What is the recommended dosage and use of Ipratropium bromide for rhinitis?

Ipratropium Bromide Dosage and Use for Rhinitis

Ipratropium bromide nasal spray is recommended at 0.03% concentration (42 μg per nostril three times daily) for perennial allergic and nonallergic rhinitis, and 0.06% concentration (84 μg per nostril three times daily) for rhinorrhea associated with the common cold in patients 5-6 years and older. 1

Approved Indications and Concentrations

• Ipratropium bromide nasal spray 0.03% (Atrovent) is FDA-approved for treating rhinorrhea associated with perennial allergic and nonallergic rhinitis in patients 6 years of age and older 1
• Ipratropium bromide nasal spray 0.06% is approved for treating rhinorrhea associated with the common cold in patients 5 years of age and older 1
• Ipratropium bromide is specifically approved for treating rhinorrhea (runny nose) and not other nasal symptoms, although one pediatric study showed modest benefit for nasal congestion 1

Mechanism of Action

• Ipratropium bromide is a quaternary ammonium muscarinic receptor antagonist that exerts its effect locally on the nasal mucosa 1
• It works by blocking cholinergically mediated secretions, which constitute a significant proportion of histamine-induced and antigen-induced nasal secretions 1
• Unlike tertiary anticholinergic amines, ipratropium bromide is poorly absorbed across biological membranes, resulting in minimal systemic anticholinergic effects 1

Dosing Schedule and Administration

• Standard dosing for perennial rhinitis: 2 sprays (42 μg) per nostril three times daily of the 0.03% concentration 2, 3
• Standard dosing for common cold: 2 sprays (84 μg) per nostril three times daily of the 0.06% concentration 1, 4
• Some research suggests that the duration of action may be longer than indicated by the three-times-daily dosing schedule, with significant effects lasting 12 hours with 40 μg and 18 hours with 80 μg doses 5

Clinical Efficacy

• Ipratropium bromide significantly decreases rhinorrhea in perennial allergic rhinitis, with 70% of patients reporting good or excellent effects on rhinorrhea with the 42 μg dose 2
• It is also effective for rhinorrhea in nonallergic rhinitis, cold-induced rhinitis (e.g., skiers), and gustatory rhinitis (runny nose associated with eating) 1, 6
• The onset of action is rapid, with effects evident from the first day of treatment 3, 6

Combination Therapy

• Concomitant use of ipratropium bromide nasal spray with antihistamines provides increased efficacy over either drug alone without increased adverse events 1, 3
• Combined use of ipratropium bromide nasal spray 0.03% with intranasal corticosteroids is more effective than either drug alone for treating rhinorrhea, without increased adverse events 1, 3
• Combination therapy should be considered in patients where rhinorrhea is one of the predominant symptoms or in patients with rhinorrhea not fully responsive to other therapy 3

Safety Profile

• Most common adverse events are mild transient episodes of epistaxis (9% vs 5% with placebo) and nasal dryness (5% vs 1% with placebo) 1
• Long-term treatment studies show that ipratropium bromide is well-tolerated without serious drug-related adverse events or clinically significant anticholinergic side effects 4
• Controlled clinical trials have demonstrated that ipratropium bromide does not alter physiologic nasal functions such as sense of smell, ciliary beat frequency, mucociliary clearance, or the air conditioning capacity of the nose 1

Special Considerations

• For patients with predominantly rhinorrhea symptoms, ipratropium bromide alone may be sufficient 3, 6
• For patients with multiple rhinitis symptoms, combination therapy with intranasal corticosteroids or antihistamines is recommended 1, 3
• Long-term treatment studies suggest that after initial control, the dose can potentially be reduced to the lowest amount required to control rhinorrhea 4