Combair Inhalation Aerosol: A Combined Bronchodilator for COPD

Combair Inhalation Aerosol is a combined bronchodilator containing Salbutamol (as Sulphate) and Ipratropium Bromide. It is a hydrofluoroalkane (HFA) based, environment-friendly inhaler, meaning it does not contain CFCs. It is indicated for patients with Chronic Obstructive Pulmonary Disease (COPD) who are already on a regular bronchodilator but continue to experience bronchospasm and require additional bronchodilation.

How Combair Works (Pharmacology)

Combair works by combining two distinct bronchodilator mechanisms to maximize the therapeutic response:

1. Salbutamol (Short-acting beta2-adrenergic bronchodilator): This component works by stimulating beta-2 adrenergic receptors in the airways, leading to the relaxation of bronchial smooth muscles and widening of the airways.
2. Ipratropium Bromide (Anticholinergic bronchodilator): This component prevents the increase in intracellular concentration of cyclic guanosine monophosphate, which is caused by the interaction of acetylcholine with muscarinic receptors on bronchial smooth muscle. This leads to relaxation of the airways.

By utilizing both anticholinergic (parasympatholytic) and sympathomimetic mechanisms, Combair is designed to produce a greater bronchodilatory effect than either drug used alone at its recommended dosage.

Key Indications & Benefits

Combair Inhalation Aerosol is indicated for:

• Patients with Chronic Obstructive Pulmonary Disease (COPD).
• Specifically for those already on a regular aerosol bronchodilator but who continue to have evidence of bronchospasm and require a second bronchodilator.

Dosage & Administration

• Adult dose (Including the elderly): 2 puffs 4 times a day.
• Patients may take additional puffs as required, but the total number of puffs should not exceed 12 in 24 hours.
• Always use as directed by the physician.

Proper Inhaler Administration (Important for effectiveness):

1. Take off the cap.
2. Shake the inhaler vigorously (at least six times) before each use.
3. If new or unused for a week, shake well and release one puff into the air to test.
4. Breathe out as fully and comfortably as possible, holding the inhaler upright.
5. Place the mouthpiece between teeth and close lips firmly around it.
6. While breathing deeply and slowly through the mouth, press down firmly and fully on the canister to release medicine.
7. Remove inhaler from mouth. Hold breath for at least 10 seconds or as long as comfortable.
8. If more than one puff is prescribed, wait 1 minute between puffs, shake, and repeat steps 4-7.
9. After use, replace the cap on the mouthpiece and rinse mouth with water.
10. Periodically check technique in a mirror; if a white mist is seen, repeat procedure from step 4 carefully.

Cleaning Instructions (at least once a week):

• Remove canister.
• Rinse the plastic actuator and cap in warm water (do not put metal canister in water).
• Dry thoroughly and gently replace the metal canister into the actuator with a twisting motion.
• Put the cap on the mouthpiece.

Important Considerations & Warnings

It is crucial to discuss your full medical history with your doctor before using Combair.

Contraindications:

• Patients with a history of hypersensitivity to Soya-Lecithin or related food products such as soybean and peanut.
• Patients hypersensitive to any other components of the drug product or to atropine or its derivatives.

Side Effects:

• Due to Salbutamol: Mild tremor and headache (usually disappear with continuous treatment). Very rare reports of muscle cramps, hypersensitivity reactions (including angioedema, urticaria, bronchospasm, and hypotension).
• Due to Ipratropium Bromide: Headache, influenza, chest pain, nausea, dyspnea, coughing, pharyngitis, sinusitis (rarely reported).

Pregnancy & Lactation:

• Ipratropium Bromide: Pregnancy Category B (no teratogenic effects demonstrated in studies).
• Salbutamol: Pregnancy Category C (teratogenic in animals).
• There are no adequate and well-controlled studies of this combination in pregnant women. Use during pregnancy only if the potential benefit justifies the potential risk to the fetus.
• It is not known if components are excreted in human milk. Use with caution in nursing mothers.

Precautions & Warnings:

• Due to the presence of Ipratropium Bromide, use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder-neck obstruction.
• Due to the presence of sympathomimetic amines (Salbutamol Sulphate), use with caution in patients with:
  • Convulsive disorders
  • Hyperthyroidism
  • Diabetes mellitus
  • Unusual responsiveness to sympathomimetic amines.

Drug Interactions:

• Used concomitantly with other common COPD drugs (sympathomimetic bronchodilators, methylxanthines, steroids), but no formal drug interaction studies exist with this combination.
• Ipratropium Bromide: Co-administer cautiously with other anticholinergic agents and sympathomimetic agents as it may increase the risk of adverse cardiovascular effects.
• Beta-2-agonists (like Salbutamol): Administer with extreme caution in patients taking non-potassium sparing diuretics, monoamine oxidase inhibitors, or tricyclic antidepressants.

Overdose Effects

• Overdose effects are primarily related to Salbutamol Sulphate.
• Manifestations may include: anginal pain, hypertension, hypokalemia (low potassium), and tachycardia (fast heart rate).

Storage Conditions

• Do not puncture, break, or incinerate the pressurized canister even when apparently empty.
• Avoid storage in direct sunlight or heat.
• Store in a cool and dry place.
• Keep away from children.
• Keep away from eyes.