II. Indications

  1. Short acting agents for rescue use only

III. Adverse Effects: Scheduled short acting MDI use

  1. Loss of indicator for worsening Asthma
  2. Delays use of Inhaled Corticosteroid
  3. Increases airway hyper-reactivity
  4. Greater allergen exposure
    1. Treats only acute phase reaction
  5. Regular use associated with increased mortality
    1. Terbutaline may be more risk than other preparations
  6. Acute Coronary Syndrome risk in those with CAD risk
    1. Au (2002) Chest 121:846-51 [PubMed]

IV. Monitoring Use

  1. Most Metered Dose Inhalers supply 100-120 two spray doses
  2. Four times daily dosing will last one month
  3. In well controlled Asthma, Inhaler will last one year

V. Efficacy

  1. Albuterol HFA is at least as effective as CFC
    1. HFA replaces CFC Inhalers due to ozone depletion
    2. Less force and smaller plume than CFC Inhaler
    3. However small particle allows 2-3x lung deposition
    4. Less coordination needed in HFA firing and inhaling
    5. Spacer devices should still be used with HFA Inhalers
  2. Albuterol MDI as effective as Nebulizer in ER and home
    1. Used with spacer (and mask in younger children)
    2. See Spacer Devices for Asthma Inhalers
  3. Albuterol MDI has significant advantages over Nebulizer
    1. No special equipment or maintenance
    2. Uses only 10% of the amount Albuterol nebulized
    3. Minimal risk of contamination
  4. Reduced efficacy of Bronchodilators in the 20% of patients with arginine Genotype
    1. Israel (2001) Int Arch Allergy Immunol 124:183-6 [PubMed]
    2. Wechsler (2005) Am J Respir Crit Care Med 172(1):12-8 [PubMed]
  5. References
    1. Delgado (2003) Arch Pediatr Adolesc Med 157:76-80 [PubMed]
    2. Mandelberg (1997) Chest 112:1501-5 [PubMed]
    3. Newman (2002) Chest 121:1036-41 [PubMed]

VI. Technique: Hydrofluoroalkane Inhaler (HFA Inhaler)

  1. Prior to first use
    1. Shake new Inhaler for 45 seconds
    2. Prime Inhaler by spraying 3-4 puffs into air (do not inhale)
  2. Later uses
    1. Same technique as with CFC Inhalers
    2. Breath out, spray, and inhale deeply
    3. Hold breath for 10 seconds
    4. Wait one minute, while shaking Inhaler
    5. Repeat one more puff as above
  3. Other pointers
    1. Do not use "float test" (placing Inhaler in water) to see if has any medicine remaining
    2. Tally on the package the number of 2-puff doses used (expect about 100, 2-puff doses)

VII. Preparations: Short Acting

  1. Terbutaline (Brethaire)
    1. Cost: $14.68 per 30 days
    2. Dose: 2 puffs q4-6 hours
    3. Not as potently dosed as others
    4. Use for patients sensitive to adrenergic effects
  2. Pirbuterol (Maxair)
    1. Maxair Autohaler will be only CFC Inhaler on U.S. market
    2. Cost: $19.53 per 30 days
    3. Dose: 2 puffs q4-6 hours
  3. Albuterol (Ventolin, Proventil, ProAir HFA, ProAir RespiClick)
    1. Preparations
      1. ProAir HFA Inhalers
        1. Replaced CFC Inhalers
        2. Generic as of December 2016
      2. ProAir RespiClick (Dry Powder Inhaler, released 2015)
        1. Requires deep inhalation, but no spacer needed
        2. Approved age 12 years and older
    2. Cost
      1. Expensive ($50/Inhaler) - no generic HFA Inhalers (until december 2016)
    3. Dose
      1. Standard: 2 puffs q4-6 hours
      2. Severe COPD exacerbation: 6-8 puffs q1-2 hour (max)
  4. Levalbuterol (Xoponex): Active R-isomer of Albuterol
    1. Cost: $50 per month
    2. Dose: 2 puffs up to every 4-6 hours
    3. Benefit
      1. No benefit over Albuterol in most patients
      2. Less FEV1 decline with chronic use than Albuterol
      3. Hilaire (2007) Am fam Physician 75:247-8 [PubMed]
  5. Isoproterenol
    1. Dose: 2 puffs q3-4 hours
  6. Isoetharine
    1. Dose: 2 puffs q4 hours
  7. Metaproterenol
    1. Dose: 2 puffs q4-6 hours
  8. Bitolterol
    1. Dose: 2 puffs q4-6 hours

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Cost: Medications

ALBUTEROL (on 2/19/2015 at Target.com)
ALBUTEROL 2 MG/5 ML Syrup #90 for $10.00 $0.11 each
ALBUTEROL NEB (on 2/19/2015 at Target.com)
ALBUTEROL NEB 0.083%* Solution #90 for $10.00 $0.11 each
albuterol (on 8/17/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
ALBUTEROL 2.5 MG/0.5 ML SOL Generic $0.36 each
ALBUTEROL 5 MG/ML SOLUTION Generic $0.60 per ml
ALBUTEROL SUL 0.63 MG/3 ML SOL Generic $0.29 per ml
ALBUTEROL SUL 1.25 MG/3 ML SOL Generic $0.25 per ml
ALBUTEROL SUL 2.5 MG/3 ML SOLN Generic $0.04 per ml
ALBUTEROL SULF 2 MG/5 ML SYRUP Generic $0.02 per ml
ALBUTEROL SULFATE 2 MG TAB Generic $4.41 each
ALBUTEROL SULFATE 4 MG TAB Generic $3.96 each
ALBUTEROL SULFATE ER 4 MG TAB Generic $1.30 each
ALBUTEROL SULFATE ER 8 MG TAB Generic $2.23 each
ventolin (on 1/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
VENTOLIN HFA 90 MCG INHALER $2.73 per gram
proventil (on 1/7/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
PROVENTIL HFA 90 MCG INHALER $10.27 per gram
levalbuterol (on 8/17/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
LEVALBUTEROL 0.31 MG/3 ML SOL Generic $0.67 per ml
LEVALBUTEROL 0.63 MG/3 ML SOL Generic $0.63 per ml
LEVALBUTEROL 1.25 MG/3 ML SOL Generic $0.58 per ml
LEVALBUTEROL CONC 1.25 MG/0.5 Generic $5.25 each
xopenex (on 5/18/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
XOPENEX 1.25 MG/3 ML SOLUTION Generic $0.58 per ml
XOPENEX HFA 45 MCG INHALER $4.41 per gram

Ontology: Adrenergic beta-Agonists (C0001644)

Definition (MSH) Drugs that selectively bind to and activate beta-adrenergic receptors.
Concepts Pharmacologic Substance (T121)
MSH D000318
SnomedCT 349920008, 373227004
English beta Adrenergic Receptor Agonists, Adrenergic beta Agonist, Adrenergic beta Agonists, Adrenergic beta Receptor Agonist, Adrenergic beta Receptor Agonists, Adrenergic beta-Agonist, Adrenergic beta-Receptor Agonist, Adrenergic beta-Receptor Agonists, Agonist, Adrenergic beta-Receptor, Agonist, beta-Adrenergic, Agonist, beta-Adrenergic Receptor, Agonists, Adrenergic beta-Receptor, Agonists, beta-Adrenergic, Agonists, beta-Adrenergic Receptor, Receptor Agonist, beta-Adrenergic, Receptor Agonists, beta Adrenergic, Receptor Agonists, beta-Adrenergic, Receptors Agonists, Adrenergic beta, beta Adrenergic Agonist, beta Adrenergic Agonists, beta Adrenergic Receptor Agonist, beta-Adrenergic Agonist, beta-Adrenergic Receptor Agonist, beta-Adrenergic Receptor Agonists, beta-Agonist, Adrenergic, beta-Agonists, Adrenergic, beta-Receptor Agonist, Adrenergic, beta-Receptor Agonists, Adrenergic, Beta-Adrenergic Agonist, ADREN BETA AG, ADREN BETA RECEPT AGON, BETA ADREN AG, BETA ADREN AGON, ADREN BETA RECEPT AG, RECEPT AGON BETA ADREN, RECEPT AGON ADREN BETA, BETA ADREN RECEPT AG, ADRENERGIC RECEPTOR AGONISTS BETA, ADRENERGIC AGONISTS BETA, ADREN BETA AGON, BETA ADREN RECEPT AGON, beta-Adrenergic Agonists, Betamimetics, antiadrenergic beta receptor agents (medication), antiadrenergic beta receptor agents, adrenergic beta receptor agonists, Adrenergic beta-Agonists, beta-adrenergic receptor agonists, beta adrenergic agonist, beta-adrenergic agonist, beta-adrenergic agonists, agonists beta adrenergic receptor, beta adrenergic agonists, Adrenergic beta agonists, Beta-adrenoceptor agonist, Beta-adrenoceptor agonist (product), Beta-adrenoceptor agonist (substance), Beta-adrenergic Agonists
Swedish Adrenerga betastimulerare
Czech receptory adrenergní beta - agonisté
Portuguese Agonistas beta-Adrenérgicos, Agonistas dos Receptores Adrenérgicos beta, Agonistas Adrenérgicos beta, beta-Agonistas Adrenérgicos, Agonistas dos Receptores beta-Adrenérgicos, Agonistas dos beta-Receptores Adrenérgicos
Finnish Beeta-agonistit
French Agonistes beta-adrénergiques, Agonistes des adrénorécepteurs bêta, Bêta-adrénergiques, Bêta-stimulants, Sympathomimétiques bêta, Agoniste bêta-adrénergique, Agonistes bêta-adrénergiques, Agonistes des récepteurs bêta-adrénergiques, Bêta-mimétiques
Russian ADRENERGICHESKIE BETA-AGONISTY, ADRENORETSEPTOROV-BETA AGONISTY, BETA-ADRENORETSEPTOROV AGONISTY, ADRENERGICHESKIKH BETA-RETSEPTOROV AGONISTY, АДРЕНЕРГИЧЕСКИЕ БЕТА-АГОНИСТЫ, АДРЕНЕРГИЧЕСКИХ БЕТА-РЕЦЕПТОРОВ АГОНИСТЫ, АДРЕНОРЕЦЕПТОРОВ-БЕТА АГОНИСТЫ, БЕТА-АДРЕНОРЕЦЕПТОРОВ АГОНИСТЫ
Spanish Agonistas beta-Adrenérgicos, Agonistas de los beta-Receptores Adrenérgicos, Agonistas Adrenérgicos beta, Agonistas de los Receptores Adrenérgicos beta, Agonistas de los Receptores beta-Adrenérgicos, beta-Agonistas Adrenérgicos, agonista beta adrenérgico (producto), agonista beta adrenérgico (sustancia), agonista beta adrenérgico, agonista betadrenérgico (sustancia), agonista betadrenérgico
German ADRENERGE AGONISTEN BETA, Adrenerge Beta-Agonisten, Beta-Adrenomimetika, Beta-Rezeptorenagonisten
Polish Agoniści adrenergiczni beta, Beta-mimetyki, Agoniści receptora adrenergicznego beta
Japanese β-アドレナリン作動性受容体作用薬, β-作動剤, β-作動薬, β-作用薬, β-刺激薬, β-受容体作用薬, アドレナリンベータアゴニスト, アドレナリン作用性ベータ受容体作用薬, ベータアドレナリン作用性受容体作用薬, β作動薬, β刺激剤, β刺激薬, β受容体刺激薬, アドレナリン作用性ベータ受容体作用剤, アドレナリン作用性ベータ受容体作用物質, アドレナリン作用性ベータ受容器作用物質
Italian Beta-agonisti adrenergici

Ontology: Albuterol (C0001927)

Definition (MSH) A short-acting beta-2 adrenergic agonist that is primarily used as a bronchodilator agent to treat ASTHMA. Albuterol is prepared as a racemic mixture of R(-) and S(+) stereoisomers. The stereospecific preparation of R(-) isomer of albuterol is referred to as levalbuterol.
Definition (CHV) asthma inhaler
Definition (CHV) asthma inhaler
Definition (NCI) A racemic mixture of the r-isomer levalbuterol and s-albuterol, a short-acting sympathomimetic agent with bronchodilator activity. Albuterol stimulates beta-2 adrenergic receptors in the lungs, thereby activating the enzyme adenylate cyclase that catalyzes the conversion of adenosine triphosphate (ATP) to cyclic-3',5'-adenosine monophosphate (cAMP). Increased cAMP concentrations relax bronchial smooth muscle, relieve bronchospasms, and reduce inflammatory cell mediator release, especially from mast cells. Albuterol although to a lesser extent, also stimulates beta-1 adrenergic receptors, thereby increasing the force and rate of myocardial contraction.
Definition (CSP) short-acting beta2-adrenergic agonist with its main clinical use in asthma.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D000420
SnomedCT 326162005, 134493007, 372897005, 91143003
LNC LP17843-1, MTHU013596
English Albuterol, 1,3-Benzenedimethanol, alpha1-(((1,1-dimethylethyl)amino)methyl)-4-hydroxy-, 2-t-Butylamino-1-(4-hydroxy-3-hydroxy-3-hydroxymethyl)phenylethanol, Salbutamol [obstetric], albuterol, albuterol (medication), Albuterol [Chemical/Ingredient], salbutamol, Salbutamol [inhalation preparations 2] (product), Salbutamol [inhalation preparations 2], Salbutamol [obstetric] (product), ALBUTEROL, Salbutamol product, Albuterol (product), Albuterol (substance), Salbutamol [inhalation preparations 2] (substance), Salbutamol [obstetric] (substance), Salbutamol
Swedish Albuterol
Czech salbutamol, albuterol
Finnish Salbutamoli
French Albutérol, Salbutamol, 2-t-Butylamino-1-(4-hydroxy-3-hydroxy-3-hydroxyméthyl)phényléthanol
Italian 2-t-Butilamino-1-(4-idrossi-3-idrossi-3-idrossimetil)feniletanolo, Salbutamolo, Albuterolo
Russian SAL'BUTAMOL, AL'BUTEROL, АЛЬБУТЕРОЛ, САЛЬБУТАМОЛ
Japanese 硫酸サルブタモール, アルブテロール, サルブタモール
Spanish albuterol (producto), salbutamol, salbutamol (producto), Salbutamol [inhalation preparations 2], Salbutamol [inhalation preparations 2] (product), salbutamol [obstétrico], salbutamol [preparaciones para inhalación 2], salbutamol [preparaciones para inhalación 2] (producto), salbutamol [obstétrico] (producto), albuterol (sustancia), albuterol, Albuterol, Salbutamol
Croatian ALBUTEROL
Polish Salbutamol, Albuterol
German Albuterol
Portuguese Albuterol, Salbutamol

Ontology: Bronchodilator Agents (C0006280)

Definition (NCI_NCI-GLOSS) A type of drug that causes small airways in the lungs to open up. Bronchodilators are inhaled and are used to treat breathing disorders, such as asthma or emphysema.
Definition (MSH) Agents that cause an increase in the expansion of a bronchus or bronchial tubes.
Definition (CSP) agent that causes an expansion of the lumen of a bronchus or bronchiole.
Concepts Pharmacologic Substance (T121)
MSH D001993
SnomedCT 116091006, 300900000, 373241008, 353866001, 372580007
LNC LP31460-6
English Agents, Bronchodilator, Bronchodilator Agents, Agents, Bronchial-Dilating, Bronchial Dilating Agents, Bronchial-Dilating Agents, Bronchodilators, lumen dilator, bronchodilators, bronchodilator agents, bronchodilators (medication), bronchodilator, Bronchodilator (product), Bronchodilator agents (substance), Bronchodilator agents, Bronchodilator preparations, Bronchodilator, Bronchodilator (substance), Bronchodilator preparations (product), Bronchodilator preparations (substance)
French Agents bronchodilatateurs, Bronchodilatateurs
Swedish Bronkvidgande medel
Czech bronchodilatancia
Finnish Bronkodilataattorit
Russian BRONKHORASSHIRIAIUSHCHIE SREDSTVA, БРОНХОРАСШИРЯЮЩИЕ СРЕДСТВА
Japanese 気管支拡張剤, 気管支拡張薬
Croatian BRONHODILATORI
Polish Leki rozszerzające oskrzela, Środki broncholityczne
Portuguese Dilatadores Brônquicos, Efeito Broncodilatador, Agentes Broncodilatadores, Dilatadores Bronquiais, Fármacos Broncodilatadores, Broncodilatadores
Spanish Dilatadores Bronquiales, Broncodilatadores, agentes broncodilatadores, broncodilatador (producto), agentes broncodilatadores (sustancia), Agentes Broncodilatadores, Efecto Broncodilatador, Fármacos Broncodilatadores, broncodilatador (sustancia), broncodilatador, preparaciones con broncodilatadores (producto), preparaciones con broncodilatadores (sustancia), preparaciones con broncodilatadores
German Bronchienerweiternde Mittel, Bronchodilatatoren
Italian Broncodilatatori

Ontology: Ventolin (C0033744)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D000420
French Ventoline
English ventolin, Ventolin

Ontology: pirbuterol (C0071129)

Definition (NCI) A short-acting, beta-adrenergic receptor agonist with bronchodilator activity. Pirbuterol selectively binds to beta-2 adrenergic receptors in bronchial smooth muscle, thereby activating intracellular adenyl cyclase, an enzyme that catalyzes the conversion of adenosine triphosphate (ATP) to cyclic-3',5'-adenosine monophosphate (cAMP). Increased cAMP levels cause relaxation of bronchial smooth muscle, relieve bronchospasms, improve mucociliary clearance and inhibit the release of mediators of immediate hypersensitivity from cells, especially from mast cells.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C009118
SnomedCT 108611006, 372516006
English pirbuterol, pyrbuterol, pirbuterol (medication), pirbuterol [Chemical/Ingredient], PIRBUTEROL, Pirbuterol, Pirbuterol (product), Pirbuterol (substance)
Spanish pirbuterol (producto), pirbuterol (sustancia), pirbuterol

Ontology: Proventil (C0699770)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D000420
French Proventil
English proventil, Proventil

Ontology: Brethaire (C0701015)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D013726
English brethaire, AstraZeneca Brand of Terbutaline, Brethaire, Terbutaline AstraZeneca Brand

Ontology: Maxair (C0721597)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C009118
English Maxair, 3M brand of pirbuterol acetate, maxair

Ontology: Levalbuterol (C0772501)

Definition (NCI) A short-acting sympathomimetic beta-2 adrenergic receptor agonist with bronchodilator activity. Levalbuterol binds to beta-2 adrenergic receptors in bronchial smooth muscle and activates intracellular adenyl cyclase, an enzyme that catalyzes the conversion of adenosine triphosphate (ATP) to cyclic-3',5'-adenosine monophosphate (cAMP). Increased cAMP levels lead to the activation of protein kinase A, which inhibits the phosphorylation of myosin and lowers intracellular ionic calcium concentrations, resulting in relaxation of bronchial smooth muscles. The increased cAMP concentrations also inhibit the release of inflammatory mediators, especially from mast cells.
Definition (MSH) The R-isomer of albuterol.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D064412
SnomedCT 116090007, 398965008
LNC LP171617-6
English Levalbuterol [Chemical/Ingredient], Levalbuterol, LEVALBUTEROL, levalbuterol, Levalbuterol (product), Levalbuterol (substance)
Czech levalbuterol
French Levalbutérol, Lévosalbutamol
German Levosalbutamol, Levalbuterol
Italian Levalbuterolo
Russian КСОПЕНЕКС, LEVALBUTEROL, ЛЕВАЛЬБУТЕРОЛ, ЛЕВАЛБУТЕРОЛ, LEVAL'BUTEROL, KSOPENEKS
Spanish levalbuterol (producto), levalbuterol (sustancia), levalbuterol, levo-salbutamol

Ontology: Xopenex (C0876218)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D064412
English xopenex, Xopenex
Czech Xopenex
French Xopenex
German Xopenex