Tiotropium is a long acting muscarinic antagonist (LAMA) that is also known by the brand name Spiriva. It comes as an inhaled aerosol solution as well as an inhaled capsule. The main indications are for the treatment of COPD and Asthma. Tiotropium works through reversible competitive inhibition of acetylcholine at type 3 muscarinic receptors in bronchial smooth muscle which leads to bronchodilation. The medication is poorly absorbed in the GI and hepatically metabolized via the CYP2D6 and CYP3A4 pathways. The time to peak is between 5-7 minutes with the half-life elimination between 25-44 hours. Although the data in pregnancy and lactation is limited, the benefits for use likely outweighs the risk for a patient dealing with uncontrolled asthma. Some common side effects are cough, headache, GERD, rash and UTI. Some serious side effects are paradoxical bronchospasms and angle-closure glaucoma. It is important to note that tiotropium is not intended to be a quick-relief inhaler and should not be used for flare-ups or shortness of breath. It is recommended to clean the inhaler once monthly with water air dried. After usage the patient should rinse the mouth out; not due to the risk of thrush like with an ICS but to help prevent xerostomia and throat irritation. 

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