Atrovent

Atrovent contains ipratropium bromide, a short-acting anticholinergic (antimuscarinic) bronchodilator used in the management of chronic obstructive pulmonary disease (COPD) and, in some settings, as an adjunct to beta-2 agonist therapy in acute severe asthma.

It works by blocking muscarinic M3 receptors in bronchial smooth muscle, reducing acetylcholine-mediated bronchoconstriction and mucus hypersecretion.

Ipratropium is delivered by metered-dose inhaler, nebuliser solution, or nasal spray. In COPD, it is a well-established first-line bronchodilator and can be used regularly or as needed.

Its onset of action is slower than that of short-acting beta-2 agonists (15 to 30 minutes versus 5 minutes for salbutamol), but its effect persists for four to six hours.

In acute asthma exacerbations, ipratropium nebulised with salbutamol provides additive bronchodilatation.

Atrovent has minimal systemic anticholinergic effects when delivered by inhalation, as only a small fraction of the inhaled dose is absorbed.

This gives it a favourable safety profile suitable for long-term use.

For metered-dose inhaler: shake the inhaler before use and actuate into the mouth during a slow, deep inhalation. Hold your breath for up to ten seconds, then exhale slowly.

Use a spacer device if coordination is difficult.

For nebuliser: add the prescribed volume to the nebuliser chamber and inhale the mist through a mouthpiece or mask until the solution is finished (typically 5 to 15 minutes).

For nasal spray: prime before first use and direct the spray into each nostril as directed.

COPD (metered-dose inhaler): 20 to 40 micrograms (1 to 2 puffs) three to four times daily. Maximum: 12 puffs per day.

Nebuliser solution (COPD or acute asthma): 250 to 500 micrograms up to four times daily; may be combined with salbutamol in the same nebulisation.

Nasal spray (rhinorrhoea): 2 sprays per nostril two to three times daily. Dosing may be adjusted based on clinical response.

Common: dry mouth (the most frequently reported), headache, cough, nausea, pharyngeal irritation.

Uncommon: urinary retention (particularly in men with prostatic hypertrophy), constipation, tachycardia, blurred vision (if the mist contacts the eyes), dizziness.

Rare: paradoxical bronchospasm immediately after inhalation (discontinue and use an alternative if this occurs), glaucoma precipitation (especially if sprayed into the eyes), allergic reactions including rash and angioedema.

Advise patients not to spray the inhaler or nebuliser mist directly into the eyes, as ipratropium can precipitate or worsen acute angle-closure glaucoma and cause pupillary dilatation.

Use a mouthpiece rather than a face mask for nebulisation where possible to avoid ocular exposure.

Use with caution in patients with prostatic hyperplasia or bladder-neck obstruction (risk of urinary retention).

If paradoxical bronchospasm occurs, discontinue and administer an alternative bronchodilator.

Contraindicated in patients with known hypersensitivity to ipratropium bromide, atropine or its derivatives, or any excipient.

Atrovent is not indicated for the acute relief of bronchospasm as monotherapy in asthma (use a short-acting beta-2 agonist instead).