Standard dose of inhaled albuterol significantly increases QT dispersion compared to low dose of albuterol plus ipratropium bromide therapy in moderate to severe acute asthma attacks in children

Combination of ipratropium bromide and salbutamol in children and adolescents with asthma: A meta-analysis

BACKGROUND

A combination of ipratropium bromide (IB) and salbutamol is commonly used to treat asthma in children and adolescents; however, there has been a lack of consistency in its usage in clinical practice.

OBJECTIVE

To evaluate the efficacy and safety of IB + salbutamol in the treatment of asthma in children and adolescents.

METHODS

The MEDLINE, Embase, and Cochrane Library as well as other Chinese biomedical databases (including China Biological Medicine Database, Chinese National Knowledge Infrastructure, Chongqing VIP, and Wanfang Chinese language bibliographic database) were systematically searched from the earliest record date to September 2020 for randomized controlled trials in children and adolescents (≤18 years) with asthma who received IB + salbutamol or salbutamol alone. The primary outcomes included hospital admission and adverse events. A random effects model with a 95% confidence interval (CI) was used. Subgroup analysis was performed according to age, severity of asthma, and co-interventions with other asthma controllers. This study was registered with PROSPERO.

RESULTS

Of the 1061 studies that were identified, 55 met the inclusion criteria and involved 6396 participants. IB + salbutamol significantly reduced the risk of hospital admission compared with salbutamol alone (risk ratio [RR] 0.79; 95% CI 0.66-0.95; p = 0.01; I2 = 40%). Subgroup analysis only showed significant difference in the risk of hospital admission in participants with severe asthma exacerbation (RR 0.73; 95% CI 0.60-0.88; p = 0.0009; I2 = 4%) and moderate-to-severe exacerbation (RR 0.69; 95% CI 0.50-0.96; p = 0.03; I2 = 3%). There were no significant differences in the risk of adverse events between IB + salbutamol group and salbutamol alone group (RR 1.77; 95% CI 0.63-4.98).

CONCLUSION

IB + salbutamol may be more effective than salbutamol alone for the treatment of asthma in children and adolescents, especially in those with severe and moderate to severe asthma exacerbation. The very low to high quality of evidence indicated that future well-designed double-blind RCTs with large sample are needed for research on evaluating the effectiveness of IB + salbutamol treatment for asthma in children and adolescents.

Electronic health record (EHR) based postmarketing surveillance of adverse events associated with pediatric off-label medication use: A case study of short-acting beta-2 agonists and arrhythmias

PURPOSE

Use electronic health record (EHR) data to (1) estimate the risk of arrhythmia associated with inhaled short-acting beta-2 agonists (SABA) in pediatric patients and (2) determine whether risk varied by on-label versus off-label prescribing.

METHODS

Retrospective cohort study of 335 041 children ≤18 years using EHR primary care data from 2 pediatric health systems (2011-2013). A series of monthly pseudotrials were created, using propensity score methodology to balance baseline characteristics between SABA-exposed (identified by prescription) and SABA-unexposed children. Association between SABA and subsequent arrhythmia for each health system was estimated through pooled logistic regression with separate estimates for children initiating under and over 4 years old (off-label and on-label, respectively).

RESULTS

Eleven percent of the cohort received a SABA prescription, 57% occurred under the age of 4 years (off-label). During the follow-up period, there were 283 first arrhythmia events, most commonly atrial tachyarrhythmias and premature ventricular/atrial contractions. In 1 health system, adjusted risk for arrhythmia was increased among exposed children (OR 1.89, 95% CI 1.31-2.73) without evidence of interaction between label status and risk. The absolute adjusted rate difference was 3.6/10 000 person-years of SABA exposure. The association between SABA exposure and arrhythmias was less strong in the second system (OR 1.26, 95% CI 0.30-5.33).

CONCLUSION

Using EHR data, we could estimate the risk of a rare event associated with medication use and determine difference in risk related to on-label versus off-label status. These findings support the value of EHR-based data for postmarketing drug studies in the pediatric population.

Effect of Ventolin on QTc in children with respiratory distress

INTRODUCTION

β2-agonists are first election drugs for the treatment of respiratory disease that may alter cardiac autonomic modulation. The aim of this study was to evaluate the effects of nebulized Ventolin on electrocardiogram, particularly QTc interval to assess the potential arrhythmogenic risks.

METHODS

A total of 192 patients between 2 months and 15 years which received nebulized Ventolin were enrolled in this study. Patients were divided into two groups. Electrocardiograms of patients before and after nebulized Ventolin were taken. Differences between two groups were assessed using a paired student's t test.

RESULTS

There was statistically significant differences in QTc before and after Ventolin in each groups (P<0.005).Ventolin effect on QTc interval in both groups did not differ. In first group, there was statistically significant differences between heart rate before and after Ventolin taken (P=0.009) but in second group there was not statistically significant differences between heart rate (P=0.345).

CONCLUSION

Although Ventolin can cause changes in QTc, Ventolin with 0.15 mg/kg/dose in comparison with 0.1 mg/kg/dose does not cause significant changes in QTc.

Inhaled albuterol/salbutamol and ipratropium bromide and their combination in the treatment of chronic obstructive pulmonary disease

IMPORTANCE OF THE FIELD

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality throughout the world. Combination therapy with albuterol and ipratropium bromide was approved > 15 years ago for the treatment of COPD. We review the mechanism of action, clinical efficacy, and safety of albuterol, ipratropium and combined albuterol-ipratropium therapy.

AREAS COVERED IN THIS REVIEW

We conducted a PubMed literature search using the keywords COPD, albuterol, ipratropium bromide and Combivent (Boehringer Ingelheim Corp., Ridgefield, CT, USA); pertinent references within the identified citations are included in the review. Data from the manufacturers are also evaluated.

WHAT THE READER WILL GAIN

At the time of its approval, albuterol/ipratropium bromide was an innovative combination of existing medications for the treatment of COPD. The combined formulation provides better improvement in airflow than either component alone and, by reducing the number of separate inhalers, simplifies therapy and improves compliance compared with the individual components.

TAKE HOME MESSAGE

The recent development and approval of longer acting and more potent beta agonists, anticholinergics and newer combination treatments have surpassed many of the advantages of combined albuterol-ipratropium for the treatment of patients with stable COPD.

Evaluation of albuterol 1.25 mg and 0.62 mg for nebulization in 6- to 12-year-old children with moderately severe asthma

To assess the efficacy and safety of 2 different strengths of a manufactured albuterol solution for nebulization (AccuNeb(R); DEY, L.P., Napa, Calif), 349 children with moderate to severe asthma were enrolled in this prospective, multicenter, double-blind, placebo-controlled study. For 4 wk, children 6 to 12 y old were randomly assigned to 1.25 mg (A1) or 0.62 mg (A2) albuterol or placebo (P), nebulized 3 times daily for 4 weeks. Pulmonary function and safety were evaluated at weeks 0, 2, and 4 (visits 2-4). Nonparametric tests (Kruskal-Wallis and Wilcoxon's rank-sum) were used to compare treatments. Primary endpoint (week 4, %Delta area under the curve [AUC] forced expiratory volume in 1 sec [FEV(1)]) results for A1, A2, and P were 90.3% x h*, 73.6% x h*, and 34.2% x h. Secondary assessments for A1, A2, and P were as follows: (1) week 2, %DeltaAUC FEV1 (99.5%*h*, 104.5% x h*, and 43.6% x h); (2) maximum FEV1 (28.6%*, 26.3%*, and 13.4%); and (3) duration of effect (116.8 min*, 115.9 min*, and 39.2 min). A2 was more effective in children 10 y of age or younger and in children 11 to 12 y of age who weighed </=40 kg or had less severe asthma; A1 was more effective in children 11 to 12 y of age who weighed >40 kg or had more severe asthma. Adverse events (occurring in 47% of children) were considered unrelated to drug treatment. Observations on electrocardiogram (notably QTc interval) were similar to those for placebo. A1 and A2 appeared effective in improving pulmonary function and were well tolerated in children aged 6 to 12 y.