Atrovent Nasal Spray

Name: Atrovent Nasal Spray

Side effects

Adverse reaction information on ATROVENT Nasal Spray 0.06% in patients with the common cold was derived from two multicenter, vehicle-controlled clinical trials involving 1,276 patients (195 patients on ATROVENT Nasal Spray 0.03%, 352 patients on ATROVENT Nasal Spray 0.06%, 189 patients on ATROVENT Nasal Spray 0.12%, 351 patients on vehicle and 189 patients receiving no treatment).

Table 1 shows adverse events reported for patients who received ATROVENT Nasal Spray 0.06% at the recommended dose of 84 mcg per nostril, or vehicle, administered three or four times daily, where the incidence is 1% or greater in the ATROVENT group and higher in the ATROVENT group than in the vehicle group.

Table 1 % of Patients with Common Cold Reporting Events1

  Atrovent® (ipratropium bromide) Nasal Spray 0.06% Vehicle Control
No. of Patients 352 351
Epistaxis2 8.2% 2.3%
Nasal Dryness 4.8% 2.8%
Dry Mouth/Throat 1.4% 0.3%
Nasal Congestion 1.1% 0.0%
1 This table includes adverse events for which the incidence was 1% or greater in the ATROVENT group and higher in the ATROVENT group than in the vehicle group.
2 Epistaxis reported by 5.4% of ATROVENT patients and 1.4% of vehicle patients, blood-tinged nasal mucus by 2.8% of ATROVENT patients and 0.9% of vehicle patients.

ATROVENT Nasal Spray 0.06% was well tolerated by most patients. The most frequently reported adverse events were transient episodes of nasal dryness or epistaxis. The majority of these adverse events (96%) were mild or moderate in nature, none was considered serious, and none resulted in hospitalization. No patient required treatment for nasal dryness, and only three patients (<1%) required treatment for epistaxis, which consisted of local application of pressure or a moisturizing agent (e.g., petroleum jelly). No patient receiving ATROVENT

Nasal Spray 0.06% was discontinued from the trial due to either nasal dryness or bleeding. Adverse events reported by less than 1% of the patients receiving ATROVENT Nasal Spray 0.06% during the controlled clinical trials that are potentially related to ATROVENT's local effects or systemic anticholinergic effects include: taste perversion, nasal burning, conjunctivitis, coughing, dizziness, hoarseness, palpitation, pharyngitis, tachycardia, thirst, tinnitus, and blurred vision. No controlled trial was conducted to address the relative incidence of adverse events for three times daily versus four times daily therapy.

Nasal adverse events seen in the clinical trial with seasonal allergic rhinitis (SAR) patients (see Table 2) were similar to those seen in the common cold trials. Additional events were reported at a higher rate in the SAR trial due in part to the longer duration of the trial and the inclusion of Upper Respiratory Tract Infection (URI) as an adverse event. In common cold trials, URI was the disease under study and not an adverse event.

Table 2 % of Patients with SAR Reporting Events1

  Atrovent® (ipratropium bromide) Nasal Spray 0.06% Vehicle Control
No. of Patients 218 211
Epistaxis2 6.0% 3.3%
Pharyngitis 5.0% 3.8%
URI 5.0% 3.3%
Nasal Dryness 4.6% 0.9%
Headache 4.1% 0.5%
Dry Mouth/Throat 4.1% 0.0%
Taste Perversion 3.7% 1.4%
Sinusitis 2.8% 2.8%
Pain 1.8% 0.9%
Diarrhea 1.8% 0.5%
1 This table includes adverse events for which the incidence was 1% or greater in the ATROVENT group and higher in the ATROVENT group than in the vehicle group.
2 Epistaxis reported by 3.7% of ATROVENT patients and 2.4% of vehicle patients, blood-tinged nasal mucus by 2.3% of ATROVENT patients and 1.9% of vehicle patients.

There were no reports of allergic-type reactions in the controlled clinical common cold and SAR trials.

Post-Marketing Experience

Allergic-type reactions such as skin rash, angioedema, including that of the throat, tongue, lips and face, generalized urticaria (including giant urticaria), laryngospasm, and anaphylactic reactions have been reported with ATROVENT Nasal Spray 0.06% and for other ipratropium bromide-containing products, with positive rechallenge in some cases.

Additional side effects identified from the published literature and/or post-marketing surveillance on the use of ipratropium bromide-containing products (singly or in combination with albuterol), include: urinary retention, prostatic disorders, mydriasis, cases of precipitation or worsening of narrow-angle glaucoma, acute eye pain, ocular irritation, wheezing, dryness of the oropharynx, tachycardia, edema, gastrointestinal distress (diarrhea, nausea, vomiting), bowel obstruction, constipation, nasal discomfort, throat irritation, hypersensitivity, accommodation disorder, intraocular pressure increased, glaucoma, halo vision, conjunctival hyperaemia, corneal edema, heart rate increased, bronchospasm, pharyngeal edema, gastrointestinal motility disorder, mouth edema, stomatitis, and pruritus.

After oral inhalation of ipratropium bromide in patients suffering from COPD/Asthma supraventricular tachycardia and atrial fibrillation have been reported.

Clinical Trials

The clinical trials for Atrovent® (ipratropium bromide) Nasal Spray 0.03% were conducted in patients with nonallergic perennial rhinitis (NAPR) and in patients with allergic perennial rhinitis (APR). APR patients were those who experienced symptoms of nasal hypersecretion and nasal congestion or sneezing when exposed to specific perennial allergens (e.g., dust mites, molds) and were skin test positive to these allergens. NAPR patients were those who experienced symptoms of nasal hypersecretion and nasal congestion or sneezing throughout the year, but were skin test negative to common perennial allergens.

In four controlled, four- and eight-week comparisons of Atrovent Nasal Spray 0.03% (42 mcg per nostril, two or three times daily) with its vehicle, in patients with allergic or nonallergic perennial rhinitis, there was a statistically significant decrease in the severity and duration of rhinorrhea in the ATROVENT group throughout the entire study period. An effect was seen as early as the first day of therapy.

There was no effect of ATROVENT Nasal Spray 0.03% on degree of nasal congestion, sneezing, or postnasal drip. The response to Atrovent Nasal Spray 0.03% did not appear to be affected by the type of perennial rhinitis (NAPR or APR), age, or gender. No controlled clinical trials directly compared the efficacy of BID versus TID treatment.

Warnings

Immediate hypersensitivity reactions may occur after administration of ipratropium bromide, as demonstrated by urticaria, angioedema, rash, bronchospasm, anaphylaxis, and oropharyngeal edema. If such a reaction occurs, therapy with Atrovent Nasal Spray 0.03% should be stopped at once and alternative treatment should be considered.

Precautions

General

1. Effects Seen with Anticholinergic Drugs: Atrovent Nasal Spray 0.03% should be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia, or bladder neck obstruction, particularly if they are receiving an anticholinergic by another route. 2. Use in Hepatic or Renal Disease: Atrovent Nasal Spray 0.03% has not been studied in patients with hepatic or renal insufficiency. It should be used with caution in those patient populations.

Information for Patients

Patients should be advised that temporary blurring of vision, precipitation or worsening of narrow-angle glaucoma, mydriasis, increased intraocular pressure, acute eye pain or discomfort, visual halos or colored images in association with red eyes from conjunctival and corneal congestion may result if Atrovent Nasal Spray 0.03% comes into direct contact with the eyes. Patients should be instructed to avoid spraying Atrovent Nasal Spray 0.03% in or around their eyes. Patients who experience eye pain, blurred vision, excessive nasal dryness, or episodes of nasal bleeding should be instructed to contact their doctor. To ensure proper dosing, patients should be advised not to alter the size of the nasal spray opening. Patients should be reminded to carefully read and follow the accompanying Patient's Instructions for Use.

Since dizziness, accommodation disorder, mydriasis, and blurred vision may occur with use of ATROVENT, patients should be cautioned about engaging in activities requiring balance and visual acuity such as driving a car or operating appliances, machinery, etc.

Drug Interactions

No controlled clinical trials were conducted to investigate potential drug-drug interactions. There is potential for an additive interaction with other concomitantly administered medications with anticholinergic properties, including ATROVENT for oral inhalation.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Two-year oral carcinogenicity studies in rats and mice have revealed no carcinogenic activity at doses up to 6 mg/kg. This dose corresponds in rats and mice to approximately 190 and 95 times the maximum recommended daily intranasal dose in adults, respectively, and approximately 110 and 55 times the maximum recommended daily intranasal dose in children, respectively, on a mg/m2 basis. 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 1,600 times the maximum recommended daily intranasal dose in adults on a mg/m2 basis) was unaffected by ipratropium bromide administration. At an oral dose of 500 mg/kg (approximately 16,000 times the maximum recommended daily intranasal dose in adults on a mg/m2 basis), ipratropium bromide produced a decrease in the conception rate.

Pregnancy

Teratogenic Effects: Pregnancy Category B.

There are no adequate and well-controlled studies for ATROVENT in pregnant women. Because animal reproduction studies are not always predictive of human response, Atrovent Nasal Spray 0.03% should be used during pregnancy only if clearly needed.

Oral reproduction studies were performed at ipratropium doses of 10 mg/kg in mice, 1,000 mg/kg in rats and 125 mg/kg in rabbits. These doses correspond, in each species, respectively, to approximately 160, 32,000, and 8,000 times the maximum recommended daily intranasal dose (MRDID) in adults on a mg/m2 basis. Inhalation reproduction studies were conducted in rats and rabbits at doses of 1.5 and 1.8 mg/kg, respectively, (approximately 50 and 120 times, respectively, the MRDID in adults on a mg/m2 basis). 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 2,900 times the MRDID in adults on a mg/m2 basis) 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.

Labor and Delivery

The effect of ipratropium bromide on labor and delivery is unknown.

Nursing Mothers

It is known that some ipratropium bromide is systemically absorbed following nasal administration; however the portion which may be excreted in human milk is unknown. Because lipid-insoluble quaternary cations pass into breast milk, caution should be exercised when Atrovent Nasal Spray 0.03% is administered to a nursing mother.

Pediatric Use

The safety of Atrovent® (ipratropium bromide) Nasal Spray 0.03% at a dose of two sprays (42 mcg) per nostril two or three times daily (total dose 168 to 252 mcg/day) has been demonstrated in 77 pediatric patients 6-12 years of age in placebo-controlled, 4-week trials and in 55 pediatric patients in active-controlled, 6 month trials. The effectiveness of Atrovent Nasal Spray 0.03% for the treatment of rhinorrhea associated with allergic and nonallergic perennial rhinitis in this pediatric age group is based on an extrapolation of the demonstrated efficacy of Atrovent Nasal Spray 0.03% in adults with these conditions and the likelihood that the disease course, pathophysiology, and the drug's effects are substantially similar to that of the adults. The recommended dose for the pediatric population is based on within and cross-study comparisons of the efficacy of ATROVENT Nasal Spray 0.03% in adults and pediatric patients and on its safety profile in both adults and pediatric patients. The safety and effectiveness of Atrovent Nasal Spray 0.03% in patients under 6 years of age have not been established.

Overdosage

Acute overdosage by intranasal administration is unlikely since ipratropium bromide is not well absorbed systemically after intranasal or oral administration. Following administration of a 20 mg oral dose (equivalent to ingesting more than four bottles of Atrovent Nasal Spray 0.03%) to 10 male volunteers, no change in heart rate or blood pressure was noted. Following a 2 mg intravenous infusion over 15 minutes to the same 10 male volunteers, plasma ipratropium concentrations of 22-45 ng/mL were observed (>100 times the concentrations observed following intranasal administration). Following intravenous infusion these 10 volunteers had a mean increase of heart rate of 50 bpm and less than 20 mmHg change in systolic or diastolic blood pressure at the time of peak ipratropium levels.

How is Atrovent Nasal Spray Supplied

Atrovent® (ipratropium bromide) Nasal Spray 0.03% is supplied in a white high density polyethylene (HDPE) bottle fitted with a metered nasal spray pump, a green safety clip to prevent accidental discharge of the spray, and a clear plastic dust cap. It contains 31.1 g of product formulation, 345 sprays, each delivering 21 mcg of ipratropium bromide per spray (70 μL), or 28 days of therapy at the maximum recommended dose (two sprays per nostril three times a day) (NDC 0597-0081-30).

Store tightly closed at 25°C (77°F); excursions permitted to 15°-30°C (59°-86°F) [see USP Controlled Room Temperature]. Avoid freezing. Keep out of reach of children. Do not spray in the eyes.

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.

Distributed by:
Boehringer Ingelheim Pharmaceuticals, Inc.
Ridgefield, CT 06877 USA

Licensed from:
Boehringer Ingelheim International GmbH

Copyright 2011 Boehringer Ingelheim International GmbH
ALL RIGHTS RESERVED

Revised: February 2011

IT4000EB112011
10001900/07

What is ipratropium nasal (atrovent nasal)?

Ipratropium nasal is used to treat runny nose caused by seasonal allergies (hay fever). This medication will not treat stuffy nose, sneezing, or cough.

Ipratropium nasal may also be used for other purposes not listed in this medication guide.

What should i avoid while using ipratropium nasal (atrovent nasal)?

Do not use other nasal sprays, nasal gels, or nasal inhalers unless approved by your doctor.

Avoid getting ipratropium nasal in your eyes. If this happens, rinse with water.

Where can i get more information?

Your pharmacist can provide more information about ipratropium nasal.

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

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