3.1.2 Antimuscarinic bronchodilators

Advice on how to obtain placebo inhalers can be obtained from the NHS Devon CCG Medicines Optimisation Team, please contact: d-ccg.medicinesoptimisation@nhs.net

Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly; in addition, not all inhalers with the same primary ingredient are interchangeable due to differences in particle size.

MDI = Metered dose inhaler; DPI = Dry powder inhaler

When prescribing a pressurised MDI, remind patients to check and remove the mouthpiece cover properly before inhaling a dose and to shake the inhaler to remove loose objects that may have become trapped in the inhaler during storage. The mouthpiece cover should be replaced securely after use. See MHRA Drug Safety Alert July 2018 for further details

Short acting muscarinic antagonists (SAMA)

Ipratropium bromide
  • Atrovent® aerosol inhalation 20 micrograms/dose (MDI) (£5.56 = 200 doses)
  • Nebuliser solution 250 micrograms/ml (£3.28 = 20 x 2ml unit dose vials)

Indications and dose

  • Chronic obstructive pulmonary disease
    • By aerosol inhalation, 20–40 micrograms 3–4 times daily
    • By inhalation of nebulised solution, reversible airways obstruction in chronic obstructive pulmonary disease, 250–500 micrograms 3–4 times daily


  1. Acute angle glaucoma may occur with ipratropium particularly when used in a nebuliser with salbutamol. Care should be taken to avoid escape from the mask into the eyes.

Long acting muscarinic antagonists (LAMA)

Glycopyrronium bromide
  • Seebri® Breezhaler® 55 micrograms inhalation powder, hard capsule (DPI) (£27.50 = 30 capsules plus device)

Indications and dose


  1. The commissioning of glycopyrronium inhaled therapy is accepted in Devon for the maintenance treatment of patients with COPD who require a long acting bronchodilator (see Commissioning Policy for more details)
  • Spiriva® Respimat® 2.5 microgram/dose solution for inhalation (MDI) (£23.00 = 30 days)
  • Braltus® Zonda® 10 microgram inhalation powder, capsule (DPI) (£25.80 = 30 days)



  • Adult over 18 years:
    • Inhalation solution, 5 micrograms once daily (two puffs) (Spiriva® Respimat®)
    • Inhalation powder capsule, 10 micrograms once daily (one capsule) (Braltus® Zonda®)


  1. The MHRA update below also applies to tiotropium delivered by the Zonda® device.
  2. MHRA Drug Safety Update (February 2015): When using tiotropium delivered via Respimat® or Handihaler® to treat chronic obstructive pulmonary disease (COPD):
    1. take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:
      1. myocardial infarction in the last 6 months
      2. unstable or life threatening cardiac arrhythmia
      3. cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
      4. hospitalisation for heart failure (NYHA Class III or IV) within the past year
    2. tell these patients to report any worsening of cardiac symptoms after starting tiotropium; patients with these conditions were excluded from clinical trials of tiotropium, including TIOSPIR
    3. review the treatment of all patients already taking tiotropium as part of the comprehensive management plan to ensure that it remains appropriate for them; regularly review treatment of patients at high risk of cardiovascular events
    4. remind patients not to exceed the recommended once daily dose
  3. MHRA Drug Safety Update (May 2018): Braltus® (tiotropium): risk of inhalation of capsule if placed in the mouthpiece of the inhaler
    1. Train patients in the correct use of their Zonda® inhaler; a placebo device is available for training purposes and instructions for patients are provided in the patient information leaflet and on the carton
    2. Tell patients to store capsules in the screw-cap bottle provided (never in the inhaler) and to always check the mouthpiece is clear before inhaling
  • Eklira® Genuair® inhalation powder 375 microgram (DPI) (£28.60 = 60 dose unit)

Indications and dose


  1. There is a lack of robust published evidence comparing aclidinium to other bronchodilators and a lack of good quality long term data on efficacy for aclidinium. Because of this it is recommended that aclidinium is reserved for patients who cannot tolerate the first line LAMAs
  2. The commissioning of aclidinium inhalation powder is accepted in Devon for the maintenance treatment of patients with COPD who require a long acting bronchodilator (see Commissioning Policy for more details)


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