Abstract
Studies in patient preferences provide crucial information on the evaluation of asthma symptoms as well as the effects of medication on the wellbeing of the patients and the levels of functional activities. These studies have been insufficient in evaluation the effectiveness of albuterol in treating asthma. Albuterol has been in use for over 40 years but is said to be associated with various side effects that include tremor. The introduction of levalbuterol in 1999 has brought an opportunity to assess patient predilections between albuterol and lavalbuterol. When albuterol was approved in 2005, studies suggested that its used resulted in better respiratory parameters as well as fewer hospitalizations that brought about very little, if any, side effects and thus led to generally lower treatment costs. Studies in levalbuterol reported conditions of bronchodilation as compared to the side effects of albuterol. However, lower doses of levalbuterol reported bronchodilation with very little side effects in persons with asthma. This particular study evaluates the treatment of asthma in children by caregivers who use either albuterol or levalbuterol. The subjects for this study were children under the age of twelve years. Various interviews were scheduled for caregivers, and the main questions were the satisfaction level of their children with asthma. The caregivers are supposed to report contentment on discontent. The patients were administered with albuterol and levalbuterol for four consecutive weeks. After the first dose, levalbuterol created a greater increase in the change compared to doses of albuterol in nearly all patients including with those with relentless asthma. The main purpose of this study is to provide a comparative view of asthma related therapies, as well as the outcomes of treatment after the maintenance treatment of asthma using levalbuterol and albuterol.
Key words: albuterol, levalbuterol, asthma, bronchodilation, satisfaction, dosage, satisfaction
Introduction
Asthma is among the most common and chronic pulmonary illnesses that affect more than fourteen million people in the United States
A stepwise approach to disease management is necessary for the assessment and eventual treatment of asthma. One of the main goals of asthma treatment is to uphold the wellbeing of people as one of the main humanistic upshot measures. Today, clinicians use many other measures as ways of disease management with a need to control the effects of asthma as well as the wellbeing of the patients. These measures include patient satisfaction as well as other health related measures that are centered on the quality of life. Studies on patient preferences have revealed that the impact of medication side effects is greater in patients’ quality of life. Patients’ compliance with the medication is necessary for successful control of asthma (Ameredes, 2009). Disease control measures are also very crucial in reinforcing the positive perceptions of the treatment of asthma.
The baseline distinctiveness for the two groups of patients (those who were administered with albuterol as well as those who were administered with levalbuterol) was very distinctive. Those who used levalbuterol were relatively younger as compared to the albuterol group. The study showed that there was much expenditure for the albuterol patients was more, as compared to the levalbuterol patients (Nelson, 1998). Therefore, levalbuterol should be the drug of choice for the treatment of asthma in Kentucky Medicaid patients. However, various studies are required to verify this hypothesis. In the medical field, albuterol has been in use for more than forty years. This is one of the factors that make it preferable. Due to the mixture of the two isomers (R)-albuterol and (S)-albuterol that are considered inert, albuterol is considered somewhat classical in the medical field. However, the single-isomer formulation that has been manufactured recently is used therapeutically when the other component is deemed to be undesirable. Research has also shown that raemic albuterol and levalbuterol are important since they produce effects that can be used as prescriptions for cancer treatment. The treatments include corticosteroid strengthening and the diminution of inflammatory mediators. However, on the other hand, (S)-albuterol produces the contradictory effects.
Literature Review
The review of the literature regarding the relationship between albuterol and levalbuterol in the healing of heightened asthma can be highlighted in the various articles that have been selected, with an aim of providing a critical review of the various ways in which the two drugs have been associated with the treatment of asthma. These articles are presented below, followed by a critical literature review of the articles.
- Ameredes, B. (2009). Levalbuterol versus albuterol. Current Allergy Asthma Report, 401-409.
- Nelson, H. (1998). Improved bronchodilation with levalbuterol compared with racemic albuterol in patients with asthma. Journal of Allergy and Clinical Immunology, 943-952.
3. Ozminkowski, R., & Wang, S. (2007). The Impact of Nebulized levalbuterol on Health Care Payments for Elderly Asthma and Chronic Obstructive Pulmonary Disease Patients in Medicaid Plans. Dis Manage Health Outcomes, 41-55
Most asthma exacerbations are dealt with in various outpatient systems. However, more severe conditions require hospitalization. These hospitalizations are responsible for the foremost healthcare expenditures by patients. In the United States
Ameredes (2009) in the journal of Current Allergy Asthma Report carried out a research that brought out various results tha are useful in this research. The main purpose of his study was to find out the distinctive difference between albuterol and levalbuterol. The objectives of his research were to find out whether levalbuterol reduced the costs of treating asthma as compared to albuterol and to find out the various ways that levalbuterol and albuterol were different. He used a correlational research design that brought forward thirty seven patients who were diagnosed with acute asthma. The patients in his sample were children between the ages of 6-18. The findings of the research as well as its synopsis is discussed below.
The main therapy in the treatment of asthma is the administration of β2-receptor agonists that reverse the acute airway obstruction as well as other conditions such as cough. According to Reed (1985), levalbuterol and albuterol are the most common short acting β2-receptor agonists in the treatment of asthma. Racemic albuterol is responsible for the bronchodilation of the drug (Lovtall, Palmqvist, Aevidsson, Maloney, Vantresca, & Ward, 2004). However, the safety of albuterol and lavalbuterol is generally different. The S-isomer has been believed to be inert in nature and thus the presence of the drug in its inert state. The drug is now thought to foreshorten the duration of R-albuterol (Handley, 2000).
Vitro and animal studies have shown significant outcomes that can be used as a basis of analysis. Many research studies reveal that albuterol is associated with severe effects that are bothersome. This could be because of the fact that inhalation of racemic albuterol leads to pushiness in circulating S-albuterol twelve times more than levalbuterol (Ameredes, 2009). Levalbuterol has been acclaimed to be a safer form of albuterol but it comes at very expensive prices. This is because it costs five times more than racemic albuterol. Many authors in their publications from studies have revealed that the use of leavalbuterol leads to better respiratory parameters as compared to albuterol. However, their pattern of outcomes can not apply universally becasue other studies propose that there is not a clear difference in clinical endpoints. Ozminkowski & Wang (2007) state in a different study related to the current one that the various publications that have resulted from various surveys are difficult for doctors to follow. Most of these data highlight the effects f albuterol and levalbuterol in efficiency and safety.
However, this clinical research provides no pre-eminence of levalbuterol over albuterol. However, the effects of levalbuterol may be severe to asthma patients that have overused albuterol. Ameredes (2009) suggests that there have been highly heterogenous results from various surveys that reveal the clear difference of albuterol from levalbuterol. However, subsequent research activities, as indicated by different research papers written, revealed that there are equivalences between albuterol and levalbuterol. This was indicated with the study revealing that the effects of levalbuteriol were similar to those of albuterol with very minimal effects. The above studies were shot-term, and thus a short-time approach would be used to evaluate the two drugs. This approach, however, did not measure the difference that existed between albuterol and its isomers, if used chronically. When a patient inhales racemic albuterol, he or she has a persistent effect that is caused by (S)-albuterol. This is in comparison to levalbuterol. This suggests potential contradictory effects that are experimented clinically. Although there are many researches that havfe been carried out, there are no exact evidences of the superior nature that levalbuterol has over racemicalbuterol. Howevr, the author notes that the effects of levalbuterol are much felt when the patients are of moderate to sevre conditions. This is in effects especially when there is the overuse of albuterol. On the contrary, recent research that has aided in the inclusion of hydroflouroalkane formulation has been effective in narrowing the costs between the two types of inhalers. However, the hydroflouroalkane still remains in a nebulized form. Therfore, the way physicians select these two drugs is purely on their personal knowledge, availabilty, the cost and the prescribing habits that they have. On the other hand, racemic albuterol is used widely in the treatment of acute asthma as compared to levalbuterol.
Nelson (1998), in the Journal of Allergy and Immunology, suggested a clinical trial that would compare albuterol and levalbuterol. The study was based on both children and adults that were diagnosed on acute asthma in the United States United States
Clinical studies have been carried out in pediatric patients with asthma. According to Gawchik (2007), a randomized placebo-controlled trial was necessary to compare the two drugs. In his study, he found out that there was no difference in bronchodilation with levalbuterol and albuterol. This is because there was no dose-related correlation in children with moderate asthma. However, the dose-related correlation was found in children with severe asthma. In another study of acutely asthmatic patients between the ages of 6-18 years, there was a conclusion that more expensive levalbuterol did not reduce the amount of return visits to the hospital for further asthma management as compared to racemic albuterol (PerrinFayolle, 1996). The study further tried to come out with the effects of albuterol as compared levalbuterol. In the research, the author clearly stated that albuterol is purely used for thetreatment of symptoms that are occasional and insisted that an overdose of the drug can be fatal. One of the precautionary measures that should be taken when using albuterol, is that the use should be dicontinued if there are signs of hypersensitivity. The main points to note and stop the use of albuterol according to Gawchick are:
I. Abnormal heart rhythms
II. Diabetes
III. Epilepsy this is coupled with seizure disorder
IV. Hart diseases
The researcher also notes that the following side effects may be a sign of hypersensitvity
I. Wheezing
II. Pounding heart
III. Tight chest
IV. Nervousness
V. Blood pressure
VI. Chest pain
On the other hand, contrary to this, the researcher also writes about the new form of albuterol inhalers that are in use in the market since 2009 in a bid to compare albuterol to levalbuterol Gawchik (2007). He notes that due to the recent changes, the new form is adjusted and bettr in terms of the security of use due to the fact that they are both human and environmentally friendly. The chloroflouroalkane found in rescue inhalers both levalbuterol and albuterol have been found to harm the environment. Therfore, the inclusion of hydroflouroalkane has been important as a propellant. This is actually a positive step in the study of the effects of the two types of drugs.
Ozminkowski & Wang, (2007) In another randomized study that was age-stratified, patients presented to the emergency department gave an outcome of admission. The study was aimed at finding out the level of admission of patients to the emergency section and the return rate after discharge. The objectives of this study were to find out the patient-return rate after treatment in the emergency section and find out the role played by levalbuterol in assisting the quick recovery of patients in the emergency section. The admission rate was lower in the levalbuterol group as compared to the albuterol group. The risk of the admitted group was greater in the albutrerol groups than the levalbuterol group. However, this did not indicate that hospital stay in the levalbuterol group was short and that there were no adverse effects in both groups. In this study, the conclusion was that substituting the administration of levalbuterol with albuterol would reduce the number of hospitalizations. In the emergency treatment of acute asthma, albuterol was the best medication (Qureshi, 2005). In the same research, the author notes several factors. First and foremost, he acknowlegdes the fact that abuterol is the most commonlyprescribed inhaler with beta-2 agonist. In addition to that, he notes that it is also considered as the best drug when it comes to reversal of acute bronchospasm. Due to the equal mixture of (S) and (R)-albuterols, there is little effect of broncholdilating activities. On the contrary, the (R)- albuterol have a better binding effect to beta-2 receptors as compared to the (S)-albuterol. In the resaerch, the author notes the reasons that led to the creation of levalbuterol. They include:
I. Fewer incidences of transcient tachycardia
II. There is the chance of better tolerabilty as compared to albuterol
III. And the issue of efficacy
A further examination of the research, showed that patients benefit more from levalbuterol.
This study, like in many other studies, levalbuterol resulted in Forced Expiratory Values (FEV) that were equivalent to or better than those that were observable in albuterol. The β-mediated effects were lower for a single dose of levalbuterol as compared to racemic albuterol. In this studies, treatment of asthma using levalbuterol was cheaper due to the little numbers of hospital admissions (Tripp, 2008). In this particular study, levalbuterol treatment in the emergency department was cost effective because it led to a situation of patients recovering faster and thus reducing the cost of healthcare. Nevertheless, like in other surveys, the outcomes in the study revealed that levalbuteriol was better than albuterol in a sense that patients treated with levalbuterol required less medication after recovery and that they had shorter lengths of hospital stay. A regression analysis revealed that levalbuterol was allied with duration of stay savings. Another study conducted by Truitt, Witko, & Halpern (2003), similar improvements in FEV showed mean heart rate becoming less with levalbuiterol. In the same study, the author notes that there are lower mean heart rates when it comes to the treatment of asthma using levalbuterol. This is a study that was carried out in comaprison to albuterol. However, the researchers note that the magnitude of the difference is minute, however, it is important to study these differences in order to come out with the most probable results. Nonetheless, the author notes that results may be helpful to patients who are affected with arrhythmias, cardiac conditions and structural heart diseases. This is because if the differences are not considered, it may worsen the heart situation. Therfore, the author notes that the transcient tachycardia that is witnessed in heart patients may be a key indicator of the dose dependancy that is formed with time by patients who use levalbuterol and albuterol. Howevr, he notes that the issue of tolrance is till a bit controversial. There are some researches that have noted that the overuse of racemic albuterol may lead to some factors that include hypokalemia and even incresed mortality. Therefore, due to the lack of bronchodilator activities in (S)-albuterol, there may arise the situation of worsening air activity or rather proinflammatory effects. This is due to the fact that it is it is metabolized 10-fold slower than levalbuterol. This could additinally result in the accumulation of (S)-isomer over (R)-albuterol leading to paradoxic bronchospasm.
In another study, Nowak (2008) and his colleagues comapred the effects that are brought forth by nebulized levalbuterol. This was in comoparison to the ones that are nbrought forth by racemmic albuterol. The subjects were 627 adults who sufferd from acute asthma. The subjects were radnomly given the opportunity to use either 1.25 mg of levalbuterol or 2.5 mg of albuterol. This was after twenty minutes of emergency admission and later after 40 minutes and later it was administered clinically after that. Nonetheless, all the p[atients received 40 mg of prednisone. The level of expiratory volume was forcefully increased by 40 percent when the patients were administered with levalbuteral, this is in comaprison to racemic albuterol hence this coresponded to a fourty percent reduction in the subjects who required hospitalization. The effects of levalbuterol were evident in patients who had severe asthma and they were at high levels greater than 1095 miligrams per milimitere. The high circulation levels of (S)-albuterol are thought to be the main cause of excessive use of racemic albuterol. The number os relapses in the two groups after a period of thiorty days, did not differ.
In another trial that had the same researcher Nowak (2008) , there was the study of patients who suffered from acute asthma. The others suffered from chronic obstructive pulmonary disease (COPD). There was a comapred treatment od levalbuterol and albuterol that were administred in a period of 6 to 8 hours in 1.25 and 2.5 miligrams repectively. There were fewer nebulizations that were required when it came to the case of levalbuteral. On the other hadn, there was an increased need of rescue aerosols in the period of 14 days hospitalization. Howevr, most of the other outcomes werte similar in the two groups. This is including the costs and study of te pulmonary functions. Other members in his group, Tritt and his colleagues carried out a retrospective chart review on hospitalized patients whoo had asthma and COPD and the results were much more or less the same. Therfore, they concluded that the benefit of levalbuteral and albuteral is usually greatest in patients who had moderate as comapred to severe asthma. In particular, those who had an overuse of albuterol. The other main factor that was noted when comapring the two agents is cost. Before the year 2009, the metered-dose inhaler (MDI) that had generic formulations was widely available and in adittion to that, there were also versions of albuterol that were much cheap. They included proventil and ventolin. This fact also applied to levalbuteral. On the contrary, many of the MDI formulations contained a lot of chloroflourocarbon and therfore, this meant that they had to be banned by the FDA (food and drug administration). This was particularly due to environemntal reasons.therfore, the unavailabilty os the MDI has led to the leveling in price of the two agents. Howevr, there are variations in the cost of levalbuteral nebulization as compared to albuteral nebulization. The limitations that levalbuteral faces include:
I. Higher costs
II. Small sample size in terms of testing
III. Inadequate power
IV. Lack of support by many researchers
This however, does not mean that albutearl should be preffered over levalbuteral. There are instances when levalbuteral tends to be widely accepted. They include:
I. There is a need by patients who have severe chronic athma to get the doses of beta-2 agonist this is in spite of the use of controller therapies
II. The other reason is that the patients who suffere from asthma or COPD and other cardiac diseases have a likelihood of worsening the situation when they are exposed to tachycardia and this therefore means that they are safer when using levalbuteral as comapred to albuteral
III. There is poor adherence to medication by patients who have suffered from tachycardia
Research question/hypothesis
This research was guided by a number of questions that were significant in arriving at the various conclusions in the study. The research questions for the research were as follows:
- What is the satisfaction rate that patients with acute asthma experience during the administration of albuterol and levalbuterol?
- What are the relative benefits between levalbuterol and albuterol?
- Does levalbuterol or albuterol have a contribution in the severity of patients with asthma?
Hypothesis: A stepwise approach to disease management is necessary for the assessment and eventual treatment of asthma.
Proposed operational definitions for outcome (and intervention) variables
Satisfaction – following the interviews that were scheduled for caregivers regarding the satisfaction of their children, albuterol was different from levalbuterol in the treatment of asthma. Satisfaction refers to an outcome that is favorable to the patient and unconditionally helps the patient to overcome the effects of a condition.
Benefits – the benefit of levalbuterol over albuterol was accomplished. The various studies revealed that albuterol was expensive but was effective in reducing the period of admission to emergency departments. Benefits here refer to the best outcomes from a certain therapeutic activity.
Severity of patients – patients who used levalbuterol recovered faster than those who used albuterol. Severity refers to the worsening of the patient’s condition in relation to a medication that has been administered to the patient.
Objectives
The objectives of this case study were based on the study questions and were as follows:
- To find out the contentment rate that patients with acute asthma experience during the administration of albuterol and levalbuterol
- To evaluate the general benefits of levalbuterol and albuterol from the clinical surveys
- To find out whether levalbuterol or albuterol contribute in the severity of patients with
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