Tiotropium

Spiriva

bronchodilator lamainhaled (dry powder — HandiHaler) · inhaled (soft mist — Respimat)Onset: 30 minutesDuration: 24+ hours (once-daily dosing)

Mechanism of Action

Long-acting muscarinic antagonist (LAMA). Dissociates very slowly from M1 and M3 receptors, providing prolonged bronchodilation. Blocks parasympathetic bronchoconstriction and reduces mucus hypersecretion.

Dosing

Adult

HandiHaler: 18 mcg (one capsule) inhaled once daily. Respimat inhaler: 2.5 mcg × 2 actuations (5 mcg total) once daily

Once-daily dosing due to long receptor binding kinetics

Indications

COPD maintenance therapy (first-line)
Asthma (adjunct in adults uncontrolled on ICS/LABA)
Reduction of COPD exacerbations

Contraindications

Hypersensitivity to tiotropium, atropine, or ipratropium
Acute narrow-angle glaucoma

Side Effects

Dry mouth (most common)
Constipation
Urinary retention
Pharyngitis
Sinusitis
Paradoxical bronchospasm

Monitoring Parameters

FEV1 and spirometry
COPD exacerbation frequency
Urinary symptoms (especially in men with BPH)
Intraocular pressure (glaucoma patients)

Drug Interactions

Other anticholinergics (additive effects)
Do not combine with ipratropium

Clinical Pearls

Once-daily dosing improves compliance vs. ipratropium
Capsules for HandiHaler are NOT to be swallowed — inhale only
Respimat inhaler (soft mist) has different technique than MDI
Reduces COPD exacerbation rate; shown to be superior to ipratropium for COPD maintenance
Not indicated for acute bronchospasm — onset too slow

Mnemonic

💡 TiO = Twenty-four hOurs — one puff a day keeps COPD at bay

NBRC High-Yield

LAMA — once-daily maintenance for COPD
Do NOT use for acute bronchospasm (onset 30 min; duration 24 hr)
Capsules for HandiHaler must be inhaled, NOT swallowed
Superior to ipratropium for COPD maintenance
Side effect: dry mouth most common; urinary retention in BPH patients

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