Tiotropium in asthma – perspectives for the primary care physician

ABSTRACT

Asthma is a heterogeneous disease characterized by airway inflammation resulting from complex interactions between multiple hosts as well as environmental factors. As a chronic respiratory condition, asthma exerts a significant impact on patients and the healthcare system. Per the Global Initiative for Asthma (GINA), inhaled corticosteroids (ICS) with/without long-acting beta₂-agonists (LABAs) should be used as the preferred controllers for the management of asthma. Despite a range of therapeutic options, many patients with asthma remain uncontrolled, resulting in an increased risk of hospitalization and emergency room visits and a worsened quality of life. Tiotropium (Spiriva®, Boehringer Ingelheim Pharmaceuticals, Inc; 1.25 µg, two puffs, once daily), delivered via the Respimat® inhaler (Boehringer Ingelheim Pharmaceuticals, Inc.), was the first long-acting muscarinic antagonist to be approved as an add-on maintenance treatment option for patients with asthma aged ≥6 years at GINA steps 4 and 5. By binding to the muscarinic receptors M1 and M3 in the bronchial airways, tiotropium antagonizes the action of acetylcholine, leading to smooth muscle relaxation and reduced mucus secretion.

The efficacy and safety of tiotropium add-on to ICS±LABA maintenance treatment have been evaluated in randomized controlled trials (RCTs) involving patients with a range of asthma severities (mild, moderate, and severe) and across age groups (children, adolescents, and adults). Add-on tiotropium was found to be well tolerated and efficacious in all RCTs. Moreover, the findings from real-world studies complement results from RCTs, showing beneficial effects of tiotropium in reducing exacerbations, hospitalization, emergency room visits, and asthma worsening.

In this review article, we discuss the pathophysiology of asthma and the role of tiotropium in the management of asthma from the perspective of a primary care physician.

KEYWORDS:

• Asthma
• pathophysiology
• long-acting muscarinic antagonists
• LAMA
• tiotropium Respimat®
• add-on treatment
• primary care

Acknowledgments

The authors meet the criteria for authorship as recommended by the International Committee of Medical Journal Editors. The authors received no direct compensation related to the development of the manuscript. Writing, editorial support, and formatting assistance were provided by Jidnyasa Mulekar, PhD, and Praveen Kaul, PhD, of Cactus Life Sciences (part of Cactus Communications), which was contracted and funded by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). BIPI was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations.

Declaration of interest

Alan Kaplan has received personal fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, NovoNordisk, Merck Frosst, Novartis, Pfizer, Teva, Trudel, and Sanofi. He also receives non-financial support from Boehringer Ingelheim and Trudel. Ku-Lang Chang reports no conflicts of interest.

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Notes on contributors

Alan Kaplan

Alan Kaplan: Dr. Alan Kaplan is a board-certified Family Physician working in York Region, Ontario, Canada and the Chairperson of the Family Physician Airways Group of Canada (www.fpagc.com), the Past-Chairperson of the Respiratory Section of the College of Family Physicians of Canada, and Senate member of the International Primary Care Respiratory Group. He co-chaired the Community Standards of COPD program for Health Quality Ontario. He is the medical director of the Pulmonary Rehabilitation program for the local health integration network.

Ku-Lang Chang: Dr. Chang is board certified in Family Medicine and a Fellow of the American Academy of Family Physicians. Dr. Chang is involved in asthma and COPD research. She is a Medical Review Officer and Medical Director for UF Health Gainesville Occupational Health.