Anticholinergics for chronic obstructive pulmonary disease (COPD)

Examples

Prescription anticholinergics

Generic Name	Brand Name
ipratropium bromide (short-acting)	Atrovent
tiotropium bromide (long-acting)	Spiriva

Prescription anticholinergic and short-acting beta2-agonist combination

Generic Name	Brand Name
ipratropium bromide and salbutamol sulfate	Combivent

Ipratropium bromide alone and combined with salbutamol sulfate is available in metered-dose inhaler (MDI) and nebulizer forms. One medication may be available in multiple forms. Your health professional will help you decide which form is best for you.

Tiotropium bromide is available only in dry powder form for inhalation in a HandiHaler.

Anticholinergics come in two forms: short acting and long acting. The short-acting form relieves symptoms and the long-acting form helps prevent breathing problems. Short-acting anticholinergics are used for treating stable COPD in a person whose symptoms come and go (intermittent symptoms). Long-acting anticholinergics are effective and convenient for preventing and treating COPD in a person whose symptoms do not go away (persistent symptoms).

How It Works

Anticholinergics relax and enlarge (dilate) the airways in the lungs, making breathing easier (bronchodilators). They may protect the airways from spasms that can suddenly cause the airway to become narrower (bronchospasm). They also may reduce the amount of mucus produced by the airways.

Why It Is Used

Anticholinergics generally are considered first-line therapy for treating persistent symptoms of chronic obstructive pulmonary disease (COPD). Because these drugs may take some time to have an effect on breathing, they usually are taken on a regular schedule. They are used for both short- and long-term relief of symptoms.

How Well It Works

A number of studies indicate that inhaled anticholinergics improve lung function as measured by tests (spirometry). There is no evidence of their effect on the progression of the disease.¹

Studies have shown that:¹

• In short-term treatment, ipratropium and tiotropium both improved lung function compared to a placebo.
• After one year of treatment, tiotropium improved lung function and reduced the number of COPD exacerbations and hospital admissions compared to a placebo.

Combining an anticholinergic with a beta2-agonist may help your lung function more than using either medication alone.¹ Doing so usually increases your cost but may also reduce the risk of side effects compared to increasing the dose of one medication.²

Side Effects

A mild cough and dry mouth are the most common side effects.

There have been rare reports of closed-angle glaucoma after using inhaled ipratropium. Call your health professional immediately if an eye becomes red or painful or if you have misty vision after using this medication.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

While anticholinergics generally are regarded as the first-line treatment for the persistent symptoms in most cases of COPD, short-acting beta2-agonists may be the first choice for treating symptoms of stable COPD that come and go (intermittent symptoms).

Spirometry may be done before and after you try an anticholinergic for the first time to see whether the medication has had an effect. However, even if the medicine has no measurable effect, it still may be beneficial and may be prescribed by your health professional.

Nebulizers normally are no better at delivering anticholinergics deep into the lungs than a properly used metered-dose inhaler. Occasionally your health professional may prescribe a nebulizer. Although a nebulizer can deliver a very large dose of medication, it also may increase side effects of the medication.

Tiotropium is to be used only with a HandiHaler, a type of dry powder inhaler (DPI).

Most health professionals recommend that everyone using a metered-dose inhaler also use a spacer. However, you should not use a spacer with a dry powder inhaler (DPI).

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Author:	Douglas Dana Robin Parks, MS	Last Updated: August 28, 2006
Medical Review:	Renée M. Crichlow, MD - Family Medicine Tom Bailey, MD - Family Medicine Ken Y. Yoneda, MD - Pulmonology
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