Ipratropium (Atrovent) question

[Shishkabob]

So, going through my Brady drug guide, studying for a quiz on Wednesday and looking at Atrovent. Contraindications are pretty simple, but had a question.

One of the only 2 contraindications is
"It should not be used as the primary treatment for acute episodes of bronchospasm"



Why? Yes, I know albuterol tends to be the go-to, and Duoneb when needed. Vent, or anyone, wanna regale me on the specifics? Did I miss something obvious?

 

[Sasha]

Atrovent is to be used with albuterol. It wont treat bronchospasm by itself, to my knowledge.

 

[rmellish]

Atrovent is to be used with albuterol. It wont treat bronchospasm by itself, to my knowledge.

I figure ipratropium would act as a muscarinic antagonist, but I'm not sure how quickly this effect occurs, or the degree of effect it would have.

 

[daedalus]

Probably because Albuterol is a adrenergic agonist that directly causes bronchodilation while Atrovent is an anticholinergic that will only prevent further parasympathetic activity.

 

[MSDeltaFlt]

So, going through my Brady drug guide, studying for a quiz on Wednesday and looking at Atrovent. Contraindications are pretty simple, but had a question.

One of the only 2 contraindications is
"It should not be used as the primary treatment for acute episodes of bronchospasm"



Why? Yes, I know albuterol tends to be the go-to, and Duoneb when needed. Vent, or anyone, wanna regale me on the specifics? Did I miss something obvious?

Albuterol kicks in faster than Atrovent. Atrovent lasts longer, but doesn't kick in as fast. You may use Duoneb when needed because it still has albuterol in it. Make sense?

 

[lafmedic1]

On a side note is ipatropium still peanut oil based ? I know we had peanut allergy listed as a contrindication .

 

[VentMedic]

On a side note is ipatropium still peanut oil based ? I know we had peanut allergy listed as a contrindication .

This has never been an issue for the liquid and that includes Duoneb or any of the Albuterol/Atrovent liquid combos by various manufacturers. There will also be a Xopenex/Atrovent combo in the future.

The Atrovent MDI when it was using a CFC proellant used a Lecithin base.

The HFA Atrovent MDI does not so the soy allergy is not an issue.

However, Combivent MDI has not be able to reformulate to HFA and are still CFC. The FDA has granted them a few more months to achieve this or risk being taken off the market completely.

Atrovent should not be used with patients who have narrow angle glaucoma. Some of the disorders and disease processes get overlooked in an H&P because they are considered to be unimportant. However, the meds used to treat something else can have serious effects or exacerbate something else.

Atrovent is primarily used for COPD such at that with emphysema. Since it has a different mechanism of action, asthmatics do not always need it unless they have a similar obstructive component as found in other forms of COPD. Thus, you may not find many asthmatics on Spiriva unless they are using GP as a physician who is just tossing samples of meds at them at random without any plan of care in mind. Also, if the patient is using Spiriva correctly, the Atrovent will have little effect.

Atrovent will be used by itself to treat some with COPD and if they are not bronchospastic. It may give them relief but not always immediately. They will usually take it as a scheduled med or PRN at the first signs of decompensation. However, they will usually also have a Albuterol inhaler nearby. For some, they become sensitive to the Albuterol as they develop more cardiac problems from advanced COPD.

Still, for rescue, the use of Albuterol or Xopenex is still recommended regardless of what other med is added or to follow.

 

[PapaBear434]

Probably because Albuterol is a adrenergic agonist that directly causes bronchodilation while Atrovent is an anticholinergic that will only prevent further parasympathetic activity.

Pretty much what I came in to say, as I just had that quiz myself.

 

[VentMedic]

Here is the clinical pharmacology of Albuterol and Atrovent taken form their websites. They are two different meds with different actions.

Again, Atrovent is primarily indicated for those with COPD such as emphysema and chronic bronchitis.

Atrovent is an anticholinergic (parasympatholytic) agent. It appears to inhibit vagally-mediated reflexes by antagonizing the action of acetylcholine, the transmitter agent released at the neuromuscular junctions in the lung. Anticholinergics prevent the increases in intracellular concentration of cyclic guanosine monophosphate (cyclic GMP) which are caused by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle

Albuterol has a preferential effect on beta2-adrenergic receptors. Beta2-adrenergic receptors are the predominant receptors in bronchial smooth muscle, Activation of beta2-adrenergic receptors on airway smooth muscle leads to the activation of adenylcyclase and to an increase in the intracellular concentration of cyclic-3′,5′-adenosine monophosphate (cyclic AMP). This increase of cyclic AMP leads to the activation of protein kinase A, which inhibits the phosphorylation of myosin and lowers intracellular ionic calcium concentrations, resulting in relaxation. Albuterol relaxes the smooth muscles of all airways, from the trachea to the terminal bronchioles. Albuterol acts as a functional antagonist to relax the airway irrespective of the spasmogen involved, thus protecting against all bronchoconstrictor challenges. Increased cyclic AMP concentrations are also associated with the inhibition of release of mediators from mast cells in the airway.


We also have another drug, Intal, (Cromolyn sodium) which acts by inhibiting the release of mediators from mast cells.

Also, get familar with the new MDIs. Since they have reformulated to the HFA propellant, the names have changed and you may not see regular "Albuterol" inhaler. You will be seeing ProAir, Ventolin and Proventil.

There are also new names for the solutions with AccuNeb being one for Albuterol sulfate and it comes in different dosages.

Vospire ER is the albuterol sulfate tablets.

There names are for the U.S. as Canada and Mexico as well as the European countries have their own trade names and newer meds that are not available in the U.S. at this time as well as other approved routes in their country such as IV.




.

 

[ResTech]

The main reason for Atrovent is for the synergistic effect when administered together with Albuterol. Both albuterol and atrovent work by different mechanisms or pathways so when administered together you get a greater efficacy then if each med was administered alone.

Atrovent is a parasympatholytic which as you know works by blocking acetylcholine at the muscarinic receptors in the lungs to reduce bronchoconstriction. Atrovent has a greater onset of action time and its maximum effect is less than albuterol which is why I understand it not to be recommend for administration solely by itself. And factoring the synergistic effect with albuterol, it makes sense to administer atrovent together.

Its 1:30am and is all I can recall from class at the moment. zzzzzz zzzzz

 

[Shishkabob]

See, that's what I've come to understand, but wondered why they had it as a contraindication instead of "Pre-hospital considerations" or something.

Guess it's just an editorial thing.

 

[ResTech]

I guess maybe they listed it as a contraindication as a sole medication because it has a likelihood of failing and not reversing the bronchoconstriction if given alone and so you always go for the albuterol or albuterol/ipratropium... just a guess.

 

[austinmedic2004]

So, let's clarify exactly why you use Atrovent, a parasympatholytic much like atropine...I haven't seen anyone mention the specific reason, so here it is. I am sure everyone is familiar with why you would use Atropine for an organophosphate poisonoing...it will dry the secretions caused by the hyper-parasympathetic state induced by the acetocholinesterase inhibition. So, to take this mechanism of action to, specifically, the asthmatic patient we need to look at what is happening. We are getting a histamine response leading to secretions in addition to a narrowing of the bronchioles caused again by an inflammatory response. Depending on the severity of the reactive airway disease process, the beta-2 properties of albuterol may be enough to relieve the reaction...however, if the inflammatory response is severe enough you will need the assistance of Atrovent to in effect dry up the secretions released as a result.

 

[VentMedic]

So, let's clarify exactly why you use Atrovent, a parasympatholytic much like atropine...I haven't seen anyone mention the specific reason, so here it is. I am sure everyone is familiar with why you would use Atropine for an organophosphate poisonoing...it will dry the secretions caused by the hyper-parasympathetic state induced by the acetocholinesterase inhibition. So, to take this mechanism of action to, specifically, the asthmatic patient we need to look at what is happening. We are getting a histamine response leading to secretions in addition to a narrowing of the bronchioles caused again by an inflammatory response. Depending on the severity of the reactive airway disease process, the beta-2 properties of albuterol may be enough to relieve the reaction...however, if the inflammatory response is severe enough you will need the assistance of Atrovent to in effect dry up the secretions released as a result.

Atrovent is not an anti-inflammatory. Many asthmatics already have thick tenacious secretions that need mobilizing. The EPR-3 also no longer promotes Atrovent for those that have asthma unless they have another COPD component.

Atrovent IS NOT a rescue medication and should not be promoted as one. It has its purposes and can be used with albuterol.

 

[ResTech]

Atrovent does have a drying effect due to being an anticholinergic and will be effective in drying some secretions. It is my understanding though that Atrovent is administered pre-hospital for it's ability to aid in bronchodilation which is additive to the bronchodilation effect brought about by the beta-2 stimulation from Albuterol. In other words, atrovent is not indicated for its drying effect as you said but instead for its ability to bronchodilate through an additional pathway (blocking acetylcholine) in addition to a beta-2 agonist.

If the inflammatory response is severe enough, wouldn't Solu-Medrol or a similar steroid be indicated and not atrovent to reduce the inflammation which should also reduce the secretions from the inflammatory response?

 

[terrible one]

Not to hijack this thread but Im curious as do any of your protocols include Mag Sulfate for the treatment of Asthma/COPD refractory to an Albuterol treatment for a patient that will not benefit from Epi?

 

[Melbourne MICA]

Thunder gone

Stole my thunder Venty and others. Atrovent increases vagal tone (parasympathetic via muscarinic receptors) and attacks bronchospasm that way as opposed to say Salbutamol which you know is a beta 2 agonist (sympathetics). This is why bronchospasm management is a multipronged attack via the neb route.

Another beta agonist you will be familiar with is adrenaline though I'm still not sure why its affects are counterproductive in asthma (except when the pt is pegging out). (Venty this is where you come in -again).

So I guess it figures you wouldn't give it to someone who is already brady lest 40 beats per minute becomes 10 beats per minute.

Ahh - The wonders of pharmacology.

MM

 

[VentMedic]

Atrovent does have a drying effect due to being an anticholinergic and will be effective in drying some secretions. It is my understanding though that Atrovent is administered pre-hospital for it's ability to aid in bronchodilation which is additive to the bronchodilation effect brought about by the beta-2 stimulation from Albuterol. In other words, atrovent is not indicated for its drying effect as you said but instead for its ability to bronchodilate through an additional pathway (blocking acetylcholine) in addition to a beta-2 agonist.

If the inflammatory response is severe enough, wouldn't Solu-Medrol or a similar steroid be indicated and not atrovent to reduce the inflammation which should also reduce the secretions from the inflammatory response?

Again, Atrovent is NOT an anti-inflammatory. We do have other MDIs and liquid nebulizers that are anti-inflammatories as well as Solu-medrol. But, before administering, it is always good to first see how much the patient is already taking.

We do not use it just for drying secretions but to reduce the contractility of smooth muscle. However, Atrovent is available in a nasal spray that is use to treat rhinorrhea.

Dry muscus in the lungs is not always a good thing. Mucus plugs can create massive atelectasis, require intubation and even bronchoscopy.

One Atrovent is probably not going to do harm to a patient but one has to understand the whole disease process and the goals.

quote terrible one
Not to hijack this thread but Im curious as do any of your protocols include Mag Sulfate for the treatment of Asthma/COPD refractory to an Albuterol treatment for a patient that will not benefit from Epi?

How do you know the patient is refractory to Albuterol? Some patients may require over 12 hours of a 20 mg/hour Albuterol treatement given continuously with a special neb. We also give a concentrated 5 mg Albuterol treatment with a breath activated nebulizer to ensure more than 20% reaches the patient. This is for inhospital and on CCT/Specialty transport. As well, we may also need to give the treatment with heliox.

Mag Sulfate has its place in Asthma but in COPD patients it is still controversial. Due to age, many other medical conditions and medications they are taken it is given with caution or after lab values are confirmed.

While Asthma is listed in the COPD category, it is treated differently as are those with emphysema, Cystic Fibrosis, bronchitis and bronchiectasis.

 

[terrible one]

How do you know the patient is refractory to Albuterol? Some patients may require over 12 hours of a 20 mg/hour Albuterol treatement given continuously with a special neb. We also give a concentrated 5 mg Albuterol treatment with a breath activated nebulizer to ensure more than 20% reaches the patient. This is for inhospital and on CCT/Specialty transport. As well, we may also need to give the treatment with heliox.

Mag Sulfate has its place in Asthma but in COPD patients it is still controversial. Due to age, many other medical conditions and medications they are taken it is given with caution or after lab values are confirmed.

While Asthma is listed in the COPD category, it is treated differently as are those with emphysema, Cystic Fibrosis, bronchitis and bronchiectasis.

Maybe refractory was the wrong the word, but a patient in moderate to severe distress not benefiting from Albuterol Tx. (Pre-hospital Setting) What is the mechanism of action of Mag for a respiratory patient?

 

[VentMedic]

What is the mechanism of action of Mag for a respiratory patient?

Magnesium sulfate inhibits smooth muscle contraction, decreases histamine release from mast cells, and inhibits acetylcholine release.