Tiotropium (LAMA) step-up therapy for asthma uncontrolled with ICS works as well as adding LABA

Tiotropium bromide (Spiriva) is a long-acting anticholinergic agent (LAMA) approved for the treatment of chronic obstructive pulmonary disease (COPD) but not asthma.

210 patients with asthma were included in a trial with the addition of tiotropium to an inhaled glucocorticoid (ICS), as compared with a doubling of the dose of the inhaled glucocorticoid or the addition of the LABA salmeterol (a component of Advair).

The use of tiotropium resulted in a superior primary outcome, as compared with a doubling of the dose of an inhaled glucocorticoid, as assessed by:

- measuring the morning peak expiratory flow (PEF), with a mean difference of 26 liters per minute.
- the proportion of asthma-control days
- the forced expiratory volume in 1 second (FEV1) before bronchodilation, with a difference of 0.10 liters (a small difference)
- daily symptom scores

The addition of tiotropium was also noninferior to the addition of salmeterol for all assessed outcomes and increased the prebronchodilator FEV1 more than did salmeterol, with a difference of 0.11 liters.

When added to an inhaled glucocorticoid, tiotropium improved symptoms and lung function in patients with inadequately controlled asthma. Its effects appeared to be equivalent to those with the addition of salmeterol.

It looks like we will have to add Spiriva to the list of the asthma inhalers below:

Asthma Inhalers, including the cost of each inhaler (click to enlarge the image).


Tiotropium Bromide Step-Up Therapy for Adults with Uncontrolled Asthma. N Engl J Med 2010; 363:1715-1726, October 28, 2010.
Wind of Change? The TALC Trial Blows into Town
Tiotropium has a profound effect on methacholine challenge - it has to be stopped 1 week prior to challenge http://goo.gl/DiCb2

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