Asthma, acute moderate to severe exacerbations (management in primary or acute care settings) (off-label use):
Soft-mist inhaler (ipratropium bromide 20 mcg/albuterol 100 mcg per actuation): Oral inhalation: 4 to 8 inhalations every 20 minutes for 3 doses, then as needed (Ref).
Nebulization solution (ipratropium bromide 0.5 mg/albuterol 2.5 mg per 3 mL vial): Oral inhalation: 1 vial (3 mL) every 20 minutes for 3 doses, then as needed (Ref).
Chronic obstructive pulmonary disease:
Acute exacerbation: Note: Although similar efficacy exists among formulations, some experts prefer nebulized therapy during severe chronic obstructive pulmonary disease (COPD) exacerbations (Ref).
Nebulization solution (ipratropium bromide 0.5 mg/albuterol 2.5 mg per 3 mL vial): Oral inhalation: 1 vial every 1 hour (up to 3 doses), then every 2 to 4 hours as needed (Ref).
Soft-mist inhaler (ipratropium bromide 20 mcg/albuterol 100 mcg per actuation): Oral inhalation:
For patients at home or office management: 1 inhalation every 4 to 6 hours as needed (Ref).
For patients requiring emergency department or hospital-based care: 1 inhalation every 1 hour (up to 3 doses), then every 2 to 4 hours as needed (Ref).
Intermittent symptom relief: Note: Use for intermittent symptoms on an as-needed basis rather than regularly scheduled maintenance therapy (Ref).
Soft-mist inhaler (ipratropium bromide 20 mcg/albuterol 100 mcg per actuation): Oral inhalation: 1 inhalation every 4 to 6 hours as needed (maximum: 6 inhalations/day) (Ref).
Nebulization solution (ipratropium bromide 0.5 mg/albuterol 2.5 mg per 3 mL vial): Oral inhalation: 1 vial every 4 to 6 hours as needed (maximum: 6 vials/day) (Ref).
Maintenance: Depending on symptoms and exacerbation risk, preferred therapy is a single long-acting bronchodilator (long-acting beta agonist or long-acting muscarinic antagonist). In patients with more symptoms (eg, group B), preferred therapy is dual long-acting bronchodilator therapy (Ref).
Soft-mist inhaler (ipratropium bromide 20 mcg/albuterol 100 mcg per actuation): Oral inhalation: 1 inhalation 4 times daily; may take up to 2 additional inhalations per day as needed (maximum dose: 6 inhalations/day).
Nebulization solution (ipratropium bromide 0.5 mg/albuterol 2.5 mg per 3 mL vial): Oral inhalation: Initial: 1 vial 4 times daily; may administer up to 2 additional vials per day as needed (maximum dose: 6 vials/day).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Refer to adult dosing.
(For additional information see "Ipratropium and albuterol: Pediatric drug information")
Asthma, acute exacerbation: Limited data available: Note: Only indicated for severe exacerbations during initial management in an acute care setting (eg, emergency department). Ipratropium has not been shown to provide further benefit (eg, after first 24 hours) once the patient is hospitalized (Ref):
Infants and Children: Nebulization solution (ipratropium bromide 0.5 mg/albuterol 2.5 mg): Oral inhalation: 1.5 to 3 mL every 20 minutes for 3 doses, then as needed for up to 3 hours.
Adolescents: Nebulization solution (ipratropium bromide 0.5 mg/albuterol 2.5 mg): Oral inhalation: 3 mL every 20 minutes for 3 doses, then as needed for up to 3 hours.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied). Use with caution.
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied). Use with caution.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Also see individual agents.
1% to 10%:
Cardiovascular: Angina pectoris (<2%), cardiac arrhythmia (<2%), chest discomfort (<2%), edema (<2%), hypertension (<2%), palpitations (<2%), tachycardia (<2%)
Central nervous system: Headache (3%), pain (≥2%), dizziness (<2%), fatigue (<2%), insomnia (<2%), nervousness (<2%), voice disorder (<2%)
Dermatologic: Pruritus (<2%), skin rash (<2%)
Endocrine & metabolic: Hypokalemia (<2%)
Gastrointestinal: Constipation (<2%), diarrhea (<2%), dysgeusia (<2%), dyspepsia (<2%), vomiting (<2%), xerostomia (<2%)
Genitourinary: Dysuria (<2%), urinary tract infection (<2%)
Neuromuscular & skeletal: Arthralgia (<2%), asthenia (<2%), muscle spasm (<2%), myalgia (<2%), tremor (<2%)
Ophthalmic: Eye pain (<2%)
Respiratory: Cough (3% to 7%), nasopharyngitis (4%), bronchitis (3%), upper respiratory tract infection (3%), pharyngitis (≥2%), respiratory insufficiency (≥2%), sinusitis (≥2%), dyspnea (2%), bronchospasm (<2%), dry throat (<2%), flu-like symptoms (<2%), increased bronchial secretions (<2%), pharyngolaryngeal pain (<2%), wheezing (<2%)
Frequency not defined: Gastrointestinal: Nausea
<1%, postmarketing, and/or case reports: Accommodation disturbance, anaphylaxis, angioedema, blurred vision, central nervous system stimulation, conjunctival hyperemia, corneal edema, decreased diastolic blood pressure, dry secretions, eye irritation, gastrointestinal motility disorder, glaucoma, hyperhidrosis, hypersensitivity reaction, increased systolic blood pressure, ischemic heart disease, mouth edema, myasthenia, mydriasis, nasal congestion, paradoxical bronchospasm, pharyngeal edema, psychiatric disturbance, stomatitis, throat irritation, urinary retention, visual halos around lights
Hypersensitivity to ipratropium, albuterol, atropine (and its derivatives) or any component of the formulation
Canadian labeling: Additional contraindications (not in US labeling): Cardiac tachyarrhythmias, hypertrophic obstructive cardiomyopathy
Concerns related to adverse effects:
• Bronchospasm: Paradoxical bronchospasm that may be life-threatening may occur with use of inhaled bronchodilating agents; this should be distinguished from inadequate response. If bronchospasm occurs, discontinue ipratropium/albuterol and institute alternative therapy.
• CNS effects: May cause dizziness and blurred vision; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving).
• Hypersensitivity reactions: Hypersensitivity reactions (urticaria, angioedema, rash, bronchospasm, oropharyngeal edema), including anaphylaxis have been reported; discontinue therapy immediately if patient develops an allergic reaction.
• Serious effects/fatalities: Do not exceed recommended dose (including doses from other combined inhaled sympathomimetics [eg, short- and/or long-acting beta-agonists]); serious adverse events, including fatalities, have been associated with excessive use of inhaled sympathomimetics.
• Sympathomimetic amines sensitivity: Use albuterol with caution in patients with sensitivity to sympathomimetic amines.
Disease-related concerns:
• Cardiovascular disease: Use albuterol with caution in patients with cardiovascular disease (arrhythmia, coronary insufficiency, hypertension, HF); beta-agonists have been reported to produce ECG changes (flattening of the T wave, prolongation of the QTc interval, ST segment depression) and/or cause elevation in blood pressure, heart rate and result in CNS stimulation/excitation. Beta2-agonists may also increase risk of arrhythmias and myocardial ischemia. In a scientific statement from the American Heart Association, albuterol has been determined to be an agent that may either cause direct myocardial toxicity or exacerbate underlying myocardial dysfunction (magnitude: moderate to major) (AHA [Page 2016]).
• Diabetes: Use albuterol with caution in patients with diabetes mellitus; beta2-agonists may increase serum glucose and aggravate preexisting diabetes and ketoacidosis (effect is usually transient).
• Glaucoma: Use ipratropium with caution in patients with narrow-angle glaucoma; may increase intraocular pressure.
• Hyperthyroidism: Use albuterol with caution in hyperthyroidism; may stimulate thyroid activity.
• Hypokalemia: Use albuterol with caution in patients with hypokalemia; beta2-agonists may decrease serum potassium (effect is usually transient).
• Prostatic hyperplasia/bladder neck obstruction: Use ipratropium with caution in patients with prostatic hyperplasia or bladder neck obstruction; ipratropium may cause urinary retention.
• Seizure disorder: Use albuterol with caution in patients with seizure disorders; beta-agonists may result in CNS stimulation/excitation.
Combivent Respimat 4 g cartridges contain 120 actuations.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, for nebulization:
Generic: Ipratropium bromide 0.5 mg and albuterol (base) 2.5 mg per 3 mL (30s, 60s)
Solution, for oral inhalation [spray]:
Combivent Respimat: Ipratropium bromide 20 mcg and albuterol (base) 100 mcg per inhalation (4 g) [contains benzalkonium chloride]
Yes: Solution for nebulization
Aerosol solution (Combivent Respimat Inhalation)
20-100 mcg/ACT (per gram): $146.80
Solution (Ipratropium-Albuterol Inhalation)
0.5-2.5 (3) mg/3 mL (per mL): $0.26 - $1.67
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, for nebulization: Ipratropium bromide 0.5 mg and albuterol (base) 2.5 mg per 2.5 mL
Inhalation: For oral inhalation; avoid spraying in eyes.
Nebulization solution: Remove unit-dose vial from foil pouch and squeeze contents into nebulizer reservoir; connect nebulizer to air compressor with a mouthpiece or face mask. Breathe deeply and evenly until all medication has been inhaled; inhalation time is about 5 to 15 minutes. Clean nebulizer after use.
Soft-mist inhaler: Prior to first use insert cartridge into inhaler; prime inhaler (or if not used in >21 days) by pointing towards the ground and actuate until aerosol cloud is seen, then repeat 3 additional times before use. If not used for >3 days; actuate once before use. Clean the mouthpiece (including the metal part inside the mouthpiece) at least once a week with a damp cloth or tissue only.
Oral inhalation: Nebulization solution: Administer via jet nebulizer to an air compressor with an adequate air flow, equipped with a mouthpiece or face mask.
Chronic obstructive pulmonary disease: Treatment of chronic obstructive pulmonary disease (COPD) in those patients who are currently on a regular bronchodilator who continue to have bronchospasms and require a second bronchodilator
Asthma, acute moderate to severe exacerbations (management in primary or acute care settings)
DuoNeb may be confused with DuoTrav, Duovent UDV
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Agents with Clinically Relevant Anticholinergic Effects: Ipratropium (Oral Inhalation) may enhance the anticholinergic effect of Agents with Clinically Relevant Anticholinergic Effects. Risk X: Avoid combination
Atomoxetine: May enhance the tachycardic effect of Beta2-Agonists. Risk C: Monitor therapy
Atomoxetine: May enhance the hypertensive effect of Sympathomimetics. Atomoxetine may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Atosiban: Beta2-Agonists may enhance the adverse/toxic effect of Atosiban. Specifically, there may be an increased risk for pulmonary edema and/or dyspnea. Risk C: Monitor therapy
Beta2-Agonists (Short-Acting): May enhance the adverse/toxic effect of other Beta2-Agonists (Short-Acting). Management: Avoid coadministration of more than one short-acting beta2-agonist whenever possible. If combined, use cautiously, and monitor for increased toxicities, particularly cardiovascular effects (eg, tachycardia, arrhythmias). Risk D: Consider therapy modification
Beta-Blockers (Beta1 Selective): May diminish the bronchodilatory effect of Beta2-Agonists. Of particular concern with nonselective beta-blockers or higher doses of the beta1 selective beta-blockers. Risk C: Monitor therapy
Beta-Blockers (Nonselective): May diminish the bronchodilatory effect of Beta2-Agonists. Risk X: Avoid combination
Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Cocaine (Topical): May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Risk D: Consider therapy modification
Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Risk C: Monitor therapy
Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy
Haloperidol: QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of Haloperidol. Risk C: Monitor therapy
Inhaled Anticholinergic Agents: May enhance the anticholinergic effect of other Inhaled Anticholinergic Agents. Risk C: Monitor therapy
Kratom: May enhance the adverse/toxic effect of Sympathomimetics. Risk X: Avoid combination
Levothyroxine: May enhance the adverse/toxic effect of Sympathomimetics. Specifically, the risk of coronary insufficiency may be increased in patients with coronary artery disease. Levothyroxine may enhance the therapeutic effect of Sympathomimetics. Sympathomimetics may enhance the therapeutic effect of Levothyroxine. Risk C: Monitor therapy
Linezolid: May enhance the hypertensive effect of Sympathomimetics. Management: Consider initial dose reductions of sympathomimetic agents, and closely monitor for enhanced blood pressure elevations, in patients receiving linezolid. Risk D: Consider therapy modification
Loop Diuretics: Beta2-Agonists may enhance the hypokalemic effect of Loop Diuretics. Risk C: Monitor therapy
Loxapine: Agents to Treat Airway Disease may enhance the adverse/toxic effect of Loxapine. More specifically, the use of Agents to Treat Airway Disease is likely a marker of patients who are likely at a greater risk for experiencing significant bronchospasm from use of inhaled loxapine. Management: This is specific to the Adasuve brand of loxapine, which is an inhaled formulation. This does not apply to non-inhaled formulations of loxapine. Risk X: Avoid combination
Methacholine: Ipratropium (Oral Inhalation) may diminish the therapeutic effect of Methacholine. Management: Hold ipratropium for 12 hours before methacholine use. Risk D: Consider therapy modification
Monoamine Oxidase Inhibitors: May enhance the adverse/toxic effect of Beta2-Agonists. Risk C: Monitor therapy
Ozanimod: May enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy
QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy
Solriamfetol: Sympathomimetics may enhance the hypertensive effect of Solriamfetol. Sympathomimetics may enhance the tachycardic effect of Solriamfetol. Risk C: Monitor therapy
Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Risk C: Monitor therapy
Tedizolid: May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Theophylline Derivatives: Beta2-Agonists may enhance the adverse/toxic effect of Theophylline Derivatives. Specifically, sympathomimetic effects may be increased. Theophylline Derivatives may enhance the hypokalemic effect of Beta2-Agonists. Risk C: Monitor therapy
Thiazide and Thiazide-Like Diuretics: Beta2-Agonists may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor therapy
Refer to individual monographs.
It is not known if ipratropium or albuterol are present in breast milk.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother. Refer to individual monographs.
FEV1, peak flow, and/or other pulmonary function tests; blood pressure, heart rate; CNS stimulation; serum glucose, serum potassium; signs/symptoms of glaucoma; hypersensitivity reactions; urinary retention; shortness of breath
See individual agents.
See individual agents.
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