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]

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

V. Dosing: Asthma

  1. Avoid in age <6 years
  2. Spiriva (Tiotropium) Respimat (half dose of COPD preparation) for age >=6 years
    1. Two 1.25 mg dose inhalations once daily

VI. Dosing: Combinations

  1. Stiolto Respimat (Tiotropium/Olodaterol)
    1. Long-Acting Beta-2 Agonist (Olodaterol) combined with long-acting Anticholinergic (Tiotropium)
    2. Inhale once daily

VII. Precautions

  1. See Long-acting Anticholinergic Bronchodilator
  2. 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. Efficacy

  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

X. Safety

  1. Pregnancy Category C
  2. Avoid in Lactation

XII. 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

tiotropium (on 10/18/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
TIOTROPIUM 18 MCG CAP-INHALER Generic $13.88 each
spiriva (on 1/1/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
SPIRIVA RESPIMAT 1.25 MCG INH $122.86 per gram
SPIRIVA RESPIMAT 2.5 MCG INH $122.72 per gram