From the Guidelines
Albuterol generally causes more tachycardia than levalbuterol. Albuterol is a racemic mixture containing both R-albuterol (levalbuterol) and S-albuterol isomers, while levalbuterol contains only the R-isomer which is responsible for bronchodilation. The S-isomer in albuterol contributes to side effects like tachycardia without adding therapeutic benefit. Clinical studies have shown that levalbuterol typically produces less cardiac stimulation at equivalent bronchodilating doses 1. For patients concerned about cardiac side effects, levalbuterol may be preferable, especially those with underlying heart conditions or who experience significant palpitations with albuterol. However, levalbuterol is generally more expensive than albuterol. Typical dosing for levalbuterol is 0.63-1.25 mg via nebulizer every 6-8 hours or 45-90 mcg via metered-dose inhaler (1-2 puffs) every 4-6 hours, while albuterol is dosed at 2.5-5 mg via nebulizer or 90 mcg (1-2 puffs) via inhaler. Both medications effectively treat bronchospasm, but the reduced cardiac side effect profile may make levalbuterol advantageous for certain patients.
Some key points to consider when choosing between albuterol and levalbuterol include:
- The potential for tachycardia and other cardiac side effects
- The presence of underlying heart conditions or a history of palpitations
- The cost of the medication, as levalbuterol is generally more expensive than albuterol
- The equivalent bronchodilating doses of each medication, as levalbuterol may produce less cardiac stimulation at these doses 1.
It's also important to note that the evidence suggests that levalbuterol and albuterol have similar effectiveness in treating bronchospasm, but the reduced cardiac side effect profile of levalbuterol may make it a better choice for certain patients 1. Ultimately, the decision between albuterol and levalbuterol should be made on a case-by-case basis, taking into account the individual patient's needs and medical history.
From the FDA Drug Label
However, all beta-adrenergic agonist drugs can produce a significant cardiovascular effect in some patients, as measured by pulse rate, blood pressure, symptoms, and/or electrocardiographic changes The FDA drug label does not answer the question.
From the Research
Comparison of Tachycardia Effects
- The study 2 found that in critically ill adult patients, nebulized albuterol and ipratropium does not cause significant tachycardia or tachyarrhythmias, and substitution of levalbuterol for albuterol to avoid tachycardia and tachyarrhythmias is unwarranted.
- Another study 3 showed that short-term use of nebulized albuterol and levalbuterol was associated with similar changes in heart rate in intensive care patients with or without baseline tachycardia.
- A review 4 noted that evidence for using either racemic albuterol or levalbuterol for respiratory disease management in patients with baseline tachyarrhythmias is lacking and insufficient.
Pediatric Population
- A study 5 comparing the cardiac effects of levalbuterol with those of racemic albuterol in pediatric patients found that both treatments produced similar effects on heart rate, with no clinically significant differences detected in heart rate changes between the two treatment groups.
- Another study 6 found that supraventricular tachycardia (SVT) is rare during hospital-based treatment for acute asthma using inhaled short-acting beta agonists (SABAs) and has low morbidity and mortality, with no examined variables associated with SABA-induced SVT.
Tachycardia Incidence
- The study 6 reported an incidence of SVT of 3.9 per 10,000 episodes of SABA treatment, and 5.1 per 10,000 children with asthma receiving hospital-based asthma care, with two episodes of SVT following treatment with only levalbuterol, three after only albuterol, and two after both albuterol and levalbuterol treatment.
- The study 2 found that only one patient stopped treatment because of a 5-beat run of ventricular tachycardia (one in 70 patients [1.4%]).