Tiotropium

1. Indication
   1. Chronic Obstructive Pulmonary Disease (COPD)
2. Mechanism
   1. Long-acting Anticholinergic Bronchodilator
3. Dosing
   1. Inhale one 18 mcg dose once daily
4. Precautions
   1. Avoid use of 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
5. Advantages
   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
6. Disadvantages
   1. Expensive: $117 per month
   2. May cause Dry Mouth
7. Adverse Effects
   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
8. References
   1. Panning (2003) Pharmacotherapy 23:183-9
   2. Hutton (2004) Am Fam Physician 69(12):2901-2