3.1.2 Antimuscarinic bronchodilators

COPD

ChoiceDrugDosage

Formulary choice

Short-acting antimuscarinic bronchodilator

Ipratropium bromide MDI 20micrograms/metered inhalation

Dose:
20 to 40 micrograms, in early treatment up to 80micrograms at a time, 3 to 4 times daily

Formulary choices

Long-acting
antimuscarinic bronchodilators

Braltus® 10microgram inhalation powder capsules with Zonda® inhaler
Delivers same dose of tiotropium as Spiriva® Handihaler®

Dose: 10 micrograms once daily
Or
Spiriva Respimat® inhalation solution 2.5micrograms/dose (tiotropium) Dose: 5 micrograms (two inhalations) once daily
Or a newer LAMA agent:
Eklira Genuir®▼DPI
322micrograms/dose (aclidinium)
Dose:
One inhalation twice daily
Or
Seebri Breezhaler®▼ 44 microgram inhalation powder caps with device (glycopyrronium)Dose:
One capsule inhalation daily
Or
Incruse Ellipta®▼ DPI 55micrograms/dose (umeclidinium)Dose:
One inhalation daily

Prescribing Notes

  • LAMAs are only licensed for COPD, with the exception of Spiriva Respimat® (tiotropium) which is licensed as an adjunct to inhaled corticosteroids and long-acting beta2 agonists in patients with asthma who have suffered one or more severe exacerbations in the last year (refer to High-dose Therapies step of ‘British Asthma Guidelines’).
  • Short-acting antimuscarinic agents (SAMAs) should be discontinued when long-acting antimuscarinic agents (LAMAs) are initiated.
  • All newer LAMAs lack patient-orientated outcome data beyond 52 weeks.
  • LAMAs are not suitable for the relief of acute bronchospasm and must not be given in combination with ipratropium.
  • Patients with very severe COPD who are receiving regular home nebulised ipratropium or Combivent® (containing ipratropium and salbutamol) should not be prescribed a LAMA in addition.
  • Consider renal function when selecting LAMA (tiotropium caution eGFR <50mL/min, glycopyrronium caution eGFR<30mL/min).

Cautions

  • Antimuscarinic bronchodilators should be used with caution in patients with prostatic hyperplasia, bladder outflow obstruction and those susceptible to angle-closure glaucoma (see below).
  • LAMAs should be used with caution in cardiac disorders (particularly cardiac rhythm disorders) see HSCB newsletter ‘LAMAs and Cardiovascular Risk’.
  • Acute angle-closure glaucoma has been reported with nebulised ipratropium, particularly when given with nebulised salbutamol (and possibly other beta2 agonists); care is needed to protect the patient’s eyes from nebulised drug or from drug powder e.g. administer via mouthpiece.
  • For the Braltus Zonda device, ensure the patient knows to insert the capsule into the correct place of the inhaler. See MHRA .