3.1.2 Antimuscarinic bronchodilators
Ipratropium bromide MDI 20micrograms/metered inhalation
20 to 40 micrograms, in early treatment up to 80micrograms at a time, 3 to 4 times daily
Braltus® 10microgram inhalation powder capsules with Zonda® inhaler
|Dose: 10 micrograms once daily|
|Spiriva Respimat® inhalation solution 2.5micrograms/dose (tiotropium)||Dose: 5 micrograms (two inhalations) once daily|
|Or a newer LAMA agent:|
One inhalation twice daily
|Seebri Breezhaler®▼ 44 microgram inhalation powder caps with device (glycopyrronium)||Dose:|
One capsule inhalation daily
|Incruse Ellipta®▼ DPI 55micrograms/dose (umeclidinium)||Dose:|
One inhalation daily
- 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).
- 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 .