Albuterol

BackgroundProspective evidence is lacking regarding incremental benefits of long-acting dual- versus mono-bronchodilation in improving symptoms and preventing short-term disease worsening/treatment failure in low exacerbation risk patients with chronic obstructive pulmonary disease (COPD) not receiving inhaled corticosteroids.MethodsThe 24-week, double-blind, double-dummy, parallel-group Early MAXimisation of bronchodilation for improving COPD stability (EMAX) trial randomised patients at low exacerbation risk not receiving inhaled corticosteroids, to umeclidinium/vilanterol 62.5/25 μg once-daily, umeclidinium 62.5 μg once-daily or salmeterol 50 μg twice-daily. The primary endpoint was trough forced expiratory volume in 1 s (FEV1) at Week 24. The study was also powered for the secondary endpoint of Transition Dyspnoea Index at Week 24. Other efficacy assessments included spirometry, symptoms, heath status and short-term disease worsening measured by the composite endpoint of clinically important deterioration using three definitions.ResultsChange from baseline in trough FEV1 at Week 24 was 66 mL (95% confidence interval [CI]: 43, 89) and 141 mL (95% CI: 118, 164) greater with umeclidinium/vilanterol versus umeclidinium and salmeterol, respectively (both p ConclusionsUmeclidinium/vilanterol consistently provides early and sustained improvements in lung function and symptoms and reduces the risk of deterioration/treatment failure versus umeclidinium or salmeterol in symptomatic patients with low exacerbation risk not receiving inhaled corticosteroids. These findings suggest a potential for early use of dual bronchodilators to help optimise therapy in this patient group.

Asthmatic airways are inflamed and undergo remodelling. Inhaled corticosteroids and long-acting β2-agonist combinations are more effective than inhaled corticosteroid monotherapy in controlling disease exacerbations, but their effect on airway remodelling and inflammation remains ill-defined. This study evaluates the contribution of inhaled fluticasone and salmeterol, alone or combined, to the reversal of bronchial remodelling and inflammation. Severely asthmatic horses (6 horses/group) were treated with fluticasone, salmeterol, fluticasone/salmeterol, or with antigen avoidance for 12 weeks. Lung function, central and peripheral airway remodelling, and bronchoalveolar inflammation were assessed. Fluticasone/salmeterol and fluticasone monotherapy decreased peripheral airway smooth muscle remodelling after 12 weeks (p = 0.007 and p = 0.02, respectively). On average, a 30% decrease was observed with both treatments. In central airways, fluticasone/salmeterol reversed extracellular matrix remodelling after 12 weeks, both within the lamina propria (decreased thickness, p = 0.005) and within the smooth muscle layer (p = 0.004). Only fluticasone/salmeterol decreased bronchoalveolar neutrophilia (p = 0.03) to the same extent as antigen avoidance already after 8 weeks. In conclusion, this study shows that fluticasone/salmeterol combination decreases extracellular matrix remodelling in central airways and intraluminal neutrophilia. Fluticasone/salmeterol and fluticasone monotherapy equally reverse peripheral airway smooth muscle remodelling.

Acetylcholine receptor deficiency is the most common form of the congenital myasthenic syndromes, a heterogeneous collection of genetic disorders of neuromuscular transmission characterized by fatiguable muscle weakness. Most patients with acetylcholine receptor deficiency respond well to acetylcholinesterase inhibitors; however, in some cases the efficacy of acetylcholinesterase inhibitors diminishes over time. Patients with acetylcholine receptor deficiency can also benefit from the addition of a β2-adrenergic receptor agonist to their medication. The working mechanism of β2-adrenergic agonists in myasthenic patients is not fully understood. Here, we report the long-term follow-up for the addition of β2-adrenergic agonists for a cohort of patients with acetylcholine receptor deficiency on anticholinesterase medication that demonstrates a sustained quantitative improvement. Coincidently we used a disease model to mirror the treatment of acetylcholine receptor deficiency, and demonstrate improved muscle fatigue, improved neuromuscular transmission and improved synaptic structure resulting from the addition of the β2-adrenergic agonist salbutamol to the anticholinesterase medication pyridostigmine. Following an initial improvement in muscle fatiguability, a gradual decline in the effect of pyridostigmine was observed in mice treated with pyridostigmine alone (P < 0.001). Combination therapy with pyridostigmine and salbutamol counteracted this decline (P < 0.001). Studies of compound muscle action potential decrement at high nerve stimulation frequencies (P < 0.05) and miniature end-plate potential amplitude analysis (P < 0.01) showed an improvement in mice following combination therapy, compared to pyridostigmine monotherapy. Pyridostigmine alone reduced postsynaptic areas (P < 0.001) and postsynaptic folding (P < 0.01). Combination therapy increased postsynaptic area (P < 0.001) and promoted the formation of postsynaptic junctional folds (P < 0.001), in particular in fast-twitch muscles. In conclusion, we demonstrate for the first time how the improvement seen in patients from adding salbutamol to their medication can be explained in an experimental model of acetylcholine receptor deficiency, the most common form of congenital myasthenic syndrome. Salbutamol enhances neuromuscular junction synaptic structure by counteracting the detrimental effects of long-term acetylcholinesterase inhibitors on the postsynaptic neuromuscular junction. The results have implications for both autoimmune and genetic myasthenias where anticholinesterase medication is a standard treatment.

ImportanceTransitioning from metered-dose inhalers to propellant-free dry-powder inhalers could reduce health care-related greenhouse gas emissions, but the clinical difference in outcomes that may be associated with this switch is uncertain.ObjectiveTo evaluate the clinical difference in outcomes associated with a July 2021 Veterans Health Administration (VHA) formulary change that replaced budesonide-formoterol metered-dose inhaler with fluticasone-salmeterol dry-powder inhaler for the treatment of chronic obstructive pulmonary disease and asthma.Design, setting, and participantsThis within-person, self-controlled case series (SCCS) and matched observational cohort study (cohort study) used data from the US Veterans Affairs health care system from January 2018 through December 2022. Veterans who were prescribed a combination inhaler before and after the formulary change were included in both the SCCS and cohort study. Data were analyzed between April 19, 2024, and April 4, 2025.ExposuresTreatment with budesonide-formoterol metered-dose inhaler vs fluticasone-salmeterol dry-powder inhaler.Main outcomes and measuresRescue medication use (albuterol and prednisone fills), emergency department visits, and hospitalizations (all-cause, respiratory-related, and pneumonia-specific) were assessed.ResultsFollowing the VHA formulary change, 260 268 patients switched from budesonide-formoterol metered-dose therapy to fluticasone-salmeterol dry-powder therapy. In the SCCS (median [IQR] age, 71 [62-75] years; 91% male), among patients who switched inhalers and experienced the adverse outcomes of interest, treatment with fluticasone-salmeterol dry-powder inhaler therapy was associated with a 10% decrease in albuterol fills (incidence rate ratio [IRR], 0.90 [95% CI, 0.90-0.91]), a 2% increase in prednisone fills (IRR, 1.02 [95% CI, 1.01-1.03]), a 5% increase in all-cause emergency department visits (IRR, 1.05 [95% CI, 1.04-1.06]), an 8% increase in all-cause hospitalizations (IRR, 1.08 [95% CI, 1.06-1.09]), a 10% increase in respiratory-related hospitalizations (IRR, 1.10 [95% CI, 1.07-1.14]), and a 24% increase in pneumonia-specific hospitalizations (IRR, 1.24 [95% CI, 1.17-1.31]). In the cohort study of 258 557 patients (mean [SD] age, 68.9 [11.3] years; 94% male), those who switched to a fluticasone-salmeterol dry-powder inhaler had no difference in mortality (1.89% vs 1.90%; adjusted absolute difference, -0.01 percentage points [95% CI, -0.12 to 0.10 percentage points]) but had increases in all-cause hospitalizations (16.14% vs 15.64%; adjusted absolute difference, 0.49 percentage points [95% CI, 0.21-0.78 percentage points]), respiratory-related hospitalizations (3.15% vs 2.74%; adjusted absolute difference, 0.41 percentage points [95% CI, 0.27-0.55 percentage points]), and pneumonia-related hospitalizations (1.15% vs 1.03%; adjusted absolute difference, 0.12 percentage points [95% CI, 0.04-0.21 percentage points]) at 180 days after the switch compared with matched patients who did not switch.Conclusions and relevanceThe study found that the VHA formulary transition from budesonide-formoterol metered-dose inhaler to fluticasone-salmeterol dry-powder inhaler was associated with increased health care utilization, suggesting potential harm and the need to reevaluate this policy change.