Ipratropium inhaler (Atrovent): uses, side effects and cautions

Ipratropium bromide belongs to the anticholinergic group, drugs that block acetylcholine, a messenger that tells airway muscle to tighten and glands to make mucus. By blocking it, ipratropium relaxes the airways. The emc entry licenses Atrovent Inhaler CFC-Free for regular treatment of reversible bronchospasm in chronic obstructive pulmonary disease (COPD) and chronic asthma.

It is related to tiotropium but much shorter acting, which is why it is taken three or four times daily and not once.

The entry gives the usual adult pattern as 1 or 2 puffs three or four times a day, with some people needing up to 4 puffs at a time early in treatment. Children aged 6 to 12 usually take 1 or 2 puffs three times a day, and under-6s 1 puff three times a day, with an adult supervising. The recommended dose should not be exceeded, and your prescriber and leaflet decide your own pattern.

Because the onset is slower than a salbutamol type reliever, it is not designed as an emergency rescue medicine. Medical advice must be sought if treatment does not produce a worthwhile improvement, if the condition worsens, or if the response fades; and an acute or rapidly worsening breathlessness should be seen by a doctor at once.

Press the canister twice into the air before first use, or if it has been unused for 3 days or longer. For each dose, remove the cap, hold the inhaler upright, breathe out gently, close your lips round the mouthpiece, then breathe in slowly and deeply while pressing the canister. Hold the breath for 10 seconds or as long as is comfortable. If you need a second puff, wait at least a minute.

The inhaler can be used with the Aerochamber Plus spacer, which helps people who find it hard to time a breath with the press. The canister is not transparent and you cannot see when it empties; it delivers 200 puffs, which usually lasts 3 to 4 weeks of regular use, and should be replaced once the labelled number has been used even if some liquid seems left. Wash the plastic mouthpiece in warm soapy water, rinse and air-dry it, and never use the mouthpiece with another inhaler.

Anticholinergics need care in people prone to or with narrow-angle glaucoma. Isolated reports describe eye pain, dilated pupils and raised eye pressure when the aerosol has contacted the eyes, so keep the spray away from them. Eye pain or discomfort, blurred vision, haloes around lights or coloured images with red eyes can signal acute narrow-angle glaucoma and need urgent specialist advice.

The inhaler should be used with caution in people with pre-existing blockage of urinary outflow, such as an enlarged prostate or bladder outflow obstruction, and in people with cystic fibrosis, who may be prone to gut motility problems. Each puff contains about 8 mg of alcohol, which the entry says will not have a noticeable effect.

The commonest reported effects are headache, throat irritation, cough, dry mouth, gut upset including constipation, diarrhoea and vomiting, nausea and dizziness. Headache and dizziness are listed as common. Local irritation can occur, as with other inhaled treatments.

Hypersensitivity is listed as uncommon and has shown as hives, rash, swelling of the tongue, lips and face, bronchospasm and anaphylaxis. A sudden worsening of wheeze right after a dose, called paradoxical bronchospasm, should be treated with a fast-acting inhaled bronchodilator and the ipratropium stopped and reviewed. Swelling of the face or throat, collapse or severe breathing difficulty calls for 999. Suspected side effects can be reported through the Yellow Card scheme.

Long-term use with other anticholinergic medicines has not been studied and is not recommended. Combining ipratropium with beta-adrenergic bronchodilators or xanthines such as theophylline can give an additive bronchodilating effect, which clinicians may use deliberately.

The entry reports no experience of use in human pregnancy or breastfeeding, so it should not be used unless the expected benefit to the mother outweighs risk to the fetus or infant; animal studies showed no harm to the embryo. It is unlikely the drug reaches a breastfed infant to an important extent, though caution is advised. People may feel dizzy or have blurred vision or dilated pupils, and should avoid driving or machinery if they do.

It is contraindicated in anyone with known hypersensitivity to atropine or its derivatives, including ipratropium bromide, or to any component of the product. Tell your prescriber about any previous reaction to atropine-type medicines before starting.