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Cystic Fibrosis Pregnancy: Use with caution — limited data; consider risk/benefit with specialist

Mannitol (Inhaled)

Brand names: Bronchitol

Adult dose

Dose: 400 mg (10 x 40 mg capsules) twice daily
Route: Inhalation via Bronchitol inhaler device
Frequency: Twice daily
Max: 400 mg BD
Initiation dose tolerance test (DTT) mandatory before first treatment course. Use Bronchitol-specific inhaler only. Administer before physiotherapy. Licensed for CF aged >=6 years where dornase alfa suboptimal or not tolerated. Salbutamol 15 min before each dose.

Paediatric dose

Route: Inhalation
Frequency: Twice daily
Max: 400 mg BD
Licensed from age 6 years. Same adult dose. DTT mandatory before initiation.

Dose adjustments

Renal

No adjustment required

Hepatic

No adjustment required

Clinical pearls

  • Mannitol challenge test is used diagnostically for asthma (indirect bronchoprovocation) — completely separate use from Bronchitol in CF; do not confuse these
  • Dose tolerance test (DTT): increasing doses of mannitol with FEV1 at 60 sec after each step; >=15% FEV1 fall = treatment contraindicated
  • MAN-01 trial (Bilton et al. Thorax 2013): 400 mg BD improved FEV1 and reduced exacerbations in CF patients not on dornase alfa
  • Mechanism: osmotic hydration of airway surface liquid — similar to hypertonic saline but delivered as dry powder via DPI
  • Must use only the Bronchitol inhaler device — not interchangeable with other DPI devices

Contraindications

  • Non-CF bronchiectasis (not licensed)
  • Mannitol tolerance test failure (bronchoconstriction)
  • Hypersensitivity to mannitol
  • Avoid combining routinely with dornase alfa — clinical trial exclusion

Side effects

  • Bronchospasm (prevent with salbutamol pre-treatment)
  • Cough
  • Haemoptysis
  • Chest discomfort
  • Nausea
  • Decreased FEV1 after dose (transient)

Interactions

  • Salbutamol — use as pre-treatment 15 min before each dose

Monitoring

  • FEV1 pre and post DTT
  • FEV1 and FVC at follow-up
  • Haemoptysis
  • Exacerbation frequency

Reference: BNFc; BNF 90; BNFc; MAN-01 Trial (Bilton et al. Thorax 2013); NICE TA266; SPC Bronchitol. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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