Glycopyrrolate and neostigmine, quaternary ammonium compounds, bearing a positively charged ionic nitrogen, pass the placenta with greater difficulty than nonionic compounds (e.g., atropine). Atropine Hyoscine Glycopyrrolate Use Antisialogogue Mx reflex mediated ↓HR, with anticholinesterase Discuss the clinical implications of these differences . Glycopyrrolate is not as effective at increasing HR as is atropine – but it is still used as much, if not more, for this purpose (more especially in adult populations). Consequently it has no central effects, and is thus an alternative to atropine in the elderly patient. It is a Important aspect of glycopyrrolate – Glycopyrrolate does not cross the blood brain barriers (BBB) ,,,,, due its polar (charged) structure ,, & therefore does not exert CNS effects. Glycopyrrolate, being about twice as potent as atropine in the clinical situation, was used in half the dosage of atropine. Glycopyrrolate: a synthetic quaternary amine. Glycopyrrolate 0.005-0.01 mg/kg IM and IV Up to 5 minutes (IV) 30-45 minutes (IM) Up to 1 hour (IV) 60-90 minutes (IM) No Table 1: Atropine vs. glycopyrrolate – drug effects on the cardiovascular system similar in dogs and cats *Depending on the dose of anticholinergic given, it is not uncommon to see a worsening of the The mechanism of action of aluminum chloride is ... Glycopyrrolate is used off label for the treatment of primary hyperhidrosis. | CO# 1 & 2 ... Glycopyrrolate. [13] It is used no more than once every 24 hours on both underarms. It is advantageous over atropine in that it does NOT cross the blood-brain barrier. This condition results from excessive activity of afferent neurons whose stretch receptors are in the carotid sinus.By reflex mechanisms,this excessive affer-ent input to the medulla oblongata causes pronounced bradycardia, which is reversible by atropine. Mechanism of Action Glycopyrrolate, 3[(cyclopentylhydroxyphenyl-acetyl)oxy]-1,1-dimethyl pyrrolidinium bromide, inhibits the action of acetylcholine on peripheral acetylcholine (muscarinic) receptors on smooth muscle, cardiac muscle, the sinoatrial and atrioventricular nodes, exocrine glands, and to a lesser degree, autonomic ganglia. Glycopyrrolate reduces volume and acidity of gastric secretions at therapeutic doses. 15: 329 – Scopolamine - Medical Countermeasures Database. Atropine: Mechanism of Action. [13] . 3. Glycopyrrolate; Propantheline. Glycopyrrolate and atropine were compared as to their effects on heart rate, arrhythmias, blood pressure, and volume of oropharyngeal secretions. Thus, the use of therapy with anticholinergics and β2-agonists, either simultaneously or in sequence, has produced positive as well as negative results in trials. Mechanism of action Glycopyrronium is a muscarinic antagonist with the highest affinity for M1 receptors, followed by M3, M2/M4, and M5. Atropine: used IV in ACLS protocol for symptomatic bradycardia; Glycopyrrolate: used as an anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. Alon Winnie. Rautakorpi P, Ali-Melkkila T, Kaila T, et al. Glycopyrrolate occurs as a white, odorless crystalline powder. Atropine administration in pregnant women may cause fetal tachycardia and a decrease in beat-to-beat variability of the fetal heart rate. What is glycopyrrolate? atropine. Little or no CNS effects with glycopyrrolate. In the airways, glycopyrrolate exhibits pharmacological effects through inhibition of M3 receptor at the smooth muscle leading to bronchodilation. Glycopyrrolate is among the more common anticholinergic medications. Atropine, as detailed below, is a nonselective muscarinic antagonist. Atropine competitively blocks the effects of acetylcholine, including excess acetylcholine due to organophosphorus poisoning, at muscarinic cholinergic receptors on smooth muscle, cardiac muscle, secretory gland cells, and in peripheral autonomic ganglia and the central nervous system. Table 1: Atropine vs. glycopyrrolate – drug effects on the cardiovascular system similar in dogs and cats *Depending on the dose of anticholinergic given, it is not uncommon to see a worsening of the bradycardia before HR increases. The combination of neostigmine with either atropine or glycopyrrolate did not significantly increase the overall incidence (0–24 h) of vomiting (P=0.48) or nausea (P=0.08). Several studies have demonstrated that glycopyrrolate is superior to atropine because its anticholinergic effects are more prolonged, lasting several hours. 1982,1983 The heart rate changes minimally after IV administration, causing fewer arrhythmias and offering an advantage when tachycardia might be detrimental. Pharmacokinetics. – This is unlike other commons antimuscarinics such as atropine which are non-polar (uncharged) and can cross the BBB . Mechanism of Action Ipratropium bromide is an anticholinergic (parasympatholytic) agent which, based on animal studies, appears to inhibit vagally mediated reflexes by antagonizing the action of acetylcholine, the transmitter agent released at neuromuscular junctions in the lung. Mechanism of action: Glycopyrrolate is a quaternary ammonium anticholinergic agent. Glycopyrrolate protects against neo- stigrnine-induced bradycardia, produces less initial tachycardia, causes a lower incidence of cardiac arrhythmias, and is a superior oropharyngeal drying agent. Mechanism of Action of Glycopyrrolate It inhibits the action of acetylcholine like other anticholinergic (antimuscarinic) agents, on structures innervated by postganglionic cholinergic nerves and on smooth muscles that respond to acetylcholine but lack cholinergic innervations. The two anticholinergics, atropine and glycopyrrolate, were used for premedication and as an adjunct to reversal of residual neuromuscular block in a double-blind study. Tachycardia The most likely response after intramuscular administration of atropine, glycopyrrolate, or scopolamine for premedication is an increase in heart rate, which may indicate a weak cholinergic antagonist effect of these drugs. Enhancing Healthcare Team Outcomes Concentrations of glycopyrrolate in umbilical venous and aterial blood and in the amniotic fluid are low after intramuscular administration to parturients. Palliative Medicine. It is thus possible that the action on M4 muscarinic receptors in the salivary glands may be responsible for the improvement in sialorrhea. Mechanism Of Action. The onset of action is 15 to 30 minutes following intramuscular (IM) injection. Atropineand glycopyrrolate are parasympatholytic agents that competitivelyblock the action of acetylcholine at muscarinic receptors. Strength of the present study is that, we compared the antiemetic efficacy of 3 drugs with different mechanism of action. 3. HR should increase within 5-10 minutes, … 2009a(4)/1999a(11): Compare & contrast atropine and glycopyrrolate. Glycopyrronium competitively blocks muscarinic receptors, thus inhibiting cholinergic transmission. glycopyrrolate. i.e., glycopyrrolate or atropine. 1984,1985 It should be noted that prolonged and … carbachol increases and atropine decreases cholinergic effects/transmission. ... pharmacological actions by glycopyrronium bromide is qualitatively similar to that of the naturally occurring alkaloids atropine and scopolamine, but differs with regard to duration and intensity. Glycopyrrolate, being about twice as potent as atropine in the clinical situation, was used in half the dosage of atropine. Animal studies indicate that this action is achieved via a dual mechanism: Atropine, a naturally occurring belladonna alkaloid, is a racemic mixture of equal parts of d- and l-hyoscyamine, whose activity is due almost entirely to the levo isomer of the drug. Cardiac action: The atropine results in modifications of the heart rate. Atropine isa naturally occurring tertiary amine that crosses the blood-brainbarrier and shares significant structural and functional similaritywith scopolamine, homatropine, and ipratropium. Anticholinergic drugs can help treat a variety of conditions, including chronic obstructive pulmonary disease, bladder conditions, gastrointestinal disorders, and symptoms of Parkinson’s disease. Name of Chemical Defense therapeutic agent/device. After IM administration of glycopyrrolate to adults, the mean half-life value is … onset of action of glycopyrrolate on the cardiovascu-lar system is slower than that of atropine. Mechanism of action. We contend that the placental passage of neostigmine, which produces a pronounced pharmacologic effect, exceeds that of glycopyrrolate. Glycopyrrolate is excreted unchanged primarily in the bile and urine. Chemical Defense therapeutic area (s) Scopolamine is an anticholinergic anticonvulsant that has been studied for use against organophosphate intoxication. In the present study, placental transfer and maternal and fetal hemodynamic effects of atropine and glycopyrrolate were compared in chronically and in acutely instrumented, unanesthetized pregnant ewes. With 3rd-degree block, there is a complete block and disassociation of the electrical activity that is occurring in the atria and ventricles. Strength of the present study is that, we compared the antiemetic efficacy of 3 drugs with different mechanism of action. This activity outlines the indications, mechanism of action, safe administration, adverse effects, contraindications, toxicology, and monitoring of atropine. Pyridostigmine is a medication used to treat myasthenia gravis. For reversal of anaesthesia, along with neostigmine, atropine was used in order to avoid bias instead of glycopyrrolate which is otherwise used routinely which further adds to the strength of the study. Effect of interaction is not clear, use caution. blockade can be overcomeby raising the concentration of endogenous ligand (ACh) or cholinergic agonist at the receptors. Mechanism of Action. Therefore, glycopyrrolate does not appear to … Atropine is commonly classified as an anticholinergic or antiparasympathetic (parasympatholytic) drug. It is used no more than once every 24 hours on both underarms. Use Caution/Monitor. Antimuscarinic drugs bind to post-synaptic muscarinic receptors, competitively block the binding of ACh . The duration of action of glycopyrrolate is approximately 2–4 hours while that of atropine is approximately 60–90 minutes (Muir and Hubbell, 1989). Use Caution/Monitor. Glycopyrronium bromide affects the gastrointestinal tracts, liver and kidney but has a very limited effect on the brain and the central nervous system. Glycopyrrolate comes as a tablet and solution (liquid) to take by mouth. Neostigmine metilsulfate is a quaternary ammonium anticholinesterase. Mechanism of action Atropine binds to and inhibit muscarinic acetylcholine receptors, producing a wide range of anticholinergic effects. 1999a(11): Briefly compare and contrast the clinical pharmacology of atropine, hyoscine (scopolamine) and glycopyrrolate. What is glycopyrrolate, and how does it work (mechanism of action)? The topical formulation is available as a single-use cloth pre-moistened with a 2.4% glycopyrronium solution. Penetration of glycopyrrolate and [3] atropine through the blood-brain barrier in children. Glycopyrrolate helps to control conditions such as peptic ulcers that involve excessive stomach acid production. Mechanism of Action Blocks progesterone receptors in the decidua (lining of uterus): Endometrial lining breaks down When u …. Muscarinic effects. The recom- drugs. ... Glycopyrrolate (Duration of action) 2 - 4 hours. Indications, dose, contra-indications, side-effects, interactions, cautions, warnings and other safety information for GLYCOPYRRONIUM BROMIDE. 2. Glycopyrrolate is a synthetic anti-cholinergic medication. It occurs naturally in the Calabar bean and the Manchineel tree. J Pain Sympt Manage, in press, 2012 Back, I. N., Jenkins, K., Blower, A., Beckhelling, J., 2001 A Study Comparing Hyoscine Hydrobromide and glycopyrrolate in the treatment of death rattle. The role for anticholinergic medications in acute asthma is not well-defined. Glycopyrrolate as a Substitute for Atropine in Neostigmine Reversal of Muscle Relaxant Drugs. Glycopyrrolate belongs to a class of drugs known as anticholinergics. Atropine, a naturally occurring belladonna alkaloid, is a racemic mixture of equal parts of d- and l-hyoscyamine, whose activity is due almost entirely to the levo isomer of the drug. Atropine vs Glycopyrrolate l. Tachycardias not as extreme with glycopyrrolate. N/A ... acetyl cholinesterase inhibitors are combined with a muscarinic receptor antagonist such as Glycopyrrolate or Hyoscine or Atropine to offset the muscarinic activation resulting from esterase inhibition Pharmacokinets of Atropine Main Differences of Beta Blocker vs. Calcium Channel Blocking Medications. Glycopyrrolate has a more gradual onset and longer duration of action than atropine. Atropine, Dicyclomine, Glycopyrrolate, Hyoscyamine, Donnatal, Propantheline. Randomized double blind trial of sublingual atropine vs. Mechanism of Action of Atropine + Prednisolone (Eye Pre.) Therefore, the current recommendations for the use of these drugs in the emergency department (ED) and hospital management of asthma … Unlike atropine, glycopyrrolate in normal doses (0.004 mg/kg) does not appear to affect fetal heart rate or fetal heart rate variability to a significant degree. J Pharmacol Exp Ther 2009 Aug; 330 (2): 660-8 mended initial dosage of glycopyrrolate oral solution in these 6. It selectively inhibits the muscarinic receptors and antagonizes the muscarine like actions of Acetyl choline The improvement of our patient’s sialorrhea with atropine drops suggests a mechanism with possible muscarinic receptor involvement. It takes 24 hours to reach steady state and for acute symptoms other drugs should be used. Inhaled glycopyrrolate is thus of value as both monotherapy and in combination with other classes of medication for maintenance treatment of COPD. Atropine increases the firing of the sinoatrial node (atria) and conduction through the atrioventricular node (AV) of the heart by blocking the action of the vagus nerve. Atropine (Mechanism of action) Blocks acetylcholine (ACH - neurotransmitter) at muscarenic receptors at terminal ends of the parasympathetic nervous system. Atropine, Dicyclomine, Glycopyrrolate, Hyoscyamine, Donnatal, Propantheline. Glycopyrrolate (Analgesia) No analgesic effect. ... longer duration of effect vs. atropine; Injectable preparations; Similar adverse effects as atropine; The major differences between beta blocker and calcium channel medications exist in the mechanism of action in the nervous system with the beta blockers acting on beta receptors and calcium channel blockers performing their function on the calcium channels. Acetylcholine is the neurotransmitter for the entire parasympathetic nervous system (parasympathetic ganglions and effector cells), parts of the sympathetic nervous system (sympathetic ganglions, adrenal … atropine IV/IM and glycopyrrolate both decrease cholinergic effects/transmission. We contend that the placental passage of neostigmine, which produces a pronounced pharmacologic effect, exceeds that of glycopyrrolate. Atropine Mechanism of Action 1. The clinical significance of this is unclear. The two anticholinergics, atropine and glycopyrrolate, were used for premedication and as an adjunct to reversal of residual neuromuscular block in a double-blind study. Glycopyrrolate, being about twice as potent as atropine in the clinical situation, was used in half the dosage of atropine. Effect of Atropine or Glycopyrrolate on the Prevention of Bradycardia During Sedation Using Dexmedetomidine in Adult Patients Undergoing Lower Extremity Surgery Under Spinal Anesthesia The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. In low doses, a slight slowing of the heart is attributed to the incidental parasympathetic effect and central vagal stimulation that leads to a short term increase of acetylcholine. GLYCOPYRROLATE AND ATROPINE IN THE PREVENTION OF BRADYCARDIA AND ARRHYTHMIAS FOLLOWING REPEATED DOSES OF SUXAMETHONIUM IN CHILDREN D. W. GREEN, A. S. E. BRISTOW AND M. FISHER SUMMARY The effectiveness of administration of grycopyrrolate 5 and 10 fig kg' an d atropine 10 and 20 fig kg'1 i.v. Mechanism of Action. Glycopyrrolate is a synthetic quaternary amine that crosses the blood-brain barrier poorly and is less likely than atropine to cause altered mental status or tachycardia. 2. Atropine acts as a competitive, reversible antagonist of muscarinic receptors: an anticholinergic drug. Glycopyrrolate is also used to reduce drooling in children ages 3 to 16 who have certain medical conditions, such as cerebral palsy.. Glycopyrrolate injection is also used during surgery to reduce secretions in your stomach or … We found no significant difference in outcome between patients treated prior to ECT with atropine versus glycopyrrolate, as assessed by the above measures. 4. To reduce saliva and drooling in children with certain medical conditions, the solution is usually taken 3 times a day. In horse studies, after a single intravenous infusion, the observed tendencies of glycopyrronium … Mechanism of Action of Atropine Atropine is an anticholinergic drug. Urinary antispasmotic agents: Flavoxate, Oxybutynin , Propantheline ,Tolterodine dicyclomine - bentyl® Dicyclomine relieves smooth muscle spasm of the gastrointestinal tract. Atropine Versus Glycopyrrolate in Preventing Spinal Anesthesia Induced Hypotension in Lower Limb Surgeries The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. carbachol increases and glycopyrrolate decreases cholinergic effects/transmission. It is also used together with atropine to end. Mechanism of action of anticholinergic medications. Shankar Ramamurthy. Retained respiratory secretions can be treated with anticholinergic agents such as atropine, scopolamine or glycopyrrolate, and by turning the patient to the side (Back 2001, Wildiers 2002). Download PDF. Glycopyrrolate and neostigmine, quaternary ammonium compounds, bearing a positively charged ionic nitrogen, pass the placenta with greater difficulty than nonionic compounds (e.g., atropine). Glycopyrrolate has a more gradual onset and longer duration of action than atropine. ECFA Egypt. Pharmacol Toxicol patients is 0.02 mg/kg three times daily. It is a more potent anti-sialogogue than atropine, but has slightly weaker cardiac effects. If atropine is unavailable or in limited supply, intravenous glycopyrrolate or diphenhydramine may provide an alternative anticholinergic agent for treating muscarinic toxicity; however, glycopyrrolate does not cross the blood-brain barrier and cannot treat central effects of … The two anticholinergics, atropine and glycopyrrolate, were used for premedication … Animal studies indicate that this action is achieved via a dual mechanism: Mechanism of action Glycopyrrolate is an anticholinergic agent which inhibits the acetylcholine activity on smooth muscles and structures innervated by postganglionic nerves.2 This results in bronchodilation, decreased volume and acidity of gastric secretions, as well as control of excessive pharyngeal, tracheal and bronchial secretions.2 Atropine and other anticholinergic drugs (e.g., glycopyrrolate) are frequently applied as parasympatholytic agents in emergency cases with severe bradycardia, particularly high-degree atrioventricular (AV) block, and during anesthesiologic and diagnostic procedures. Mechanism of action: Glycopyrrolate is a quaternary ammonium anticholinergic agent. 1 , 19 , 16 Secretions from salivary 4 and sweat 5 glands, as well as gastric acid secretions, 6 are … It has approximately twice the potency of atropine. The primary clinical use of cholinesterase inhibitors, also called anticholinesterases, is to reverse nondepolarizing muscle blockade. This review covers the mechanism of action of inhaled glycopyrrolate, including its pharmacokinetic, pharmacodynamic, and safety profiles, and effects on mucus secretion. Glycopyrrolate Injection, USP is a clear, colorless, sterile liquid; pH 2.0 to 3.0. The scopolamine patch releases ~1 mg over 72 hours. Start studying atropine vs Glycopyrrolate. This activity outlines the indications, mechanism of action, dosing, important adverse effects, contraindications, monitoring, the toxicity of glycopyrrolate. This is thought to be due to blockade of presynaptic M 1 receptors that normally inhibit acetylcholine release. Placebo for the management of death rattle. Mechanism of Action: Glycopyrrolate is a long-acting muscarinic antagonist which is often referred to as an anticholinergic. Glycopyrrolate has five times the anti-secretory potency compared to atropine but is poorly and erratically absorbed orally. ... glycopyrrolate. This review covers the mechanism of action of inhaled glycopyrrolate, including its pharmacokinetic, pharmacodynamic, and safety profiles, and effects on mucus secretion. It has similar affinity to the subtypes of muscarinic receptors M1 to M5. Atropine can be useful in patients with carotid sinus syncope. and inhibit their action.2. Survey of Anesthesiology, 1973. Objective: To determine the drug therapy effects of atropine alone and the combined therapy of atropine and glycopyrrolate in patients with organophosphate poisoning. In this case, atropine eye drops were given sublingually, as is common practice in many hospices and palliative care units. Anticholinergic drugs competitively inhibit binding of the neurotransmitter, acetylcholine. For reversal of anaesthesia, along with neostigmine, atropine was used in order to avoid bias instead of glycopyrrolate which is otherwise used routinely which further adds to the strength of the study. Download Full PDF Package. This makes it advantageous in avoiding the CNS affects of atropine and scopolomine. Atropine About Atropine Anti-cholinergic,Belladona alkaloid, Antidote ,Antispasmodic Agent,antiarrythmic,vagolytic , Mydriatic. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The injectable forms of glycopyrrolate and atropine bear an FDA-approved indication for use in peri-operative secretion reduction, though neither has explicit approval for the reduction of noisy breathing near death. Mechanism of action. Glycopyrrolate works by blocking acetylcholine activity on smooth muscles and other tissues. It is used perioperatively as a muscarinic receptor antagonist. There was no significant increase in the risk of vomiting with standard (2.5 mg) compared with smaller (1.5 mg) doses of neostigmine. Glycopyrrolate has a more gradual onset and longer duration of action than atropine. COMPARISON OF I.V. Glycopyrrolate is strongly ionised and therefore unable to cross the blood-brain barrier. Anticholinergic effects last up to 7 hours after parenteral administration, and vagal inhibition lasts 2 to 3 hours. Whereas the nicotinic receptor is blocked via the NMBA, neostigmine’s effect on the muscarinic receptor results in increased bronchospasms, gastric motility, secretions, and bradycardia. Vavetsi 2008 evaluated outpatients with bradycardia for the effectiveness of atropine or isoproterenol (a beta-agonist with similar mechanism of action compared to epinephrine). 16 Muscarinic receptors M1 to M4 are found in the lung, although M3 is predominantly responsible for bronchoconstriction and airway secretions. … It is soluble in water and alcohol, and practically insoluble in chloroform and ether. Neostigmine metilsulfate is a quaternary ammonium anticholinesterase. Onset of action IM, IV Atropine 15-20 … Atropine and glycopyrrolate have minimal effects upon blood pressure unless cardiac output is highly dependent upon heart rate. (Clark 2002) However, its use … Urinary antispasmotic agents: Flavoxate, Oxybutynin , Propantheline ,Tolterodine dicyclomine - bentyl® Dicyclomine relieves smooth muscle spasm of the gastrointestinal tract. The topical formulation is available as a single-use cloth pre-moistened with a 2.4% glycopyrronium solution. These results clearly show that glycopyrrolate in the doses used produces no significant effect on either intraocular pressure or pupil size. Evidence-based medicine for Chemical Defense. Inhaled glycopyrrolate is thus of value as both monotherapy and in combination with other classes of medication for maintenance treatment of COPD. ... Glycopyrrolate in doses of 1-2 mg, I.V., (0.025 mg/kg in children) has been suggested as an alternative to atropine, and is said to have fewer CNS side effects. Glycopyrrolate has a 2 to 4-hour duration of action after intravenous administration, while atropine has 30 minutes. Heisler M et al. Reversal of neuromuscular blockade (NMB) can occur by ... mechanism ofaction. Atropine-refractory bradycardias might be responsive to epinephrine. Unlike atropine, glycopyrrolate is completely ionized at physiological pH values. In premedication, the primary indication is the inhibition of salivation. The incidence of CRBD was significantly lower in the glycopyrrolate group than in the atropine group at 0 h (65 % vs. 89 %, p = 0.025) and 1 h (54 % vs. 89 %, p = 0.002) postoperatively. Mode of Action Vagally mediated reflex bronchoconstriction Irritant aerosols, cold air, high flows, smoke, fumes, histamine release Afferent impulse to CNS = reflex cholinergic efferent impulse = bronchospasm + cough + mucus Can be blocked by competitive inhibitors of acetylcholine Pharmacology. Atropine and glycopyrrolate competitively block the action of acetylcholine at muscarinic receptors. 1. Glycopyrrolate has a 2 to 4-hour duration of action after intravenous administration, while atropine has 30 minutes. Cardiovascular Action. How to use glycopyrrolate oral . Apply knowledge of a drugs mechanism of action and disease pathophysiology in the development of a therapeutic plan that includes correct dosing, and correct monitoring for effectiveness. They target either muscarinic acetylcholine receptors or, … glycopyrrolate inhaled. The mechanism of action described below for the individual components applies to BEVESPI AEROSPHERE. Atropine is commonly classified as an anticholinergic or antiparasympathetic (parasympatholytic) drug. Atropine is a muscarinic receptor antagonist that is used to inhibit the effects of excessive vagal activation on the heart, which is manifested as sinus bradycardia and AV nodal block.Therefore, atropine can temporarily revert sinus bradycardia to normal sinus rhythm and reverse AV nodal blocks by removing vagal influences. For the treatment of ulcers, the tablet is usually taken 2 or 3 times a day. Patients and methods: Total one hundred patients with history of organophosphorus Take this medication by mouth, usually 2 to 3 times a day or as directed by your doctor. These drugs represent two different classes of medications (an anticholinergic, and a long-acting selective beta 2 -adrenoceptor agonist) that have different effects on clinical physiology and inflammatory indices of COPD.
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glycopyrrolate vs atropine mechanism of action