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For children with acute asthma exacerbations, does levalbuterol work better or have fewer side effects than albuterol?
Bob: If you have not seen a big marketing push from your local drug reps on levalbuterol (Xopenex), you will very likely be targeted in the future (more about that later). But is levalbuterol really better than the traditional beta agonist, albuterol (Proventil), in children with acute exacerbations of asthma?
What does this article say?
Bob: This study is a prospective randomized trial of 129 children two to 14 years of age who presented to the emergency department with an acute exacerbation of asthma. One half of the children received nebulized albuterol, and the other half received levalbuterol. The doses chosen were weight based, and participants were eligible to receive up to five nebulization treatments.
What was the outcome? There was no difference between these agents in any effectiveness outcomes, including asthma scores, FEV1 measures, number of nebulizations required, respiratory rates, pulse oximetry readings, length of emergency department care, or hospitalization rates (Table 1).
Levalbuterol has been promoted to have fewer side effects than albuterol. But were fewer side effects noted with this agent? Absolutely not (Table 1).
Should we believe this study?
Bob: While there are a couple of minor limitations to this study, I believe it does get to the right answer. Why? Albuterol is composed of equal parts of a racemic mixture of R- and S-enantiomers; levalbuterol is composed of only the active R-enantiomer. Both agents contain an active ingredient, so there is no good reason why one should outperform the other. Some have postulated that the inactive S-enantiomer in albuterol may result in unwanted effects; however, this study debunks that theory.
Andrea: One limitation of this study is that most of the participants had moderate asthma, raising the question about whether the results would be similar in children with severe asthma. And because of the low hospitalization rate (13 percent), firm conclusions regarding this end point cannot be drawn. Another limitation is the relatively small sample size, making it possible that, if there was a clinically meaningful difference, there were too few study participants for it to be statistically significant.
But I agree with Bob; these are similar drugs and there...