How to Use a Spiriva Inhalers for COPD

Woman holding spiriva inhaler
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Spiriva (tiotropium bromide) is a long-acting medication that you might be prescribed for the management of your COPD or asthma. This medication is available in two formulations, Spiriva HandiHaler (tiotropium bromide inhalation powder) and Spiriva Respimat (tiotropium bromide inhalation spray), both of which are taken by inhalation.

Used once per day, Spiriva is approved for the prevention of everyday COPD and asthma symptoms and for the prevention of acute COPD or asthma exacerbations. This medication is not approved for the treatment of exacerbations or acute dyspnea (shortness of breath).

Uses

First approved by the US Food and Drug Administration (FDA) in 2004, Spiriva is used to counteract the symptoms of bronchospasm, which is severe and/or sudden narrowing of the bronchi (airways) in the lungs. Symptoms of bronchospasm in asthma and COPD include shortness of breath, wheezing, and chest tightness.

This medication is an anticholinergic bronchodilator. It binds to cholinergic receptors on the muscles of the bronchi to oppose airway muscle contraction (which narrows the bronchi). Spiriva widens the airways, providing relief of symptoms and preventing exacerbations.

Both forms of Spiriva have similar indications, but Spiriva Respimat is approved for the treatment of asthma, while Spiriva HandiHaler is not.

Approved uses for Spiriva:

  • Spiriva HandiHaler: This medication is approved for indicated for the long-term maintenance treatment of bronchospasm associated with COPD and for reducing COPD exacerbations.
  • Spiriva Respimat: This medication is approved for the maintenance treatment of bronchospasm associated with COPD and for reducing COPD exacerbations. It's also approved for the long-term once-daily maintenance treatment of asthma in patients 12 years of age and older.

Off-Label Uses

Spiriva HandiHaler has been used off-label for maintenance treatment of asthma, and both formulations of tiotropium bromine have been used off label for the treatment of asthma exacerbation, COPD exacerbation, and for treatment of breathing difficulties associated with acute upper respiratory infections (without a diagnosis of asthma or COPD).

Before Taking

Spiriva can be used as a first-line agent in COPD treatment and the inhalation spray can be used as a first-line treatment for asthma. This means that it is not necessary to try other medications first before using Spiriva. Additionally, Spiriva can be used with other medications, or it can be used alone.

Precautions and Contraindications

You should not take this medication if you have ever had an adverse reaction to Atrovent (ipratropium) or any form of tiotropium bromide. It is also not recommended if you have hypersensitivity reactions to milk or milk proteins.

Its effect on pregnant women and babies of nursing mothers has not been studied, and this medication should only be used with extreme caution in these situations.

Spiriva can worsen the following conditions:

  • Glaucoma
  • Bladder problems or trouble passing urine
  • Kidney disease
  • Prostate problems

Other Drug Name(s)

There are no generic versions of Spiriva.

Atrovent (ipratropium bromide) is a similar anticholinergic medication taken with an inhaler or with a nebulizer.

Dosage

Both formulations of Spiriva are taken once daily using two inhalations per dose. The medication dose and inhaler device are specific to each brand.

The dose used for asthma is one half of the dose used for COPD.

How to Prepare

Do not swallow the medication directly. Use your medication and the inhaler according to the package instructions. Each of these Spiriva formulations is prepared a little bit differently.

Spiriva Respimat

Spiriva Respimat is available in 1.25 mcg or 2.5 mcg strengths and is taken as two inhalations per dose, for a total dose of 2.5 mcg or 5 mcg each time. For COPD, the daily dose is 5 mcg per day. For asthma, the daily dose is 2.5 mcg per day.

When you are using your inhaler for the first time, you need to insert your Spiriva Respimat cartridge into your inhaler. You have to prime it by spraying the inhaler toward the ground until an aerosol cloud is visible. Repeat this process three more times.

If you don't use your inhaler for more than 3 days, you will need to prime it again by spraying once until an aerosol cloud is visible. And if you don't use your inhaler for more than 21 days, you need to prime it all over again by spraying the inhaler until an aerosol cloud is visible. Then repeat the process three more times to prepare the inhaler for use. 

Spiriva HandiHaler

Your Spiriva HandiHaler prescription will include Spiriva capsules and a HandiHaler device. Each Spiriva capsule contains 18 mcg dry powder formulation of tiotropium, and the dose requires two sprays to deliver one capsule worth of medication.

When you are ready to use your medication, you should place a Spiriva capsule into the tiny slot in the center chamber of the HandiHaler device. Then you need to close the white mouthpiece cover and press the green button on the side of the HandiHaler device as you inhale the medication through the mouthpiece. 

When using Spiriva HandiHaler, you should hear a rattling sound as you take a deep breath. This indicates the medication is being dispensed correctly from the capsule. If you don’t hear a rattling sound:

  • Check to make sure the mouthpiece on your Spiriva HandiHaler is tightly closed
  • Hold your HandiHaler upright and tap it gently on a tabletop, counter or another hard surface
  • Try inhaling again

If you still don’t hear or feel the capsule rattle, talk to your doctor or pharmacist as soon as possible.

How to Take

After you properly place your medication into your device, place the inhaler to your mouth and tightly seal your lips around the mouthpiece. Breathe in quickly and deeply through the device.

Hold your breath for five to ten seconds, and then breathe out normally. Rinse your mouth with water or brush your teeth after each use. Remove the medication from the device after each use and throw it away.

Be sure to clean your device according to the instructions.

Modifications

Because this medication is inhaled and comes in fixed doses, the dose is not easily modifiable.

Storage

Do not store medications in your inhaler ahead of time—place the medicine into the device before each use.

Both formulations of the medication should be stored at 25°C (77°F); excursions permitted to 15°–30°C (59°–86°F) and should not be exposed to extreme heat.

Side Effects

The side effects for Spiriva Handihaler and Spiriva Respimat are generally similar, although some people may be able to tolerate one of them more than the other.

Common

There are a number of common side effects that don't cause serious harm but may be uncomfortable. If these side effects persist or cause severe distress for you, be sure to talk to your doctor.

Common side effects include:

  • Cough
  • Dry mouth
  • Headaches
  • Sore throat
  • Sinusitis

Severe

Serious side effects are not common, but they can be harmful to your health. Be sure to talk to your doctor promptly if you experience any severe side effects when taking this medication.

Severe side effects include:

  • Any type of allergic reaction such as skin rash, hives, swelling of the face, lips, or tongue
  • Difficulty breathing
  • Changes in vision
  • Chest pain
  • Rapid heartbeat or heart palpitations
  • Infection or flu-like symptoms
  • Trouble passing urine or change in the amount of urine

In 2008, the FDA placed a warning about the risk of stroke with this medication. While the warning was lifted, research still shows that this medication can increase the risk of cardiovascular disease, including strokes and heart attacks.

Warnings and Interactions

Spiriva may interact with other anticholinergic drugs, causing additive side effects. 

Anticholinergics include antidepressants and anti-diarrhea medications. If you aren't sure whether any of your other medications are anticholinergics, you can ask your pharmacist to review your list of medications (you might have prescriptions from different doctors) to see if there are any potential interactions.

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Article Sources
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  1. Food and Drug Administration. SPIRIVA® HandiHaler label. Updated December 2009.

  2. Food and Drug Administration. SPIRIVA® RESPIMAT® label. Updated September 2015.

  3. Schmiedl S, Fischer R, Ibanez L, et al. Tiotropium Respimat(®) vs. HandiHaler(®): real-life usage and TIOSPIR trial generalizability. Br J Clin Pharmacol. 2016;81(2):379-88.doi:10.1111/bcp.12808

  4. Liou JT, Lin CW, Tsai CL, et al. Risk of severe cardiovascular events from add-on tiotropium in chronic obstructive pulmonary disease. Mayo Clin Proc. 2018;93(10):1462-1473.doi:10.1016/j.mayocp.2018.05.030