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3yr
Share your Opinion: LAMA for COPD via SMI

Long-acting muscarinic antagonist (LAMA) monotherapy is recommended as first-line therapy for chronic obstructive pulmonary disease (COPD) per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, and D.



The first LAMA to be approved for COPD was tiotropium bromide. It is administered once daily due to its long duration of action. At first, this medication was delivered by a dry-powder inhaler (DPI) in the form of an inhalation powder. Now, it is available as an inhalation spray delivered via a soft mist inhaler (SMI). The SMI minimizes the necessity for strong inspiratory airflow, which is an issue with DPIs.



Short- and long-term clinical trials suggest that tiotropium bromide is safe and effective, and when compared with placebo/active comparators, improves lung function, health-related quality of life, and exercise endurance, as well as decreasing dyspnea, lung hyperinflation, exacerbations, and need for rescue medication compared.



Discussion questions: Which of your patients best respond to tiotropium bromide? How has treatment improved with the introduction of inhalation spray delivered by SMI?


  • 3yr
    Tiotropium as 1st line for patients with mild COPD and add LABA for moderate to severe COPD patients.
  • 3yr
    It works well as a first line treatment for mild copd. Use with LABA for moderate copd
  • 3yr
    Patient with mild copd can be treated with Tiotropium as first line. For moderate to severe copd add to LABA.
  • 3yr
    LAMA for COPD is a good first line mono Rx for mild COPD (though there is a pro-con debate from CHEST 2021 I believe that had one side argue to go right to the LAMA-LABA combo instead), as part of separate double and triple therapy for more moderate - severe. Also, add on rx for asthma patients. The SMI offered in the Respimat device is quite novel and adds benefit to those with lower PIFR. I was worried when this was released that it would be too complicated for patients to use, but fortunately that is not the case
  • 3yr
    Most helpful in mild to moderate copd with extensive mucous production.
  • 4yr
    SMI or DPI with tiotropium work well for patients with moderate COPD FEV1 50% .Between 39 to 50% the SMI seems to help better as they tend to have more problems with
    low inspiratory flow. those patient with more a bronchitic component also seem to respond better i.e. less dyspnea, exacerbation, on the other those those with emphysema componnent improve lung function, better exercise endurance and less hyperinflation
  • 4yr
    Best to use daily as directed, but some patients do not use correctly
  • 4yr
    LAMA, including tiotropium, are a standard maintenance for the vast majority of COPD patients and part of step up therapy for uncontrolled asthma patients. The SMI does offer a good option for those with lower PIFR, and has been easier than expected for patients to use correctly. Manual dexterity issues with the handihaler/capsule was a common problem (with the capsule ending up on the floor or worse)
  • 4yr
    I much prefer the Respimat format; capsules were difficult for some patients to remove from foil packet. Additionally some patients dislike DPI inhalers in general. Slow delivery reduces the hand/breath coordination issue as well. LAMA reasonable to avoid the possible naked LABA issue as well with regards to asthma. Still see the rare urinary retention issue with LAMA but pretty minimal.
  • 4yr
    Patients with moderate to severe and very severe COPD, persistent symptoms on rescue inhalers alone, and/or frequent exacerbations respond well to tiotropium. It is easier for patients to use it with SMI.
  • 4yr
    Most of the patients with mild to moderate COPD respond well to LAMA, either alone or in combination. SMI inhaler is easier to use and provides better delivery, especially elderly patients
  • 4yr
    Usually patients respond well to spiriva , with the SMI inhaler it is easier for patients to inhale medication, , easier to use , especially for patients with arthritis .
  • 4yr
    If the patient responded to DPI, he/she would most likely respond to SMI with an additional benefit of dosing flexibility. Cost and formulary coverage can still remain challenging for some patients.
  • 4yr
    Almost all of my COPD patients have responded well to tiotropium. Patients seem to get more improvement since the introduction of SMI technology.
  • 4yr
    Effective in most, especially early, Mild-Moderate COPD w/excessive mucous production. SMI is a more efficient delivery device, easier to use, and requires less inspiratory effort.
  • 4yr
    Almost all patients with COPD can benefit from tiotropium. Either as a singular agent or in combination with other agents is beneficial for all stages of copd. The smooth Mist inhaler increases ease of inspiration as well as overall distribution in the lungs in the even fashion. Additionally subjectively patients feel better relief with the Mist as opposed to the dry powder.
  • 4yr
    Best response from patients with excessive mucous production. Some patients do not tolerate dry powder so this is beneficial and some have poor inspiratory ability so soft mist is helpful for them
  • 4yr
    Great med when u are able to open the container
  • 4yr
    Spiriva ( Tiotropium ) was the first LAMA that came in the market and and it was quite a cumbesome device to use and needed quite a bit of dexterity to use it but being the only one of its kind it was the stadard therapy as the 1st line in managemetn of COPD later on lot of the competitive LAMA agents have come up in Elllipa and MDI devices and the later Stiolto ( Tiopropium ) has come in the SMI which is still tricky to use and patients find it confusing how to use the Mist and not a very desirable one as compared to other devices However the compound of Tiopropium itself is pretty good and early COPD patients with out the active inflamatory component respond well to it and as the disease progresses due course of time addition of the LABA and ICS becomes inevitable !
  • 4yr
    Some patients with difficult to control asthma responds to it.
  • 4yr
    The ones that seem to get the most benefit are the long term smokers that still have quite a bit of expectorated mucus daily - which is mostly men > women. Once the mucus produced drops a lot, it does not seem to work as well.
  • 4yr
    Most helpful in mucopurulent bronchitis spectrum of COPD. Ease and better drug delivery
  • 4yr
    Moderate to severe…better results with the spray

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