Ask the Experts: Risks and benefits of using ipratropium and tiotropium together

Do you have a question for Kristine Petrasko? Click hereView other questions and answers about asthma: Click hereQuestion: My question relates to COPD and Asthma. I work in a busy hospital and we have many patients who are on a combination of tiotropium and ipratropium, in addition to a LABA/steroid. Can you tell me what are the risks and benefits of using ipratropium and tiotropium together? Should we pursue trying to have one of the anticholinergics discontinued because of duplicate therapy? Answer: Combination use of bronchodilators has been shown to be beneficial in many patients with COPD. However, most studies have indicated that this is in considering two bronchodilator agents with different pharmacological mechanisms of action. For example, the use of the short acting bronchodilators (ipratropium) and short acting Beta-2 agonists (salbutamol) together have been shown to provide superior bronchodilation than either agent alone. We also know that in combining tiotropium with a LABA (ie. formoterol), there is evidence of additive effects on pulmonary function in patients with moderate to severe COPD.The agents most in question (tiotropium and ipratropium) should really be used separately. We have seen that tiotropium has been shown to have more sustained effects on pulmonary function, activity related dyspnea and quality of life in comparison to regular dose (40ug QID) of ipratropium. This does not look, however, at the higher end dosage ranges of ipratropium that we may actually see in practice. A recent study published in the American College of Chest Physicians looked at a comparison between two different short acting bronchodilators (ipratropium and fenoterol) being added to maintenance dosing of tiotropium. Although the study did demonstrate that both classes were relatively effective when added to the tiotropium, the fenoterol appeared to provide greater additional bronchodilation as compared to the ipratropium. Again, this may be explained by the fact that agents with different pharmacological mechanisms when combined have more of an effect on improving bronchodilation.Furthermore, when considering safety of these two agents (ipratropium and tiotropium) used together one must consider the side effect profiles of each individual agent. According to the current guidelines, the pharmacokinetics of the LAAC tiotropium would likely indicate that the addition of SABD (ipratropium) would not result in additive beneficial effects with bronchodilation, but may instead increase the adverse effects imposed on susceptible patients. The current guidelines and recommendations do not promote the combination of these two agents.With regards to what we are seeing in practice, some practitioners are prescribing the use of LAAC agents along with SABA’s or SABD’s. However, it is the SABA’s that are important to consider for concomitant use with LAAC’s as their primary use is for emergency or acute situations. The SABA’s (ie. salbutamol) have a faster onset of action with a shorter duration of action, and of course, a different mechanism of action from the LAAC agent tiotropium. Again, the current guidelines do not recommend concurrent use of the LAAC (tiotropium) and SABD (ipratropium) agents; as well, it does not recommend the use of ipratropium as regular maintenance therapy. So, to answer your question, ideally, the ipratropium should probably be discontinued.**NOTE: Please see the new updated guidelines (November 2007) available on the CTS website and the upcoming CPJ respiratory supplement in the Nov/Dec 2007 issue.(LAAC = Long acting anticholinergic; SABA = short acting beta agonist; SABD = short acting bronchodilator).Experts are available on a variety of pharmacy-related topics. Click here

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