Ipratropium Bromide (Atrovent HFA) is an anticholinergic medicine that is used as an oral inhalational medicine via an inhaler, nebulizer, or oral capsule devices. It causes bronchodilators and reduces airway secretion. It is used in the treatment of patients with obstructive airway disease.

Ipratropium Bromide (Atrovent HFA) Uses:

• Chronic obstructive pulmonary disease:

  • It is recommended for people with chronic obstructive lung disorders as a maintenance medication (emphysema and chronic bronchitis).

• Off Label Use of Ipratropium in Adults:

  • It may be used as off-label medicine in patients with acute exacerbation of asthma in combination with other drugs (salbutamol and prednisolone or hydrocortisone).

Ipratropium Bromide dose in adults:

Ipratropium Bromide (Atrovent HFA) Dose in the treatment of COPD: Inhalation:

• Nebulization solution:

  • 5 milligram (500 microgram, one unit-dose vial) three or four times a day.

• Metered-dose inhaler (MDI):

  • The daily dose cap is set at 12 inhalations (204 mcg) per day.
  • Two (34 mcg) inhalations, four times each day. 

Ipratropium Bromide (Atrovent HFA) Dose in the treatment of acute exacerbations of asthma (off-label):

• Average to extreme worsenings:

  • Inhalation:

Key point:

It must be made available in combination with other drugs such as short-acting beta-adrenergic agonist drugs such as albuterol.

• • Nebulization solution:

    • Three doses of 0.5 milligrams (500 micrograms, one unit-dose vial) every 20 minutes, followed by as needed [Ref].
    • MDI: For a maximum of three hours, provide 8 inhalations (136 mcg) spaced every 20 minutes as necessary.

Ipratropium Bromide dose in children:

Ipratropium Bromide (Atrovent HFA) Dose in the treatment of acute exacerbation of Asthma:

Note:

• After the patient is admitted to the hospital for the initial 24 hours, ipratropium has not been proven to be helpful.
• It may be used in emergency settings for the treatment of moderate to severe exacerbation of asthma when the response to short-acting beta-agonists is inadequate.

• Children:

  • Nebulization:

    • The typically reported dosage used in clinical studies is 250 mcg given every 1 to 8 hours, with the time between doses increasing until the patient is stabilized.
    • It has also been used in combination with short-acting beta-agonists for up to two days after the patient has been hospitalized, however, in clinical trials, no additional benefit has been observed.
    • Three doses of 0.25 to 0.5 mg (250 to 500 mcg) every 20 minutes for an hour should be given, then as needed.

    Metered-dose inhaler:

    • For up to three hours, take 4 to 8 puffs every 20 minutes as necessary.

• Adolescents:

  • Metered-dose inhaler:

    • 8 puffs, as required, every 20 minutes for up to three hours.

  • Nebulization:

    • Three doses of 0.5 mg (500 mcg) every 20 minutes, followed by as needed

Ipratropium Bromide (Atrovent HFA) Dose in the maintenance treatment of nonacute Asthma: 

Note: Ipratropium has not been shown to be beneficial in the long-term control of asthma.

• Children <12 years:

  • Metered-dose inhaler:

    • The dose should not exceed twelve inhalations/day
    • 1 to 2 inhalations every six hours.

  • Nebulization:

    • 250–500 mcg (0.25–0.5 mg; every six-eight hours)

• Children ≥12 years and Adolescents:

  • Metered-dose inhaler:

    • The highest daily dose is 12 inhalations/day
    • 2 to 3 inhalations every six hours.

  • Nebulization:

    • Every six hours, 0.25 to 0.5 mg (250 to 500 mcg).

Ipratropium bromide (Atrovent HFA) dosage for the treatment of bronchospasm brought on by long-term respiratory illnesses:

• Young children (under 12) and adolescents:

  • Nebulization:

    • 0.5 mg three or four times daily, spaced six to eight hours apart (500 mcg, one unit-dose vial).

Ipratropium Bromide (Atrovent HFA) Dose in the treatment of Bronchospasm, wheezing: 

• Infants:

  • Nebulization:

    • Ipratropium has not been shown to be effective in trials. Some cases have reported an improvement in clinical symptoms.
    • Every four hours, take 0.125 to 0.25 mg (125 to 250 mcg).

Pregnancy Risk Factor B

• Animal reproduction studies have not shown any adverse outcomes for fetuses.

Ipratropium use during breastfeeding:

• It is unknown if the drug will be excreted into breast milk. It is recommended that breastfeeding mothers use it with caution.

Dose in Kidney Disease:

• The drug has not been studied in patients with kidney disease.
• Dosage adjustment has not been recommended by the manufacturer.

Dose in Liver Disease:

• The drug has not been studied in patients with liver disease.
• The manufacturer has not recommended dosage adjustment.

Common Side Effects of Ipratropium Bromide (Atrovent HFA):

• Respiratory:

  • Sinusitis
  • Exacerbation of chronic obstructive pulmonary disease
  • Bronchitis

Less Common Side Effects of Ipratropium Bromide (Atrovent HFA):

• Respiratory:

  • Dyspnea
  • Upper respiratory tract infection
  • Flu-like symptoms
  • Cough
  • Rhinitis

• Genitourinary:

  • Urinary tract infection

• Central nervous system:

  • Dizziness
  • Headache

• Gastrointestinal:

  • Dyspepsia
  • Nausea
  • Xerostomia
  • Dysgeusia

• Neuromuscular & skeletal:

  • Back pain

Contraindications to Ipratropium Bromide (Atrovent HFA):

• Allergic reactions to the drug, atropine (and related products), or any element of such formulation.

Cautions and alerts

• Bronchospasm

  • Patients occasionally have paradoxical bronchospasm, which has the potential to be fatal.
  • Paradoxical bronchospasm can be difficult to distinguish from inadequate treatment. The drug should be stopped immediately and diagnosed as soon as possible.

• CNS effects

  • It can cause blurred vision and dizziness. If patients are required to be alert for tasks such as driving or operating heavy machinery, they should be warned.

• Hypersensitivity reactions

  • Allergies can manifest as urticaria or rash, bronchospasm or oropharyngeal swelling.
  • Anaphylaxis has been reported occasionally with the drug.
  • The patient must immediately stop receiving treatment if they develop any symptoms that could indicate an allergic reaction.

• Glaucoma:

  • It is possible for the intraocular pressure to rise due to the drug. Patients with narrow-angle vision should not use it.

• Prostatic hyperplasia, bladder neck obstruction

  • Patients at high risk for urinary retention, such as those with bladder neck obstruction or prostatic hyperplasia, should not use it.

Monitoring Parameters:

• Signs and symptoms of raised intraocular pressure/ glaucoma
• Allergic reactions to the drug
• Urinary retention especially in elderly patients and those at risk (BPH)
• FEV-1, peak flow, and/ or other lung function tests

   

  How to administer Ipratropium Bromide (Atrovent HFA)?

  It is indicated for oral inhalation only. Directly spraying into the eyes should be avoided.

  Metered-dose inhaler:

  •  
  • The inhaler does not require shaking before its use.
  • If three or more days have passed and the inhaler has not been used, it should be reprimed.
  • The mouthpiece should be washed once every week in warm water for 30 seconds or more and let dry.
  • When using the inhaler for the first time, prime it by spraying it at least two times in the air.
  • When the dose indicator of the inhaler displays "0", the inhaler should be discarded.

  Nebulization solution:

  • The solution is squeezed into the nebulizer reservoir once the vial is removed from the foil pouch.
  • Connect the nebulizer to the compressor and switch it on.
  • Ask the patient to breathe in deeply until the medicine in the nebulizer has been inhaled completely. It may take 5 to 15 minutes.
  • After nebulization, clean the nebulizer.

   

  Mechanism of action of Ipratropium Bromide (Atrovent HFA):

  It is an anticholinergic drug that prevents Acetylcholine from reaching the parasympathetic nerve endings in the smooth muscle of the bronchi. It results in bronchodilation. When applied to the nasal mucosa, it prevents secretion from the mucosa.

   

   

• Duration:

  • Metered-dose inhaler:
    • 2 to 4 hours

•  

   

• The onset of action:

  • Bronchodilation: Within 15 minutes
• Nebulization solution:
  • 4 to 5 hours (up to 7 to 8 hours in some patients)

• Absorption:

  • It does not easily enter the systemic circulation from the digestive tract or the surface of the lungs.
  • Nebulizing a dose of 2 mg results in the absorption of about 7% of the medication.

   

• Protein Binding:

  • ≤9%

• Distribution:

  • The dose that reaches the lower airways is 15%.

   

  Metabolism:

  • It undergoes a minimal amount of metabolism, producing inert ester hydrolysis products.

  Excretion:

  • Urine (50%)

   

• Peak effect:

  • 1 to 2 hours

• Half-life elimination:

  • 2 hours

• International Brand Names of Ipratropium Bromide:

  • Atrovent HFA
  • RATIO-Ipratropium
  • TEVA-Ipratropium Bromide
  • APO-Ipravent
  • PHL-Ipratropium
  • Aeron
  • Midatrol
  • Nastropium
  • Optra
  • Aerotrop
  • Aerovent
  • Alovent
  • APO-Ipravent Sterules
  • Atrovent HFA
  • Atem
  • Atropulm
  • Atrovent
  • Atrovent Aerosol
  • Atrovent N
  • Atrovent Nasal
  • PMS-Ipratropium
  • RATIO-Ipratropium UDV
  • Atrovent UDV
  • I-Patrimol
  • Ipromate
  • Tropium
  • Tropivent
  • Iprovent
  • Ipragard
  • Ipratec
  • Ipravent
  • Ipraxa
  • Iprex
  • Plautis
  • Rinatec

   

  Ipratropium Brand Names in Pakistan:

  Ipratropium Bromide Inhaler 20 mcg in Pakistan
  Optra Hfa	Getz Pharma Pakistan (Pvt) Ltd.

   

  Ipratropium Bromide Inhaler 40 mcg/actu in Pakistan
  Atem	Chiesi Pharmaceuticals (Pvt) Ltd.

   

  Ipratropium Bromide Nebuliser 0.025 %w/v in Pakistan
  Atem	Chiesi Pharmaceuticals (Pvt) Ltd.
  Ipratee	Geofman Pharmaceuticals

   

  Ipratropium Bromide Solution 0.25 mg/ml in Pakistan
  Optra	Getz Pharma Pakistan (Pvt) Ltd.

   

  Ipratropium Bromide Rota Caps 40 mcg in Pakistan
  Ipratec	Highnoon Laboratories Ltd.