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Am Fam Physician. 2005;72(11):2219-2220

Clinical Question

Is tiotropium (Spiriva) effective for treatment of chronic obstructive pulmonary disease (COPD)?

Evidence-Based Answer

In patients with moderate or severe COPD, tiotropium reduces exacerbations, hospitalizations, and symptom scores and improves health-related quality of life compared with placebo and ipratropium (Atrovent). However, more study is needed to determine tiotropium’s role in the treatment of COPD compared with long-acting beta agonists.

Practice Pointers

The first-line treatment for patients with stable COPD is albuterol (Ventolin).1 For patients whose symptoms are not adequately controlled with albuterol, second-line options include tiotropium, salmeterol (Serevent), formoterol (Foradil), ipratropium, albuterol/ipratropium (Combivent), and levalbuterol (Xopenex). According to the Institute for Clinical Systems Improvement guidelines on COPD,1 tiotropium as a scheduled bronchodilator has significant advantages for patients whose symptoms are not controlled by albuterol.

Tiotropium is a once-daily inhaled selective anticholinergic medication for COPD. It is related to ipratropium but costs around $115 per month, whereas ipratropium (two to four puffs four times per day) costs around $67 per month. Tiotropium may be taken in conjunction with theophylline, steroids, or beta agonists, but it has not been studied with ipratropium. Tiotropium is renally excreted, and dry mouth is the most common adverse effect.

To compare the effectiveness of tiotropium with other treatments, Barr and colleagues reviewed the literature and found nine randomized controlled trials with a total of 6,584 patients. They found that, compared with treatment with placebo or ipratropium, 14 patients must be treated for one year with tiotropium to prevent one COPD exacerbation, and 30 need to be treated to prevent one hospitalization. Tiotropium was more effective than placebo or ipratropium but not more effective than long-acting beta agonists regarding improvement in symptoms or quality of life. There was no statistical difference between exacerbation and hospitalization rates for patients treated with tiotropium compared with long-acting beta agonists.

Tiotropium shows promise as a first-line scheduled bronchodilator, but longer trials and trials comparing tiotropium with long-acting beta agonists are needed.

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