#152 Tempered Enthusiasm for Tiotropium in Asthma
CLINICAL QUESTION
Is tiotropium useful as add-on therapy in asthmatic patients who are poorly controlled on an Inhaled Corticosteroid (ICS) or ICS + Long-Acting Beta Agonist (LABA)?
BOTTOM LINE
In moderate-severe asthma, uncontrolled on ICS or ICS+LABA, the addition of Tiotropium prevents exacerbations for one in 18-36 patients over 4-52 weeks. Much of the research is at high risk of bias and changes in other surrogate outcomes (like FEV1) are of uncertain clinical importance.
Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
EVIDENCE
- Systematic review, 13 RCTs (4,966 patients >12 years), asthma, 4-52 weeks duration, 11/13 trials used Respimat® inhaler:1
- Tiotropium + ICS versus ICS (moderate asthma):
- Improved PEF (22-24 L/min) and FEV1 (140-150 mL).
- Reduced number of patients with ≥1 exacerbation [10.5% versus 13.3%, Number Needed to Treat (NNT)=36].
- Tiotropium + ICS + LABA versus ICS + LABA (severe asthma):
- Improved PEF (16-20 L/min) and FEV1 (80-120 mL).
- Reduced number of patients with ≥1 exacerbation (18.2% versus 24.0%, NNT=18).
- No difference in adverse events.
- Minimum clinically important difference (MCID) for FEV1 is 230 mL.2
- Limitations: 6/13 trials were unpublished manufacturer trials.
- Tiotropium + ICS versus ICS (moderate asthma):
- Two of the above unpublished trials were subsequently published together.3
- 2,103 asthma patients on ICS, randomized to once-daily tiotropium (Respimat® inhaler), twice-daily salmeterol or placebo, 24 weeks:
- Both tiotropium and salmeterol had similar statistically significant improvement in FEV1 although neither reached MCID.2
- Asthma exacerbations (requiring oral steroids) not well reported, conflicting results.
- Limitations: Industry-sponsored, multiple outcomes with selective reporting, no mention of rescue medications or hospitalizations.
- 2,103 asthma patients on ICS, randomized to once-daily tiotropium (Respimat® inhaler), twice-daily salmeterol or placebo, 24 weeks:
- Smaller systematic reviews (5-6 RCTs) report that tiotropium added to ICS ± LABA increases PEF and FEV1.4,5
- 2015 Global Initiative for Asthma guidelines state tiotropium is an option in patients on medium- to high-dose ICS + LABA in patients ≥18 years.6
- Tiotropium is available in two types of inhalers: HandiHaler® (dry powder capsule inhaler) and Respimat® (aqueous solution soft mist inhaler).7
- There is controversy regarding the possibility of increased mortality with tiotropium delivered via the Respimat® inhaler in COPD, particularly in those with cardiovascular disease and arrhythmias, but the data is inconsistent.8-10
Latest Tools for Practice
#378 Tony Romo-sozumab: Winning touchdown in osteoporosis or interception for the loss?
What is the efficacy and safety of romosozumab in postmenopausal women with osteoporosis?
#377 How to slow the flow IV: Combined oral contraceptives
In premenopausal heavy menstrual bleeding due to benign etiology, do combined oral contraceptives (COC) improve patient outcomes?
#376 Testosterone supplementation for cis-gender men: Let’s (andro-)pause for a moment (Update)
What are the benefits and harms of testosterone supplementation in healthy cis-gender men or those with age-related low testosterone?
both COPD and Asthma trials seem to have a lot of cross over , and overall limited positive POO’s