any unstable or life-threatening cardiac arrhythmia requiring intervention or change in drug therapy during the last year.
5. Subjects with asthma (subject treated for asthma in the last 2 years, history of childhood asthma is permitted), cystic fibrosis, clinical diagnosis of bronchiectasis, interstitial lung disease, pulmonary thromboembolic disease or known active tuberculosis.
6. A history of thoracotomy with pulmonary resection. Subjects with a history of thoracotomy for other reasons should be evaluated as per exclusion criterion no. 2.
7. Malignancy for which the subject has undergone resection, radiation, chemotherapy or biological treatments within the last two years or is currently on active radiation therapy, chemotherapy or biological treatment. Subjects with treated basal cell carcinoma and non-invasive squamous cell skin carcinoma are allowed.
8. Hospitalization for cardiac failure (New York Heart Association (NYHA) class III or IV) during the past year.
9. Known hypersensitivity to anticholinergic drugs, lactose, or any other components of the HandiHaler® or MDI inhalation solution delivery system.
10. Known moderate to severe renal impairment as judged by the investigator.
11. Known narrow angle glaucoma as judged by the investigator.
12. Significant symptomatic prostatic hyperplasia or bladder-neck obstruction. Subjects whose symptoms are controlled on treatment may be included.
13. Pregnant or nursing women or women of childbearing potential not using a medically approved means of contraception (i.e., oral contraceptives, intrauterine devices, diaphragm or sub dermal implants e.g., Norplant) for at least three months prior to and for the duration of the trial.
14. Significant alcohol or drug abuse within the past 12 months.
15. Previously randomized in this study or currently participating in another interventional study.
16. Visual impairment that as judged by the investigator does not allow the subject to independently read and complete the questionnaires and eDiary.
17. Any significant or new ECG findings at Visit 1 as judged by the investigator, including, but not limited to signs of acute ischemia, arrhythmia.
18. Treatment with any restricted pulmonary medication.
19. Residing in an assisted living facility.
20. Use of chronic oxygen therapy for > 12 hours/day prior to hospitalization.