Tiotropium bromide (Spiriva)

Today's med: Tiotropium bromide (ty oh TRO pee um)  
(brand name: Spiriva HandiHaler) 

Snapshot:   

Use: COPD

·         Action:  long-acting, 24 hour, anticholinergic bronchodilator (Inhibits smooth muscle receptors, 

                     leading to bronchodilation)

·          SE: antimuscarinic effects; urinary retention, constipation, acute angle closure glaucoma, palpitations

·         CI: narrow-angle glaucoma, prostatic hyperplasia, urinaryretention, or bladder-neck obstruction.

Drug Class: Anticholinergic agent

Other Drugs in this class: Ipratropium bromide, Ipratropium bromide/albuterol, Glycopyrronium bromide, Atropine, Benzatropine, Tropicamide, Doxylamine, Dicycloverine, Tiotropium bromide monohydrate, Diphenoxylate/Atropine, Propantheline bromide, Dicyclomine hydrochloride, Benztropine mesylate, Methylscopolamine bromide, Mepenzolate, Mepenzolate bromide, Atropine/Hyoscyamine/Scopolamine/Phenobarbital, Difenoxin/Atropine, Propantheline, Chlorpheniramine/Methscopolamine/Pseudoephedrine, Pseudoephedrine/Methscopolamine, Phenylephrine/Methscopolamine/Chlorpheniramine, Chlorpheniramine/Methscopolamine, Atropine Sulfate, Edrophonium/Atropine

Indications: Maintenance treatment of bronchospasm associated with COPD (including bronchitis and emphysema); reduction of COPD exacerbations

Action:  Competitively and reversibly inhibits the action of acetylcholine at type 3 muscarinic (M₃) receptors in bronchial smooth muscle causing bronchodilation.  Poorly absorbed from GI tract, systemic absorption may occur from lung.

Contraindications: Hypersensitivity to tiotropium or ipratropium, or any component of the formulation (contains lactose)

Adverse Effects:>10%:

Gastrointestinal: Xerostomia (5% to 16%)

Respiratory: Upper respiratory tract infection (41%), pharyngitis (9% to 13%), sinusitis (7% to 11%)

1% to 10%:

Cardiovascular: Chest pain (1% to 7%), edema (dependent, 5%)

Central nervous system: Headache (6%), insomnia (4%), depression (1% to 4%), dysphonia (1% to 3%)

Dermatologic: Rash (4%)

Endocrine & metabolic: Hypercholesterolemia (1% to 3%), hyperglycemia (1% to 3%)

Gastrointestinal: Dyspepsia (6%), abdominal pain (5%), constipation (4% to 5%), vomiting (4%), gastroesophageal reflux (1% to 3%), stomatitis (including ulcerative; 1% to 3%)

Genitourinary: Urinary tract infection (7%)

Neuromuscular & skeletal: Arthralgia (4%), myalgia (4%), arthritis (≥3%), leg pain (1% to 3%), paresthesia (1% to 3%), skeletal pain (1% to 3%)

Ocular: Cataract (1% to 3%)

Respiratory: Rhinitis (6%), epistaxis (4%), cough (≥3%), laryngitis (1% to 3%)

Miscellaneous: Infection (4%), moniliasis (4%), flu-like syndrome (≥3%), allergic reaction (1% to 3%), herpes zoster (1% to 3%)

<1% (Limited to important or life-threatening): Angioedema; application site irritation (glossitis, mouth ulceration, pharyngolaryngeal pain); atrial fibrillation, blurred vision, candidiasis (oral), dizziness, dehydration, dry skin, dysphagia, gingivitis, glaucoma, hoarseness, hypersensitivity reactions, ileus (paralytic), intestinal obstruction, intraocular pressure increased, joint swelling, palpitation, paradoxical bronchospasm, pruritus, pupil dilation (if powder comes in contact with eyes), skin infection, skin ulcer, supraventricular tachycardia, tachycardia, throat irritation, urinary difficulty, urinary retention, urticaria

Concerns related to adverse effects:

• Bronchospasm: Rarely, paradoxical bronchospasm may occur with use of inhaled bronchodilating agents; discontinue use and consider other therapy if bronchospasm occurs.

• Hypersensitivity reactions: Immediate hypersensitivity reactions (urticaria, angioedema, rash, bronchospasm) have been reported. Discontinue immediately if signs/symptoms occur. Use with caution in patients with a history of hypersensitivity to atropine.

Disease-related concerns:

• Glaucoma: Tiotropium may worsen symptoms of narrow-angle glaucoma; use with caution.

• Myasthenia gravis: Tiotropium may worsen symptoms of myasthenia gravis; use with caution.

• Prostatic hyperplasia/bladder neck obstruction: Tiotropium may worsen the symptoms of prostatic hyperplasia and/or bladder neck obstruction; use with caution.

• Renal impairment: Use with caution in patients with moderate-to-severe renal impairment (Cl_cr ≤50 mL/minute); monitor closely for anticholinergic adverse events.

Other warnings/precautions:

• Appropriate administration: Not indicated for the initial (rescue) treatment of acute episodes of bronchospasm.

• Appropriate use: The contents of Spiriva® capsules are for inhalation only via the HandiHaler® device. Capsules should not be swallowed; there have been reports of incorrect administration (swallowing of the capsules).

• Avoid ocular contact: Avoid inadvertent instillation of powder into the eyes; may dilate pupils and/or cause blurred vision. 

Pregnancy Risk Factor C 

Standard Dosing:  Oral inhalation: Adults: Contents of 1 capsule (18 mcg) inhaled once daily using HandiHaler® device. Note: To ensure drug delivery the contents of each capsule should be inhaled twice.

 
Administration

Administer once daily at the same time each day. Remove capsule from foil blister immediately before use. Capsule should not be swallowed. Place capsule in the capsule-chamber in the base of the HandiHaler® Inhaler. Must only use the HandiHaler® Inhaler. Close mouthpiece until a click is heard, leaving dustcap open. Exhale fully. Do not exhale into inhaler. Tilt head slightly back and inhale (rapidly, steadily and deeply); the capsule vibration may be heard within the device. Hold breath as long as possible. If any powder remains in capsule, exhale and inhale again. Repeat until capsule is empty. Throw away empty capsule; do not leave in inhaler. Do not use a spacer with the HandiHaler® Inhaler. Do not use HandiHaler® device for other medications. Always keep capsules and inhaler dry.

Delivery of dose: Instruct patient to place mouthpiece gently between teeth, closing lips around inhaler. Instruct patient to inhale deeply and hold breath for 5-10 seconds. The amount of drug delivered is small, and the individual will not sense the medication as it is inhaled. Remove mouthpiece prior to exhalation. Patient should not breathe out through the mouthpiece.

Drug interactions:  Drug interactions Link

A total of 342 drugs (2481 brand and generic names) are known to interact with tiotropium.

• 340 moderate drug interactions (2475 brand and generic names)
• 2 minor drug interactions (6 brand and generic names)

Show all medications in the database that may interact with tiotropium.

DO NOT USE in cases of urinary retention, Myesthenia gravis, Prostatic hyperplasia/bladder neck obstruction, Glaucoma or renal impairment.

COPD: need to 'Tiotrate' your breathing (not for acute episodes)