Other Anticholinergics
Severe
Database
Additive antimuscarinic toxicity
Avoid concurrent inhaled/systemic antimuscarinics
Source: Kimi deep-research + Cla
Drug reference
Tiotropium
Long-acting inhaled antimuscarinic (LAMA) · Bronchodilator
Also known as Tiotropium bromide, Spiriva, Braltus, Tiova, Tiofex
START
COPD: HandiHaler 18 mcg or Respimat 5 mcg once daily (maintenance, not rescue)
TYPICAL MAX
18 mcg/day (HandiHaler) or 5 mcg/day (Respimat)
STOP IF
Acute angle-closure glaucoma, severe urinary retention, paradoxical bronchospasm
WATCH
Inhaler technique, anticholinergic effects (eye/bladder), exacerbation frequency
CDSCO approvedSchedule HATC R03BB04
KDIGO 2024 + manufacturer label
- ONSET
- 30min · bronchodilation onset
- PEAK
- 2h · peak FEV1
- t½
- 1d · terminal t½
- DURATION
- 1d · once-daily effect
EXCRETION
~74% renal unchanged; minimal metabolism
route + CYP
INTERACTIONS
1 major
SEVERE in our sources
PREGNANCY
Use only if clearly needed — limited human data
FDA category + note
Top interactionssee all 4 →
- Other AnticholinergicsSevereDatabaseKimi deep-research + Cla
Available in India
26 branded formulations and 17 fixed-dose combinations. Look up specific brands in the Drugs workspace.
Mechanism
Long-acting competitive antagonist at muscarinic receptors (kinetic selectivity for M3 with slow dissociation), producing prolonged bronchodilation by inhibiting acetylcholine-mediated airway smooth-muscle contraction.
Indications
Maintenance bronchodilation in COPD (reduces exacerbations)Long-term maintenance treatment of asthma (Respimat, add-on)
Dosing
- Adult
- HandiHaler 18 mcg inhaled once daily; Respimat 5 mcg (2 puffs of 2.5 mcg) once daily for COPD; asthma Respimat 5 mcg once daily.
- Pediatric
- ≥6 years asthma (Respimat) 2.5 mcg once daily (specialist).
- Renal adjustment
- CrCl ≤50 mL/min (renally cleared): use only if benefit outweighs risk; monitor anticholinergic effects.
- Hepatic adjustment
- No adjustment needed.
- Geriatric
- No dose change; monitor anticholinergic adverse effects.
- Max dose
- 18 mcg/day (HandiHaler) or 5 mcg/day (Respimat)
Pharmacokinetics
Onset
~30 min; sustained
Peak effect
~1–3 h (FEV1)
Duration
>24 h (once-daily)
Half-life
~25 h (terminal)
Bioavailability
Inhaled ~33% (low oral)
Protein binding
~72%
Metabolism
Limited CYP2D6/3A4; mostly non-enzymatic ester cleavage
Excretion
Renal (≈74% of IV dose unchanged)
Contraindications
- Hypersensitivity to tiotropium, ipratropium or atropine derivatives
- Not for acute bronchospasm (not a rescue inhaler)
- Caution: narrow-angle glaucoma, bladder-neck obstruction/prostatic hyperplasia
Side effects
Common
Dry mouthPharyngitis/coughConstipationUrinary retention (esp. men with BPH)
Serious
- Acute narrow-angle glaucoma (eye exposure)
- Urinary retention
- Paradoxical bronchospasm
- Hypersensitivity/angioedema
Pregnancy & lactation
Pregnancy
Use only if clearly needed — limited human data
Lactation
Limited data; low systemic exposure — caution
Drug interactions
Beta Blockers
Moderate
Database
Bronchoconstriction antagonising therapy
Prefer cardioselective beta-blocker; monitor
Source: Kimi deep-research + Cla
Cns Anticholinergic Burden
Moderate
Database
Additive cognitive/constipation effects in elderly
Review anticholinergic burden
Source: Kimi deep-research + Cla
Drugs Precipitating Glaucoma
Moderate
Database
Additive intraocular pressure risk if eye exposure
Avoid eye contact with mist; caution in glaucoma
Source: Kimi deep-research + Cla
8 additional low-confidence interactions hidden — those rows lack a documented mechanism or management plan in our sources.
Related guidelines
Ask House about Tiotropium
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Sources: Goodman & Gilman 14e, Katzung, BNF, Nelson·Verified: 2026-05-19 · House clinical team·Cockpit curated: 2026-05-19