In which of the following geriatric patients would initiating tiotropium (Spiriva) for COPD maintenance therapy be contraindicated?

Question

Accepted Answer

✅ A. A 74-year-old man with narrow-angle glaucoma and symptomatic benign prostatic hyperplasia
Tiotropium is a long-acting muscarinic antagonist (LAMA) with systemic anticholinergic activity. The two classic relative contraindications in the geriatric population are narrow-angle glaucoma (anticholinergic effect can precipitate an acute angle-closure attack) and urinary retention/BPH (anticholinergic effect worsens bladder outlet obstruction). Both are present in this patient, making tiotropium inappropriate. An alternative maintenance controller (such as a LABA or ICS/LABA combination) should be chosen instead.

❌ B. A 70-year-old woman with well-controlled hypertension on lisinopril
Hypertension is not a contraindication to tiotropium. LAMAs have minimal cardiovascular effects, and tiotropium is appropriate first-line COPD maintenance in this patient.

❌ C. A 68-year-old man with GOLD Group B COPD and no comorbidities
This is precisely the patient who benefits most from tiotropium — GOLD recommends a long-acting bronchodilator (LAMA preferred) for Group B COPD. No contraindication exists.

❌ D. An 80-year-old woman with stage 3 chronic kidney disease (eGFR 45)
Tiotropium has minimal systemic absorption and can generally be used in renal impairment without dose adjustment. CKD alone is not a contraindication.

:::danger
Anticholinergics (tiotropium, ipratropium, oxybutynin) can trigger acute angle-closure glaucoma and precipitate urinary retention in BPH. Screen every older adult for these two conditions before prescribing a LAMA.
:::

Tiotropium

✅ Indications

⚙️ Mechanism of Action

📏 Dosing

🚫 Contraindications

⚠️ Adverse Effects

🔬 Monitoring

💎 Board Pearls

Practice Questions

Related Drugs in This Class

Sources

Ready to practice?