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A Quick Refresher on LABAs and SABAs

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Most common short-acting beta-agonist (SABA) medications are albuterol and levalbuterol. Similarly, the most common long-acting beta-agonist (LABA) medications are salmeterol and olodaterol. These medications are used to help alleviate the many symptoms of asthma and chronic obstructive pulmonary disease (COPD).

SABAs are in the beta-2 adrenergic agonist bronchodilators family. Their onset of action is roughly seen in 15 minutes and lasts for about four to six hours. The common side effects of SABA medications are fast heart rate and tremors. They are used as rescue medications to relax and open the airway passages in the lungs. Consequently, SABAs resolve symptoms such as shortness of breath, cough, and wheezing. The main chemical structure difference between albuterol and levalbuterol is that albuterol is made up of R-albuterol (active form) and S-albuterol (inactive form), whereas levalbuterol is composed of R-albuterol (active form). Both albuterol and levalbuterol are approved for ages four years and older and they are used to treat or prevent bronchospasms. Usually, they are dosed at one to two puffs by mouth every four to six hours. If using albuterol for exercise-induced bronchospasm, it’s important to instruct patients to take their dose 15 to 30 minutes before starting exercise. 


Image 1: Chemical Structure of Albuterol     
Image 2: Chemical Structure of Levalbuterol

LABA medications are in the beta-2 adrenergic agonist bronchodilators family as well, but are seen in chronic settings compared to SABA medications. LABAs are commonly used in asthma and COPD. Their effects are seen in about 30 minutes and their duration lasts for about 12 to 24 hours. Salmeterol can be used to treat asthma, but the patient must be on an inhaled corticosteroid at the same time. Salmeterol is also used to prevent exercise-induced bronchospasm and is indicated for maintenance treatment of COPD. The common dose is usually one inhalation by mouth twice daily. On the other hand, olodaterol is considered ultra-LABA compared to salmeterol because of its effects lasting closer to 24 hours. Olodaterol is only indicated for COPD, unlike all the other medications we discussed thus far. Commonly, olodaterol is dosed at two inhalations by mouth daily. It is also important to note is that salmeterol and olodaterol are available in combination inhalers.

Table 1: Summary of inhalers

The SABAs discussed are available in metered dose inhalers or dry powder inhalers. The LABAs mentioned are available in Diskus inhalers or soft mist inhalers. The adverse effects are dependent on the dosage form. Lastly, it is crucial to educate patients on proper usage of the inhalers, such as priming, storage, and missed doses in counseling settings.

Keep in mind that SABAs have short-acting properties and LABAs have long-acting properties. One way to remember the effect of these inhalers is that SABAs start with an “S” which can be associated with short-acting properties, and LABAs start with an “L” which can be associated with long-acting properties. Even though this quick refresher does not list of all SABAs and LABAs, we have provided the most common medications from these classes to help with these educational concepts. If using a more in-depth study approach, mnemonics, flashcards, and practice exams are always a helpful way to master even more comprehensive material.

-Dagmara Zajac, 2022 RxPharmacist Intern

References:

  1. Albuterol. American Chemical Society. Available at: https://www.acs.org/content/acs/en/molecule-of-the-week/archive/a/albuterol.html (Accessed: October 10, 2022). 
  2.  Ameredes BT, Calhoun WJ. Levalbuterol versus albuterol. Curr Allergy Asthma Rep. 2009;9(5):401-409. doi:10.1007/s11882-009-0058-6
  3. Hsu E, Bajaj T. Beta 2 Agonists. [Updated 2022 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542249/
  4. Levalbuterol. National Center for Biotechnology Information. PubChem Compound Database. U.S. National Library of Medicine. Available at: https://pubchem.ncbi.nlm.nih.gov/compound/Levalbuterol#section=Structures (Accessed: October 10, 2022). 
  5. Levalbuterol oral inhalation: Medlineplus Drug Information. MedlinePlus. U.S. National Library of Medicine. Available at: https://medlineplus.gov/druginfo/meds/a603025.html (Accessed: October 10, 2022). 
  6.  Lanser, C. (2021) Beta-agonists (sabas and labas), AlphaNet. Available at: https://www.alphanet.org/living-with-alpha-1/medications-for-alpha-1/beta-agonists/ (Accessed: October 10, 2022). 
  7. ProAir HFA (albuterol) [prescribing information]. Parsippany, NJ: Teva Pharmaceuticals USA, Inc; August 2020.
  8. Serevent Diskus (salmeterol) [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; February 2022.
  9. Striverdi Respimat (Olodaterol) [prescribing information]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals Inc; November 2021.
  10. Xopenex HFA (levalbuterol) [prescribing information]. Marlborough, MA: Sunovion Pharmaceuticals Inc; February 2017.

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Rising Rates of Asthma and the Hygiene Hypothesis

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Many years ago, I came across a tale of The Wheezing Wolf and the Three Little Pigs , you could call it a breathless spin on a timeless children’s classic. It is also a tale that manages to very creatively highlight a disease state which affects a large number of children worldwide, specifically asthma. It is estimated more than 22 million people (~6 million children) in the United States have some form of asthma, a chronic but reversible condition which causes inflammation and bronchoconstriction of our airways.1

Although there is no magic bullet or cure for people who suffer from asthma, we do have a large variety of medications that allow for proper management to help prevent long term airway remodeling, permanent lung damage, hospital stays and emergency room visits.1 You might be wondering what causes people to acquire asthma. Data is gathered meticulously to better highlight trends in asthma for this very reason. For example, one trend already identified makes clear that African American and Hispanic children are generally more likely to experience mortality from asthma related causes.1 Below you will find several interactable modules which outline the rise in asthma cases over time and the demographic aggregation of cases across the United States.

One theory which has gained traction over the years to explain rising cases of asthma is called the hygiene hypothesis. This hypothesis suggests our post natal immune response is compromised by an ultra clean environment.3 There is evidence to suggest lower levels of the bacterial protein lipopolysaccharide (LPS) in a person’s home would predispose them to develop conditions like asthma (LPS helps our immune system grow and learn by switching on toll-like receptor 4 (TLR4) on T-cells).3 If you would like to learn more about how this may relate to the COVID-19 pandemic, the following article is a nice read: The hygiene hypothesis, the COVID pandemic, and consequences for the human microbiome.

As a whole, asthma attacks can vary in severity and in nature from one person to another. Common triggers include tobacco smoke, dust mites, pollen, air pollution, mold, a man’s best friend, perfumes, harsh cleaners/disinfectants and even acid reflux.2 It is important for patients who suffer from asthma to identify and avoid triggers. For example, encouraging tobacco cessation in households with smokers or using an air cleaner with a HEPA filter for people who may be allergic to their furry friends.2

Lastly, if there is one thing we know from the hygiene hypothesis, it’s that people love to clean their homes. It is especially true now perhaps more than ever before and we may very well see an even steeper rate of asthma cases moving forward, even if just from COVID sequelae alone. Here is a CDC guide for properly cleaning and disinfecting homes that patients (especially those sensitive to harsh detergents or cleaners) may find useful; it’s even COVID approved. 

References

  1. U.S. Food and Drug Administration. Asthma Fact Sheet. Accessed May 2, 2021. Retrieved from https://www.fda.gov/consumers/minority-health-and-health-equity/asthma-fact-sheet.
  2. Centers for Disease Control and Prevention. Common Asthma Triggers. Accessed May 2, 2021. Retrieved from https://www.cdc.gov/asthma/triggers.html.
  3. U.S. Food and Drug Administration. Asthma: The Hygiene Hypothesis. Accessed May 2, 2021. Retrieved from https://www.fda.gov/vaccines-blood-biologics/consumers-biologics/asthma-hygiene-hypothesis.
  4. National Center for Health Statistics, Centers for Disease Control and Prevention. Asthma Data Visualizations. Accessed May 2, 2021. https://www.cdc.gov/asthma/data-visualizations/default.htm.

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