Albuterol or Salbutamol is a Beta receptor agonist used to relieve bronchospasm as in patients with Asthma, Chronic obstructive pulmonary disease, and Bronchiectasis. It is also used for the treatment of exercise-induced bronchospasm and as an off-label treatment in patients with hyperkalemia.

Albuterol Dose in Adults

Albuterol for Bronchospasm:

(Download NAEPP 2007 guidelines for the diagnosis and prevention of asthma) Inhaled via Metered-dose inhaler (MDI) or dry powder inhalation (90 mcg/actuation): 2 inhalations or puffs 4 to 6 a day if needed. Some patients may get relief with a single inhalation. If the patient does not get relief even with additional inhalations, he/she should promptly seek medical advice. For the maintenance therapy in combination with corticosteroids:

• 1 to 2 inhalations 4 to 6 times a day to a maximum of 8 inhalations daily is recommended.

Dry powder inhalation (Ventolin Diskus 200 mcg/inhalation:

• For acute treatment: 200 mcg or a single inhalation to a maximum of 4 inhalations (equivalent to 800 mcg/day) is recommended.
• If the patient's symptoms persist and there is inadequate relief for 3 hours or more, medical advice should be sought.

Maintenance therapy in combination with corticosteroids:

• 200 mcg or a single inhalation every 4 to 6 hours to a maximum of 800 mcg per day or 4 inhalations is recommended.

When used for Nebulization:

• 2.5 mg of albuterol thrice or four times a day as needed. For quick relief: 1.25 - 5 mg every 4 to 8 hours as needed.

Oral albuterol (not the preferred route in asthmatics) Regular-release tablets: 2 to 4 mg 3 to 4 times daily to a maximum dose of 32 mg. Extended-release tablets: 8 mg twice daily to a maximum of 32 mg per day. Patients who are lean may require 4 mg twice daily.

IV continuous infusion of albuterol (Use only is severe bronchospasm and status asthmaticus):

Initiate therapy with 5 mcg/minute and increase the dose to 10 to 20 mcg/minute at 15- to 30-minute intervals if required.

Albuterol Inhalational therapy in acute severe exacerbation of asthma:

• 4 to 8 inhalations or puffs every 20 minutes for up to 4 hours, then every 1 to 4 hours as needed via a metered-dose inhaler or dry powder inhaler (90 mcg/actuation).
• 2.5 - 5 mg every 20 minutes for 3 doses, then 2.5 - 10 mg every 1 - 4 hours as needed as Nebulization, or 10 - 15 mg/hour by continuous nebulization

Albuterol dose for the prevention of exercise-induced bronchospasm:

• 2 inhalations 5 minutes prior to exercise via a metered-dose inhaler or dry powder inhaler (90 mcg/actuation) or
• a single puff or inhalation of 200 mcg of Ventolin Diskus (dry powder inhaler) 15 minutes before exercise.

Albuterol dose for the treatment of Hyperkalemia:

10 to 20 mg over 10 minutes via nebulization in combination with other recommended therapies such as calcium gluconate, insulin, dextrose, and sodium bicarbonate.

Albuterol Dose in Childrens

Albuterol dose in Acute exacerbation of Asthma:

Patients with mild to moderate exacerbations:

• Infants and Children less than 5 years of age:
  • Metered-dose inhaler (90 mcg/actuation): 2 to 6 inhalations every 20 minutes for 2 to 3 doses.
  • Nebulization: 2.5 mg every 20 minutes for the first hour if required.

• Children 6 years of age or more and Adolescents:
  • Metered-dose inhaler (90 mcg/actuation): 2 to 10 inhalations every 20 minutes for 2 to 3 doses during the first hour

Albuterol Dose in the Emergency care/hospital:

• Children 4 years of age or more:
  • Metered-dose inhaler (90 mcg/actuation):
    • 4 to 8 puffs every 20 minutes for 3 doses then every 1 to 4 hours.
  • Nebulization in children 2 years of age or more:
    • Intermittent:
      • 0.15 mg/kg/dose (minimum dose: 2.5 mg/dose) every 20 minutes for 3 doses then 0.15 to 0.3 mg/kg/dose not to exceed 10 mg/dose every 1 to 4 hours.
    • Continuous nebulization:
      • Optimal dose is not established, however, the following regimens may be used:
      • 0.5 mg/kg/hour.
    • Fixed-dose:
      • Less than 20 kgs: 10 mg/hour
      • 20 kgs or more: 20 mg/hour

• Adolescents:
  • Metered-dose inhaler (90 mcg/actuation):
    • 4 - 8 puffs every 20 minutes for up to 4 hours, then every 1 - 4 hours
  • Intermittent nebulization:
    • 2.5 - 5 mg every 20 minutes for 3 doses then 2.5 - 10 mg every 1 - 4 hours as needed
  • Continuous nebulization: 10 - 15 mg/hour
  • Alternate dosing:
    • Less than 20 kgs: 10 mg/hour
    • 20 kgs or more: 20 mg/hour

Albuterol dose in the maintenance therapy of Asthma:

• Metered-dose inhaler:
  • Infants, Children, and Adolescents: 2 inhalations every 4 to 6 hours as needed.

Note: albuterol is not recommended for long-term daily maintenance therapy. Regular use that exceeds two or more times a week requires step-up therapy with an inhaled steroid or a long-acting Beta-agonist.

• Nebulization:
  • Infants and Children less than 5 years: 0.63 to 2.5 mg every 4 to 6 hours as needed
  • Children 5 years of age or more and Adolescents:1.25 to 5 mg every 4 - 8 hours as needed

Immediate-release oral formulation (syrup and tablets):

• Children 2 - 6 years:
  • 0.1 mg/kg/dose (maximum dose is 2 mg/dose) thrice times daily. The dose may be increased in severe cases to 0.2 mg/kg/dose (maximum dose of 4 mg/dose) thrice daily.
• Children older than 6 years of age and Adolescents 14 years of age or less:
  • 2 mg/dose 3 - 4 times daily. Gradually increase the dose to a maximum of 24 mg/day if an inadequate response is seen.
• Adolescents older than 14 years of age:
  • 2 to 4 mg/dose 3 - 4 times daily. Gradually increase the dose to 32 mg/day if the desired response is not achieved.

Sustained-release salbutamol tablets:

• Children 6 years of age or more:
  • 4 mg twice daily. Increase the dose gradually to 24 mg/day if control not achieved
• Adolescents:
  • 8 mg twice daily. Some patients may require a low dose i.e. 4 mg twice daily. The dose may be gradually increased to a maximum of 32 mg per day.

Albuterol (Salbutamol) dose for the prevention of Exercise-induced bronchospasm:

• Metered-dose inhaler (90 mcg/actuation):

  • Infants and Children less than 5 years of age: 1 - 2 inhalations 5 to 20 minutes before exercising.
  • Children 5 years of age or more and Adolescents: 2 inhalations 5 - 20 minutes before exercising

• 100 mcg/actuation (Airomir):

  • Children 6 - 11 years: 1 inhalation 30 minutes prior to exercise
  • Children 12 years of age or more and Adolescents: 2 inhalations 30 minutes prior to exercise.

• Dry powder inhaler:

  • Ventolin Diskus 200 mcg/inhalation:
    • Children 4 years of age or more and Adolescents: 1 inhalation 15 minutes before exercise.

Albuterol (Salbutamol) dose for the treatment of Hyperkalemia:

• Weight-based dose via nebulization in Infants, Children, and Adolescents:
  • 0.3 to 0.5 mg/kg/dose.
• Fixed dose via nebulization in children 5 years of age or more and Adolescents:
  • 25 kgs or less: 2.5 mg nebulized over 10 minutes. Repeat the dose if necessary.
  • 25 kgs or more: 5 mg nebulized over 10 minutes. Repeat the dose if necessary

Note: Salbutamol should not be used as the sole treatment for hyperkalemia.

Albuterol Pregnancy Risk Factor C

• Albuterol crosses the placental barrier, and congenital anomalies such as limb defects or cleft palates have been reported after maternal albuterol use.
• However, uncontrolled asthma can pose greater dangers to both the mother and her baby. 
• There have been reports of increased risks for perinatal mortality, preterm births, low infant weight, preeclampsia, and preterm births in mothers with poorly controlled asthma.
• Albuterol, however, is the preferred short-acting beta-agonist during pregnancy when treatment for asthma.
• If higher doses are taken, monitor the newborn's plasma glucose for 24 hours. Albuterol is used to reduce uterine contractility. 
• It is not approved for use as a tocolytic. It can cause pulmonary edema, especially in mothers.

Albuterol use during Breastfeeding

• The WHO states that albuterol can be used by breastfeeding mothers in the recommended doses.    

Salbutamol dose in kidney disease:

• No dose adjustment has been recommended by the manufacturer in patients with Kidney disease, those on hemodialysis, peritoneal dialysis or CRRT.

Salbutamol dose in liver disease:

• No dose adjustment has been provided by the manufacturer in patients with liver disease.

Side effects of albuterol (Salbutamol):

• Central nervous system:
  • Excitement & nervousness.
• Neuromuscular & skeletal:
  • Tremors
• Respiratory:
  • Upper respiratory tract infection
  • Bronchospasm
  • Pharyngitis.

Less Common Side effects of albuterol (Salbutamol):

• Cardiovascular:
  • Tachycardia
  • Hypertension
  • Chest Pain
  • Edema
  • Extrasystoles
  • Chest Discomfort
  • Flushing
  • Palpitations.
• Central Nervous System:
  • Shakiness
  • Headache
  • Dizziness
  • Insomnia
  • Anxiety
  • Ataxia
  • Depression
  • Drowsiness
  • Rigors
  • Voice Disorder
  • Hyperactive Behavior In Children And Adolescents
  • Malaise
  • Pain
  • Migraine
  • Emotional Lability
  • Fatigue
  • Restlessness
  • Vertigo.
• Dermatologic:
  • Excessive Sweating
  • Skin Rash
  • Urticaria
  • Pallor.
• Endocrine & Metabolic:
  • Increased Serum Glucose And Diabetes Mellitus.
• Gastrointestinal:
  • Nausea
  • Vomiting
  • Unpleasant Taste
  • Gastroenteritis
  • Increased Appetite
  • Viral Gastroenteritis
  • Diarrhea
  • Eructation
  • Flatulence
  • Glossitis
  • Xerostomia
  • Dyspepsia
  • Anorexia.
• Genitourinary:
  • Urinary Tract Infection
  • Difficulty In Micturition
• Hematologic & Oncologic:
  • Decreased Hematocrit
  • Decreased Hemoglobin
  • Decreased White Blood Cell Count
  • Lymphadenopathy.
• Hepatic:
  • Increased Serum ALT
  • Increased Serum AST
• Miscellaneous:
  • Hypersensitivity Reactions
  • Cold Symptoms
  • Infections.
• Neuromuscular & Skeletal:
  • Muscle Cramps
  • Musculoskeletal Pain
  • Back Pain
  • Hyperkinesia
  • Leg Cramps.
• Ophthalmic:
  • Conjunctivitis
• Otic:
  • Otitis Media
  • Otalgia
  • Tinnitus.
• Respiratory:
  • Throat Irritation
  • Viral Upper Respiratory Tract Infection
  • Nasopharyngitis
  • Oropharyngeal Pain
  • Sinusitis
  • Dyspnea
  • Laryngitis
  • Oropharyngeal Edema
  • Bronchitis
  • Increased Bronchial Secretions
  • Epistaxis
  • Nasal Congestion
  • Headache.

Other Rare Reports Of Albuterol Side Effects:

• Anaphylaxis & Angioedema
• Atrial Fibrillation
• Exacerbation Of Diabetes Mellitus
• Hoarseness
• Hyperglycemia
• Hypokalemia
• Hypotension
• Irritability
• Ketoacidosis
• Lactic Acidosis
• Muscle Spasm
• Mydriasis
• Paradoxical Bronchospasm
• Peripheral Vasodilation
• Stomach Pain
• Supraventricular Tachycardia
• Tongue Ulcer
• Weakness.

Contraindications to Albuterol (Salbutamol):

• Allergy to albuterol and any component of the formulation
• Patients who use dry powder inhalers have severe hypersensitivity reactions to milk proteins.
• Tachyarrhythmias

Warnings and Precautions

• Allergy immediateReports of urticaria and bronchospasm as well as rash and angioedema were made.

• Sometimesparadoxical bronchospasmReports indicate that it could be fatal.

• Patients with a history of heart disease should be cautiousCardiovascular disease.The risk of arrhythmias may be increased by beta-agonists such as albuterol. Albuterol may cause myocardial toxicities and worsen heart failure.

• Beta-agonists can increase serum glucose levels. Patients with diabetes should be cautious when using beta-agonists.diabetes mellitus

• Patients with diabetes should not use beta-agonists. They can also raise intraocular pressure.glaucoma.

• Patients with a history of hypertension should not take Albuterol.hyperthyroidismIt stimulates thyroid activity.

• Patients with low serum potassium should not take beta-agonists.Hypokalemia.

• Patients with a history of heart disease should be treated cautiouslyRenal impairment
• Beta-agonists may result in CNS stimulation/excitation and should be used with caution in patients withseizures.

Albuterol (salbutamol): Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Monitor:

• Monitor FEV1, peak flow, and other pulmonary function tests to see response to therapy.
• Monitor blood pressure, heart rate, serum glucose, serum potassium, serum creatinine, asthma symptoms, and arterial blood gases if required.

How to administer Albuterol (Salbutamol)?

The intravenous salbutamol should always be diluted and administers via an infusion pump

Oral inhalational therapy:

• Metered-dose inhalers:
  • Shake the inhaler well before use.
  • Release 3 to 4 test sprays if the inhaler has not been used for more than 2 weeks or when it has been dropped.
  • Clean the HFA inhalers with warm water at least once per week and allow to air dry completely prior to its use.
• Dry powder inhalers:
  • These inhaler devices are breath-actuated and do not require priming. The inhaler must be kept clean and dry with a tissue or a dry cloth as needed. It should not be washed or put underwater.
• How to use Ventolin Diskus?
  • To activate the Diskus device, slide the lever using the thumb grip as far as it will go till a click is heard.
  • Before inhaling, breathe out fully. (Do not exhale into the Diskus device).
  • Bring mouthpiece to lips and inhale steadily and deeply through the Diskus;
  • Hold the breath for about 10 seconds and exhale slowly.
  • To close the Diskus device, slide thumb grip back as far as it will go towards its original position.
  • Diskus device counts down from 60 to 1. The last 5 doses are numbered in red. Diskus device should be kept dry.

How to use salbutamol via Nebulization:

• Concentrated solutions should be diluted before use
• Adjust the nebulizer flow to deliver dosage over 5 - 15 minutes
• Use a mask if the patient is unable to hold the mouthpiece in the mouth.

Oral tablets should not be crushed or chewed.

Mechanism of action of Salbutamol (Albuterol):

• Salbutamol works as a beta-agonist and relaxes the bronchial smooth muscle. 
• It causes hypokalemia by driving potassium into cells.

The beginning of actionIt takes less than 30 seconds to inhale the formulations, and less than 30 minutes to take orally.

Time of actionFor nebulized/inhalational medicine, it takes 3 to 6 hours. For immediate-release oral medicine, it takes 6 to 8 hours. Extended-release salbutamol can last up to 12 hours.

MetabolismIt is via the Hepatic Route.

Half-life eliminationIt takes less than 4 hours, 5-6 and 9 hours respectively for the immediate-release oral, inhalational and extended-release oral tablet, respectively.

Time required to reach peak serum concentrationIt takes 30 minutes to complete, but less than 2 hours and up to 6 hours respectively for the immediate-release oral, inhalational and extended-release oral.

ExcretionIt is mostly through the Urine.   

Salbutamol (Albuterol) international Brand Names:

• Aero-Vent
• Aerolin
• Aeromol
• Airmax
• Airomir
• Asmacaire
• Asmadil
• Asmalat
• Asmalin Pulmoneb
• Asmatol
• Asmavent
• Asmed
• Asmidon
• Asmol
• Asmol CFCFree
• Assal
• Asthalin
• Asthalin HFA
• Asthalin Inhaler
• Asvimol
• Avedox-FC
• Bajapres
• Bemin
• Bresaltec
• Brodil
• Brodil HFA
• Broncho-Spray
• Broncholin S
• Bronchosol
• Broncolin
• Brondisal
• Bropil
• Brytolin
• Butalin
• Butamol
• Butavent
• Buto-Air
• Buto-Asma
• Butotal
• Buventol
• Buventol Easyhaler
• Ciplabutol
• Cotran
• Derihaler
• Durasol CR
• Easyhaler Salbutamol
• Ecosal
• Farcolin
• Farmarest
• Grafalin
• Hivent DS
• Huma-Salmol
• Inbumed
• Lebasma
• Libretin
• Medolin
• Mozal
• Nebsal
• Neoventil
• Respigen
• Salamol
• Salapin
• Salbetol
• Salbo 2
• Salbron
• Salbuflo
• Salbul
• Salbulin
• Salbutalan
• Salbutamol
• Salbutamol-GW
• Salbutan
• Salbutin
• Salbutol
• Salbutrim
• Salmaplon
• Salmolin
• Salomol
• Saltam
• Solia
• Sultanol
• Synvent HFA
• Teoden
• Unibron
• Velutine
• Venalax
• Venderol
• Venetlin
• Ventamol
• Venterol
• Venteze
• Ventilan
• Ventilastin
• Ventilastin
• Novolizer
• Ventodisk
• Ventol
• Ventolin CFC-Free
• Ventolin HFA
• Ventoline
• Ventylor
• Volmax
• Zenmolin
• Zibil
• Zomm

Salbutamol (Albuterol) Brand Names in Pakistan: