Ipratropium + Fenoterol


Concise Prescribing Info
Indications/Uses
Listed in Dosage.
Dosage/Direction for Use
Adult : Inhalation Asthma; COPD As soln for inhalation releasing ipratropium 20 mcg and fenoterol 50 mcg/actuation: Acute asthma attack: 1 puff for prompt relief, 1 further dose may be given if there is no relief after 5 min; further doses may be required if there is no relief after 2 admin. Intermittent and long-term treatment: 1 puff up to 4 times/day. Max: 6 puffs/day. As soln fo nebulisation containing ipratropium 0.5 mg and fenoterol 1.25 mg/4 mL: 4 mL (in NaCl soln) via nebuliser as soon as asthma attack starts; a 2nd dose may be given in severe cases.
Dosage Details
Inhalation/Respiratory
Asthma, Chronic obstructive pulmonary disease
Adult: Available preparations:
Ipratropium 20 mcg and fenoterol 50 mcg/actuation soln for inhalation
Acute asthma attack: 1 puff for prompt relief. If there is no improvement after 5 min, 1 further dose may be given; further doses may be required if there is no relief after 2 admin. Intermittent and long-term treatment: 1 puff up to 4 times daily. Max: 6 puffs daily.

Ipratropium 0.5 mg and fenoterol 1.25 mg/4 mL soln for nebulisation
4 mL (in NaCl soln) via nebuliser as soon as asthma attack starts. A 2nd dose may be required in severe cases.
Child: As soln for inhalation: >6 yr 1 puff, up to Max 3 puffs daily. As soln for nebulisation:  ≥12 yr Same as adult dose.
Contraindications
Hypersensitivity to ipratropium or fenoterol, atropine, or its derivatives. Hypertrophic obstructive cardiomyopathy, tachyarrhythmia.
Special Precautions
Patient w/ CV disease (e.g. recent MI, arrhythmia, HTN, heart failure, vascular disorders), cystic fibrosis, DM, narrow-angle glaucoma, hyperthyroidism, pheochromocytoma, prostatic hyperplasia/bladder-neck obstruction, seizure disorder. Childn. Pregnancy and lactation.
Adverse Reactions
Significant: Hypokalaemia, AF, cardiac arrhythmia, ischemic heart disease, palpitations, QT prolongation, supraventricular tachycardia, tachycardia.
Nervous: Headache, nervousness, tremor, weakness, dizziness.
CV: HTN, palpitation, hot flushes, hypotension.
GI: Glossitis, xerostomia, nausea, stomatitis, constipation, diarrhoea, vomiting, throat irritation.
Resp: Cough, pharyngitis, hoarseness, throat irritation.
Genitourinary: Urinary retention.
Endocrine: Hyperglycaemia.
Musculoskeletal: Muscle cramps, myalgia.
Ophthalmologic: Visual accommodation disturbance, eye pain, increased intraocular pressure, mydriasis, acute angle-closure glaucoma.
Dermatologic: Diaphoresis.
Potentially Fatal: Paradoxical bronchospasm. Rarely, anaphylaxis (e.g. urticaria, angioedema, rash, bronchospasm).
Patient Counseling Information
Rinse mouth every after inhalation. This drug may cause dizziness, tremor and visual disturbances, if affected, do no drive or operate machinery. Avoid contact w/ eyes.
MonitoringParameters
Monitor spirometry [e.g. FEV (forced expiratory volume), FVC (forced vital capacity)] and serum K level.
Overdosage
Symptoms: Tachycardia, palpitation, tremor, hypotension, HTN, angina pain, widening of the pulse pressure, arrhythmia, flushing, dry mouth, visual disturbances. Management: Administer sedatives or tranquilisers. For severe cases, employ intensive therapy. β1-selective blockers may be given as specific antidote.
Drug Interactions
Enhanced bronchodilatory effect w/ β-adrenergic drugs and xanthine derivatives (e.g. theophylline). Increased risk of adverse effects w/ MAOIs or TCAs. Increased risk of CV effects w/ halogenated hydrocarbons (e.g. halothane). Reduced bronchodilatory effect w/ β-blockers. Increased risk of hypokalaemia w/ xanthine derivatives, corticosteroids, diuretics.
Action
Description: Ipratropium bromide is a nonselective competitive antimuscarinic agent. It causes bronchodilation by blocking the action of acetylcholine induced stimulation of guanyl cyclase hence reducing formation of cyclic guanosine monophosphate (cGMP) at parasympathetic site.
Fenoterol is a direct-acting β2 sympathomimetic agent. It relaxes bronchial smooth muscles via protein phosphorylation (protein kinase A) by stimulating adenylate cyclase, thereby increasing cyclic-3’- 5’-adenosine monophosphate (cAMP) levels.
Onset: Ipratropium: Bronchodilation: W/in 15 min.
Fenoterol: Bronchodilation: 5 min.
Duration: Ipratropium: 4-8 hr.
Fenoterol: 6-8 hr.
Pharmacokinetics:
Absorption: Ipratropium: 10-30% of a dose is deposited in the lungs while only a small amount reaches systemic circulation. Bioavailability: 7-28%.
Fenoterol: Incompletely absorbed from the GI tract. Bioavailability: 7%.
Distribution: Deposited in lungs (10-39%).
Ipratropium: Plasma protein binding: <20%.
Fenoterol: Enters breast milk. Plasma protein binding: Approx 40-55%.
Metabolism: Ipratropium: Metabolised in the liver to α-phenylacrylic acid, phenylacetic acid-N-isopropylnortropine ester methobromide, N- isopropylnortropine methobromide.
Fenoterol: Undergoes extensive first-pass metabolism via sulfate conjugation.
Excretion: Ipratropium: Via urine and faeces. Elimination half-life: 1.6 hr.
Fenoterol: Via urine and bile (mainly as inactive sulfate conjugate). Elimination half-life: Approx 3 hr.
Chemical Structure

Chemical Structure Image
Ipratropium bromide

Source: National Center for Biotechnology Information. PubChem Database. Ipratropium bromide, CID=657308, https://pubchem.ncbi.nlm.nih.gov/compound/Ipratropium-bromide (accessed on Jan. 21, 2020)


Chemical Structure Image
Fenoterol

Source: National Center for Biotechnology Information. PubChem Database. Fenoterol, CID=3343, https://pubchem.ncbi.nlm.nih.gov/compound/Fenoterol (accessed on Jan. 20, 2020)

Storage
Store between 15-25°C. Protect from light and heat.
ATC Classification
R03AL01 - fenoterol and ipratropium bromide ; Belongs to the class of combination of adrenergics with anticholinergics, that may also include a corticosteroid. Used in the treatment of obstructive airway diseases.
References
Anon. Ipratropium and Fenoterol. Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 01/08/2017.

Buckingham R (ed). Fenoterol. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 01/08/2017.

Buckingham R (ed). Ipratropium Bromide. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 01/08/2017.

McEvoy GK, Snow EK, Miller J et al (eds). Ipratropium Bromide. AHFS Drug Information (AHFS DI) [online]. American Society of Health-System Pharmacists (ASHP). https://www.medicinescomplete.com. Accessed 01/08/2017.

Disclaimer: This information is independently developed by MIMS based on Ipratropium + Fenoterol from various references and is provided for your reference only. Therapeutic uses, prescribing information and product availability may vary between countries. Please refer to MIMS Product Monographs for specific and locally approved prescribing information. Although great effort has been made to ensure content accuracy, MIMS shall not be held responsible or liable for any claims or damages arising from the use or misuse of the information contained herein, its contents or omissions, or otherwise. Copyright © 2020 MIMS. All rights reserved. Powered by MIMS.com
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