page200
therapy
(see
Management
of
Acute
Asthma
table,
p.
173).
The aerosol
inhalation of
ipratropium can be used for
short-term relief in mild chronic obstructive pulmonary
disease in patients who are not
using a long-acting
antimuscarinic drug.
Its maximal
effect
occurs 30–60
minutes after use;
its duration of action is 3 to 6 hours
and bronchodilation can usually be maintained with
treatment 3 times a day.
Tiotropium,
a long-acting antimuscarinic bronchodila-
tor, is effective for the management of chronic obstruc-
tive pulmonary disease; it is not suitable for the relief of
acute bronchospasm.
Cautions
Antimuscarinic bronchodilators should be
used with caution in patients with prostatic hyperplasia,
bladder outflow obstruction,
and those susceptible to
angle-closure
glaucoma
(see
below);
interactions:
Appendix 1 (antimuscarinics).
Glaucoma
Acute
angle-closure
glaucoma
reported
with nebulised ipratropium,
particularly when given
with nebulised salbutamol
(and possibly other
beta
2
agonists);
care needed to protect
patient’s eyes from
nebulised drug or from drug powder.
Side-effects
Dry mouth is the most
common side-
effect of antimuscarinic bronchodilators;
also constipa-
tion,
cough,
paradoxical
bronchospasm,
headache,
diz-
ziness;
less commonly nausea,
tachycardia, palpitation,
atrial fibrillation, urinary retention, angle-closure glauc-
oma, and blurred vision occur. Raised intra-ocular pres-
sure has occurred rarely.
IPRATROPIUM BROMIDE
Indications
reversible airways obstruction,
particu-
larly in chronic obstructive pulmonary disease; rhin-
itis (section 12.2.2)
Cautions
see notes above
Pregnancy
see p.
170
Breast-feeding
see p.
170
Side-effects
see notes above;
also vomiting,
diarr-
hoea,
local irritation;
rarely
laryngospasm,
eye pain,
mydriasis
Dose
. By aerosol inhalation,
20–40 micrograms,
3–4 times
daily;
CHILD
up to 6 years 20 micrograms 3 times daily,
6–12 years 20–40 micrograms 3 times daily
. By inhalation of powder,
ADULT
and
CHILD
over 12
years, 40 micrograms 3–4 times daily (may be
doubled in less responsive patients)
. By inhalation of nebulised solution,
reversible air-
ways obstruction in chronic obstructive pulmonary
disease,
250–500 micrograms 3–4 times daily
Acute bronchospasm (but see also Management of
Acute Asthma table,
p.
173),
500 micrograms
repeated as necessary;
CHILD
under 5 years 125–
250 micrograms,
max.
1 mg daily;
6–12 years
250 micrograms,
max.
1 mg daily
Counselling
Advise patient not to exceed prescribed dose
and to follow manufacturer’s directions
Ipratropium Bromide
(Non-proprietary) A
Nebuliser solution
,
ipratropium bromide 250 micr-
ograms/mL,
net price 20 1-mL (250-microgram)
unit-dose vials = £6.75, 60 1-mL = £21.78; 20 2-
mL (500-microgram) = £7.43, 60 2-mL = £26.97. If
dilution is necessary use only sterile sodium chloride
0.9%
Atrovent
c
(Boehringer Ingelheim) A
Aerocaps
c
(dry powder for inhalation;
for use with
Atrovent Aerohaler
c
),
green,
ipratropium bromide
40 micrograms,
net price pack of 100 caps with
Aerohaler
c
= £14.53; 100 caps = £10.53. Counselling,
administration
Note
One
Atrovent
Aerocap
c
is equivalent
to 2 puffs of
Atrovent
c
metered aerosol inhalation
Aerosol inhalation
T,
ipratropium bromide 20 micr-
ograms/metered inhalation, net price 200-dose unit =
£5.05.
Counselling,
administration
Nebuliser solution
,
isotonic,
ipratropium bromide
250 micrograms/mL, net price 20 1-mL unit-dose
vials = £4.14,
60 1-mL vials = £12.44;
20 2-mL
vials = £4.87,
60 2-mL vials = £14.59.
If dilution is
necessary use only sterile sodium chloride 0.9%
Ipratropium Steri-Neb
c
(IVAX) A
Nebuliser solution
,
isotonic,
ipratropium bromide
250 micrograms/mL, net price 20 1-mL (250-
microgram) unit-dose vials = £8.72; 20 2-mL (500-
microgram) = £9.94.
If dilution is necessary use only
sterile sodium chloride 0.9%
Respontin
c
(A&H) A
Nebuliser solution
,
isotonic,
ipratropium bromide
250 micrograms/mL, net price 20 1-mL (250-
microgram) unit-dose vials = £4.78; 20 2-mL (500-
microgram) = £5.60.
If dilution is necessary use only
sterile sodium chloride 0.9%
Compound ipratropium preparations
Section 3.1.4
TIOTROPIUM
Indications
maintenance treatment of chronic
obstructive pulmonary disease
Cautions
see notes above; also cardiac rhythm disor-
ders (with
Spiriva Respimat
)
Renal impairment
plasma-tiotropium concentration
raised;
use with caution if eGFR less than 50 mL/
minute/1.73 m
2
Side-effects
see notes above;
less commonly
taste
disturbance,
stomatitis,
gastro-oesophageal reflux
disease,
pharyngitis,
dysphonia,
dysphagia,
dysuria,
epistaxis,
oropharyngeal candidiasis;
rarely
intestinal
obstruction (including paralytic ileus), laryngitis,
insomnia, urinary-tract infection,
skin infection,
sinusitis,
dental caries,
gingivitis,
glossitis,
skin ulcer;
also reported
dehydration, joint swelling,
dry skin
Dose
. See under preparations below
Spiriva
c
(Boehringer Ingelheim) A
Inhalation powder, hard capsule
(for use with
HandiHaler
c
device),
green,
tiotropium (as tiotro-
pium bromide monohydrate) 18 micrograms, net price
30-cap pack with
HandiHaler
c
device = £34.87,
30-
cap refill = £31.89.
Counselling,
administration
Dose
by inhalation of powder,
ADULT over 18 years,
18 micr-
ograms once daily
Respimat
c
(solution for inhalation)T,
tiotropium (as
tiotropium bromide monohydrate) 2.5 micrograms/
metered inhalation,
net price 60-dose unit = £36.27.
Counselling,
administration
Dose
by inhalation, ADULT over 18 years, 5 micrograms (2 puffs)
once daily
Note
The
Scottish Medicines Consortium
has advised (November
2007) that
Spiriva Respimat
c
is restricted for use in chronic
obstructive pulmonary disease in patients who have poor manual
dexterity and difficulty using the
Handihaler
c
device
180
3.1.2 Antimuscarinic bronchodilators
BNF 61
3
Respiratory system