III. Precautions

  1. Risk of increased mortality and of more severe and life threatening Asthma Exacerbations are FDA Black Box Warnings
    1. Postulated to mask a patients awareness of severe Asthma Exacerbation
  2. Not a substitute for Inhaled Corticosteroids
    1. Steroids are key management of persistent Asthma
    2. Long-acting Beta Agonists are in addition to Inhaled Corticosteroids
    3. Lazarus (2001) JAMA 285:2583-93 [PubMed]
  3. Do NOT exceed dosing schedule (e.g. Serevent bid)
    1. Use a short acting Beta agonist for rescue use
  4. Tolerance over time to Protective effect
    1. Effect diminishes over one month of use
    2. Reference
      1. Simons (1997) Pediatrics 99:655-9 [PubMed]

IV. Preparations: Long-acting Beta Agonists

  1. Salmeterol (Serevent) Dry Powder Diskus (50 ug/inhale)
    1. One inhalation every 12 hours
  2. Serevent Inhalation aerosol MDI (21 ug/puff)
    1. Adults: 2 puffs every 12 hours
    2. Child: 1-2 puffs every 12 hours
  3. Formoterol (Foradil)
    1. One inhalation every 12 hours
  4. Indacaterol (Arcapta)
    1. Once daily dosing
    2. FDA approved for COPD (not proven to prevent COPD exacerbations)
    3. Same cardiovascular risks as other long acting beta agonists
    4. Reference
      1. (2012) presc lett 19(1): 2
  5. Arformoterol (Brovana)
    1. Dose: 15 mcg twice daily

V. Preparations: Combination of Long-acting Beta Agonists with Corticosteroids

  1. Advair (Fluticasone/Salmeterol: 100/50, 250/50, 500/50)
    1. Dose: One puff twice daily
  2. Symbicort (Budesonide/Formoterol: 80/4.5, 160/4.5)
    1. Dose: One puff twice daily
  3. Breo Ellipta (Fluticasone/Vilanterol: 100/25)
    1. Only indicated for COPD (not Asthma)
    2. Dose: One puff once daily

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Cost: Medications

serevent (on 1/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
SEREVENT DISKUS 50 MCG $5.18 each
foradil (on 3/23/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
FORADIL AEROLIZER 12 MCG CAP $3.91 each
arcapta (on 8/17/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
ARCAPTA NEOHALER 75 MCG CAP $6.88 each
advair (on 1/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
ADVAIR 100-50 DISKUS $4.40 each
ADVAIR 250-50 DISKUS $5.48 each
ADVAIR 500-50 DISKUS $7.10 each
ADVAIR HFA 115-21 MCG INHALER $27.01 per gram
ADVAIR HFA 230-21 MCG INHALER $35.91 per gram
ADVAIR HFA 45-21 MCG INHALER $21.71 per gram
symbicort (on 1/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
SYMBICORT 160-4.5 MCG INHALER $27.66 per gram
SYMBICORT 80-4.5 MCG INHALER $24.06 per gram
breo ellipta (on 1/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
BREO ELLIPTA 100-25 MCG INH $4.79 each
BREO ELLIPTA 200-25 MCG INH $4.82 each
brovana (on 7/20/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
BROVANA 15 MCG/2 ML SOLUTION $6.73 per ml

Ontology: formoterol (C0060657)

Definition (NCI) A long-acting beta-adrenergic receptor agonist with bronchodilator activity. Formoterol 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 reduce mediator substance release from inflammatory cells, especially from mast cells.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C012629
SnomedCT 320260000, 395969001, 386171009, 414289007
English N-(2-hydroxy-5-(1-hydroxy-2-((2-(4-methoxyphenyl)-1-methylethyl)amino)ethyl)phenyl)formamide, (E)-2-butenedioate (2:1) (salt), eformoterol, formoterol [Chemical/Ingredient], Eformoterol (product), Eformoterol (substance), FORMOTEROL, Formoterol (product), Formoterol, Eformoterol, Formoterol (substance), formoterol
Spanish eformoterol, eformoterol (producto), eformoterol (sustancia), formoterol (producto), formoterol, formoterol (sustancia)

Ontology: salmeterol (C0073992)

Definition (NCI) A highly selective, long-acting beta-2 adrenergic agonist with bronchodilatory activity. Salmeterol's benzene moiety resembles the structure of catecholamines, and occupies the active site of beta-2 adrenergic receptor, while the long, lipophilic side chain of salmeterol, binds to the so called 'exosite' near the beta-2 adrenergic receptors. The binding at the exosite allows the active portion of the molecule to remain at the receptor site and continually engage and disengage with the receptor, therefore providing a long duration of action. This agent stimulates intracellular adenyl cyclase to catalyze the conversion of adenosine triphosphate to cyclic-3',5'-adenosine monophosphate (cAMP). Increased cAMP levels result in relaxation of bronchiolar smooth muscle, bronchodilation and increased bronchial airflow.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C057823
SnomedCT 108605008, 372515005
English salmeterol, salmeterol (medication), salmeterol [Chemical/Ingredient], SALMETEROL, Salmeterol, Salmeterol product, Salmeterol (product), Salmeterol (substance)
Spanish salmeterol (producto), salmeterol (sustancia), salmeterol

Ontology: Selective beta-2 adrenoceptor stimulants (C0354671)

Concepts Pharmacologic Substance (T121)
SnomedCT 320073005, 373215002
English Selective beta-2 stimulants, Selective beta-2 adrenoceptor stimulants, Selective beta-2 agonists, Selective beta-2 adrenoceptor stimulants (product), Selective beta-2 adrenoceptor stimulants (substance)
Spanish estimulantes selectivos de receptores adrenérgicos beta 2 (sustancia), estimulantes selectivos de receptores adrenérgicos beta 2, estimulantes selectivos beta 2 adrenérgicos (producto), estimulantes selectivos beta 2 adrenérgicos (sustancia), estimulantes selectivos beta 2 adrenérgicos

Ontology: Foradil (C0592533)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C012629
English Foradil, Schering brand of formoterol fumarate, foradil

Ontology: Serevent (C0700491)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C057823
English Serevent, Glaxo Wellcome brand of salmeterol xinafoate, serevent

Ontology: Arcapta (C3162477)

Concepts Organic Chemical (T109) , Pharmacologic Substance (T121)
English Arcapta