Tiotropium Inhalers

1. Introduction

Tiotropium is a long-acting muscarinic antagonist (LAMA) used as a bronchodilator for managing chronic obstructive pulmonary disease (COPD) and asthma. It works by blocking muscarinic (M3) receptors in the airway, leading to bronchodilation and reduced mucus secretion.

2. Indications

  • Chronic Obstructive Pulmonary Disease (COPD): Maintenance treatment to reduce symptoms and exacerbations.
  • Asthma (Adults & Children ≥6 years): Add-on therapy in moderate to severe persistent asthma not controlled by inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA).

3. Dosage

Adults & Elderly:

  • COPD:
    • 18 mcg once daily via HandiHaler (dry powder inhaler).
    • 2.5 mcg once daily via Respimat (soft mist inhaler, 2 inhalations per dose).
  • Asthma (Adults & Adolescents ≥6 years):
    • 2.5 mcg once daily via Respimat (2 inhalations per dose).

Paediatric Use:

  • Children ≥6 years with severe asthma: 2.5 mcg once daily (Respimat).
  • Children <6 years: Not recommended.

Renal Impairment:

  • No dose adjustment, but use with caution in severe renal disease (CrCl <30 mL/min) due to increased drug exposure.

Hepatic Impairment:

  • No dose adjustment required.

4. Administration

  • HandiHaler (Capsules for Inhalation):
    • Insert the capsule into the HandiHaler device.
    • Press the piercing button once to puncture the capsule.
    • Inhale deeply and slowly through the mouthpiece.
    • Do not swallow the capsule.
  • Respimat (Soft Mist Inhaler):
    • Prime before first use by pressing the dose-release button until a mist appears.
    • Take two inhalations once daily.
    • Hold breath for 5–10 seconds after inhaling.
  • General Instructions:
    • Use at the same time each day.
    • Rinse mouth after use to reduce dry mouth and throat irritation.
    • Do not expose to moisture; store inhaler properly.

5. Forms Available

  • HandiHaler (Dry Powder Inhaler): 18 mcg capsule for inhalation.
  • Respimat (Soft Mist Inhaler): 2.5 mcg per puff, 60 puffs per inhaler.

6. Side Effects

6.1 Common Side Effects:

  • Dry mouth
  • Throat irritation
  • Cough
  • Headache

6.2 Less Common Side Effects:

  • Dizziness
  • Hoarseness
  • Constipation

6.3 Rare but Serious Side Effects:

  • Paradoxical bronchospasm (worsening breathing difficulty)
  • Blurred vision and eye pain (if mist contacts eyes, risk of acute angle-closure glaucoma)
  • Urinary retention (especially in older men with prostate issues)
  • Palpitations or arrhythmias

7. Warnings

  • Not for Acute Relief: Tiotropium is not a rescue inhaler. Use salbutamol (albuterol) for acute symptoms.
  • Glaucoma Risk: Avoid eye contact with mist; may cause acute angle-closure glaucoma.
  • Urinary Retention: Caution in benign prostatic hyperplasia (BPH) and bladder obstruction.
  • Paradoxical Bronchospasm: Discontinue immediately if symptoms worsen after use.

8. Precautions

  • Avoid in patients with severe hypersensitivity to atropine derivatives.
  • Use with caution in patients with cardiovascular diseases, as it may cause palpitations or arrhythmias.
  • Monitor elderly patients for dry mouth, constipation, and urinary retention.

9. Interactions

  • Other Anticholinergics (e.g., ipratropium, glycopyrronium): Increased risk of systemic anticholinergic effects.
  • Beta-Agonists (e.g., salmeterol, formoterol): Safe to use together for additional bronchodilation.
  • Diuretics (e.g., furosemide): May worsen dehydration and electrolyte imbalances.

10. Monitoring Parameters

  • Lung function (FEV1, peak flow): Regular monitoring in COPD/asthma patients.
  • Signs of urinary retention: Difficulty urinating, weak stream.
  • Dry mouth and constipation: Monitor in elderly patients.

11. Use in Children

  • Approved for asthma in children ≥6 years via Respimat.
  • Not recommended for children <6 years.

12. Use in Pregnancy

  • Category C: Use only if the benefits outweigh the risks.
  • No conclusive human studies, but animal data suggest potential fetal harm.

13. Use in Elderly

  • Safe in elderly patients, but monitor for urinary retention, constipation, and dry mouth.

14. Use in Kidney Disease

  • No dose adjustment, but use with caution in severe renal impairment (CrCl <30 mL/min).

15. Use in Liver Disease

  • No dose adjustment required.

16. Patient Counselling Points

  • Do not use tiotropium as a rescue inhaler; always keep a salbutamol inhaler for sudden breathing difficulties.
  • Use inhaler properly: Learn correct technique to ensure effectiveness.
  • Avoid getting the mist in your eyes (can cause blurred vision and eye pain).
  • Drink plenty of water and use sugar-free gum to help with dry mouth.
  • Report difficulty urinating or constipation to your doctor.
  • Clean inhaler weekly to prevent clogging.

17. Table of Brand Names, Manufacturer, and Prices in USD

Brand NameManufacturerStrength/Dosage FormPrice (USD)
Spiriva HandiHalerBoehringer Ingelheim18 mcg Capsule$90 (30 doses)
Spiriva RespimatBoehringer Ingelheim2.5 mcg/puff Inhaler$120 (60 doses)
Generic TiotropiumVarious18 mcg Capsule$60 (30 doses)

18. 15 FAQs (Frequently Asked Questions)

1. What is Tiotropium used for?
Tiotropium is used for COPD and asthma maintenance therapy.

2. Can Tiotropium be used for asthma?
Yes, it is an add-on therapy for severe asthma in patients ≥6 years.

3. How long does Tiotropium take to work?
Bronchodilation starts within 30 minutes, with peak effect in 3–4 hours.

4. Can Tiotropium be used in acute asthma attacks?
No, it is not a rescue medication. Use salbutamol or albuterol for sudden symptoms.

5. What is the difference between HandiHaler and Respimat?

  • HandiHaler: Uses capsules for inhalation (18 mcg, once daily).
  • Respimat: Soft mist inhaler (2.5 mcg per puff, two puffs once daily).

6. Can Tiotropium cause dry mouth?
Yes, dry mouth is a common side effect.

7. Can Tiotropium be taken with other inhalers?
Yes, it is often combined with LABAs (salmeterol, formoterol) for better control.

8. What should I do if I miss a dose?
Take it as soon as possible, but do not double dose.

9. Can Tiotropium cause eye problems?
Yes, if mist enters the eyes, it can increase eye pressure and cause glaucoma.

10. Can Tiotropium cause palpitations?
Yes, but it is uncommon.