Salbutamol in the 1980s. A reappraisal of its clinical efficacy

The evolution of beta2-agonists

Beta-agonists have been widely used in the treatment of asthma for many years Although concerns have been expressed over their safety based largely upon epidemics of increased mortality in asthmatics associated with high doses of isoprenaline in the 1960s and fenoterol in the 1970s and 1980s, the specific beta2-agonists are vital drugs in asthma management. The short-acting beta2-agonists have an important prophylactic role in the prevention of exercise-induced bronchoconstriction, and are essential in the emergency treatment of severe asthma. However, little if any benefit seems to be derived from regular use of short-acting beta2-agonists and regular or frequent use can increase the severity of the condition. The development of beta2-agonists with long-acting properties, such as salmeterol and formoterol, has provided advantages over short-acting beta-agonists, such as prolonged bronchodilation, reduced day- and night-time symptoms and improved quality of sleep, and has reduced the requirement for short-acting beta2-agonists as relief medication. Both drugs are well tolerated and, when added to inhaled corticosteroids, produce greater mprovement in lung function than increased steroid dose alone. Because of its rapid onset of action, formoterol also has the potential to be used for as-needed bronchodilator therapy in asthma.

The influence of active secretion processes on intestinal absorption of salbutamol in the rat

Salbutamol was perfused in the small intestine of rat using a standard rat gut "in situ" preparation: (1) in inhibitor-free solution at seven different concentrations (0.15, 0.29, 1.20, 5.0, 9.0, 13.0 and 18.0mM); (2) at a 0.29mM concentration - thought to be close to the allometric dose in man - in the presence of a non-specific enzyme inhibitor, sodium azide (0.3, 3.0 and 6.0mM); and (3) at 0.29mM in the presence of a selective secretion inhibitor, verapamil (10.0 and 20.0mM). In free solution, the mixed-order rate constants, k'(a), of salbutamol increase as the solute concentration increases until an apparent asymptotic value is reached. This could be due to the saturation of enzymatic systems responsible for the secretion of the drug from the enterocyte to the luminal fluid, a process that could explain the poor absorption of salbutamol. In the presence of sodium azide, the k(a) values increased about 1.5-fold, whereas in the presence of verapamil they increased two- to three-fold. These results indicate that salbutamol can act as a substrate of an intestinal secretory transport, which probably includes--at least in part--the enzyme P-glycoprotein, since verapamil has been shown to inhibit this enzyme by dose-dependent competition. This leads to a secretion-limited peroral absorption of salbutamol, which contributes to the poor oral bioavailability of the drug. The possible options for improving salbutamol absorption are discussed.

Cyclodextrin as a potential drug carrier in salbutamol dry powder aerosols: the in-vitro deposition and toxicity studies of the complexes

This research was carried out to develop a new carrier in dry powder aerosols. Two types of cyclodextrin were chosen; gamma cyclodextrin (GCD) and dimethyl-beta-cyclodextrin (DMCD) as carriers in dry powder formulations. Salbutamol was used as a model drug and a control formulation containing lactose and the drug was included. A twin-stage impinger (TSI) was used to evaluate in delivery efficiency of those dry powder formulations. The toxicity of cyclodextrin complexes was investigated in the rat by monitoring blood urea nitrogen (BUN) and urinary creatinine, as well as determining haemolysis of human red blood cells. The release of salbutamol from dry powder formulations was also studied over a period of time. From the results obtained, it was found that the formulation containing GCD-enhanced drug delivery to the lower stage of the TSI (deposition = 65%) much greater than that of both formulations containing DMCD (50%) and the control formulation (40%) (P<0.05). After injecting the GCD complex BUN and creatinine levels in rats were similar to those obtained in the control while those receiving DMCD complex had higher BUN and creatinine. The haemolysis of red blood cells incubated with the DMCD complex was higher than that obtained in the GCD complex. The drug release in both formulations containing GCD and DMCD was fast (over 70% was released in 5 min) and nearly all the drug was released within 30 min. It can be concluded that GCD and DMCD are able to promote salbutamol delivery in dry powder inhaler compared to a formulation containing lactose. In addition, GCD is relatively safe in the rat if the amount of GCD in the formulation is similar to this experiment.

Asthma, asthma medication and autonomic nervous system dysfunction

Asthma is associated with autonomic nervous imbalance: an increased bronchial sensitivity to cholinergic constrictors and possibly a decreased sensitivity to beta2-adrenergic dilators have been reported in this disease. Also, non-adrenergic and non-cholinergic (NANC) mediators have a small regulatory effect on airway function. These mediators contribute to the pathogenesis of asthma not only by regulating smooth muscle tone in the airways but also by affecting pulmonary blood flow, endothelial permeability and airway secretions. In many studies increased parasympathetic responsiveness has been associated with clinical asthma or the worsening of asthma in adults. However, most of the studies in children have not found association between autonomic dysfunction and asthma. Therefore, the autonomic dysfunction in asthma may be related to more advanced disease or long-term asthma medication in adults. This article briefly reviews the relationships between airway inflammation, beta2-agonist, anticholinergic and glucocorticoid medication as well as autonomic nervous function in asthma.

The pharmacokinetics of levosalbutamol: what are the clinical implications?

Salbutamol (albuterol) is a beta2-adrenoceptor agonist used as a bronchodilator for the treatment of asthma and as a uterine relaxant for the suspension of premature labour. Salbutamol has been marketed as a racemic mixture, although beta2-agonist activity resides almost exclusively in the (R)-enantiomer. The enantioselective disposition of salbutamol and the possibility that (S)-salbutamol has adverse effects have led to the development of an enantiomerically pure (R)-salbutamol formulation known as levosalbutamol (levalbuterol). Salbutamol is metabolised almost exclusively by sulphotransferase (SULT) 1A3 to an inactive metabolite. (R)-Salbutamol is metabolised up to 12 times faster than (S)-salbutamol. This leads to relatively higher plasma concentrations of (S)- salbutamol following all routes of administration, but particularly following oral administration because of extensive metabolism by the intestine. Enantiomer concentrations are similar for the first hour following an inhaled dose, reflecting the fact that salbutamol in the lung probably undergoes little metabolism. Subsequently, (S)-salbutamol predominates due to absorption and metabolism of the swallowed portion of the inhaled dose. Following oral or inhaled administration of enantiomerically pure salbutamol, a small amount (6%) is converted to the other enantiomer, probably by acid-catalysed racemisation in the stomach. Tissue binding of salbutamol is not enantioselective and plasma protein binding is relatively low. Both enantiomers are actively excreted into the urine. Compared with healthy individuals, patients with asthma do not have substantially different pharmacokinetics of the salbutamol enantiomers, but they do appear to have less drug delivered to the lung following inhaled administration because of their narrowed airways. Levosalbutamol elicits an equal or slightly larger response than an equivalent dose of the racemic mixture. This is probably due to competitive inhibition between the enantiomers at beta-adrenoceptors. Pharmacokinetic-pharmacodynamic relationships for levosalbutamol show relatively large interindividual variations. Functionally significant genetic polymorphisms have been identified for beta2-adrenoceptors, SULT1A3 and organic action transporters, all of which affect the disposition or action of levosalbutamol. Animal, in vitro and some clinical studies have reported deleterious effects of (S)-salbutamol on smooth muscle contractility or lung function. However, well-designed clinical studies in patients with asthma have failed to find evidence of significant toxicity associated with (S)-salbutamol. The clinical consequences of relatively higher plasma concentrations of (S)-salbutamol following administration of racemate remain unclear, but in the absence of clear evidence of toxicity the clinical superiority of levosalbutamol over racemic salbutamol appears to be small.

Effects of short-term oral salbutamol administration on exercise endurance and metabolism

The present study examined whether oral short-term administration of salbutamol (Sal) modifies performance and selected hormonal and metabolic variables during submaximal exercise. Eight recreational male athletes completed two cycling trials at 80-85% peak O(2) consumption until exhaustion after either gelatin placebo (Pla) or oral Sal (12 mg/day for 3 wk) treatment, according to a double-blind and randomized protocol. Blood samples were collected at rest, after 5, 10, and 15 min, and at exhaustion to determine growth hormone (GH), cortisol, testosterone, triiodothyronine (T(3)), C peptide, free fatty acid (FFA), blood glucose, lactate, and blood urea values. Time of cycling was significantly increased after chronic Sal intake (Sal: 30.5 +/- 3.1 vs. Pla: 23.7 +/- 1.6 min, P < 0.05). No change in any variable was found before cycling except a decrease in blood urea concentration and an increase in T(3) after Sal that remained significant throughout the exercise test (P < 0.05). Compared with rest, exercise resulted in a significant increase in GH, cortisol, testosterone, T(3), FFAs, and lactate and a decrease in C peptide after both treatments with higher exercise FFA levels and exhaustion GH concentrations after Sal (P < 0.05). Sal but not Pla significantly decreased exercise blood glucose levels. From these data, short-term Sal intake did appear to improve performance during intense submaximal exercise with concomitant increase in substrate availability and utilization, but the exact mechanisms involved need further investigation.

Effect of salbutamol on muscle strength and endurance performance in nonasthmatic men

PURPOSE

The ergogenic effect of acute beta2-adrenergic agonist administration in nonasthmatic individuals has not been clearly demonstrated. Therefore, the acute effects of oral administration of the beta2-adrenergic agonist salbutamol (4 mg) on muscle strength and endurance performance were studied in 16 nonasthmatic men in a double-blind randomized cross-over study.

METHODS

Peak expiratory flow (Mini Wright Peakflowmeter), isokinetic strength of the knee extensors and knee flexors at four angular velocities (Cybex II dynamometer), and endurance performance in a cycle ergometer test until exhaustion at 70% of maximal workload were measured.

RESULTS

Peak expiratory flow increased from 601 +/- 67 L x min(-1) to 629 +/- 64 L x min(-1) after salbutamol (P < 0.05). Peak torque was higher after salbutamol than after placebo (4.4% for the knee extensors, 4.9% for the knee flexors) (P < 0.05). Mean endurance time increased from 3,039 +/- 1,031 s after placebo to 3,439 +/- 1,287 s after salbutamol (P = 0.19). When four subjects complaining about adverse side effects were excluded from the analysis, the increase in endurance time (729 +/- 1,007 s or 29%) was statistically significant (P <-0.05). Salbutamol did not affect VO2, respiratory exchange ratio, heart rate, and plasma free fatty acid and glycerol concentration during exercise; plasma lactate and potassium concentrations were increased (P < 0.05).

CONCLUSIONS

Under the conditions of this study, oral salbutamol appears to be an effective ergogenic aid in nonasthmatic individuals not experiencing adverse side effects.

Reproducibility of bronchodilator response for a reservoir dry powder inhaler following routine clinical use

The performance of dry powder inhaler (DPI) devices, particularly reservoir DPIs, may be influenced by environmental conditions. This study compared the bronchodilator efficacy and in vitro aerosol characteristics of salbutamol, delivered via a novel reservoir DPI (Clickhaler) and a conventional pressurized metered-dose inhaler (MDI) before and after use of the DPI in clinical practice. Following a screening visit, patients received cumulative doses of salbutamol (100, 200, and 400 microg) via DPI or MDI on separate days in a double-blind, crossover design before and after a 4-week period, during which the DPI was used as the patients' first-line bronchodilator. Lung function responses (forced expiratory volume in 1 sec [FEV1], forced vital capacity [FVC], and peak expiratory flow [PEF]) to salbutamol delivered by DPI and MDI and in vitro aerosol characteristics were not significantly different before and after the period of DPI patient use. DPI performance, assessed in vivo and in vitro, is maintained following an extended period of patient use.

Enantiomeric disposition of inhaled, intravenous and oral racemic-salbutamol in man--no evidence of enantioselective lung metabolism

Aims To establish whether enantioselective metabolism of racemic (rac )-salbutamol occurs in the lungs by determining its enantiomeric disposition following inhalation, in the absence and presence of oral charcoal, compared with that following the oral and intravenous routes. Methods Fifteen healthy subjects (eight male) were randomized into an open design, crossover study. Plasma and urine salbutamol enantiomer concentrations were measured for 24 h following oral (2 mg) with or without oral charcoal (to block oral absorption), inhaled (MDI; 1200 microg) with or without oral charcoal and intravenous (500 microg) rac-salbutamol. Systemic exposure (plasma AUC(0,infinity) and urinary excretion (Au24h ) of both enantiomers were calculated, and relative exposure to (R)-salbutamol both in plasma (AUC(R)-/AUC(S)- ) and urine (Au(R)-/Au(S)- ) was derived for each route. Relative exposure after the inhaled with charcoal and oral routes were compared with the intravenous route. Results AUC(R)-/AUC(S)- [geometric mean (95% CI)] was similar following the intravenous [0.32 (0.28, 0.36)] and inhaled with charcoal rates [0.29 (0.24, 0.36); P=0.046], but was far lower following oral dosing [0.05 (0.03, 0.07); P<0.001]. Similar results were found when relative exposure was analysed using Au24h. Conclusions These results show no evidence of significant enantioselective presystemic metabolism in the lungs, whilst confirming it in the gut and systemic circulation, indicating that the (R)- and (S)-enantiomers are present in similar quantities in the airways following inhaled rac-salbutamol.

Intranasal salbutamol instillation in asthma attack

Beta-two sympathomimetic drugs are the treatment of choice for asthmatic attack. Their main effect is to dilate the bronchi by a direct action on beta-two adrenoreceptors on the smooth muscle, and also by mediator release inhibition from mast cells. Salbutamol is widely used in the treatment of bronchial asthma, and is usually administered either by inhalation, orally, or parenterally. The nasal route seems to afford an effective way to administer medications, since the nasal mucosa has a relatively large surface area, and there is no gastrointestinal-hepatic first pass-effect, thus avoiding extensive loss of the administered drug. We describe herein the use of nasal salbutamol in 3 patients with severe asthma attacks who were refractory to conventional therapy, with favorable responses and without significant undesirable effects.

Plasma and muscle polyamine levels in aerobically exercised rats treated with salbutamol

The induction of hypertrophy of cardiac and skeletal muscles has been studied after treatment with two different salbutamol dosages, therapeutic and doping. Treatment of rats subjected to a physical training schedule with repeated doses (16 microg kg(-1) per day or 3 mg kg(-1) per day) of salbutamol, a specific beta-adrenergic agonist, induced a marked increase in both skeletal and heart-muscle weight, whereas total body weight did not change significantly. Adrenergic involvement of salbutamol-linked muscle hypertrophy was demonstrated by co-administration of the non-specific beta-adrenergic antagonist, propranolol (20 mg kg(-1) per day). Salbutamol-induced muscle hypertrophy was associated with an increase in serum, skeletal-muscle and heart levels of the naturally occurring polyamines putrescine, spermidine and spermine. These observations suggest the involvement of polyamines in muscle hypertrophy and the possible role of blood polyamines as exposure biomarkers in beta-adrenergic-muscle hypertrophy.

Determination of the enantiomers of albuterol in human and canine plasma by enantioselective high-performance liquid chromatography on a teicoplanin-based chiral stationary phase

A sensitive enantioselective high-performance chromatographic (HPLC) method was developed validated to determine low levels of (-)-R and (+)-S-albuterol in plasma. Baseline resolution was achieved by using a teicoplanin-based chiral stationary phase with a polar organic mobile phase consisting of methanol/ acetonitrile/glacial acetic acid/diethylamine, 40:60:0.3:0.2, (v/v/v/v) and a flow-rate of 1.0 ml/min. Enantioselectivity (alpha) equaled 1.18 and resolution (RS) equaled 1.8. By using fluorescence detection maximized at 230 and 310 nm for excitation and emission, respectively, concentrations of each enantiomer could be measured down to 125 pg/ml from a 1-ml plasma sample. Initially, the method was applied to plasma samples from a small single-dose inhalation study of racemic albuterol in a human volunteer and, later, to in vivo samples from a canine inhalation study of the single enantiomer, (-)-R-albuterol. Results from the canine study showed that no chiral inversion of (-)-R-albuterol occurs in the dog.

Altered cardiovascular autonomic regulation after salmeterol treatment in asthmatic children

The effects of therapeutic 4 weeks' inhaled salmeterol treatment on the cardiovascular and respiratory autonomic nervous regulation was studied in 11 asthmatic children using inhaled corticosteroid medication. The study followed a randomized, double-blind, placebo-controlled cross-over design. The salmeterol dose was 50 micrograms twice daily. The 4-week salmeterol treatment increased baseline heart rate, low-frequency/high-frequency (LF/HF) variability ratio of R-R intervals, LF variability of systolic arterial pressure (SAP) and maximum tidal volume during the deep breathing test, as well as morning and evening peak expiratory flow (PEF) values. The 4-week salmeterol treatment decreased baseline HF variability of R-R intervals. As a response to the acute 600 micrograms of salbutamol, the changes in heart rate, HF variability of R-R intervals and diastolic blood pressure were significantly smaller after 4 weeks' salmeterol treatment. In conclusion, 4 weeks' therapeutic salmeterol treatment decreases basal cardiovagal reactivity, increases sympathetic dominance in the cardiovascular autonomic balance and improves pulmonary function. A tolerance develops in the cardiovascular response but not in the bronchodilatory response.

Formulation and preparation of controlled release pellets of salbutamol by the air suspension technique

A controlled release preparation of salbutamol may improve patient compliance, minimise side effects and be valuable in the treatment of nocturnal asthma by extending drug action throughout the night. The aim of the study was therefore to formulate a controlled release pellet preparation of salbutamol via the air suspension technique. The study established that curing for 24 h at 38 +/- 0.5 degrees C was necessary for homogeneous film coats of Eudragit RS30D and hence stable drug release characteristics. Pellets coated with 6% Eudragit RS30D (polymer), 12.5% triethyl citrate (plasticiser) and 0.5% magnesium stearate (antitackiness agent) displayed desirable controlled drug release characteristics over the 8 h testing period. The manufacturing conditions employed in the study were shown to be reproducible thus ensuring reproducibility of drug release characteristics between batches of salbutamol controlled release pellets. Short term stability testing on the newly formulated pellets indicated no significant change in drug release characteristics relative to the initial drug release data when stored for 8 weeks at room temperature 20 +/- 2 degrees C or 37 degrees C with 80% Relative Humidity or at low temperature (5 +/- 1 degrees C). However, pellets stored at 40 degrees C showed a slower in-vitro drug release after 8 weeks of storage and therefore failed to maintain their initial drug release profile.

Effects of inhaled albuterol and ipratropium bromide on autonomic control of the cardiovascular system

STUDY OBJECTIVE

Systemic administration of beta-agonist and anticholinergic drugs markedly impair normal autonomic heart rate control. The purpose of this study was to quantify and compare the effects of therapeutic doses of inhaled albuterol and ipratropium on autonomic control of the cardiovascular system.

DESIGN

Randomized, double-blind, placebo-controlled, crossover design study.

SETTING

Tertiary-care hospital.

SUBJECTS

Twelve healthy male volunteers.

INTERVENTIONS

Subjects self-administered four puffs through a spacer device from one of three identical inhalers containing albuterol (100 microg per puff), ipratropium (20 microg per puff), or placebo in three different testing sessions.

MEASUREMENTS

ECG and noninvasive continuous BP traces were recorded at baseline and from 45 to 75 min after administration of the drug. Autonomic control of the cardiovascular system was quantified by analysis of spontaneous baroreflex sensitivity and power spectral analysis of heart rate variability.

RESULTS

Neither albuterol nor ipratropium caused a significant alteration in baroreflex sensitivity, normalized low-power frequency, or normalized high-power frequency. No adverse effects were reported by subjects.

CONCLUSIONS

Inhalation of four puffs of albuterol (400 microg) or ipratropium (80 microg) does not alter the autonomic control of the cardiovascular system in young, healthy male subjects.

Microencapsulated Eudragit RS30D-coated controlled-release pellets: the influence of dissolution variables and topographical evaluation

The air suspension technique was employed to prepare Eudragit RS30D-coated controlled-release pellets of salbutamol. Drug release in dissolution studies can be dependent on the dissolution method and medium used. Thus, the aim of this study was to investigate the influence of various dissolution methods and dissolution medium pH values on drug release from a batch of pellets which displayed controlled drug-release characteristics over an 8-h period in deionized water using the rotating basket method. In vitro testing using the official USP XXII (rotating basket and rotating paddle) and non-official (rotating bottle) methods showed drug release to be independent of the method used. The prepared pellets displayed pH-dependent drug-release characteristics when tested in hydrochloric acid (pH 1.5), phosphate buffer (pH 6.8) and deionized water (pH 7.2). Also, in vitro testing, which exposed the pellets to a changing pH gradient that simulated the gastrointestinal pH conditions following oral administration, was used to confirm the drug-release characteristics. The results showed controlled-release characteristics to be maintained, with the drug being released over an 8-h period. Scanning electron microscopic evaluation proved useful in the elucidation of the physical characteristics of the controlled-release pellets as well as in the identification of a possible mode of drug transfer into the dissolution medium.

The effect of salbutamol on performance in endurance cyclists

The effect of salbutamol (S) on cycling performance was examined in 15 highly trained non-asthmatic male cyclists. A double-blind, randomized cross-over design was used with S or placebo (P) administered using a metered-dose inhaler and a spacer device 20 min before each testing session. The S dose was 400 micrograms (four puffs), which is twice the normal therapeutic level. Subjects were habituated to all the laboratory procedures in the week prior to actual data collection. The subjects performed four tests under S and P conditions on separate days over 2 weeks. These included measurement of maximal O2 uptake (VO2max) (cycle ergometry) with assessment of pulmonary function before and after, a submaximal (90% of ventilatory threshold) square-wave work transition from a base of unloaded cycling, a 60-s modified Wingate test, and a simulated 20 km time trial. No significant differences were observed in any of the dependent variables related to aerobic endurance or cycling performance between the S and P conditions. These results support other findings that an acute dose (400 micrograms) of S has no performance-enhancing properties.

Enantioselective disposition of albuterol in humans

The study of enantioselective disposition of chiral drugs is important to provide a rationale of plasma concentration-effect relationships, which are often misleading when based on total drug concentration. It is also important when considering new dosage routes or formulations in order to optimize therapeutic plasma concentrations of the active enantiomer. Improvements in the sensitivity and selectivity of biological assays coupled with the developments in chiral analysis have made it possible to study the enantioselective disposition of drugs. Although valuable pharmacokinetic data were obtained for the beta 2-agonists by nonenantioselective methodology, more recent chiral studies have revealed the existence of extensive enantioselectivity in the disposition of these agents. The most significant features of the enantioselective disposition of albuterol are the relatively rapid plasma clearance and low bioavailability of the eutomer. Although this in itself does not necessarily justify the development of a single enantiomer formulation, the implications of the high levels of distomer after i.v. and oral dosing await clarification. Similarly, more work is required to elucidate the consequences of the major difference in disposition between albuterol and terbutaline in humans through both in vivo and in vitro studies of the mechanisms giving rise to this phenomenon. The enantioselective disposition of the other clinically used beta 2-agonists, such as fenoterol, formoterol, and salmeterol also needs to be characterized. The metabolism of the majority of beta 2-agonists is generally by conjugation to give one major metabolite. The situation is therefore uncomplicated by multiple metabolic pathways, which may differ in the extent and direction of their enantioselectivity. Many beta 2-agonists are excreted largely unchanged in the urine making studies of urinary excretion accessible without the requirement for very sensitive assays. The realization that the enantiomers of beta 2-agonists previously thought of as "inactive" may be associated with toxic effects is a further compelling reason to study the enantioselective pharmacokinetics of this class of drugs. In addition, the role of enantiomers in producing side effects, such as tremor and reduction in renal function, needs to be reassessed. The beta 2-agonists can be looked on as textbook examples of the inherent danger of ignoring chirality in the study of pharmacokinetics and pharmacodynamics. The growing body of information on the enantioselective disposition of beta 2-agonists in humans will enhance the rational use of these drugs in the future management of patients.

Enantioselective disposition of salbutamol in man following oral and intravenous administration

1 Salbutamol is a beta 2-adrenoceptor stimulant used clinically as a racemate where the activity resides predominantly in the (-)R enantiomer with little or no activity attributed to the (+)S enantiomer. Salbutamol undergoes extensive pre-systemic metabolism and active renal excretion. 2 The pharmacokinetics of the enantiomers of salbutamol have been investigated after intravenous (1.6 mg) and oral (4 mg) dosing with racemic drug to seven normal male volunteers. Plasma and urine samples were analysed by chiral h.p.l.c. after solid phase extraction. 3 The ratio of (-)R/(+)S salbutamol in plasma and urine following intravenous administration ranged from near unity soon after dosing to about 0.66 after 8 h. The ratio remained at about 0.3 in both plasma and urine over the 8 h following an oral dose. 4 The following pharmacokinetic parameters for (+)S and (-)R salbutamol were found to be significantly different (P < 0.05) after intravenous administration (clearance 0.39 +/- 0.12 vs 0.62 +/- 0.18 1 h-1 kg-1, terminal phase half-life 2.85 +/- 0.83 vs 2.00 +/- 0.49 h, amount excreted unchanged in urine 55 +/- 11 vs 46 +/- 8%) and following oral administration (amount excreted unchanged in urine 32 +/- 11 vs 8 +/- 4% and bioavailability 0.71 +/- 0.09 vs 0.30 +/- 0.07). 5 The active (-)R enantiomer of salbutamol undergoes significantly faster metabolism in man than the inactive (+)S enantiomer resulting in considerably lower bioavailability of the active enantiomer following oral administration.

Determination of salbutamol enantiomers in human plasma and urine by chiral high-performance liquid chromatography

Enantiomers of salbutamol were directly separated (Rs = 1.16) and quantitated at therapeutic concentrations after solid-phase extraction from human plasma and urine by normal-phase high-performance liquid chromatography on a chiral column with fluorescence detection. The assay was linear for each enantiomer between 1.25 and 500 ng ml-1 and had a minimum limit of detection of 250 pg ml-1. A 3-ml plasma or 1-ml urine sample was required for quantitation at therapeutic doses. Inter-day variation was 5.0% for S-(+)- and 6.5% for R-(-)-salbutamol. The assay was used to compare enantioselective disposition after single doses of racemate by the intravenous, oral and rectal routes.

Acute safety of the CFC-free propellant HFA-134a from a pressurized metered dose inhaler

The acute safety of the alternative chlorofluorocarbon-free (CFC-free) propellant HFA-134a from a pressurized metered-dose inhaler (MDI) was assessed in 12 healthy male subjects according to a double-blind, randomized, crossover design. On each of three consecutive days, cumulative doses of 1,2,4,8 and 16 inhalations were administered 30 min apart from one of three MDIs. The three MDIs contained either the HFA-134a CFC-free system without drug (HFA-Placebo), the CFC-free system with salbutamol sulphate (HFA-Salbutamol), or a conventional CFC propellant mixture without drug (CFC-Placebo). Pulmonary function (FEV1, FEF25-75%), cardiovascular performance (heart rate and blood pressure), objective tremor measurements and serum potassium were measured after each incremental dose. Similar responses for pulmonary function, cardiovascular performance, tremor and serum potassium were observed between the HFA-Placebo and CFC-Placebo groups. No statistically significant difference was seen in change from baseline of any parameter between the two propellant systems. The administration of HFA-Salbutamol produced statistically significant dose-related increases in heart rate, systolic blood pressure and tremor and a significant dose-related decrease in serum potassium; these responses were expected based on cumulative doses of active drug. Blood samples for HFA-134a analysis were collected to measure systemic absorption of this propellant. Levels of HFA-134a between 200 and 700 ng.ml-1 were detected in all subjects given the CFC-free system. This study shows that acute inhalation of HFA-134a in a CFC-free system is as safe as a CFC propellant system. Salbutamol sulphate in the CFC-free system can be delivered in a dose-linear fashion, without any noticeable change in the safety profile of active drug.

Analysis of beta-agonists in urine and tissues by capillary gas chromatography-mass spectrometry: in vivo study of salbutamol disposition in calves

The fate of salbutamol sulphate given orally has been investigated in calves. The urinary excretion rate and the tissue distribution of this beta-agonistic drug were studied by capillary gas chromatography coupled to low resolution mass spectrometry (GC-LRMS) under electron impact (EI) ionization mode, using an hexadeuterated salbutamol analogue as the internal standard. The parent drug and metabolites were extracted via solid phase extraction (SPE) mixed-phase-containing disposable columns and analysed as their trimethylsilyl derivatives. A more efficient clean-up had to be carried out for tissue samples. An acidic precipitation followed by a liquid-liquid extraction were therefore performed before the SPE. Moreover, the problem of tissue digestion was elucidated by means of an ultrasonic probe. Samples were also analysed before and after enzymic hydrolysis using purified beta-glucuronidase and a mixture of beta-glucuronidase and arylsulphatase, to obtain evidence of phase II conjugation mechanisms. Both free salbutamol and conjugated metabolites were detected in urine and tissue samples. Except for liver or kidney, salbutamol was rapidly cleared from most tissues after a withdrawal period. The possible excretion of some phase I metabolites was also investigated, using further analyses under positive chemical ionization LRMS and high resolution mass spectrometry (HRMS).

The effect of nebulized salbutamol therapy on the incidence of postoperative chest infection in high risk patients

Patients who smoke heavily and those with pre-existing airflow obstruction are at particular risk of postoperative respiratory infection following upper abdominal surgery. This invariably prolongs hospital stay and increases morbidity. In order to determine whether high dose bronchodilator therapy in the perioperative period reduced the risk of infection, all patients undergoing elective upper abdominal surgery were assessed for risk of developing postoperative infection. Fifty-three patients were identified as high risk according to previously published criteria and were randomly allocated to receive nebulized salbutamol (5 mg) or saline placebo 6 hourly for 48 h beginning 1 h preoperatively. There was no difference in rates of postoperative chest infection in the two groups and this study, therefore, provides no support for the routine preoperative use of bronchodilators in these patients.

The beta 2-agonist controversy. Observations, explanations and relationship to asthma epidemiology

Links between frequent use of inhaled beta 2-agonists and morbidity and mortality from asthma appear probable. Two mortality epidemics followed the marketing of potent inhaled adrenergic agents. Case-control studies in New Zealand linked mortality with prescription of fenoterol, especially in severe asthma. A Saskatchewan case-control study confirmed an association of mortality with fenoterol, and also with frequent use of salbutamol (albuterol). Cardiac effects of beta 2-agonists do not cause mortality, but frequent use of these agents may increase the chronic severity of asthma, hence increasing the number of asthmatic patients at risk of death in an acute attack. Frequent use of beta 2-agonists may reduce lung function, increasing airway responsiveness, and impair control of asthma, despite use of inhaled corticosteroids. Mechanisms for this effect may include tachyphylaxis to nonbronchodilator effects, increased responsiveness to allergen, interaction with corticosteroid receptors, altered mucociliary function, differential effects of enantiomers, and masking of symptoms by beta 2-agonist use. The withdrawal of fenoterol from New Zealand in 1990 was associated with a substantial decline in morbidity and mortality. Overall, the evidence suggests that frequent use of inhaled beta 2-agonists has a deleterious effect on the control of asthma. Epidemics of mortality are explained by an increase in chronic severity of asthma following introduction of more potent beta 2-agonists. While beta 2-agonists remain essential for relief of breakthrough symptoms, long term use, particularly with high doses of potent agents, appears to be detrimental.

Comparison of the effects of salbutamol and clenbuterol on skeletal muscle mass and carcass composition in senescent rats

Aging decreases skeletal muscle mass and strength, making elderly subjects particularly vulnerable to catabolic effects of age-related diseases. Clenbuterol, a muscle anabolic beta 2-adrenergic agonist, has reduced or restored skeletal muscle losses in experimental catabolic states. However, the doses of clenbuterol used to prevent or reverse muscle wasting in most animal models have exceeded the estimated safe dose in man. Recently, another beta 2-adrenergic agonist, salbuamol (albuterol), has been shown to increase muscle weight and protein content in young rats at a dose similar to that used clinically. In contrast to clenbuterol, salbutamol is currently approved for human use as a bronchodilator in the United States. This study has compared the muscle and protein anabolic effects of salbutamol at a clinically relevant dose with those of clenbuterol at a dose typically used in animal models of muscle wasting. Salbutamol and clenbuterol were administered by implanted osmotic minipumps to Fisher-344 rats aged 3 and 24 months at doses of 1.03 mg and 600 micrograms per kilogram per 24 hours for 3 weeks. The weights of five hindlimb muscles, as well as carcass protein and fat content, were determined. Salbutamol and clenbuterol increased combined hindlimb muscle weight 19% and 28% in young rats, with 19% and 25% increases in old rats. Similarly, these drugs increased gastrocnemius weight and protein content 19% and 24% in young rats, with 19% and 23% increases in old rats. Salbutamol and clenbuterol increased carcass protein content 20% and 30% in young rats, with 12% and 21% increases in old rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic optimisation of asthma treatment

Asthma is generally managed with bronchodilator therapy and/or anti-inflammatory drugs. Guidelines now advocate selection of drugs and pharmaceutical formulations (long-acting vs short-acting, inhaled vs systemic) on the basis of disease severity. Theophylline has a narrow therapeutic margin. Clearance is highly variable and plasma concentrations should be monitored to avoid the occurrence of plasma concentration-related adverse effects. The rate of absorption of theophylline differs depending on the sustained release formulation administered. Some products do not provide sufficient plasma drug concentrations for therapeutic efficacy over a 12-hour period, particularly in patients with high clearance rates (e.g. children and patients who smoke). Administration of drugs via inhalation offers several advantages over systemic routes of administration (e.g. adverse effects are decreased). Inhalation is now advocated as first-line therapy. Aerosol medications available for the treatment of asthma are beta 2-agonist (including the newer long-acting agents such as salmeterol), corticosteroids, anticholinergic drugs, sodium cromoglycate (cromolyn sodium) and nedocromil. To reach the airways, aerosolised particles should be 1 to 5 microns in diameter. Particles of this size can be produced by nebuliser for continuous administration or by metered-dose inhaler and drug powder inhaler for unit dose medication. For efficient use of the metered-dose inhaler, slow inhalation and actuation must be coordinated. However, efficacy and convenience can be improved when spacer devices are used. Furthermore, spacer devices lessen the oropharyngeal adverse effects of inhaled corticosteroids. Dry powder inhalers are more easily used by children and elderly patients than metered-dose inhalers. Regardless of the device used, a maximum of 10% of the inhaled dose reaches the airways. The rest of the dose is swallowed and absorbed through the gastrointestinal tract. Most inhaled drugs have low oral bioavailability, either because of a high first-pass metabolism (beta 2-agonists and glucocorticoids) or because of lack of absorption (sodium cromoglycate). Sulphation of beta 2-agonists occurs in the wall of the gastrointestinal tract and extensive metabolism of inhaled corticosteroids occurs in the liver. Low bioavailability of the swallowed fraction contributes to reduced adverse effects. The pharmacokinetic properties of an inhaled drug are of interest. The fraction of the dose absorbed through the lung has the same disposition characteristics as an intravenous dose, and the swallowed fraction has the same disposition as an orally administered dose. However, for many drugs, pharmacokinetic data after inhalation are limited and cannot be used as a criteria for selection of therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Hypokalemia after pediatric albuterol overdose: a case series

Sympathomimetic use results in a triad of hypokalemia, hyperglycemia, and elevated white blood cell count. Transient hypokalemia results from activation of the Na+/K+ pump and transport of potassium intracellularly. Increased serum glucose and insulin may also contribute to the intracellular shift of potassium after sympathomimetic use. Four cases of accidental pediatric albuterol ingestion with significant hypokalemia are reported. Four children between 1 and 6 years of age presented to the emergency department within 5 hours of ingesting 3.0, 1.1, 3.7, and 1.7 mg/kg albuterol, respectively. All four presented alert and oriented in no apparent distress. The most common findings were vomiting, sinus tachycardia, and hypokalemia (2.3, 2.5, 2.8, and 2.5 mmol/L, respectively). Each child received a single dose of activated charcoal and intravenous potassium replacement. All patients recovered uneventfully within 12 to 24 hours with supportive care only. These cases demonstrated that significant depressions in serum potassium can occur after pediatric albuterol overdose. Although transient, the dose-response relationship and duration of effect is unknown. Although significant hypokalemia can occur after ingestion of oral sympathomimetics, replacement should be managed on an individual basis until further studies are completed.

Serum concentration and cardiovascular effects of salbutamol after oral and rectal administration in healthy volunteers

In order to evaluate rectal administration of salbutamol (SB), five healthy volunteers were dosed orally and rectally with racemic SB (0.1 mg/kg) solution. Compared with the oral SB, the rectal SB gave significantly higher serum SB concentration immediately after dosing but slightly lower levels in the elimination phase. The Cmax following rectal administration was 17.9 ng/ml (17.0 ng/ml for oral administration), the tmax 0.67 h (1.5 h for oral administration) and the AUC 98.2 ng/ml/h (100 ng/ml/h for oral administration). Heart rate also rose more rapidly to a maximum of 70% above baseline values after rectal dosing. The rate continued to be twice larger than after oral dosing for up to 5 h. The concentration versus response curves indicated that rectal SB was more effective than oral SB at increasing heart rate at the same SB concentration in serum. A plausible explanation for this phenomenon might be a difference in the stereo-selective first-pass metabolism of the two enantiomers. Therefore, the rectal dose of SB administered as a suppository for prophylactic treatment of asthma should be lower than that used orally.

Duration of preventive effect of inhaled salbutamol on early airway response to allergen in asthmatic subjects

Salbutamol is known to effectively prevent early asthmatic response (EAR) after specific bronchial provocation test (sBPT) in asthmatic subjects, but the time-course of this protection is not known. In this study the effects of 200 micrograms salbutamol inhaled 2 h before sBPT were compared with 200 micrograms salbutamol inhaled 10 min before sBPT in eight asthmatic subjects sensitized to Phleum pratensis (PP) or Dermatophagoides pteronyssinus (DP). All subjects showed an EAR (% decrease in FEV1 from baseline value: 30.4 +/- 11%) in a preliminary sBPT performed with cumulated doses of extracts of PP or DP titrated in biological units (BU). Each subject performed, on two different days, in a random, double-blind, cross-over study, two puffs of placebo 2 h before sBPT and two puffs of salbutamol 10 min before sBPT (treatment A) or two puffs of salbutamol 2 h before sBPT and two puffs of placebo 10 min before sBPT (treatment B). Baseline FEV1 were similar in both tests. In treatment B, 10 min, 1 h and 2 h after salbutamol inhalation, FEV1 increased significantly with respect to placebo inhalation in treatment A. Ten minutes after salbutamol inhalation in treatment A, FEV1 became similar to that obtained 2 h after salbutamol inhalation and 10 min after placebo in treatment B. Allergen inhalation induced an EAR in only one out of eight subjects after treatment A, and five of the eight subjects after treatment B.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhaled salmeterol in the treatment of patients with moderate to severe reversible obstructive airways disease--a 3-month comparison of the efficacy and safety of twice-daily salmeterol (100 micrograms) with salmeterol (50 micrograms)

Three-hundred and fifty patients with moderate to severe reversible obstructive airways disease (forced expiratory volume in 1 s or peak expiratory flow rate < or = 50% predicted, a 15% reversibility to inhaled salbutamol and symptomatic) were recruited into a multi-centre, multinational, double-blind, parallel-group randomized study. Two-hundred and eighty-three patients were randomized to receive 50 micrograms salmeterol twice daily or 100 micrograms salmeterol twice daily administered from a metered-dose inhaler for 3 months. Salbutamol (100 micrograms per metered actuation) was provided for symptomatic relief. Morning and evening peak expiratory flow rate (PEFR), day-time and night-time asthma symptoms and additional bronchodilator usage were recorded by the patient on a daily basis. Lung function and patient/physician assessment of treatment efficacy were recorded at scheduled clinic visits. Safety was determined by monitoring adverse events and standard biochemical, haematological and cardiovascular parameters. Salmeterol 100 micrograms twice daily was consistently superior to salmeterol 50 micrograms twice daily in morning and evening PEFR measurements (mean differences between the treatments: 10-14 l min-1 for morning, 95% CI-0, 22 l min-1, P = 0.047; and 10-15 l min-1 for evening, 95% CI 2, 22 l min-1, P = 0.023). The improvement in PEFR was independent of concurrent steroid usage, with the most marked improvement being seen in the more severe asthmatics requiring concurrent oral corticosteroids (mean differences between the treatments: 27-31 l min-1, 95% CI: 3,55 l m-1, P = 0.027).(ABSTRACT TRUNCATED AT 250 WORDS)

Salmeterol xinafoate. A review of its pharmacological properties and therapeutic potential in reversible obstructive airways disease

Salmeterol xinafoate, like salbutamol (albuterol), is a saligenin derivative, and a selective beta 2-adrenoceptor agonist. It produces bronchodilation for at least 12 hours following inhalation of a single 50 micrograms dose. Salmeterol is intended for regular twice-daily treatment of reversible airways obstruction and not for immediate symptomatic relief, and when used in this manner, 50 micrograms twice daily is more effective than salbutamol 200 micrograms or terbutaline 500 micrograms administered 4 times daily, or individually titrated oral doses of theophylline in improving objective and subjective criteria of efficacy in patients with mild to moderate asthma. Salmeterol 100 micrograms inhaled twice daily may provide better control than the lower dose in patients with severe asthma. The long duration of effect of salmeterol makes it particularly suitable for treating patients with nocturnal asthma in whom it improves sleep quality. The place of salmeterol, like that of other beta 2-adrenoceptor agonists used regularly in the treatment of asthma, is being debated. Patients in need of regular beta 2-agonist therapy should also be regarded as candidates for inhaled corticosteroids to counteract underlying inflammation. Thus, salmeterol may be particularly useful in patients requiring regular treatment with beta 2-agonists for nocturnal asthma and results of trials in progress involving large numbers of patients are awaited with interest.

Formoterol. A review of its pharmacological properties and therapeutic potential in reversible obstructive airways disease

Formoterol, a long-acting beta 2-selective adrenoceptor agonist, produces dose-proportional bronchodilation in patients with obstructive airways disease with a reversible component. A significant effect occurs within minutes of inhalation of a therapeutic formoterol dose and persists for approximately 12 hours. Oral formoterol has a slower onset of action than the inhaled formulations, but also produces prolonged bronchodilatory effects. Inhaled formoterol has shown a therapeutic efficacy equivalent to or better than comparable dosages of the conventional beta 2-agonists salbutamol, fenoterol and terbutaline in short and long term trials, in both adults and children with asthma. Its prolonged duration of action permits a twice-daily dosage regimen and results in improved control of nocturnal symptoms by reducing the 'morning dip'. Formoterol also compares well with oral slow release theophylline. In addition, significantly more patients with chronic obstructive airways disease (COAD) had an improvement in symptoms when treated with formoterol compared with salbutamol or fenoterol. Noncomparative studies indicate formoterol also provides effective prophylaxis of exercise-induced asthma. Development of tachyphylaxis has not been observed. Formoterol is generally well tolerated. Adverse effects observed represent predictable extensions of its pharmacology. Tremor and palpitations are most frequently reported. The incidence of adverse events is dose-proportional and therefore related to the route of administration, being more frequent following oral than inhalation therapy. The long-acting beta 2-agonists, including formoterol, represent a significant advance over current maintenance or prophylactic bronchodilator therapy with intermediate-acting beta 2-agonists such as salbutamol, fenoterol and terbutaline, predominantly because of the twice daily administration regimen. However, comparisons with other long-acting beta 2-agonists, such as salmeterol, evaluation of its role in improving symptom control in patients failing to respond to prophylactic therapy, and clarification of the optimal role of beta 2-agonists in asthma maintenance therapy are required to fully determine the value of formoterol in the management of obstructive airways disease.

The effect of respiratory disorders on clinical pharmacokinetic variables

Respiratory disorders induce several pathophysiological changes involving gas exchange and acid-base balance, regional haemodynamics, and alterations of the alveolocapillary membrane. The consequences for the absorption, distribution and elimination of drugs are evaluated. Drug absorption after inhalation is not significantly impaired in patients. With drugs administered by this route, an average of 10% of the dose reaches the lungs. It is not completely clear whether changes in pulmonary endothelium in respiratory failure enhance lung absorption. The effects of changes in blood pH on plasma protein binding and volume of distribution are discussed, but relevant data are not available to explain the distribution changes observed in acutely ill patients. Lung diffusion of some antimicrobial agents is enhanced in patients with pulmonary infections. Decreased cardiac output and hepatic blood flow in patients under mechanical ventilation cause an increase in the plasma concentration of drugs with a high hepatic extraction ratio, such as lidocaine (lignocaine). On a theoretical basis, hypoxia should lead to decreased biotransformation of drugs with a low hepatic extraction ratio, but in vivo data with phenazone (antipyrine) or theophylline are conflicting. The effects of disease on the lung clearance of drugs are discussed but clinically relevant data are lacking. The pharmacokinetics of drugs in patients with asthma or chronic obstructive pulmonary disease are reviewed. Stable asthma and chronic obstructive pulmonary disease do not appear to affect the disposition of theophylline or beta 2-agonists such as salbutamol (albuterol) or terbutaline. Important variations in theophylline pharmacokinetics have been reported in critically ill patients, the causes of which are more likely to be linked to the poor condition of the patients than to a direct effect of hypoxia or hypercapnia. Little is known regarding the pharmacokinetics of cromoglycate, ipratropium, corticoids or antimicrobial agents in pulmonary disease. In patients under mechanical ventilation, the half-life of midazolam, a new benzodiazepine used as a sedative, has been found to be lengthened but the underlying mechanism is not well understood. Pulmonary absorption of pentamidine was found to be increased in patients under mechanical ventilation. Pharmacokinetic impairment does occur in patients with severe pulmonary disease but more work is needed to understand the exact mechanisms and to propose proper dosage regimens.