Long-Acting Beta Agonist

Long acting beta Agonists (LABA) act primarily at beta-2 receptors to result in bronchodilation
1. Adverse effects occur with beta-1 activity

Adverse outcomes in Asthma with Long-Acting Beta Agonist (LABA)
1. LABA use in Asthma was associated with increased Asthma deaths, increased intubations and hospitalizations
  1. McMahon (2011) Pediatrics 128(5): e1147-54 [PubMed]
2. However FDA review of more recent studies found similar adverse outcomes with Inhaled Corticosteroids
  1. FDA removed LABA black box warning (see FDA communication link below)
Risk of increased mortality and of more severe and life threatening Asthma Exacerbations
1. Postulated to mask a patients awareness of severe Asthma Exacerbation
2. FDA Black Box Warnings placed in 2003, but removed in 2017 (based on newer data as above)
  1. https://www.fda.gov/Drugs/DrugSafety/ucm589587.htm
Not a substitute for Inhaled Corticosteroids
1. Steroids are key management of persistent Asthma
2. Long-Acting Beta Agonists are in addition to Inhaled Corticosteroids
3. Lazarus (2001) JAMA 285:2583-93 [PubMed]
Do NOT exceed dosing schedule (e.g. Serevent bid) except Formoterol in SMART Protocol
1. Use a short acting Beta Agonist for rescue use
2. Exception: See SMART Protocol below
Tolerance over time to Protective effect
1. Effect diminishes over one month of use
2. Reference
  1. Simons (1997) Pediatrics 99:655-9 [PubMed]

Salmeterol (Serevent) Dry Powder Diskus (50 ug/inhale)
1. One inhalation every 12 hours
Serevent Inhalation aerosol MDI (21 ug/puff)
1. Adults: 2 puffs every 12 hours
2. Child: 1-2 puffs every 12 hours
Formoterol (Foradil)
1. See Formoterol
2. One inhalation every 12 hours
3. Rapid onset within 5 minutes (contrast 15-30 minutes for other LABAs)
Indacaterol (Arcapta Neohaler)
1. Once daily dosing
2. FDA approved for COPD (not proven to prevent COPD exacerbations)
3. Same Cardiovascular Risks as other long acting beta Agonists
4. Reference
  1. (2012) presc lett 19(1): 2
Arformoterol (Brovana)
1. Dose: 15 mcg twice daily

Advair Diskus (Fluticasone/Salmeterol: 100/50, 250/50, 500/50)
1. Dose: One puff twice daily
Wixela Inhub (Fluticasone/Salmeterol)
1. Released in 2019 at $150/Inhaler
AirDuo (Fluticasone/Salmeterol: 55/14, 113/14, 232/14)
1. Dose: One puff twice daily
2. Generic available in 2017 for $90/month (compare with $475/month for Advair)
3. (2017) Presc Lett 24(7)
Symbicort (Budesonide/Formoterol: 80/4.5, 160/4.5)
1. Dose: One puff twice daily
Dulera (Mometasone/Formoterol: 50/5, 100/5, 200/5)
1. Dose: Two puffs twice daily
Breo Ellipta (Fluticasone/Vilanterol: 100/25)
1. Only indicated for COPD (not Asthma)
2. Dose: One puff once daily
Trelegy Ellipta (Umeclidinium AND Fluticasone/Vilanterol)
1. Indicated for severe COPD when an Inhaled Steroid and a LAMA and LABA are both indicated
2. Indicated in Severe Asthma not controlled on medium to high dose Inhaled Corticosteroid and LABA
3. Available in 2 strengths of fluticasone component (100 mcg for COPD or Asthma, 200 mcg for Asthma only)
4. Dosing 1 puff daily of Dry Powder Inhaler
5. (2020) Presc Lett, 27(11): 62