Version July 2025
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.
(For additional information see "Ipratropium and albuterol: Drug information")
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. Nebulized therapy is preferred in hospitalized patients (Ref).
Nebulization solution (ipratropium bromide 0.5 mg/albuterol 2.5 mg per 3 mL vial): Oral inhalation: 1 vial every 1 to 2 hours (up to 3 doses), then every 2 to 4 hours as needed (Ref); maximum dose: 6 vials per first 12 hours (Ref).
Soft-mist inhaler (ipratropium bromide 20 mcg/albuterol 100 mcg per actuation): Oral inhalation:
1 inhalation every 1 to 2 hours (up to 3 doses), then every 2 to 4 hours as needed (Ref); maximum dose: 6 inhalations per first 12 hours (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 dose: 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 dose: 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).
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Also see individual agents.
1% to 10%:
Cardiovascular: Chest discomfort (<2%), chest pain (3%), hypertension (<2%), palpitations (<2%), tachycardia (<2%)
Dermatologic: Pruritus (<2%), skin rash (<2%)
Endocrine & metabolic: Hypokalemia (<2%)
Gastrointestinal: Constipation (<2%), diarrhea (2%), dyspepsia (1%), nausea (1%), vomiting (<2%), xerostomia (<2%)
Genitourinary: Urinary tract infection (2%)
Nervous system: Asthenia (<2%), dizziness (<2%), headache (3%), pain (1%), tremor (<2%), voice disorder (>1%)
Neuromuscular & skeletal: Lower limb cramp (1%), muscle spasm (<2%), myalgia (<2%)
Ophthalmic: Eye pain (<2%)
Respiratory: Bronchitis (2% to 3%), cough (3% to 7%), dyspnea (2%), flu-like symptoms (<2%), nasopharyngitis (4%), pharyngitis (4%), pharyngolaryngeal pain (<2%), pneumonia (1%), upper respiratory tract infection (3%), wheezing (<2%)
Postmarketing:
Cardiovascular: Decreased diastolic blood pressure, flushing, increased systolic blood pressure, ischemic heart disease
Dermatologic: Hyperhidrosis
Endocrine & metabolic: Metabolic acidosis
Gastrointestinal: Dysgeusia, gastrointestinal motility disorder, stomatitis
Genitourinary: Urinary retention
Hypersensitivity: Hypersensitivity reaction (including angioedema), mouth edema
Nervous system: Body pain, central nervous system stimulation, drowsiness, mental status changes, myasthenia
Neuromuscular & skeletal: Back pain
Ophthalmic: Accommodation disturbance, blurred vision, conjunctival hyperemia, corneal edema, eye irritation, glaucoma (including exacerbation of angle-closure glaucoma), increased intraocular pressure, mydriasis, visual halos around lights
Respiratory: Dry secretions, nasal congestion, paradoxical bronchospasm, pharyngeal edema, sinusitis, throat irritation
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): $151.21
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
Oral inhalation: Nebulization solution: Administer via jet nebulizer to an air compressor with an adequate air flow, equipped with a mouthpiece or face mask.
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.
Nebulization solution:
US labeling: Store at 2°C to 25°C (36°F to 77°F) in foil pouch until ready to use. Protect from light. Use within 1 week of removing from foil pouch. May vary by product; also refer to manufacturer's labeling.
Canadian labeling: Store at 15°C to 25°C (59°F to 77°F). Protect from light and heat.
Soft mist inhaler: Store at 20°C to 25°C (68°F to 77°F). Excursions permitted to 15°C to 30°C (59°F to 86°F); avoid freezing. Discard 3 months after first actuation or after labeled number of actuations has been reached and locking mechanism is engaged, whichever comes first.
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 (FDA approved in adults); has also been used in the treatment of asthma exacerbations
DuoNeb may be confused with DuoTrav, Duovent UDV
Refer to individual components.
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.
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
Agents with Clinically Relevant Anticholinergic Effects: Ipratropium (Oral Inhalation) may increase anticholinergic effects of Agents with Clinically Relevant Anticholinergic Effects. Risk X: Avoid
Atomoxetine: May increase hypertensive effects of Sympathomimetics. Atomoxetine may increase tachycardic effects of Sympathomimetics. Risk C: Monitor
Atomoxetine: May increase tachycardic effects of Beta2-Agonists. Atomoxetine may increase hypertensive effects of Beta2-Agonists. Risk C: Monitor
Atosiban: Beta2-Agonists may increase adverse/toxic effects of Atosiban. Specifically, there may be an increased risk for pulmonary edema and/or dyspnea. Risk C: Monitor
Beta-Blockers (Beta1 Selective): May decrease bronchodilatory effects of Beta2-Agonists. Of particular concern with nonselective beta-blockers or higher doses of the beta1 selective beta-blockers. Risk C: Monitor
Beta-Blockers (Nonselective): May decrease bronchodilatory effects of Beta2-Agonists. Risk X: Avoid
Beta2-Agonists (Short-Acting): May increase adverse/toxic effects of 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
Cannabinoid-Containing Products: May increase tachycardic effects of Sympathomimetics. Risk C: Monitor
Cocaine (Topical): May increase hypertensive effects 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
Dihydralazine: Sympathomimetics may decrease therapeutic effects of Dihydralazine. Risk C: Monitor
Doxofylline: Sympathomimetics may increase adverse/toxic effects of Doxofylline. Risk C: Monitor
Esketamine (Injection): May increase adverse/toxic effects of Sympathomimetics. Specifically, the risk for elevated heart rate, hypertension, and arrhythmias may be increased. Risk C: Monitor
Guanethidine: May increase hypertensive effects of Sympathomimetics. Guanethidine may increase arrhythmogenic effects of Sympathomimetics. Risk C: Monitor
Haloperidol: QT-prolonging Agents (Indeterminate Risk - Caution) may increase QTc-prolonging effects of Haloperidol. Risk C: Monitor
Inhaled Anticholinergic Agents: May increase anticholinergic effects of Inhaled Anticholinergic Agents. Risk C: Monitor
Kratom: May increase adverse/toxic effects of Sympathomimetics. Risk X: Avoid
Levothyroxine: May increase therapeutic effects of Sympathomimetics. Sympathomimetics may increase therapeutic effects of Levothyroxine. Levothyroxine may increase adverse/toxic effects of Sympathomimetics. Specifically, the risk of coronary insufficiency may be increased in patients with coronary artery disease. Risk C: Monitor
Linezolid: May increase hypertensive effects 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 increase hypokalemic effects of Loop Diuretics. Risk C: Monitor
Loxapine: Agents to Treat Airway Disease may increase adverse/toxic effects 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
Methacholine: Ipratropium (Oral Inhalation) may decrease therapeutic effects of Methacholine. Management: Hold ipratropium for 12 hours before methacholine use. Risk D: Consider Therapy Modification
Monoamine Oxidase Inhibitors: May increase adverse/toxic effects of Beta2-Agonists. Risk C: Monitor
QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Caution) may increase QTc-prolonging effects 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
Solriamfetol: Sympathomimetics may increase hypertensive effects of Solriamfetol. Sympathomimetics may increase tachycardic effects of Solriamfetol. Risk C: Monitor
Sympathomimetics: May increase adverse/toxic effects of Sympathomimetics. Risk C: Monitor
Tedizolid: May increase adverse/toxic effects of Sympathomimetics. Specifically, the risk for increased blood pressure and heart rate may be increased. Risk C: Monitor
Theophylline Derivatives: May increase hypokalemic effects of Beta2-Agonists. Beta2-Agonists may increase adverse/toxic effects of Theophylline Derivatives. Specifically, sympathomimetic effects may be increased. Risk C: Monitor
Thiazide and Thiazide-Like Diuretics: Beta2-Agonists may increase hypokalemic effects of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor
Refer to individual monographs.
See individual agents.
See individual agents.
