Tools for Practice Outils pour la pratique

#152 Tempered Enthusiasm for Tiotropium in Asthma

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)?

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.  

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

  • Systematic review, 13 RCTs (4,966 patients >12 years), asthma, 4-52 weeks duration11/13 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    • Limitations: 6/13 trials were unpublished manufacturer trials. 
  • Two of the above unpublished trials were subsequently published together.3  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 placebo24 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-sponsoredmultiple outcomes with selective reporting, no mention of rescue medications or hospitalizations. 
  • Smaller systematic reviews (5-6 RCTsreport 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
Derniers outils pour la pratique

#370 Antibiotics or no antibiotics for acute diverticulitis, that is the question!

Do antibiotics change clinical outcomes for patients with acute uncomplicated diverticulitis?
Read Lire 0.25 credits available Crédits disponibles

#369 Remind me, do medications that target brain amyloid improve my dementia?

Are amyloid-targeting monoclonal antibodies safe and effective for mild cognitive impairment or Alzheimer’s dementia?
Read Lire 0.25 credits available Crédits disponibles

#368 Sodium Restriction in Heart Failure: Beneficial or pouring salt in the wound?

Does sodium restriction improve outcomes in patients with chronic heart failure?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • Arden Barry PharmD ACPR
  • Christina Korownyk MD CCFP

1. Rodrigo GJ, Castro-Rodriguez JA. Chest. 2015; 147:388-96.

2. Santanello NC, Zhang J, Seidenberg B, et al. Eur Respir J. 1999; 14:23-7.

3. Kerstjens HA, Casale TB, Bleecker ER, et al. Lancet Respir Med. 2015; 3:367-76.

4. Tian JW, Cheb JW, Chen R, et al. Respir Care. 2014; 59:654-66.

5. Befekadu E, Onofrei C, Colice GL. J Asthma Allergy. 2014; 7:11-21.

6. Global Initiative for Asthma. Global strategy for asthma management and prevention (2015 update). Available at: (Last accessed June 19, 2015)

7. Spiriva® Respimat® inhalation solution (2.5 mcg tiotropium per actuation) [product monograph]. Burlington, ON: Boehringer Ingelheim (Canada) Ltd; 2015 May 20.

8. Singh S, Loke YK, Enright PL, et al. BMJ. 2011; 324:d3215.

9. Verhamme KM, Afonso A, Romio S, et al. Eur Respir J. 2013; 42:606-15.

10. Wise RA, Anzueto A, Cotton D, et al. N Engl J Med. 2013; 369:1491-1501.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.