Tiotropium for uncontrolled asthma

Tiotropium, a long-acting anticholinergic inhaler, is approved for treatment of chronic obstructive pulmonary disease. A new study suggests that it may also be effective for patients with asthma.

In a study of 210 adults with asthma with inadequate control with inhaled glucocorticoids, tiotropium was compared to doubling the dose of glucocorticoids, and was also compared to the addition of salmeterol, a long-acting beta agonist (LABA). Tiotropium was superior to doubling the dose of inhaled glucocorticoid as assessed by measuring the morning peak expiratory flow (PEF) (P < 0.001). It also improved evening PEF, asthma control days, and FEV1, as well as daily symptom scores. The addition of tiotropium was also non-inferior to the addition of salmeterol for all assessed outcomes and was superior to salmeterol in measures of prebronchodilator FEV1 (P = 0.003).

The authors conclude that tiotropium is superior to doubling the dose of glucocorticoid in patients with inadequately controlled asthma, and is equivalent to the addition of salmeterol in the same patient group (published online N Engl J Med Sept. 19, 2010). This study is important because it may result in options for patients with poorly controlled asthma beyond adding a LABA. Recently, asthma experts and the FDA have questioned the safety of LABA therapy (FDA Drug Safety Communication June 2, 2010), and a recent meta-analysis suggests that use of LABAs without concomitant inhaled corticosteroids increase the risk for intubation or death (Am J Med 2010;123:322-328).