ATROVENT
Clinical safety rating: caution
Comprehensive clinical and safety monograph for ATROVENT (ATROVENT).
Antagonist at muscarinic acetylcholine receptors (M1-M5), particularly M1, M2, and M3 receptors in bronchial smooth muscle, inhibiting acetylcholine-mediated bronchoconstriction and mucus secretion.
| Metabolism | Partially hydrolyzed to inactive metabolites; minor metabolism via cytochrome P450 (CYP) enzymes (CYP2D6, CYP3A4); primarily excreted unchanged in urine and feces. |
| Excretion | Primarily renal (up to 70% unchanged) and biliary (30%) |
| Half-life | Terminal elimination half-life is approximately 2 hours; clinical effects last longer due to receptor binding. |
| Protein binding | 14-21% bound to albumin |
| Volume of Distribution | 1.0 L/kg; indicates extensive tissue distribution |
| Bioavailability | Inhalation: 19% of dose reaches systemic circulation; oral: 2% due to poor absorption and first-pass metabolism |
| Onset of Action | Inhalation: 15-30 minutes |
| Duration of Action | 4-6 hours by inhalation |
Ipratropium bromide 500 mcg via nebulization every 6-8 hours or 2 puffs (34 mcg/puff) from metered-dose inhaler 4 times daily as needed. Maximum: 12 puffs/day.
| Dosage form | SOLUTION |
| Renal impairment | No dosage adjustment required in renal impairment, as drug is minimally renally excreted. |
| Liver impairment | No dosage adjustment required in hepatic impairment; pharmacokinetics unaffected. |
| Pediatric use | Children <5 years: 250-500 mcg via nebulization every 6-8 hours. Children 5-12 years: 1-2 puffs (34-68 mcg) 4 times daily via inhaler. Maximum: 8 puffs/day. |
| Geriatric use | Same as adult dosing; no specific age-related adjustment needed. Monitor for anticholinergic side effects in elderly (e.g., urinary retention, confusion). |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
Comprehensive clinical and safety monograph for ATROVENT (ATROVENT).
| Breastfeeding | Ipratropium is poorly absorbed orally and likely excreted in breast milk in negligible amounts. M/P ratio not established. Compatible with breastfeeding; use with caution in preterm infants due to potential anticholinergic effects. |
| Teratogenic Risk | Pregnancy Category B. No evidence of teratogenicity in animal studies. In humans, no adequate well-controlled studies; however, risk appears low. First trimester: not associated with major malformations. Second/third trimesters: potential for fetal tachycardia if maternal tachycardia occurs; consider risk-benefit. |
■ FDA Black Box Warning
Not approved for acute episodes of bronchospasm; may cause paradoxical bronchospasm; not a first-line treatment for asthma.
| Serious Effects |
Hypersensitivity to ipratropium bromide or any component of the formulation; hypersensitivity to atropine or its derivatives.
| Precautions | May cause paradoxical bronchospasm (discontinue immediately); use with caution in patients with narrow-angle glaucoma, prostatic hyperplasia, or bladder neck obstruction; may cause immediate hypersensitivity reactions; not indicated for acute exacerbations; may cause dry mouth or throat irritation. |
| Food/Dietary | No known food interactions. Avoid alcohol as it may worsen dizziness or drowsiness. |
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| Fetal Monitoring |
| Monitor maternal heart rate and respiratory status. Fetal heart rate monitoring in third trimester if maternal tachycardia develops. No routine fetal monitoring required unless maternal adverse effects occur. |
| Fertility Effects | No known effect on human fertility. Animal studies show no impairment of fertility at clinically relevant doses. |
| Clinical Pearls | Ipratropium bromide (Atrovent) is a quaternary ammonium anticholinergic bronchodilator; negligible systemic absorption. Use with caution in patients with narrow-angle glaucoma, prostatic hyperplasia, or bladder neck obstruction. Not indicated for acute exacerbations; shorter onset than beta-agonists. Add as second-line in COPD or asthma when beta-agonists alone insufficient. Monitor for paradoxical bronchospasm. When using MDI, use spacer to improve lung deposition and reduce oropharyngeal deposition. |
| Patient Advice | Use exactly as prescribed; do not increase dose or frequency. · Do not use for sudden breathing problems; have a rescue inhaler (e.g., albuterol) for attacks. · Rinse mouth with water (do not swallow) after each use to prevent dry mouth and hoarseness. · Avoid getting spray in eyes; may cause blurred vision, eye pain, or worsen glaucoma. · Store canister at room temperature away from heat and open flame; do not puncture. · Seek medical help if you experience worsening breathing, hives, or swelling of face/lips. |