Levalbuterol is as effective as racemic albuterol in lowering serum potassium

Effect of inhaled albuterol on whole blood potassium concentrations in dogs

BACKGROUND

Albuterol by inhalation (IH) is a common treatment for hyperkalemia in humans but its effect on blood potassium concentrations in dogs is unknown.

OBJECTIVE

Determine whether albuterol (IH) decreases blood potassium concentrations in healthy normokalemic dogs and if effects are dose-dependent.

ANIMALS

Ten healthy dogs.

METHODS

Prospective, crossover experimental study. Albuterol sulfate was administered at a low-dose (90 μg) in phase I and, 7 days later, high-dose (450 μg) in phase II. Blood potassium and glucose concentrations (measured via blood gas analyzer) and heart rates were obtained at baseline and then 3, 5, 10, 15, 30, 60, 90, 120, 180, and 360 minutes after inhaler actuation.

RESULTS

Blood potassium concentrations decreased rapidly after albuterol delivery with a significant reduction compared to baseline within 30 minutes in both phases (P = .05). The potassium nadir concentration of phase I occurred at 60 minutes (mean, SD; 4.07 mmol/L, 0.4) and was significantly decreased from baseline, (4.30 mmol/L, 0.3; t(9) = 2.40, P = .04). The potassium nadir concentration of phase II occurred at 30 minutes (mean, SD; 3.96 mmol/L, 0.39) and was also significantly decreased from baseline, (4.33 mmol/L, 0.4; t(9) = 2.22, P = .05). The potassium nadir concentration decreased by 0.1 mmol/L for each 10 μg/kg increase in dose of albuterol (P = .01). Five dogs had ≥1 hyperglycemic measurement (ie, >112 mg/dL). No median heart rate was tachycardic nor was any mean blood glucose concentration hyperglycemic at any time point.

CONCLUSION AND CLINICAL IMPORTANCE

Albuterol IH decreases blood potassium concentrations in a dose-dependent manner without clinically meaningful alterations to heart rate or blood glucose concentrations in healthy dogs. The mean decrease in potassium concentration at the high-dose of albuterol was modest (0.38 mmol/L).

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Prise en charge de l’hyperkaliémie aux urgences

L’hyperkaliémie est l’un des désordres hydroélectrolytiques les plus fréquemment rencontrés aux urgences. Les étiologies principales sont l’insuffisance rénale aiguë ou chronique, le diabète et l’insuffisance cardiaque. L’hyperkaliémie aiguë peut être une urgence vitale, car elle est potentiellement létale du fait du risque d’arythmie cardiaque. Sa prise en charge aux urgences manque actuellement de recommandations claires en ce qui concerne le seuil d’intervention et les thérapeutiques à utiliser. Les thérapeutiques couramment appliquées sont fondées sur un faible niveau de preuve, et leurs effets secondaires sont mal connus. Des études supplémentaires sont nécessaires pour évaluer l’utilisation de ces traitements et celle de nouveaux traitements potentiellement prometteurs. Nous faisons ici une mise au point sur les données connues en termes d’épidémiologie, de manifestations cliniques et électrocardiographiques, et des différentes thérapeutiques qui peuvent être proposées dans la prise en charge de l’hyperkaliémie aux urgences.

Pharmacological interventions for the acute management of hyperkalaemia in adults

BACKGROUND

Hyperkalaemia is a potentially life-threatening electrolyte disturbance which may lead to cardiac arrhythmias and death. Renal replacement therapy is known to be effective in treating hyperkalaemia, but safe and effective pharmacological interventions are needed to prevent dialysis or avoid the complications of hyperkalaemia until dialysis is performed.

OBJECTIVES

This review looked at the benefits and harms of pharmacological treatments used in the acute management of hyperkalaemia in adults. This review evaluated the therapies that reduce serum potassium as well as those that prevent complications of hyperkalaemia.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Specialised Register to 18 August 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs looking at any pharmacological intervention for the acute management of hyperkalaemia in adults were included in this review. Non-standard study designs such as cross-over studies were also included. Eligible studies enrolled adults (aged 18 years and over) with hyperkalaemia, defined as serum potassium concentration ≥ 4.9 mmol/L, to receive pharmacological therapy to reduce serum potassium or to prevent arrhythmias. Patients with artificially induced hyperkalaemia were excluded from this review.

DATA COLLECTION AND ANALYSIS

All three authors screened titles and abstracts, and data extraction and risk of bias assessment was performed independently by at least two authors. Studies reported in non-English language journals were translated before assessment. Authors were contacted when information about results or study methodology was missing from the original publication. Although we planned to group all studies of a particular pharmacological therapy regardless of administration route or dose for analysis, we were unable to conduct meta-analyses because of the small numbers of studies evaluating any given treatment. For continuous data we reported mean difference (MD) and 95% confidence intervals (CI).

MAIN RESULTS

We included seven studies (241 participants) in this review. Meta-analysis of these seven included studies was not possible due to heterogeneity of the treatments and because many of the studies did not provide sufficient statistical information with their results. Allocation and blinding methodology was poorly described in most studies. No study evaluated the efficacy of pharmacological interventions for preventing clinically relevant outcomes such as mortality and cardiac arrhythmias; however there is evidence that several commonly used therapies effectively reduce serum potassium levels. Salbutamol administered via either nebulizer or metered-dose inhaler (MDI) significantly reduced serum potassium compared with placebo. The peak effect of 10 mg nebulised salbutamol was seen at 120 minutes (MD -1.29 mmol/L, 95% CI -1.64 to -0.94) and at 90 minutes for 20 mg nebulised salbutamol (1 study: MD -1.18 mmol/L, 95% CI -1.54 to -0.82). One study reported 1.2 mg salbutamol via MDI 1.2 mg produced a significant decrease in serum potassium beginning at 10 minutes (MD -0.20 mmol/L, P < 0.05) and a maximal decrease at 60 minutes (MD -0.34 mmol/L, P < 0.0001). Intravenous (IV) and nebulised salbutamol produced comparable effects (2 studies). When compared to other interventions, salbutamol had similar effect to insulin-dextrose (2 studies) but was more effective than bicarbonate at 60 minutes (MD -0.46 mmol/L, 95% CI -0.82 to -0.10; 1 study). Insulin-dextrose was more effective than IV bicarbonate (1 study) and aminophylline (1 study). Insulin-dextrose, bicarbonate and aminophylline were not studied in any placebo-controlled studies. None of the included studies evaluated the effect of IV calcium or potassium binding resins in the treatment of hyperkalaemia.

AUTHORS' CONCLUSIONS

Evidence for the acute pharmacological management of hyperkalaemia is limited, with no clinical studies demonstrating a reduction in adverse patient outcomes. Of the studied agents, salbutamol via any route and IV insulin-dextrose appear to be most effective at reducing serum potassium. There is limited evidence to support the use of other interventions, such as IV sodium bicarbonate or aminophylline. The effectiveness of potassium binding resins and IV calcium salts has not been tested in RCTs and requires further study before firm recommendations for clinical practice can be made.

A survey demonstrating lack of consensus on the sequence of medications for treatment of hyperkalemia among pediatric critical care providers

OBJECTIVE

Hyperkalemia is one of the reversible causes of cardiac arrest in children. The Advanced Cardiovascular Life Support guidelines have specific recommendations on the choice and sequence of medications for treatment of life-threatening hyperkalemia. However, the Pediatric Advanced Life Support guidelines have no specific treatment recommendations. The objective of this study was to measure the extent to which opinions diverge among pediatricians on the choice and sequence of medication administration in the management of hyperkalemia during cardiac arrest.

DESIGN

Scenario-based survey.

SETTING

A hypothetical hospital area covered by the pediatric rapid response team.

PATIENTS

A hypothetical scenario of a 7-year old child receiving a blood transfusion who is suddenly unresponsive and found to be in pulseless ventricular tachycardia with stat labs revealing a potassium level of 8.3.

INTERVENTIONS

A scenario-based survey of PICU fellows and attendings at a PICU Fellows Boot Camp.

MEASUREMENT AND MAIN RESULTS

Eighty-four fellows and 24 attendings responded to the survey. The response rate was 89%. Calcium was chosen most frequently as the first drug to be administered (calcium chloride, 40/115 [34.8%]; calcium gluconate, 62/115 [53.9%]) while 38 of 115 respondents (33%) chose a drug other than calcium. Only 17 of 115 respondents (15%) would use calcium, sodium bicarbonate, insulin, and dextrose in the advanced cardiovascular life support-recommended sequence. PICU attendings were significantly more likely to administer the advanced cardiovascular life support-recommended sequence than fellows (attendings, 8/24 [33%] vs fellows, 9/84 [11%]; p = 0.007).

CONCLUSION

This survey revealed notable variability in the choice and sequence of medications for treatment of life-threatening hyperkalemia with surprisingly few participants in compliance with the advanced cardiovascular life support hyperkalemia guidelines. A standardized approach for pediatric life-threatening hyperkalemia is recommended to improve resuscitation quality.

Treatment and pathogenesis of acute hyperkalemia

This article focuses on the pathogenesis, clinical manifestations, and various treatment modalities for acute hyperkalemia and presents a systematic approach to selecting a treatment strategy. Hyperkalemia, a life-threatening condition caused by extracellular potassium shift or decreased renal potassium excretion, usually presents with non-specific symptoms. Early recognition of moderate to severe hyperkalemia is vital in preventing fatal cardiac arrhythmias and muscle paralysis. Management of hyperkalemia includes the elimination of reversible causes (diet, medications), rapidly acting therapies that shift potassium into cells and block the cardiac membrane effects of hyperkalemia, and measures to facilitate removal of potassium from the body (saline diuresis, oral binding resins, and hemodialysis). Hyperkalemia with potassium level more than 6.5 mEq/L or EKG changes is a medical emergency and should be treated accordingly. Treatment should be started with calcium gluconate to stabilize cardiomyocyte membranes, followed by insulin injection, and b-agonists administration. Hemodialysis remains the most reliable method to remove potassium from the body and should be used in cases refractory to medical treatment. Prompt detection and proper treatment are crucial in preventing lethal outcomes.

Short-term effects of inhaled salbutamol on autonomic cardiovascular control in healthy subjects: a placebo-controlled study

AIMS

To investigate short-term effects of inhaled salbutamol on haemodynamic changes and cardiovascular autonomic control.

METHODS

A randomized, single-blinded, placebo-controlled study of 0.2 mg of inhaled salbutamol was conducted on 12 healthy nonsmoking volunteers with a mean age of 24 +/- 2 years at two different testing sessions. Non-invasively obtained continuous haemodynamic measurements of cardiac output, beat-to-beat arterial blood pressure, and total peripheral resistance were recorded prior to and for a total of 120 min after inhalation of the respective study drug. Continuous cardiovascular autonomic tone was recorded using power spectral analysis of heart rate and blood pressure variability. Spontaneous baroreceptor activity was assessed by the sequence method.

RESULTS

There were no significant changes in any of the baseline parameters between the different testing sessions. Inhalation of salbutamol caused a significant increase in cardiac output from 6.7 +/- 1.3 to 7.7 +/- 1.4 l min(-1) (P < 0.05), and a decrease in total peripheral resistance from 1076 +/- 192 to 905 +/- 172 dyne s(-1) cm(-5) (P < 0.05) within 15 min after inhalation. Moreover, salbutamol significantly increased sympathetically mediated low-frequency heart rate variability (P < 0.01), whereas parasympathetically mediated high-frequency heart rate variability decreased (P < 0.01). All changes persisted for approximately 30 min and were fully reversible at 120 min. There were no significant changes in systolic blood pressure variability or spontaneous baroreceptor activity.

CONCLUSIONS

Inhalation of therapeutic doses of salbutamol in healthy subjects resulted in significant haemodynamic changes and a shift of sympathovagal balance towards increased sympathetic tone in the absence of baroreceptor activation.

The management of hyperkalemia in patients with cardiovascular disease

The development of hyperkalemia is common in patients with cardiac and kidney disease who are administered drugs that antagonize the renin-angiotensin-aldosterone system (RAAS). As the results of large-scale clinical trials in hypertension, chronic kidney disease, and congestive heart failure demonstrate benefits of RAAS blockade alone or, in some cases, in combination therapies, the incidence of hyperkalemia has increased in clinical practice. Although there is potential for adverse events in the presence of hyperkalemia, there also are potential benefits of RAAS blockers that support their use in high-risk patient populations. Management of hyperkalemia may be improved by identifying the levels of potassium that may potentially induce harm and using appropriate strategies to avert the levels that may be dangerous or life threatening.

Stereoconfiguration of antiallergic and immunologic drugs

OBJECTIVE

To review the concept of chirality and its current role in the pharmacology of antiallergic, antiasthmatic, and immunologic agents.

DATA SOURCES

Ovid MEDLINE and PubMed databases from 1950 to the present time were searched.

STUDY SELECTION

Articles that described the pharmacology of chiral antiallergic, antiasthmatic, and immunologic medications were used for this review.

RESULTS

Stereoselectivity affects the pharmacologic profiles of medications in different ways from class to class and within the classes. This summary illustrates that enantiomers differ not only in potency in receptor binding and physiologic effects but also in pharmacokinetic parameters such as volume of distribution, plasma protein binding, metabolism, and clearance. Different enantiomers may produce unrelated pharmacologic effects as well. This review summarizes the variety of possible effects that different stereoisomers may produce and further underlines the importance of the purification and in-depth analysis of chiral compounds.

CONCLUSION

Chirality plays an important role in pharmacokinetics and pharmacodynamics of various pharmaceutical agents. The importance of stereoisomeric purity in the pharmacologic industry has increased during the past decade as demonstrated by the increased number of studies that examined the in vivo and in vitro effects produced by changes in stereoconfiguration of pharmaceutical agents. This review highlights such effects in certain frequently used medications used in the treatment of asthma and various allergic and immunologic disorders.

Invasive amebiasis: an update on diagnosis and management

In its invasive form, the trophozoite is responsible for clinical syndromes, ranging from classical dysentery to extraintestinal disease with emphasis on hepatic amebiasis. Abdominal pain, tenderness and diarrhea of watery stool, sometimes with blood, are the predominant symptoms of amebic colitis. Besides the microscopic identification of Entamoeba histolytica, diagnosis should be based on the detection of specific antigens in the stool or PCR associated with the occult blood in the stool. Amebic dysentery is treated with metronidazole, followed by a luminal amebicide. The trophozoite reaches the liver causing hepatic amebiasis. Right upper quadrant pain, fever and hepatomegaly are the predominant symptoms. The diagnosis is made by the finding of E. histolytica in the hepatic fluid, or in the necrotic material at the edge of the lesion in a minority of patients, and by detection of antigens or DNA. Ultrasonography is the initial imaging procedure indicated. The local perforation of hepatic lesion leads to important and serious complications.

Comparison of bronchodilator responses of levosalbutamol and salbutamol given via a pressurized metered dose inhaler: a randomized, double blind, single-dose, crossover study

BACKGROUND

Salbutamol, the most widely used short-acting beta(2)-agonist, consists of a racemic mixture of equal amounts of two enantiomers, (R)-salbutamol and (S)-salbutamol. The bronchodilator effects of salbutamol are attributed entirely to (R)-salbutamol (levosalbutamol), while (S)-salbutamol has been shown to possess bronchospastic and pro-inflammatory effects both in vitro and in vivo studies. Levosalbutamol, the (R)-enantiomer of salbutamol is currently available only in a liquid formulation for use via a nebulizer. Recently, levosalbutamol to be administered via a pressurized metered dose inhaler (pMDI) has been developed.

AIMS

To compare the time-dependent bronchodilator responses of single doses of 100mcg levosalbutamol and 200 mcg racemic salbutamol administered via a pMDI in subjects with stable mild-to-moderate bronchial asthma over a period of 6h.

METHODS

Single doses of 100 mcg levosalbutamol, 200 mcg salbutamol and placebo were administered with a pMDI in 30 stable asthmatic subjects in a randomized, double-blind, placebo-controlled, three-way cross over study. Forced expiratory volume in 1s (FEV(1)) and forced vital capacity (FVC) were measured at baseline, and over 6h post-study drug administration.

RESULTS

Levosalbutamol and salbutamol produced significantly better bronchodilator responses than placebo. Both the drugs showed equivalent time-dependent bronchodilator responses as measured by area under curve for percent change in FEV(1) and FVC over 6h. The time to onset of action, mean maximum bronchodilator response and duration of bronchodilator response were similar between levosalbutamol and salbutamol.

CONCLUSION

A single dose of 100 mcg levosalbutamol administered by a pMDI produced a similar bronchodilator response as salbutamol when measured over 6h in subjects with stable, mild-to-moderate bronchial asthma.

Potassium disorders—clinical spectrum and emergency management

Potassium disorders are common and may precipitate cardiac arrhythmias or cardiopulmonary arrest. They are an anticipated complication in patients with renal failure, but may also occur in patients with no previous history of renal disease. They have a broad clinical spectrum of presentation and this paper will highlight the life-threatening arrhythmias associated with both hyperkalaemia and hypokalaemia. Although the medical literature to date has provided a foundation for the therapeutic options available, this has not translated into consistent medical practice. Treatment algorithms have undoubtedly been useful in the management of other medical emergencies such as cardiac arrest and acute asthma. Hence, we have applied this strategy to the treatment of hyperkalaemia and hypokalaemia which may prove valuable in clinical practice.

Emergency interventions for hyperkalaemia

BACKGROUND

Hyperkalaemia occurs in outpatients and in between 1% and 10% of hospitalised patients. When severe, consequences include arrhythmia and death.

OBJECTIVES

To review randomised evidence informing the emergency (i.e. acute, rather than chronic) management of hyperkalaemia

SEARCH STRATEGY

We searched MEDLINE (1966-2003), EMBASE (1980-2003), The Cochrane Library (issue 4, 2003), and SciSearch using the text words hyperkal* or hyperpotass* (* indicates truncation). We also searched selected journals and abstracts of meetings. The reference lists of recent review articles, textbooks, and relevant papers were reviewed for additional potentially relevant titles.

SELECTION CRITERIA

All selection was performed in duplicate. Articles were considered relevant if they were randomised, quasi-randomised or cross-over randomised studies of pharmacological or other interventions to treat non-neonatal humans with hyperkalaemia, reporting on clinically-important outcomes, or serum potassium levels within the first six hours of administration.

DATA COLLECTION AND ANALYSIS

All data extraction was performed in duplicate. We extracted quality information, and details of the patient population, intervention, baseline and follow-up potassium values. We extracted information about arrhythmias, mortality and adverse effects. Where possible, meta-analysis was performed using random effects models.

MAIN RESULTS

None of the studies of clinically-relevant hyperkalaemia reported mortality or cardiac arrhythmias. Reports focussed on serum potassium levels. Many studies were small, and not all intervention groups had sufficient data for meta-analysis to be performed. On the basis of small studies, inhaled beta-agonists, nebulised beta-agonists, and intravenous (IV) insulin-and-glucose were all effective, and the combination of nebulised beta agonists with IV insulin-and-glucose was more effective than either alone. Dialysis is effective. Results were equivocal for IV bicarbonate. K-absorbing resin was not effective by four hours, and longer follow up data on this intervention were not available from RCTs.

AUTHORS' CONCLUSIONS

Nebulised or inhaled salbutamol, or IV insulin-and-glucose are the first-line therapies for the management of emergency hyperkalaemia that are best supported by the evidence. Their combination may be more effective than either alone, and should be considered when hyperkalaemia is severe. When arrhythmias are present, a wealth of anecdotal and animal data suggests that IV calcium is effective in treating arrhythmia. Further studies of the optimal use of combination treatments and of the adverse effects of treatments are needed.