Short-acting Beta Agonist

Aka: Short-acting Beta Agonist, Inhaled Beta Adrenergic Agonist, Inhaled Beta Agonist, Inhaled Bronchodilator, Bronchodilator, Albuterol, Ventolin, Proventil, Inhaled Terbutaline, Brethaire, Pirbuterol, Maxair, Levalbuterol, Xopenex

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II. Indications

  1. Short acting agents for rescue use only

III. Mechanism

  1. Inhaled Bronchodilators target Beta 2 Adrenergic Receptors
    1. Adverse effects (e.g. Tachycardia) are related to Beta 1 Adrenergic Receptor activity

IV. 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]

V. Management: 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

VI. 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]

VII. 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)

VIII. 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. Generic Proair HFA and Ventolin HFA available in 2019 at $35 for 200 puff Inhaler
    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: Originally $50 per month (now generic as of 2016)
    2. Dose: 2 puffs up to every 4-6 hours
    3. Benefit
      1. No benefit over Albuterol in most patients
        1. Less FEV1 decline with chronic use than Albuterol
        2. 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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Related Studies

Cost: Medications

albuterol (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
ALBUTEROL 2.5 MG/0.5 ML SOL Generic $0.35 each
ALBUTEROL 5 MG/ML SOLUTION Generic $2.32 per ml
ALBUTEROL HFA 90 MCG INHALER Generic $3.23 per gram
ALBUTEROL SUL 0.63 MG/3 ML SOL Generic $0.14 per ml
ALBUTEROL SUL 1.25 MG/3 ML SOL Generic $0.20 per ml
ALBUTEROL SUL 2.5 MG/3 ML SOLN Generic $0.04 per ml
ALBUTEROL SULF 2 MG/5 ML SYRUP Generic $0.04 per ml
ALBUTEROL SULFATE 2 MG TAB Generic $0.32 each
ALBUTEROL SULFATE 4 MG TAB Generic $0.45 each
ventolin (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
VENTOLIN HFA 90 MCG INHALER Generic $1.86 per gram
proventil (on 5/18/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
PROVENTIL HFA 90 MCG INHALER Generic $3.23 per gram
levalbuterol (on 2/23/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
LEVALBUTEROL 0.31 MG/3 ML SOL Generic $0.34 per ml
LEVALBUTEROL 0.63 MG/3 ML SOL Generic $0.37 per ml
LEVALBUTEROL 1.25 MG/3 ML SOL Generic $0.35 per ml
LEVALBUTEROL TAR HFA 45 MCG INH Generic $3.58 per gram
xopenex (on 5/18/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
XOPENEX HFA 45 MCG INHALER Generic $3.58 per gram
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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