New use for ipratropium: Pediatric emergencies

Drug long used to treat adult COPD

An old drug is getting new attention for the treatment of acute asthmatic episodes in children.

The addition of ipratropium to standard drug treatments reduced the overall incidence of hospital admissions in children treated in the emergency room by nearly 9% and the hospitalization of children having severe attacks by 15.1%, according to findings by researchers at the Children’s Hospital of the King’s Daughters at Eastern Virginia Medical School in Norfolk, VA.

In the randomized double-blind placebo- controlled study of 434 children ages 2 to 18, researchers found those who received 2.5 ml of ipratropium bromide added to the second and third does of a nebulized solution of albuterol (2.5 or 5 mg per dose, depending on body weight) were less likely to be hospitalized than those in the control group who received 2.5 ml of normal saline instead of the ipratropium.

All patients also received a corticosteroid (2 mg of prednisone or prednisolone per kilogram of body weight) given orally with the second dose of albuterol.

Doctors found overall, in the ipratropium group, 27.4% of the children were hospitalized, compared with 36.5% in the control group.

For those with moderate asthma (defined as peak expiratory rate of 50% to 70% of the predicted value or a score of 8 to 11 on a 15-point scale), hospitalization rates were similar between the ipratropium group and the control group, at 10.1% and 10.7%, respectively.

However, the results were dramatic in the group of children with severe asthma (defined as peak expiratory flow rate of less than 50% or an asthma score of 12 to 15 on a 15-point scale). Only 37.5% of the ipratropium group required hospitalization compared to 52.6% in the control group.

The use of ipratropium is "not a panacea," says Arno Zaritsky, MD, chairman of the department of pediatrics at the Children’s Hospital of the King’s Daughters and co-author of the study published in The New England Journal of Medicine in October. "It’s just one more thing that we now know to be useful in kids with severe asthma to help get them turned around."

Zaritsky says ipratropium may be particularly helpful because patients on home albuterol sometimes find the drug may in time lose its effectiveness, "So it’s giving you another way of treating that constriction the airways when you’ve lost some of the responsiveness to the albuterol because you’ve been using it frequently at home."

It is also cost-efficient, at approximately $3 a dose. It is sold under the brand name Atrovent but is available in generic form.

Ipratropium has long been available in a metered dose inhaler for adults with chronic obstructive pulmonary disease, but the King’s Daughters study is the first in children. Zaritsky speculates the drug may be even more effective in severe attacks in adults.

Zaritsky says the drug helps relax the airways by working on the parasympathetic nervous system. Unlike atropine, which has been used in similar situations for decades, he says, "Ipra tropium was developed because it acts only on the airways. It is not absorbed. We looked very carefully for side effects and for all intents and purposes, side effects are minor at best."

Some patients reported the drug caused dry mouth, so if it is used on a long-term basis, ipratropium could cause drying of the mucous membranes, Zaritsky says.

"It is not really clear that it is going to be helpful to use on a long-term basis," he adds. "The data is just not out there."