INHALED ANTICHOLINERGICS (MUSCARINIC ANTAGONISTS)

SAMA - short-acting muscarinic antagonists | SABA - short-acting beta agonist | LABA - long-acting beta agonist | ICS - inhaled corticosteroids | LAMA - long-acting muscarinic antagonists
PRICING INFO


References:
ASTHMA STUDIES


COPD STUDIES


Drug Dosage form Dosage Generic/Price Other Mechanism of Action FDA-approved indication Side Effects Drug Interactions Precautions / Contraindications
Aclidinium

Tudorza Pressair®
Inhaler - Tudorza Pressair®
  • Delivers 400 mcg of aclidinium inhalation powder per actuation
  • Comes in inhaler with 30 or 60 doses
COPD
  • One inhalation twice a day
NO/$$$$
  • Discard inhaler 45 days after opening pouch
  • Anticholinergic - blocks muscarinic receptors on bronchial smooth muscle and reduces intrinsic vagal tone of the airway
  • Chronic Obstructive Pulmonary Disease (COPD)

  • Aclidinium is NOT indicated to treat acute bronchospasm
Anticholinergic side effects
  • Pupil dilation - may cause pupils to dilate. Avoid spraying in eyes.
  • Urinary retention - may cause urinary retention
  • See anticholinergic medications for more

From Tudorza PI®
NOTE: P = % of patients on placebo who reported side effect
  • Headache - 6.6%, P - 5%
  • Nasopharyngitis - 5.5%, P - 3.9%
  • Cough - 3%, P - 2.2%
  • Diarrhea - 2.7%, P - 1.4%
  • Sinusitis - 1.7%, P - 0.8%
  • Rhinitis - 1.6%, P - 1.2%
  • Severe allergy to milk proteins - DO NOT USE. Contains lactose.
  • Hypersensitivity reactions - hypersensitivity reactions including anaphylaxis have occurred
  • Glaucoma - aclidinium may cause pupil dilation which can precipitate or worsen narrow-angle glaucoma
  • Paradoxical bronchospasm - paradoxical bronchospasm has occurred in some patients
  • Benign prostatic hypertrophy (BPH) - aclidinium may worsen urinary retention seen in BPH
  • Liver disease - has not been studied extensively
  • Kidney disease - no dose adjustment necessary
Drug Dosage form Dosage Generic/Price Other Mechanism /
FDA-approved indications
Side Effects Drug Interactions Precautions / Contraindications
Ipratropium

Atrovent®
Inhaler - Atrovent HFA®
  • Delivers 17 mcg of ipratropium per actuation (200 actuations per inhaler)

Nebulizer
  • Ipratropium 0.02% (0.5 mg/2.5 ml)
  • Comes in package of 25 nebs
COPD
    Atrovent HFA®
    • Two puffs four times a day
    • Max: 12 puffs in 24 hours
    Nebulizer
    • One neb every 6 - 8 hours

Acute Asthma Exacerbations

See NHLBI asthma exacerbation recommendations
Atrovent HFA®
NO/$$$$

Ipratropium nebs
YES/$

Atrovent HFA®
  • Does not require shaking
  • Prime before first use by releasing 2 test sprays
  • Re-prime inhaler if not used for more than 3 days
  • Avoid spraying in eyes

Nebulizer
  • May mix with albuterol. Use within one hour after mixing.
  • Protect nebs from sunlight

Mechanism
  • Anticholinergic - blocks muscarinic receptors on bronchial smooth muscle and reduces intrinsic vagal tone of the airway

FDA-approved indication
  • Chronic Obstructive Pulmonary Disease (COPD)
  • NHLBI 2007 asthma guidelines state that anticholinergic agents provide additive benefit to SABA in moderate-to-severe asthma exacerbations, and may be used as an alternative bronchodilator for patients who do not tolerate SABA
Anticholinergic side effects
  • Pupil dilation - may cause pupils to dilate. Avoid spraying in eyes.
  • Urinary retention - may cause urinary retention
  • See anticholinergic medications for more

From Atrovent PI®
NOTE: P = % of patients on placebo who reported side effect
  • Bronchitis- 10%, P - 6%
  • Shortness of breath - 8%, P - 4%
  • Dizziness- 3%, P - 2%
  • Dry mouth - 4%, P - 2%
  • Nausea- 4%, P - 2%
  • Glaucoma - ipratropium may cause pupil dilation which can precipitate or worsen narrow-angle glaucoma
  • Paradoxical bronchospasm - paradoxical bronchospasm has occurred in some patients
  • Benign prostatic hypertrophy (BPH) - ipratropium may worsen urinary retention seen in BPH
  • Liver disease - has not been studied extensively
  • Kidney disease - has not been studied extensively

Drug Dosage form Dosage Generic/Price Other Mechanism /
FDA-approved indications
Side Effects Drug Interactions Precautions / Contraindications
Tiotropium

Spiriva® Handihaler

Spiriva® Respimat
Spiriva® Handihaler
  • Delivers 18 mcg of tiotropium inhalation powder per actuation
  • Comes in carton with 30 or 90 capsules

Spiriva® Respimat
  • Carton contains cartridge and inhaler
  • Cartridge contains 60 metered sprays
  • Comes in two doses:
    • Tiotropium 1.25 mcg/actuation
    • Tiotropium 2.5 mcg/actuation
COPD
    Spiriva® Handihaler
    • One capsule once daily
    • Two inhalations should be taken from device for each capsule
    Spiriva® Respimat
    • Two inhalations (5 mcg) once daily
    • Use 2.5 mcg inhaler in COPD

Asthma (≥ 6 years old)

    Spiriva® Respimat
    • Two inhalations (2.5 mcg) once daily
    • Use 1.25 mcg inhaler in Asthma
    • May take up to 8 weeks before full benefit is seen
Handihaler
NO/$$$$

Respimat
NO/$$$$
Spiriva® Handihaler
  • May store at room temperature
  • Use capsule immediately after removing from blister pack

Spiriva® Respimat
  • Inhaler is good for 3 months after first use
  • Inhaler must be primed prior to first use and if not used for more than 3 days. See patient instructions for details.
Mechanism
  • Anticholinergic - blocks muscarinic receptors on bronchial smooth muscle and reduces intrinsic vagal tone of the airway

FDA-approved indications

Spiriva® Handihaler
  • Chronic Obstructive Pulmonary Disease (COPD) - long-term maintenance and prevention of COPD exacerbations
  • Tiotropium is NOT indicated to treat acute bronchospasm

Spiriva® Respimat
  • Chronic Obstructive Pulmonary Disease (COPD) - tiotropium is indicated for long-term maintenance and prevention of COPD exacerbations
  • Asthma - maintenance treatment of asthma in patients 6 years of age and older
  • Tiotropium is NOT indicated to treat acute bronchospasm
Anticholinergic side effects
  • Pupil dilation - may cause pupils to dilate. Avoid spraying in eyes.
  • Urinary retention - may cause urinary retention
  • See anticholinergic medications for more

From Spiriva® Handihaler PI
NOTE: P = % of patients on placebo who reported side effect
  • Upper Respiratory infection - 41%, P - 37%
  • Dry mouth - 16%, P - 3%
  • Sinusitis- 11%, P - 9%
  • Pharyngitis- 9%, P - 7%
  • Chest pain - 7%, P - 5%
  • Urinary tract infection - 7%, P - 5%
  • Shortness of breath - 6%, P - 5%
  • Abdominal pain - 5%, P - 3%

From Spiriva® Respimat PI
NOTE: P = % of patients on placebo who reported side effect
  • Pharyngitis- 11.5%, P - 10.1%
  • Cough- 5.8%, P - 5.5%
  • Dry mouth - 4.1%, P - 1.6%
  • Sinusitis - 3.1%, P - 2.7%
  • Severe allergy to milk proteins (Handihaler® only) - DO NOT USE. Contains lactose.
  • Glaucoma - tiotropium may cause pupil dilation which can precipitate or worsen narrow-angle glaucoma
  • Paradoxical bronchospasm - paradoxical bronchospasm has occurred in some patients
  • Benign prostatic hypertrophy (BPH) - ipratropium may worsen urinary retention seen in BPH
  • Liver disease - has not been studied extensively
  • Kidney disease - CrCl ≤ 60 ml/min - monitor patient closely for anticholinergic side effects
Drug Dosage form Dosage Generic/Price Other Mechanism of Action FDA-approved indications Side Effects Drug Interactions Precautions / Contraindications
Umeclidinium

Incruse Ellipta®
Inhaler - Incruse Ellipta®
  • Delivers 62.5 mcg of umeclidinium inhalation powder per actuation
  • Comes in package with 30 doses
COPD
  • One inhalation once daily
  • Inhale at the same time each day
NO/$$$$
  • Discard inhaler 6 weeks after opening foil pouch
  • Anticholinergic - blocks muscarinic receptors on bronchial smooth muscle and reduces intrinsic vagal tone of the airway
  • Chronic Obstructive Pulmonary Disease (COPD)

  • Umeclidinium is NOT indicated to treat acute bronchospasm
Anticholinergic side effects
  • Pupil dilation - may cause pupils to dilate. Avoid spraying in eyes.
  • Urinary retention - may cause urinary retention
  • See anticholinergic medications for more

From Incruse Ellipta PI®
NOTE: P = % of patients on placebo who reported side effect
  • Nasopharyngitis - 8%, P - 7%
  • Upper respiratory infection - 5%, P - 4%
  • Cough - 3%, P - 2%
  • Arthralgia - 2%, P - 1%
  • Severe allergy to milk proteins - DO NOT USE. Contains lactose.
  • Glaucoma - umeclidinium may cause pupil dilation which can precipitate or worsen narrow-angle glaucoma
  • Paradoxical bronchospasm - paradoxical bronchospasm has occurred in some patients
  • Benign prostatic hypertrophy (BPH) - umeclidinium may worsen urinary retention seen in BPH
  • Kidney disease - no dose adjustment necessary
  • Liver disease
    • Mild-to-moderate (Child-Pugh A/B): no dose adjustment necessary
    • Severe (Child-Pugh C): has not been studied
Drug Dosage form Dosage Generic/Price Other FDA-approved indications
Combivent Respimat®
Duoneb®

albuterol + ipratropium
Inhaler - Combivent Respimat®
  • Inhaler delivers 100 mcg of albuterol and 20 mcg of ipratropium per actuation
  • Each inhaler contains 120 actuations

Nebulizer solution - Duoneb®
  • Ipratropium 0.5 mg/Albuterol 3 mg per 3 ml neb
  • Comes in box of 30 or 60 nebs
Acute bronchospasm in COPD
    Combivent Respimat®
    • Dosing: One inhalation four times a day with up to two additional inhalations if required
    • Max: Six inhalations in 24 hours

    Duoneb®
    • Dosing: One neb four times a day with up to two additional nebs if required
    • Max: Six nebs in 24 hours

Acute asthma exacerbation

See NHLBI asthma exacerbation recommendations

Combivent Respimat®
NO/$$$$

Duoneb®
YES/$
  • Combivent Respimat® is good for 3 months after first use

  • See Combivent Respimat® patient insert for priming instructions
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Relief of bronchospasm

  • Ipratropium is a short-acting anticholinergic agent
  • Albuterol is a short-acting beta agonist
Drug Dosage form Dosage Generic/Price Other FDA-approved indications
Bevespi Aerosphere™

formoterol + glycopyrrolate
Inhaler
  • Device delivers 4.8 mcg of formoterol and 9 mcg of glycopyrrolate per actuation
  • Each inhaler contains 120 inhalations
COPD
  • Two inhalations twice a day
NO/$$$$

  • Inhaler must be primed. See package insert for instructions.
  • See Bevespi Aerosphere PI for complete prescribing information
  • Inhaler is good for 3 months after removal from foil pouch
  • Chronic Obstructive Pulmonary Disease (COPD)
  • NOT for relief of acute bronchospasm

  • Glycopyrrolate is a long-acting anticholinergic agent
  • Formoterol is a long-acting beta agonist
Drug Dosage form Dosage Generic Other FDA-approved indications
Utibron® Neohaler

indacaterol + glycopyrrolate
Utibron® Neohaler
  • Each capsule contains 27.5 mcg of indacaterol and 15.6 mcg of glycopyrrolate powder
  • Inhaler comes with 60 inhalation capsules
COPD
  • One inhalation twice a day
  • Use at the same time every day
NO/$$$$
  • See Utibron® PI for complete prescribing information
  • Use with caution in patients with severe milk allergy. Contains lactose.

  • Maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)

  • NOT for relief of acute bronchospasm

  • Glycopyrrolate is a long-acting anticholinergic agent
  • Indacaterol is a long-acting beta agonist

Drug Dosage form Dosage Generic Other FDA-approved indications
Stiolto® Respimat

olodaterol + tiotropium
Stiolto® Respimat inhaler
  • Inhaler delivers tiotropium 3.124 mcg (equivalent to 2.5 mcg tiotropium) and olodaterol 2.736 mcg (equivalent to 2.5 mcg olodaterol) per spray
  • Inhaler comes with 60 actuations
COPD
  • Two inhalations once daily
  • Use at the same time every day
NO/$$$$
  • See Stiolto® PI for complete prescribing information

  • Inhaler should be primed. See patient instructions for details

  • Maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)

  • NOT for relief of acute bronchospasm

  • Tiotropium is a long-acting anticholinergic agent
  • Olodaterol is a long-acting beta agonist
Drug Dosage form Dosage Generic/Price Other FDA-approved indications
Anoro Ellipta®

vilanterol + umeclidinium
Anoro Ellipta® inhaler
  • Each powder inhalation contains umeclidinium 62.5 mcg and vilanterol 25 mcg
  • Inhaler comes with 30 inhalations
COPD
  • One inhalation once daily
NO/$$$$
  • See Anoro Ellipta® PI for complete prescribing information

  • Discard inhaler 6 weeks after opening the foil tray

  • DO NOT USE in patients with severe milk allergy

  • Vilanterol is a CYP3A4 substrate. Use caution with strong CYP3A4 inhibitors.

  • DO NOT USE in patients with congenital long QT syndrome [4]
  • Maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)

  • NOT for relief of acute bronchospasm

  • Umeclidinium is a long-acting anticholinergic agent
  • Vilanterol is a long-acting beta agonist
Drug Dosage form Dosage Generic/Price Other Indications
(FDA-approved)
Trelegy Ellipta®

fluticasone + vilanterol + umeclidinium
Trelegy Ellipta® inhaler
  • Inhaler delivers 100 mcg of fluticasone, 62.5 mcg of umeclidinium, and 25 mcg of vilanterol powder per inhalation
  • Inhaler comes with 30 inhalations
COPD
  • One inhalation once daily
NO/$$$$
  • See Trelegy Ellipta® PI for complete prescribing information

  • Discard inhaler 6 weeks after opening the foil tray

  • DO NOT USE in patients with severe milk allergy

  • Vilanterol is a CYP3A4 substrate. Use caution with strong CYP3A4 inhibitors.
  • Maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD)
  • NOT for relief of acute bronchospasm