Full text of DOI:10.2165/00044011-200222040-00006

Clin Drug Invest 2002; 22 (4): 263-268
1173-2563/02/0004-0263/$25.00/0
ORIGINAL RESEARCH ARTICLE
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Efficacy of Ipratropium Bromide Aqueous
Nasal Spray in the Prevention of Nasal
Secretion Induced by Inhaled Methacholine
A. Smeraldi,1 E. Crimi,1 M. Milanese,1 A. Rossetti,2 L. Cantini 2 and V. B ru s as c o1
1
2
Department of Motor Sciences, University of Genoa, Genoa, Italy
Medical Department, Chiesi Group, Parma, Italy
Abstract
Objective: The present study was conducted to assess if a new formulation of
ipratropium bromide nasal spray could prevent the nasal hypersecretion induced
by a whole nasal challenge with increasing doses of methacholine.
Patients and methods: Twenty adult outpatients with ongoing hypersecretive
rhinitis were selected and, after a preliminary session without any pretreatment,
randomised to receive a single dose of nasal aqueous ipratropium bromide 80μg
and matched placebo administered via a metered pump 60 minutes before metha-
choline challenge on two consecutive days. In each session, methacholine was
inhaled into the nostrils at four increasing concentrations of 1, 4, 16 and 64 mg/ml,
at 20-minute intervals. The induced secretion was evaluated by weighing a cotton
tampon placed in each nostril for 30 seconds following the methacholine stimu-
lation; weights were adjusted for spontaneous secretion. In addition, an acoustic
rhinometer was used to measure the change in resistance and volume of each
nasal cavity.
Results: The nasal discharge (adjusted for pretreatment values) was significantly
reduced after pretreatment with ipratropium bromide, both in the cumulative
weight (p < 0.01) and at each methacholine concentration (p < 0.05 after 1
and 4 mg/ml, p < 0.01 after 16 and 64 mg/ml). No relevant changes in nasal
patency were observed during the test without pretreatment, nor during the two
treatment sessions; similarly, no significant differences were observed in the
comparison between active drug and placebo for both resistance and volume.
Conclusions: The results of the present study demonstrate that an intranasal
aqueous solution of ipratropium bromide reduces the nasal discharge induced
by locally applied methacholine. No effects were seen in the parameters used to
measure nasal congestion.
Rhinorrhoea is a symptom common to both
The submucosal nasal glands and the goblet
cells of the nasal mucosa are the main sources of
nasal secretion.[1] These glands have an abundant
innervation that stems from the cholinergic
nervous system.[2] In fact, a profuse hyper-reactiv-
primary chronic rhinitis (i.e. vasomotor rhinitis or
nonallergic rhinitis) and secondary chronic rhinitis
(i.e. allergic rhinitis), as well as to the common
cold.

264
Smeraldi et al.
ity of the nasal mucosa is caused when surgical
operation on the vidian nerve is followed by the
administration of methacholine (a cholinergic ag-
onist).[3] Nasal provocation with methacholine,
which binds reversibly to the muscarinic receptors
on the seromucous glands, is the standard model
used in the induction of secretion, and allows a
local triggering without any systemic effect.[4]
Anticholinergic drugs are therefore useful in treat-
ing excessive rhinorrhoea in patients with rhinitis.
Ipratropium bromide, a derivative of scopolamine
with a quaternary ammonium structure, is an
anticholinergic drug and was the first muscarinic
receptor blocker to achieve wide therapeutic use in
pressurised aerosol form. The efficacy and toler-
ability profiles were demonstrated in clinical trials,
both in long-term treatment[5,6] and in the preven-
tion of rhinorrhoea induced by methacholine.[7-9]
In addition, intranasal ipratropium bromide pro-
vides effective relief and control of rhinorrhoea in
the common cold.[10,11]
Recently, a new formulation of ipratropium
bromide nasal spray, an aqueous solution delivered
via a metered pump, has been developed without
using potentially ozone-depleting propellants.
The aim of the present study was to assess
whether pretreatment with intranasal ipratropium
bromide aqueous spray could prevent the nasal
secretion induced by increasing doses of metha-
choline inhaled in both nostrils during a whole
nasal challenge, in comparison with matched
placebo. A secondary objective was to investigate
if local stimulation with methacholine could in-
duce nasal congestion, by measuring the size and
resistance of the nasal cavity via acoustic rhino-
metry, and to verify if ipratropium bromide could
prevent such an event.
4 days a week, or for 2 to 3 weeks per month in the
previous 6 months. The study was conducted out-
side of seasonal sensitising periods and patients
were to stay in the same geographic area for the
total study duration.
Patients were excluded from taking part in the
study if they had evidence of nasal polyps and/or
an abnormal nasal septum, airways infection in the
previous 2 weeks, asthma and acute or chronic
sinusitis, history of abnormal laboratory tests, his-
tory of clinically significant concomitant diseases,
pregnancy or risk of pregnancy, hypersensitivity to
parasympathetic agonists and/or anticholinergic
drugs, and exposure to potential allergens for the
total study period. In addition, they had to abstain
from the use of anticholinergic and short-acting
antihistamines in the previous week, use of nasal
decongestants and nonsteroidal anti-inflammatory
drugs in the previous 2 weeks, use of cortico-
steroids, sodium cromoglycate and nedocromil in
the previous 4 weeks, and use of long-acting anti-
histamines in the previous 6 weeks. Patients were
also admitted to the treatment phase if the cumula-
tive weight of nasal secretion was at least 50mg
in a preliminary test done without any preventive
treatment.
Patients gave their written informed consent
before any study-related procedure was started.
The study protocol was approved by the Ethics
Committee of the ‘Dipartimento di Scienze
Motorie e Riabilitative’, University of Genoa, Italy.
Study Design and Protocol
This was a randomised, double-blind, placebo-
controlled, crossover design trial. Eligible patients
entered a 3- to 5-day run-in period and were then
randomised to receive a single dose of 80μg ipra-
tropium bromide nasal spray in an aqueous solu-
tion (Rinoatem Aqua®, Chiesi Farmaceutici SpA,
Parma, Italy) administered via a metered pump and
matched placebo on two consecutive days, with
a 3- to 5-day washout between the two tests. After
a screening visit, when patients were checked
against the inclusion/exclusion criteria, they were
submitted to a methacholine challenge test without
Patients and Methods
Study Population
Adult outpatients with allergic and nonallergic
hypersecretive rhinitis were recruited on the basis
of evidence of rhinorrhoea in the month before
starting the trial for at least 1 hour a day and at least
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Clin Drug Invest 2002; 22 (4)

Ipratropium Bromide and Nasal Secretion
265
any pretreatment prior to being assigned to the two
treatment days with ipratropium bromide and
placebo. Patients were allocated to one of the two
sequences (ipratropium bromide-placebo or vice-
versa) following a four-block design (i.e. two
sequences in each four-patient group). In the two
treatment sessions the challenge test was done
60 minutes after the intake of the assigned drug.
Methacholine chloride (Lofarma, Milan, Italy)
in powder form was dissolved in saline solution to
obtain concentrations of 1, 4, 16 and 64 mg/ml in
a 10μl volume. Increasing methacholine concen-
trations were delivered via bilateral intranasal
aerosolisation with a French-Rosenthal dosimeter
(Sensor Medics Srl, Milan, Italy). The four admini-
strations of methacholine were separated by 20-
minute intervals. In each application, 20 nasal
inhalations were performed. The device was set to
deliver the methacholine aerosol during the last
0.4 seconds of each inspiration to minimise depo-
sition in the intrathoracic airways. This was ob-
tained by introducing a 0.6-second delay between
the triggering of the valve opener by the inspiratory
flow and the opening of the valve. To evaluate the
spontaneous secretion, a cotton tampon (Dental
rolls, Roeko, Italy) was applied in each nostril
(for 30 seconds) before the procedure was started
and it was weighed using an electronic balance
(PB 153, Mettler Toledo) sensitive to 0.01mg.
Likewise, the secretion induced by methacholine
was measured after 30 seconds, as previously
described, and the net secretion weight was calcu-
lated using the following formula: post-stimula-
tion tampon weight minus tampon weight minus
spontaneous secretion weight.
signs (pulse and blood pressure) were measured at
the start of each session and 10 minutes after re-
moval of the cotton tampon at each methacholine
stimulation. Adverse events were recorded each
session day.
Statistics
The sample size was based on an hypothesis of
superiority between the active drug and placebo.
The cumulative weight of net secretion after the
four challenges was considered as the primary
variable. Estimating a mean value of 90mg in the
placebo group (30mg as standard deviation) and an
expected difference between treatments of 30mg,
at an α level of 0.05 and a power of 90%, 20 evalu-
able patients were required to demonstrate that the
active drug was more effective than placebo in the
prevention of the cumulative secretion after the
four stimulations.
An ANOVAmodel for the crossover design was
used in the analysis of the secretion weight and of
airway patency parameters.
SAS® software version 6.12 was used for data
management and analysis. Values were reported as
means and standard deviation or standard error,
when appropriate.
Results
The study population was made up of 20 patients
in total, six males and 14 females, with a mean age
of 36.7 17.0 years. The mean duration of the
disease was 8.1 6.4 years: 10 patients had allergic
seasonal rhinitis and the other 10 had vasomotor
rhinitis. The individual demographic charac-
teristics of the patient population are presented in
table I.
Figure 1 shows the results of the nasal secretion
weight in the basal test without any pretreatment
and in the two pretreatment sessions, including the
values measured at each methacholine challenge
test after the intake of ipratropium bromide or
placebo. The mean cumulative weights of nasal
secretion were 115.4mg (SE 11.0) in the prelimi-
nary session without pretreatment, 69.1mg (SE
11.3) after treatment with ipratropium bromide and
In addition, the patency of nasal airways was
measured at the start of each session and 5 minutes
after removal of the cotton tampon at each step of
methacholine challenge using an acoustic rhino-
meter EccoVision® (Sensor Medics, Italy). An
analysis was carried out on a segment of 6cm taken
from the nose tip, and the resistance (Req, cm
H2O/L/min) and volume of the analysed segment
(Vol, cm3) were calculated in both sides. Values of
the left and right sides were then averaged. Vital
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Clin Drug Invest 2002; 22 (4)

266
Smeraldi et al.
Table I. Demographic details of the patient population
Patient no.
Age (years)
Gender
Height (cm)
Weight (kg)
Duration of
Diagnosis
illness (years)
1
34
M
F
188
79
10
AR
VR
VR
AR
VR
AR
AR
VR
VR
VR
AR
AR
VR
AR
VR
VR
AR
AR
AR
VR
2
26
160
60
3
3
51
F
164
73
3
4
19
F
175
60
19
5
20
F
160
52
20
6
50
F
156
48
3
7
51
F
160
54
3
8
57
M
F
175
80
5
9
67
163
60
18
10
18
F
170
55
6
11
25
F
164
46
7
12
67
F
170
55
10
13
42
F
163
52
2
14
36
M
M
F
175
70
18
15
22
178
70
3
16
57
162
67
1
17
25
F
164
52
5
18
19
M
M
F
180
71
2
19
19
189
93
10
20
29
161
52
14
Mean SD
Total
36.7 17.04
168.85 9.58
62.45 12.46
8.1 6.41
6 M; 14 F
10 AR; 10 VR
AR = allergic rhinitis; VR = vasomotor rhinitis.
160
140
120
100
80
No treatment
Active
Placebo
**
60
**
**
40
*
*
20
0
Total
1
4
16
64
Methacholine concentration (mg/ml)
Fig. 1. Weight of nasal secretions with and without pretreatment with ipratropium bromide or placebo (showing SE bars).
* p < 0.05; ** p < 0.01.
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Clin Drug Invest 2002; 22 (4)

Ipratropium Bromide and Nasal Secretion
267
Table II. Acoustic rhinometry: calculated resistance (cm H2O/L/min)a
No treatment (mean SE)
Ipratropium bromide (mean SE) Placebo (mean SE)
Pretreatment
4.13 0.78
4.77 1.11
6.53 3.09
4.73 1.74
5.35 1.98
5.46 1.68
3.98 0.66
4.57 0.93
4.10 0.86
4.46 1.28
4.10 0.83
5.14 1.37
Prestimulation
5.06 1.59
5.24 1.61
4.99 1.51
5.33 1.52
5.87 1.69
First methacholine stimulation (1 mg/ml)
Second methacholine stimulation (4 mg/ml)
Third methacholine stimulation (16 mg/ml)
Fourth methacholine stimulation (64 mg/ml)
a
Nonsignificant differences between and within groups.
Table III. Acoustic rhinometry: volume of the analysis segment (cm3)a
No treatment (mean SE)
Ipratropium bromide (mean SE) Placebo (mean SE)
Pretreatment
7.06 0.81
6.73 0.54
6.73 0.66
6.59 0.54
6.41 0.50
6.28 0.54
6.97 0.59
6.70 0.65
6.57 0.56
6.43 0.51
6.35 0.54
6.11 0.47
Prestimulation
7.77 0.76
7.00 0.60
7.35 0.77
7.42 0.71
7.44 0.82
First methacholine stimulation (1 mg/ml)
Second methacholine stimulation (4 mg/ml)
Third methacholine stimulation (16 mg/ml)
Fourth methacholine stimulation (64 mg/ml)
a
Nonsignificant differences between and within groups.
124.6mg (SE 14.1) after treatment with matched
placebo. The comparison between treatments for
the total weight of nasal secretion (adjusted for pre-
treatment values) showed a statistically significant
difference (p < 0.01) in favour of the active drug.
Furthermore, there was a significant difference
between ipratropium bromide and placebo when
the secretion weights were compared at each
methacholine concentration (p < 0.05 after 1 and
4 mg/ml, p < 0.01 after 16 and 64 mg/ml). A dose-
linearity in response after prestimulation with the
four scalar doses of methacholine was evident
after treatment with both ipratropium bromide
and placebo.
The results of the acoustic rhinometry tests,
done before treatment, before the start of the first
stimulation, and after each methacholine stimula-
tion, are reported in table II (calculated resistance)
and in table III (volume of the analysis segment).
No relevant changes were observed in either para-
meter during the basal test without any pretreat-
ment, or in the two pretreatment sessions. The
analysis of the results did not show any significant
change over the pretreatment value (or prestimula-
tion value in the basal test) on any of the three test
days. Similarly, no differences between groups
were observed in the comparison between ipra-
tropium bromide and placebo for either variable.
No clinically significant changes were reported
for pulse and blood pressure. No adverse events
occurred during the total study period.
Discussion
The results of the present study demonstrate
that an aqueous solution of ipratropium bromide,
given intranasally in a single dose of 80μg via
metered pump, is effective in the prevention of
nasal hypersecretion induced by local applications
of methacholine. In addition to total weight of
nasal secretions, significant differences between
the active drug and placebo have been shown at
each methacholine stimulation, given at increasing
concentrations of 1, 4, 16 and 64 mg/ml. Taking
into account that the weight of active drug and
placebo in each delivered dose is around 90mg,
which may contribute to the weight of nasal secre-
tion measured after the stimulation tests, the esti-
mated net difference between the two treatments is
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Clin Drug Invest 2002; 22 (4)

268
Smeraldi et al.
even higher. The weight-per-shot can also explain
why the cumulative nasal secretion measured in the
test day without any pretreatment tended to be
lower than that measured in the sessions with
placebo, thereby suggesting the lack of any appar-
ent placebo effect.
Conclusion
It can be concluded that intranasal ipratropium
bromide provides efficient prevention of nasal
hypersecretion induced by locally applied metha-
choline, as studied in a validated and reliable
experimental model.
The methods used in the present study for the
assessment of nasal secretion and nasal congestion
include a whole nasal challenge, a dose response
curve, the recovery of nasal secretions by means of
a weighed cotton tampon, and the subtraction of the
spontaneous secretions. Unpublished data col-
lected in our centre showed good reproducibility of
the method, with a 10% coefficient of variation be-
tween two repeated challenges in eight patients.
Previous dose-response trials used single side nasal
challenge with local paper filter application,[8,9]
collection of the secretions via a microtube, and the
measurement of runny nose and congestion via
rating scales. In our study an acoustic rhinometer,
a validated method to show changes of the nasal
cavity before and after a given treatment,[12] was
used.
Acknowledgements
This study was sponsored by a grant from Chiesi
Farmaceutici SpA, Parma, Italy.
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Correspondence and offprints: Dr L. Cantini, Medical
Department Chiesi Farmaceutici, Via Palermo 26/A,
Parma, Italy.
E-mail: l.cantini@chiesigroup.com
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Clin Drug Invest 2002; 22 (4)