What are Long-Acting Muscarinic Antagonist (LAMA) medications for a patient with Chronic Obstructive Pulmonary Disease (COPD)?

Long-Acting Muscarinic Antagonists (LAMAs) for COPD

LAMAs are a class of long-acting anticholinergic bronchodilators that work by blocking muscarinic receptors (M1-M5) in the airways, with primary action at the M3 receptor on smooth muscle to produce bronchodilation lasting 24 hours or longer. 1, 2

Available LAMA Medications

The following LAMAs are FDA-approved for COPD maintenance therapy:

• Tiotropium - The most extensively studied LAMA, available as a single agent or in combination products 2, 3
• Umeclidinium - A long-acting muscarinic antagonist with similar affinity to muscarinic receptor subtypes M1 through M5 1
• Glycopyrronium (glycopyrrolate) - Available in multiple formulations 4, 3
• Aclidinium - A twice-daily LAMA option 3

Mechanism of Action

• LAMAs produce bronchodilation through competitive and reversible inhibition of M3 muscarinic receptors on airway smooth muscle, with effects lasting longer than 24 hours 1
• The bronchodilation is predominantly a site-specific effect in the airways, preventing methacholine- and acetylcholine-induced bronchoconstriction in a dose-dependent manner 1

Clinical Efficacy

• LAMAs are superior to short-acting muscarinic antagonists (SAMAs) like ipratropium for reducing COPD exacerbations and decreasing hospitalizations 5
• LAMAs demonstrate greater efficacy in exacerbation reduction compared to LABAs when evaluated collectively in meta-analyses 4
• All LAMAs provide similar clinical benefits in improving lung function, reducing dyspnea, decreasing exacerbation risk, and improving quality of life 6

Available Combination Products

LAMA/LABA fixed-dose combinations include:

• Umeclidinium/vilanterol (ANORO ELLIPTA) - Delivers 62.5 mcg umeclidinium and 25 mcg vilanterol per dose 1
• Tiotropium/olodaterol (STIOLTO RESPIMAT) - Delivers 2.5 mcg tiotropium and 2.5 mcg olodaterol per actuation (two actuations equal one dose) 2
• Glycopyrronium/indacaterol - Available as a once-daily combination 4, 3
• Aclidinium/formoterol - A twice-daily combination option 3

Guideline Recommendations

• The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends LAMAs as first-line maintenance therapy for patients with moderate to severe COPD requiring regular bronchodilator therapy 5, 6
• The American College of Chest Physicians recommends LAMAs as first-line maintenance therapy for moderate to severe COPD, while ipratropium is generally reserved for rescue medication or patients who cannot tolerate LAMAs 5
• For initial LAMA therapy, starting with generic tiotropium is recommended if available and affordable 6

Common Pitfalls

• Avoid using LAMAs as monotherapy in patients with asthma - LABA monotherapy (including LAMA/LABA combinations) without an inhaled corticosteroid is contraindicated in asthma patients 2
• Do not initiate LAMA therapy in acutely deteriorating COPD patients; these medications are for maintenance therapy only 2
• Use with caution in patients with narrow-angle glaucoma or urinary retention, as worsening of these conditions may occur 2
• Instruct patients on proper inhaler technique, as poor technique is associated with reduced symptom control, particularly in older patients using multiple devices 4