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GOLD recommends LABA/LAMA therapy as the preferred way to initiate treatment for patients in both Group B and Group E1

LAMA/LABA is the preferred initial pharmacological treatment for the majority of patients with COPD
  • *
    Single inhaler therapy may be more convenient and effective than multiple inhalers; single inhalers improve adherence to treatment. Exacerbations refers to the number of exacerbations per year; eos: blood eosinophil count in cells per microliter; mMRC: modified Medical Research Council dyspnea questionnaire; CATTM: COPD Assessment TestTM.

Adapted from © 2024, 2025 Global Initiative for Chronic Obstructive Lung Disease, Inc. Available from www.goldcopd.org; published in Deer Park, IL, USA.

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The use of LABA + ICS is no longer encouraged for the treatment of COPD1

Learn more about using LAMA/LABA in COPD from the Chair of the GOLD Science Committee

00:00:00

Gold 2023 and the place of LAMA/LABA dual bronchodilation
The views, thoughts, and opinions expressed in the presentation do not represent the personal opinion of the speaker and not those of Boehringer Ingelheim or GOLD

00:00:07

Hello everybody. My name is Klaus Vogelmeier and I'm going to share with you what's new in the GOLD 2023 document.

00:00:15

In this particular segment, I'm going to talk about the place of LAMA/LABA dual bronchodilation.
There are now new key points for the use of bronchodilators and in this segment, we say that when you initiate treatment with long acting bronchodilators, in contrast to the GOLD 2022 document where we recommended to start with a single long acting bronchodilator, in particular a LAMA, now we say the preferred choice is a combination of long acting muscarinic antagonist and a long acting beta 2 agonist.

00:00:53

And if you have a patient that is for whatever reason on a single bronchodilator then you should escalate to two bronchodilators if this patient is still dyspneic.
And with regards to the use of anti-inflammatory drugs, we say now that we do not encourage any longer the use of a LABA + ICS combination in COPD. So therefore, if there is an indication for an ICS, you should use a LABA+LAMA+ICS combination instead of a LABA+ICS combination.

00:01:30

Now when it comes to the specific recommendations based on the category where the patients are in when they are diagnosed, when this is a patient that's in category A, these are patients that have a low symptom load and no prominent exacerbation history, there is still the recommendation that a bronchodilator can be used.
I personally prefer a LAMA because I think that they, LAMAs have the best record with regard to effects in COPD when they're used as single drugs. But there is the general recommendation that you may use whatever bronchodilator you may choose. With regard to group B, that's the biggest group of COPD patients, these are the individuals that have a relevant symptom load and that have no permanent exacerbation history, we now recommend a LABA+LAMA combination as an initial treatment.
The same is true for group E. These are individuals that suffer from exacerbations or relevant exacerbations that have at least two moderate and/or at least one severe exacerbation in the past. And these patients also should start with a LABA+LAMA combination.
There is one little caveat there. If patients have a high eosinophil count that's beyond 300 cells per microliter, you may consider to start with a LABA+LAMA+ICS. But this is a practical recommendation based on the findings regarding the higher likelihood that an ICS works or is effective regarding exacerbation prevention, the higher the eosinophil count in the blood is. But this has not been tested prospectively in newly diagnosed individuals.

00:03:32

Now, a very important issue with regard to COPD treatment is the so-called management cycle: review, assess, adjust. That means when a patient comes to your office after you have initiated treatment and the patient tells you that he or she is still dyspneic, then one of the very important issues is that you discuss with the patient and consider other causes of dyspnea that should be investigated and treated appropriately. Regarding assessment, you should assess if the patient is able to deal with the inhaler that you prescribed adequately.
For example, can he forcefully and deeply inhale? Then he would qualify for a dry powder inhaler.
Or is he able to make a slow and deep maneuver with coordination? Then he would be a candidate for a metered dose inhaler or a soft mist inhaler.
And regarding adjustment of treatment, it is important to consider switching devices or molecules and to consider comorbidities.

00:04:44

With regard to pharmacological treatment, in the follow-up period, we have two strata. We have a dyspnea stratum and an exacerbation stratum. And what is very important is to understand that if a patient in the dyspnea stratum where symptoms are the predominant issue is still dyspneic under a LABA+LAMA treatment, then you may consider switching inhalers and molecules. You may consider implementing or escalating non-pharmacological treatments, and you should investigate other causes of this.
Additional ICS can only be considered in individuals that exacerbate under treatment. So if a patient that has been treated with a LABA+LAMA combination still suffers from exacerbations, these are the candidates for trying an inhaled corticosteroid in addition to the LABA+LAMA, in particular if the eosinophils count is high.
Thank you very much for your attention

Review the 2025 GOLD report.

GOLD, Global Initiative for Chronic Obstructive Lung Disease; LAMA, long-acting muscarinic antagonist; LABA, long-acting beta2-agonist; ICS, inhaled corticosteroid.

INDICATION for STIOLTO RESPIMAT

STIOLTO® RESPIMAT® (tiotropium bromide and olodaterol) Inhalation Spray is a combination of tiotropium, an anticholinergic, and olodaterol, a long-acting beta2-adrenergic agonist (LABA), indicated for the long-term, once-daily maintenance treatment of patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema.

Important Limitations of Use

STIOLTO is NOT indicated to treat acute deterioration of COPD and is not indicated to treat asthma.

IMPORTANT SAFETY INFORMATION for STIOLTO RESPIMAT
CONTRAINDICATION

Use of a LABA, including STIOLTO RESPIMAT, without an inhaled corticosteroid (ICS) is contraindicated in patients with asthma.

STIOLTO is contraindicated in patients with hypersensitivity to tiotropium, ipratropium (atropine derivatives), olodaterol, or any component of this product.

In clinical trials and postmarketing experience with tiotropium, immediate hypersensitivity reactions, including angioedema (including swelling of the lips, tongue, or throat), itching, or rash have been reported. Hypersensitivity reactions were also reported in clinical trials with STIOLTO.

WARNINGS AND PRECAUTIONS

LABA as monotherapy (without an ICS), for asthma increases the risk of asthma-related death, and in pediatric and adolescent patients, increases the risk of asthma-related hospitalizations.

Do not initiate STIOLTO in patients with acutely deteriorating COPD, which may be a life-threatening condition, or used as rescue therapy for acute symptoms. Acute symptoms should be treated with an inhaled short-acting beta2-agonist.

STIOLTO should not be used more often or at higher doses than recommended, or with other LABAs as an overdose may result.

If immediate hypersensitivity reactions occur, such as urticaria, angioedema, rash, bronchospasm, anaphylaxis, or itching, discontinue STIOLTO at once and consider alternative treatment. Patients with a history of hypersensitivity reactions to atropine or its derivatives should be closely monitored for similar hypersensitivity reactions to STIOLTO.

If paradoxical bronchospasm occurs, discontinue STIOLTO immediately and institute alternative therapy.

STIOLTO can produce a clinically significant cardiovascular effect in some patients, as measured by increases in pulse rate, systolic or diastolic blood pressure, and/or symptoms. If such effects occur, STIOLTO may need to be discontinued.

Use caution in patients with convulsive disorders, thyrotoxicosis, diabetes mellitus, ketoacidosis, in patients with known or suspected prolongation of the QT interval, and in patients who are unusually responsive to sympathomimetic amines.

Use with caution in patients with narrow-angle glaucoma. Instruct patients to contact a physician immediately if signs or symptoms of acute narrow-angle glaucoma develop.

Use with caution in patients with urinary retention especially in patients with prostatic hyperplasia or bladder-neck obstruction. Instruct patients to consult a physician immediately should any of these signs or symptoms develop.

Patients with moderate to severe renal impairment (creatinine clearance of <60 mL/min) should be monitored closely for anticholinergic side effects.

Be alert to hypokalemia and hyperglycemia.

ADVERSE REACTIONS

The most common adverse reactions with STIOLTO (>3% incidence and higher than an active control) were: nasopharyngitis, 12.4% (11.7%/12.6%), cough, 3.9% (4.4%/3.0%), and back pain, 3.6% (1.8%/3.4%).

DRUG INTERACTIONS

  • Use caution if administering adrenergic drugs because sympathetic effects of olodaterol may be potentiated.

  • Concomitant treatment with xanthine derivatives, steroids, or diuretics may potentiate any hypokalemic effect of olodaterol.

  • Use with caution in patients taking non–potassium-sparing diuretics, as the ECG changes and/or hypokalemia may worsen with concomitant beta-agonists.

  • The action of adrenergic agents on the cardiovascular system may be potentiated by monoamine oxidase inhibitors or tricyclic antidepressants or other drugs known to prolong the QTc interval. Therefore, STIOLTO should be used with extreme caution in patients being treated with these drugs. Use beta-blockers with caution as they not only block the therapeutic effects of beta-agonists, but may produce severe bronchospasm in patients with COPD.

  • Avoid co-administration of STIOLTO with other anticholinergic-containing drugs as this may lead to an increase in anticholinergic adverse effects.  

STIOLTO is for oral inhalation only.

The STIOLTO cartridge is only intended for use with the STIOLTO RESPIMAT inhaler.

Inform patients not to spray STIOLTO into the eyes as this may cause blurring of vision and pupil dilation.

CL-STO-100021 6.5.2019

Please see full Prescribing Information, Patient Information, and Instructions for Use for STIOLTO RESPIMAT.

Reference

  1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Accessed, November 18, 2024. https://goldcopd.org/2025-gold-report/