Berodual

Berodual is a combination inhaler from Boehringer Ingelheim that contains two bronchodilating active ingredients: the beta-2 agonist fenoterol and the anticholinergic ipratropium bromide.

The combination works through two different mechanisms and is therefore more effective than either active ingredient alone. Berodual is often used in the emergency department for acute shortness of breath, but it can also be used for regular therapy.

Available as a metered-dose inhaler and as a solution for nebulizers.

Berodual works through two mechanisms:

Fenoterol (beta-2 agonist):

• Activates beta-2 receptors in the bronchial muscles
• Rapid bronchodilation (3-5 minutes)
• Duration of action: 4-6 hours
• Inhibits the release of bronchoconstricting and pro-inflammatory messenger substances from mast cells

Ipratropium bromide (anticholinergic):

• Blocks muscarinic receptors
• Bronchodilation (onset in 15-30 minutes)
• Duration of action: 4-6 hours
• Reduces mucus secretion

Synergistic effect: The two active ingredients complement each other: fenoterol acts quickly, ipratropium enhances and prolongs the effect. Together they are more effective than the sum of their individual effects.

Berodual is suitable for:

• Acute shortness of breath in COPD
• Asthma exacerbations
• As-needed therapy for obstructive airway diseases
• Before diagnostic procedures (bronchoscopy)

Advantages:

• Dual action through two mechanisms
• Rapid onset of action
• More effective than single active ingredients
• As a nebulizer solution for severe attacks

Limitations:

• Not a controller therapy for asthma
• Does not contain a corticosteroid
• In asthma, an ICS is always needed in addition

Metered-dose inhaler:

• 50 µg fenoterol + 20 µg ipratropium per puff
• As needed: 1-2 puffs
• For long-term therapy: 1-2 puffs 3x daily
• Maximum: 8 puffs per day

Inhalation solution (nebulizer):

• 0.5 ml (5 pumps with the solution dispenser) = 250 µg fenoterol hydrobromide + 125 µg ipratropium bromide
• Acute shortness of breath: 1-2 ml (20-40 drops)
• Dilute to 3-4 ml with 0.9% NaCl
• 3-4x daily, more often if needed (under medical supervision)

Berodual N metered-dose inhaler: Formulation with the propellant norflurane and the same active ingredient content.

Metered-dose inhaler: 1. Remove the protective cap, shake the inhaler 2. Breathe out deeply 3. Close your lips around the mouthpiece 4. Breathe in slowly and deeply while spraying 5. Hold your breath for 10 seconds 6. Breathe out slowly 7. For a second puff, wait 1-2 minutes

Nebulizer: 1. Put the drops into the nebulizer container 2. Dilute with NaCl 0.9% (to approx. 3-4 ml) 3. Inhale for 5-15 minutes 4. Breathe normally, occasionally take a deep breath

For acute shortness of breath: Inhale 2 puffs immediately, repeat after 5 minutes if necessary. For severe shortness of breath, call emergency medical services!

Caution: Do not spray into the eyes!

Do not use in cases of:

• Hypersensitivity to fenoterol, ipratropium or atropine derivatives
• Hypertrophic obstructive cardiomyopathy
• Tachyarrhythmias

Use with caution in cases of:

• Severe heart disease
• Recent heart attack
• Untreated diabetes
• Pheochromocytoma
• Narrow-angle glaucoma
• Prostatic hyperplasia

Pregnancy: Only if clearly indicated. Fenoterol can inhibit labor contractions.

Breastfeeding: Non-clinical data show that fenoterol passes into breast milk. Caution is advised when used during breastfeeding.

Common:

• Tremor (shaking)
• Dry mouth
• Headache
• Cough
• Nervousness

Uncommon:

• Racing heart
• Palpitations
• Dizziness
• Nausea
• Hoarseness

Rare:

• Paradoxical bronchospasm
• Narrow-angle glaucoma (on contact with the eyes)
• Hypokalemia
• Allergic reactions

Note: Tremor and racing heart are typical beta-2 agonist side effects. Rarely, reduced blood flow to the heart muscle (myocardial ischemia) can occur. If you have severe heart disease and notice chest pain or other signs of worsening heart disease, seek medical advice.

Use with caution with:

• Beta blockers – can cancel out the effect of fenoterol
• MAO inhibitors – increased cardiovascular effects
• Tricyclic antidepressants – increased effect on the heart
• Other sympathomimetics – additive effects
• Corticosteroids, diuretics – risk of hypokalemia

Synergistic effect: With xanthines (theophylline) – may be desirable, but use caution regarding side effects.