What are the recommended doses of syrup levosalbutamol (levalbuterol) for children and adults with asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Levosalbutamol (Levalbuterol) Syrup Dosing

For children 6-11 years, levosalbutamol syrup should be dosed at 0.31 mg three times daily by nebulization, not exceeding 0.63 mg three times daily; for adolescents ≥12 years and adults, start with 0.63 mg three times daily every 6-8 hours, with escalation to 1.25 mg three times daily for inadequate response or severe disease. 1

Pediatric Dosing (6-11 Years)

• Starting dose: 0.31 mg administered three times daily by nebulization 1
• Maximum dose: 0.63 mg three times daily (routine dosing should not exceed this) 1
• Levosalbutamol is administered at half the milligram dose of racemic albuterol to provide comparable efficacy and safety 2

Adolescent and Adult Dosing (≥12 Years)

• Starting dose: 0.63 mg three times daily, every 6-8 hours by nebulization 1
• For more severe asthma or inadequate response: 1.25 mg three times daily 1
• Patients receiving the highest dose (1.25 mg) require close monitoring for adverse systemic effects, balancing risks against potential improved efficacy 1

Acute Exacerbation Dosing

For acute asthma or COPD exacerbations, the dosing differs from maintenance therapy:

• Children: 0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses, then 0.075-0.15 mg/kg up to 5 mg every 1-4 hours as needed 2
• Adults: 1.25-2.5 mg every 20 minutes for 3 doses, then 1.25-5 mg every 1-4 hours as needed 2

Important Clinical Considerations

Administration Details

• Levosalbutamol is for oral inhalation only via nebulization using a standard jet nebulizer with face mask or mouthpiece connected to an air compressor 1
• Safety and efficacy established with PARI LC Jet™ and PARI LC Plus™ nebulizers with PARI Master Dura-Neb® 2000 and Dura-Neb® 3000 compressors 1
• Do not mix with other drugs in nebulizer as compatibility has not been established 1

Monitoring and Adjustment

• If a previously effective regimen fails to provide usual response, this signals asthma destabilization requiring reevaluation and consideration of anti-inflammatory treatment (corticosteroids) 1
• Patients on maximum doses need close monitoring for beta-mediated adverse effects including tremor, palpitations, and tachycardia 1, 3

Comparative Efficacy

• Levosalbutamol every 6-8 hours requires significantly fewer total nebulizations compared to racemic albuterol every 1-4 hours in hospitalized patients (median 10 vs 12 nebulizations, p=0.031) 4
• Both treatments provide similar improvements in pulmonary function and symptom scores 4

Common Pitfalls to Avoid

• Do not exceed recommended maximum doses as this increases risk of beta-mediated side effects without additional bronchodilation benefit 1
• Recognize paradoxical bronchospasm which may occur with first use of a new vial and requires immediate discontinuation 1
• Do not use as monotherapy for severe exacerbations - combine with oxygen and systemic corticosteroids per guidelines 2

Contraindications

• Hypersensitivity to levalbuterol or racemic albuterol (reactions include urticaria, angioedema, rash, bronchospasm, anaphylaxis, oropharyngeal edema) 1