Dosing

Chronic obstructive pulmonary disease

Type	Age Range	Dose	Licensed
Maintenance	From 18 years	5micrograms - ONCE a DAY - inhalation - using a metered dose device

Asthma: Add-on maintenance treatment

Type	Age Range	Dose	Licensed
Maintenance	From 6 years	5micrograms - ONCE a DAY - inhalation - using a metered dose device

Safety Advice Warnings

Adverse effects (report/action)

• Drug induced bronchospasm may occur
• Prolonged treatment may lead to dental caries

Advice concerning formulation

• Not all available brands are recommended for all age groups
• Not all presentations are licensed for all indications

Advice on Administration

• Avoid contact with eyes

Advice on possible excipients

• Some formulations contain lactose

Discontinue due to test or exam

• Discontinue if paradoxical bronchospasm occurs

Patient Counselling

• Advise ability to drive/operate machinery may be affected by side effects
• Advise patient to report any blurred vision or any other eye symptoms
• Advise patient to report new or worsening signs of cardiac failure
• Asthma: Advise patients benefit of therapy is apparent after several doses
• Ensure patient has a fast acting bronchodilator available

Pre-treatment points to consider

• Not to be used as the sole or main treatment for severe or unstable asthma

Recommended monitoring

• Check patient is using correct inhaler technique
• Monitor closely patient at risk of cardiovascular disorders

Safety/advice in other condition

• Not to be used to relieve an acute asthmatic attack

Drug Interactions

With	Risk	Severity
METHACHOLINE	Methacholine effect reduced; review dosing, see product literature	Significant Risk: Usually avoid combination. Use combination only under special circumstances, taking any necessary action to reduce risk.
AMANTADINE	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
ANTIHISTAMINES - SEDATIVE	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CODEINE	Antimuscarinic side effects may be increased/risk of paralytic ileus	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
CYCLIZINE (IN COMBINATION WITH STRONG OPIOIDS)	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
DISOPYRAMIDE	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
MAOIS	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
NEFOPAM	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
TRICYCLIC ANTIDEPRESSANTS	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
TRICYCLIC ANTIDEPRESSANTS AND PHENOTHIAZINES (COMBINED PRODUCT)	Antimuscarinic side effects may be increased	Moderate Risk: Minimise risk. Take action necessary to reduce risk. Counsel patient.
(OXYPERTINE)	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
(REMOXIPRIDE)	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
(TRIFLUPERIDOL)	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
(ZOTEPINE)	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
AMISULPRIDE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ARIPIPRAZOLE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
BENPERIDOL	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
CLOZAPINE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
DROPERIDOL	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
FLUSPIRILENE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
HALOPERIDOL	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
LOXAPINE (INHALED)	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
LOXAPINE (ORAL)	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
MEMANTINE	effect may be increased by	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
OLANZAPINE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
PALIPERIDONE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
PHENOTHIAZINES	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
PIMOZIDE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
QUETIAPINE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
SERTINDOLE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
SULPIRIDE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.
ZIPRASIDONE	Antimuscarinic side effects may be increased	Low Risk: No action needed. Risk of adverse outcomes appears small and depends upon the condition of the patient. Counsel patient.

Precautions

• Benign prostatic hyperplasia
• Bladder outflow obstruction
• Breastfeeding
• Cardiac arrhythmias
• Children aged 6 to 18 years
• Galactosaemia
• Glucose-galactose malabsorption syndrome
• Lactose intolerance
• Narrow angle glaucoma
• New York Heart Association class III failure
• New York Heart Association class IV failure
• Pregnancy
• Renal impairment - creatinine clearance below 50ml/minute
• Within 6 months of a myocardial infarction

Contraindications

• Children under 6 years
• Cystic fibrosis

Side Effects

• Anaphylactic reaction
• Angioneurotic oedema
• Atrial fibrillation
• Blurred vision
• Bronchospasm
• Candidiasis (mouth or throat)
• Conjunctival vascular congestion
• Constipation
• Corneal oedema
• Cough
• Dehydration
• Dizziness
• Dry mouth
• Dry skin
• Dysphagia
• Dysphonia
• Dysuria
• Epistaxis
• Eye pain
• Gastroesophageal reflux disease
• Gingivitis
• Glaucoma
• Glossitis
• Headache
• Hypersensitivity reactions
• Increase in dental caries
• Increased intra-ocular pressure
• Insomnia
• Intestinal obstruction
• Joint swelling
• Laryngitis
• Nausea
• Palpitations
• Paralytic ileus
• Pharyngitis
• Pruritus
• Rash
• Sinusitis
• Skin infection
• Skin ulcer
• Stomatitis
• Supraventricular tachycardia
• Tachycardia
• Taste disturbances
• Urinary retention
• Urinary tract infections
• Urticaria