Bronchodilator Pregnancy: C — limited data; use only if benefit outweighs risk

Tiotropium

Brand names: Spiriva, Spiriva Respimat

Adult dose

Dose: 18mcg OD (HandiHaler) or 5mcg OD (Respimat)

Route: Inhaled (dry powder or mist)

Frequency: Once daily

Max: 18mcg/day (HandiHaler); 5mcg/day (Respimat)

COPD maintenance: once daily at same time each day. If using Respimat (2.5mcg/actuation): 2 puffs = 5mcg. Do not swallow capsule contents — only for inhalation device.

Dose adjustments

Renal

Use with caution if GFR <50 ml/min — renally excreted. Risk of anticholinergic side effects.

Clinical pearls

UPLIFT trial: tiotropium in COPD reduced exacerbations by 14%, hospitalisations by 14%, and improved QoL vs placebo.
Long-acting anticholinergic (LAMA) — foundation of GOLD group B/E COPD treatment. First-line for symptomatic COPD.
Spiriva Respimat vs HandiHaler: equivalent efficacy. Respimat initially raised AF concern (TIOSPIR trial resolved — no significant CV difference).
Patient instruction: insert capsule, press button to pierce, inhale DEEPLY and QUICKLY for dry powder; slow and steady for mist inhaler.

Contraindications

Hypersensitivity to atropine or ipratropium
Acute angle-closure glaucoma (relative — systemic absorption minimal)
Symptomatic prostate hypertrophy / bladder neck obstruction

Side effects

Dry mouth (most common — 16%)
Urinary tract infection
Constipation
Urinary retention (especially elderly males)
Tachycardia (rare — much less than beta-agonists)

Interactions

Other anticholinergic drugs: additive effect — avoid combination
Ipratropium: do not co-prescribe

Monitoring

FEV₁
CAT/mMRC score
exacerbation frequency
symptoms of urinary retention

Reference: GOLD COPD Guidelines 2024; UPLIFT Trial NEJM 2008; NICE BNF 84. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pediatric Asthma Severity Score (PASS) · Paediatric Respiratory

Drugs

Pathways