Levalbuterol vs Albuterol

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foroneaudience

Foroneaudience
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I know this is probably like beating a dead horse, but we still have levalbuterol on our formulary.

I have found several articles comparing the two, but most of the studies are very small and involve pediatric asthma patients and these usually show a small benefit in levalbuterol. There was also a recent study in CHEST and a small study in AJHP done in 2003 that didn't show a difference in ADRs in critically ill patients (which is along the lines of what I'm looking for). We have several cardio surgeons that swear by levalbuterol for their patients and that is why it is still on our formulary.

I was wondering if anyone had a formal P&T monograph for an autosub to albuterol. All I want are your references to see if there is something major I am not finding.

Thanks in advance.
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Your director needs to nut up and tell the cardiologist to STFU and use albuterol. Every hospital I've ever been to auto subs albuterol. Kids weren't going around having heart arrhythmias all day long.
 
We learned that from the "Improved bronchodilation with levalbuterol compared with racemic
albuterol in patients with asthma" study, the only real differences were in first dose (better FEV1 with leva statistically but not after 4 weeks) and an increased HR of a whopping 4 bpm with the racemic mixture. Sure this is common knowledge but I'm a student still so idk if it is or not.
 
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Unfortunately our P&T meetings are run through evidence based medicine. We can't tell someone to "STFU" especially if we cannot produce compelling evidence. The point of this post is to inquire what other hospitals have done. Apparently this point was missed.
 
Sparda29 said:
We keep it in stock as a non-formulary item that must be approved by the DOP and the chief of medicine.
Click to expand...

How often do you actually get requests for it since its non-form? What is the basis for approval? Just curious!
 
Well I only work there 2 nights a week. Usually I see one order in the two days I'm working there. I haven't seen an order for it for about 3 weeks now though. Definitely possible it's being dispensed on the other days when I'm not working.

Usually we only keep 1 box in stock. When we dispense it, we only dispense like a 7 day supply anyway. Nurses be stealin drugs and ****.

Basis for approval? I really don't know. If it were up to me, I wouldn't even keep it in stock.
 
Sparda29 said:
Well I only work there 2 nights a week. Usually I see one order in the two days I'm working there. I haven't seen an order for it for about 3 weeks now though. Definitely possible it's being dispensed on the other days when I'm not working.

Usually we only keep 1 box in stock. When we dispense it, we only dispense like a 7 day supply anyway. Nurses be stealin drugs and ****.

Basis for approval? I really don't know. If it were up to me, I wouldn't even keep it in stock.
Click to expand...

Ah good thanks!
 
I'm on rotation at a pediatric asthma/CF clinic right now and we treat the two almost exactly the same.

Most of our levalbuterol patients are on such only because the parents are inconsolably convinced it's the only medication that will help their kid ("because it says so online").
 
We use albuterol much, much more but we do dispense levalbuterol daily. We definitely don't stock it in the Pyxis like we do albuterol though. We make respiratory come pick it up :smuggrin:
 
We don't have a formulary, per say, so we have it. Most of our patients are pretty weak, though, so it's not that big of an issue. As an LTAC, we're more interested in keeping our average length of stay at 25 days or more.
 
Its the same identical s h i t. S-albuterol in the recemic mixture ia physiologically inert. active part is the r albuterol. same identical even the tachycardia rate. Look at the package insert.

The only way it can make a difference is if a patient is slow in metabolizing albuterol then sinve racemic mixture has 2x the amount of albuterol, they can accumulate it......in theory. no study has shown it. take xopenex off the formulary.
 
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We have it as a non-formulary item...requires approval from the Chief of Staff (or designated representative) to use. Pretty much only gets approval if a patient has a history of cardiac arrhythmias on albuterol (never happens) or pediatrics with crazy parents (frequently happens). When it's a patient satisfaction issue, we let it fly. Press Ganey rules the world.
 
Let me repeat... xopenex and albuterol share the same active ingredient. R-albuterol.

They are identical. Same. Same Same. identical Hello. Same.

WTF. S-albuterol in the recemic mixture has no Beta activity....physiologically inert.

Look at the package insert in the ADR section. Equivalent dosing has almost identical tach rate. Because they're the same.

The only difference is xopenex is indicated q8h. While albuterol is given q4-6h....so which will have more tachycardia? Well...albuterol....because you use it more..

It's the same stuff.. identical.

Get it????

:thumbdown:
 
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Z - why use facts when you can use anecdotes?

I rage a little anytime I see it ordered. Isn't it going generic this year? At least I will rage slightly less when that happens.
 
foroneaudience said:
Unfortunately our P&T meetings are run through evidence based medicine. We can't tell someone to "STFU" especially if we cannot produce compelling evidence. The point of this post is to inquire what other hospitals have done. Apparently this point was missed.
Click to expand...

If it was evidence based, then you wouldn't have it on the formulary. Sounds like it's marketing based decision to me.
 
spacecowgirl said:
Z - why use facts when you can use anecdotes?

I rage a little anytime I see it ordered. Isn't it going generic this year? At least I will rage slightly less when that happens.
Click to expand...

I'll give you an anecdote. I sat next to the ex Sepracor National Marketing director on a flight from New Hampshire to Charlotte... he admitted to me Xopenex was the biggest scam ever. But that's only an anecdote.
 
We make them fill out the non-formulary form and most of the time, they're just too lazy to do it and just order albuterol instead. Ahh...lazy people...so wonderful.
 
Found this online. If I have time, I will read them all the studies. I personally wouldn't recommend levalbuterol unless pt had an underlying cardiac condition where tachycardia would precipitate a problem. Even then, it would be iffy.

Dissent (username) says, "So actually the data aren't exactly a slam dunk and they definitely aren't strongly in favor. I would say they are overall, weakly in favor. Unfortunately there aren't any meta-analyses. Here are the RCTs."

L-albuterol is WORSE than racemic albuterol-
http://www.ncbi.nlm.nih.gov/pubmed/21275850

They are the same
http://www.ncbi.nlm.nih.gov/pubmed/18044102
http://www.ncbi.nlm.nih.gov/pubmed/15988423
http://www.ncbi.nlm.nih.gov/pubmed/11742271
http://www.ncbi.nlm.nih.gov/pubmed/10200010

L-albuterol is BETTER than racemic albuterol
http://www.ncbi.nlm.nih.gov/pubmed/16635694
http://www.ncbi.nlm.nih.gov/pubmed/15709454
http://www.ncbi.nlm.nih.gov/pubmed/14657817
 
Pharmacy Kid said:
Found this online. If I have time, I will read them all the studies. I personally wouldn't recommend levalbuterol unless pt had an underlying cardiac condition where tachycardia would precipitate a problem. Even then, it would be iffy.

Dissent (username) says, "So actually the data aren't exactly a slam dunk and they definitely aren't strongly in favor. I would say they are overall, weakly in favor. Unfortunately there aren't any meta-analyses. Here are the RCTs."

L-albuterol is WORSE than racemic albuterol-
http://www.ncbi.nlm.nih.gov/pubmed/21275850

They are the same
http://www.ncbi.nlm.nih.gov/pubmed/18044102
http://www.ncbi.nlm.nih.gov/pubmed/15988423
http://www.ncbi.nlm.nih.gov/pubmed/11742271
http://www.ncbi.nlm.nih.gov/pubmed/10200010

L-albuterol is BETTER than racemic albuterol
http://www.ncbi.nlm.nih.gov/pubmed/16635694
http://www.ncbi.nlm.nih.gov/pubmed/15709454
http://www.ncbi.nlm.nih.gov/pubmed/14657817
Click to expand...


It's the same chit. Aint no better or worse.
 
One last time...here's Levalbuterol & Albuterol. It's the same.

ralbuterol.png
 
3D for those spatially challenged..

albuteroc01.jpg
 
lol Z, this is one of your funnier contributions. You're taking me back to last semesters med chem. I'm glad I got an A in that class. Clearly I learned something because I bitch everytime one of the pharmacists says "whatever" when it's ordered at my institution...I guess next time they try to cut FTEs, I'll pull out the Xopenex, Pristiq, and Clarinex.
Edit: add Nuvigil to that list that makes us bleed money.
 
rxlea said:
lol Z, this is one of your funnier contributions. You're taking me back to last semesters med chem. I'm glad I got an A in that class. Clearly I learned something because I bitch everytime one of the pharmacists says "whatever" when it's ordered at my institution...I guess next time they try to cut FTEs, I'll pull out the Xopenex, Pristiq, and Clarinex.
Edit: add Nuvigil to that list that makes us bleed money.
Click to expand...

It's amazing to me that most pharmacists don't know the difference/same between xopenex vs. albuterol.. Not even isomers.. they're the same. Why people think xopenex is better...I don't know. Better packaging? Better looking reps? Lies? Free food??? safer???? less tachycardia??? faster?? quicker???

People are f***kin stupid.
 
Table 3: Adverse Events Reported in a 4-Week, Controlled Clinical Trial in Adults and
Body System


Placebo Xopenex 1.25 mg Xopenex 0.63 mg Racemic albuterol 2.5 mg

Cardiovascular System
Tachycardia 0 2.7 2.8 2.7
Click to expand...

That's straight out of the PI. Look at the tachycardia rates.. 2.7 vs. 2.7. That's called the "SAME."

Save xopenex for cardiac patients with arrhythmia risk? My ass....
 
Its Z said:
Its the same identical s h i t. S-albuterol in the recemic mixture ia physiologically inert. active part is the r albuterol. same identical even the tachycardia rate. Look at the package insert.

The only way it can make a difference is if a patient is slow in metabolizing albuterol then sinve racemic mixture has 2x the amount of albuterol, they can accumulate it......in theory. no study has shown it. take xopenex off the formulary.
Click to expand...

You are the man, well said dammit
 
R xxx said:
We make them fill out the non-formulary form and most of the time, they're just too lazy to do it and just order albuterol instead. Ahh...lazy people...so wonderful.
Click to expand...

Right on. Auto-sub stop 90+% of the use. Ours has a provision allowing MD to write clinical justification to override it. Easier passage through P&T, and you know docs don't bother writing justifications. ;)
 
Its Z said:
It's amazing to me that most pharmacists don't know the difference/same between xopenex vs. albuterol.. Not even isomers.. they're the same. Why people think xopenex is better...I don't know. Better packaging? Better looking reps? Lies? Free food??? safer???? less tachycardia??? faster?? quicker???

People are f***kin stupid.
Click to expand...

Same by definition would mean 100% identical which they aren't. :D It's like telling a patient Generic and Brand are 100% the same, active ingredient is but not inactive.

I do agree that albuterol is just as equivalent as xopenex based on the fact they share the same active isomer. The manufacturer of Xopenex would love to tell you otherwise though especially with their claim of lower ADR's which in theory is a possibility but BS to me.
 
In the workplace, you have to pick your battles and take things day by day.
 
Me and my preceptor had a cool conversation about this today. He had some patients report preferring lev so he wondered if there was anything to the AE profile being different. I recalled this thread and we pulled out the PI to take a look. Very revealing. :D

SDN FTW! :thumbup:
 
spacecowgirl said:
Z - why use facts when you can use anecdotes?

I rage a little anytime I see it ordered. Isn't it going generic this year? At least I will rage slightly less when that happens.
Click to expand...

Xopenex is already generic but not in all strengths and the pricing isn't that great .
 
rxlea said:
I'm going to pull out the PI next time ;)
Click to expand...

Then take a highlighter and highlight the air rates and hand it to whoever. You dont need to say a word.
 
owlegrad said:
Me and my preceptor had a cool conversation about this today. He had some patients report preferring lev so he wondered if there was anything to the AE profile being different. I recalled this thread and we pulled out the PI to take a look. Very revealing. :D

SDN FTW! :thumbup:
Click to expand...
Youre welcome
 
I've heard of drugs where levo and dextro have either different effects for example L-thyroxine vs D-thyroxine.
Source - http://en.wikipedia.org/wiki/Dextrothyroxine

and..

Drugs where the levo and dextro both have activity, however one is greater than the other. An example would be D-amphetamine and L-amphetamine, with D being more potent.
Source - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1083612/pdf/jnnpsyc00204-0180.pdf

and..

Drugs where levo/dextro activity is 100% or 0%, as the examples above.

Is there a webpage with a summary with this kind of information? Or is it acquired overtime?
 
amox said:
I've heard of drugs where levo and dextro have either different effects for example L-thyroxine vs D-thyroxine.
Source - http://en.wikipedia.org/wiki/Dextrothyroxine

and..

Drugs where the levo and dextro both have activity, however one is greater than the other. An example would be D-amphetamine and L-amphetamine, with D being more potent.
Source - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1083612/pdf/jnnpsyc00204-0180.pdf

and..

Drugs where levo/dextro activity is 100% or 0%, as the examples above.

Is there a webpage with a summary with this kind of information? Or is it acquired overtime?
Click to expand...

It's mostly acquired over time as far as I'm aware. Warfarin is probably one of the most clinically significant racemic mixtures. Different CYP enzymes metabolize each enantiomer, and the S-enantiomer is a more potent VKA, so SMX/TMP and metronidazole are pretty big interactions, whereas ketoconazole is relatively "milder."

Then you have your armodafinil, dexlansoprazole, desvenlafaxine, desloratadine, levocetirizine, etc. The manufacturers are always trying to find their "less side effects" and "better response rate" niches that don't always exist until you look at relative risks and p-values blah blah blah. They're *usually* lame clinically insignificant patent extenders if you ask me.
 
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