Long-acting beta-adrenoceptor agonist
Long-acting beta-adrenoceptor agonists (LABAs, more specifically β2-agonists) are usually prescribed for moderate to severe persistent asthma patients or patients with chronic obstructive pulmonary disease (COPD). They are designed to reduce the need for shorter-acting β2-agonists such as salbutamol, as they have a duration of action of approximately 12 hours in comparison with the 4- to 6-hour duration of salbutamol, making them candidates for sparing high doses of corticosteroids or treating nocturnal asthma and providing symptomatic improvement in patients with COPD. With the exception of formoterol, long-acting β2-agonists are not recommended for the treatment of acute asthma exacerbations because of their slower onset of action compared to salbutamol. Their long duration of action is due to the addition of a long, lipophilic side-chain that binds to an exosite on adrenergic receptors. This allows the active portion of the molecule to continuously bind and unbind at β2 receptors in the smooth muscle in the lungs.
When combined with inhaled steroids, beta-adrenoceptor agonists can improve symptoms. In children this benefit is uncertain and they may be potentially harmful. They should not be used without an accompanying steroid due to an increased risk of severe symptoms, including exacerbation in both children and adults. At least with formoterol, an increased risk appears to be present even when steroids are used and this risk has not been ruled out for salmeterol.
Some currently available long-acting beta-adrenoceptor agonists are:
Two ultra-long-acting beta-adrenoceptor agonists that have a duration of action of 24 hours, allowing for once-daily dosing are now approved.
- Indacaterol (approved by the European Medicines Agency (EMA) under the trade name Onbrez on November 30, 2009, and by the United States Food and Drug Administration (FDA) under the trade name Arcapta Neohaler, on July 1, 2011)
- Olodaterol (approved in some European countries as Striverdi)
- Vilanterol (combination of the synthetic inhaled corticosteroid fluticasone furoate (FF) and the long-acting beta2-adrenergic agonist vilanterol trifenatate was approved by US Food and Drug Administration (FDA) in May 2013 as once-daily inhaled therapy for the treatment of chronic obstructive pulmonary disease (COPD). The product is called Breo Ellipta in the United States and Relvar Ellipta in Europe.
- Carmoterol (Under Development)
- LAS100977 (Under Development)
- PF-610355 (Under Development)
While the use of inhaled LABAs are still recommended in asthma guidelines for the resulting improved symptom control, further concerns have been raised, by a large meta-analysis of the pooled results from 19 trials with 33,826 participants, that salmeterol may increase the small risks of asthma deaths, and this additional risk is not reduced with the additional use of inhaled steroids (e.g., as with the combination product Fluticasone/salmeterol). This seems to occur because although LABAs relieve asthma symptoms, they also promote bronchial inflammation and sensitivity without warning.
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- Ducharme, FM; Ni Chroinin, M; Greenstone, I; Lasserson, TJ (May 12, 2010). "Addition of long-acting beta2-agonists to inhaled corticosteroids versus same dose inhaled corticosteroids for chronic asthma in adults and children.". Cochrane database of systematic reviews (Online) (5): CD005535. doi:10.1002/14651858.CD005535.pub2. PMID 20464739.
- Ducharme, FM; Ni Chroinin, M; Greenstone, I; Lasserson, TJ (Apr 14, 2010). "Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma.". Cochrane database of systematic reviews (Online) (4): CD005533. doi:10.1002/14651858.CD005533.pub2. PMID 20393943.
- Fanta CH (March 2009). "Asthma". New England Journal of Medicine 360 (10): 1002–14. doi:10.1056/NEJMra0804579. PMID 19264689.
- Cates CJ, Lasserson TJ, Jaeschke R (2009). Cates, Christopher J, ed. "Regular treatment with salmeterol and inhaled steroids for chronic asthma: serious adverse events". Cochrane Database Syst Rev (3): CD006922. doi:10.1002/14651858.CD006922.pub2. PMID 19588410.
- Cates CJ, Cates MJ (2008). Cates, Christopher J, ed. "Regular treatment with salmeterol for chronic asthma: serious adverse events". Cochrane Database Syst Rev (3): CD006363. doi:10.1002/14651858.CD006363.pub2. PMID 18646149.
- "FDA Drug Safety Communication: New safety requirements for long-acting inhaled asthma medications called Long-Acting Beta-Agonists (LABAs)". FDA. Feb 2010.
Based on the available information, FDA concludes there is an increased risk for severe exacerbation of asthma symptoms, leading to hospitalizations in pediatric and adult patients as well as death in some patients using LABAs for the treatment of asthma. The agency is requiring the REMS and class-labeling changes to improve the safe use of these products.
- Cates, CJ; Cates, MJ (Apr 18, 2012). "Regular treatment with formoterol for chronic asthma: serious adverse events.". Cochrane database of systematic reviews (Online) 4: CD006923. doi:10.1002/14651858.CD006923.pub3. PMID 22513944.
- Cates, CJ; Cates, MJ (Jul 16, 2008). "Regular treatment with salmeterol for chronic asthma: serious adverse events.". Cochrane database of systematic reviews (Online) (3): CD006363. doi:10.1002/14651858.CD006363.pub2. PMID 18646149.
- Cazzola M, Matera MG, Lötvall J (July 2005). "Ultra long-acting beta 2-agonists in development for asthma and chronic obstructive pulmonary disease". Expert Opin Investig Drugs 14 (7): 775–83. doi:10.1517/135437188.8.131.525. PMID 16022567.
- European Public Assessment Report for Onbrez Breezhaler
- "FDA approves Arcapta Neohaler to treat chronic obstructive pulmonary disease" (Press release). U.S. Food and Drug Administration. 2011-07-01. Retrieved 2011-07-02.
- "New once-daily Striverdi (olodaterol) Respimat gains approval in first EU countries". Boehringer-Ingelheim. 18 October 2013.
- Osterweil, Neil (10 May 2013). "FDA Approves 'Son of Advair' for COPD Exacerbations". Medscape. Retrieved 17 April 2014.
- Cazzola, Mario; Luigino Calzetta; Maria Gabriella Matera3 (May 2011). "β2-adrenoceptor agonists: current and future direction". Br J Pharmacol. 163 (1): 4–17. doi:10.1111/j.1476-5381.2011.01216.x. PMC 3085864. PMID 21232045. Retrieved 17 April 2014.
- British Thoracic Society & Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Guideline No. 63. Edinburgh:SIGN; 2004. (HTML, Full PDF, Summary PDF)
- Salpeter S, Buckley N, Ormiston T, Salpeter E (2006). "Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths". Ann Intern Med 144 (12): 904–12. doi:10.7326/0003-4819-144-12-200606200-00126. PMID 16754916.
- Krishna Ramanujan (June 9, 2006). "Common asthma inhalers cause up to 80 percent of asthma-related deaths, Cornell and Stanford researchers assert". ChronicalOnline - Cornell University.
In 2011, the FDA issued a safety alert for Long-Acting Beta-Agonists (LABAs):