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# Tiova (tiotropium)
## Overview
Tiotropium is a long-acting, non-selective muscarinic receptor antagonist (LAMA). It binds to M1, M2, and M3 receptors in the airway, resulting in prolonged bronchodilation by inhibiting cholinergic bronchoconstriction. It has a slow dissociation from M3 receptors, allowing for once-daily dosing.
## Primary Indications
* **COPD:** Long-term, once-daily maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease.
* **Asthma:** Maintenance treatment of asthma in patients 6 years and older.
## Adult Dosing
* **COPD:** 18 mcg (one capsule) once daily via HandiHaler; OR 5 mcg (two actuations of 2.5 mcg) once daily via Respimat soft mist inhaler.
* **Asthma:** 2.5 mcg (two actuations of 1.25 mcg) once daily via Respimat.
* **Maximum Dose:** Do not exceed once-daily administration.
## Pediatric Dosing
* **Asthma (6–17 years):** 2.5 mcg (two actuations of 1.25 mcg) once daily via Respimat.
* **Safety/Efficacy:** Not established for children <6 years.
## Dose Adjustments
* **Renal Impairment:** No initial dosage adjustment required. However, monitor patients with moderate-to-severe renal impairment (CrCl <50 mL/min) closely for anticholinergic effects.
* **Hepatic Impairment:** No formal dosage adjustment established; monitor as appropriate.
## Contraindications
* Hypersensitivity to tiotropium, ipratropium, or any component of the formulation.
* History of hypersensitivity to milk proteins (applies to HandiHaler capsules containing lactose).
## Adverse Effects
* **Common:** Dry mouth (most frequent), pharyngitis, sinusitis, upper respiratory tract infection, cough.
* **Serious:** Paradoxical bronchospasm, acute narrow-angle glaucoma, urinary retention, worsening of prostatic hyperplasia, and anaphylaxis.
## Key Drug Interactions
* **Anticholinergics:** Concomitant use with other anticholinergic drugs (e.g., ipratropium, umeclidinium) may potentiate adverse effects (e.g., urinary retention, constipation, xerostomia). Avoid duplicate therapy.
## Monitoring
* **Therapeutic:** Symptom control (dyspnea, frequency of rescue inhaler use, FEV1 improvement).
* **Safety:** Monitor for signs of urinary retention or ocular pain (suggesting narrow-angle glaucoma). Observe for paradoxical bronchospasm immediately following administration.
## Clinical Pearls
* **Administration:** Ensure patients understand the specific device instructions. HandiHaler capsules are for inhalation only; **do not swallow**.
* **Device Priming:** Respimat inhalers must be primed before first use or if unused for >3 days (or >21 days, depending on specific model instructions; check package insert).
* **Maintenance Only:** Tiotropium is not indicated for the relief of acute bronchospasm (rescue therapy). Patients must have a separate short-acting beta-agonist (e.g., albuterol) available for emergencies.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice protocols may vary by institution. Always consult the latest FDA-approved prescribing information, local formulary guidelines, and patient-specific medical history before prescribing or administering medication.
