Tiotropium

SPIRIVA

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Pronunciation: tee-oe-TRO-pee-um (spe-REE-va)

Tiotropium ballicule: receptor binding, kinetics and half-life diagram — Mechanism of action: Tiotropium ballicule

Tiotropium SPIRIVA mascot mnemonic cartoon — Visual mnemonic: Tiotropium mascot
**“Tio’s tropical Spiral”**
red as a beet” → anticholinergic

What it isLong-acting muscarinic antagonist bronchodilator; COPD maintenance and add-on asthma treatment.

Why this oneHas the longest clinical track record among LAMAs, and its soft-mist formulation also carries an asthma indication.

What limits itDry mouth, urinary retention, and glaucoma can worsen; it is maintenance only, and powder capsules must be inhaled, not swallowed.

Pearls

Asthma add-on to ICS from age 6; modest exacerbation benefit.
RESPIMAT 2 puffs once daily; HANDIHALER capsules available generically.

Tiotropium molecular structure (skeletal formula) — Molecular structure: Tiotropium

Tiotropium prescription history

Animated chart of estimated U.S. prescriptions per year, Asthma/COPD meds (1924–2026). Tiotropium enters in 2004 (estimated).

FDA-approved for

COPD (2004)

Principal riskAnticholinergic effects; acute urinary retention

Classes and tags

Clinical profile

Therapeutic safety burden1 / 4

Overdose danger2 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism4 / 4

Embryofetal risk2 / 4

Legacy pregnancy categoryC

Defining liabilityTremor, tachycardia or anticholinergic effects; excessive beta-agonist exposure can cause hypokalemia and arrhythmia.

FDA label

Read the full label on DailyMed ↗

NO BOXED WARNINGS

FDA dosing	Population	Start	Target	Max
COPD, maintenance	Adults	Two inhalations of one 18 mcg capsule QD	18 mcg QD

Renal No adjustment needed; monitor closely for anticholinergic effects if CrCl <60 mL/min

Hepatic No adjustment needed (not studied)

Do not exceed one dose (two inhalations) per 24 hours

Instructions

For oral inhalation only; do not swallow capsules
Use capsules only with the HandiHaler device
Not a rescue medication; not for acute bronchospasm
Do not take more than one dose in 24 hours

Available strengths

powder 0.018 mg/inh
cap 18 mcg
spray 1.25, 2.5 mcg/inh

Contraindications

Hypersensitivity to tiotropium, ipratropium, or product components (including angioedema)

Cautions

Not for acute use/rescue
Immediate hypersensitivity reactions including angioedema; caution with severe milk-protein hypersensitivity
Paradoxical bronchospasm
Worsening of narrow-angle glaucoma
Worsening of urinary retention

Adverse reactions

Upper respiratory tract infection
Dry mouth
Sinusitis, pharyngitis
Non-specific chest pain
Urinary tract infection, dyspepsia, rhinitis

Pregnancy Limited human data insufficient to inform risk

Lactation No human data; present in milk of lactating rats

Cost

Tiotropium (SPIRIVA)

Strength		#/mo	generic $/unit	CostPlus
0.018 mg/inh	powder	per unit		not offered

NADAC is a voluntary CMS survey of what retail community pharmacies pay for the drugs they stock. Tiotropium is dispensed outside retail pharmacies, so it rarely appears on surveyed invoices.

Generic entry2023

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Self-check

Which tiotropium formulation also has an asthma indication?
Soft mist.
Should tiotropium powder capsules be swallowed?
No; inhaled.