Is albuterol (short-acting beta-agonist) PO (per oral) liquid an alternative treatment for a coughing asthmatic?

Oral Albuterol Is Not Recommended for Coughing Asthmatic Patients

Oral albuterol liquid is not recommended as an alternative treatment for coughing asthmatic patients. 1 According to the American College of Chest Physicians evidence-based clinical practice guidelines, albuterol (whether oral or inhaled) is not recommended for patients with acute or chronic cough not due to asthma, with a Grade D recommendation indicating no benefit.

Evidence Against Oral Albuterol for Asthmatic Cough

The evidence clearly shows that:

• Oral short-acting beta2-agonists are less potent, take longer to act, and have more side effects compared with inhaled short-acting beta2-agonists. Their use is strongly discouraged. 1

• The FDA labeling for albuterol indicates that less than 20% of a single albuterol dose is absorbed following inhalation administration, with the remainder recovered from the nebulizer apparatus and expired air. 2 This suggests that oral administration would result in higher systemic concentrations and potentially more adverse effects.

• Systemic side effects of albuterol include:

  • Tachycardia
  • Skeletal muscle tremor
  • Hypokalemia
  • Hyperglycemia
  • Decreased levels of plasma potassium, phosphate, calcium, and magnesium 2, 3

Preferred Treatment Options for Coughing Asthma

For asthmatic patients with cough, the recommended treatments are:

1. Inhaled Short-Acting Beta2-Agonists (SABAs):

   • Albuterol delivered via metered-dose inhaler (MDI) with spacer or nebulizer is the treatment of choice for relief of acute symptoms 1
   • Provides rapid, dose-dependent bronchodilation with minimal side effects 1
   • Onset of action within 5 minutes, peak effect at 30-60 minutes, duration 4-6 hours 1

2. Inhaled Corticosteroids (ICS):

   • For patients with chronic cough due to asthma, inhaled corticosteroids should be considered as first-line treatment 1
   • For cough variant asthma, if response to ICS is incomplete, consider stepping up the ICS dose and adding a leukotriene inhibitor 1

3. Combination Therapy:

   • Recent evidence suggests that a fixed-dose combination of albuterol and budesonide as rescue medication can reduce the risk of severe asthma exacerbation compared to albuterol alone 4

Special Considerations for Asthmatic Cough

• For patients with known pre-existing asthma who experience anaphylaxis, administration of an asthma-reliever medication (such as inhaled albuterol) may provide adjunctive therapy for wheezing, coughing, and shortness of breath, but does not replace epinephrine in anaphylaxis management 1

• Increasing use of SABA treatment or use more than 2 days per week for symptom relief generally indicates inadequate asthma control and the need for initiating or intensifying anti-inflammatory therapy 1

• Proper inhaler technique is essential for effective medication delivery, and patients should be regularly assessed for correct technique 5

Common Pitfalls to Avoid

1. Overreliance on rescue medications: Using albuterol more than twice weekly for symptom control suggests inadequate control and the need for controller medication 5

2. Improper delivery method: Using oral albuterol instead of inhaled formulations results in more systemic side effects with less bronchodilatory benefit 1, 3

3. Delayed anti-inflammatory treatment: Failing to address the underlying inflammation in asthma by relying solely on bronchodilators 6

4. Inadequate monitoring: Not recognizing that increasing use of rescue medication indicates worsening asthma control 5

In conclusion, oral albuterol liquid should not be used as an alternative treatment for coughing asthmatic patients. Inhaled albuterol via MDI with spacer or nebulizer, along with appropriate anti-inflammatory therapy, remains the standard of care for managing cough in asthma.