How does Xopenex (levalbuterol) compare to albuterol in a patient with a history of supraventricular tachycardia (SVT)?

From the Guidelines

For a patient with a history of supraventricular tachycardia (SVT), Xopenex (levalbuterol) is generally preferred over albuterol due to its fewer cardiovascular side effects, as evidenced by studies such as 1 and 1. Levalbuterol is the R-isomer of albuterol and typically causes fewer cardiovascular side effects, making it a safer option for patients with cardiac concerns like SVT. The standard dosing for levalbuterol via nebulizer is 0.63-1.25 mg every 6-8 hours, while the metered-dose inhaler delivers 45-90 mcg per puff with 1-2 puffs every 4-6 hours as needed. Both medications work as short-acting beta-2 agonists to relieve bronchospasm, but albuterol contains both R and S isomers, with the S-isomer potentially contributing to increased heart rate and tremor without adding bronchodilatory benefit. When treating a patient with SVT history, it's essential to monitor heart rate and rhythm during therapy with either medication, but especially with albuterol, as recommended by guidelines such as 1. Some key points to consider when choosing between Xopenex and albuterol for a patient with SVT include:

• The potential for increased heart rate and tremor with albuterol due to its S-isomer content
• The importance of monitoring heart rate and rhythm during therapy with either medication
• The preference for levalbuterol due to its safer cardiovascular side effect profile, as supported by studies like 1 If levalbuterol is unavailable, albuterol can still be used with careful monitoring, starting at lower doses (1.25-2.5 mg for nebulization or 1-2 puffs of 90 mcg/puff MDI) and titrating as needed while watching for cardiac effects, in line with recommendations from 1 and 1.

From the FDA Drug Label

The incidence of certain systemic beta-adrenergic adverse effects (e.g., tremor, nervousness) was slightly less in the Xopenex 0. 63 mg group compared with the other active treatment groups. Changes in heart rate 15 minutes after drug administration and in plasma glucose and potassium 1 hour after drug administration on day 1 and day 29 were clinically comparable in the Xopenex 1.25 mg and racemic albuterol 2. 5 mg groups Changes in heart rate and plasma glucose were slightly less in the Xopenex 0. 63 mg group compared with the other active treatment groups Cardiovascular System: Tachycardia 0 2.7 2.8 2.7

In a patient with a history of SVT (Supraventricular Tachycardia), the choice between Xopenex and albuterol should be made with caution.

• Tachycardia was reported in 2.7% of patients receiving Xopenex 1.25 mg and Xopenex 0.63 mg, and 2.7% of patients receiving racemic albuterol 2.5 mg.
• The incidence of systemic beta-adrenergic adverse effects (e.g., tremor, nervousness) was slightly less in the Xopenex 0.63 mg group compared with the other active treatment groups.
• Changes in heart rate were clinically comparable in the Xopenex 1.25 mg and racemic albuterol 2.5 mg groups, but slightly less in the Xopenex 0.63 mg group. Based on the available data, Xopenex 0.63 mg may be a slightly better option for patients with a history of SVT, due to its lower incidence of systemic beta-adrenergic adverse effects and changes in heart rate. However, the clinical significance of these small differences is unknown 2.

From the Research

Comparison of Xopenex and Albuterol

• Xopenex, also known as levalbuterol, is a bronchodilator used to treat asthma and chronic obstructive pulmonary disease (COPD) 3.
• Albuterol is another bronchodilator commonly used to treat asthma and COPD.
• In patients with a history of supraventricular tachycardia (SVT), the choice between Xopenex and albuterol should be based on the individual patient's needs and medical history.

Effects on Heart Rate

• A study published in 2011 found that nebulized albuterol and levalbuterol (Xopenex) had similar effects on heart rate in critically ill adult patients 3.
• The study found that the mean change in heart rate after albuterol was 0.89 ± 4.5 beats/min, compared to 0.85 ± 5.3 beats/min after levalbuterol.
• However, another group in the study found that heart rate decreased by 0.16 ± 5.1 beats/min after albuterol, compared to an increase of 1.4 ± 5.4 beats/min after levalbuterol.

Management of SVT

• SVT is a common cardiac rhythm disturbance that can be managed with various treatments, including vagal maneuvers, adenosine, beta-blockers, and calcium channel blockers 4, 5, 6, 7.
• In patients with a history of SVT, it is essential to consider the potential effects of bronchodilators on heart rate and rhythm.
• The choice between Xopenex and albuterol should be based on the individual patient's needs and medical history, as well as the potential risks and benefits of each medication.