//fpnotebook.com/
Long-acting Beta Agonist
Aka: Long-acting Beta Agonist, Long-Acting Beta-2 Agonist, Long-Acting Inhaled Bronchodilator, Salmeterol, Serevent, Formoterol, Foradil, Indacaterol, Arcapta, Advair, Symbicort, Dulera, Breo Ellipta, Arformoterol, Brovana, Trelegy Ellipta, Single Maintenance and Reliever Therapy, SMART Asthma Management Protocol
- See Also
- Short-acting Beta Agonist
- Beta Agonist
- Indications
- Moderate Persistent Asthma
- Severe Persistent Asthma
- Precautions
- Adverse outcomes in Asthma with Long-acting Beta Agonist (LABA)
- LABA use in Asthma was associated with increased Asthma deaths, increased intubations and hospitalizations
- McMahon (2011) Pediatrics 128(5): e1147-54 [PubMed]
- However FDA review of more recent studies found similar adverse outcomes with Inhaled Corticosteroids
- FDA removed LABA black box warning (see FDA communication link below)
- Risk of increased mortality and of more severe and life threatening Asthma Exacerbations
- Postulated to mask a patients awareness of severe Asthma Exacerbation
- FDA Black Box Warnings placed in 2003, but removed in 2017 (based on newer data as above)
- https://www.fda.gov/Drugs/DrugSafety/ucm589587.htm
- Not a substitute for Inhaled Corticosteroids
- Steroids are key management of persistent Asthma
- Long-acting Beta Agonists are in addition to Inhaled Corticosteroids
- Lazarus (2001) JAMA 285:2583-93 [PubMed]
- Do NOT exceed dosing schedule (e.g. Serevent bid) except Formoterol in SMART Protocol
- Use a short acting Beta agonist for rescue use
- Exception: See SMART Protocol below
- Tolerance over time to Protective effect
- Effect diminishes over one month of use
- Reference
- Simons (1997) Pediatrics 99:655-9 [PubMed]
- Preparations: Long-acting Beta Agonists (LABA)
- Salmeterol (Serevent) Dry Powder Diskus (50 ug/inhale)
- One inhalation every 12 hours
- Serevent Inhalation aerosol MDI (21 ug/puff)
- Adults: 2 puffs every 12 hours
- Child: 1-2 puffs every 12 hours
- Formoterol (Foradil)
- One inhalation every 12 hours
- Rapid onset within 5 minutes (contrast 15-30 minutes for other LABAs)
- Indacaterol (Arcapta Neohaler)
- Once daily dosing
- FDA approved for COPD (not proven to prevent COPD exacerbations)
- Same cardiovascular risks as other long acting beta agonists
- Reference
- (2012) presc lett 19(1): 2
- Arformoterol (Brovana)
- Dose: 15 mcg twice daily
- Preparations: Combination of Long-acting Beta Agonists with Corticosteroids
- Advair Diskus (Fluticasone/Salmeterol: 100/50, 250/50, 500/50)
- Dose: One puff twice daily
- Wixela Inhub (Fluticasone/Salmeterol)
- Released in 2019 at $150/Inhaler
- AirDuo (Fluticasone/Salmeterol: 55/14, 113/14, 232/14)
- Dose: One puff twice daily
- Generic available in 2017 for $90/month (compare with $475/month for Advair)
- (2017) Presc Lett 24(7)
- Symbicort (Budesonide/Formoterol: 80/4.5, 160/4.5)
- Dose: One puff twice daily
- Dulera (Mometasone/Formoterol: 50/5, 100/5, 200/5)
- Dose: Two puffs twice daily
- Breo Ellipta (Fluticasone/Vilanterol: 100/25)
- Only indicated for COPD (not Asthma)
- Dose: One puff once daily
- Trelegy Ellipta (Umeclidinium AND Fluticasone/Vilanterol)
- Indicated for severe COPD when an Inhaled Steroid and a LAMA and LABA are both indicated
- Indicated in Severe Asthma not controlled on medium to high dose Inhaled Corticosteroid and LABA
- Available in 2 strengths of fluticasone component (100 mcg for COPD or Asthma, 200 mcg for Asthma only)
- Dosing 1 puff daily of Dry Powder Inhaler
- (2020) Presc Lett, 27(11): 62
- Protocol: Single Maintenance and Reliever Therapy (SMART)
- Indications
- Moderate to Severe Persistent Asthma
- Uses combination Inhaled Corticosteroid with LABA products
- Limited to Formoterol due to short onset of action (5 minutes)
- Protocol uses combination agent for additional prn dose for exacerbation symptoms
- Use 1-2 puffs prn up to maximum based on age (additional doses above the maintenance dose)
- Age over 12 years old: Up to 12 puffs per day (including maintenance)
- Age 4 o 11 years old: Up to 8 puffs per day (including maintenance)
- More than 2 rescue doses per week should prompt reevaluation
- Efficacy
- Reduced systemic steroids, ED Visits, hospitalizations (NNT 16)
- Now a recommended protocol in the NHLBI Asthma Guidelines 2020
- Precautions
- Extra LABA dosing has been cautioned against in past
- Do not use with LABA agents (maintenance or rescue) other than Formoterol
- SMART Protocol has been controversial for >10 years
- Albuterol rescue Inhaler cost is far less than the combination Corticosteroid/LABA
- Extra doses may not be covered by insurance (e.g. early medication refill)
- References
- (2021) Presc Lett 28(3): 14-5
- (2010) Thorax 65(8):747-52 [PubMed]
- (2011) Drug Ther Bull 49(11):126-9 [PubMed]
- Nalin (2019) Curr Opin Allergy Clin Immunol 19(2):111-7 [PubMed]
- Cloutier (2020) J Allergy Clin Immunol 146(6):1217-20 +PMID: 33280709 [PubMed]
- References
- (2013) Presc Lett, 20(8): 43
- (2001) Med Clin North Am 43(1104):39-40 [PubMed]
- Wilson (2001) Chest 119:2021-6 [PubMed]