ipratropium bromide
Atrovent

Available forms
Available by prescription only
Inhalation solution: 0.02%
Inhaler: each metered dose supplies 18 mcg
Nasal spray: 0.03%, 0.06%

Indications and dosages
 Bronchospasm in chronic bronchitis and emphysema. Adults: Usually, two inhalations (36 mcg) q.i.d.; patient may take additional inhalations, p.r.n., but shouldn’t exceed 12 inhalations in 24 hours or 500 mcg q 6 to 8 hours via oral nebulizer.
 Rhinorrhea caused by allergic and nonallergic perennial rhinitis.
0.03% nasal spray. Adults and children age 6 and older: Two sprays (42 mcg) per nostril b.i.d. or t.i.d.
 Rhinorrhea caused by the common cold.
0.06% nasal spray
Adults and children age 12 and older: Two sprays (84 mcg) per nostril t.i.d. or q.i.d.
Children ages 5 to 11: Two sprays (84 mcg) per nostril t.i.d.

Pharmacodynamics
Anticholinergic action: Ipratropium appears to inhibit vagally mediated reflexes by antagonizing the action of acetylcholine. Anticholinergics prevent the increases in intracellular concentration of cyclic guanosine monophosphate (cyclic GMP) that result from the interaction of acetylcholine with the muscarinic receptor on bronchial smooth muscle.
 The bronchodilation following inhalation is primarily a local, site-specific effect, not a systemic one.

Pharmacokinetics
Absorption: Not readily absorbed into systemic circulation either from the surface of the lung or from the GI tract as confirmed by blood levels and renal excretion studies. Much of an inhaled dose is swallowed.
Distribution: Not applicable.
Metabolism: Metabolism is hepatic; elimination half-life is about 2 hours.
Excretion: Most of an administered dose is excreted unchanged in feces. Absorbed drug is excreted in urine and bile.

Contraindications and precautions
Contraindicated in patients hypersensitive to drug or atropine or its derivatives and in those with a history of hypersensitivity to soya lecithin or related food products, such as soybeans and peanuts. Use cautiously in patients with angle-closure glaucoma, prostatic hyperplasia, and bladder-neck obstruction.

Interactions
Drug-drug. Antimuscarinics, including ophthalmic preparations: May produce additive effects. Avoid use together.
Fluorocarbon propellant-containing oral inhalants, such as adrenocorticoids, cromolyn, glucocorticoids, and sympathomimetics: May increase risk of fluorocarbon toxicity if too-closely timed administration of ipratropium and other oral inhalants containing fluorocarbon propellant. A 5-minute interval between administration of such agents is recommended.
Drug-herb. Jaborandi tree, pill-bearing spurge: Decreases drug effect. Monitor patient closely and discourage herb usage.

Adverse reactions
CNS: dizziness, headache, nervousness, pain.
CV: palpitations, chest pain.
EENT: cough, blurred vision, rhinitis, pharyngitis, sinusitis.
GI: nausea, GI distress, dry mouth.
Musculoskeletal: back pain.
Respiratory: upper respiratory tract infection, bronchitis, cough, dyspnea, bronchospasm, increased sputum.
Skin: rash.
Other: flulike symptoms.

Effects on lab test results
None reported.

Overdose and treatment
Acute overdose by inhalation is unlikely because ipratropium isn’t well absorbed systemically after aerosol or oral administration.

Special considerations
• Because of delayed onset of bronchodilation, drug isn’t recommended for treating acute respiratory distress.
• Nasal spray pump requires priming with seven actuations of the pump. If used regularly as recommended, no further priming is needed. If not used for longer than 24 hours, the pump will require two actuations. If not used for longer than 7 days, the pump will require seven actuations to reprime.
Breast-feeding patients
• It isn’t known whether drug appears in breast milk. Although lipid-insoluble quaternary bases pass into breast milk, ipratropium is unlikely to reach the infant, especially when taken by aerosol. Use cautiously in breast-feeding women.
Pediatric patients
• Safety and efficacy of nebulization or inhaler in children younger than 12 haven’t been established.

Patient education
• Instruct patient on correct method of administration.
• Advise patient to allow 1 minute between inhalations.
• Instruct patient to take a missed dose as soon as possible, unless it’s almost time for the next scheduled dose, in which case he should skip the missed dose. Warn him to never double the dose.
• Suggest sugarless hard candy, gum, ice, or saliva substitute to relieve dry mouth. Tell patient to report dry mouth if it persists longer than 2 weeks.
• Instruct patient to call if he experiences no benefits within 30 minutes after administration or if condition worsens.

Reactions may be common, uncommon, life-threatening, or COMMON AND LIFE THREATENING.
◆ Canada only
◇ Unlabeled clinical use