No symptoms specific to overdosage have been encountered. In view of the wide therapeutic window and topical administration of Ratio-Ipratropium (Inhalation), no serious anticholinergic symptoms are to be expected. As with other anticholinergics, dry mouth, visual accommodation disturbances and tachycardia would be the expected symptoms and signs of overdose.
Ratio-Ipratropium (Inhalation) UDVs are contraindicated in patients with known hypersensitivity to atropine or its derivatives (such as the active substance ipratropium bromide) or to any other component of the product.
Not applicable.
Many of the listed undesirable effects can be assigned to the anticholinergic properties of Ratio-Ipratropium (Inhalation). As with all inhalation therapy Ratio-Ipratropium (Inhalation) may show symptoms of local irritation. Adverse drug reactions were identified from data obtained in clinical trials and pharmacovigilance during post approval use of the drug.
The most frequent side effects reported in clinical trials were headache, throat irritation, cough, dry mouth, gastro-intestinal motility disorders (including constipation, diarrhoea and vomiting), nausea, and dizziness.
Frequencies
| Very common | > 1/10 |
| Common | > 1/100 < 1/10 |
| Uncommon | > 1/1,000< 1/100 |
| Rare | > 1/10,000 < 1/1,000 |
| Very rare | < 1/10,000 |
| Immune system disorder | |
| Hypersensitivity | Uncommon |
| Anaphylactic reaction | Uncommon |
| Angioedema of tongue, lips & face | Uncommon |
| Nervous system disorders | |
| Headache | Common |
| Dizziness | Common |
| Eye disorders | |
| Blurred vision | Uncommon |
| Mydriasis (1) | Uncommon |
| Intraocular pressure increased (1) | Uncommon |
| Glaucoma (1) | Uncommon |
| Eye pain (1) | Uncommon |
| Halo vision | Uncommon |
| Conjunctival hyperaemia | Uncommon |
| Corneal oedema | Uncommon |
| Accommodation disorder | Rare |
| Cardiac Disorders | |
| Palpitations | Uncommon |
| Supraventricular tachycardia | Uncommon |
| Atrial fibrillation | Rare |
| Heart rate increased | Rare |
| Respiratory, Thoracic and Mediastinal Disorders | |
| Throat irritation | Common |
| Cough | Common |
| Bronchospasm | Uncommon |
| Paradoxical bronchospasm(2) | Uncommon |
| Laryngospasm | Uncommon |
| Pharyngeal oedema | Uncommon |
| Dry throat | Uncommon |
| Gastro-intestinal Disorders | |
| Dry mouth | Common |
| Nausea | Common |
| Gastro-intestinal motility disorder | Common |
| e.g. Diarrhoea | Uncommon |
| Constipation | Uncommon |
| Vomiting | Uncommon |
| Stomatitis | Uncommon |
| Skin and subcutaneous tissue disorders | |
| Rash | Uncommon |
| Pruritus | Uncommon |
| Urticaria | Rare |
| Renal and Urinary Disorders | |
| Urinary retention(3) | Uncommon |
(2) As with other inhalation therapy, inhalation induced bronchoconstriction may occur with an immediate increase in wheezing after dosing. This should be treated straight away with a fast acting inhaled bronchodilator. Ratio-Ipratropium (Inhalation) UDVs should be discontinued immediately, the patient assessed and, if necessary, alterative treatment instituted.
(3) the risk of urinary retention may be increased in patients with pre-existing urinary outflow tract obstruction.
Reporting of suspected adverse reactions
Reporting suspected adverse reaction after authorisation of the medicinal product is important. It allows continued monitoring of the benefit / risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
The toxicity of ipratropium bromide has been investigated extensively in the following types of studies: acute, subchronic and chronic toxicity, carcinogenicity, reproductive toxicity and mutagenicity via oral, intravenous, subcutaneous, intranasal and/or inhalation routes. Based on these toxicity studies, the probability of systemic anticholinergic side effects decreases in the following order:
intravenous > subcutaneous > oral > inhalation > intranasal.
Pre-clinically, ipratropium bromide was found to be well-tolerated. Two-year carcinogenicity studies in rats and mice have revealed no carcinogenic activity at doses up to approximately 1,200 times the maximum recommended human daily dose for intranasal ipratropium. Results of various mutagenicity tests were negative.
Studies to investigate the possible influence of ipratropium bromide on fertility, embryo-fetotoxicity, and peri-/postnatal development have been performed on mice, rats and rabbits. High oral levels, i.e. 1000 mg/kg/day in the rat and 125 mg/kg/day in the rabbit were maternotoxic for both species and embryo-/fetotoxic in the rat, where the fetal weight was reduced. Treatment-related malformations were not observed. The highest, technically feasible doses for inhalation of the pressurised inhalation, solution, 1.5 mg/kg/day (human equivalent dose of 0.24 mg/kg/day) in rats and 1.8 mg/kg/day (human equivalent dose of 0.576 mg/kg/day) in rabbits, showed no adverse effects on reproduction.
These doses are 6- and 14-fold the maximum recommended human daily dose (MRHDD) of 2 mg or 0.04 mg/kg (based on a body weight of 50 kg).
Ratio-Ipratropium (Inhalation) UDVs are indicated for treatment of reversible bronchospasm associated with chronic obstructive pulmonary disease (COPD).
Ratio-Ipratropium (Inhalation) UDVs are indicated, when used concomitantly with inhaled beta2-agonists, for treatment of reversible airways obstruction as in acute and chronic asthma.
Pharmacotherapeutic group: Anticholinergics
ATC Code: R03BB01
Ratio-Ipratropium (Inhalation) is a quaternary ammonium compound with anticholinergic (parasympatholytic) properties. In nonclinical studies, it appears to inhibit vagally mediated reflexes by antagonising the action of acetylcholine, the transmitter agent released from the vagus nerve. Anticholinergics prevent the increase in intracellular concentration of Ca++ which is caused by interaction of acetylcholine with the muscarinic receptor on bronchial smooth muscle. Ca++ release is mediated by the second messenger system consisting of IP3 (inositol triphosphate) and DAG (diacylglycerol).
The bronchodilation following inhalation of Ratio-Ipratropium (Inhalation) is induced by local drug concentrations sufficient for anticholinergic efficacy at the bronchial smooth muscle and not by systemic drug concentrations.
In clinical trials using metered dose inhalers in patients with reversible bronchospasm associated with chronic obstructive pulmonary disease significant improvements in pulmonary function (FEV1 increases of 15% or more) occurred within 15 minutes, reached a peak in 1-2 hours, and persisted for approximately 4 hours.
Preclinical and clinical evidence suggest no deleterious effect of Ratio-Ipratropium (Inhalation) on airway mucous secretion, mucociliary clearance or gas exchange.
The bronchodilator effect of Ratio-Ipratropium (Inhalation) in the treatment of acute bronchospasm associated with asthma has been shown in studies in adults and children > 6 years of age. In most of these studies Ratio-Ipratropium (Inhalation) was administered in combination with an inhaled beta2-agonist.
Absorption
The therapeutic effect of Ratio-Ipratropium (Inhalation) is produced by a local action in the airways. Time courses of bronchodilation and systemic pharmacokinetics do not run in parallel.
Following inhalation, 10 to 30% of a dose is generally deposited in the lungs, depending on the formulation, device and inhalation technique. The major part of the dose is swallowed and passes through the gastro-intestinal tract.
The portion of the dose deposited in the lungs reaches the circulation rapidly (within minutes).
Cumulative renal excretion (0-24 hrs) of the parent compound is approximated to 46% of an intravenously administered dose, below 1% of an oral dose and approximately 3 to 13% of an inhaled dose. Based on these data the total systemic bioavailability of oral and inhaled doses of ipratropium bromide is estimated at 2% and 7 to 28% respectively.
Taking this into account, swallowed dose portions of ipratropium bromide do not contribute significantly to systemic exposure.
Distribution
The drug is minimally (less than 20%) bound to plasma proteins. Nonclinical data indicate that the quaternary amine ipratropium does not cross the placental or the blood-brain barrier.
Biotransformation
After intravenous administration approximately 60% of the dose is metabolised, mainly by conjugation (40%), whereas after inhalation about 77% of the systemically available dose is metabolised by ester hydrolysis (41%) and conjugation (36%).
The known metabolites, which are formed by hydrolysis, dehydration or elimination of the hydroxy-methyl group in the tropic acid moiety, show very little or no affinity for the muscarinic receptor and have to be regarded as ineffective
Elimination
Ipratropium has a mean total clearance of 2.3 L/min and a renal clearance of 0.9 L/min.
In an excretion balance study cumulative renal excretion (6 days) of drug-related radioactivity (including parent compound and all metabolites) accounted for 72.1% after intravenous administration, 9.3% after oral administration and 3.2% after inhalation. Total radioactivity excreted via the faeces was 6.3% following intravenous application, 88.5% following oral dosing and 69.4% after inhalation. Regarding the excretion of drug-related radioactivity after intravenous administration, the main excretion occurs via the kidneys. The half-life for elimination of drug-related radioactivity (parent compound and metabolites) is 3.2 hours.
Use of the nebuliser solution should be subject to close medical supervision during initial dosing.
Hypersensitivity
Immediate hypersensitivity reactions following the use of Ratio-Ipratropium (Inhalation) have been demonstrated by cases of urticaria, angioedema, rash, bronchospasm, oropharyngeal oedema and anaphylaxis.
Paradoxical bronchospasm
As with other inhalation therapy, inhalation induced bronchoconstriction may occur with an immediate increase in wheezing after dosing. This should be treated straight away with a fast acting inhaled bronchodilator. Ratio-Ipratropium (Inhalation) UDVs should be discontinued immediately, the patient assessed and, if necessary, alternative treatment instituted.
Ocular complications
Caution is advocated in the use of anticholinergic agents in patients predisposed to or with narrow-angle glaucoma.
There have been isolated reports of ocular complications (i.e. mydriasis, increased intra-ocular pressure, narrow-angle glaucoma, eye pain) when aerosolised ipratropium bromide, either alone or in combination with an adrenergic beta2-agonist, has come into contact with the eyes during nebuliser therapy.
Eye pain or discomfort, blurred vision, visual halos or coloured images in association with red eyes from conjunctival congestion and corneal oedema may be signs of acute narrow-angle glaucoma. Should any combination of these symptoms develop, treatment with miotic drops should be initiated and specialist advice sought immediately.
Patients must be instructed in the correct administration of Ratio-Ipratropium (Inhalation) UDVs. Care must be taken not to allow the solution or mist to enter the eyes. It is recommended that the nebulised solution is administered via a mouthpiece. If this is not available and a nebuliser mask is used, it must fit properly. Patients who may be predisposed to glaucoma should be warned specifically to protect their eyes.
Renal and urinary effects
Ratio-Ipratropium (Inhalation) UDVs should be used with caution in patients with pre-existing urinary outflow tract obstruction (e.g. prostatic hyperplasia or bladder-outflow obstruction).
Gastro-intestinal motility disturbances
As patients with cystic fibrosis may be prone to gastro-intestinal motility disturbances, Ratio-Ipratropium (Inhalation), as with other anticholinergics, should be used with caution in these patients.
No studies on the effects on the ability to drive and use machines have been performed. However, patients should be advised that they may experience undesirable effects such as dizziness, accommodation disorder, mydriasis and blurred vision during treatment with Ratio-Ipratropium (Inhalation). If patients experience the above mentioned side effects they should avoid potentially hazardous tasks such as driving or operating machinery.
The dosage should be adapted to the individual needs of the patient. In children aged 12 years and under, only Ratio-Ipratropium (Inhalation) 250 UDVs, 1 ml should be used. The following doses are recommended:
Adults (including the elderly) and adolescents > 12 years of age:
250 - 500 micrograms (i.e. one vial of 250 micrograms in 1 ml or 1 vial of 500 micrograms in 2 ml) 3 to 4 times daily.
For treatment of acute bronchospasm, 500 micrograms.
Repeated doses can be administered until the patient is stable. The time interval between the doses may be determined by the physician.
It is advisable not to exceed the recommended daily dose during either acute or maintenance treatment. Daily doses exceeding 2 mg in adults and adolescents > 12 years of age should only be given under medical supervision.
Children 6 - 12 years of age:
250 micrograms (i.e. one vial of 250 micrograms in 1ml) up to a total daily dose of 1mg (4 vials).
The time interval between doses may be determined by the physician.
Children 0 - 5 years of age (for treatment of acute asthma only):
125 - 250 micrograms (i.e. half to one vial of 250 micrograms in 1 ml) up to a total daily dose of 1 mg (4 vials).
Ipratropium bromide should be administered no more frequently than 6 hourly in children under 5 years of age.
For acute bronchospasm, repeated doses may be administered until the patient is stable.
If therapy does not produce a significant improvement or if the patient's condition gets worse, medical advice must be sought. The patient should be instructed that in the case of acute or rapidly worsening dyspnoea a physician should be consulted immediately.
Ratio-Ipratropium (Inhalation) UDVs may be combined with a short-acting beta2-agonist in the same nebuliser chamber, for simultaneous administration where co-administration is required. The solution should be used as soon as possible after mixing and any unused solution should be discarded.
Ratio-Ipratropium (Inhalation) UDVs can be administered using a range of commercially available nebulising devices. The dose of nebuliser solution may need to be diluted in order to obtain a final volume suitable for the particular nebuliser being used (usually 2 - 4 mL); if dilution is necessary use only sterile sodium chloride 0.9% solution.
Ratio-Ipratropium (Inhalation) UDVs and disodium cromoglycate inhalation solutions that contain the preservative benzalkonium chloride should not be administered simultaneously in the same nebuliser as precipitation may occur.
The unit dose vials are intended only for inhalation with suitable nebulising devices and should not be taken orally or administered parenterally.
Please refer to the patient information leaflet for instructions on use with a nebuliser.
None.
