From the Guidelines
Non-albuterol rescue inhalers, such as levalbuterol (Xopenex) and ipratropium bromide (Atrovent), are viable alternatives for patients who experience side effects from albuterol or require additional bronchodilation, with levalbuterol typically prescribed as 1-2 inhalations (45-90 mcg) every 4-6 hours, as seen in studies 1.
Key Points
- Levalbuterol is the R-isomer of albuterol, with potentially fewer side effects, and is usually prescribed as 1-2 inhalations (45-90 mcg) every 4-6 hours, as noted in 1.
- Ipratropium works by blocking acetylcholine receptors in the airways, typically dosed at 2 inhalations (34 mcg each) every 4-6 hours as needed, as seen in 1.
- Combination inhalers like ipratropium-albuterol (Combivent) can be used for patients with both COPD and asthma, with 1 inhalation every 4-6 hours, as mentioned in 1.
Mechanism of Action
- Ipratropium is an anticholinergic that blocks parasympathetic nerve impulses, while levalbuterol is a more selective beta-2 agonist, as explained in 1.
- These alternatives work through different mechanisms than albuterol, with ipratropium having a slower onset but potentially longer duration of action, as noted in 1.
Clinical Considerations
- Patients should be aware that these medications may have different onset times compared to albuterol, with ipratropium having a slower onset but potentially longer duration of action, as seen in 1.
- The choice of non-albuterol rescue inhaler depends on the individual patient's needs and medical history, as mentioned in 1.
From the FDA Drug Label
The bronchodilator responses to 1.25 mg of Xopenex Inhalation Solution and 2. 5 mg of racemic albuterol sulfate inhalation solution were clinically comparable over the 6-hour evaluation period, except for a slightly longer duration of action (>15% increase in FEV1 from baseline) after administration of 1. 25 mg of Xopenex Inhalation Solution. Xopenex Inhalation Solution at a dose of 1.25 mg produced a slightly higher rate of systemic beta-adrenergic adverse effects than the 2. 5 mg dose of racemic albuterol sulfate inhalation solution. In a clinical study in adults with mild-to-moderate asthma, comparable efficacy (as measured by change from baseline FEV1) and safety (as measured by heart rate, blood pressure, ECG, serum potassium, and tremor) were demonstrated after a cumulative dose of 5 mg of Xopenex Inhalation Solution (four consecutive doses of 1. 25 mg administered every 30 minutes) and 10 mg of racemic albuterol sulfate inhalation solution (four consecutive doses of 2. 5 mg administered every 30 minutes).
Levalbuterol (Xopenex) is a non-albuterol rescue inhaler, as it is the (R)-enantiomer of albuterol.
- Key points:
From the Research
Non-Albuterol Rescue Inhaler Options
- Ipratropium bromide is a non-albuterol rescue inhaler option that has been studied in combination with salbutamol for the treatment of chronic obstructive pulmonary disease (COPD) and asthma 3, 4, 5, 6
- The combination of ipratropium bromide and salbutamol has been shown to be effective in reducing the risk of hospital admission and improving lung function in patients with acute asthma exacerbations 5, 6
- However, the addition of ipratropium bromide to salbutamol has not been shown to be beneficial in all studies, and the results have been inconsistent 3, 4
Alternative Rescue Inhaler Options
- A fixed-dose combination of albuterol and budesonide has been studied as a rescue inhaler option for patients with uncontrolled moderate-to-severe asthma 7
- This combination has been shown to reduce the risk of severe asthma exacerbations compared to albuterol alone 7
- However, this option is not a non-albuterol rescue inhaler, as it still contains albuterol