Tiotropium in the treatment of asthma

Asthma: Diagnosis and Treatment

Asthma is an obstructive lung disease affecting >230 million people worldwide and a significant cause of morbidity in patients of all ages. It is a heterogeneous disease with a complex pathophysiology and phenotype. Diagnosis is made with thorough history-taking and physical examination, and the condition is characterised by variable airflow obstruction and airway hyper-responsiveness. Understanding the severity of the disease is important, and treatment is aimed at symptom control and the prevention of future exacerbations. Pharmacologic treatment with beta-agonists for intermittent asthma and inhaled corticosteroids and a combination of inhaled corticosteroids and long-acting beta-2 agonists for persistent asthma are recommended. Additional and alternative treatments with leukotriene modifiers, anticholinergics, biologics, and bronchial thermoplasty are also available. However, understanding an individual’s disease phenotype, endotype, and comorbidities is necessary for asthma treatment, with appropriate consultation with asthma specialists required for those with severe asthma.

Evaluation of inhaled tiotropium in asthma, uncontrolled with standard combination therapy

INTRODUCTION

In uncontrolled asthma, the suboptimally inhibited airways inflammation is the main pathogenic event. Addition of other medications to the regular regimen might be able to improve disease control by enhancing bronchodilation and/or by reducing the bronchial inflammation. Tiotropium is currently under evaluation as a potential such therapy.

AREAS COVERED

The long-term efficacy and safety of tiotropium was recently evaluated in two studies in patients with poorly controlled asthma under inhaled corticosteroids + long-acting β2 agonists. Tiotropium was able to improve lung function and the effect was sustained, reduced the exacerbations risk (and in particular severe exacerbations risk), but had a marginal effect on symptoms and on quality of life.

EXPERT OPINION

In asthma, inhaled tiotropium is able to increase the bronchodilation, and might also be able to exert an anti-inflammatory effect.

Aclidinium bromide in experimental asthma

Underlying inflammation in asthma increases the activity of the cholinergic nervous system, contributing to bronchoconstriction/airway hyper-responsiveness (AHR) and mucus hypersecretion. Inhaled anticholinergics with shorter duration of action were initially used and then discontinued when other bronchodilators became available. Previous preclinical and clinical studies have demonstrated that tiotropium bromide, a long-acting anticholinergic currently approved for chronic obstructive pulmonary disease, might be an effective therapy in asthma. Aclidinium bromide is an inhaled compound in the same class as tiotropium, which is currently being investigated in chronic obstructive pulmonary disease and asthma. In the evaluated study, it was found to reduce AHR and eosinophilic airway inflammation in an acute model of asthma.