Umeclidinium

Umeclidinium is a long-acting muscarinic antagonist taken once daily for COPD, available alone and in fixed combinations with vilanterol or with fluticasone furoate and vilanterol. Onset is within 15 minutes and the effect lasts 24 hours.

Classification. Long-acting antimuscarinic bronchodilator.

Mechanism. Competitive blockade of M3 receptors with prolonged receptor occupancy.

Pharmacokinetics. Low systemic absorption after inhalation. Metabolised mainly by CYP2D6 and a P-glycoprotein substrate. Elimination is mostly faecal.

First-line, COPD maintenance. 55 micrograms (delivered dose) once daily. In some regions the labelled strength is 62.5 micrograms (metered dose). Maximum one inhalation daily.

Fixed combination. Umeclidinium with vilanterol 55/22 micrograms once daily.

Specialist, triple therapy. Fluticasone furoate, umeclidinium and vilanterol 92/55/22 micrograms once daily when exacerbations continue despite dual therapy and eosinophils favour a corticosteroid.

Emergency. Not used.

Titration and loading. None.

Contraindications. Hypersensitivity, including severe milk protein allergy because the powder contains lactose with milk protein. Use with caution in narrow-angle glaucoma and urinary retention.

Serious adverse effects. Paradoxical bronchospasm, acute angle-closure glaucoma, urinary retention, supraventricular arrhythmia, hypersensitivity.

Common adverse effects. Headache, nasopharyngitis, cough, constipation, dry mouth.

Interactions. Other anticholinergic drugs. Strong CYP2D6 inhibitors may raise exposure modestly; no dose change is usually needed.

Common prescribing errors. Prescribing alongside another LAMA. Using for acute relief.

Special groups.

• Pregnancy and breastfeeding: limited data; use only if the benefit outweighs risk.

• Older adults: no adjustment.

• Kidney impairment: no adjustment. Liver impairment: no adjustment in mild to moderate; not studied in severe.

Formulations. Multidose dry powder inhaler; fixed combinations.

Technique. Open the cover until it clicks, inhale once steadily and deeply, hold the breath for as long as comfortable, close the cover.

Baseline. Spirometry, symptom score, eye and urinary history.

Monitoring. Symptoms, exacerbations, technique, eye and urinary symptoms.

Stop and reduce rules. Stop for glaucoma symptoms, retention or paradoxical bronchospasm. Therapeutic drug monitoring is not used.

Referral and escalation. Refer when exacerbations continue on triple therapy.