When is ipratropium bromide contraindicated (e.g., hypersensitivity to anticholinergics, narrow‑angle glaucoma, severe urinary retention or obstructive benign prostatic hyperplasia, gastrointestinal or urinary tract obstruction, infants younger than 2 years)?

Contraindications to Ipratropium Bromide

Ipratropium bromide is absolutely contraindicated in patients with known hypersensitivity to ipratropium, atropine, or atropine derivatives, and should be used with extreme caution—or avoided entirely—in patients with narrow-angle glaucoma, severe urinary retention, obstructive benign prostatic hyperplasia (BPH), and gastrointestinal or urinary tract obstruction. 1

Absolute Contraindication

• Hypersensitivity: The FDA drug label explicitly states that ipratropium is contraindicated in patients with known or suspected hypersensitivity to ipratropium bromide, atropine, or any atropine derivatives. 1

Relative Contraindications and High-Risk Populations Requiring Extreme Caution

Narrow-Angle Glaucoma

• Acute angle-closure glaucoma (AACG) can be precipitated by nebulized ipratropium, particularly when administered via face mask rather than mouthpiece, because the drug can reach the eyes and increase intraocular pressure. 2
• Patients at highest risk include those with shallow anterior chambers, hypermetropia, or pre-existing chronic angle-closure glaucoma. 2
• Risk mitigation: Use a mouthpiece instead of a face mask whenever possible to minimize ocular exposure; ensure proper mask fit if a mask must be used; consider protective eyewear during nebulization. 3, 2

Urinary Retention and Benign Prostatic Hyperplasia

• Elderly men with prostatic hypertrophy are at significant risk for developing acute urinary retention when treated with ipratropium, even though the drug is poorly absorbed systemically. 4, 5
• Case reports document urinary retention resolving promptly after ipratropium discontinuation in elderly men with BPH. 4, 5
• Before initiating therapy in men with LUTS or BPH symptoms, measure postvoid residual volume to rule out baseline retention; if anticholinergic therapy is deemed necessary, use the lowest effective dose and monitor closely. 6
• Large doses should be avoided in elderly males with known or suspected prostatic enlargement. 5

Gastrointestinal and Urinary Tract Obstruction

• Anticholinergic effects can worsen obstructive conditions by reducing smooth muscle motility in the gastrointestinal and urinary tracts.
• Avoid ipratropium in patients with known bowel obstruction, paralytic ileus, or complete urinary tract obstruction.

Infants Younger Than 2 Years

• Safety and efficacy data are limited in very young infants; the FDA-approved intranasal formulations are indicated only for children ≥5 years (0.06%) or ≥6 years (0.03%). 7, 3
• For acute asthma in children under 4 years, ipratropium via MDI must be delivered using a valved holding chamber with face mask, and dosing should be reduced (half-doses of approximately 100–125 mcg for very young children). 3

Clinical Algorithm for Safe Use

1. Screen for hypersensitivity history: Ask specifically about prior reactions to ipratropium, atropine, or related anticholinergics. 1
2. Assess ocular risk: Identify patients with narrow-angle glaucoma, shallow anterior chambers, or hypermetropia; if ipratropium is essential, use a mouthpiece and avoid face masks. 3, 2
3. Evaluate urinary function in elderly men: Measure postvoid residual volume in men with BPH symptoms or LUTS before starting therapy; avoid or use cautiously if retention is present. 4, 6, 5
4. Rule out obstructive conditions: Do not use in patients with known bowel obstruction, paralytic ileus, or complete urinary obstruction.
5. Age-appropriate dosing: Use reduced doses and proper delivery devices (spacer + mask) in children under 4 years; avoid routine use in infants under 2 years unless benefits clearly outweigh risks. 3

Common Pitfalls to Avoid

• Do not assume systemic absorption is negligible: Although ipratropium is a quaternary ammonium compound with poor systemic absorption, clinically significant anticholinergic effects (urinary retention, glaucoma exacerbation) have been documented. 4, 2, 5
• Do not use nebulized ipratropium with a face mask in patients at risk for glaucoma: Always prefer a mouthpiece or T-piece to minimize ocular exposure. 3, 2
• Do not prescribe high doses to elderly men without assessing prostate and bladder function: Even standard doses can precipitate retention in susceptible individuals. 4, 5
• Do not delay alternative therapy in patients with absolute contraindications: If ipratropium is contraindicated, rely on short-acting beta-agonists and corticosteroids for acute exacerbations. 7, 3