UK Clinical Pharmacy Association

Vilanterol

Brands of Long-acting Beta2 adrenoreceptor agonists - oral and inhaled

This list is not exhaustive.

  • Bambuterol: Bambec®
  • Formoterol: Oxis®
  • Indacaterol: Onbrez®
  • Olodaterol: Striverdi®
  • Salmeterol: Serevent®

Combination products

  • AirFluSal®
  • Anoro®
  • Atectura®
  • Bevespi®
  • Duaklir®
  • DuoResp®
  • Enerzair®
  • Fobumix®
  • Flutiform®
  • Fostair®
  • Luforbec®
  • Relvar®
  • Seretide®
  • Spiolto®
  • Symbicort®
  • Trelegy®
  • Trimbow®
  • Trixeo®
  • Ultibro®

Issues for surgery

For asthma and chronic obstructive pulmonary disease (COPD) – increased risk of exacerbation if omitted.

Advice in the perioperative period

Elective and emergency surgery 

Continue (including combination products). 

There are numerous inhaled preparations which contain long acting beta2 adrenoceptor agonists, either as single agents or in combination products with corticosteroids and/or antimuscarinics – all of these can be continued pre-operatively. Check active ingredients of currently available preparations in British National Formulary and see also Corticosteroids - inhaled, nebulised and intranasal drug records and Antimuscarinics - inhaled and nebulised drug records, if applicable.

Advise patients who are prescribed regular long acting beta2 adrenoceptor agonists but do not usually take them regularly to do so pre-operatively to optimise disease control prior to anaesthesia.

Confirm the inhaler brand, strength and device with the patient.

Post-operative advice

Restart post-operatively as soon as next dose is due.

For patients taking bambuterol tablets

Monitor renal function – dose reduction may be necessary if renal function is impaired post-operatively (consult current product literature).

If swallowing difficulties or unreliable oral absorption post-operatively consider inhaled administration of long-acting beta2 adrenoceptor agonist, or rescue doses of short-acting beta2 adrenoceptor agonist.

Interactions with common anaesthetic agents

Halogenated anaesthetics

Long-acting beta2 adrenoceptor agonists may cause hypokalaemia. Concomitant use with medications that prolong the QT-interval (e.g. desflurane, isoflurane, sevoflurane and possibly thiopental) increases the risk of torsades de pointes. Monitor serum potassium and QT-interval with concomitant treatment. 

Neuromuscular blocking drugs (NMBDs)

Bambuterol, but not other long-acting beta2 adrenoceptor agonists, can prolong the recovery time from neuromuscular blockade with suxamethonium and mivacurium. The effect appears to be related to both the dose and the timing of bambuterol administration; the manufacturer suggests this interaction should be considered for other NMBDs metabolised by plasma cholinesterase. However, the interaction is thought to only be clinically significant in patients with abnormal plasma cholinesterase activity. 

Interactions with other common medicines used in the perioperative period

Corticosteroids

Dexamethasone and hydrocortisone may cause hypokalaemia which would potentiate any long acting beta2 adrenoceptor agonist mediated hypokalaemia Hypokalaemia increases the risk of torsades de pointes with medications which prolong the QT-interval e.g. antiemetics (domperidone, droperdiol, granisetron, haloperidol, ondansetron and possibly prochlorperazine), antimicrobials (ciprofloxacin, clarithromycin, erythromycin) and loperamide.

Macrolides

See also Corticosteroids above.

Clarithromycin, a potent CYP3A4 inhibitor, is expected to markedly increase the exposure to inhaled salmeterol but not other long-acting beta2 adrenoceptor agonists. Erythromycin, however, is not expected to interact with salmeterol to a clinically significant extent. The manufacturer of salmeterol advises avoid concomitant treatment with potent CYP3A4 inhibitors due to the risk of QT-interval prolongation; however, as clarithromycin is an appropriate treatment for COPD exacerbations the combination is likely to be commonly used. Bear the interaction in mind if QT-interval prolongation is noted on an electrocardiogram (ECG).

Further information

None relevant.

References

Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 27th June 2021]

Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 27th June 2021]

Summary of Product Characteristics – Bambec® (bambuterol) Tablets 10mg. AstraZeneca UK Limited. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text January 2017]

Summary of Product Characteristics – Oxis® (formoterol) Turbohaler 6, inhalation powder. AstraZeneca UK Limited. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text March 2020]

Summary of Product Characteristics – Striverdi® (olodaterol) Respimat 2.5 microgram, solution for inhalation. Boehringer Ingelheim Limited. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text January 2021]

Summary of Product Characteristics – Onbrez® (indacaterol) Breezhaler 150 microgram inhalation powder, hard capsules. Novartis Pharmaceuticals UK Limited. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text January 2021]

Summary of Product Characteristics – Serevent® (salmeterol) Accuhaler. GlaxoSmithKline UK. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text November 2019]