Friday, January 15, 2010

Albuterol vs. Xopenex - the debate continues!

Three years ago, I posted an article that stirred up huge debate regarding the value of Xopenex vs. Albuterol.

Amazing how many comments that post still gets!! I thought I'd bring it back to top of the blog to see who else wanted to weigh in.

Here's the original post.

18 comments:

Sara C. said...

I find the comment that Xop also causes increased heart rate interesting. Back in 2001, my daughter had RSV, she was 2 months old. The albuterol by neb that she was getting q4 in the hospital caused her to go so tachy the doctors were concerned. On the Xop, her heart rate stayed the same. She was in PICU, so on heart monitors.

My other daughter uses Xop in her inhaler, and she needs 2 puffs, rather than the 4-5 that she needs from an albuterol inhaler. (per her pulmonologist) She doesn't seem to have adverse affects from albuterol in her nebulizer, unless we have to piggy back...but when she needs a rescue at school, I'm glad that we the Xop there, that works better.

Interesting post. I often think anecdotal evidence is much stronger than that of studies, anyway.

Ester Creek Coop said...

My son got RSV as an infant and thereafter had serious breathing difficulties with any cold/flu virus. From 5-11 mo he was in the ER 4x and admitted to peds 3x for a total of 9 nights in hospital. We noticed a huge difference with Xopenex vs Albuterol in the hospital nebs but the bigger difference came when we switched from nebs to inhalers using an aerochamber and mask. The way this was explained to us is that the aerochamber has a static charge that attracts the biggest droplets so these do not get absorbed (to maintain the charge, you have to wash the chamber gently on a regular basis and can't wipe or scrub the interior). These larger droplets are the ones that get only as far as the mucus membranes of the mouth and of course are quickly absorbed. Because so much of the medicine in a nebulizer treatment or inhaler without aerochamber is absorbed by the MOUTH and never makes it to the lungs, the side effect profiles of ALL meds are higher with these delivery methods; more systemic absorption. We can use Albuterol HFA with the aerochamber and get far less side effects than with a Xopenex nebulizer. At this point, the price difference is nonexistent since all the inhalers got put into the HFA formulation to avoid the CFCs and every company got to repatent them. In a neb treatment, though, the price difference is significant. ER docs and even many pediatricians in hospital and clinic practice still order neb treatments but our excellent pulmonologist told us to always insist on aerochamber treatments in the hospital. One ER doc then said, so why are you here if you can do this at home? Well, b/c he was having such a hard time breathing that he needed the Albuterol inhaler EVERY 30 minutes (which he otherwise would have been on continuous nebulizer) and our doctor told us that if he needs the treatment more than once in 2 hours, we must take him to the hospital to check O2 Sat levels, monitor heart rate, etc. The hospital loses out when parents/ and nurses administer meds by aerochamber b/c then their respiratory therapists don't have a job! I donated our neb machine to a low-income clinic and swear by these aerochambers. Typically insurance won't cover them which is ridiculous and hopefully will change soon. We keep one at home and one in his "rescue meds kit" that goes anywhere he goes. They were each about $75 two years ago, often cheaper online. Anyway, I highly recommend that people use these aerochambers. They especially work on infants/toddler who cannot take the deep breath on an inhaler (and this is why infants/toddlers get subjected to ridiculous side effects through nebulizers, regardless of the Albuterol vs. Xopenex). I have had some coughing fits while sick that only stopped when I used my son's Albuterol HFA and aerochamber and I never had the side effects I would have if I took the med directly. We also use the chamber for his Flovent; again, because it traps the larger particles in a steroid inhaler, there is less absorption in the mouth, more medicine gets to the lungs and there is LESS systemic absorption, a good thing. I would NEVER want to administer a steroid by nebulizer to a young child, considering how much systemic absorption there would be for an infant/toddler. The best thing is, too, these are portable, small, don't require electricity and take seconds, not minutes to do. You put the mask over the child's face, they take normal breaths while you count to 10 slowly, then you are done. I know I sound like a fanatic or sales rep but I'm not. I just cannot believe that these are not more widely used by everyone of all ages.

RW said...

I'm always amazed by the idiotic dismissive attitudes so many doctors and other people with medical training have towards patients' observations of their own experiences. If they read about the same "case" in a medical journal, they would take it seriously, but because it came from an actual patient (or patient's parent) they dismiss it as a misperception, and often attribute it to the person's strong emotions concerning the condition being treated. They "correct" the evidence being presented to them by referring to textbooks and studies. They fail to notice when they have a real-life case study under their noses. Just because some aspect of reality has not made it into "approved" literature, doesn't mean it can't be happening! Use your scientific training to figure out how to this new piece of data can make sense with what is already known.

Here's an example of such scientific thinking by me, a lay person (no medical training except CPR and an incomplete phlebotomy course!):

Assuming that Snotty Anonymous Medical Student (let's call him/her "SAMS") is correct in this statement,

"both albuterol and xopenex have the exact same active ingredient in it (the "R" enantiomer molecule). The only difference is that albuterol also has an inactive "S" enantiomer that doesn't contribute to therapy,"

I theorize that the inactive "S" enantiomer (I don't know what an enantiomer is, but this does not affect my ability to reason logically) is what is causing the more severe side effects of Albuterol compared with Xopenex. It may be inactive in the lungs, where it is needed, but capable of affecting the heart and possibly also the brain, based on the symptoms commenters have described. It could be that some people's hearts, etc. are not affected by the "S" molecule, but some people's bodies react to the "S" molecule as if it were an "R" molecule. If the latter is a small group, it will not impact the overall side effect profile of albuterol vs. Xopenex.

RW said...

continued...

A quick google search reveals this handy review of the literature, which includes a different theory based on additional data:
http://www.medscape.com/
viewarticle/719008

Some key quotes:
"Deleterious effects of racemic albuterol, especially with overuse, include hypokalemia, tachyphylaxis, and even increased mortality.[3,8,9] (S)-albuterol lacks bronchodilator activity and is metabolized 10-fold more slowly than levalbuterol, and some have theorized that it may also have negative effects such as worsening airway reactivity or proinflammatory effects.[8] This could result in preferential accumulation of the (S)-isomer over (R)-albuterol in the lung, potentially resulting in paradoxic bronchospasm.[8,9]"

"Nowak and colleagues[10] compared the effects of nebulized levalbuterol with those of racemic albuterol in 627 adults with an acute asthma exacerbation. Patients were randomly assigned to receive either levalbuterol 1.25 mg or albuterol 2.5 mg every 20 minutes upon emergency admission, then every 40 minutes for 3 additional doses, then as often as clinically necessary for 24 hours. All patients also received prednisone 40 mg. Levalbuterol increased forced expiratory volume by nearly 40% compared with racemic albuterol, corresponding to a 40% reduction in required hospitalizations compared with racemic albuterol. The benefit of levalbuterol was especially apparent in patients with severe asthma who had high levels of (S)-albuterol (> 1095 mg/mL). High circulating levels of [S]-albuterol are thought to be the result of excessive use of racemic albuterol."

"Ameredes and Calhoun[1] concluded that the benefit of levalbuterol over albuterol may be greatest in patients with moderate to severe asthma, particularly in those with albuterol overuse."

So there you have it! Science marches on despite idiots like SAMS and the respiratory therapist who hates those annoying parents that are making his/her job so much harder with their silly worries about how their "precious snowflake" might die or something. Sheesh, they really should get a hobby and stay in the PICU waiting room...OR MAYBE NOT, since it turns out they actually were RIGHT ABOUT their child's medical condition. Time for some more CEUs, bitch!

RW said...

Well, it turns out that science has been plugging away and backs up all those "emotional" patients and their parents:

http://www.medscape.com/viewarticle/719008

"the benefit of levalbuterol over albuterol may be greatest in patients with moderate to severe asthma, particularly in those with albuterol overuse."

"Deleterious effects of racemic albuterol, especially with overuse, include hypokalemia, tachyphylaxis, and even increased mortality.[3,8,9] (S)-albuterol lacks bronchodilator activity and is metabolized 10-fold more slowly than levalbuterol, and some have theorized that it may also have negative effects such as worsening airway reactivity or proinflammatory effects.[8] This could result in preferential accumulation of the (S)-isomer over (R)-albuterol in the lung, potentially resulting in paradoxic bronchospasm.[8,9]"

"Nowak and colleagues[10] compared the effects of nebulized levalbuterol with those of racemic albuterol....Levalbuterol increased forced expiratory volume by nearly 40% compared with racemic albuterol, corresponding to a 40% reduction in required hospitalizations compared with racemic albuterol. The benefit of levalbuterol was especially apparent in patients with severe asthma who had high levels of (S)-albuterol (> 1095 mg/mL). High circulating levels of [S]-albuterol are thought to be the result of excessive use of racemic albuterol."

Time to get some more CEUs, respiratory therapist bitches!

Nikki and David Goldbeck said...

I have just been informed that Medicare will no longer pay for Xopenex. I have afib and have found that albuterol triggers afibs while XOp does not. This may be a serious problem for me. Ideas?

Anonymous said...

In response to Ester Creek Coop....First off I find it insulting that you think all a Respiratory Therapist does is breathing treatments in an ER...Let's not forget who intubates, does/interprets EKG's,assist in CPR/Code Blues, does NT/OT sux and 100 other things...ohh and yes gives breathing trts....Furthermore an aerochamber does not have a static charge (how would it achieve this? due to the fact that it would have to build up some type of electric charge) it works by helping the pt take a "slow deep breath" during or after activation of the MDI, and it also helps the pt by depositing smaller particles in the lower lung bases (read your litature!! just don't throw out random info that is incorrect and confuses people)....It is a good idea to take your child to the ER if he/she does require that many trt's at home so often...In that you are correct...Mostly the reason that hospitals/ER's use nebs is due to the fact that most pts can't take a large enough breath to move the meds deep enough into their lungs, hence the longer time frame with the hope that they will eventually be able to move the meds into the deeper lung bases and by default open up the smaller alveoli there which helps in 02/C02 exchange....There is a method behind the madness...Finally to the whole albuterol vs. Xop debate, you have to also take into acct the fact that both meds come in several doses (did your child receive the correct dosage? the peds dose? or did they get the adult dose?) this makes a difference, especially since xop comes in 3 different doeses ....1.25/0.63/0.31 and they do make a difference....Lastly every pt is different and some will be affected by Albuterol and some won't....the same goes for Xop...that's why a good health care professional trts every pt as an individual not one of the masses...

Anonymous said...

Albuterol also contains sulfur as sulfate which is a respiratory irritant, Xopenex does not.

ShannonRae said...

I just left my son's Asthma Dr. today - and she told me the "S" enantiomer actually bogs down the delivery of the needed medicine and overtime renders allbuterol ineffective because it becomes built up in the childs system. I have to pay out of pocket for Xop because it is so evidently better for my son. He has "uncontrolled" asthma and it's such a scary thing - and it is infuriating to have an insurance company block your right to a better medicine based on cost to them. Digusted.

mimi said...

I am using albuterol inhaler dose is 80 mcg 2puffs I get this internal as well as external shaky tremor feeling. This really scares me also my heart really starts to beat fast which is another thing i to have to worry about especially because I suffer with anxiety and panic attacks. I am wondering if maybe the dose is to high or if I am taking wrong type of inhaler because of what's in the albuterol.

mimi said...

I am using albuterol inhaler dose is 80 mcg 2puffs I get this internal as well as external shaky tremor feeling. This really scares me also my heart really starts to beat fast which is another thing i to have to worry about especially because I suffer with anxiety and panic attacks. I am wondering if maybe the dose is to high or if I am taking wrong type of inhaler because of what's in the albuterol.

Aimee said...

@ShannonRae - I hear you. My maintenance meds aren't covered in the states, and Qvar costs a fortune!! Hoping to have better luck once I am "legal" here in Canada.



@Mimi - again, Xopenex is good at preventing the shakes, as is MaxAir. And now that I've learned how it works, ProAir is working for me, too.



Note that ProAir is generic and is often really inexpensive, while the other two can be quite pricey.

Anonymous said...

I've been on an albuterol inhaler since I could remember, have, and probably always will have, asthma. I haven't had the heart problem issue at all with my inhaler, and im now 24. I used to have a nebulizer when I was younger, and we used it about once or twice a day at home, I don't know what we used in because I was so little, but I don't ever remember being a hyperactive kid that bounces off the wall, i've never been that way. As its been stated before, the medication will effect people differently. The manufacturer of my albuterol inhaler has changed multiple times and I can only get the HFA stuff now cause its all environmentally friendly or whatever, and my psychiatrist recently had me try xopenex with my anxiety to help calm me down *so i technically already have the racing heart issues* and help out my asthma. Tried it for 3 months, cost me too much money and it never helped me during an attack, I ended up having to use it multiple times to get my breathing back to normal. I like the albuterol, its less expensive and I don't have to use it all up before my refill date and hope to God I don't have an asthma attack in the mean time. I get refills every month of my albuterol, not necessarily needing it because my inhaler is out, but as a back up incase I should ever have bad episodes and run out quicker, etc.

that's my 2 cents though. I have had asthma since I was 3. 21 years strong, alive, and only on steroids once and only for a couple months.

Maria Malerbi said...

Thanks for this post (many years later)! I'm a 22 year old chemical engineering student who was just discharged from the hospital yesterday! They started me on xopenex as opposed to my normal albuterol. I need to follow up with my pulmonologist, but I'm a big fan already.
My heart rate was above 120 the entire time I was there and they were hesitant to give me treatments and prednisone due to this. The xopenex had less of an effect on my heart rate and tachycardia.
I think it has been mentioned before but xopenex was originally developed to increase function (because it removed the inert s-enantiomer) while decreasing side effects. The side effects are lessened because a smaller dose of xopenex is needed compared to albuterol. It's not as common because xopenex hasn't been proven to work any better (apart from side effects) and is more expensive.

Aimee said...

So glad you're on the mend, Maria - and glad you found the post helpful.

Anonymous said...

I am a respiratory therapist with 40 years of experience. At least two studies have shown that daily use of albuterol can indeed can deleterious effects by the build up of the S isomer. However, if you are using albuterol more than twice a month, your asthma is out of control. It is not meant to be used on a regular basis, but only as a rescue drug. If you are using it more often, you need to see your doctor and get an asthma action plan started. Some posts here insist that there is more tachycardia with albuterol. Albuterol is normally prescribe at 2.5 mg per dose, which is 1.25 mg of each isomer. Xopenex for children is often prescribed at 0.62 mg, which is half the dose of albuterol. If you are taking half a dose, you will naturally get less side effects. You can get albuterol in 1.25 mg doses. As for using inhalers, you should always use a spacer with an inhaler and inhale slowly, and hold your breath and count to 10 before exhaling. This method will cause more of the med to reach the lungs and much less will rain out in the mouth. The new spacers are coated so that static electriciy will not cause the medication to adhere to the inner surface of the spacer. The inhalere needs to be shaken for at least 10 seconds before each puff and you should wait at least 1 minute between puffs. If you start feeling the side effects, then you have had enough. You should not attempt to give an aerosol treatment to a crying baby or child. The drug will mostly wind up in the stomach. If you go to the Xopenex web site, and look at the dosing information, you will see that their own studies show essentially no difference in duration of action and side effects of xopenex and albuterol. In fact, it shows a slightly longer duration of action with albuterol. Xopenex does not advertise that their product lasts longer or has fewer side effects than albuterol. If they did, they would suffer the wrath of the FDA. Their salesmen latched on to the two previously mentioned studies, bragging that it had less side effects. People assumed that they meant tachycardia and nervousness, which is not true. One last thing, a unit dose of albuterol costs our hospital 13 cents. A unit dose of Xopenex costs $3.61. Our pharmacy automatically substitutes albuterol for xopenex, unless the physician specifies that it is to be dispensed as written. I hope this sheds some light on the controversy.

Kia said...

TO ANONYMOUS: whoever Anonymous is....and i knoow it could be different people hence the term, seems to be the mpst intelligent/well informed/correctly informed person on this site.....I myself have a child, who just turned eight, with Chronic childhood astma...we use Pulmicort ( a preventative asthma med) 2 puffs twice daily with a spacer....then we have Albuterol and Xopomex......now the reason being was because we did just have her on albuterol in an emergency inhaler for school in case she started coughing bad and in form for the Nebulizer we have. BUT, she would get so shaky and jittery and complain that "her Heart Hurt" I asked the doctor if there was anythiing we could give her besides Albuterol that would make her less shaky and THE DOCTOR recomended Xopomex....unfortunately she obviously doesnt use it all the time because the Pulmicort seems to be doing its job so when i called in to get it refiled and it had inevitably expired they ended up giving Albuterol again...but she has an asthma recheck in 2 days and I can say thos from PERSONAL EXPERIENCE......I LOVE THE XOPOMEX WAY WAY WAAAAY MORE THAN THE ALbuterol.........but as Anonym said...each paitient is different.....Thanks for listening _Ki

Anonymous said...

Albuterol's "inactive" ingredient is a refrigerant (like Freon) which is an asphyxiant and outlawed in most developed countries. Since when does inhaling such a substance contribute to health? Since Never.