You may have seen commercials of a person with an elephant sitting on her chest. Here’s a link in case you may have missed them. It’s a clever marketing strategy to reinforce the idea that a serious breathing problem like chronic bronchitis, COPD or emphysema can feel like an elephant weighing you down. But that image of the elephant might distract you from the voice-over announcer’s long list of side effects.
Here is a Spiriva question from Mimi, a visitor to our website:
Q. My elderly mother was prescribed a number of medications to treat her COPD [chronic obstructive pulmonary disease]. She developed many symptoms though a couple were attributed to other causes… the red/blue hot leg being one, memory problems, terrible weakness and edema. She had been alert, active and mentally bright up until she started taking Spiriva, prednisone and other inhaled meds.
She kept having episodes that looked like heart attacks, yet weren’t. She kept being taken to the hospital for treatment. It was a terrible way for her to end her life in her 93rd year. She’d been so healthy until she started taking those meds. We were told there were no other treatments.
I honestly think that when she died suddenly one night it was because of a pulmonary embolism. Her primary care doctor thinks so too. Now I read that that can be caused by corticosteroids. Her mother and her aunt all lived to a ripe old ages [98, 102] almost disease free until the end. I think Mom might have lived longer and healthier without all the treatments.
A. Tiotropium, the active ingredient in Spiriva, is considered a strong anticholinergic medication. That means it affects the activity of the neurochemical acetylcholine. Although there is no mention in the official Spiriva prescribing information about cognitive dysfunction, drugs that have anticholinergic activity can cause confusion, mental fogginess or even memory problems. Another classic complication is constipation.
The commercials on television do not mention anything about mental fogginess. They do say the following, though:
“Tell your doctor if you have kidney problems, glaucoma, trouble urinating or an enlarged prostate. These may worsen with Spiriva…Stop taking Spiriva and seek immediate medical help if your breathing suddenly worsens, your throat or tongue swells, you get hives, vision changes or eye pain, or problems passing urine. Other side effects include dry mouth and constipation.”
Other side effects of Spiriva include:
SPIRIVA (TIOTROPIUM) SIDE EFFECTS:
- Dry Mouth
- Severe constipation
- Upper respiratory tract infection, sore throat, cold symptoms, sinus infection
- Worsened breathing problems, bronchospasm
- Chest pain, irregular heart rhythms, palpitations
- Digestive tract distress, heartburn, stomach pain, reflux
- Depression, difficulty sleeping
- Fluid retention
- Arthritis or joint pain, muscle pain (myalgia)
- Nose bleeds, runny nose
- Dehydration, dry skin
- Difficulty urinating, urinary retention
- Severe allergic reaction, hives, itching, rash, swelling of tongue, throat or lips
- Visual problems, glaucoma, cataracts
- Yeast infections in mouth and throat, mouth ulcers, hoarseness
- Voice changes
- Cholesterol elevation
Tiotropium is an Anticholinergic Drug:
Okay, so what does it mean when a medication has strong anticholinergic activity? Acetylcholine is a critical neurochemical that affects your entire body. Without this chemical you could not lift a pencil, blink or think. It is crucial inside the brain as well as outside the brain. When drugs interfere with the normal activity of acetylcholine, we call them anticholinergic. You can learn more about this critical process and other anticholinergic drugs at this link:
What are common symptoms of anticholinergic activity? Dry mouth is a classic tip off. Acetylcholine is essential to keep mucus membranes functioning normally. When the effects of acetylcholine are blocked, secretions are reduced and body parts get dry. That’s why people complain of dry skin, dry mouth, dry eyes, blurred vision, dehydration, constipation and urinary retention. That last one means that people may have trouble urinating or emptying their bladder completely.
Go back and read the symptoms listed for Spiriva during the video advertisement. To make it easy here are a couple of key ones: “problems passing urine,” “dry mouth,” and “constipation.” By the way, anticholinergic drugs can make glaucoma worse, hence the warning:
“Tell your doctor if you have kidney problems, glaucoma, trouble urinating or an enlarged prostate. These may worsen with Spiriva…”
Why should anyone care if a medicine is considered anticholinergic? Besides the side effects mentioned above, there are concerns that anticholinergic drugs may impact cognitive function. An article in Geriatrics & Gerontology International (April, 2017) described it this way:
“The use of anticholinergic drugs had been strongly linked to adverse health outcomes among older adults, especially in cognitive impairment or dementia. The present study aimed to evaluate the cognitive decline related to the use of anticholinergicdrugs among older men living in the veterans’ homes in Taiwan.”
The authors concluded:
“Exposure to anticholinergic drugs significantly increased the risk for short-term cognitive decline among older men, and the adverse effects remained similar when antipsychotics were excluded for analysis. A further intervention study is required to evaluate whether reducing anticholinergic burden might improve cognitive function among older adults.”
Another article in the journal Aging Clinical and Experimental Research (Feb. 2016) summarizes the situation this way:
“The use of medication with anticholinergic properties is widespread among older subjects. Many drugs of common use such as antispasmodics, bronchodilators, antiarrhythmics, antihistamines, anti-hypertensive drugs, antiparkinson agents, skeletal muscle relaxants, and psychotropic drugs have been demonstrated to have an anticholinergic activity. The most frequent adverse effects are dry mouth, nausea, vomiting, constipation, abdominal pain, urinary retention, blurred vision, tachycardia and neurologic impairment such as confusion, agitation and coma.”
The authors conclude conclude:
“Overall, minimizing anticholinergic burden should always be encouraged in clinical practice to improve short-term memory, confusion and delirium, quality of life and daily functioning.”
No one should ever stop any medication with careful consultation with the prescribing physician. That includes Spiriva!
Stories from Visitors:
Other visitors to our website have shared the following concerns:
A self-described “Old Fart in Florida” asks:
“Anyone have any of the dry mouth, dry lips, sore tongue problems using a Spiriva inhaler?”
“I also have a problem with urine retention, and when this happens I reduce Spiriva to every other day and it seems to clear up. I take Symbicort – 1 puff 2 x a day (child’s dose) which has worked very well for me.”
M.F.C. also wonders about urinary retention:
“I have been diagnosed with COPD. I was using Spiriva for about 6-8 weeks when I developed a urine retention problem.The Spiriva did help the breathing problem but the side effects were more than I could tolerate. I am now on Advair 100/50 and I truly believe that is also causing side effects that are troublesome. I am waiting to see a pulmonologist but can’t get an appt. till Dec. The Advair does help the breathing but the side effects concern me.”
Spiriva and Cardiovascular Complications:
One of the most controversial issues around Spiriva (tiotropium) (and other long-acting bronchodilators) has to do with cardiovascular risks. An epidemiological study from Canada suggested that when older patients start taking such medications, they increased their risk of trips to an emergency department or hospitalization due to cardiovascular causes. This study reignites a controversy about the cardiovascular safety of these drugs for COPD patients. Here is a commentary that puts this whole issue into perspective.
An article in the International Journal of Chronic Obstructive Pulmonary Disease (Nov. 25, 2016) discusses LAMAs and LABAs. A LAMA is a long-acting muscarinic antagonist. That’s doctorspeak for an anticholineric drug like tiotropium. A LABA is a long-acting beta agonist. That means it is a bronchodilator like salmeterol or formoterol. Here is what the authors say about cardiovascular complications:
“Due to their mechanisms of action, both LAMAs and LABAs have the potential to cause cardiac-related adverse events (AEs). LAMAs suppress parasympathetic control of heart rate (HR) and LABAs stimulate sympathetic control of HR. These effects serve to raise HR with the potential to cause cardiac arrhythmias, myocardial infarction (MI), stroke, and sudden death in susceptible patients.”
The authors strongly argue for additional studies to determine the cardiovascular safety of LAMAs and LABAs. In fact they are undertaking just such a study, but results won’t be known for some time.
In the Meantime:
Until this confusion is resolved, physicians and patients will need to be vigilant for any symptoms that might suggest heart or other vascular complications.
Should you wish to learn more about a different approach to COPD and asthma, you may find the book by David Hahn, MD, MPH, of interest. It is titled: “A Cure for Asthma: What Your Doctor Isn’t Telling You–And Why.” What is fascinating about Dr. Hahn’s book is that it discusses in detail the use of antibiotics for helping overcome asthma symtpoms. The same antibiotic he reviews, azithromycin, has been tested in the treatment of COPD. An article in the New England Journal of Medicine (Aug. 25, 2011) concluded:
“Among selected subjects with COPD, azithromycin taken daily for 1 year, when added to usual treatment, decreased the frequency of exacerbations and improved quality of life but caused hearing decrements in a small percentage of subjects.”
Should you be interested in more information about the use of antibiotics in the treatment of asthma, we think Dr. Hahn’s book is valuable. We are proud to be publishing this ground-breaking book. If you know someone with asthma, please let him or her know about this important information. Here is a link to more information about Dr. Hahn’s provocative book. If you want to go straight to the shopping cart, here is the link.
Remember, no one should ever stop any medication without careful communication with the prescribing physician. That is especially true for life-threatening conditions like asthma or COPD.
To learn more about anticholinergic drugs, here is a link:
Share your own experiences with Spiriva below. Has it worked well for your COPD symptoms? Have you had to contend with side effects? Let us and other visitors to this website know how you have made out with this medication.