Tiotropium Slows Worsening (Decline in Lung Function) in Early COPD

Tiotropium Slows Worsening (Progression) in Those with Early COPD

Background: Tiotropium (brand name: Spiriva) is a once daily long-acting inhaled bronchodilator that has been approved for treatment of COPD for over 10 years. Studies show that it opens the airways to make it easier to breathe, reduces air trapped in the lungs, and improves both quality of life and ability to exercise.

Spiriva HandiHaler - tiotropium slows worsening of COPD

Spiriva HandiHaler dry powder inhaler


However, no bronchodilator has been shown to slow the expected worsening (progression) in breathing tests over time.

Study: Dr. Zhou and other investigators in China compared the changes in breathing tests of Spiriva HandiHaler and a placebo (inactive medication) over 2 years in those with “early-stage” COPD. The authors proposed that regular use of this bronchodilator would slow the expected decline in lung function as measured by expiratory volume in one second (FEV1).

FEV1 is used to grade COPD severity and assess COPD prognosis

Diagram of spirometry to diagnose COPD. FEV1 is the amount of air exhaled in one second.

Only patients with “early-stage” COPD were studied with FEV1 of 50% or higher of the predicted value. The study was conducted in 24 centers in mainland China between October 2011 and September 2015. The findings were reported in the September 7, 2017, issue of the New England Journal of Medicine, volume 377; pages 923-936.

Results: 841 patients completed the trial: 388 received tiotropium and 383 received placebo. Average age was 64 years, and 85% were men. Most patients did not complain of any shortness of breath.

The annual decline in FEV1 was significantly less in those treated with tiotropium compared with placebo when breathing tests were performed after inhaling albuterol in the pulmonary function laboratory at 2 years. The difference between treatments was 22 milliliters per year.

Conclusions: The authors concluded that tiotropium slows worsening in those with early-stage COPD as measured by post-bronchodilator FEV1.

My Comments: The current recommendations for prescribing one or two long-acting bronchodilators is to reduce symptoms and to reduce the risk of a flare-up (exacerbation) in those with COPD. However,this study challenges that approach by showing that early treatment slows progression of COPD as measured by breathing tests.

An editorial in the September 7 issue of the New England Journal of Medicine by Drs. Ko and Wong from the Chinese University of Hong Kong suggested it is likely that other long-acting bronchodilators would provide a similar benefit.

In caring for those with COPD in my practice, I have observed that many individuals have stable breathing tests when tested over several years. I believe that this stability is likely due to two factors: 1. regular use of long-acting bronchodilators; and 2. avoiding a COPD flare-up (exacerbation).

What is the Best Maintenance Bronchodilator Therapy for my COPD?

Maintenance Bronchodilator Therapy – Four Combinations Available in a Single Inhaler

Dear Dr. Mahler:

I have severe COPD and I was wondering roughly how long does it take to get on a maintenance program that works. This May will be a year and I still use my nebulizer with a duoneb every 4 hours and my emergency inhaler (Ventolin) when needed. My pulmonologist knows this. Should I see another pulmonologist??? I figure I should of been getting some relief. I have been smoke free for 3 months and will not go back to smoking again. Could you please point me in the right direction???

Jeff from Lubbock, TX

Dear Jeff:

DuoNeb is a very good short-acting combination of two different bronchodilators – albuterol and ipratropium. They work in different ways to open the breathing tubes by relaxing the muscle that wraps around the tubes. Short-acting bronchodilators last approximately 4 – 6 hours, and then the breathing tubes return to previous narrowing. Also, Ventolin is a brand name for albuterol delivered in an inhaler.

Maintenance bronchodilator therapy keep the breahting tubes open for 12 - 24 hours.

View of smooth muscle wrapping around the outside of the breathing tubes

All studies show that long-acting bronchodilators are more effective in keeping the breathing tubes open for a longer time and making it easier to breathe compared with short-acting medications. There are many choices of long-acting bronchodilators to use that are delivered in different types of inhalers.

In the past few years four different combination of long-acting bronchodilators in a single device have been approved for use in the United States by the Food and Drug Administration. I have several posts describing these medications used as maintenance bronchodilator therapy. They include in alphabetical order of brand names: Anoro Ellipta – a dry powder inhaler; Bevespi Aerosphere – a metered-dose inhaler; Stiolto Respimat – a soft mist inhaler; and Utibron Neohaler – a dry powder inhaler. Anoro and Stiolto are used once a day as their effects last for 24 hours, while Bevespi and Utibron are used twice a day because they last 12 hours.

Jeff – I suggest that you ask your pulmonologist about a trial of one of these dual long-acting bronchodilators instead of taking DuoNeb. In my practice, I give samples to be used for 2 – 4 weeks as a trial, and then schedule a follow-up appointment to assess whether the medication is helping the person “breathe easier.”

You may wish to share this post with your pulmonologist. If he or she is unwilling to try one of these long-acting combination medications, then I would consider seeing a different health care provider.

Best wishes,

Donald A. Mahler, M.D.