Levalbuterol vs. Albuterol: Differences, similarities, and which is better for you

Drug overview & main differences | Conditions treated | Efficacy | Insurance coverage and cost comparison | Side effects | Drug interactions | Warnings | FAQ

Levalbuterol and albuterol are two drugs used in the treatment of bronchospasm related to asthma and chronic obstructive pulmonary disease (COPD). Asthma is a respiratory disease that affects people of all ages. It is characterized by wheezing, cough, shortness of breath, and chest tightness. It is estimated that asthma affects approximately 24 million people in the United States, including 7 million children.

COPD, sometimes referred to as emphysema, has similar characteristics to asthma, but also includes the production of thick mucus in the airway. The exact cause of asthma is unknown, but the majority of patients who develop COPD have a history of smoking or long-term exposure to lung irritants.

Bronchospasm describes a process that occurs in both asthma and COPD where the airways contract, making it difficult to pass air through. This is sometimes referred to as bronchoconstriction. Levalbuterol and albuterol both treat bronchospasm, but they work differently.

What are the main differences between Levalbuterol and Albuterol?

Levalbuterol is a prescription drug that is a moderately selective, short-acting beta-2-receptor agonist (SABA). Levalbuterol is the more active R-enantiomer of the albuterol racemic mixture. Levalbuterol stimulates the beta receptors resulting in relaxation of bronchial and tracheal smooth muscle and a more open airway. Levalbuterol is available as a metered-dose inhaler (MDI) delivering a 45 mcg dose per actuation. It is also available as a solution to be used in a nebulizer machine. This nebulizer solution is available in concentrations of 0.31 mg/3 ml, 0.63 mg/3 ml, and 1.25 mg/3ml.

Albuterol is a prescription drug that is also a moderately selective, short-acting beta-2-receptor agonist (SABA). Albuterol is a racemic mixture of R-enantiomers and S-enantiomers with the R-enantiomer being the more active isomer and the active ingredient in levalbuterol. Racemic albuterol is available in oral tablets in strengths of immediate-release 2 mg and 4 mg and extended-release 4 mg and 8 mg. Albuterol is also available in an oral solution in a concentration of 2 mg/5 ml. Albuterol also comes in a metered-dose inhaler delivering 90 mcg per actuation as well as a variety of nebulizer solutions.

Main differences between Levalbuterol and Albuterol
	Levalbuterol	Albuterol
Drug class	Moderately selective short-acting beta-2-agonist	Moderately selective short-acting beta-2-agonist
Brand/generic status	Brand and generic available	Brand and generic available
What is the brand name?	Xopenex	ProAir, Proventil, Ventolin, Accuneb, Vospire
What form(s) does the drug come in?	Metered-dose inhaler, nebulizer solution	Metered-dose inhaler, nebulizer solution, oral tablets, oral solution
What is the standard dosage?	0.63 mg via nebulizer or 45 mcg via MDI every 4-6 hours	2.5 mg via nebulizer or 90 mcg via MDI every 4-6 hours
How long is the typical treatment?	Intermittent, short term	Intermittent, short-term
Who typically uses the medication?	Children 4 years of age and older, adults	Infants, children, adults

Conditions treated by Levalbuterol and Albuterol

Levalbuterol and albuterol both work by stimulating beta receptors to cause relaxation of smooth muscle in the airways, thereby allowing the airways to open up and carry more air to the lungs with less resistance.

Both levalbuterol and albuterol are FDA approved in the treatment of asthma exacerbations, transient bronchospasms or wheezing, and COPD-related bronchospasm. It is important to note that neither drug is approved as prophylaxis, or prevention, for these indications. However, albuterol is approved to be used in the prophylaxis of exercise-induced bronchospasm. Typically, albuterol would be administered 15 minutes prior to the anticipated exercise to reduce the likelihood of bronchospasm caused by exercise. Levalbuterol is sometimes used off-label for this indication as well. Off-label means the drug has not been approved for use in this indication by the Food and Drug Administration (FDA).

The following chart lists the most commonly known uses for these drugs. Only your healthcare provider can determine if these drugs are appropriate for your condition. In cases of severe asthma and COPD bronchospasm, please seek treatment in the nearest emergency department.

Condition	Levalbuterol	Albuterol
Asthma exacerbation	Yes	Yes
Transient bronchospasm/ episodic wheezing	Yes	Yes
Exercise-induced bronchospasm prophylaxis	Off-label	Yes
COPD associated bronchospasm	Yes	Yes
Acute treatment of hyperkalemia	Off-label	Off-label
Adjunctive treatment to neonatal respiratory illnesses	No	Off-label

Is Levalbuterol or Albuterol more effective?

Levalbuterol and albuterol have been compared extensively with regard to asthma and COPD outcomes. A 2015 study evaluated adults who were hospitalized with asthma or COPD exacerbations who were treated with either levalbuterol or albuterol administered by nebulization. The results of this clinical trial found that clinical outcomes were similar between the two drugs and both were effective at relieving the symptoms of bronchospasm. However, the cost of levalbuterol treatment was significantly more expensive than the cost of albuterol treatment, and patients in the levalbuterol group had a significantly longer hospitalization than patients in the albuterol group. Longer hospital stays also increase the overall cost of interventions.

A meta-analysis and systematic review of seven different trials, including over 1,600 patients, was done comparing levalbuterol to albuterol in acute asthma. This study found no significant difference between the drugs when comparing clinical outcomes such as respiratory rate, oxygen saturation, and change in lung volume. Lung volume is sometimes referred to as forced expiratory volume, or FEV1, in medical literature. This study concluded there was no evidence to support choosing levalbuterol over albuterol in the treatment of asthma.

While both drugs are effective, prescribers may weigh the lack of evidence of the superiority of levalbuterol and the higher cost when deciding which medication to prescribe. Levalbuterol is only approved in pediatric patients four years and older, therefore albuterol would be preferred in the younger pediatric population. Only your doctor can choose the correct medication for your condition.

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Coverage and cost comparison of Levalbuterol vs. Albuterol

Levalbuterol is a prescription drug that is typically covered by commercial insurance plans. It may be covered by either a Medicare Part D or Part B plan depending on the diagnosis. Without coverage, levalbuterol may cost you more than $170. A SingleCare coupon for generic Levalbuterol can lower the price to $30 at participating pharmacies.

Albuterol may be covered by either a Medicare Part D or Part B plan depending on the diagnosis. It is also typically covered by commercial insurance plans. Albuterol may cost as much as $40 without coverage, but with a coupon from SingleCare, you can get the generic form for less than $10 at participating pharmacies.

	Levalbuterol	Albuterol
Typically covered by insurance?	Yes	Yes
Typically covered by Medicare Part D?	Dependent on diagnosis	Dependent on diagnosis
Standard dosage	25, 0.63 mg/ 3 ml	25, 2.5 mg/ 3 ml
Typical Medicare copay	Dependent on plan	Dependent on plan
SingleCare cost	$30-$130	$10-$20

Common side effects of Levalbuterol vs. Albuterol

While levalbuterol and albuterol are moderately selective for beta receptors on the intended smooth muscle of the airways, there may still be some cardiac beta-receptor stimulation causing an increase in heart rate, known as tachycardia. Both levalbuterol and albuterol may cause nervousness and tremor. Migraine and dizziness were noted with levalbuterol, but not albuterol.

This is not intended to be a comprehensive list of potential adverse effects. Please consult your healthcare provider for a complete list of side effects.

	Levalbuterol		Albuterol
Side effect	Applicable?	Frequency	Applicable?	Frequency
Tachycardia	Yes	2.7%	Yes	2.7%
Migraine	Yes	2.7%	No	n/a
Dyspepsia	Yes	2.7%	Yes	1.4%
Leg cramps	Yes	2.7%	Yes	1.4%
Dizziness	Yes	2.7%	No	n/a
Hypertonia	No	n/a	Yes	2.7%
Nervousness	Yes	9.6%	Yes	8.1%
Tremor	Yes	6.8%	Yes	2.7%
Anxiety	Yes	2.7%	No	n/a
Increased cough	Yes	4.1%	Yes	2.7%
Viral infection	Yes	12.3%	Yes	12.2%
Rhinitis	Yes	2.7%	Yes	6.8%
Sinusitis	Yes	1.4%	Yes	2.4%
Turbinate edema	Yes	1.4%	No	n/a

Source: Levalbuterol (DailyMed) Albuterol (DailyMed)

Drug interactions of Levalbuterol vs. Albuterol

Due to their chemical similarities, the potential drug interactions for levalbuterol and albuterol are very similar. Azithromycin, a very common antibiotic often used in upper respiratory infections, should be avoided in combination with either levalbuterol or albuterol when possible. Azithromycin, when administered with short-acting beta-agonists, has an increased risk of causing QT prolongation, a type of cardiac arrhythmia. If this combination must be used, a patient’s cardiac function should be monitored closely. It is important to obtain a baseline of cardiac function prior to administering these drugs at the same time.

Beta blockers, often used to control heart rate and blood pressure, are functionally opposite of beta-agonists. Their functions will counteract each other. If a patient must be both a beta blocker and a beta-agonist, using a cardioselective beta blocker is preferred. Examples of cardioselective beta blockers include atenolol and metoprolol, among others.

This is not a complete list of potential drug interactions. Please seek the medical advice of a healthcare professional for a complete understanding of potential drug interactions.

Drug	Drug class	Levalbuterol	Albuterol
Caffeine	Xanthine derivative/ CNS stimulant	Yes	Yes
Phenylephrine Pseudoephedrine	Decongestants	Yes	Yes
Acebutolol Atenolol Betaxolol Bisoprolol Carvedilol Metoprolol Nadolol Nebivolol Propranolol Sotalol	Beta blockers (beta antagonists)	Yes	Yes
Amiodarone Dronedarone	Anti-arrhythmics	Yes	Yes
Amitriptyline Clomipramine Nortriptyline	Tricyclic antidepressants	Yes	Yes
Citalopram Escitalopram Fluoxetine Sertraline	Selective serotonin reuptake inhibitors (SSRIs)	Yes	Yes
Azithromycin Clarithromycin	Antibiotics	Yes	Yes
Fluconazole Itraconazole Ketoconazole	Antifungals	Yes	Yes

Warnings of Levalbuterol and Albuterol

Levalbuterol and albuterol may cause paradoxical bronchospasm, a condition where a patient’s bronchospasm or wheeze actually get worse instead of improving. If this occurs, therapy should be stopped immediately and a new treatment should be started.

Destabilization of asthma may occur over a period of hours, days, or longer. If an asthmatic patient begins to require an increasing amount of a bronchodilator to control asthma symptoms, this could be a sign that destabilization is occurring. Patients experiencing this may need anti-inflammatory treatments such as corticosteroids or a change in their maintenance medication regimen.

Levalbuterol and albuterol, especially at doses above the recommended amount, may cause serious cardiovascular effects such as increased heart rate and blood pressure. In some serious cases, cardiac arrest has occurred. Never exceed the recommended dosing your doctor has prescribed.

Low serum potassium levels, or hypokalemia, has been observed with levalbuterol and albuterol. This may be caused by intracellular shunting. While these drugs are sometimes used off-label to lower potassium levels intentionally, this effect should be monitored.

Frequently asked questions about Levalbuterol vs. Albuterol

What is Levalbuterol?

Levalbuterol is a prescription drug that is a short-acting beta-agonist, also known as a bronchodilator. It is used to treat bronchospasm related to asthma and COPD. It is also used off-label to help prevent exercise-induced bronchospasm. It is available in the form of a metered-dose inhaler as well as solutions to be used in a nebulizer.

What is Albuterol?

Albuterol is also a prescription drug that is a short-acting beta-agonist. It is also known as a bronchodilator and is used to treat bronchospasm related to asthma and COPD as well as to prevent exercise-induced bronchospasm. It is available in various forms including oral tablets, oral solutions, metered-dose inhalers, and solutions to be used in a nebulizer.

Are Levalbuterol and Albuterol the same?

Levalbuterol and albuterol are chemically similar, but they are not exactly the same. Albuterol is a racemic mixture of two chemical enantiomers, R-albuterol and S-albuterol. It is sometimes referred to as racemic albuterol. Levalbuterol is composed of just R-albuterol, the more active of the two compounds.

Is Levalbuterol or Albuterol better?

Retrospective comparison studies overall have shown that levalbuterol and albuterol have similar clinical outcomes. Prescribers may consider characteristics such a cost and potential adverse effects when selecting one over the other.

Can I use Levalbuterol or Albuterol while pregnant?

Levalbuterol and albuterol are both considered pregnancy category C by the FDA. This means there are no good clinical studies to show safety in pregnancy. These drugs should only be used when the benefits clearly outweigh the risks. In these cases, albuterol may be preferred due to the presence of more historical data on its use in pregnancy.

Can I use Levalbuterol or Albuterol with alcohol?

There are no direct contraindications with albuterol and alcohol. However, alcohol can slow respiratory rate and affect pulmonary function, which is counterproductive to treating bronchospasm.

Is Levalbuterol a rescue inhaler?

Yes, levalbuterol HFA is a rescue inhaler indicated for use in the treatment of acute asthma exacerbations or bronchospasms due to COPD.

Is Levalbuterol a steroid?

Levalbuterol is not a steroid or anti-inflammatory and should not be used in place of a steroid when steroid use is indicated, such as in asthma destabilization.

How long does Levalbuterol last?

On average, the effects of a single dose of levalbuterol may last five to six hours. Levalbuterol begins working about 15 minutes after administration.