II. Indication

  1. Chronic Obstructive Pulmonary Disease (COPD)
  2. Severe Asthma (third-line agent)
    1. May be added to high dose Inhaled Corticosteroid and long acting beta agonist
    2. However, other standard Asthma agents are preferred first
    3. (2015) Presc Lett 22(12):71-2
    4. Kerstgens (2015) Lancet respir med 3(5):367–76 [PubMed]

III. Mechanism

  1. Long-acting Anticholinergic Bronchodilator

IV. Dosing: COPD

  1. Spiriva (Tiotropium) Handihaler (Dry powder)
    1. Inhale one 18 mcg dose once daily
  2. Spiriva (Tiotropium) Respimat (mist)
    1. Two 2.5 mg dose inhalations once daily
  3. Tudorza Pressair (Aclidinium)
    1. Inhale twice daily
    2. May be easier to use than Spiriva (but is twice daily dosing)
  4. Incruse (Umeclidinium)
    1. Inhale one dose once daily
  5. Seebri Neohaler (Glycopyrolate)
    1. Inhale twice daily

V. Dosing: Asthma

  1. Spiriva (Tiotropium) Respimat (half dose of COPD preparation)
    1. Two 1.25 mg dose inhalations once daily

VI. Dosing: Combinations

  1. Anoro Ellipta (Umeclidinium/vilanterol)
    1. Long-Acting Beta-2 Agonist (vilanterol) combined with long-acting Anticholinergic (Umeclidinium)
    2. Inhale one dose once daily
  2. Stiolto (Tiotropium/Olodaterol)
    1. Long-Acting Beta-2 Agonist (Olodaterol) combined with long-acting Anticholinergic (Tiotropium)
    2. Inhale once daily
  3. Utibron (Glycopyrolate/Indaceterol)
    1. Long-Acting Beta-2 Agonist (Indaceterol) combined with long-acting Anticholinergic (Glycopyrolate)
    2. Inhale twice daily
  4. Bevespi Aerosphere (Formoterol/Glycopyrrolate)
    1. Two inhalations twice daily

VII. Precautions

  1. Avoid use of long-acting Anticholinergic (e.g. Spiriva) with Atrovent or Combivent due to minimal added benefit
    1. Use Albuterol MDI as short acting rescue medication instead of short acting Ipratropium
    2. Exception: May use Atrovent or Combivent while starting Spiriva in first 8-10 days

VIII. Advantages: Spiriva (likely applies to Tudorza as well)

  1. Improves mean FEV1, Dyspnea and quality of life
  2. Decreased COPD exacerbations and hospitalizations
  3. More effective than Ipratropium Bromide in COPD (10 fold increase in potency)
  4. At least as effective as Salmeterol in COPD
  5. Better compliance due to once daily dosing

IX. Disadvantages

  1. Expensive: $220 to as much as $300 per month
  2. May cause Dry Mouth

X. Adverse Effects: Spiriva (likely applies to Tudorza as well)

  1. Serious adverse effects
    1. Angioedema or other Hypersensitivity Reaction
    2. Paradoxical bronchospasm
    3. Glaucoma exacerbation
    4. Cerebrovascular Accident
      1. Initial report suggests risk as high as 2 cases per 1000 patients per year
      2. Confirmatory studies required and patients may continue on Spiriva currently
      3. (2008) Prescriber's Letter 15(4):21
  2. Common adverse effects
    1. Anticholinergic effects (e.g. blurred vision, Constipation, Dry Mouth, Urinary Retention)
    2. Gastrointestinal upset (e.g. Abdominal Pain, Dyspepsia)
    3. Rhinorrhea or Epistaxis

XI. References

  1. (2016) Presc Lett 23(2): 10
  2. (2015) Presc Lett 22(1): 4-5
  3. (2012) Presc Lett 19(12): 70
  4. Panning (2003) Pharmacotherapy 23:183-9 [PubMed]
  5. Hutton (2004) Am Fam Physician 69(12):2901-2 [PubMed]

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Cost: Medications

spiriva (on 2/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
SPIRIVA 18 MCG CP-HANDIHALER $11.80 each
SPIRIVA RESPIMAT 1.25 MCG INH $88.39 per gram
SPIRIVA RESPIMAT 2.5 MCG INH $88.50 per gram
incruse (on 10/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
INCRUSE ELLIPTA 62.5 MCG INH $9.52 each
anoro ellipta (on 2/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
ANORO ELLIPTA 62.5-25 MCG INH $5.47 each
stiolto (on 2/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
STIOLTO RESPIMAT INHAL SPRAY $81.80 per gram

Ontology: tiotropium (C0213771)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C079890
SnomedCT 407730002, 409169006
English tiotropium, tiotropium [Chemical/Ingredient], TIOTROPIUM, Tiotropium, Tiotropium (product), Tiotropium (substance)
Spanish tiotropio (producto), tiotropio, tiotropio (sustancia)

Ontology: Spiriva (C0905678)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C079890
English spiriva, Spiriva