ipratropium

General

Pronunciation:
i-pra-troe-pee-um

Trade Name(s)

• Atrovent HFA

Ther. Class.

allergy, cold and cough remedies

bronchodilators

Pharm. Class.

anticholinergics

Indications

• Inhaln Maintenance therapy of reversible airway obstruction due to COPD, including chronic bronchitis and emphysema.
• Intranasal Rhinorrhea associated with allergic and nonallergic perennial rhinitis (0.03% solution) or the common cold (0.06% solution).

Unlabeled Use(s):

Inhaln Adjunctive management of bronchospasm caused by asthma.

Action

• Inhaln Inhibits cholinergic receptors in bronchial smooth muscle, resulting in decreased concentrations of cyclic guanosine monophosphate (cGMP). Decreased levels of cGMP produce local bronchodilation.
• Intranasal Local application inhibits secretions from glands lining the nasal mucosa.

Therapeutic Effect(s):

• Inhaln Bronchodilation without systemic anticholinergic effects.
• Intranasal Decreased rhinorrhea.

Pharmacokinetics

Absorption: Minimal systemic absorption (2% for inhalation solution; 20% for inhalation aerosol; <20% following nasal use).

Distribution: 15% of dose reaches lower airways after inhalation.

Metabolism and Excretion: Small amounts absorbed are metabolized by the liver.

Half-life: 2 hr.

TIME/ACTION PROFILE ( bronchodilation)

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity to ipratropium, atropine, belladonna alkaloids, or bromide;
• Acute bronchospasm.

Use Cautiously in:

• Bladder-neck obstruction, prostatic hyperplasia, glaucoma, or urinary retention;
• Lactation: Safety not established in breastfeeding;
• Geri:   Older adults may be more sensitive to effects.

Adverse Reactions/Side Effects

CV: hypotension, palpitations

Derm: rash

EENT: blurred vision, sore throat nasal only: epistaxis, nasal dryness/irritation

GI: GI irritation, nausea

Neuro: dizziness, headache, nervousness

Resp: bronchospasm, cough

Misc: HYPERSENSITIVITY REACTIONS (including anaphylaxis)

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

↑ anticholinergic effects with other  drugs having anticholinergic properties, including  antihistamines,  phenothiazines, and  disopyramide.

Route/Dosage

Inhaln (Adults and Children >12 yr): Metered-dose inhaler (nonacute):  2 inhalations 4 times daily (not to exceed 12 inhalations/24 hr or more frequently than every 4 hr).  Metered-dose inhaler (acute exacerbations):  4–8 puffs using a spacer device as needed.  Nebulization (nonacute):  500 mcg 3–4 times daily.  Nebulization (acute exacerbations):  500 mcg every 30 min for 3 doses, then every 2–4 hr as needed.

Inhaln (Adults and Children 5–12 yr): Metered-dose inhaler (nonacute):  1–2 inhalations every 6 hr as needed (not to exceed 12 inhalations/24 hr).  Metered-dose inhaler (acute exacerbations):  4–8 puffs as needed.  Nebulization (nonacute):  250–500 mcg 4 times daily given every 6 hr.  Nebulization (acute exacerbations):  250 mcg every 20 min for 3 doses, then every 2–4 hr as needed.

Inhaln Infants: Nebulization:  125–250 mcg 3 times a day.

Inhaln (Neonates): Nebulization:  25 mcg/kg/dose 3 times a day.

Intranasal (Adults and Children >6 yr): 0.03% solution:  2 sprays in each nostril 2–3 times daily (21 mcg/spray).

Inhaln (Adults and Children >5 yr): 0.06% solution:  2 sprays in each nostril 3–4 times daily (42 mcg/spray).

Availability (generic available)

Aerosol inhaler (HFA) (chlorofluorocarbon-free): 17 mcg/inhalation in 12.9-g canister (200 inhalations)

Inhalation solution: 0.0125% , 0.02%,, 0.025% 

Nasal spray: 0.03% solution: 21 mcg/spray in 30-mL bottle (345 sprays/bottle), 0.06% solution: 42 mcg/spray in 15-mL bottle (165 sprays)

In Combination with: albuterol (Combivent Respimat). See combination drugs.

Assessment

• Assess for allergy to atropine and belladonna alkaloids; patients with these allergies may also be sensitive to ipratropium.
• Inhaln Assess respiratory status (rate, breath sounds, degree of dyspnea) before administration and at peak of medication. Consult health care provider about alternative medication if severe bronchospasm is present; onset of action is too slow for patients in acute distress.  If hypersensitivity reactions or paradoxical bronchospasm (wheezing) occurs, withhold medication and implement supportive measures (epinephrine).
• Nasal Spray: Assess patient for rhinorrhea.

Implementation

• Inhaln 

  See medication administration techniques for administration of inhalation medications.

  • When ipratropium is administered concurrently with other inhalation medications, administer adrenergic bronchodilators first, followed by ipratropium, and then corticosteroids. Wait 5 min between medications.
  • Solution for  nebulization  can be diluted with preservative-free 0.9% NaCl. Diluted solution should be used within 24 hr at room temperature or 48 hr if refrigerated. Solution can be mixed with preservative-free albuterol or cromolyn if used within 1 hr of mixing.

Patient/Family Teaching

• Explain purpose and side effects of medication to patient. Advise patient to read  Patient Information  before starting therapy. Instruct patient in proper use of inhaler, nebulizer, or nasal spray and to take medication as directed. Take missed doses as soon as remembered unless almost time for the next dose; space remaining doses evenly during day. Do not double doses.
• Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care provider before taking other medications.
• Advise patient that rinsing mouth after using inhaler, proper oral hygiene, and sugarless gum or candy may minimize dry mouth. Health care provider should be notified if stomatitis occurs or if dry mouth persists for >2 wk.
• Inhalation:

  Caution patient not to exceed 12 doses within 24 hr. Patient should notify health care provider if symptoms do not improve within 30 min after administration of medication or if condition worsens.

  • Explain need for pulmonary function tests before and periodically during therapy to determine effectiveness of medication.
  • Caution patient to avoid spraying medication in eyes; may cause blurring of vision or irritation.
  • Advise patient to inform health care provider if cough, nervousness, headache, dizziness, nausea, or GI distress occurs.
• Nasal Spray:

  Instruct patient in proper use of nasal spray. Clear nasal passages gently before administration. Do not inhale during administration, so medication remains in nasal passages. Prime pump initially with 7 actuations. If used regularly, no further priming is needed. If not used in 24 hr, prime with 2 actuations. If not used for >7 days, prime with 7 actuations.

  • Advise patient to contact health care provider if symptoms do not improve within 1–2 wk or if condition worsens.
  • Advise patient if hypersensitivity reactions occur (anaphylaxis) to seek immediate medical assistance.
  • Rep:   Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

Evaluation/Desired Outcomes

• Bronchodilation without systemic anticholinergic effects.
• Decreased rhinorrhea.