Asthma
Adjunct
In severe asthma at 2024 steps 4–5, tiotropium is added to ICS+LABA as triple therapy. Reduces exacerbation frequency and improves lung function. Not used as asthma monotherapy.
Sources
Long-acting muscarinic antagonist for inhalation (LAMA)
ATC code: R03BB04 (Tiotropium)
Brand names
Spiriva Respimat, Spiriva HandiHaler, Spiriva
Competitive antagonist at muscarinic M1–M5 receptors with slow dissociation from M3 receptors of bronchial smooth muscle (dissociation half-life around 35 hours). Reduces vagal tone, relaxes bronchial muscle and suppresses mucus hypersecretion. The 24-hour duration allows once-daily dosing. Inhaled systemic absorption is low (about 33% of dose), with most of the drug excreted unchanged in urine.
Adjunct
In severe asthma at 2024 steps 4–5, tiotropium is added to ICS+LABA as triple therapy. Reduces exacerbation frequency and improves lung function. Not used as asthma monotherapy.
Sources
First line
Tiotropium is a first-line LAMA for COPD maintenance. 2024 and GesEPOC 2024 recommend LAMA monotherapy in group B; with frequent exacerbations a LABA is added (LABA+LAMA: Spiolto, Anoro) or triple therapy ICS+LABA+LAMA (Trelegy, Trimbow). The Cochrane 2018 network meta-analysis (Oba) showed comparable efficacy with aclidinium and umeclidinium for exacerbations and mortality.
Adjunct
Tiotropium Respimat is add-on therapy for severe asthma in adults and adolescents from age 6 when ICS+LABA fail to achieve control. 2024 positions tiotropium at steps 4–5 as an option before biologics. approved tiotropium Respimat for asthma in adults in 2014 and in children from age 6 in 2017. Marketing of tiotropium in mild asthma or in children under 6 is off-label without RCT support.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Tiotropium is offered off-label as a «training bronchodilator» without a COPD or asthma diagnosis. In healthy individuals there is no meaningful FEV1 gain: bronchodilation provides benefit only when baseline obstruction is present. WADA does not prohibit tiotropium, but use without a diagnosis means unjustified chronic anticholinergic exposure: dry mouth, urinary retention, raised intraocular pressure in susceptible patients. Beers Criteria 2023 lists inhaled LAMAs among anticholinergic-burden drugs in older adults. If tiotropium is suggested to «boost breathing capacity» without obstructive disease, consider seeking a second opinion.
Not recommended
Tiotropium is a long-acting inhaled antimuscarinic (LAMA). It is prescribed for COPD and severe asthma as add-on therapy ( 2024, 2024). Tiotropium is used in inhaler form for enhanced breathing and exercise-related breathing difficulty outside a COPD or severe asthma indication. No clinical studies of prophylactic use in this setting exist. The drug causes dry mouth, urinary retention (especially in men with benign prostatic hyperplasia), and elevated intraocular pressure (especially in angle-closure glaucoma). If tiotropium was prescribed outside confirmed COPD or severe asthma, consider seeking a second opinion.
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FDA Category C. Pregnancy data are limited. AEMPS allows use in COPD and severe asthma during pregnancy if maternal benefit justifies the risk. Pregnant patients with COPD are uncommon, and in severe asthma optimisation of ICS+LABA is preferred first.
Probably compatible. Hale L3. Inhaled systemic absorption is low. AEMPS advises an individual decision in breastfeeding.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Tiotropium is evaluated for the following indications with varying evidence strength: Asthma (evidence tier A), Severe asthma (evidence tier A), Chronic obstructive pulmonary disease (evidence tier A). See the full indication matrix with dosing and citations above on this page.
Common side effects of Tiotropium (≥ 1 in 100): Dry mouth, Constipation, Throat irritation, Cough immediately after inhalation, Headache. See the Safety section for uncommon and serious reactions.
FDA category C. FDA Category C. Pregnancy data are limited. AEMPS allows use in COPD and severe asthma during pregnancy if maternal benefit justifies the risk. Pregnant patients with COPD are uncommon, and in severe asthma optimisation of ICS+LABA is preferred first.
Probably compatible. Hale L3. Inhaled systemic absorption is low. AEMPS advises an individual decision in breastfeeding.
Tiotropium is contraindicated in: Hypersensitivity to tiotropium, atropine, ipratropium; Angle-closure glaucoma (relative); Symptomatic prostatic hyperplasia with urinary retention (relative). Full list in the Safety section.