Tiotropium bromide

Clinical data
MedlinePlus a604018
Routes of
Inhalation (oral)
ATC code R03BB04 (WHO)
Legal status
Legal status
  • AU: S4 (Prescription only)
  • UK: POM (Prescription only)
  • US: ℞-only
Pharmacokinetic data
Bioavailability 19.5% (inhalation)
Metabolism Hepatic 25%
(CYP2D6, CYP3A4)
Biological half-life 5–6 days
Excretion Renal
CAS Number 136310-93-5
186691-13-4 (cation)
PubChem (CID) 5487426
DrugBank DB01409
ChemSpider 10482095 YesY
ECHA InfoCard 100.234.575
Chemical and physical data
Formula C19H22BrNO4S2
Molar mass 472.416 g/mol
3D model (Jmol) Interactive image

Tiotropium bromide (INN) is a long-acting, 24-hour, anticholinergic bronchodilator used in the management of chronic obstructive pulmonary disease (COPD). Tiotropium bromide capsules for inhalation are co-promoted by Boehringer-Ingelheim and Pfizer under the trade name Spiriva. It is also manufactured and marketed by Cipla under trade name Tiova.

Tiotroprium was discovered in 1991 and came to market in 2004.[1]

Medical uses

Tiotropium is used for maintenance treatment of chronic obstructive pulmonary disease (COPD) which includes chronic bronchitis and emphysema.[2] It is not however used for acute exacerbations.[2]

Adverse effects

Adverse effects are mainly related to its antimuscarinic effects. Common adverse drug reactions (≥1% of patients) associated with tiotropium therapy include: dry mouth and/or throat irritation. Rarely (<0.1% of patients) treatment is associated with:urinary retention, constipation, acute angle closure glaucoma, palpitations (notably supraventricular tachycardia and atrial fibrillation) and/or allergy (rash, angioedema, anaphylaxis).[3]

Tiotropium and another member of its class ipratropium were linked to increased risk of heart attacks, stroke and cardiovascular death.[4] The FDA requested further trials; these are now complete, and adequately resolve the previous safety concerns.[5]

Tiotropium mist inhaler (Respimat) has been found to be associated with an increase of all cause mortality in people with COPD.[6]


The standard dose of tiotropium is 18 mcg which is administered by a HandiHaler inhalation device.[7]

Mechanism of action

Tiotropium is a muscarinic receptor antagonist, often referred to as an antimuscarinic or anticholinergic agent. Although it does not display selectivity for specific muscarinic receptors, when topically applied it acts mainly on M3 muscarinic receptors[8] located on smooth muscle cells and submucosal glands. This leads to a reduction in smooth muscle contraction and mucus secretion and thus produces a bronchodilatory effect.

Mode of delivery

The patient removes one tiotropium capsule from the blister pack, places it into the piercing chamber of the inhalation device and closes the mouthpiece.

The capsule is manually pierced, and the medication is inhaled through the mouthpiece. It is recommended that inhalations be repeated 2 to 3 times to ensure all medication is drawn from the capsule. When properly done, the capsule will make a distinctive flutter or rattle, audible to the patient.

Once the powder capsules are removed from the blister pack, it should be taken immediately via the inhalation device. If a capsule is exposed to the air, it will rapidly degrade to the point the dose will become ineffective. Any previously exposed capsules should be discarded.

The capsules cannot be taken orally - they will not be effective as respiratory medication if absorbed through the gastrointestinal tract and may have side effects if absorbed via this route.

Front view
A previously pierced Spiriva capsule
Open (cleaning) view


  1. Corey, E.J. (2012). "Tiotropium bromide". Molecules and Medicine. John Wiley & Sons. ISBN 9781118361733.
  2. 1 2 "Spiriva Handihaler". The American Society of Health-System Pharmacists. Retrieved 3 April 2011.
  3. Rossi S, ed. (2006). Australian Medicines Handbook. Adelaide.
  4. Singh S, Loke YK, Furberg CD (September 2008). "Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis". JAMA. 300 (12): 1439–50. doi:10.1001/jama.300.12.1439. PMID 18812535.
  5. FDA. Follow-Up to the October 2008 Updated Early Communication about an Ongoing Safety Review of Tiotropium (marketed as Spiriva HandiHaler). FDA 2010
  6. Singh, S; Loke, YK; Enright, PL; Furberg, CD (Jun 14, 2011). "Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials.". BMJ (Clinical research ed.). 342: d3215. doi:10.1136/bmj.d3215. PMC 3114950Freely accessible. PMID 21672999.
  7. Wise RA, Anzueto A, Cotton D, Dahl R, Devins T, Disse B, et al. Tiotropium respimat inhaler and the risk of death in COPD. N Engl J Med. 2013 08/30; 2013/10.
  8. Kato M, Komamura K, Kitakaze M (December 2006). "Tiotropium, a novel muscarinic M3 receptor antagonist, improved symptoms of chronic obstructive pulmonary disease complicated by chronic heart failure". Circ. J. 70 (12): 1658–60. doi:10.1253/circj.70.1658. PMID 17127817.
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