Aclidinium: LAMA bronchodilator in COPD
Aclidinium (brand names Eklira Genuair, Bretaris Genuair, in combination with formoterol as Duaklir Genuair and Brimica Genuair) is a long-acting muscarinic receptor antagonist (LAMA) for inhaled treatment of chronic obstructive pulmonary disease (COPD). Approved in the EU in 2012, aclidinium is part of the standard group of bronchodilator inhalation drugs.
Compared with other LAMAs (tiotropium, glycopyrronium, umeclidinium), aclidinium has a shorter systemic half-life and a favourable cardiovascular safety profile, which is especially relevant in multimorbid COPD patients. Characteristic is the twice-daily use via the Genuair inhaler, a breath-actuated dry powder system with visual and acoustic feedback when inhalation is correct.
Mechanism of action
Aclidinium is a quaternary ammonium anticholinergic that competitively binds to muscarinic receptors. Clinically relevant in the airways are mainly M3 receptors on bronchial smooth muscle. Their activation by acetylcholine from the vagus nerve causes bronchoconstriction and mucus secretion. Aclidinium selectively inhibits this effect, leading to bronchodilation.
Compared with short-acting anticholinergics like ipratropium, aclidinium has clearly higher M3 binding affinity and a longer residence time at the receptor. At the same time it dissociates rapidly from M2 receptors, which favours selective bronchodilation without marked cardiac effects.
The systemically absorbed fraction is rapidly metabolised to inactive metabolites, which is why anticholinergic side effects such as dry mouth, urinary retention or worsening of narrow-angle glaucoma are rare.
Indications
- Maintenance therapy in COPD: in symptomatic patients to improve lung function, reduce symptoms and prevent exacerbations
- Combination therapy: with the LABA formoterol as fixed combination Duaklir Genuair twice daily, when monotherapy is insufficient
- Bronchial asthma: not approved; in asthma LAMAs are used only in addition to ICS and LABA, then with other substances such as tiotropium
According to GOLD recommendations, LAMAs are mainly used in groups B and E (symptomatic patients or those with frequent exacerbations).
Dosing and administration
Standard dose: 322 µg aclidinium bromide (corresponding to 400 µg of the aclidinium salt form) twice daily, morning and evening, by inhalation from the Genuair inhaler.
Use:
- Prepare the Genuair: remove the cap, press the button fully down then release (colour window shows green)
- Place mouth and lips firmly around the mouthpiece
- Inhale deeply and forcefully; a click confirms successful inhalation
- Hold breath for 5 to 10 seconds, then exhale
- Replace the cap
- If needed, rinse the mouth with water after inhalation to reduce dry mouth
The Genuair inhaler has a counter showing remaining inhalations and a red signal warning before the last dose. Used inhalers are not reused.
Side effects
Common: headache, nasopharyngitis, sinusitis, cough, diarrhoea, nausea, dry mouth, hoarseness.
Uncommon: tachycardia, palpitations, stomatitis, taste disturbance, rash, pruritus, urinary retention (especially in men with prostatic hyperplasia), visual disturbances.
Rare: narrow-angle glaucoma attack, paradoxical bronchospasm, severe allergic reactions with angioedema, breathing difficulties.
Important points:
- Aclidinium is not suitable for treating an acute asthma or COPD attack; short-acting bronchodilators such as salbutamol or ipratropium are needed
- In patients with narrow-angle glaucoma or prostatic hyperplasia, careful explanation of symptoms requiring medical review
- If bronchospasm occurs after inhalation, stop therapy immediately and start alternative therapy
Interactions
- Other anticholinergics (tiotropium, glycopyrronium, umeclidinium, ipratropium): additive anticholinergic effect, combination not recommended
- Sympathomimetics (LABA, SABA): sensible combination for bronchodilation, as in Duaklir Genuair
- Inhaled corticosteroids: sensible combination in patients with frequent exacerbations or asthma-COPD overlap
- Other QT-prolonging substances: theoretically additive, clinically rarely relevant under aclidinium
Special considerations
Pregnancy: limited data, use only on clear indication after benefit-risk assessment.
Breastfeeding: passage into milk insufficiently studied.
Narrow-angle glaucoma: aclidinium can raise intraocular pressure. Patients should be informed about symptoms such as eye pain, red eyes, blurred vision, halos around lights.
Prostatic hyperplasia: risk of urinary retention, especially in men with existing symptoms.
Severe cardiovascular disease: data on patients with unstable cardiovascular conditions are limited; nevertheless, aclidinium is considered cardiovascularly well-tolerated within the class.
Renal impairment: no dose adjustment required.
Hepatic impairment: no dose adjustment required.
Inhalation technique: regular check of technique, since even experienced patients make mistakes over time. Pharmacy support and training material help to maintain effectiveness long term.
Related substances
- Glycopyrronium, another LAMA
- Umeclidinium, once-daily LAMA
- Olodaterol, long-acting LABA
- Formoterol fumarate dihydrate, LABA in the fixed combination Duaklir
- Fluticasone, ICS in many COPD triple therapies
Frequently asked questions
Is aclidinium suitable for an acute attack?
No. Aclidinium has a slow onset and is designed as maintenance therapy. For acute breathlessness or a sudden attack, short-acting bronchodilators such as salbutamol or ipratropium are needed.
Why twice daily when other LAMAs work once daily?
Twice-daily use reliably covers symptoms in the second half of the day too and can ease morning complaints. Studies show that twice-daily aclidinium is particularly favourable for night-time and morning symptoms. Patient preferences differ: some prefer once-daily dosing, others the regular reminder of the twice-daily routine.
What helps with dry mouth?
Rinsing the mouth after inhalation is the simplest measure. Sugar-free sweets or chewing gum stimulate salivation. Marked dry mouth may also indicate that the dose is too high for the situation or that inhalation technique is suboptimal; a check is worthwhile.
What does the red window on the Genuair mean?
The colour window changes from green to red after each successful inhalation. The red window thus shows that the dose was correctly taken. If the window does not turn red, the inhalation should be repeated since the dose may not have reached the airways. If the window does not move at all, the inhaler may be empty.
Sources
- EMA Eklira Genuair (aclidinium) EPAR
- BfArM Federal Institute for Drugs and Medical Devices
- AWMF NVL COPD and GOLD guideline
- Gelbe Liste aclidinium monograph
Legal notice and disclaimer
The information on this page is provided for general information purposes only and does not constitute medical advice, diagnosis or treatment recommendation. It does not replace the advice of a licensed physician or pharmacist. Medicines should only be used after a doctor's prescription or pharmacy supply. All information is based on summaries of product characteristics and accepted scientific sources at the time of writing; the current SmPC of the manufacturer is always decisive. Sanoliste accepts no liability for completeness, timeliness or accuracy. In a medical emergency, dial the emergency number 112.