Albuterol Sulfate

albuterol sulfate (al byoo' ter ole) AccuNeb, Novo-Salmol (CAN), Proventil, Proventil HFA, Proventil Repetabs, Salbutamol (CAN), Ventodisk (CAN), Ventolin, Ventolin HFA, Volmax Pregnancy Category C Drug classes

Sympathomimetic drug Beta2-selective adrenergic agonist Bronchodilator Antiasthmatic Therapeutic actions

In low doses, acts relatively selectively at beta2-adrenergic receptors to cause bronchodilation and vasodilation; at higher doses, beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical sympathomimetic cardiac effects. Indications

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Relief and prevention of bronchospasm in patients with reversible obstructive airway disease Inhalation: Treatment of acute attacks of bronchospasm Prevention of exercise-induced bronchospasm Unlabeled use: Adjunct in treating serious hyperkalemia in dialysis patients; seems to lower potassium concentrations when inhaled by patients on hemodialysis

Contraindications and cautions

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Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecholamines); unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of stroke; COPD patients with degenerative heart disease. Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and ketoacidosis); hyperthyroidism; history of seizure disorders; psychoneurotic individuals; labor and delivery (oral use has delayed second stage of labor; parenteral use of beta2-adrenergic agonists can accelerate fetal heart beat and cause hypoglycemia, hypokalemia, pulmonary edema in the mother and hypoglycemia in the neonate); lactation; the elderly (more sensitive to CNS effects).

Available forms

Tablets—2, 4 mg; ER tablets—4, 8 mg; syrup—2 mg/5 mL; aerosol—90 mcg/actuation; solution for inhalation—0.083%, 0.5%, 1.25 mg/3 mL, 0.63 mg/3 mL; capsules for inhalation—200 mcg

Dosages ADULTS Oral

Initially, 2 or 4 mg (1–2 tsp syrup) tid–qid PO; may cautiously increase dosage if necessary to 4 or 8 mg qid, not to exceed 32 mg/day. Extended release tablets: 8 mg q 12 hr (Volmax); 4–8 mg q 12 hr (Proventil) Inhalation

Each actuation of aerosol dispenser delivers 90 mcg albuterol; 2 inhalations q 4–6 hr; some patients may require only 1 inhalation q 4 hr; more frequent administration or larger number of inhalations not recommended. • Prevention of exercise-induced bronchospasm: 2 inhalations 15 min prior to exercise. Solution for inhalation

2.5 mg tid to qid by nebulization. Inhalation capsules

One 200 mcg capsule q 4–6 hr up to two 200 mcg capsules q 4–6 hr. • Prevention of exercise-induced asthma: One 200 mcg capsule inhaled 15 min before exercise. PEDIATRIC PATIENTS Oral, tablets

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6–12 yr: 2 mg tid–qid. Do not exceed 24 mg/day. > 12 yr: Use adult dosage.

ER tablets

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6–11 yr: 4 mg q 12 hr (Proventil). 6–12 yr: 4 mg q 12 hr (Volmax).

Oral, syrup

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< 2 yr: Safety and efficacy not established. 2–6 yr: Initially, 0.1 mg/kg tid, not to exceed 2 mg (1 tsp) tid; if necessary, cautiously increase stepwise to 0.2 mg/kg tid. Do not exceed 4 mg (2 tsp) tid. 6–14 yr: 2 mg (1 tsp) tid–qid; if necessary, cautiously increase dosage. Do not exceed 24 mg/day in divided doses. > 14 yr: Use adult dosage.

Inhalation

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2–12 yr: For child 10–15 kg, use 1.25 mg; for child > 15 kg, use 2.5 mg. > 12 yr: Use adult dosage.

Solution for inhalation

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10–15 kg: 1.25 mg bid–tid by nebulization. > 15 kg: 2.5 mg bid–tid by nebulization.

Inhalation capsules

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> 4 yr: One 200 mcg capsule inhaled q 4–6 hr. Prevention of exercise-induced asthma: One 200 mcg capsule inhaled 15 min before exercise.

GERIATRIC PATIENTS OR PATIENTS SENSITIVE TO BETA-ADRENERGIC STIMULATION

Restrict initial dose to 2 mg tid or qid; individualize dosage thereafter. Patients > 60 yr are more likely to develop adverse effects. Pharmacokinetics Route Oral Inhalation

Onset 30 min 5 min

Peak 2–2.5 hr 1.5–2 hr

Duration 4–8 hr 3–8 hr

Metabolism: Hepatic; T1/2: 2–4 hr Distribution: Crosses placenta; enters breast milk Excretion: Urine Adverse effects

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CNS: Restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesia, insomnia, tremor, drowsiness, irritability, weakness, vertigo, headache CV: Cardiac arrhythmias, tachycardia, palpitations, PVCs (rare), anginal pain Dermatologic: Sweating, pallor, flushing GI: Nausea, vomiting, heartburn, unusual or bad taste GU: Increased incidence of leiomyomas of uterus when given in higher than human doses in preclinical studies Respiratory: Respiratory difficulties, pulmonary edema, coughing, bronchospasm, paradoxical airway resistance with repeated, excessive use of inhalation preparations

Interactions

Drug-drug • Increased sympathomimetic effects with other sympathomimetic drugs • Increased risk of toxicity, especially cardiac, when used with theophylline, aminophylline, oxtriphylline • Decreased bronchodilating effects with beta-adrenergic blockers (eg, propranolol) • Decreased effectiveness of insulin, oral hypoglycemic drugs • Decreased serum levels and therapeutic effects of digoxin Nursing considerations Assessment

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History: Hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane; unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of stroke; COPD patients who have developed degenerative heart disease; diabetes mellitus; hyperthyroidism; history of seizure disorders; psychoneurotic individuals; lactation Physical: Weight; skin color, temperature, turgor; orientation, reflexes, affect; P, BP; R, adventitious sounds; blood and urine glucose, serum electrolytes, thyroid function tests, ECG

Interventions

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Use minimal doses for minimal periods; drug tolerance can occur with prolonged use. Maintain a beta-adrenergic blocker (cardioselective beta-blocker, such as atenolol, should be used with respiratory distress) on standby in case cardiac arrhythmias occur. Prepare solution for inhalation by diluting 0.5 mL 0.5% solution with 2.5 mL normal saline; deliver over 5–15 min by nebulization. Do not exceed recommended dosage; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive.

Teaching points

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Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read the instructions that come with respiratory inhalant. These side effects may occur: Dizziness, drowsiness, fatigue, headache (use caution if driving or performing tasks that require alertness); nausea, vomiting, change in taste (eat small, frequent meals); rapid heart rate, anxiety, sweating, flushing, insomnia. Report chest pain, dizziness, insomnia, weakness, tremors or irregular heart beat, difficulty breathing, productive cough, failure to respond to usual dosage.

Adverse effects in Italic are most common; those in Bold are life-threatening.