II. Indication
- Chronic Obstructive Pulmonary Disease (COPD)
-
Severe Asthma (third-line agent)
- May be added to high dose Inhaled Corticosteroid and long acting beta Agonist
- However, other standard Asthma agents are preferred first
- (2015) Presc Lett 22(12):71-2
- Kerstgens (2015) Lancet respir med 3(5):367–76 [PubMed]
III. Mechanism
- Long-acting Anticholinergic Bronchodilator or Long-Acting Muscarinic Antagonist (LAMA)
IV. Dosing: COPD
-
Spiriva (Tiotropium) Handihaler (Dry powder)
- Inhale one 18 mcg dose once daily
-
Spiriva (Tiotropium) Respimat (mist)
- Two 2.5 mg dose inhalations once daily
- Tudorza Pressair (Aclidinium)
- Inhale twice daily
- May be easier to use than Spiriva (but is twice daily dosing)
- Incruse (Umeclidinium)
- Inhale one dose once daily
- Seebri Neohaler (Glycopyrolate)
- Inhale twice daily
- Lonhala Magnair (Glycopyrolate) Neb
- Inhale 1 vial (25 mcg) twice daily
- Lonhala is a LAMA delivered by proprietary, portable nebulizer (Magnair)
- Prescribed as a starter kit (includes nebulizer) and then as a refill kit
- Expensive (3 fold increased cost over inhaled LAMA agents) and unlikely to offer added benefit for most
- References
- (2018) Presc Lett 25(6): 36
- Revefenacin (Yupelri)
- LAMA that is nebulized once daily
- Expensive ($1000/month) at the time of release in 2019
- Consider inhaled LAMA instead for less than half the cost (e.g. Spiriva, Incruse)
- Consider nebulized Ipratropium four times daily at $25/month instead (or combined with Albuterol in duonebs)
- (2019) Presc Lett 26(4): 22
V. Dosing: Combinations
- Anoro Ellipta (Umeclidinium/Vilanterol)
- Long-Acting Beta-2 Agonist (Vilanterol) combined with long-acting Anticholinergic (Umeclidinium)
- Inhale one dose once daily
- Stiolto Respimat (Tiotropium/Olodaterol)
- Long-Acting Beta-2 Agonist (Olodaterol) combined with long-acting Anticholinergic (Tiotropium)
- Inhale once daily
- Utibron (Glycopyrolate/Indaceterol)
- Long-Acting Beta-2 Agonist (Indaceterol) combined with long-acting Anticholinergic (Glycopyrolate)
- Inhale twice daily
-
Bevespi Aerosphere (Formoterol/Glycopyrrolate)
- Two inhalations twice daily
VI. Precautions
- Avoid use of long-acting Anticholinergic (e.g. Spiriva) with Atrovent or Combivent due to minimal added benefit
- Use Albuterol MDI as short acting rescue medication instead of short acting Ipratropium
- Exception: May use Atrovent or Combivent while starting Spiriva in first 8-10 days
VII. Adverse Effects
- Serious adverse effects
- Angioedema or other Hypersensitivity Reaction
- Paradoxical bronchospasm
- Glaucoma exacerbation (esp. if dry powder contacts eye)
- Myasthenia Gravis exacerbation
- Cerebrovascular Accident
- Initial report suggests risk as high as 2 cases per 1000 patients per year
- Confirmatory studies required and patients may continue on Spiriva currently
- (2008) Prescriber's Letter 15(4):21
- Common adverse effects
- Anticholinergic effects (e.g. Blurred Vision, Constipation, Dry Mouth, Urinary Retention)
- Gastrointestinal upset (e.g. Abdominal Pain, Dyspepsia)
- Rhinorrhea or Epistaxis
VIII. References
- (2016) Presc Lett 23(2): 10
- (2015) Presc Lett 22(1): 4-5
- (2012) Presc Lett 19(12): 70
- Panning (2003) Pharmacotherapy 23:183-9 [PubMed]
- Hutton (2004) Am Fam Physician 69(12):2901-2 [PubMed]
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Related Studies
| incruse (on 8/17/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| INCRUSE ELLIPTA 62.5 MCG INH | $11.32 each | |
| anoro ellipta (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| ANORO ELLIPTA 62.5-25 MCG INH | $7.37 each | |
| stiolto (on 1/1/2023 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| STIOLTO RESPIMAT INHAL SPRAY | $112.67 per gram | |
| lonhala magnair (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| LONHALA MAGNAIR 25 MCG REFILL | $20.16 per ml | |
| yupelri (on 7/5/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| YUPELRI 175 MCG/3 ML SOLUTION | $12.96 per ml | |