Anticholinergics for Chronic Obstructive Pulmonary Disease (COPD)

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Anticholinergics for Chronic Obstructive Pulmonary Disease (COPD)


Prescription anticholinergics

Generic NameBrand Name
ipratropium (short-acting)Atrovent
tiotropium (long-acting)Spiriva

Prescription anticholinergic and short-acting beta2-agonist combination

Generic NameBrand Name
ipratropium and albuterolCombivent, DuoNeb

Ipratropium alone and combined with albuterol is available in metered-dose inhaler (MDI) and nebulizer forms. One medicine may be available in multiple forms. Your doctor will help you decide which form is best for you.

Tiotropium is available only as a powder for inhalation in a dry powder inhaler.

There are two types of anticholinergics: short-acting and long-acting. The short-acting type relieves symptoms and the long-acting type helps prevent breathing problems. Short-acting anticholinergics are used for treating stable COPD in a person whose symptoms come and go (intermittent symptoms). Long-acting anticholinergics are effective and convenient for preventing and treating COPD in a person whose symptoms do not go away (persistent symptoms).

How It Works

Anticholinergics relax and enlarge (dilate) the airways in the lungs, making breathing easier (bronchodilators). They may protect the airways from spasms that can suddenly cause the airway to become narrower (bronchospasm). They also may reduce the amount of mucus produced by the airways.

Why It Is Used

Anticholinergics typically are considered first-line therapy for treating persistent symptoms of chronic obstructive pulmonary disease (COPD). Because these medicines may take some time to have an effect on breathing, they usually are taken on a regular schedule. They are used for both short- and long-term relief of symptoms.

How Well It Works

A number of studies show that inhaled anticholinergics improve lung function as measured by tests (spirometry). They also reduce the number of COPD exacerbations.1

Studies have shown that:2

  • In short-term treatment, ipratropium and tiotropium both improved lung function compared to a placebo.
  • After one year of treatment, tiotropium improved lung function and reduced the number of COPD exacerbations and hospital admissions, compared to a placebo.

Combining an anticholinergic with a beta2-agonist may help your lung function more than using either medicine alone.2 Combining medicines also may reduce the risk of side effects compared to increasing the dose of one medicine.3

Compared to tiotropium alone, combining tiotropium with a beta2-agonist (salmeterol) and corticosteroid (fluticasone) improved lung function and quality of life and lowered the number of hospital visits.4

Side Effects

All medicines have side effects. But many people don't feel the side effects, or they are able to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side effects are also listed in the information that comes with your medicine.

Here are some important things to think about:

  • Usually the benefits of the medicine are more important than any minor side effects.
  • Side effects may go away after you take the medicine for a while.
  • If side effects still bother you and you wonder if you should keep taking the medicine, call your doctor. He or she may be able to lower your dose or change your medicine. Do not suddenly quit taking your medicine unless your doctor tells you to.

Call your doctor right away if you have:

  • Eye pain, blurry vision, or if your eye becomes red after using inhaled ipratropium. There have been rare reports of closed-angle glaucoma after the use of ipratropium.

Common side effects of this medicine include:

  • A mild cough.
  • Dry mouth.

If you have the eye disease glaucoma, talk with an eye doctor before you start taking anticholinergics. People who have glaucoma may need to be watched more closely while they are taking these medicines.

Some studies suggest that inhaled anticholinergic medicines increase the risk of heart attack or stroke.5 But other studies show that the medicines lower that risk.6 If you are concerned about this risk, talk to your doctor.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Anticholinergics typically are thought of as the first-line treatment for the persistent symptoms in most cases of COPD. But short-acting beta2-agonists may be the first choice for treating symptoms of stable COPD that come and go (intermittent symptoms).

Spirometry may be done before and after you try an anticholinergic for the first time to see whether the medicine has had an effect. But even if the medicine has no measurable effect on your lung function, it still may improve your quality of life.

Nebulizers normally are no better at delivering anticholinergics deep into the lungs than a properly used metered-dose inhaler. Sometimes your doctor may prescribe a nebulizer. A nebulizer can deliver a very large dose of medicine, but it also may increase side effects of the medicine.

Most doctors recommend that everyone using a metered-dose inhaler also use a spacer. But you should not use a spacer with a dry powder inhaler (DPI).

Click here to view an Actionset.Breathing Problems: Using a Metered-Dose Inhaler
Click here to view an Actionset.Breathing Problems: Using a Dry Powder Inhaler

Taking medicine

Medicine is one of the many tools your doctor has to treat a health problem. Taking medicine as your doctor suggests will improve your health and may prevent future problems. If you don't take your medicines properly, you may be putting your health (and perhaps your life) at risk.

There are many reasons why people have trouble taking their medicine. But in most cases, there is something you can do. For suggestions on how to work around common problems, see the topic Taking Medicines as Prescribed.

Advice for women

If you are pregnant, breast-feeding, or planning to get pregnant, do not use any medicines unless your doctor tells you to. Some medicines can harm your baby. This includes prescription and over-the-counter medicines, vitamins, herbs, and supplements. And make sure that all your doctors know that you are pregnant, breast-feeding, or planning to get pregnant.


Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.

Complete the new medication information form (PDF)(What is a PDF document?) to help you understand this medication.



  1. Tashkin DP, et al. (2008). A 4-year trial of tiotropium in chronic obstructive pulmonary disease. New England Journal of Medicine, 359(15): 1543–1554.
  2. McIvor RA, et al. (2011). COPD, search date April 2010. Online version of BMJ Clinical Evidence: http://www.clinical
  3. Global Initiative for Chronic Obstructive Lung Disease (2011). Global Strategy for the Diagnosis, Management, and Prevention of COPD. Available online:
  4. Aaron SD, et al. (2007). Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease. Annals of Internal Medicine, 146(8): 545–555.
  5. Singh S, et al. (2008). Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. JAMA, 300(12): 1439–1450.
  6. Celli B, et al. (2010). Cardiovascular safety of tiotropium in patients with COPD. Chest, 137(1): 20–30.


ByHealthwise Staff
Primary Medical ReviewerE. Gregory Thompson, MD - Internal Medicine
Specialist Medical ReviewerKen Y. Yoneda, MD - Pulmonology
Last RevisedNovember 29, 2011

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