Ipratropium


Article Author:
Hussien Saab


Article Editor:
Ayham Aboeed


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/17/2019 10:47:03 PM

Indications

Ipratropium is a bronchodilator medication that works to dilate airways of the lungs. The FDA approved indications are bronchospasms associated with chronic obstructive lung disease (COPD), which include emphysema and chronic bronchitis. Non-FDA indications include asthma exacerbations as well as clearance of secretions, especially in intubated patients in the ICU.[1]

Mechanism of Action

Ipratropium is an acetylcholine antagonist via blockade of muscarinic cholinergic receptors. Blocking cholinergic receptors decreases the production of cyclic guanosine monophosphate (cGMP). This decrease in the lung airways will lead to decreased contraction of the smooth muscles. The actions of intranasal ipratropium mimic the action of atropine by inhibiting salivary and mucous glands secretions as well as dilating bronchial smooth muscle.

Compared to atropine, orally inhaled ipratropium is a more potent antimuscarinic and bronchial dilator of smooth muscle.

Intranasal ipratropium produces a local parasympathetic response, leading to decreased water secretions of mucosal glands of the nasal system alleviating symptoms of rhinorrhea (allergic or non-allergic).[1]

Studies showed that the mean peak percent increases in FEV1 over baseline were 24 to 25 percent for oral inhaled ipratropium in COPD patients. This research noted similar changes in forced vital capacity curves. However, the combination of ipratropium and albuterol, when given via metered-dose inhaler to patients with COPD, proved more effective than either of the two agents alone.[2]

Administration

The administration of ipratropium is via inhalation either orally or intranasally.

Oral Inhalation:

The oral formulation can be aerosol inhalation or a solution for nebulization.

Aerosol inhalation:

If there is a difficulty of inhalation with actuation, a valved holding chamber (VHC) or a spacer can be given to the patient. A patient can choose between mouthpiece or a face mask along with the VHC or spacer based on patient convenience. Usually, it is more convenient patients under the age of 4 years to use a tight face mask, and VHC or spacer get the most of treatment. When using a face mask, the patient should be instructed to inhale 3 to 5 times per actuation. After administration patient to be instructed to rinse the mouth with water to decrease the side effect of mouth dryness. Patients should be instructed not to use other persons' inhaler to prevent the transfer of any possible infections. [3]

Dosage:

Adults: 

17 mcg per spray

COPD: 2 sprays every 6 hours

Asthma exacerbation, moderate to severe: 8 sprays every 20 mins as needed for up to 3 hours

No renal impairment adjustment required.

Pediatrics: 

NEB (0.02%): 0.25 MG every 20 mins up to 3 doses for asthma exacerbation that is moderate to severe: if less than 6 years old.

NEB (0.02%): 0.25-0.5 MG every 20 mins as needed up to 3 hours for asthma exacerbation that is moderate to severe: if age from 6 to 12 years old.

NEB (0.02%): 0.5 MG every 20 mins as needed up to 3 hours for asthma exacerbation that is moderate to severe: if age 13 years old or above.

Solution for nebulization:

Ipratropium can be mixed with albuterol formations in the same nebulizer within one hour of use. In the other hand, ipratropium should not be mixed with cromolyn solutions as both are incompatible.

Intranasal Inhalation:

Nasal spray solution:

Prime the unit before using for the first time.

Point the sprayer away from patients or other persons/animals.

Push the activator 6 to 7 pushes until a wide and fine spray is observed.

After that, if the unit remains unused for over 24 hours, then prime the unit again by pushing the pump at least twice before use. If the unit remains unused for more than 7 days, then prime the unit again by pushing the pump seven times all over again.

Patients should be instructed not to use other peoples' inhaler to prevent the transfer of any possible infections.[2]

Dosage:

0.03% solution: 21 mcg/spray

0.06% solution: 42 mcg/spray

Rhinorrhea (allergic or nonallergic rhinitis): 2 sprays of 0.03% solution per nostril every 6 hours. Seasonal allergic rhinitis: 2 sprays of 0.06% per nostril every 6 hours or every 8 hours.

Common cold: 2 sprays of 0.06% per nostril every 6 hours or every 8 hours

No renal impairment adjustment required.

Adverse Effects

Ipratropium Inhaled:

Most common adverse reactions:

  • Bronchitis
  • Nausea
  • Mouth dryness
  • Skin flushing
  • Dyspnea
  • Symptoms of a common cold
  • Dizziness
  • Sinusitis
  • Dyspepsia
  • Back pain
  • UTI
  • Tachycardia
  • Arrhythmias
  • Severe adverse reactions:
  • Hypersensitivity reaction
  • Paradoxical bronchospasms
  • Anaphylaxis
  • Closed-angle glaucoma

Ipratropium Intranasal:

Most common adverse reactions:

  • Upper respiratory infections
  • Epistaxis
  • Pharyngitis
  • Headache
  • Xerostomia
  • Change of taste
  • Nausea
  • Nasal irritation
  • Arrhythmias

Severe adverse reactions[4]:

  • Hypersensitivity reaction
  • Anaphylaxis

Contraindications

Contraindicaitons to ipratropium inhaler use include patients that are hypersensitive to atropine; this is secondary to the similarity in structure to atropine.

Ipratropium aerosols can cause bronchospasms (paradoxical), and this usually happens upon the initial use of this medication. Patients should understand this possibility. If this adverse reaction occurs, then this medication should be immediately discontinued.

Previous severe allergic reaction symptoms upon the use of ipratropium or atropine and its other derivatives, such as angioedema, urticaria, severe shortness of breath, oropharyngeal edema and ultimately anaphylaxis is a contraindication to ipratropium use.

Caution is necessary for the use of intranasal/inhaled ipratropium in patients with hypertrophic prostate.

Exercise caution with the use of intranasal/inhaled ipratropium in patients with obstruction of the bladder neck.[1]

Caution is recommended in the use of intranasal/inhaled ipratropium in patients with closed angle glaucoma.[1]

Ipratropium is labeled as category B with regards to pregnancy since there are no reports of teratogenesis in animals or humans with ipratropium use (aerosols or nasal spray), but studies in humans are limited. Ipratropium should only be used during pregnancy if the mother's benefits outweigh possible fetus risks.[1]

Monitoring

Ipratropium inhalation aerosol is a bronchodilator agent for chronic control of bronchospasms secondary to COPD and not a first line medication for acute bronchospasms and not used for as a rapid response agent for acute situations.

Symptoms of anaphylaxis (angioedema, urticaria, bronchospasms, rash) should be monitored, especially upon the first use of this medication. As mentioned above if these symptoms occur, the drug should be discontinued.

As mentioned above, caution is necessary for patients with prostatic hypertrophy, bladder neck obstruction, and closed angle glaucoma.

There are no recommended routine monitoring tests.

Toxicity

High doses of ipratropium can cause toxicity similar to anticholinergic toxicity symptoms.

These symptoms include:

  • Hyperthermia
  • Agitation
  • Confusion
  • Mydriasis
  • Mucosal dryness
  • Reports have demonstrated ipratropium worsens ischemic injuries in nonclinical settings

Enhancing Healthcare Team Outcomes

Ipratropium is a bronchodilator widely used for chronic obstructive pulmonary diseases. This drug is known to relieve bronchospasms and enhance patency of airways in the lungs. To prescribe this medication requires proper communication between healthcare providers as well as pharmacists, and subspecialty doctors such as pulmonologists. An interprofessional approach can be very effective in monitoring drug efficacy and adjusting the dosing and combination of this agent with other agents acting on the airways. Although most of the situations are perfectly manageable via one healthcare provider. This medication can sometimes work in combination with other agents that act on the airways, but in some instances, could be incompatible for use with other agents using the same nebulizer. Hence it is essential to obtain drug-drug interactions via pharmacists. It is critical to document any previous adverse reaction if this medication was used before, such as hypersensitivity reactions or anaphylaxis. Pharmacists should flag a prescription if those adverse reactions have been previously charted and notify the healthcare providers and patient immediately.[4]

In summary, the successful implementation of ipratropium therapy requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]


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Ipratropium - Questions

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What anticholinergic medication, when combined with beta-2 adrenergics, can relieve an asthmatic attack?



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Beta 2-adrenergic medications generally are combined with other medications to relieve bronchospasm. Which of the following is the anticholinergic medication used in this combination?



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Ipratropium is given to asthmatics. What is its mechanism of action?



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Which of the following is the mechanism of action of ipratropium in the treatment of asthma?



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A 63-year-old man comes to your office complaining of wheezing and dyspnea on exertion. He has a 35-pack-year smoking history, as well as a history of coronary artery disease, dyslipidemia and diabetes mellitus. His current medications are aspirin, atorvastatin, and metformin. Physical reveals marked bilateral wheeze. Laboratory studies including complete blood count and a basic metabolic profile are unremarkable. His most recent spirometry this morning showed FEV1 of 75% and FEV1/FVC 0.67. The physician diagnoses the patient with COPD and prescribes a drug that is delivered via an inhaler. He tells the patient that the drug will cause some dizziness and blurring of vision. What is the mechanism of action of this drug?



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A 65-year-old woman comes to the clinic complaining of frequent productive cough, dyspnea, and wheezing. Sputum is white colored. Symptoms are exacerbated on exertion. She has a history of smoking as well as a history of diabetes and hypertension. Her current medications are hydrochlorothiazide and metformin. Physical examination is remarkable for wheezing in all lung fields. Laboratory studies including complete blood count and a basic metabolic profile are unremarkable. Spirometry shows FEV1 of 70% and FEV1/FVC 0.60. Which of the following is the most likely diagnosis and which of the following medications is most commonly prescribed for diagnosis?



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What is the mechanism of action for the ipratropium in asthma therapy?



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A 65-year-old man comes to the office complaining of dyspnea on exertion and frequent wheezing. He is a smoker for 30 years with a history of heart disease, dyslipidemia, and diabetes mellitus. His current medications are aspirin, simvastatin, and insulin. Physical examination is remarkable for wheezing and prolonged expiration. Laboratory studies including complete blood count and a basic metabolic profile are unremarkable. His most recent spirometry shows FEV1 of 70% and FEV1/FVC 0.60. Which of the following best describes the most appropriate medication, the patient's diagnosis, and the most likely adverse effect of using the medication?



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A 65-year-old woman complains of dyspnea on exertion and wheezing. She states that her symptoms are exacerbated when walking uphill. She has a 25-pack-year history of smoking as well as a history of diabetes and hypertension. Her current medications are lisinopril and metformin. Physical examination is only remarkable for scattered wheezing and prolonged expiration. Laboratory studies including complete blood count and a basic metabolic profile are unremarkable. Her most recent spirometry done two weeks ago showed FEV1 of 75% and FEV1/FVC ratio of 0.64. Which of the following is the next best step in the management of this patient?



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Ipratropium - References

References

Massey KL,Gotz VP, Ipratropium bromide. Drug intelligence & clinical pharmacy. 1985 Jan     [PubMed]
In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. An 85-day multicenter trial. COMBIVENT Inhalation Aerosol Study Group. Chest. 1994 May     [PubMed]
Summers QA,Tarala RA, Nebulized ipratropium in the treatment of acute asthma. Chest. 1990 Feb     [PubMed]
    [PubMed]

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