Ipratropium bromide

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Ipratropium bromide
Ipratropium bromide.svg
Clinical data
Trade names Atrovent, Apovent, Ipraxa, others
AHFS/Drugs.com Monograph
MedlinePlus a618013
License data
Pregnancy
category
  • AU:B1
Routes of
administration 		Inhalation, nasal
ATC code
Legal status
Legal status
  • NZ:Prescription only
  • UK: POM (Prescription only)
  • US: ℞-only
Pharmacokinetic data
Protein binding 0 to 9% in vitro
Metabolism Liver
Elimination half-life 2 hours
Identifiers
  • [8-methyl-8-(1-methylethyl)- 8-azoniabicyclo[3.2.1] oct-3-yl] 3-hydroxy-2-phenyl-propanoate
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard 100.040.779 OOjs UI icon edit-ltr-progressive.svg
Chemical and physical data
Formula C20H30BrNO3
Molar mass 412.368 g·mol−1
3D model (JSmol)
  • CC(C)[N+]1(C2CCC1CC(C2)OC(=O)C(CO)C3=CC=CC=C3)C.[Br-]
  • InChI=1S/C20H30NO3.BrH/c1-14(2)21(3)16-9-10-17(21)12-18(11-16)24-20(23)19(13-22)15-7-5-4-6-8-15;/h4-8,14,16-19,22H,9-13H2,1-3H3;1H/q+1;/p-1/t16-,17+,18+,19?,21?;
  • Key:LHLMOSXCXGLMMN-WDTICOSOSA-M
 X mark.svgNYes check.svgY  (what is this?)    (verify)

Ipratropium bromide, sold under the trade name Atrovent among others, is a type of anticholinergic (SAMA: short acting muscarinic antagonist) medication which is applied by different routes: inhaler, nebulizer, or nasal spray, for different reasons. [1] [2]

Contents

The inhalant opens up the medium and large airways in the lungs. [3] [4] It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. [3] It is used by inhaler or nebulizer. [3] Onset of action is typically within 15 to 30 minutes and lasts for three to five hours. [3]

The nasal spray prevents the glands in the nose from producing large amounts of fluid. [5] [6] It is used to treat Rhinorrhea (runny nose) caused by allergic rhinitis, Nonallergic rhinitis, [5] and the common cold. [7] [2] It is used by metered-dose manual pump spray. Onset of action is within an hour. [7]

Common side effects of inhalant use include dry mouth, cough, inflammation of the airways [3] and shortness of breath. [8] Potentially serious side effects include urinary retention, worsening spasms of the airways, and a severe allergic reaction. [3] It appears to be safe in pregnancy and breastfeeding. [3] [9] Ipratropium is a short-acting muscarinic antagonist, [10] which works by causing smooth muscles to relax. [3]

Common side effects of nasal spray may include headache, dry nose, dry mouth or throat, nasal or throat irritation, nosebleeds, bad taste in mouth, nausea, dizziness, or constipation. [7] Potentially serious side effects are unusual, but include severe allergic reaction, eye pain or change in vision, or urinary retention. It is considered safe during pregnancy, but it can pass into breast milk and may harm a nursing baby. [11]

Ipratropium bromide was patented in 1966, and approved for medical use in 1974. [12] It is on the World Health Organization's List of Essential Medicines, the most important medicines needed in a health system. [13] Ipratropium is available as a generic medication. [3] In 2021, it was the 269th most commonly prescribed medication in the United States, with more than 1 million prescriptions. [14] [15]

Ipratropium nasal spray is no longer sold under the brand name Atrovent, just the generic. The FDA has found Atrovent was not withdrawn from sale for reasons of safety or effectiveness. [16]

Medical uses

Ipratropium as an inhalant can be used for the treatment of chronic obstructive pulmonary disease (COPD) and asthma exacerbation. [17] It is supplied in a canister for use in an inhaler or in single dose vials for use in a nebulizer. [18]

It is also used to treat and prevent minor and moderate bronchial asthma, especially asthma that is accompanied by cardiovascular system diseases, as it has been shown to produce fewer cardiovascular side effects. [19]

Combination with beta-adrenergic agonists increases the dilating effect on the bronchi, as when ipratropium is combined with salbutamol (albuterol — USAN) under the trade names Combivent (a non-aerosol metered-dose inhaler or MDI) and Duoneb (nebulizer) for the management of COPD and asthma, and with fenoterol (trade names Duovent and Berodual N) for the management of asthma.

Ipratropium as a nasal solution sprayed into the nostrils can reduce rhinorrhea (runny nose) but will not help nasal congestion. [20] It is supplied in a metered-dose manual pump spray. [7]

Contraindications

The main contraindication for ipratropium in any form is hypersensitivity to atropine and related substances. [21] [22]

Conditions such as narrow-angle glaucoma, prostatic hyperplasia, or bladder neck obstruction are not necessarily contraindicators, but should be taken into account, particularly if the patient is receiving an anticholinergic by another route. [2]

Peanut allergy

Previously Atrovent inhalers used chlorofluorocarbon (CFC) as a propellant and contained soy lecithin in the propellant ingredients. In 2008 all CFC inhalers were phased out and hydrofluoroalkane (HFA) inhalers replaced them. Allergy to peanuts was noted for the inhaler as a contraindication but now is not. It has never been a contraindication when administered as a nebulized solution. [23]

Side effects

If ipratropium is inhaled, side effects resembling those of other anticholinergics are minimal. However, dry mouth and sedation have been reported. Also, effects such as skin flushing, tachycardia, acute angle-closure glaucoma, nausea, palpitations and headache have been observed. Inhaled ipratropium does not decrease mucociliary clearance. [22] The inhalation itself can cause headache and irritation of the throat in a few percent of patients. [21]

Urinary retention has been reported in patients receiving doses by nebulizer. As a result, caution may be warranted, especially by men with prostatic hypertrophy. [24]

Common side effects of nasal spray are experienced at a rate of 1-6% (versus the control group of 0-3%), and may include headache, dry nose, dry mouth or throat, nasal or throat irritation, nosebleeds, bad taste in mouth, nausea, dizziness, or constipation. [7] [25] Potentially serious side effects from nasal spray are rare, but include severe allergic reaction, eye pain or change in vision, or difficulty urinating. [6]

Accidental contact with the eye should be avoided.

Interactions

Interactions with other anticholinergics like tricyclic antidepressants, anti-Parkinson drugs and quinidine, which theoretically increase side effects, are clinically irrelevant when ipratropium is administered as an inhalant. [21] [22]

Ipratropium nasal spray may interact with certain medications for depression, anxiety, or other mental health conditions, certain medications for Parkinson's disease, such as benztropine and trihexyphenidyl, atropine, certain antihistamines for allergy, cough, and cold, certain medications for bladder problems, such as oxybutynin and tolterodine, certain medications for stomach problems, such as dicyclomine and hyoscyamine, and certain medications for travel sickness, such as scopolamine. [6]

Pharmacology

Chemically, ipratropium bromide is a quaternary ammonium compound (which is indicated by the -ium per the BAN and the USAN) [26] obtained by treating atropine with isopropyl bromide, thus the name: isopropyl + atropine.[ citation needed ] It is chemically related to components of the plant Datura stramonium , which was used in ancient India for asthma. [27]

Ipratropium exhibits broncholytic action by reducing cholinergic influence on the bronchial musculature. It blocks muscarinic acetylcholine receptors, without specificity for subtypes, and therefore promotes the degradation of cyclic guanosine monophosphate (cGMP), resulting in a decreased intracellular concentration of cGMP. [28] Most likely due to actions of cGMP on intracellular calcium, this results in decreased contractility of smooth muscle in the lung, inhibiting bronchoconstriction and mucus secretion. It is a nonselective muscarinic antagonist, [21] and does not diffuse into the blood, which prevents systemic side effects. Ipratropium is a derivative of atropine [29] but is a quaternary amine and therefore does not cross the blood–brain barrier, which prevents central side effects (e.g., anticholinergic syndrome). Ipratropium should never be used in place of salbutamol (albuterol) as a rescue medication.

Related Research Articles

A bronchodilator or broncholytic is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lungs. Bronchodilators may be originating naturally within the body, or they may be medications administered for the treatment of breathing difficulties, usually in the form of inhalers. They are most useful in obstructive lung diseases, of which asthma and chronic obstructive pulmonary disease are the most common conditions. Although this remains somewhat controversial, they might be useful in bronchiolitis and bronchiectasis. They are often prescribed but of unproven significance in restrictive lung diseases.

<span class="mw-page-title-main">Salbutamol</span> Short-acting bronchodilator used for acute asthma

Salbutamol, also known as albuterol and sold under the brand name Ventolin among others, is a medication that opens up the medium and large airways in the lungs. It is a short-acting β2 adrenergic receptor agonist that causes relaxation of airway smooth muscle. It is used to treat asthma, including asthma attacks and exercise-induced bronchoconstriction, as well as chronic obstructive pulmonary disease (COPD). It may also be used to treat high blood potassium levels. Salbutamol is usually used with an inhaler or nebulizer, but it is also available in a pill, liquid, and intravenous solution. Onset of action of the inhaled version is typically within 15 minutes and lasts for two to six hours.

<span class="mw-page-title-main">Nebulizer</span> Drug delivery device

In medicine, a nebulizer or nebuliser is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. Nebulizers are commonly used for the treatment of asthma, cystic fibrosis, COPD and other respiratory diseases or disorders. They use oxygen, compressed air or ultrasonic power to break up solutions and suspensions into small aerosol droplets that are inhaled from the mouthpiece of the device. An aerosol is a mixture of gas and solid or liquid particles.

<span class="mw-page-title-main">Triamcinolone</span> Steroid medication

Triamcinolone is a glucocorticoid used to treat certain skin diseases, allergies, and rheumatic disorders among others. It is also used to prevent worsening of asthma and COPD. It can be taken in various ways including by mouth, injection into a muscle, and inhalation.

<span class="mw-page-title-main">Inhaler</span> Medical device used to deliver medicines into lungs

An inhaler is a medical device used for delivering medicines into the lungs through the work of a person's breathing. This allows medicines to be delivered to and absorbed in the lungs, which provides the ability for targeted medical treatment to this specific region of the body, as well as a reduction in the side effects of oral medications. There are a wide variety of inhalers, and they are commonly used to treat numerous medical conditions with asthma and chronic obstructive pulmonary disease (COPD) being among the most notable.

<span class="mw-page-title-main">Glycopyrronium bromide</span> Chemical compound

Glycopyrronium bromide is a medication of the muscarinic anticholinergic group. It does not cross the blood–brain barrier and consequently has few to no central effects. It is given by mouth, via intravenous injection, on the skin, and via inhalation. It is a synthetic quaternary ammonium compound. The cation, which is the active moiety, is called glycopyrronium (INN) or glycopyrrolate (USAN).

Beta<sub>2</sub>-adrenergic agonist Compounds that bind to and activate adrenergic beta-2 receptors

Beta2-adrenergic agonists, also known as adrenergic β2 receptor agonists, are a class of drugs that act on the β2 adrenergic receptor. Like other β adrenergic agonists, they cause smooth muscle relaxation. β2 adrenergic agonists' effects on smooth muscle cause dilation of bronchial passages, vasodilation in muscle and liver, relaxation of uterine muscle, and release of insulin. They are primarily used to treat asthma and other pulmonary disorders. Bronchodilators are considered an important treatment regime for chronic obstructive pulmonary disease (COPD) and are usually used in combination with short acting medications and long acting medications in a combined inhaler.

<span class="mw-page-title-main">Beclometasone</span> Chemical compound

Beclometasone or beclomethasone, also known as beclomethasone dipropionate, and sold under the brand name Qvar among others, is a steroid medication. It is available as an inhaler, cream, pills, and nasal spray. The inhaled form is used in the long-term management of asthma. The cream may be used for dermatitis and psoriasis. The pills have been used to treat ulcerative colitis. The nasal spray is used to treat allergic rhinitis and nasal polyps.

<span class="mw-page-title-main">Fluticasone propionate</span> Medication

Fluticasone propionate, sold under the brand names Flovent and Flonase among others, is a steroid medication. When inhaled it is used for the long term management of asthma and COPD. In the nose it is used for hay fever and nasal polyps. It can also be used for mouth ulcers. It works by decreasing inflammation.

Ipratropium bromide/salbutamol, sold under the brand name Combivent among others, is a combination medication used to treat chronic obstructive pulmonary disease (COPD). It contains ipratropium and salbutamol.

<span class="mw-page-title-main">Bronchoconstriction</span> Constriction of the terminal airways in the lungs

Bronchoconstriction is the constriction of the airways in the lungs due to the tightening of surrounding smooth muscle, with consequent coughing, wheezing, and shortness of breath.

<span class="mw-page-title-main">Nedocromil</span> Chemical compound

Nedocromil sodium is a medication considered as mast cell stabilizer which acts to prevent wheezing, shortness of breath, and other breathing problems caused by asthma. It is administered by an inhaler under the brand name Tilade, and as an eye drop under the brand name Alocril. The effects of nedocromil versus asthma are gradual rather than fast-acting and it is not indicated for acute respiratory distress compared to fast acting bronchodilators like albuterol or other well-known inhaler medications. Liquid preparations of nedocromil are available in the UK under the name Rapitil for use for allergic eye reactions. Nedocromil sodium has been shown to be effective in alleviating symptoms of allergic conjunctivitis.

<span class="mw-page-title-main">Levosalbutamol</span> Chemical compound

Levosalbutamol, also known as levalbuterol, is a short-acting β2 adrenergic receptor agonist used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). Evidence is inconclusive regarding the efficacy of levosalbutamol versus salbutamol or salbutamol-levosalbutamol combinations, though levosalbutamol is believed to have a better safety profile due to its more selective binding to β2 receptors versus β1.

<span class="mw-page-title-main">Azelastine</span> Chemical compound

Azelastine, sold under the brand name Optivar among others, is a H1 receptor-blocking medication primarily used as a nasal spray to treat allergic rhinitis (hay fever) and as eye drops for allergic conjunctivitis. Other uses may include asthma and skin rashes for which it is taken by mouth. Onset of effects is within minutes when used in the eyes and within an hour when used in the nose. Effects last for up to 12 hours.

<span class="mw-page-title-main">Mometasone</span> Steroid medication

Mometasone, also known as mometasone y 3 s, is a steroid medication used to treat certain skin conditions, hay fever, and asthma. Specifically it is used to prevent rather than treat asthma attacks. It can be applied to the skin, inhaled, or used in the nose. Mometasone furoate, not mometasone, is used in medical products.

<span class="mw-page-title-main">Fluticasone furoate</span> History, Structure, Drug Mechanisms of Fluticasone Furoate.

Fluticasone furoate, sold under the brand name Flonase Sensimist among others, is a corticosteroid for the treatment of non-allergic and allergic rhinitis administered by a nasal spray. It is also available as an inhaled corticosteroid to help prevent and control symptoms of asthma. It is derived from cortisol. Unlike fluticasone propionate, which is only approved for children four years and older, fluticasone furoate is approved in children as young as two years of age when used for allergies.

<span class="mw-page-title-main">Aclidinium bromide</span> Chemical compound

Aclidinium bromide (INN) is a long-acting, inhaled muscarinic antagonist (LAMA) approved in the United States on July 24, 2012 as a maintenance treatment for chronic obstructive pulmonary disease (COPD).

<span class="mw-page-title-main">Tiotropium bromide</span> Long-acting bronchodilator in the maintenance of COPD and asthma

Tiotropium bromide, sold under the brand name Spiriva among others, is a long-acting bronchodilator used in the management of chronic obstructive pulmonary disease (COPD) and asthma. Specifically it is used during periods of breathing difficulty to prevent them from getting worse, rather than to prevent them from happening. It is used by inhalation through the mouth. Onset typically begins within half an hour and lasts for 24 hours.

<span class="mw-page-title-main">Budesonide</span> Type of corticosteroid medication

Budesonide, sold under the brand name Pulmicort, among others, is a steroid medication. It is available as an inhaler, nebulization solution, pill, nasal spray, and rectal forms. The inhaled form is used in the long-term management of asthma and chronic obstructive pulmonary disease (COPD). The nasal spray is used for allergic rhinitis and nasal polyps. Modified-release pills or capsules and rectal forms may be used for inflammatory bowel disease including Crohn's disease, ulcerative colitis, and microscopic colitis.

Fluticasone furoate/umeclidinium bromide/vilanterol, sold under the brand name Trelegy Ellipta among others, is a fixed-dose combination inhaled medication that is used for the maintenance treatment of chronic obstructive pulmonary disease (COPD). The medications work in different ways: fluticasone furoate is an inhaled corticosteroid (ICS), umeclidinium is a long-acting muscarinic antagonist (LAMA), and vilanterol is a long-acting beta-agonist (LABA).

References

  1. ↑ Rxlist.com: Search Atrovent
  2. 1 2 3 Rx.com: Ipratropium
  3. 1 2 3 4 5 6 7 8 9 "Ipratropium Bromide". The American Society of Health-System Pharmacists. Archived from the original on 8 December 2015. Retrieved 2 December 2015.
  4. ↑ Al-Ahmad M, Hassab M, Al Ansari A (21 December 2020). "Allergic and Non-allergic Rhinitis". Textbook of Clinical Otolaryngology. Cham: Springer International Publishing. pp. 241–252. doi:10.1007/978-3-030-54088-3_22. ISBN   978-3-030-54087-6. S2CID   234142758. Nasal anticholinergics such as ipratropium bromide 0.03% are effective in controlling rhinorrhea, but do not relief other nasal symptoms. They block muscarinic receptors, leading to a decrease in the parasympathetic function.
  5. 1 2 Mayo Clinic: Ipratropium (Nasal Route)
  6. 1 2 3 Cleveland Clinic: Ipratropium Nasal Spray
  7. 1 2 3 4 5 Rxlist.com: Atrovent Nasal Spray
  8. ↑ RxList.com: Atrovent HFA
  9. ↑ Briggs G, Freeman RK, Yaffe SJ (2011). Drugs in pregnancy and lactation : a reference guide to fetal and neonatal risk (9th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 763. ISBN   978-1-60831-708-0.
  10. ↑ Ritter J, Flower RJ, Henderson G, Loke YK, MacEwan DJ, Rang HP (2020). Rang and Dale's pharmacology (9th ed.). Edinburgh. p. 377. ISBN   978-0-7020-8060-9. OCLC   1081403059.{{cite book}}: CS1 maint: location missing publisher (link)
  11. ↑ Drugs.com: Ipratropium nasal
  12. ↑ Fischer J, Ganellin CR (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 446. ISBN   978-3-527-60749-5.
  13. ↑ World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
  14. ↑ "The Top 300 of 2021". ClinCalc. Archived from the original on 15 January 2024. Retrieved 14 January 2024.
  15. ↑ "Ipratropium - Drug Usage Statistics". ClinCalc. Retrieved 14 January 2024.
  16. ↑ Federal Register: Determination That ATROVENT (Ipratropium Bromide) Metered Spray, 0.021 Micrograms/Spray and 0.042 Micrograms/Spray, Were Not Withdrawn From Sale for Reasons of Safety or Effectiveness
  17. ↑ Aaron SD (October 2001). "The use of ipratropium bromide for the management of acute asthma exacerbation in adults and children: a systematic review". The Journal of Asthma. 38 (7): 521–530. doi:10.1081/jas-100107116. PMID   11714074. S2CID   7335677.
  18. ↑ "Ipratropium Oral Inhalation". PubMed Health. Archived from the original on 2 September 2012. Retrieved 28 May 2012.
  19. ↑ "Ipratropium Bromide 0.5 mg/Albuterol Sulfate 3.0 mg" (PDF). FDA. 2004. Retrieved 4 January 2021.
  20. ↑ "Atrovent Nasal Spray". Drugs.com. Archived from the original on 11 January 2012. Retrieved 28 May 2012.
  21. 1 2 3 4 Haberfeld, H, ed. (2009). Austria-Codex (in German) (2009/2010 ed.). Vienna: Österreichischer Apothekerverlag. ISBN   978-3-85200-196-8.
  22. 1 2 3 Dinnendahl, V, Fricke, U, eds. (2010). Arzneistoff-Profile (in German). Vol. 2 (23 ed.). Eschborn, Germany: Govi Pharmazeutischer Verlag. ISBN   978-3-7741-9846-3.
  23. ↑ "Ipratropium Soybean and Nuts Allergy". EMSMedRx. 21 March 2011. Archived from the original on 13 May 2012. Retrieved 6 April 2013.
  24. ↑ Afonso AS, Verhamme KM, Stricker BH, Sturkenboom MC, Brusselle GG (April 2011). "Inhaled anticholinergic drugs and risk of acute urinary retention". BJU International. 107 (8): 1265–1272. doi:10.1111/j.1464-410X.2010.09600.x. PMID   20880196. S2CID   29516074.
  25. ↑ Drugs.com: Ipratropium nasal
  26. ↑ "The Use of Common Stems in the Selection of International Nonproprietary Names (INN) for Pharmaceutical Substances". who.int. World Health Organization. 2000. Archived from the original on 7 March 2012. Retrieved 18 July 2018.
  27. ↑ "History of Asthma". Allergy And Asthma. 21 December 2017. Archived from the original on 11 November 2020. Retrieved 2 September 2020. ... India, smoking the herb stramonium (an anticholinergic agent related to ipratropium and tiotropium currently used in inhalers) was used to relax the lungs.
  28. ↑ "Ipratropium". Drugs.com. Archived from the original on 19 May 2012.
  29. ↑ Yamatake Y, Sasagawa S, Yanaura S, Okamiya Y (October 1977). "[Antiallergic asthma effect of ipatropium bromide (Sch 1000) in dogs (author's transl)]" [Antiallergic asthma effect of ipratropium bromide (Sch 1000) in dogs]. Nihon Yakurigaku Zasshi. Folia Pharmacologica Japonica (in Japanese). 73 (7): 785–791. doi: 10.1254/fpj.73.785 . PMID   145994.
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