Drugs List

Therapeutic Indications

Uses

Acute asthma
Chronic asthma
Chronic obstructive airways disease (with reversible element)

Contraindications

None known

Precautions and Warnings

Benign prostatic hyperplasia
Bladder outflow obstruction
Breastfeeding
Cystic fibrosis
Narrow angle glaucoma
Pregnancy

Advise ability to drive/operate machinery may be affected by side effects
Do not allow solution or mist to enter eyes
Close medical supervision during initial dosing
Advise patient to report any blurred vision or any other eye symptoms
Discontinue if paradoxical bronchospasm occurs
Dose varies with brand
Patient should seek medical advice if usual relief is diminished

Only specialists in respiratory medicine should initiate and manage the use of nebulisers and associated nebulised medicines at home in children and adolescents for acute treatment of asthma.

Pregnancy and Lactation

Pregnancy

Use ipratropium bromide with caution in pregnancy.

Briggs et al note that ipratropium was not teratogenic in mice, rats and rabbits when administered either orally or by inhalation. A number of sources recommend the use of inhaled ipratropium for severe asthma, especially in patients not responding adequately to other therapies. There is no evidence that the drug is hazardous to the foetus, producing fewer systemic effects than atropine, and may have an additive bronchodilatory effect to Beta2 agonists.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use ipratropium bromide with caution in breastfeeding.

Ipratropium bromide may appear in breast milk but in amounts that are probably insignificant, especially after inhalation.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Anaphylactic reaction
Angioedema of tongue, lips and face
Atrial fibrillation
Blurred vision
Bronchospasm
Bronchospasm (paradoxical)
Cold extremities
Conjunctival hyperaemia
Constipation
Corneal oedema
Cough
Diarrhoea
Disturbances in accommodation
Dizziness
Dry mouth
Dry throat
Gastro-intestinal motility disturbances
Headache
Hypersensitivity reactions
Increased intra-ocular pressure
Laryngospasm
Mydriasis
Narrow angle glaucoma
Nausea
Ocular pain
Oropharyngeal oedema
Palpitations
Pruritus
Rash
Stomatitis
Supraventricular tachycardia
Tachycardia
Throat irritation
Urinary retention
Urticaria
Visual haloes
Vomiting

Presentation

Solution for nebulisation containing ipratropium bromide.

Drugs List

Therapeutic Indications

Uses

Acute asthma
Chronic asthma
Chronic obstructive airways disease (with reversible element)

Dosage

It is advisable not to exceed the recommended daily dose during acute or maintenance treatment. Daily doses exceeding 2mg in adults and children over 12 years of age should only be given under medical supervision.

Adults

Children

Contraindications

None known

Precautions and Warnings

Benign prostatic hyperplasia
Bladder outflow obstruction
Breastfeeding
Cystic fibrosis
Narrow angle glaucoma
Pregnancy

Advise ability to drive/operate machinery may be affected by side effects
Do not allow solution or mist to enter eyes
Close medical supervision during initial dosing
Advise patient to report any blurred vision or any other eye symptoms
Discontinue if paradoxical bronchospasm occurs
Dose varies with brand
Patient should seek medical advice if usual relief is diminished

Only specialists in respiratory medicine should initiate and manage the use of nebulisers and associated nebulised medicines at home in children and adolescents for acute treatment of asthma.

Pregnancy and Lactation

Pregnancy

Use ipratropium bromide with caution in pregnancy.

Briggs et al note that ipratropium was not teratogenic in mice, rats and rabbits when administered either orally or by inhalation. A number of sources recommend the use of inhaled ipratropium for severe asthma, especially in patients not responding adequately to other therapies. There is no evidence that the drug is hazardous to the foetus, producing fewer systemic effects than atropine, and may have an additive bronchodilatory effect to Beta2 agonists.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use ipratropium bromide with caution in breastfeeding.

Ipratropium bromide may appear in breast milk but in amounts that are probably insignificant, especially after inhalation.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Anaphylactic reaction
Angioedema of tongue, lips and face
Atrial fibrillation
Blurred vision
Bronchospasm
Bronchospasm (paradoxical)
Cold extremities
Conjunctival hyperaemia
Constipation
Corneal oedema
Cough
Diarrhoea
Disturbances in accommodation
Dizziness
Dry mouth
Dry throat
Gastro-intestinal motility disturbances
Headache
Hypersensitivity reactions
Increased intra-ocular pressure
Laryngospasm
Mydriasis
Narrow angle glaucoma
Nausea
Ocular pain
Oropharyngeal oedema
Palpitations
Pruritus
Rash
Stomatitis
Supraventricular tachycardia
Tachycardia
Throat irritation
Urinary retention
Urticaria
Visual haloes
Vomiting

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: December 2016

Reference Sources

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.

Summary of Product Characteristics: Atrovent 250 UDVs, 1 ml and 2 ml. Boehringer Ingelheim Limited. Revised September 2020.

Summary of Product Characteristics: Respontin Nebules. Glaxo Wellcome UK Limited. Revised November 2015.

Summary of Product Characteristics: Steri-Neb Ipratropium Unit Doses, 250 micrograms/1 ml and 500 micrograms/2 ml. IVAX Pharmaceuticals UK. Revised August 2015.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 22 August 2017