# Xopenex vs Albuterol and Atrovent



## rmellish

One of the services I part-time for just adopted new protocols for breathing treatments. Many of the medics were expecting atrovent to be added to the albuterol we already carry, but instead the medical director opted to add Xopenex. (levalbuterol) Does anyone have any experience with this drug, and how does it compare to an albuterol atrovent combination when nebulized? 

From what little I've read it serves as a replacement for an albuterol treatment, and acts in much the same way. I'm aware Atrovent is different class of drug with a different mode of action.


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## Ridryder911

Yup.. use it like it, but I will allow Vent to discuss it. She is the expert in this area. 

R/r 911


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## VentMedic

Xopenex is not new and has been around for at least 12 years...maybe longer. The MDI form with HFA propellant was released 2 years ago. 

Xopenex has a different chemical formula than albuterol. However, the studies are mixed and many hospitals rarely see the benefits to out weigh the costs to put it in the general formulary. As an RRT, I use it only at a doctor's or patient's special request. In the PFT lab, it displayed similar bronchodilation as albuterol. However, the patient must be considered and if their insurance or budget does not allow for an expensive med, other medications or lifestyle elements must be taken into consideration to control the bronchoconstriction. If the person cannot afford to buy the med, they can not be very compliant.

It is definitely not cost effective to be used as a front line and "let me try something" med in the ED on every patient with the sniffles. 

We have switched some of our long term asthma and COPD pts to Xopenex for a trial and let them decide how it works as well as doing PFTs to follow up or stress them in exercise. Some switch back to albuterol and some rave about it. 

Atrovent is down played in the new EPR-3 guidelines for asthma. It is still in COPD guidelines but controversial for cardiac patients in the long term use. It is most effective for patients with chronic air-trapping problems for relieving the cholinergic tone of the lower airways. 

Atrovent in the emergency setting is always meant to be used with a Short Acting Beta2 Agonist (SABA) such as Albuterol or Xopenex. Sometime in the future, Xopenex may be released as a combination with Atrovent similar to Duoneb with Atrovent/Albuterol.

All that being said, you will still have to follow your medical director's protocols which may be generic and not as respiratory specific with all the options for different pathways (protocols) that RRTs and RNs have in the ED, clinic or hospital settings.


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## rmellish

Would Xopenex be as apt to increase heart rate as albuterol?

Would Xopenex be considered a second line if no response from initial albuterol treatments? Protocol has it at a single administration.


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## VentMedic

No, after the initial bronchodilator challenge other medications are initiated such as steriods and a continuous Albuterol neb may be started. 
The advantage of albuterol is that it can be given in high doses over longer periods of time until other therapies start to work. It can also be given in a concentrated high dose over a very short period of time by using a breath activated nebulizer. Heliox may also have to be introduced to achieve good particle desposition. Different nebulizers may also be used to obtain the correct particle size. An acorn neb with a face mask is sometimes as effective as spitting in the wind if their nares filter the particles. Blow-by on a child is just as useless. 

Asthma and COPD have inflammatory and infection components that must be addressed SABAs are only meant to relieve some symptoms but may not be the definitive treatment. If it was, they wouldn't have called you if they had their own SABAs.

Too many expect clear breath sounds after administering SABAs. Rarely does it happen that way in the acute setting.

Your single administration of Xopenex is due to the recommended time for each dosage is q6 hours. If you carry only Xopenex you may be limited for a 2nd SABA administration and your MD may be reluctant to allow an Albuterol given under the stated Xopenex guidelines.

Albuterol has already has already had extensive studies for benefits and safety of high doses over long periods of time.

Those that experience side effects such as rapid HR have a sensitivity to the med, have taken some OTC med or herbal remedy to interact with, take MAOIs or have a cardiac condition that may need better control. 

Xopenex has the same warnings on its label as Albuterol. 

I like Xopenex and some of my patients swear by it. But, those that can afford a Xopenex MDI also have good insurance or the means to pay. They are also more likely to be compliant with better living conditions. 

If smoking is still an issue..........

Suggested reading and info sites:


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## VentMedic

ATS

http://www.thoracic.org/

EPR-2 (Asthma)

http://www.nhlbi.nih.gov/guidelines/archives/epr-2/index.htm

http://www.accessce.com/online_modules/5/110_asthma.module.htm

EPR-3 (Asthma)

http://www.nhlbi.nih.gov/guidelines/asthma/index.htm

COPD guidelines

http://www.thoracic.org/sections/copd/index.html

http://www.medscape.com/viewprogram/5903_pnt


Disclaimer:

You will still be functioning within the guidelines of your medical director. 

You may find Xopenex used more frequently in the pedi population.


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## rmellish

Thanks Vent!


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## VentMedic

One more link:


www.rcjournal.com

Just look for Xopenex or Levalbuterol with "Search for Article".

Some of the studies are positive in long term management. However, one also has to take into consideration of what LABAs and corticosteroids are being used.


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## Emtgirl21

As a severe Asthmatic here is my two cents. I perfer xopenex over albuterol because it doesnt give me the side affects like increased heart rate. I dont use atrovent because I am allergic to it. However atrovent isnt the same type of drug as albuterol and xopenex. It takes longer to kick in but it last longer so you dont get a second wave. 

Another thing also is that sometimes when I get in serious trouble xopenex wont break a cycle it takes albuterol. 

Last thing for ten days of xopenex it coast 60 dollars with insurance. I think its 218 without. For 50 albuterol breathing treatments its ten bucks.


So there is ya a different view point.


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## sixmaybemore

> Last thing for ten days of xopenex it coast 60 dollars with insurance. I think its 218 without. For 50 albuterol breathing treatments its ten bucks.



That is the one thing I clearly remember about Xopenex. It's hella expensive. I'm just glad we had double insurance at the time we had to use it. We also had to get a waiver each and every time it was prescribed (I'm not sure how many times they needed to hear about the contraindication for albuterol. Apparently, paperwork makes insurance companies HAPPY!).


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## VentMedic

sixmaybemore said:


> (I'm not sure how many times they needed to hear about the contraindication for albuterol. Apparently, paperwork makes insurance companies HAPPY!).


 
That's because the "contraindication" card was played too many times in the past decade to get insurances and hospitals to approve it. In our hospital, with some rare exceptions in peds and adults, you have to prove that your head and both arms will fall off if you take albuterol. Kids without insurance have continued to use albuterol because there are too few programs that will fund Xopenex as long as there is a cheap alternative and the evidence is not overwhelmingly showing added benefit. Most do very well especially if their parents are able to get the meds needed for their child without too much hardship. Many still use the ED as a pharmacy, knowing we'll send them home with an inhaler. However, it will not be a Xopenex HFA MDI.

The same for Advair and Symbicort. Both expensive and both have cheaper alternatives.


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## Mercuris

EMSA by protocol currently uses Albuterol/Atrovent stacks as their front line drug. While effective, Albuterol is a beta II antagonist, and therefore increases HR. Atrovent as we all know is a derivetive of peanuts of which a lot of people are allergic to. And, the only experience I have with Xopenex is in pediatric doses for my kids. I like Xopenex as it seems to have a less aggressive effect when dispensed, and seems like a good all around breathing treatment. It seems it should have a place in the pre-hospital setting for any ALS sevice


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## VentMedic

Mercuris said:


> Atrovent as we all know is a derivetive of peanuts of which a lot of people are allergic to.


 
Miss-information.

It was the propellant in the old CFC Atrovent MDI cannisters that was lecithin based. 

Liquid Atrovent in Duoneb or by itself does NOT have the same ingredients.

The HFA Atrovent no longer has that issue.

However, Combivent MDI is still CFC and contains a lecithin base for its propellant. The FDA is still debating as I am typing this on what to do with Combivent since its manufacturer has be unable to reformulate. Thus the soy or peanut allergy potential is still present in Combivent until they can change the propellant.

I repeat: *the peanut/soy allergy issue DOES NOT apply to the LIQUID form of Atrovent. *

*Nor does it apply to the new Atrovent MDI with the HFA propellant.*


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## Mercuris

Okay fair enough, it's very possible that have not been updated on the propellant base of Atrovent, thanks for pointing this out.


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## mycrofft

*Ipratropium per se is a chemical derivative of atropine*

We use an attack sequnce of: albuterol MDI, followed by albuteral 2.5 ml in 2 ml SNS via neb with Flovent or Atrovent MDI used during the neb tx depending upon what the pt is taking etc., and ususally go on to an oral prednisone loading dose. (We had a doc who would have us give 2 mg straight albuterol via neb, seemed to work a little faster but that's all. Probably wasted a bit in the plumbing).
When we had only Albuterol's predecessor and epinephrine injections as our first line rescue drugs, we lost three or more people a year. Now, with this regimen...nada. We do have albuterol abusers, though.


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## NREMT08

*Asthma since birth*

I take Xopenex, it works so much better than Albuterol, I could go on and on about it, but I wont.


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## VentMedic

mycrofft said:


> (We had a doc who would have us give 2 mg straight albuterol via neb, seemed to work a little faster but that's all. Probably wasted a bit in the plumbing).


 
Only 2 mg?  The standard Albuterol U.D. is 2.5 mg.   We give 5 mg undiluted in a breath activated neb which has very little waste.   

If we are doing a K+ protocol, we give 15 - 20 mg rapidly to attempt a shift.  

This is in the hospital or on Specialty CCT if we know the K+.


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## VentMedic

NREMT08 said:


> I take Xopenex, it works so much better than Albuterol, I could go on and on about it, but I wont.


 
May I ask, what is the frequency of your use? MDI or neb? Any other maintenance meds?

Like I said before, some patients do rave about it...and some don't. A lot also has to do with their triggers and the newer maintenance meds.


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## MedxMedic44

I work under two EMS systems currently right now in Chicago and the Chicagoland area. One system uses Xopenex or Albuterol and the other uses Albuterol and Atrovent. I work for a private provider and as such I tend to do longer transport times than the local fire-based EMS service.  I've read your post Vent and I didn't know of Atrovent's cardiac implications in respiratory-related emergencies (granted its basically neubilzed Atropine, if Im not mistaken and I know its no good for CHFer's). I prefer to use Xopenex and I've noticed that it does not increase my patients' heart rate or blood pressure and I feel it works quicker than Albuterol alone. At the same time, the Albuterol/Atrovent combination appears to work well in clearing up my patients' pulmonary distress.
I care for primarily geriatric patients as well as trach-and-vent-dependent patients, so the vast majority of our patients are in the COPD category or (I know this isn't pulmonary) in CHF. My company primarily worked in the system that used Albuterol and Atrovent and recently updated its protocols for Albuterol & Atrovent for asthma and COPD for the first dose, then Albuterol afterwards.  We recently became a two-system provider that does either successive doses of either Albuterol or Xopenex at provider's discretion. We can use Xopenex in 1.25mg doses and there is no maximum listed dose and can be used for peds.
I know of two systems in the greater Chicago-land area that do both Xopenex and Atrovent and are moving to replace Albuterol entirely. 
I know some literature have suggested we start giving beta-2 agonists in CHF again...Vent, is this a smart decision and how would Xopenex affect a CHF patient in this case, or in a patient that has pneumonia with elevated heart-rate, as these are two types of patients I encounter frequently


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## VentMedic

If you read the Xopenex literature, the warnings are almost exactly the same as Albuterol.

http://www.xopenex.com/xopenexProviders/XopenexUDV400437-R5.pdf

It also still has some dosing restrictions which makes it complicated to get approvals for a continuous neb to be done. The HR for the 1.25 mg of Xopenex was actually slightly higher than the 2.5 mg Albuterol in some studies which I believe are mentioned in the above link. 

We follow the national Asthma and COPD guidelinse. For CHF, we may try one albuterol/atrovent but usually only with a COPD/Asthma history. 

If the airways are not bronchospastic, Albuterol or Xopenex may offer nothing. That is usually the case in CHF and PNA. 

Our RT department does about 300 - 400 nebulizers per day and use a variety of meds. Usually if no difference is noted, albuterol will be the drug of choice. If the patient is tested with spirometry for Xopenex and if there is little or not difference between their previous results, they'll get albuterol unless they have terriffic insurance and insist on Xopenex. Right now the majority of patients use albuterol. 

We rely on diagnositic values as well as what the patient says. When Xopenex first came out over a decade ago, we sold it heavily because of a special incentive and a little grant money for a study. We put it up to be the greatest thing since peanut butter and jelly. The hype worked...temporarily. We had literally used a "placebo" type effect with the Xopenex make them believe it was the best thing ever. For some, you can do the "Coke" and "Pepsi" challenge and a few would think they know the difference. 

When I am in a rescue situation, I am going to give the patient all the confidence I can in whatever drug or equipment I am using. I DO NOT say X is better than A or an MDI is worthless or better or a neb is mostly wasted. I give NO negatives even if all the studies indicate some therapies are crap but that is all I have at the moment. However, I may point out some differences if I know they are already using something else. Right now that is our biggest challenge with the new HFA propellant MDIs. "It doesn't feel the same". And it doesn't.

In the acute phase of COPD and Asthma, the bronchodilator may bring some relief, but the majority of the problem will be resolved by treating the underlying cause definitively. Sometimes too much time is wasted by "try another neb" instead on moving quickly on down the protocol pathway for asthma or COPD.


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## marineman

I have nothing worthwhile to add to this thread except Vent your knowledge amazes me and I appreciate you posting all of this information. I learned more from this thread than I did by reading the entire pharmacology chapter of the textbook.

The basic summary I get is nothing has proven that Xoponex works better, it has a slower onset and longer duration and is very expensive thus making it less effective/efficient as a front line drug in the field?


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## rmellish

It may not necessarily be a first line drug, but its obviously a useful to keep in the box. Imagine a situation where a pt. has been dosing with albuterol prior to ems arrival with little to no effect. Will more albuterol be of any help or would a different drug make more sense in this case?

So, not necessarily a first line, rather an option.


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## VentMedic

marineman said:


> The basic summary I get is nothing has proven that Xoponex works better, it has a slower onset and longer duration and is very expensive thus making it less effective/efficient as a front line drug in the field?


 
Disclaimer:
It works very well for some and not for others. Some swear by it and some see no difference.

It's like Aleve, Advil, Tylenol... One medication may actually be better than the others for certain aches and pains but for some it is personal preference and what some feel works better.

My favorite trick I used to play on people (mostly residents or student doctors) was to offer them the same drug but under a different name and see if "it worked better" from their observation. 

The thing to remember is that if the underlying is severe or if the patient has not been compliant with their maintenance meds, one neb, whether it is Xopenex or Albuterol, is just a drop in the bucket with a whole lot of catching up to do to get back to baseline. The neb will only treat some symptoms and not the cause. The patient probably already tried a boxful of ampules or a canister prior to calling you. If the bronchospasm or airway constriction was easily reversed by an inhaler you probably would not have been called.

Look for the underlying: fever, persistent productive cough, environment, lung sounds, crackles?, sinus infection, flu, colds, change in prescription meds especially beta blockers, recent dental work/infection etc.


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