Clinical Question: In children with an acute moderate to severe asthma exacerbation, is levalbuterol (Xopenex) more effective and safer than albuterol (Proventil)?

Setting: Emergency department

Study Design: Randomized controlled trial (double-blinded)

Allocation: Concealed

Synopsis: Albuterol is a combination of two enantiomers (R and S), although the R isomer is thought to be the effective component. Levalbuterol contains only the R isomer. The authors of this study enrolled 129 children between two and 14 years of age with moderate to severe asthma, defined as a forced expiratory volume in one second(FEV₁) of less than 70 percent predicted or an asthma score of greater than eight of a possible 15 on a validated symptom score. Most of the children (69 percent) were defined as having moderate asthma. The children were randomly assigned, using concealed allocation, to receive 2.5 mg levalbuterol or 5.0 mg albuterol, which are equivalent doses, via nebulizer every 20 minutes for three doses, then subsequent treatments every 30 to 60 minutes as needed. Children in either group who weighed less than 55 lb (25 kg) received one half of these doses at the same intervals. All children also received oral prednisone. No differences were detected between groups inFEV₁ or asthma scores after the first three doses of the bronchodilator. There also were no differences in the total number of nebulizer treatments given, length of care, or rate of hospitalization (12 percent). Similarly, pulse rates, respiratory rates, and pulse oximetry readings were not different between the two groups.

Bottom Line: Levalbuterol is no more effective and no safer than albuterol in the treatment of moderate asthma exacerbations in children. These results are similar to the results printed on the product labeling for levalbuterol. In another study of severe asthma, there were fewer hospitalizations with levalbuterol than with albuterol treatment (Carl JC, et al. Comparison of racemic albuterol and levalbuterol for treatment of acute asthma. J Pediatr 2003;143:731–6). Given the much higher price of levalbuterol, it makes little sense to use it when albuterol is as effective. (Level of Evidence: 1b)