Anticholinergics for chronic obstructive pulmonary disease (COPD)


Prescription anticholinergics

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

Prescription anticholinergic and short-acting beta2-agonist combination

Generic Name Brand Name
ipratropium bromide and albuterol sulfate Combivent, DuoNeb

Ipratropium bromide alone and combined with albuterol sulfate 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 bromide is available only in dry powder form for inhalation in a HandiHaler.

There are 2 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 generally 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 indicate that inhaled anticholinergics improve lung function as measured by tests (spirometry). They also reduce the number of COPD exacerbations. There is no evidence of their effect on the progression of the disease.1

Studies have shown that:1

  • 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.1 Doing so usually increases your cost but, compared to increasing the dose of one medicine, may also reduce the risk of side effects.2

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.3

Side Effects

A mild cough and dry mouth are the most common side effects.

There have been rare reports of closed-angle glaucoma after using inhaled ipratropium. Call your doctor immediately if an eye becomes red or painful or if you have misty vision after using this medicine.

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

What To Think About

While anticholinergics generally are regarded as the first-line treatment for the persistent symptoms in most cases of COPD, 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. Although a nebulizer can deliver a very large dose of medicine, it also may increase side effects of the medicine.

Tiotropium is to be used only with a HandiHaler, a type of dry powder inhaler.

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).

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.

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



  1. Kerstjens H, et al. (2005). Chronic obstructive pulmonary disease. Clinical Evidence (13): 1923-1947.
  2. Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2005). Executive summary (updated 2005). In Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Available online:
  3. 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.

Last Updated: May 8, 2008

Author: Maria G. Essig, MS, ELS & Cynthia Tank

Medical Review: Caroline S. Rhoads, MD - Internal Medicine & Ken Y. Yoneda, MD - Pulmonology

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