Is tiotropium (Spiriva) recommended as a first-line treatment for children with asthma or other respiratory conditions?

Tiotropium in Children with Asthma

Tiotropium is not recommended as a first-line treatment for children with asthma but is effective as an add-on therapy in children aged 6 years and older with moderate to severe asthma that remains uncontrolled despite inhaled corticosteroids (ICS) with or without additional controller medications. 1, 2

Efficacy and Indications

• Tiotropium (Spiriva) was approved in the United States in 2015 for asthmatic patients aged 12 years and older at a once-daily 5 μg dose 1
• Clinical trials have demonstrated that tiotropium is efficacious as add-on therapy to inhaled corticosteroids with or without other maintenance therapies in children with moderate to severe symptomatic asthma 2, 3
• The 5 μg dose of tiotropium has shown greater efficacy than the 2.5 μg dose in improving lung function in children with asthma 3
• Tiotropium significantly improved peak FEV1 (139 mL improvement) and trough FEV1 (87 mL improvement) when used as add-on therapy in children aged 6-11 years with severe symptomatic asthma 3

Treatment Algorithm for Children with Asthma

First-line therapy:

• Inhaled corticosteroids remain the preferred long-term control medication for initiating therapy in children with asthma 1
• The benefits of ICS outweigh concerns about potential risks of growth velocity reduction or other possible adverse effects 1

When to consider tiotropium:

• For children aged 6 years and older with moderate to severe asthma whose symptoms remain uncontrolled despite ICS with or without additional controller medications 2, 3
• As an alternative to increasing ICS dose to high-dose or adding a LABA in children with uncontrolled asthma 1
• For adolescents aged 12-17 years with moderate symptomatic asthma, tiotropium 5 μg as add-on to ICS provides significant improvement in lung function 1

For younger children (under 6 years):

• Limited data exist on tiotropium use in children under 6 years 4
• In children aged 1-5 years, a small exploratory study showed tiotropium had similar tolerability to placebo but did not demonstrate significant differences in daytime asthma symptom scores 4
• Current evidence does not support routine use of tiotropium in children under 6 years 4

Safety Profile

• Tiotropium has demonstrated a favorable safety profile in children, with adverse events comparable to placebo 2, 4, 3
• Common adverse events include dry mouth, urinary retention, and glaucoma 1
• In clinical trials, children receiving tiotropium reported fewer asthma exacerbations compared to those receiving placebo 4
• The safety and tolerability of tiotropium in children aged 6-11 years were comparable to placebo when used as add-on therapy to ICS with other maintenance therapies 3

Important Clinical Considerations

• Tiotropium is administered once daily via the Respimat inhaler device 5
• Proper inhaler technique is essential to ensure appropriate medication delivery 5
• Tiotropium should not be used for relief of acute symptoms; a short-acting bronchodilator should always be available as rescue medication 5
• Tiotropium is not indicated for the initial treatment of acute episodes of bronchospasm where rapid response is required 5
• Care must be taken not to allow the aerosol cloud to enter the eyes as this may cause blurring of vision and pupil dilation 5

Emerging Evidence

• Recent studies suggest tiotropium may have anti-inflammatory effects in addition to its bronchodilator properties 6
• Tiotropium has shown potential to reduce asthma exacerbation risk compared with placebo in young children, though larger studies are needed to confirm this finding 4
• More research is needed to identify specific asthma phenotypes that might experience better clinical response to tiotropium compared with other adjunct medications 7