Concomitant Use of Spiriva with Trelegy
Spiriva (tiotropium) should not be taken concomitantly with Trelegy (fluticasone furoate/umeclidinium/vilanterol) due to the risk of increased anticholinergic adverse effects from using two muscarinic antagonists simultaneously. 1
Rationale for Avoiding Concurrent Use
Trelegy already contains a long-acting muscarinic antagonist (LAMA) component:
- Trelegy is a triple therapy containing umeclidinium (LAMA), vilanterol (LABA), and fluticasone furoate (ICS) 2
- Spiriva (tiotropium) is also a LAMA that works through the same mechanism as umeclidinium
The FDA drug labeling for tiotropium-containing products specifically warns against co-administration with other anticholinergic medications:
"There is potential for an additive interaction with concomitantly used anticholinergic medications. Therefore, avoid co-administration with other anticholinergic-containing drugs as this may lead to an increase in anticholinergic adverse effects." 1
Potential Risks of Combining Two LAMAs
Using two LAMAs concurrently can increase the risk of:
- Dry mouth
- Constipation
- Urinary retention (particularly in men with prostatic hyperplasia)
- Increased intraocular pressure
- Worsening of narrow-angle glaucoma
One observational study found that individuals receiving combination therapy with a short-acting and long-acting anticholinergic agent had a significantly higher risk of acute urinary retention compared to those receiving monotherapy (OR 1.84; 95% CI 1.25 to 2.71), with men and those with benign prostatic hyperplasia at highest risk 3.
Clinical Implications
While some studies have shown that adding ipratropium (a short-acting muscarinic antagonist) to tiotropium may provide spirometric improvements in lung function, the clinical significance of these improvements has not been well-established, and the risk of anticholinergic adverse effects is increased with combination therapy 3.
Therapeutic Alternatives
If a patient is currently on Trelegy, adding Spiriva would be redundant and potentially harmful since:
- Both medications target the same muscarinic receptors
- The triple therapy in Trelegy already provides optimal bronchodilation through complementary mechanisms 2
- Trelegy has demonstrated superior efficacy compared to dual therapies in reducing exacerbation rates and improving lung function 4
Monitoring Recommendations
If a patient has been inadvertently taking both medications:
- Discontinue one of the LAMA components
- Monitor for resolution of any anticholinergic side effects
- Assess for proper inhaler technique with the remaining medication
- Consider checking for drug interactions with other medications the patient may be taking
Conclusion
The combination of Spiriva with Trelegy represents a therapeutic duplication that increases the risk of adverse effects without providing additional clinical benefit. Patients should use either Trelegy alone or, if not on Trelegy, Spiriva can be considered as part of a different treatment regimen.