Long-acting anticholinergic bronchodilator indicated for once-daily maintenance treatment of bronchospasm associated with COPD (including reduction of exacerbations) and maintenance of asthma in patients ≥ 6 years.
Also known as: Spiriva, tiotropium
DailyMed approved label (SPIRIVA RESPIMAT, Boehringer Ingelheim; setID 7b656b14-fcaa-2741-f6f0-e0be48971c02).
DailyMed approved label (SPIRIVA RESPIMAT, Boehringer Ingelheim; setID 7b656b14-fcaa-2741-f6f0-e0be48971c02).
Ipratropium + tiotropium: additive anticholinergic effect — avoid combining anticholinergics.
The FDA labels of ipratropium (section 7.1) and tiotropium (section 7.2) document that anticholinergics interact additively with other anticholinergic medications and recommend avoiding administration with other anticholinergic-containing drugs. Combining two inhaled anticholinergics (LAMA + SAMA) adds no proven bronchodilator benefit and increases the risk of systemic anticholinergic effects — dry mouth, constipation, urinary retention, tachycardia and angle-closure glaucoma, especially in the elderly with prostatic hypertrophy or prior constipation. The practical guidance is to use only one inhaled anticholinergic, choosing the most appropriate for the patient; if the combination is unavoidable, monitor systemic symptoms and urinary function.
Ipratropium + tiotropium: additive anticholinergic effect — avoid combining two inhaled anticholinergics.
The FDA labels of ipratropium (section 7.1) and tiotropium (section 7.2) document: "Anticholinergics: May interact additively with concomitantly used anticholinergic medications. Avoid administration with other anticholinergic-containing drugs". Combining two inhaled anticholinergics increases the risk of systemic anticholinergic effects (dry mouth, urinary retention, angle-closure glaucoma, constipation) without proven additional bronchodilator benefit.
If unavoidable, monitor for dry mouth, urinary retention, constipation and visual changes.
Acute urinary retention, acute glaucoma or tachycardia with the combination.
Avoid combining two inhaled anticholinergics (ipratropium + tiotropium); choose monotherapy with the most appropriate agent.
DailyMed/FDA (NIH/NLM) — approved Ipratropium label (section 7.1): https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=133cc2ed-f018-4295-b84e-b24382299360 ; approved Tiotropium label (section 7.2): https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=496b38ee-45b6-4bb2-a35e-9023c3b73719
Tiotropium is given by inhalation; food does not affect its pharmacokinetics.
May be administered regardless of meals.
DailyMed approved label (SPIRIVA RESPIMAT, Boehringer Ingelheim; setID 7b656b14-fcaa-2741-f6f0-e0be48971c02).
No relevant pharmacokinetic interaction; usual moderation during treatment.
Moderate alcohol intake.
DailyMed approved label (SPIRIVA RESPIMAT, Boehringer Ingelheim; setID 7b656b14-fcaa-2741-f6f0-e0be48971c02).
Tiotropium elimination is predominantly renal; accumulation may occur.
Use with caution in severe renal impairment.
EMC-UK (MHRA) — approved Tiotropium SmPC: https://www.medicines.org.uk/emc/product/1693/smpc
Long-acting inhaled anticholinergics may precipitate acute glaucoma.
Instruct the patient to avoid eye contact; monitor ocular symptoms.
EMC-UK (MHRA) — approved Tiotropium SmPC: https://www.medicines.org.uk/emc/product/1693/smpc
Data on tiotropium in pregnancy are limited; use only if the benefit outweighs the risk.
Avoid in the 1st trimester unless strictly necessary.
Excretion into breast milk is unknown; use with caution.
No specific additional contraception.
EMC-UK (MHRA) — approved Tiotropium SmPC: https://www.medicines.org.uk/emc/product/1693/smpc
Clinical and educational support tool. The information does not replace a medical prescription or the opinion of a qualified healthcare professional.
Long-acting antimuscarinic: blockade of M3 receptors of airway smooth muscle produces sustained bronchodilation (> 24 hours); prevention of methacholine-induced bronchoconstriction is dose-dependent and lasts longer than 24 hours.
Competitive, reversible antagonism of M1–M5 muscarinic receptors, with predominant effect via M3 on bronchial smooth muscle; the effect is predominantly site-specific, at the site of inhalation.
Systemic bioavailability of 2–3% after inhalation (the inhaled fraction acts locally); oral absorption of the swallowed fraction is minimal.
Minimal hepatic metabolism (non-enzymatic ester cleavage); elimination is predominantly renal (unchanged) and fecal.
Effective half-life of 25 hours (COPD) and 44 hours (asthma) after once-daily inhalation.
Medicines from the same therapeutic group (ATC classification) or the same pharmacological class.
