, Volume 72, Issue 2, pp 273-300
Date: 12 Dec 2012

Tiotropium Bromide Inhalation Powder

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The anticholinergic agent tiotropium bromide (Spiriva®) is a long-acting bronchodilator that is indicated for the treatment of chronic obstructive pulmonary disease (COPD). This article reviews the clinical efficacy and tolerability of tiotropium bromide inhalation powder, administered using the HandiHaler® device, in patients with COPD, as well as reviewing its pharmacological properties and the results of pharmacoeconomic analyses.

Shorter-term placebo-controlled trials in patients with COPD demonstrated significantly higher trough forced expiratory volume in 1 second (FEV1) responses with tiotropium bromide than with placebo, confirming it has a duration of action of ≥24 hours and is suitable for once-daily administration. Lung function improved to a greater extent with tiotropium bromide than with ipratropium bromide or, in most instances, salmeterol. Indacaterol was shown to be non-inferior to tiotropium bromide in terms of the trough FEV1 response.

The large, 4-year UPLIFT® trial did not show a significant reduction in the annual rate of decline in FEV1 with tiotropium bromide versus placebo in patients with COPD, although subgroup analyses demonstrated a significantly lower rate of decline with tiotropium bromide than with placebo in some patient groups (e.g. patients with moderate COPD, patients aged ≥50 years, patients not receiving maintenance therapy at baseline).

Tiotropium bromide prevented exacerbations in patients with COPD, with a s3333ignificantly lower exacerbation rate and a significantly longer time to first exacerbation seen with tiotropium bromide than with placebo or salmeterol. Exacerbation rates did not significantly differ between patients receiving tiotropium bromide and those receiving salmeterol/fluticasone propionate. Tiotropium bromide also had beneficial effects on health-related quality of life (HR-QOL) and other endpoints, such as dyspnoea and rescue medication use.

Combination therapy with tiotropium bromide plus formoterol with or without budesonide improved lung function to a significantly greater extent than tiotropium bromide alone in patients with COPD. In addition, exacerbation rates were lower and HR-QOL was improved with tiotropium bromide plus budesonide/formoterol versus tiotropium bromide alone. Although the addition of salmeterol/fluticasone propionate to tiotropium bromide did not reduce the COPD exacerbation rate, it did improve lung function and HR-QOL.

Tiotropium bromide inhalation powder is generally well tolerated in patients with COPD, with anticholinergic adverse events (e.g. dry mouth, constipation, gastrointestinal obstruction, dysuria) among the most commonly reported adverse events. The UPLIFT® trial showed no significant difference between tiotropium bromide and placebo recipients in the risk of stroke, and the risk of serious cardiac adverse events (including congestive heart failure and myocardial infarction) was significantly lower with tiotropium bromide than with placebo. The absence of a detrimental effect on cardiovascular outcomes was supported by the results of a meta-analysis and pooled analyses. In addition, on-treatment mortality was lower with tiotropium bromide than with placebo in the UPLIFT® trial. Pooled analyses showed significantly lower cardiovascular mortality with tiotropium bromide than with placebo, with a meta-analysis demonstrating no significant difference between patients receiving tiotropium bromide and controls in cardiovascular mortality.

Results of modelled pharmacoeconomic analyses conducted from a healthcare payer perspective in several developed countries suggest that tiotropium bromide is a cost-effective option in patients with COPD.

In conclusion, tiotropium bromide inhalation powder is a useful option for the maintenance treatment of patients with COPD.

Various sections of the manuscript reviewed by: J.F. Donohue, Division of Pulmonary Disease and Critical Care Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; A.D. D’Urzo, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; C. Incorvaia, Department of Rehabilitation, Pulmonary Rehabilitation Unit, ICP Hospital, Milan, Italy; A. Wanner, Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.

Data Selection

Sources: Medical literature (including published and unpublished data) on tiotropium bromide in chronic obstructive pulmonary disease was identified by searching databases since 1996 (including MEDLINE and EMBASE and in-house AdisBase), bibliographies from published literature, clinical trial registries/databases and websites (including those of regional regulatory agencies and the manufacturer). Additional information (including contributory unpublished data) was also requested from the company developing the drug.
Search strategy: MEDLINE, EMBASE and AdisBase search terms were ‘tiotropium’ or ‘tiotropium bromide’ and (‘COPD’ or ‘chronic obstructive pulmonary disease’ or ‘pulmonary disease, chronic obstructive’ or ‘chronic obstructive lung disease’). Searches were last updated 19 December 2011.
Selection: Studies in patients with chronic obstructive pulmonary disease who received tiotropium bromide. Inclusion of studies was based mainly on the methods section of the trials. When available, large, well controlled trials with appropriate statistical methodology were preferred. Relevant pharmacodynamic and pharmacokinetic data are also included.
Index terms: Tiotropium bromide, chronic pulmonary obstructive disease, pharmacodynamics, pharmacokinetics, therapeutic use, tolerability, pharmacoeconomics.