Generic Name

Incruse Ellipta

Mechanism

Incruse Ellipta contains tiotropium bromide, a *long‑acting inhaled anticholinergic bronchodilator*.
• Selective M₃ muscarinic receptor antagonist → blocks acetylcholine‑mediated bronchoconstriction.
• Prolonged action due to slow dissociation from receptors, providing >24 h bronchodilation.
• Minimal β₂‑adrenergic activity → lower risk of tachycardia compared to LABAs.

Pharmacokinetics

• Route: Intratracheal inhalation via Ellipta dry‑powder inhaler.
• Absorption: ~18 % pulmonary, remainder swallowed (systemic exposure ≈ 70 %).
• Distribution: Wide tissue distribution; plasma protein binding ~75 %.
• Metabolism: Primarily hepatic (Cytochrome P450 3A4) → deactivation to inactive metabolites.
• Excretion: Urine (≈ 60 %) and feces (≈ 30 %).
• Half‑life: Pulmonary residence ≈ 8 h; systemic plasma half‑life ≈ 35 h.
• Drug interactions: Minor CYP3A4 inhibition/induction modestly changes exposure; avoid concurrent anticholinergics (e.g., glycopyrrolate) to prevent additive GI effects.

Indications

• Maintenance therapy for Chronic Obstructive Pulmonary Disease (COPD) in adults.
• Preferred once‑daily dosing for *stability and patient adherence*.
• Not an acute rescue inhaler; use short‑acting bronchodilators for exacerbations.

Contraindications

Contraindications
• Hypersensitivity to tiotropium or any excipient.
• Severe narrow‑angle glaucoma (risk of acute elevation).

Warnings
• Urinary retention → precipitate in patients with bladder outlet obstruction.
• Cardiac arrhythmias → may cause bradycardia especially in patients on β blockers.
• Pregnancy/Lactation → Category C; use only if benefit > risk.
• Elderly → increased dry mouth, constipation.

Dosing

• Adults: 18 µg (one capsule) once daily.
• Administration:

1. Tilt inhaler 10‑15° forward.

2. Breathe‑in slowly; do not exhale into device.

3. Seal lips around mouthpiece → inhale as deep as tolerated, hold breath 10 s.

4. No priming required; press the capsule against the air outlet for 5 s.
• Storage: Keep in a cool, dry place; avoid high humidity or temperatures >30 °C.

Adverse Effects

Monitoring

• Pulmonary function (spirometry) every 4–6 weeks initially, then annually.
• Cardiovascular: Monitor pulse, BP; perform ECG if arrhythmia suspected.
• Ophthalmology: Screen for glaucoma in high‑risk patients.
• Kidney/ liver: Baseline labs if significant hepatic or renal dysfunction.
• Adverse event surveillance: Report any signs of urinary retention, severe GI, or hypersensitivity.

Clinical Pearls

• Device literacy: Patients often misuse Ellipta by exhaling into the device. Train patients to inhale *without exhaling first* and to hold their breath for at least 10 seconds.
• No rescue step: Emphasize that Incruse is not a rescue inhaler; combine *tiotropium* with short‑acting β₂‑agonists (SABA) or inhaled corticosteroids (ICS) as needed.
• Titration caution: Switching from a multilevel‑dose inhaler (e.g., Bivalve®) to Ellipta can double systemic exposure; adjust dosing accordingly.
• Interaction check: Concomitant use of strong CYP3A4 inhibitors (ketoconazole, ritonavir) can raise plasma tiotropium levels; consider dose reduction or alternative bronchodilators.
• Renal considerations: In patients with CKD stage 4–5, monitor closely for exaggerated anticholinergic effects; dose adjustment not formally required but clinical vigilance is advised.
• Dry mouth mitigation: Counsel patients on adequate hydration, use of sugar‑free lozenges, and routine oral hygiene.

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• *For the most current guidelines and prescribing details, refer to the latest FDA label and peer‑reviewed COPD management literature.*