Posted by Dr. Jim Joyner
Can opioids be administered by nebulizer for shortness of breath (dyspnea)?
Opioids are the mainstay of treatment for management of severe dyspnea in hospice patients with late stage CHF and COPD. The use of opioids in dyspnea is supported by extensive experience as well as clinical studies with the use of both oral and parenteral opioids, specifically morphine. The mechanism of action is unclear and it is interesting that opioids can alleviate dyspnea in many patients without changing the respiratory rate or producing any measurable changes in blood gas parameters. The rationale for considering nebulized opioids centers on the belief that dyspnea can be relieved while avoiding potential systemic side effects associated with oral or parenteral routes. The current medical literature does not support this belief. A review article by Foral (1) and colleagues in 2004 evaluated a number of clinical studies in patients being treated for dyspnea with inhaled nebulized opioids. The authors concluded that the evidence did not support the use of nebulized morphine for the relief of dyspnea. They also reported that in all cases opioid side effects were present from mild to moderate degree. There are several other options available for conventional opioid administration routes for hospice patients, including: oral, subcutaneous, intramuscular, intravenous, rectal, transmucosal, and sublingual.
(1) Nebulized Opioids use in COPD. Chest 2004;125:363-365
Posted by Dr. Jim Joyner
Hospice Medication Management: Xopenex & Albuterol for Asthma and COPD
Xopenex (levalbuterol) is a beta-agonist type bronchodilator. Xopenex is very similar to, and is in fact an isomer of the earlier beta-agonist bronchodilator albuterol. Albuterol and Xopenex are both beta-2 selective agonist bronchodilators indicated for asthma and COPD.
Xopenex is more potent than Albuterol on a milligram per milligram basis, so theoretically Xopenex may have an advantage by having less risk of side effects since less drug is required for therapeutic effects. This theoretical advantage is not proven out by the clinical studies which have demonstrated comparable efficacy and safety between Albuterol and Xopenex in both short-term and long-term studies. The safety and efficacy of levalbuterol inhalation solution was evaluated in a 4-week, multi-center, randomized, doubleblind, placebo-controlled study in 362 adult and adolescent patients 12 years of age and older, with mild-to-moderate asthma. Efficacy was measured by the mean percent change from baseline in FEV1. A dose of 0.63 mg of levalbuterol and 2.5 mg of albuterol sulfate produced a clinically comparable mean percent change from baseline in FEV1 on both day 1 and day 29. No significant difference in side effects was demonstrated as measured by heart rate, blood pressure, and tremor. (Xopenex [package insert]. Marlborough, MA: Sepracor Inc.; 2003)
Albuterol is a more cost-effective alternative to Xopenex which appears to have very similar efficacy and a similar safety profile.
Xopenex should be reserved only for those hospice patients which exhibit intolerable adverse effects to albuterol, specifically: increased heart rate, elevated blood pressure, and/or tremor.