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Chronic Obstructive Pulmonary Disease

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Chronic Obstructive Pulmonary Disease is one of the major causes of death today. This is often translated into huge economic burdens in terms of the cost of treatment as well as the loss of productivity. Albuterol and levalbuterol are some of the drugs that are recommended for the treatment of COPD. It is worth noting that albuterol was introduced first and several studies conducted on this drug revealed that it contained several negative effects. This led to the approval of levalbuterol and indeed, studies have confirmed that this drug brings about less harmful effects compared to albuterol. However, these results are controversial, and thus, this paper intends to analyze the existing literature in order to assess which between the two drugs is appropriate. Based on the review of existing literature, this paper found out that levalbuterol produces less harmful effects, results in fewer hospitalizations, and the overall costs of treatment is cheaper, even despite the fact that albuterol is a cheaper drug compared to levalbuterol. This paper provides a good analysis of the two drugs, on the basis of which health practitioners can make their decisions when dealing with COPD. In addition, this write up provides important information that will build up on the existing literature in this filed. Basing on the advantages of levalbuterol over albuterol, this paper recommends that levalbuterol should be considered as the drug of choice when it comes to the treatment of COPD. In addition, the study recommends that further research should be conducted to provide support for the claim that levalbuterol contains a better efficacy compared to albuterol with regard to the drug composition. However, despite the differences between the two drugs, it is worth noting that levalbuterol and albuterol are actually similar in numerous aspects.

Albuterol and levalbuterol are some of the drugs that are often used in the treatment of asthma and Chronic Obstructive Pulmonary Disease (COPD).  These drugs are often confused, considering the fact that they have a similar classification and action as they are both classified as bronchodilators. Albuterol is often recommended as inhaled beta-2 agonist and can be used to deal with acute bronchospasm (Perrin-Fayolle et al., 1996). It is made up of a racemic mixture of (S)-albuterol that contains some slight or no bronchodilating action, and (R)-albuterol (levalbuterol), which is considered as an active pharmacological enantiomer in a ration of 50:50. It is worth noting that (R)-albuterol has been proved to exhibit a 100-fold more capability to bind to the beta-2 receptors compared to the (S)-albuterol (Perrin-Fayolle et al., 1996).  Research studies show that albuterol has been in use for over 40 years and is still being used today (Ozminkowsk et al., 2007). However, it is worth noting that this drug has often been associated with various side effects, such as tremor. In 2005, levalbuterol was approved as a remedy for the same condition, and indeed, studies and even manufacturers have confirmed that using levalbuterol leads to fewer hospitalizations, improved respiratory parameters, fewer adverse effects, and thus, reduced overall costs of treatment (Perrin-Fayolle et al., 1996). However, these outcomes are not universal, considering the fact that some studies have confirmed that there are no distinctions when it comes to the clinical endpoints (Ameredes et al., 2009). This has, therefore, presented some controversies with regard to whether racemic albuterol or levalbuterol should be eliminated. This paper, therefore, seeks to analyze the literature on both albuterol and levalbuterol, examining what the studies suggest about these two drugs in order to make an opinion on what makes sense clinically and what does not. The paper will also look at its impact on the field as well as at the disease management.

Description of the Disease

Chronic Obstructive Pulmonary Disease (COPD) is a gradually progressive infection of the airways, often depicted by the lung function impairment.  This basically happens when there is a co-occurrence of emphysema and chronic bronchitis, leading to the narrowing down of the airways. As a result, there is a limited airflow to the lungs and out, hence a shortness of breath, a condition that is medically known as dyspnea, is experienced (Perrin-Fayolle et al., 1996).  However, it is worth noting that this condition is often irreversible and gets worse as times go by.  COPD is normally caused by some noxious particles, particularly generated from smoking tobacco, hence prompting a response that leads to the inflammation of the lungs. It is important to note that some of the most common diseases that are associated with COPD include chronic bronchitis, emphysema, and chronic obstructive bronchitis along with the combination of highlighted conditions (Ozminkowsk et al., 2007). The diagnosis of COPD necessitates that tests are conducted regarding the functioning of the lungs. Some of the management strategies include the rehabilitation, vaccinations, drug therapy, smoking termination, and in some cases, patients are recommended to have lung transplantation.

How the Drugs Work In the Body

It is worth noting that both albuterol and levalbuterol contain the same properties, considering the fact that they both target the body’s beta-2 receptors. The two drugs serve to reduce the resistance in the airway as they are known to enlarge the diameter of the bronchi or the air passages (Ozminkowsk et al., 2007). In such a way, these drugs help to enhance the overall flow of the air both into the lungs and out. The drugs work on the beta-2 receptors resulting in the pulmonary smooth muscles relaxation. Research indicates that albuterol and levalbuterol work to increase the airflow and relax the pulmonary smooth muscle within a period of 30 minutes and are known to stay for between 4-5 hours (Perrin-Fayolle et al., 1996). Studies that have been conducted with regard to the metabolism of albuterol in the human tissues indicate a 5-11 fold better sulfoconjugation of the eutomer compared to the distomer within various human tissues (Perrin-Fayolle et al., 1996). A single dose of the albuterol dosage, whether taken orally or inhaled, results in a higher blood level within the distomer compared to the eutomer (Perrin-Fayolle et al., 1996). Perhaps, this indicates a predominance of the (s)-albuterol, an inactive product, after repeated dosing of the active (R)-albuterol. However, it is important to bear in mind that while albuterol helps in relaxing the smooth muscles and increasing the flow of air within the airways, they do not actually reduce the speed of the progression of the primary disease (Ozminkowsk et al., 2007). They only help in minimizing the signs and symptoms of exercise and wheeze limitations along with the shortness of breath, leading to a better life for the people living with COPD.

Review of the Literature

Albuterol is one of the most commonly recommended drugs for patients suffering from asthma and COPD (Perrin-Fayolle et al., 1996). However, due to the negative effects caused by the drug, levalbuterol was developed. This was based on various advantages, such as better tolerability, lesser cases of transient tachycardia, and in addition, it was noted to have a greater or similar efficacy with albuterol (Ameredes et al., 2009). However, some clinical studies indicate no significant superiority of levalbuterol, when compared to albuterol, though the effects of levalbuterol may be considered greater among the patients, particularly, when there is an overuse of albuterol (Ameredes et al., 2009). Nonetheless, Ameredes et al. (2009) highlight that numerous studies have been conducted to establish the difference between the two drugs, but the findings have always been to some extent heterogeneous. A study conducted by Purrin-Fayolle et al. (1996) found out that levalbuterol was more effective in suppressing bronchospasm if compared to albuterol. The following studies indicated equivalencies of the two drugs, and some studies even found out that levalbuterol’s 1.25mg bronchodilatory effect was the same as that of the albuterol. Clinical trials in pediatric and adult patients who were diagnosed to have asthma have indicated a lower mean heart rate among the patients using levalbuterol compared to the ones using racemic albuterol. However, the degree of difference between these two drugs is modest, and thus, may be clinically significant for the patients suffering from cardiac conditions, which could even worsen in the case of tachycardia (Truitt et al., 2003).  On the other hand, some studies have reported that there is no difference in the two drugs when it comes to the mean heart rate if these drugs are compared head-to-head (Ozminkowsk et al., 2007). This is because the negative result of increased heart rate is something that is common among all the drugs classified as beta-agonists (Ameredes et al., 2009).  Therefore, the equimolar doses of both racemic albuterol and levalbuterol would probably lead to an equal magnitude of tachycardia, implying that the transient tachycardia that is often experienced with regard to these drugs is more dependent on the dose (Perrin-Fayolle et al., 1996).

Additionally, the claim that levalbuterol is more tolerable compared to albuterol is also controversial. The harmful effects of racemic albuterol, particularly with regard to its overuse, include tachyphylaxis, hypokalemia, as well as the increased rates of mortality (Qureshi et al., 2005). It is worth noting that (S)-albuterol does not contain the bronchodilator activity, and when compared to levalbuterol, it is considered to be metabolized at a 10-fold slower rate (Qureshi et al., 2005).  With this regard, some studies have theorized that it may also contain harmful effects, for instance, the pro-inflammatory effects or airway reactivity (Ameredes et al., 2009). This might lead to the preferential buildup of the (S)-isomer compared to (R)-albuterol, hence resulting in the condition known as paradoxic bronchospasm within the lungs (Qureshi et al., 2005). One study was conducted among the hospitalized patients suffering from the chronic obstructive pulmonary disease in an aim to compare the effects of racemic albuterol (2.5 mg) treatment (every 1-4 hours) with that of nebulized levalbuterol (1.25 mg) treatment (every 6-8 hours) (Qureshi et al., 2005). Apparently, fewer levalbuterol nebulizations were needed, and the call for the rescue aerosol did not increase during the study period of hospitalization, which was basically 14 days.  However, it is worth noting that the study findings highlighted that the outcome measures between the two groups being studied were alike, including the pulmonary function and costs studies (Qureshi et al., 2005). Furthermore, Truitt and his colleagues carried out a retrospective chart review of the patients diagnosed with COPD and hospitalized and came out with the same conclusions, highlighting that the outcomes of the two drugs are similar (Truitt et al., 2003). Ameredes et al. (2009) highlight that the advantage of levalbuterol over albuterol can be considered greater among the patients that have been subjected to the overuse of albuterol.

It is also important to bear in mind that cost is one of the major factors highlighted when conducting a comparison of the two drugs (Quinn, 2004). Initially, the metered-dose inhalers, considered to be a generic formulation of albuterol, were widely used, regarding the fact that they were considered to be cheaper compared to the branded albuterol versions.  However, the metered-dose inhaler formulations were banded on the grounds that most of them contained chlorofluorocarbons and were thus faced out of the market (Quinn, 2004). The branded albuterol cost is nearly the same as that of the levalbuterol. In addition, it is noted that the cost of levalbuterol nebulization is still higher than that of the generic albuterol nebulization (Gawchik et al., 1999). Nonetheless, one study indicated that the overall cost savings related to the reduction in the number of days that the patients spend in hospital is less in those using levalbuterol compared to the ones using albuterol (Quinn, 2004). Generally, it is worth noting that levalbuterol is considered to slightly enhance the pulmonary function and lasts longer than albuterol. Basically, the pulmonary function improvement caused by 0.625 mg of levalbuterol is the same as that caused by 2.5 mg of albuterol. However, despite the differences present between the two drugs, it is worth noting that levalbuterol and albuterol are actually similar in numerous aspects, such as glucose levels, impact on blood potassium, and climax of drug action among other aspects (Quinn, 2004).

What Makes Sense and What Does Not Make Sense Clinically

Despite the fact that differences between levalbuterol and albuterol are rather controversial, it is worth noting that there are few aspects which make sense clinically while others are clearly senseless. However, it is important to note that levalbuterol is considered as a safer form of albuterol (Ameredes et al., 2009). Albuterol is most commonly associated with various negative effects, such as an increased heart rate and shakiness, and despite the fact that levalbuterol generates similar effects, most of the studies have noted that they are just minimal (Ameredes et al., 2009). Another important aspect to note is the fact that albuterol contains a shorter period of action, estimated to be 4-6 hours, while levalbuterol works for about 5-8 hours (Qureshi et al., 2005). Perhaps, this can be the reason behind the relatively higher cost of levalbuterol compared to that of albuterol. It is also important to bear in mind that when it comes to the period of hospitalization, levalbuterol is considered to be cheaper as its use is highlighted to result in lesser days of hospitalization compared to the use of albuterol.

However, what does not make sense is the claim that levalbuterol contains a better efficacy compared to albuterol. Based on the composition of the two drugs, it is highlighted that albuterol contains both (R)-albuterol and (S)-albuterol in the ration of 50:50 (Qureshi et al., 2005). In addition, it is suggested that levalbuterol is purely made up of (R)-albuterol that gives it the bronchodilation effect. It, therefore, remains unclear with regard to how levalbuterol contains a better efficacy when compared to albuterol. It is important that more studies are conducted in this area in order to establish the truths behind these claims.

Impact on the Field

This paper is of a great important, considering the fact that it has expanded the available literature regarding the topic. This paper has highlighted some of the clinical issues that have to be considered with regard to the use of albuterol and levalbuterol. In addition, the paper has highlighted an area that requires more research. This is in consideration with the fact that several studies have highlighted that levalbuterol contains a better efficacy compared to albuterol, basing on the drug composition, while, in essence, there is no solid proof to support this claim. Thus, it is important that further research is conducted in this field to establish the fact behind this claim.

Potential Impact on the Disease Management

It is worth noting that COPD is today considered as one of the major causes of deaths globally (Quinn, 2004). However, it is feared that the rates might escalate, especially with the increase of smokers as well as major lifestyle changes. Thus, this results in huge economic burdens in terms of the loss of productivity as well as the costs of healthcare. This, therefore, explains the main reason as to why COPD has to be managed. It is important that the correct and effective medication is identified to ensure that the disease is put under control. This paper has, therefore, provided an analysis of the existing literature with regard to the two drugs that are most commonly used in dealing with the disease. From the analysis, it is clear that albuterol is considered to have a shorter duration of action, be cheaper, and to generate more negative effects if compared to levalbuterol. Therefore, health practitioners can consider these aspects when dealing with COPD.

From the review of the existing literature in this field, the paper recommends that levalbuterol should be considered as the drug of choice when dealing with COPD. This is based on the facts that levalbuterol exerts fewer negative effects, causes fewer hospitalizations, and generates better respiratory parameters if compared to albuterol. Furthermore, it is highlighted that the use of levalbuterol is cheaper considering the fact that its use leads to fewer hospitalizations. However, this paper recommends that further research should be conducted to support the claim that levalbuterol contains a better efficacy than albuterol, basing on the composition of the two drugs.

Most of the clinical studies aimed at determining the relative safety of albuterol and levalbuterol have often generated varied results. The conflicting results have even made it difficult to rule out which one among the two drugs should be administered in the treatment of COPD. This paper has analyzed some of the existing studies to come up with a recommendation as to which drug should be used. Most of the studies highlight that levalbuterol brings about less negative effects, results in fewer hospitalizations, and has lower overall cost of treatment. Based on the highlighted advantages, the paper recommends that levalbuterol should be opted for as a remedy for COPD. However, the study recommends a further research to support the claim that levalbuterol is more effective than albuterol basing on the drug composition.

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