- Brand Name: Combimist L Inhaler
- Generic Name: Ipratropium / Levosalbutamol
- Preparations: Inhalers: 20 Mcg / 50 Mcg
- Available: Generic for Ipratropium / Levosalbutamol
Combimist L Inhaler is a combination medication with a strong bronchodilator effect due to the action of ipratropium and levosalbutamol, which are part of the drug.
Ipratropium bromide is an anticholinergic agent. It blocks m-cholinergic receptors of the smooth muscles of the tracheobronchial tree (mainly large and medium bronchi), suppresses reflex bronchoconstriction, reduces the secretion of the glands of the mucous membrane of the respiratory tract. It has a structural similarity to the acetylcholine molecule. It is its competitive antagonist. Ipratropium bromide effectively prevents bronchial constriction resulting from the inhalation of cigarette smoke, cold air, the action of various bronchospasm agents, and also eliminates bronchospasm associated with the influence of the vagus nerve.
Levosalbutamol is a beta2-agonist that acts on the smooth muscles of the respiratory tract, causing it to relax and prevent bronchospasm. It reduces airway resistance, increases lung capacity. It prevents the release of histamine, leukotrienes, prostaglandin D2 and other biologically active substances from mast cells. In the recommended therapeutic doses, levosalbutamol does not adversely affect the cardiovascular system, does not cause an increase in blood pressure.
Joint inhalation of ipratropium bromide and levosalbutamol has a simultaneous local effect on the m-cholinergic receptors and β2-adrenergic receptors of the lungs, as a result of which the bronchodilator effect is enhanced. Systemic absorption with joint inhalation of ipratropium bromide and levosalbutamol does not increase.
Indications for use
- Bronchospastic syndrome in patients with COPD and bronchial asthma.
The dosage, duration of treatment and frequency of use is delected individually, depending on the indications, age, dosage form used.
- Nervous system: headache; dizziness, excessive fatigue, tremor, paresthesia, insomnia, nervousness; motor coordination disorders, mental disorders and psychotic reactions such as dysphoria, memory impairment, fear, depression.
- Cardiovascular system: palpitations, tachycardia; increased systolic blood pressure, arrhythmia; decrease in systolic blood pressure.
- Digestive system: dry mouth, nausea; vomiting, taste perversion, diarrhea.
- Respiratory system: cough, dysphonia; nasal congestion, stridor, paradoxical bronchospasm, shortness of breath.
- Senses: (if the drug gets into the eyes) increase in intraocular pressure, acute pain in the eye, impaired visual acuity, mydriasis, injection of the sclera, conjunctival hyperemia, angle-closure glaucoma.
- Musculoskeletal system: tremor; myalgia, muscle cramps, muscle weakness, arthralgia.
- Urinary system: urinary retention, dysuria.
- Metabolism: hypokalemia, hyperglycemia.
- Dermatological reactions: alopecia, sweating.
- Allergic reactions: angioedema of the tongue, lips, face, skin rash (including urticaria, up to giant), laryngospasm, bronchospasm, itching, anaphylactic shock.
- Hypertrophic obstructive cardiomyopathy;
- I trimester of pregnancy;
- Children’s age up to 12 years;
- Hypersensitivity to salbutamol, ipratropium bromide, atropine or their derivatives.
The drug is used with caution in patients with angle-closure glaucoma, urinary tract obstruction (including against the background of prostatic hyperplasia), severe organic diseases of the cardiovascular system, pheochromocytoma, hyperthyroidism, insufficiently controlled diabetes mellitus, cystic fibrosis, recent myocardial infarction, II and III trimesters pregnancy, lactation (breastfeeding).
Pregnancy and breastfeeding
It is not recommended to use Combimist L Inhaler in the II and III trimesters of pregnancy and during breastfeeding, except in cases where the expected benefit to the mother outweighs any possible risk to the fetus and infant. The medicine is contraindicated in the first trimester of pregnancy.
Use in children
Combimist L Inhaler is contraindicated for use in children under the age of 12 years. For children over 12 years of age, the drug is usually used 3-4 times / day in the form of inhalation.
Use in elderly patients
Elderly patients, as well as adults, usually use the drug 3-4 times / day in the form of inhalation.
In order to avoid overdose, it is not recommended to exceed the maximum allowable daily dose.
Patients should be instructed on the correct use of Combimist L Inhaler and warned about the inadmissibility of getting the medicine into the eyes.
In patients with asthma or moderate forms of COPD, symptomatic treatment may be preferable to regular use.
It is necessary to further analyze the addition or intensification of anti-inflammatory therapy to control airway inflammation in patients with bronchial asthma and steroid-dependent forms of COPD.
Regular use of beta2-agonists in high doses can worsen the course of the disease. With an increase in bronchial obstruction, a simple increase in the dose of Combimist L Inhaler above the recommended one for a long period of time is inappropriate and even dangerous. To prevent life-threatening deterioration in the course of the disease, the patient’s treatment plan should be reviewed.
Treatment with beta2-agonists can lead to severe hypokalemia. Particular caution should be exercised in cases of severe airway obstruction since concomitant treatment with xanthine derivatives, diuretics and corticosteroids may cause hypokalemia. Hypokalemia may lead to an increased risk of arrhythmia in patients receiving digoxin. In addition, hypoxia can exacerbate the effect of hypokalemia on heart rate. In such situations, it is recommended to check the concentration of potassium in the blood serum.
In patients with cystic fibrosis, Combimist L Inhaler should be administered with caution due to the fact that symptoms of gastrointestinal motility may appear. Such patients should be warned about the need to inform the doctor about any changes in the function of the gastrointestinal tract.
If larger doses than recommended are required to relieve symptoms of bronchial obstruction (or bronchospasm), the patient’s treatment plan should be reviewed.
There are no data on the effect of the drug on the ability to drive vehicles and / or other mechanisms. However, during the period of treatment with Combimist L Inhaler, care should be taken when driving vehicles and engaging in potentially hazardous activities that require an increased concentration of attention and speed of psychomotor reactions since the medicine can cause dizziness and headache.
Symptoms: ipratropium bromide overdose is unlikely due to low systemic absorption after inhalation, therefore, all symptoms of an overdose are mainly associated with the systemic action of levosalbutamol. Symptoms of levosalbutamol overdose may include headache, nausea, vomiting, angina pectoris, arterial hypertension, arterial hypotension, hypokalemia, hyperglycemia, tachycardia, arrhythmia, chest pain, tremor, flushing, anxiety, hallucinations and dizziness.
Treatment: symptomatic, including the introduction of cardioselective beta-blockers. However, you should bear in mind that cardioselective beta-blockers can increase bronchospasm.
The combined use of additional beta2-agonists, corticosteroids, anticholinergics and xanthine derivatives can enhance the bronchodilator effect of Combimist L Inhaler on the respiratory tract and cause severe side effects. When used together with beta-blockers, the effectivess of the bronchodilator may decrease.
MAO inhibitors and tricyclic antidepressants can enhance the beta-adrenergic effect of levosalbutamol and lead to a sharp decrease in blood pressure.
Inhalation anesthesia using anesthetics containing halogenated hydrocarbons, such as halothane, trichloroethylene and enflurane, can exacerbate the side effects of beta2-agonists on the cardiovascular system, so careful monitoring of patients is required. Alternatively, you can stop using the inhaler before surgery.
Theophylline and other xanthines increase the likelihood of developing tachyarrhythmias.
The drug can enhance the effect of CNS stimulants, increase the likelihood of glycoside intoxication, and enhance the cardiotropic effect of thyroid hormones.
A possible increase in heart rate and blood pressure while using the bronchodilator may necessitate dose adjustment of antihypertensive and antianginal drugs.
Diuretics and corticosteroids enhance the hypokalemic effect of levosalbutamol.
Anticholinergic drugs increase the risk of increased intraocular pressure.