Ipratropium

Article Author:
Hussien Saab
Article Editor:
Ayham Aboeed
Updated:
10/8/2019 1:39:19 PM
PubMed Link:
Ipratropium

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]


References

[1] Massey KL,Gotz VP, Ipratropium bromide. Drug intelligence & clinical pharmacy. 1985 Jan     [PubMed PMID: 3155676]
[2] 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 PMID: 8181328]
[3] Summers QA,Tarala RA, Nebulized ipratropium in the treatment of acute asthma. Chest. 1990 Feb     [PubMed PMID: 2137076]
[4] Kopsaftis ZA,Sulaiman NS,Mountain OD,Carson-Chahhoud KV,Phillips PA,Smith BJ, Short-acting bronchodilators for the management of acute exacerbations of chronic obstructive pulmonary disease in the hospital setting: systematic review. Systematic reviews. 2018 Nov 29     [PubMed PMID: 30497532]