The Debate: Albuterol or Levalbuterol

Health Professional

Albuterol and Levalbuterol are both bronchodilators, both can provide instant relief from an asthma attack, and can conveniently be carried in a pocket or purse for convenience. So which of these two great rescue medicines is best for you?

Albuterol might just be the greatest gift ever to asthmatics. It was approved by the FDA in 1982 and quickly became the most popular asthma medicine of the 20th century, and perhaps the most popular one of all time. It made breathing easy fast and without all the side effects of older bronchodilators like Alupent and Bronchosol.

One of the few problems with Albuterol was that it contained both a R-Isomer that relaxed smooth muscle, and an S-Isomer that did not relax smooth muscle. Studies later discovered that the S-Isomer actually caused paradoxical bronchospasm in about 8 percent of those who use the medicine.

According to the Annals of Pharmacotherapy, paradoxical bronchospasm is an adverse side effect of Albuterol. It's when the medicine causes bronchospasm. This may be a result of either the propellant used or the evil S-Isomer.

Scientists were unable to separate the R-Isomer from the S-Isomer until the later 1990s, and in 1999 the R-Isomer was isolated and referred to as Levalbuterol and marketed as Xopenex. Albuterol officially had competition.

The problem with getting Xopenex on the market was that the patent for Albuterol had expired, and generic Albuterols made this medicine fairly inexpensive. The patented Xopenex would cost six times that of Albuterol (Albuterol 26 cents an amp, and Xopenex $1.55).

So the makers of Xopenex had the challenge of convincing doctors that Xopenex was better than Albuterol. Their salespeople had trouble convincing doctors, so they decided on a unique marketing method of convincing respiratory therapists and nurses and having us sell the new product to doctors.

What they did was take us RTs out to eat at fancy restaurants and let us order anything off the menu. We jumped all over this and ordered the most expensive items on the menu. Then we ordered drinks. Since it took forever for the food to arrive, by the time it did we were drunk.

Then the salesperson showed us all these studies that proved Xopenex not only didn't have the S-Isomer, it also was stronger, had fewer side effects, and lasted longer than Albuterol. At first glance, it looked to be the new asthma miracle medicine.

Yet then we RTs started giving Xopenex to patients, and we noticed something: it did not work better than Ventolin, and it did not appear to have less side effects, and it did not last longer. In fact, it appeared to work no better than Albuterol.

Then we learned the initial studies were funded by the makers of Xopenex. Independent studies (as reported by the University of Michigan) proved Levalbuterol was not much different from Albuterol other than that it costs six times more.

So what do you believe? What medicine works best to treat your asthma? Which rescue medicine should your doctor prescribe?

The answer to that is: it depends on you and your doctor. Due to cost, I think most hospitals and doctors prescribe Albuterol as the default bronchodilator. Yet if it doesn't work well enough, or if side effects are an issue, Xopenex is available for trial.

Still, it only makes sense to me that if you are prescribed Xopenex you should never take Albuterol, because if you do you'll be getting the dreaded S-Isomer in your system, and doing so would defeat the purpose of using Xopenex in the first place.

In the future, once the cost of Xopenex equals that of Albuterol, in only makes sense that Xopenex would be the medicine of choice. In the meantime, it is my humble opinion that Albuterol would work fine for most asthmatics in most situations.