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Ipratropium (Nasal)

Pronunciation

Pronunciation

(i pra TROE pee um)

Index Terms

  • Ipratropium Bromide

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Nasal, as bromide:

Atrovent: 0.03% (30 mL [DSC]); 0.06% (15 mL [DSC])

Generic: 0.03% (30 mL); 0.06% (15 mL)

Brand Names: U.S.

  • Atrovent [DSC]

Pharmacologic Category

  • Anticholinergic Agent

Pharmacology

Local application to nasal mucosa inhibits serous and seromucous gland secretions.

Absorption

<20%

Metabolism

To inactive metabolites via ester hydrolysis

Excretion

Allergic rhinitis: Urine (as unchanged drug): Pediatrics: Up to 11.1%; Adults: Up to 5.6%

Common cold: Urine (as unchanged drug): Pediatrics: Up to 7.8%; Adults: Up to 8.1%

Onset of Action

15 minutes

Protein Binding

Up to 9% (albumin)

Use: Labeled Indications

Allergic/nonallergic perennial rhinitis (0.03% solution): Symptomatic relief of rhinorrhea associated with allergic and nonallergic perennial rhinitis in adults and children ≥6 years.

Colds (0.06% solution): Symptomatic relief of rhinorrhea associated with the common cold in adults and children ≥5 years.

Seasonal allergic rhinitis (0.06% solution): Symptomatic relief of rhinorrhea associated with seasonal allergic rhinitis in adults and children ≥5 years.

Contraindications

Hypersensitivity to ipratropium, atropine (and its derivatives), or any component of the formulation

Dosing: Adult

Allergic/nonallergic perennial rhinitis: Intranasal (0.03% solution): Two sprays (21 mcg/spray) in each nostril 2 or 3 times daily (total dose: 168 to 252 mcg/day)

Colds (symptomatic relief of rhinorrhea): Intranasal (0.06% solution): Two sprays (42 mcg/spray) in each nostril 3 or 4 times daily (total dose: 504 to 672 mcg/day); use beyond 4 days has not been established

Seasonal allergic rhinitis: Intranasal (0.06% solution): Two sprays (42 mcg/spray) in each nostril 4 times daily (total dose: 672 mcg/day); use beyond 3 weeks has not been established

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Allergic/nonallergic perennial rhinitis: Children ≥6 years and Adolescents: Intranasal (0.03% solution): Refer to adult dosing.

Colds (symptomatic relief of rhinorrhea):

Children 5 to 11 years: Intranasal (0.06% solution): Two sprays (42 mcg/spray) in each nostril 3 times daily (total dose: 504 mcg/day); use beyond 4 days has not been established.

Children ≥12 years and Adolescents: Intranasal (0.06% solution): Refer to adult dosing.

Seasonal allergic rhinitis: Children ≥5 years and Adolescents: Intranasal (0.06% solution): Refer to adult dosing.

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied); use with caution.

Dosing: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied); use with caution.

Administration

Administer by the intranasal route only. Avoid spraying into or around the eyes. Blow nose gently to clear nostrils before use. Prior to initial use, prime pump by releasing 7 test sprays into the air. If the inhaler has not been used for >24 hours, reprime by releasing 2 test sprays into the air. If the inhaler has not been used for more than 7 days, reprime by releasing 7 test sprays into the air.

Storage

Store at 25°C (77°F); excursions permitted to 15°C and 25°C (59°F and 77°F). Avoid freezing.

Drug Interactions

AbobotulinumtoxinA: Anticholinergic Agents may enhance the anticholinergic effect of AbobotulinumtoxinA. Monitor therapy

Acetylcholinesterase Inhibitors: May diminish the therapeutic effect of Anticholinergic Agents. Anticholinergic Agents may diminish the therapeutic effect of Acetylcholinesterase Inhibitors. Monitor therapy

Aclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Analgesics (Opioid): Anticholinergic Agents may enhance the adverse/toxic effect of Analgesics (Opioid). Specifically, the risk for constipation and urinary retention may be increased with this combination. Monitor therapy

Anticholinergic Agents: May enhance the adverse/toxic effect of other Anticholinergic Agents. Monitor therapy

Cannabinoid-Containing Products: Anticholinergic Agents may enhance the tachycardic effect of Cannabinoid-Containing Products. Exceptions: Cannabidiol. Monitor therapy

Chloral Betaine: May enhance the adverse/toxic effect of Anticholinergic Agents. Monitor therapy

Cimetropium: Anticholinergic Agents may enhance the anticholinergic effect of Cimetropium. Avoid combination

Eluxadoline: Anticholinergic Agents may enhance the constipating effect of Eluxadoline. Avoid combination

Gastrointestinal Agents (Prokinetic): Anticholinergic Agents may diminish the therapeutic effect of Gastrointestinal Agents (Prokinetic). Monitor therapy

Glucagon: Anticholinergic Agents may enhance the adverse/toxic effect of Glucagon. Specifically, the risk of gastrointestinal adverse effects may be increased. Avoid combination

Glycopyrrolate (Oral Inhalation): Anticholinergic Agents may enhance the anticholinergic effect of Glycopyrrolate (Oral Inhalation). Avoid combination

Ipratropium (Oral Inhalation): May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Itopride: Anticholinergic Agents may diminish the therapeutic effect of Itopride. Monitor therapy

Levosulpiride: Anticholinergic Agents may diminish the therapeutic effect of Levosulpiride. Avoid combination

Mianserin: May enhance the anticholinergic effect of Anticholinergic Agents. Monitor therapy

Mirabegron: Anticholinergic Agents may enhance the adverse/toxic effect of Mirabegron. Monitor therapy

Nitroglycerin: Anticholinergic Agents may decrease the absorption of Nitroglycerin. Specifically, anticholinergic agents may decrease the dissolution of sublingual nitroglycerin tablets, possibly impairing or slowing nitroglycerin absorption. Avoid combination

OnabotulinumtoxinA: Anticholinergic Agents may enhance the anticholinergic effect of OnabotulinumtoxinA. Monitor therapy

Oxatomide: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Potassium Chloride: Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Chloride. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium chloride. Avoid combination

Pramlintide: May enhance the anticholinergic effect of Anticholinergic Agents. These effects are specific to the GI tract. Consider therapy modification

Ramosetron: Anticholinergic Agents may enhance the constipating effect of Ramosetron. Monitor therapy

RimabotulinumtoxinB: Anticholinergic Agents may enhance the anticholinergic effect of RimabotulinumtoxinB. Monitor therapy

Secretin: Anticholinergic Agents may diminish the therapeutic effect of Secretin. Management: Avoid using drugs with substantial anticholinergic effects in patients receiving secretin whenever possible. If such agents must be used in combination, monitor closely for a diminished response to secretin. Consider therapy modification

Thiazide and Thiazide-Like Diuretics: Anticholinergic Agents may increase the serum concentration of Thiazide and Thiazide-Like Diuretics. Monitor therapy

Tiotropium: Anticholinergic Agents may enhance the anticholinergic effect of Tiotropium. Avoid combination

Topiramate: Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate. Monitor therapy

Umeclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Adverse Reactions

1% to 10%:

Central nervous system: Headache (4% to 10%)

Gastrointestinal: Dysgeusia (≤4%), xerostomia (1% to 4%), diarrhea (2%), nausea (2%)

Respiratory: Upper respiratory tract infection (5% to 10%), epistaxis (6% to 9%), pharyngitis (≤8%), dry nose (≤5%), nasal mucosa irritation (2%), nasal congestion (1%)

<2% (Limited to important or life-threatening): Anaphylaxis, angioedema, blurred vision, burning sensation of the nose, conjunctivitis, cough, dizziness, eye irritation, hoarseness, increased thirst, laryngospasm, palpitations, skin rash, tachycardia, tinnitus, urticaria

Warnings/Precautions

Concerns related to adverse effects:

• CNS effects: May cause dizziness, accommodation disorder, mydriasis and blurred vision; patients must be cautioned about performing tasks that require mental alertness (eg, operating machinery or driving).

• Hypersensitivity reactions: Immediate hypersensitivity reactions (urticaria, angioedema, rash, bronchospasm, oropharyngeal edema, and anaphylaxis) have been reported. Discontinue use immediately if allergic or anaphylactoid/anaphylactic reactions occur.

Disease-related concerns:

• Glaucoma: Use with caution in patients with narrow-angle glaucoma.

• Hepatic impairment: Use with caution in patients with hepatic impairment.

• Prostatic hyperplasia/bladder neck obstruction: Use with caution in patients with prostatic hyperplasia or bladder neck obstruction.

• Renal impairment: Use with caution in patients with renal impairment.

Other warnings/precautions:

• Appropriate use: Avoid direct contact with eye. Temporary blurred vision, precipitating or worsening of narrow-angle glaucoma, mydriasis, increased intraocular pressure, acute eye pain, visual halos or colored images secondary to conjunctival and/or corneal congestion may occur. The 0.03% and 0.06% solutions do not relieve nasal congestion, sneezing, or postnasal drip associated with allergic or nonallergic perennial rhinitis or the common cold.

Pregnancy Risk Factor

B

Pregnancy Considerations

Adverse events have not been observed in animal reproduction studies.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Have patient report immediately to prescriber severe nasal irritation, severe nosebleeds, or vision changes (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.