Case Study: MH is an 11-year-old female patient with asthma and is with her mom to fill a new prescription for levalbuterol (Xopenex HFA). The pharmacist tells MH's mom that the co-payment is $120 for the inhaler. She asks whether a less expensive alternative is available. The pharmacist recommends albuterol (ProAir HFA) and calls MH's pediatrician to try to change the prescription. The pediatrician expresses concern that albuterol could cause more adverse effects, such as an increased heart rate and tremors. Upon further discussion, the pharmacist learns the MH has a medical history for asthma, atopic dermatitis, and seasonal allergies only.


Can MH Safely take albuterol instead of levalbuterol?


Answer: Both albuterol and levalbuterol are short-acting β-agonists (SABAs) used to treat acute asthma exacerbations. Albuterol is the racemic mixture of equal parts (R)-albuterol and (S)-albuterol (levalbuterol) is the therapeutically active moiety responsible for promoting bronchodilation at β2 receptors. (S)-albuterol is clinically inert but is thought to be responsible for adverse effects, notably tachycardia. The results of a small study comparing the cardiovascular effects of albuterol and levalbuterol in pediatric patients without preexisting cardiovascular disease identified no clinically significant differences in heart rate.1 Additionally, in children with preexisting heart disease, SABA use does increase the heart rate, but the observed increase was equivalent between both preparations.2 It seems reasonable that MH can safely try albuterol, especially if cost is a barrier. If she uses her inhaler as needed and with proper technique, her overall risk of adverse effects should be minimal.

References
  1. Bio LL, Willey VJ, Poon CY. Comparison of levalbuterol and racemic albuterol based on cardiac adverse effects in children. J Pediatr Pharmacol Ther. 2011;16(3):191-198. doi: 10.5863/1551-6776-16.3.191.
  2. Kelly A, Kennedy A, John BM, Duane B, et al. A comparison of heart rate changes associated with levalbuterol and racemic albuterol in pediatric cardiology patients. Ann Pharmacother. 2013;47(5):644-650. doi:10.1345/aph.1S003.