title: Comparison of levalbuterol and racemic albuterol in hospitalized patients with acute asthma or COPD: a 2-week, multicenter, randomized, open-label study.
abstract: BACKGROUND
  The National Heart, Lung, and Blood Institute guideline recommends that dosing racemic albuterol be administered every 1 to 4 hours for treating patients with asthma or chronic obstructive pulmonary disease (COPD) in the hospital. Previously published preliminary and retrospective studies suggested that levalbuterol can be administered every 8 hours for the treatment of bronchoconstriction in hospitalized patients. However, it is unclear how the different dosing regimens affect the total number of nebulizations (scheduled plus as-needed treatments) and the costs of treatment of bronchoconstriction in a hospital setting. Moreover, it is not clear how the different dosing regimens affect symptom outcomes and health status in hospitalized patients with asthma or COPD.
  
  
  OBJECTIVE
  The aim of this study was to evaluate these issues in hospitalized patients with acute asthma or COPD.
  
  
  METHODS
  In this prospective, multicenter, randomized, open-label study, hospitalized patients aged > or = 18 years were randomly assigned to receive 14-day treatment with levalbuterol 1.25 mg q6-8h or racemic albuterol 2.5 mg q1-4h, administered per routine hospital practice at each institution. The primary efficacy end point was total number of nebulizations during hospitalization. Pulmonary function, symptom evaluation (subject general well-being score [SGWB], disease symptom assessment [DSA], and beta-mediated adverse effect scores), hospital costs (excluding medication costs) and hospital length of stay (LOS) were also evaluated.
  
  
  RESULTS
  In the intent-to-treat population (n = 479; levalbuterol, 241;racemic albuterol, 238), the mean (SE) age was 55.3 (16.9) years, the majority of patients were white (57.8%), and the mean (SE) weight was 80.9 (24.5) kg. Demographic characteristics were similar between the 2 treatment groups, except that there were more females with COPD in the levalbuterol treatment group (63.88%) compared with the racemic albuterol treatment group (45.5%) (P = 0.005). Patients treated with levalbuterol required significantly fewer median total nebulizations (10 vs 12; P = 0.031) and scheduled nebulizations (9 vs 11; P = 0.009) compared with those in the racemic albuterol group. The 2 treatment groups required 0 rescue nebulizations. Mean (SD) forced expiratory volume in 1 second improved from baseline with both levalbuterol and racemic albuterol (0.06 [0.43] and 0.10 [0.37] L, respectively); these improvements were maintained throughout the hospital stay (0.11 [0.48] and 0.16 [0.52] L). DSA and SGWB scores improved significantly from baseline in both treatment groups, and beta-mediated adverse effects mean scores were significantly greater with levalbuterol versus racemic albuterol (P < 0.001). In the levalbuterol and racemic albuterol treatment groups, hospital LOS (70.6 and 65.7 hours, respectively), time to discharge (66.0 and 62.8 hours), and total hospital costs (least squares mean [SE], US $4869.30 [$343.58] and $4899.41 [$343.20]) were similar.
  
  
  CONCLUSIONS
  In these hospitalized patients with acute asthma or COPD treated with levalbuterol every 6 to 8 hours or racemic albuterol every 1 to 4 hours, significantly fewer total nebulizations were required with levalbuterol, without an increased need for rescue nebulizations during 14 days of hospitalization. Both treatments were associated with improvements from baseline in symptoms and health status. The costs of treating bronchoconstriction in hospitalized patients were similar between the levalbuterol and racemic albuterol groups.
authors.affiliation: School of Medicine, University of North Carolina, Chapel Hill, North Carolina 27599-7020, USA. jdonohue@med.unc.edu
authors.forename: James F
authors.initials: JF
authors.lastname: Donohue
authors.forename: Nicola A
authors.initials: NA
authors.lastname: Hanania
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Ciubotaru
authors.forename: Les
authors.initials: L
authors.lastname: Noe
authors.forename: David J
authors.initials: DJ
authors.lastname: Pasta
authors.forename: Kendyl
authors.initials: K
authors.lastname: Schaefer
authors.forename: Raymond
authors.initials: R
authors.lastname: Claus
authors.forename: William T
authors.initials: WT
authors.lastname: Andrews
authors.forename: James
authors.initials: J
authors.lastname: Roach
mesh_terms: D000208:Acute Disease; D000368:Aged; D000420:Albuterol / Q000737:chemistry* / Q000191:economics / Q000627:therapeutic use*; D001249:Asthma / Q000188:drug therapy*; D001993:Bronchodilator Agents / Q000737:chemistry* / Q000191:economics / Q000627:therapeutic use*; D005260:Female; D017721:Hospital Costs; D006760:Hospitalization; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy*; D012129:Respiratory Function Tests; D012720:Severity of Illness Index; D013237:Stereoisomerism
chemical_list: D001993:Bronchodilator Agents; D000420:Albuterol