Brands of glycopyrronium
This list is not intended to be exhaustive.
Inhaled: Seebri®
Inhaled (combination products, with beta-2 adrenoceptor agonist): Bevespi®, Ultibro®
Inhaled (combination products, with corticosteroid and beta-2 adrenoceptor agonist): Bevespi®, Enerzair®, Trimbow®, Trixeo®
Issues for surgery
Increased risk of exacerbation of chronic obstructive pulmonary disease (COPD) if omitted.
For combination products containing corticosteroids – potential increased risk of acute adrenal insufficiency (e.g. severe hypotension, tiredness and weakness, confusion, psychosis, tachycardia) if omitted – see Further information.
Advice in the perioperative period
Elective and emergency surgery
Continue (including combination products).
There are numerous inhaled preparations which contain glycopyrronium, either as single agents or in combination products with corticosteroids and / or beta-2 adrenoceptor agonists – all of these can be continued pre-operatively. Check active ingredients of currently available preparations in British National Formulary.
Advise patients who are prescribed regular inhaled glycopyrronium inhaled preparations but do not usually take them regularly to do so pre-operatively to optimise breathing prior to anaesthesia.
Confirm the inhaler brand, device, and strength with the patient.
Post-operative advice
Restart post-operatively as soon as next dose is due.
If patients are unable to resume their usual inhaled medication post-operatively consider nebulised ipratropium if clinically appropriate.
Interactions with common anaesthetic agents
For interactions with products containing corticosteroids / beta-2 adrenoceptor agonists - see individual monographs.
Antimuscarinic action
Antimuscarinic action may be additive with agents that also have antimuscarinic effects such as atropine. Concomitant administration of inhaled antimuscarinics with other medication known to have antimuscarinic effects has not been studied and is therefore not recommended by the manufacturers; however, in practice monitor patient for adverse effects.
Interactions with other common medicines used in the perioperative period
For interactions with products containing corticosteroids / beta-2 adrenoceptor agonists - see individual monographs.
Antimuscarinic action
Antiemetics
The antimuscarinic action of glycopyrronium may be additive with antiemetics that also have antimuscarinic effects such as cyclizine, haloperidol, levomepromazine or prochlorperazine.
Nefopam
The antimuscarinic action of glycopyrronium may be additive with nefopam which also has antimuscarinic effects.
Concomitant administration of inhaled glycopyrronium with other medication known to have antimuscarinic effects has not been studied and is therefore not recommended by the manufacturers; however, in practice monitor patient for adverse effects.
Further information
Products containing corticosteroids
Systemic absorption
Although not intended it is possible that inhaled administration of corticosteroids may result in systemic absorption, particularly if high doses are used or with prolonged treatment.
Adrenal suppression, perioperative stress and corticosteroid replacement
Whilst adrenal insufficiency is most common in patients taking systemic corticosteroids there is evidence that this can occur with chronic corticosteroid administration via other routes. High doses and prolonged treatment duration results in increased systemic absorption and therefore risk of adrenal insufficiency; however, there is no dose, administration route or treatment duration for which the risk of adrenal insufficiency can safely be excluded. Meta-analysis indicates incidence of adrenal insufficiency is lower in patients prescribed intranasal (4.2%) and inhaled (7.8%) corticosteroids compared to oral (48.7%) and intra-articular (52.2%) corticosteroids, although this incidence is likely to be higher in individuals receiving corticosteroids by multiple routes.
The possibility of adrenal insufficiency should be considered in individuals taking inhaled or intranasal corticosteroids who fail to improve as anticipated post-operatively. Current evidence on the necessity of administering perioperative stress-dose steroids for patients with suspected secondary adrenal insufficiency is inadequate to either support or refute this practice; however, if adrenal insufficiency is suspected, corticosteroid replacement appears to carry minimal risk compared with the risk of adrenal crisis.
References
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 4th February 2021]
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 4th February 2021]
Summary of Product Characteristics – Seebri® (glycopyrronium) Breezhaler 44 micrograms inhalation powder, hard capsules. Novartis Pharmaceuticals UK Ltd. Accessed via www.medicines.org.uk 04/02/2021 [date of revision of the text December 2019]