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Tiotropium Benefits Some Patients Who Don't Respond to β-Agonists

Summary and Comment |
November 27, 2013

Tiotropium Benefits Some Patients Who Don't Respond to β-Agonists

  1. David J. Amrol, MD

Bronchodilator response and greater obstruction predict better response to tiotropium.

  1. David J. Amrol, MD

Tiotropium (Spiriva), a long-acting antimuscarinic agent, is FDA approved as first-line therapy for patients with chronic obstructive pulmonary disease; however, as add-on therapy, it also benefits some patients with asthma that is not controlled by inhaled corticosteroids (ICS) alone. To evaluate predictors of response to tiotropium (compared with the long-acting β-agonist salmeterol [Serevent]), researchers analyzed data from a previous 14-week crossover trial in which double-dose ICS, ICS plus salmeterol, and ICS plus tiotropium were compared in 210 adult asthma patients.

Roughly equal numbers of patients responded to tiotropium and salmeterol. Some patients responded just to tiotropium (26%) or just to salmeterol (14%) but not both. Patients with greater forced expiratory volume in 1 second (FEV1) reversibility to short-acting bronchodilators (either ipratropium or albuterol) and patients with lower pretreatment FEV1/forced vital capacity responded better to tiotropium than to salmeterol. Younger patients and those with higher cholinergic tone (inferred by lower resting heart rate) reported more asthma-control days with tiotropium than with salmeterol.

Comment

Because a larger body of evidence supports benefit for long-acting β-agonists and because they are FDA approved, they are still first-line therapy for patients whose asthma is not controlled by inhaled corticosteroids alone. A subset of nonresponders to long-acting β-agonists will respond to long-acting antimuscarinic agents and vice versa. Younger patients and those with more baseline obstruction and bronchodilator reversibility actually might do better with long-acting antimuscarinic agents.

  • Disclosures for David J. Amrol, MD at time of publication Consultant / advisory board Dyax Leadership positions in professional societies South Carolina Allergy Society (President)

Citation(s):

Reader Comments (2)

Michael Bone BSc MB DCH FRCP Physician, Allergy/Immunology, South Tyneside NHS Foundation Trust

What's new? Nice hint about vagal tone.
Don't forget evidence of enhanced vagal tone at night in asthma. I often use tiotropium at night for those with marked nocturnal symptoms.

P Lepera

Define refractory patients by clinical symptoms and FEV1. There is a body of evidence supports benefit for long-acting β-agonists . They are front -line therapy for patients whose asthma is not controlled by inhaled corticosteroids alone. A subset of nonresponders to long-acting β-agonists will respond to long-acting antimuscarinic agents such as spiiriva.

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