Source:http://www4.wiwiss.fu-berlin.de/dailymed/resource/drugs/340
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Atrovent HFA (Aerosol, Metered)
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Patients should be instructed on the proper use of their inhaler (see Patient's Instructions for Use). Patients should be advised that although Atrovent' HFA (ipratropium bromide HFA) Inhalation Aerosol may have a slightly different taste and inhalation sensation than that of an inhaler containing Atrovent' (ipratropium bromide) Inhalation Aerosol CFC, they are comparable in terms of the safety and efficacy. ATROVENT HFA Inhalation Aerosol is a solution aerosol that does not require shaking. However, as with any other metered dose inhaler, some coordination is required between actuating the canister and inhaling the medication. Patients should "prime" or actuate ATROVENT HFA Inhalation Aerosol before using for the first time by releasing 2 test sprays into the air away from the face. In cases where the inhaler has not been used for more than 3 days, prime the inhaler again by releasing 2 test sprays into the air away from the face. Patients should avoid spraying ATROVENT HFA Inhalation Aerosol into their eyes. The usual starting dose of ATROVENT HFA Inhalation Aerosol is two inhalations four times a day. Patients may take additional inhalations as required; however, the total number of inhalations should not exceed 12 in 24 hours. Each actuation of ATROVENT HFA Inhalation Aerosol delivers 17 mcg of ipratropium bromide from the mouthpiece.
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The active ingredient in ATROVENT HFA Inhalation Aerosol is ipratropium bromide (as the monohydrate). It is an anticholinergic bronchodilator chemically described as 8-azoniabicyclo[3.2.1]octane, 3-(3-hydroxy-1-oxo-2-phenylpropoxy)-8-methyl-8-(1-methylethyl)-, bromide monohydrate, (3-endo, 8-syn)-: a synthetic quaternary ammonium compound, chemically related to atropine. The structural formula for ipratropium bromide is: CHBrNO���HO ipratropium bromide Mol. Wt. 430.4 Ipratropium bromide is a white to off-white crystalline substance, freely soluble in water and methanol, sparingly soluble in ethanol, and insoluble in lipophilic solvents such as ether, chloroform, and fluorocarbons. ATROVENT HFA Inhalation Aerosol is a pressurized metered-dose aerosol unit for oral inhalation that contains a solution of ipratropium bromide. The 200 inhalation unit has a net weight of 12.9 grams. After priming, each actuation of the inhaler delivers 21 mcg of ipratropium bromide from the valve in 56 mg of solution and delivers 17 mcg of ipratropium bromide from the mouthpiece. The actual amount of drug delivered to the lung may depend on patient factors, such as the coordination between the actuation of the device and inspiration through the delivery system. Theexcipients are HFA-134a (1,1,1,2-tetrafluoroethane) as propellant, purified water, dehydrated alcohol, and anhydrous citric acid. This product does not contain chlorofluorocarbons (CFCs) as propellants. Atrovent HFA (ipratropium bromide HFA) Inhalation Aerosol should be primed before using for the first time by releasing 2 test sprays into the air away from the face. In cases where the inhaler has not been used for more than 3 days, prime the inhaler again by releasing 2 test sprays into the air away from the face.
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Mechanism of Action: Ipratropium bromide is an anticholinergic (parasympatholytic) agent which, based on animal studies, 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.<br/>Pharmacodynamic Properties: Controlled clinical studies have demonstrated that Atrovent (ipratropium bromide) Inhalation Aerosol CFC does not alter either mucociliary clearance or the volume or viscosity of respiratory secretions.<br/>Pharmacokinetics and Metabolism: Most of an administered dose is swallowed as shown by fecal excretion studies. Ipratropium bromide is a quaternary amine. It is not readily absorbed into the systemic circulation either from the surface of the lung or from the gastrointestinal tract as confirmed by blood level and renal excretion studies. Autoradiographic studies in rats have shown that ipratropium bromide does not penetrate the blood-brain barrier. The half-life of elimination is about 2 hours after inhalation or intravenous administration. Ipratropium bromide is minimally bound (0 to 9% in vitro) to plasma albumin and��-acid glycoprotein. It is partially metabolized to inactive ester hydrolysis products. Following intravenous administration, approximately one-half of the dose is excreted unchanged in the urine. A pharmacokinetic study with 29 chronic obstructive pulmonary disease (COPD) patients (48-79 years of age) demonstrated that mean peak plasma ipratropium concentrations of 59��20 pg/mL were obtained following a single administration of 4 inhalations of ATROVENT HFA Inhalation Aerosol (84 mcg). Plasma ipratropium concentrations rapidly declined to 24��15 pg/mL by six hours. When these patients were administered 4 inhalations QID (16 inhalations/day=336 mcg) for one week, the mean peak plasma ipratropium concentration increased to 82��39 pg/mL with a trough (6 hour) concentration of 28��12 pg/mL at steady state.<br/>Special Populations:<br/>Geriatric Patients: In the pharmacokinetic study with 29 COPD patients, a subset of 14 patients were>65 years of age. Mean peak plasma ipratropium concentrations of 56��24 pg/mL were obtained following a single administration of 4 inhalations (21 mcg/puff) of Atrovent HFA (ipratropium bromide HFA) Inhalation Aerosol (84 mcg). When these 14 patients were administered 4 inhalations QID (16 inhalations/day) for one week, the mean peak plasma ipratropium concentration only increased to 84��50 pg/mL indicating that the pharmacokinetic behavior of ipratropium bromide in the geriatric population is consistent with younger patients.<br/>Renally Impaired Patients: The pharmacokinetics of ATROVENT HFA Inhalation Aerosol have not been studied in patients with renal insufficiency.<br/>Hepatically Impaired Patients: The pharmacokinetics of ATROVENT HFA Inhalation Aerosol have not been studied in patients with hepatic insufficiency.
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ATROVENT HFA Inhalation Aerosol is contraindicated in patients with a history of hypersensitivity to ipratropium bromide or other ATROVENT HFA Inhalation Aerosol components. ATROVENT HFA Inhalation Aerosol is also contraindicated in patients who are hypersensitive to atropine or its derivatives.
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ATROVENT HFA Inhalation Aerosol is supplied in a 12.9 g pressurized stainless steel canister as a metered-dose inhaler with a white mouthpiece that has a clear, colorless sleeve and a green protective cap (NDC 0597-0087-17). The ATROVENT HFA Inhalation Aerosol canister is to be used only with the accompanying ATROVENT HFA Inhalation Aerosol mouthpiece. This mouthpiece should not be used with other aerosol medications. Similarly, the canister should not be used with other mouthpieces. Each actuation of ATROVENT HFA Inhalation Aerosol delivers 21 mcg of ipratropium bromide from the valve and 17 mcg from the mouthpiece. Each 12.9 gram canister provides sufficient medication for 200 actuations. The canister should be discarded after the labeled number of actuations has been used. The amount of medication in each actuation cannot be assured after this point, even though the canister is not completely empty. Store at 25��C (77��F); excursions permitted to 15��-30��C (59��-86��F) [see USP Controlled Room Temperature]. For optimal results, the canister should be at room temperature before use. Address medical inquiries to: http://us.boehringer-ingelheim.com, (800) 542-6257 or (800) 459-9906 TTY. Patients should be reminded to read and follow the accompanying���Patient's Instructions for Use���, which should be dispensed with the product. Contents Under Pressure: Do not puncture. Do not use or store near heat or open flame. Exposure to temperatures above 120��F may cause bursting. Never throw the inhaler into a fire or incinerator. Warning: Keep out of children's reach. Avoid spraying in eyes. Distributed by:Boehringer Ingelheim Pharmaceuticals, Inc.Ridgefield, CT 06877 USA Licensed from:Boehringer Ingelheim International GmbH ��Copyright Boehringer Ingelheim International GmbH2007, ALL RIGHTS RESERVED Rev: July 2007 IT1902CG050710003001/US/410003001/US/4U.S. Patent No. 6,739,333
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General: ATROVENT HFA Inhalation Aerosol should be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder-neck obstruction.<br/>Information for Patients: Appropriate and safe use of ATROVENT HFA Inhalation Aerosol includes providing the patient with the information listed below and an understanding of the way it should be administered (see Patient's Instructions for Use). Patients should be advised that ATROVENT HFA Inhalation Aerosol is a bronchodilator for the maintenance treatment of bronchospasm associated with COPD and is not indicated for the initial treatment of acute episodes of bronchospasm where rescue therapy is required for rapid response. Patients should be cautioned to avoid spraying the aerosol into their eyes and be advised that this may result in precipitation or worsening of narrow-angle glaucoma, mydriasis, increased intraocular pressure, acute eye pain or discomfort, temporary blurring of vision, visual halos or colored images in association with red eyes from conjunctival and corneal congestion. Patients should also be advised that should any combination of these symptoms develop, they should consult their physician immediately. The action of Atrovent' HFA (ipratropium bromide HFA) Inhalation Aerosol should last 2-4 hours. Patients should be advised not to increase the dose or frequency of ATROVENT HFA Inhalation Aerosol without patients consulting their physician. Patients should also be advised to seek immediate medical attention if treatment with ATROVENT HFA Inhalation Aerosol becomes less effective for symptomatic relief, their symptoms become worse, and/or patients need to use the product more frequently than usual. Patients should be advised on the use of ATROVENT HFA Inhalation Aerosol in relation to other inhaled drugs. Patients should be reminded that ATROVENT HFA Inhalation Aerosol should be used consistently as prescribed throughout the course of therapy. Patients should be advised that although the taste and inhalation sensation of ATROVENT HFA Inhalation Aerosol may be slightly different from that of the CFC (chlorofluorocarbon) formulation of ATROVENT Inhalation Aerosol, they are comparable in terms of safety and efficacy.<br/>Drug Interactions: ATROVENT HFA Inhalation Aerosol has been used concomitantly with other drugs, including sympathomimetic bronchodilators, methylxanthines, oral and inhaled steroids, that may be used in the treatment of chronic obstructive pulmonary disease. With the exception of albuterol, there are no formal studies fully evaluating the interaction effects of ATROVENT and these drugs with respect to effectiveness. Anticholinergic agents: Although ipratropium bromide is minimally absorbed into the systemic circulation, there is some potential for an additive interaction with concomitantly used anticholinergic medications. Caution is therefore advised in the co-administration of ATROVENT HFA Inhalation Aerosol with other anticholinergic-containing drugs.<br/>Carcinogenesis, Mutagenesis, Impairment of Fertility: In two-year oral carcinogenicity studies in rats and mice, ipratropium bromide at oral doses up to 6 mg/kg (approximately 240 and 120 times the maximum recommended daily inhalation dose in adults on a mg/mbasis) showed no carcinogenic activity. Results of various mutagenicity studies (Ames test, mouse dominant lethal test, mouse micronucleus test and chromosome aberration of bone marrow in Chinese hamsters) were negative. Fertility of male or female rats at oral doses up to 50 mg/kg (approximately 2000 times the maximum recommended daily inhalation dose in adults on a mg/mbasis) was unaffected by ipratropium bromide administration. At an oral dose of 500 mg/kg (approximately 20,000 times the maximum recommended daily inhalation dose in adults on a mg/mbasis), ipratropium bromide produced a decrease in the conception rate.<br/>Pregnancy:<br/>Teratogenic Effects:Pregnancy Category B.: Oral reproduction studies were performed at doses of 10 mg/kg/day in mice, 1,000 mg/kg in rats and 125 mg/kg/day in rabbits. These doses correspond in each species, respectively, to approximately 200, 40000, and 10000 times the maximum recommended daily inhalation dose in adults on a mg/mbasis. Inhalation reproduction studies were conducted in rats and rabbits at doses of 1.5 and 1.8 mg/kg (approximately 60 and 140 times the maximum recommended daily inhalation dose in adults on a mg/mbasis). These studies demonstrated no evidence of teratogenic effects as a result of ipratropium bromide. At oral doses 90 mg/kg and above in rats (approximately 3600 times the maximum recommended daily inhalation dose in adults on a mg/mbasis) embryotoxicity was observed as increased resorption. This effect is not considered relevant to human use due to the large doses at which it was observed and the difference in route of administration. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, Atrovent' HFA (ipratropium bromide HFA) Inhalation Aerosol should be used during pregnancy only if clearly needed.<br/>Nursing Mothers: It is not known whether the active component, ipratropium bromide, is excreted in human milk. Although lipid-insoluble quaternary cations pass into breast milk, it is unlikely that ipratropium bromide would reach the infant to an important extent, especially when taken by aerosol. However, because many drugs are excreted in human milk, caution should be exercised when ATROVENT HFA Inhalation Aerosol is administered to a nursing mother.<br/>Pediatric Use: Safety and effectiveness in the pediatric population have not been established.<br/>Geriatric Use: In the pivotal 12-week study, both ATROVENT HFA Inhalation Aerosol and Atrovent (ipratropium bromide) Inhalation Aerosol CFC formulations were equally effective in patients over 65 years of age and under 65 years of age. Of the total number of subjects in clinical studies of ATROVENT HFA Inhalation Aerosol, 57% were���65 years of age. No overall differences in safety or effectiveness were observed between these subjects and younger subjects.
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Acute overdose by inhalation is unlikely since ipratropium bromide is not well absorbed systemically after inhalation or oral administration. Oral median lethal doses of ipratropium bromide were greater than 1000 mg/kg in mice (approximately 20,000 times the maximum recommended daily inhalation dose in adults on a mg/mbasis); 1,700 mg/kg in rats (approximately 68,000 times the maximum recommended daily inhalation dose in adults on a mg/mbasis); and 400 mg/kg in dogs (approximately 53,000 times the maximum recommended daily inhalation dose in adults on a mg/mbasis).
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ipratropium bromide
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Atrovent HFA (Aerosol, Metered)
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The adverse reaction information concerning ATROVENT HFA Inhalation Aerosol is derived from two 12-week, double-blind, parallel group studies and one open-label, parallel group study that compared ATROVENT HFA Inhalation Aerosol, ATROVENT Inhalation Aerosol CFC, and placebo (in one study only) in 1,010 COPD patients. The following table lists the incidence of adverse events that occurred at a rate of greater than or equal to 3% in any ipratropium bromide group. Overall, the incidence and nature of the adverse events reported for ATROVENT HFA Inhalation Aerosol, ATROVENT Inhalation Aerosol CFC, and placebo were comparable. In the one open label controlled study in 456 COPD patients, the overall incidence of adverse events was also similar between Atrovent' HFA (ipratropium bromide HFA) Inhalation Aerosol and Atrovent' (ipratropium bromide) Inhalation Aerosol CFC formulations. Overall, in the above mentioned studies, 9.3% of the patients taking 42 mcg ATROVENT HFA Inhalation Aerosol and 8.7% of the patients taking 42 mcg ATROVENT Inhalation Aerosol CFC reported at least one adverse event that was considered by the investigator to be related to the study drug. The most common drug-related adverse events were dry mouth (1.6% of ATROVENT HFA Inhalation Aerosol and 0.9% of ATROVENT Inhalation Aerosol CFC patients), and taste perversion (bitter taste) (0.9% of ATROVENT HFA Inhalation Aerosol and 0.3% of ATROVENT Inhalation Aerosol CFC patients). As an anticholinergic drug, cases of precipitation or worsening of narrow-angle glaucoma, mydriasis, acute eye pain, hypotension, palpitations, urinary retention, tachycardia, constipation, bronchospasm, including paradoxical bronchospasm have been reported. Allergic-type reactions such as skin rash, pruritus, angioedema of tongue, lips and face, urticaria (including giant urticaria), laryngospasm and anaphylactic reactions have been reported .<br/>Post-Marketing Experience: In a 5-year placebo-controlled trial, hospitalizations for supraventricular tachycardia and/or atrial fibrillation occurred with an incidence rate of 0.5% in COPD patients receiving ATROVENT Inhalation Aerosol CFC. Allergic-type reactions such as skin rash, angioedema of tongue, lips and face, urticaria (including giant urticaria), laryngospasm and anaphylactic reactions have been reported, with positive rechallenge in some cases. Many of the patients had a history of allergies to other drugs and/or foods, including soybean. Additionally, urinary retention, mydriasis, gastrointestinal distress (diarrhea, nausea, vomiting), and bronchospasm, including paradoxical bronchospasm, have been reported during the post-marketing period with use of ATROVENT Inhalation Aerosol CFC.
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ATROVENT HFA Inhalation Aerosol is a bronchodilator for the maintenance treatment of bronchospasm associated with COPD and is not indicated for the initial treatment of acute episodes of bronchospasm where rescue therapy is required for rapid response. Immediate hypersensitivity reactions may occur after administration of ipratropium bromide, as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm, anaphylaxis, and oropharyngeal edema. Inhaled medicines, including ATROVENT HFA Inhalation Aerosol, may cause paradoxical bronchospasm. If this occurs, treatment with ATROVENT HFA Inhalation Aerosol should be stopped and other treatments considered.
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ATROVENT HFA Inhalation Aerosol is indicated as a bronchodilator for maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease, including chronic bronchitis and emphysema.
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Atrovent HFA
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