What is the recommended dosing and administration of ipratropium bromide (Ipratropium) nasal spray for allergic or non‑allergic rhinitis in adults, adolescents (≥12 years) and children (6‑11 years)?

Ipratropium Nasal Spray Dosing

For allergic or non-allergic rhinitis in adults and adolescents ≥12 years, use ipratropium bromide 0.03% nasal spray, 2 sprays (42 mcg) per nostril three times daily; for children 6-11 years, use the same dose (2 sprays per nostril three times daily). 1

Concentration Selection by Indication

• Use 0.03% concentration for perennial allergic rhinitis and nonallergic rhinitis in patients ≥6 years of age 1
• Use 0.06% concentration only for common cold-associated rhinorrhea (not for chronic rhinitis), dosed as 2 sprays (84 mcg) per nostril 3-4 times daily 2
• The 0.06% formulation is approved for common cold in patients ≥5 years but should not be used beyond 4 days for this indication 2

Standard Dosing Regimen for Rhinitis

Adults and Adolescents (≥12 years)

• Ipratropium bromide 0.03%: 2 sprays (42 mcg) per nostril three times daily 1, 3
• Total daily dose: 252 mcg/day 3
• This regimen is effective for controlling rhinorrhea in both allergic and nonallergic rhinitis 1

Children (6-11 years)

• Ipratropium bromide 0.03%: 2 sprays (42 mcg) per nostril twice daily for initial therapy 3
• For perennial allergic rhinitis, children may benefit from three times daily dosing if twice daily is insufficient 3
• The twice-daily regimen is particularly effective in nonallergic rhinitis, while allergic rhinitis may require more frequent administration 3

Administration Technique

• Prime the pump with 7 sprays before first use 2
• If not used for >24 hours, reprime with 2 sprays 2
• If not used for >7 days, reprime with 7 sprays 2
• Avoid spraying into eyes to prevent anticholinergic ocular effects 2

Duration of Therapy

• Long-term use (up to 1 year) is safe and effective for perennial rhinitis 4
• After 6 months, the dose can be reduced to the lowest amount required to control rhinorrhea 4
• For seasonal allergic rhinitis with 0.06% formulation, safety beyond 3 weeks has not been established 2

Clinical Efficacy Considerations

• Onset of action is rapid, typically within the first day of treatment 5
• Maximum effect lasts at least 4 hours, with significant effect demonstrable for 12 hours with standard dosing 6
• Ipratropium specifically targets rhinorrhea and has no effect on nasal congestion 1
• It does not improve sneezing; antihistamines are more appropriate for this symptom 1

Combination Therapy for Enhanced Control

• Combining ipratropium 0.03% with intranasal corticosteroids is more effective than either agent alone for rhinorrhea without increased adverse events 1, 5
• The combination shows benefit from the first day and continues throughout treatment 5
• Ipratropium has faster onset during the first week, while corticosteroids better control congestion and sneezing 5
• Consider combination therapy when rhinorrhea is a predominant symptom or when patients don't fully respond to corticosteroids alone 5

Common Pitfalls to Avoid

• Do not use ipratropium as monotherapy if congestion is a primary complaint, as it will not address this symptom 1
• Do not confuse the 0.03% concentration (for chronic rhinitis) with the 0.06% concentration (for common cold only) 1, 2
• In patients with prior poor response to nasal steroids, ipratropium remains equally effective, making it a valuable option in steroid non-responders 5
• Monitor for mild epistaxis (9% vs 5% placebo) and nasal dryness (5% vs 1% placebo), though these are typically self-limiting 1, 7

Dose Adjustment Strategy

• Start with three times daily dosing for most patients 1, 3
• After 6 months of successful treatment, consider reducing to the minimum effective dose 4
• Some patients with nonallergic rhinitis may achieve adequate control with twice-daily dosing 3, 6
• As-needed dosing after a morning dose may be appropriate given the 12-hour duration of effect 6