COPD
| Choice | Drug | Dosage |
Formulary choice | 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 | Braltus® 10microgram inhalation powder capsules with Zonda® inhaler | 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 .