Question: When is Spiriva Respimat used in asthma patients? Recently I have seen it being prescribed for not only COPD patients but asthma ones as well. When is it appropriate in asthma?

Answer: The Canadian Thoracic Society in late 2017 released a position statement on: the Recognition and management of severe asthma. In this statement paper the guidelines for asthma treatment, particularly severe asthma, have been updated and include the use of Spiriva Respimat for uncontrolled severe asthma in their step up therapy for asthma control.Asthma is highly prevalent, affecting approximately 8.4% of Canadians.(1) The standard treatment for asthma control is the use of inhaled corticosteroids for maintenance. If a patient is non adherent to treatment or has improper inhaler/device technique that should be addressed first before adding on more pharmacotherapy. When a patient comes for refills to the pharmacy it is a great opportunity to check compliance and technique to assess patient outcomes.The diagnosis of asthma should be objectively confirmed, including spirometry in all individuals with suspected uncontrolled asthma. Asthma is uncontrolled if a patient experiences:daytime symptoms 4 days a week or more, 1 or more nighttime symptom in a week, limitations in physical activity due to wheezing/chest tightness/coughing/shortness or breath, absence from work or school due to asthma, need for a fast acting beta agonist four times a week or more, FEV1 or PEF less than 90% of personal best, PEF diurnal variation more than 15%, or sputum eosinophils greater than 3%.Domestic and work environments for triggers should be assessed and controlled or changed if possible. For example if a cat allergy is causing asthma symptoms the cat should be removed if possible from the home environment. Removing triggers from work environments such as industrial inhalants, dust, and chemicals can sometimes be more challenging but should be addressed.Co-morbid conditions such as viral or bacterial infections could also be causing the asthma to exacerbate and be uncontrolled. These should be diagnosed and treated to remove the exacerbation. Alternate diagnosis should also be considered for co-morbid conditions by the physician or specialist such as gastro-esophageal reflux or cystic fibrosis. If the co-morbidities are left untreated it could be very difficult to handle controlling asthma.After increasing the dose of ICS (inhaled corticosteroids) and adding LABA a (long acting beta agonist), second line therapy would be adding a leukotriene receptor antagonist (LTRA).If control is still not achieved in patients 12 years and older long acting muscarinic antagonists (LAMA) therapy can be initiated.Tiotropium bromide belongs to a class of medications called long-acting muscarinic antagonists (LAMA). LAMAs achieve bronchodilation by a mechanism that is distinct from the direct smooth muscle relaxation that occurs with long-acting beta agonist (LABA) therapy. LAMAs prevent acetylcholine-mediated bronchoconstriction by competitively antagonizing M3-receptors in the airways, and thereby permitting bronchodilation. The prolonged half-lives of LAMA mean that these agents only need to be administered once or twice daily. LAMAs have emerged initially as a therapy for chronic obstructive lung disease (COPD), with comparable efficacy to LABA. (2)Some children and adults with asthma will remain uncontrolled despite the use of ICS +/- LABA or other add on therapy. Hence in recent years many clinical trials have been conducted to determine the role of tiotropium in the management of moderate to severe persistent asthma. Potential side effects specific to LAMAs include dry mouth, mydriasis, urinary retention and metallic taste. (3)Tiotropium bromide soft mist inhalation therapy is safe and effective in improving lung function and reducing severe asthma exacerbations in adults and adolescents with uncontrolled asthma despite ICS and LABA. (3)So yes, you may see prescriptions for Spiriva Respimat for patients with uncontrolled asthma despite ICS therapy with add on controller therapies including a LABA and possibly LTRA if their asthma remains uncontrolled. Treatment with tiotropium in this population of asthma patients offers them possible control with relatively modest cost and convenience (ease of administration) compared to biologic therapy.References:(1) Government of Canada. Fast facts about asthma: Data compiled from the 2011 Survey on Lining with Chronic Diseases in Canada. http:/www.phac-aspc.gc.ca/cd-mrc/asthma_fs_asthme-eng.php. Accessed July 24,2017.(2) (NICE) NIfHCE. Chronic obstructive pulmonary disease in over 16s: Diagnosis and Management 2010. nice.org.uk/guidance/cg101.(3) Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, ISSN:2474-5332 (print) 2474-5340 (online) Journal homepage: http://www.tandfonline.com/loi/ucts20 Recognition and management

Question: When is Spiriva Respimat used in asthma patients? Recently I have seen it being prescribed for not only COPD patients but asthma ones as well. When is it appropriate in asthma?

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