Administration
Administer tiotropium powder by oral inhalation only using a special oral inhalation device (HandiHaler) that delivers powdered drug from capsules. Do not take capsules orally, as intended effects on the lungs will not be obtained. 
Administer tiotropium solution by oral inhalation only using a specific inhaler (Spiriva Respimat) that delivers a metered-dose spray.
Administer tiotropium/olodaterol in fixed combination by oral inhalation only using a specific inhaler (Stiolto Respimat) that delivers a metered-dose spray.
Spiriva Respimat and Stiolto Respimat inhalers deliver the drugs in an aqueous solution and mechanically produce a fine aerosol mist from the orally inhaled solutions. 
Administer tiotropium or tiotropium/olodaterol orally inhaled solutions once daily at the same time every day. 
In patients with asthma receiving orally inhaled tiotropium solution, may take 4–8 weeks to achieve maximum clinical benefit.
Oral Inhalation Powder
Open the dust cap by pressing the green piercing button. Pull the dust cap upward on the side opposite the hinge of the Handihaler device to expose the mouthpiece. Open the mouthpiece by pulling the mouthpiece ridge upward on the side opposite the hinge of the inhaler to expose the center chamber. Carefully open the blister card to expose only one capsule immediately before use. Capsule contains only a small amount of powder; do not open. Place capsule into the center chamber of the inhaler, and close the inhaler mouthpiece firmly until it snaps (clicks) into position, leaving the dust cap open (up). (See Stability.) Push down on the mouthpiece ridge to make sure that the mouthpiece is seated in the gray base of the inhaler. Hold the inhaler with the seated mouthpiece upward, depress the green button on the side of the inhaler completely (until the button is flush with the gray base of the inhaler), then release the button. The green button pierces the capsule and disperses the powdered drug upon inspiration.  Do not press the green piercing button more than once.  Do not shake the Handihaler device. Piercing the capsule may produce small gelatin pieces, which may pass into the mouth or throat; gelatin pieces not expected to cause any harm.
Exhale completely; do not exhale into the HandiHaler device. Hold the inhaler by the gray base; take care not to block the air intake vents near the mouthpiece ridge. With the head kept level, place the mouthpiece of the inhaler between the lips (inhaler is in a horizontal position) and inhale deeply and slowly through the inhaler with a rate sufficient to hear or feel the loaded capsule vibrate (rattle).  Pressure from inhalation will disperse the drug from center chamber into air stream created by the patient’s inhalation. Continue breathing until the lungs are full. Remove the inhaler from the mouth and hold the breath for a few seconds, then resume normal breathing. Breathe out completely and inhale once again (from the same capsule) to ensure full delivery of the powder. Do not press the green piercing button again. Upon completion of the second inhalation, open the mouthpiece and tip the device to dispose of the used capsule; close the mouthpiece and dust cap of the inhaler device.
Do not take extra doses despite not being able to hear or feel the capsule vibrate. Tap the inhaler device on a table, holding the gray base in an upright position. Then check to see that the mouthpiece is properly seated in the gray base and attempt to inhale through the device again. If vibration still cannot be felt or heard, throw away the capsule, lift the green piercing button to open the base of the device, and check the center chamber for pieces of the capsule. Turn the device upside down and gently but firmly tap to remove any capsule pieces, then call clinician for instructions. (See Advice to Patients.)
If no improvement in COPD symptoms, make sure patient is inhaling the drug using the oral inhaler rather than swallowing the dry-powder capsules. (See Accidental Oral Ingestion under Cautions.)
Clean the Handihaler device as needed. Open the dust cap and mouthpiece, then open the base by lifting the green piercing button; look in the center chamber for any capsule pieces or powder buildup and tap out if present. Rinse device with warm water (do not use cleaning agents or detergents), pressing the green piercing button a few times so that the center chamber and piercing needle are under the running water; check that remaining powder or capsule pieces are removed. Dry the inhaler well by tipping excess water out on a paper towel; leave dust cap, mouthpiece, and gray base open by fully spreading it out to air dry for 24 hours. Do not use a hair dryer to dry the device. Do not use the inhaler when wet. If needed, clean the outside of the mouthpiece with a clean, damp cloth. 
Oral Inhalation Solution
Before first use of either Spiriva Respimat or Stiolto Respimat, place inhaler cartridge into inhaler.  Consult the manufacturer's prescribing information for detailed information on inhaler preparation.  Write discard date (3 months after cartridge is inserted into inhaler) on inhaler label. 
Prime inhaler before first use by turning clear base in direction of black arrows on label until click is heard (one-half turn) with inhaler upright and cap closed.  Flip cap until it fully snaps open, then point inhaler away from face, press dose release button, then close cap. 
Repeat these steps until spray is visible, then for 3 additional times.  Repeat initial actuation step of priming process (without 3 additional repetitions) after periods of nonuse (i.e., for >3 days).  If inhaler is not used for >21 days, repeat entire priming process. 
To administer a dose, hold inhaler upright with cap closed; turn clear base in direction of black arrows on label until click is heard (one-half turn).  Flip cap until it snaps fully open. 
Before inhaling dose, exhale slowly and completely.  Close lips around end of mouthpiece without covering air vents.  Pointing inhaler toward back of throat, press dose release button while taking a slow, deep inhalation through the mouth, continuing to inhale for as long as possible.  Hold the breath for 10 seconds (or as long as comfortable).  Repeat procedure once more to administer a full dose (2 inhalations), then close cap. 
Using only a damp tissue or cloth, clean mouthpiece of the inhaler, including metal part inside, at least once weekly.  Outside of inhaler can be wiped with a damp cloth.  Inhaler function not affected by minor mouthpiece discoloration. 
Dosage
Available as tiotropium bromide monohydrate; dosage expressed in terms of anhydrous tiotropium. 
Each capsule of the Spiriva Handihaler contains 18 mcg of tiotropium as an inhalation powder. However, the precise amount of drug delivered to the lungs depends on factors such as the patient’s inspiratory flow.
Each actuation of the Spiriva Respimat inhaler delivers 1.56 or 3.1 mcg of tiotropium bromide monohydrate (equivalent to 1.25 or 2.5 mcg of tiotropium, respectively) per metered spray.
Each actuation of the Stiolto Respimat inhaler delivers 3.1 mcg of tiotropium bromide monohydrate (equivalent to 2.5 mcg of tiotropium) and 2.7 mcg of olodaterol hydrochloride (equivalent to 2.5 mcg of olodaterol) per metered spray.
Precise amount of drug delivered to lungs depends on factors (e.g., patient's coordination between actuation of the inhaler and inspiration through the delivery system).  Respimat inhaler mechanically releases dose; delivered dose not dependent on patient's inspiratory effort. 
Commercially available inhaler delivers 60 metered sprays equivalent to 30 doses (2 actuations per dose) of the drug. 
Pediatric Patients
Asthma
Oral Inhalation
Tiotropium solution in patients ≥6 years of age: 2.5 mcg (2 inhalations of 1.25 mcg per metered spray) once daily.
Adults
COPD
Oral Inhalation
Tiotropium powder: 18 mcg (contents of one capsule) once daily. 
Tiotropium solution: 5 mcg (2 inhalations of 2.5 mcg per metered spray) once daily.
Tiotropium/olodaterol fixed-combination therapy: 5 mcg of tiotropium and 5 mcg of olodaterol (2 inhalations) once daily.
Asthma
Oral Inhalation
Tiotropium solution: 2.5 mcg (2 inhalations of 1.25 mcg per metered spray) once daily.
Special Populations
Hepatic Impairment
No dosage adjustments required.  
Renal Impairment
No dosage adjustments required.  
Geriatric Patients
No dosage adjustments required.  
 Detailed Tiotropium dosage information
