This Is the Number One Inhaler for COPD

Photo Credit: Boehringer.

Since there are several different kinds of inhalers that are used to treat COPD, many patients may wonder “which one is best?”  While acknowledging that it’s dangerous to generalize that there is a ‘single best medicine’ for any condition, in the case of COPD, one class of medicines does tend to stand above the others, which has earned this class the title of “first-line agent” for treating COPD.

The class of medication is called the anticholinergic inhalers, of which there are currently two on the market:  Spiriva (tiotropium) and Turdoza (aclidinium bromide).

  Since Turdoza came on the market in 2012, the vast majority of clinical trials involving COPD patients used the medication Spiriva (which came on the market in 2004).  Thus, in this article, we will talk mainly about Spiriva by summarizing two important research studies about Tiotropium, that supports its position “the first choice of an inhaler for COPD patients."  Then, we will discuss the side effects of Spiriva.

In the March 24, 2011 edition of the New England Journal of Medicine (one of the premier medical journals), a team of researchers hoped to figure out which class of medications was better at preventing COPD exacerbations:  anticholinergics or long-acting beta agonists.  To do so, they compared Tiotropium (Spiriva, the anticholinergic) with Salmeterol (Serevent, the long-acting beta agonist) in patients with moderate to severe COPD.  They measured the time it took for patients to experience their first COPD exacerbation.

  They found that patients who used Spiriva had a 17% reduction in their risk of a COPD exacerbation and a 28% reduction in the risk to a severe exacerbation.  Patients who used Spiriva had 187 days until their first exacerbation where patients who used Serevent had 145 days to the first exacerbation.

In addition, patients who took Spiriva had less need for steroids (such as prednisone) and antibiotics.  There were no differences in rates or types of side effects from the medications.

Another study in the New England Journal of Medicine (from 2008) found did an experiment where they followed 3000 patients who took Spiriva and compared them with 3000 patients who used a ‘sham’ inhaler.   Both groups of patients were allowed to use their other medications during the study.  The patients who used Spiriva, however, had better lung function, fewer hospitalizations, less respiratory failure, and better scores in symptom surveys than patients who did not use Spiriva.   This study led researchers to conclude that Spiriva can improve symptoms, reduce exacerbations and improve the quality of life for patients with COPD (when compared to those who did not use Spiriva).

Though Spiriva is the usually the first choice for an inhaler, there are other inhalers that are indicated in COPD, such as Advair, Symbicort, and others.

  Many patients require more than one inhaler, and for some patients, Spiriva is NOT the best choice (for example, if they experience side effects). There are also some inhalers that should not be combined with Spiriva (for example, do not use Spiriva and Combivent together)

Side effects of Spiriva are very rare, and may include:

Urinary retention (especially in men with enlarged prostate)

Allergic reaction (hives, itching, rash, swelling of lips/tongue/throat)

Glaucoma (eye pain, blurred vision, seeing halos or odd colors)

More common side effects of Spiriva include:

Dry mouth

Sinus infection

Sore throat

Blurry vision

High heart rate

Upper respiratory tract infections

For an interesting Perspectives essay about the Side Effects of Spiriva (published in the New England Journal of Medicine), click here.

One last word about Spiriva- there are two kinds of inhaler devices for Spiriva (the Handihaler and the Respimat).  For more information about the two kinds of inhaler options, click here.


Tashkin DP, Celli B, Senn S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med 2008;359:1543-54.

Vogelmeier C, Hederer B, Glaab T, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med 2011;364:1093-103.

Wise RA, Anzueto A, Cotton D, et al. Tiotropium Respimat inhaler and the risk of death in COPD. N Engl J Med 2013;369:1491-501.

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