tiotropium bromide monohydrate: clinical use

Prescribing considerations

• Confirm a maintenance indication and a separate acute-relief plan.
• In asthma, use only as add-on anti-inflammatory treatment.
• Assess the patient’s ability to prepare and operate the Respimat device.
• Use only when expected benefit outweighs risk in moderate-to-severe renal impairment.
• Use caution with narrow-angle glaucoma, prostatic hyperplasia, bladder-neck obstruction and relevant recent or unstable cardiac disease.
• Benzalkonium chloride may provoke wheezing or breathing difficulty, particularly in asthma.

Contraindications and cautions

• Hypersensitivity to tiotropium, any listed excipient, atropine or atropine derivatives such as ipratropium or oxitropium.

Monitoring

• Symptom control, exacerbations and reliance on rapid-acting relief.
• Adherence and inhaler technique.
• Dry mouth, dental health, ocular symptoms, urinary retention and other anticholinergic effects.
• Renal function and tolerability with renal impairment.
• Cardiac symptoms in patients with relevant cardiovascular risk.

Clinical pharmacology

Tiotropium is a quaternary ammonium, long-acting muscarinic antagonist. Slow dissociation from airway M3 receptors supports prolonged bronchodilation. Absorbed medicine is cleared mainly through the kidneys.

Formulation and product differences

• The selected formulation is a clear inhalation solution in a replaceable cartridge for the reusable Respimat soft-mist inhaler.
• Technique differs from capsule-based tiotropium dry-powder inhalers; devices and cartridges should not be interchanged without appropriate instructions.
• The solution contains benzalkonium chloride, which may cause bronchospasm or breathing difficulty.

Inhaled preparation

Route: Inhaled

Strengths: 2.5 micrograms

Capsule

Route: Oral

Strengths: 18 micrograms