to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of perphenazine by pharmacodynamic antagonism. Use Caution/Monitor. perphenazine increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia. perphenazine increases toxicity of glycopyrrolate inhaled by unknown mechanism. Use Caution/Monitor.physostigmineMonitor Closely (1)physostigmine increases and glycopyrrolate inhaled decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.pilocarpineMonitor Closely (1)pilocarpine increases and glycopyrrolate inhaled decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.pimozideMonitor Closely (3)glycopyrrolate inhaled decreases levels of pimozide by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of pimozide by pharmacodynamic antagonism. Use Caution/Monitor. pimozide increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.pralidoximeMonitor Closely (1)glycopyrrolate inhaled and pralidoxime both decrease cholinergic effects/transmission. Use Caution/Monitor.pramlintideSerious - Use Alternative (1)pramlintide, glycopyrrolate inhaled. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Synergistic inhibition of GI motility.prochlorperazineMonitor Closely (3)glycopyrrolate inhaled decreases levels of prochlorperazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of prochlorperazine by pharmacodynamic antagonism. Use Caution/Monitor. prochlorperazine increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.Minor (1)prochlorperazine increases toxicity of glycopyrrolate inhaled by unknown mechanism. Minor/Significance Unknown.promazineMinor (1)promazine increases toxicity of glycopyrrolate inhaled by unknown mechanism. Minor/Significance Unknown.promethazineMonitor Closely (3)glycopyrrolate inhaled decreases levels of promethazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of promethazine by pharmacodynamic antagonism. Use Caution/Monitor. promethazine increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.Minor (1)promethazine increases toxicity of glycopyrrolate inhaled by unknown mechanism. Minor/Significance Unknown.propanthelineMonitor Closely (1)glycopyrrolate inhaled and propantheline both decrease cholinergic effects/transmission. Use Caution/Monitor.protriptylineMonitor Closely (2)glycopyrrolate inhaled and protriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor. protriptyline increases levels of glycopyrrolate inhaled by unknown mechanism. Use Caution/Monitor.pyridostigmineMonitor Closely (1)pyridostigmine increases and glycopyrrolate inhaled decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.quetiapineMonitor Closely (3)glycopyrrolate inhaled decreases levels of quetiapine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of quetiapine by pharmacodynamic antagonism. Use Caution/Monitor. quetiapine increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.rapacuroniumMonitor Closely (1)glycopyrrolate inhaled and rapacuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.revefenacinSerious - Use Alternative (1)revefenacin and glycopyrrolate inhaled both decrease cholinergic effects/transmission. Avoid or Use Alternate Drug. Coadministration may cause additive anticholinergic effects.rimantadineMonitor Closely (1)glycopyrrolate inhaled, rimantadine. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Enhanced CNS side effects.Minor (1)rimantadine increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Minor/Significance Unknown.risperidoneMonitor Closely (3)glycopyrrolate inhaled decreases levels of risperidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of risperidone by pharmacodynamic antagonism. Use Caution/Monitor. risperidone increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.rivastigmineMonitor Closely (1)rivastigmine increases and glycopyrrolate inhaled decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.rocuroniumMonitor Closely (1)glycopyrrolate inhaled and rocuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.scopolamineMonitor Closely (1)glycopyrrolate inhaled and scopolamine both decrease cholinergic effects/transmission. Use Caution/Monitor.solifenacinMonitor Closely (1)glycopyrrolate inhaled and solifenacin both decrease cholinergic effects/transmission. Use Caution/Monitor.succinylcholineMonitor Closely (1)succinylcholine increases and glycopyrrolate inhaled decreases cholinergic effects/transmission. Effect of interaction is not clear, use caution. Use Caution/Monitor.thioridazineMonitor Closely (3)glycopyrrolate inhaled decreases levels of thioridazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of thioridazine by pharmacodynamic antagonism. Use Caution/Monitor. thioridazine increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.Minor (1)thioridazine increases toxicity of glycopyrrolate inhaled by unknown mechanism. Minor/Significance Unknown.thiothixeneMonitor Closely (3)glycopyrrolate inhaled decreases levels of thiothixene by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of thiothixene by pharmacodynamic antagonism. Use Caution/Monitor. thiothixene increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.tiotropiumMonitor Closely (1)glycopyrrolate inhaled and tiotropium both decrease cholinergic effects/transmission. Use Caution/Monitor.tolterodineMonitor Closely (1)glycopyrrolate inhaled and tolterodine both decrease cholinergic effects/transmission. Use Caution/Monitor.trazodoneMinor (2)glycopyrrolate inhaled and trazodone both decrease cholinergic effects/transmission. Minor/Significance Unknown. trazodone increases levels of glycopyrrolate inhaled by unknown mechanism. Minor/Significance Unknown.trifluoperazineMonitor Closely (3)glycopyrrolate inhaled decreases levels of trifluoperazine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of trifluoperazine by pharmacodynamic antagonism. Use Caution/Monitor. trifluoperazine increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.Minor (1)trifluoperazine increases toxicity of glycopyrrolate inhaled by unknown mechanism. Minor/Significance Unknown.trihexyphenidylMonitor Closely (1)glycopyrrolate inhaled and trihexyphenidyl both decrease cholinergic effects/transmission. Use Caution/Monitor. Potential for additive anticholinergic effects.trimipramineMonitor Closely (2)glycopyrrolate inhaled and trimipramine both decrease cholinergic effects/transmission. Use Caution/Monitor. trimipramine increases levels of glycopyrrolate inhaled by unknown mechanism. Use Caution/Monitor.trospium chlorideMonitor Closely (1)glycopyrrolate inhaled and trospium chloride both decrease cholinergic effects/transmission. Use Caution/Monitor.umeclidinium bromideMonitor Closely (1)umeclidinium bromide and glycopyrrolate inhaled both decrease cholinergic effects/transmission. Use Caution/Monitor. If possible, avoid coadministration of additional anticholinergic agents umeclidinium bromide/vilanterol inhaledContraindicated (1)glycopyrrolate inhaled, umeclidinium bromide/vilanterol inhaled. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Duplicate therapy.vecuroniumMonitor Closely (1)glycopyrrolate inhaled and vecuronium both decrease cholinergic effects/transmission. Use Caution/Monitor.ziprasidoneMonitor Closely (3)glycopyrrolate inhaled decreases levels of ziprasidone by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of ziprasidone by pharmacodynamic antagonism. Use Caution/Monitor. ziprasidone increases effects of glycopyrrolate inhaled by pharmacodynamic synergism. Use Caution/Monitor. Additive anticholinergic effects, possible hypoglycemia.zotepineMonitor Closely (2)glycopyrrolate inhaled decreases levels of zotepine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. glycopyrrolate inhaled decreases levels of zotepine by pharmacodynamic antagonism. Use Caution/Monitor. 1-10% Upper respiratory tract infection (3.4%) Nasopharyngitis (2.1%) Oropharyngeal pain (1.8%) Urinary tract infection (1.4%) Sinusitis (1.4%) Contraindications Hypersensitivity Cautions Should not be initiated in patients with acutely deteriorating or potentially life-threatening episodes of COPD; also do not use for the relief of acute symptoms (ie, as rescue therapy) for treating acute episodes of bronchospasm Can produce paradoxical bronchospasm that may be life-threatening Immediate hypersensitivity reactions have been reported after administration of indacaterol or glycopyrrolate; if signs suggesting allergic reactions occur, in particular, angioedema (including difficulties in breathing or swallowing, swelling of the tongue, lips, and face), urticaria, or skin rash, therapy should be discontinued immediately and alternative therapy instituted; use drug with caution in patients with severe hypersensitivity to milk proteins Worsening of narrow-angle glaucoma or urinary retention may occur; use with caution in patients with prostatic hyperplasia, or bladder-neck obstruction and instruct patients to contact a physician immediately if symptoms occur Drug interaction overview Concomitant use with anticholinergic medications may cause additive anticholinergic effects; if possible, avoid coadministration Pregnancy There are no adequate and well-controlled studies in pregnant women; women should be advised to contact their physician if they become pregnant while receiving therapy Potential effect of therapy on labor and delivery unknown; drug should be used during labor and delivery only if potential benefit to patient justifies potential risk to fetus Animal data In animal reproduction studies, there were no evidence of fetal harm or structural abnormalities in Wistar rats or New Zealand White rabbits at inhaled doses approximately 1,400 and 530 times, respectively, the maximum recommended human dose (MRHD of 31.2 mcg) on an area under the curve (AUC) basis Lactation There are no data on the presence of glycopyrrolate or its metabolites in human milk, effects on breastfed infant, or on milk production; however, in a study of lactating rats, glycopyrrolate was present in the milk The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for therapy and any potential adverse effects on breastfed child from drug or from underlying maternal conditionPregnancy Categories A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk. B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available. Mechanism of Action Long-acting muscarinic antagonist (LAMA); often referred to as an anticholinergic; produces bronchodilation by inhibiting acetylcholine’s effect on muscarinic receptors in the airway smooth muscle Absorption Absolute bioavailability: 40% Peak plasma time: 5 minutes Distribution Protein bound: 38-41% Vd: 83-376 L Metabolism Hydroxylated to a variety of mono-and bishydroxylated metabolites and direct hydrolysis results in the formation of a carboxylic acid derivative (M9) M9 is hydrolyzed by multiple CYP isoenzymes Elimination Half-life: 33-53 hr (glycopyrrolate inhaled) Excretion: 60-70% urine; 30-40% nonrenal (mostly by metabolism; also biliary) Oral Inhalation Encapsulated powder for inhalation Do not swallow the capsules, as the intended effects on the lungs will not be obtained Seebri capsules should only be used with the Neohaler device Should be administered at the same time of the day, (1 capsule in the morning and 1 capsule in the evening), every day More frequent administration or a greater number of inhalations (>1 capsule BID) is not recommended Solution for inhalation Lonhala vials should be used with Magnair device for nebulization only; do not use Magnair with any other vials Should be administered at the same time of the day, (1 vial in the morning and 1 vial in the evening), every day Storage Encapsulated powder for inhalation Store in a dry place at controlled room temperature (25°C [77°F]); excursions permitted to 15-30°C (59-86°F) Store capsules in the blister package that they are packaged in, and only remove immediately before use with the Neohaler device Solution for inhalation Store vials in the protective foil pouch at 20-25°C (68-77°F) After opening the foil pouch, unused unit-dose vials should be returned to, and stored in, the foil pouch Once a foil pouch is opened, discard the vials if not used within 7 days An opened unit-dose vial should be used right away Discard any unit-dose vial if the solution is not colorless No images available for this drug. No images available for this drug.A Patient Handout is not currently available for this monograph.Print FormularyPatient DiscountsAdding plans allows you to compare formulary status to other drugs in the same class.To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.Create Your List of PlansAdding plans allows you to:View the formulary and any restrictions for each plan.Manage and view all your plans together – even plans in different states.Compare formulary status to other drugs in the same class.Access your plan list on any device – mobile or desktop. The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information. View explanations for tiers and restrictions Tier Description 1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs. 2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs. 3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs. 4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products. 5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products. 6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products. NC NOT COVERED – Drugs that are not covered by the plan. Code Definition PA Prior Authorization Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription. QL Quantity Limits Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered. ST