Brovana: A better COPD medicine

A relatively new medicine on the market that is slowly gaining acceptance by the medical community is aformoterol (Brovana).  The medicine is quickly gaining acceptance by the medical community to the benefit of the many patients with chronic obstructive pulmonary disease (COPD).

There are four reasons why Brovana is gaining acceptance

1.  It's fast acting beta adrenergic (SABA) like albuterol (Ventolin).

2.  It's long acting beta adrenergic (LABA) like Salmeterol (Serevent), a medicine in the common inhaler Advair

3.  It's only available as a solution, and must be taken using a nebulizer.

4.  The nebulizer route allows better airway distribution in patients with airflow limitation as compared with the Advair inhaler.

5.  It can be taken with Pulmicort to get the same medicinal benefits as Advair.

6.  Both Brovana and Pulmicort only need to be taken twice a day, once in the morning and once in the evening.

7.  Ventolin can still be prescribed for as needed use between doses of Brovana.

Brovana equal to Ventolin as a quick relief inhalant

Brovana (aformoterol) is best known as the only long acting beta adrenergic (LABA) available as a solution to be taken with a nebulizer. Better yet, evidence suggests it is equally effective as Ventolin as a rescue medicine.

A 2011 study by Das et al studied the efficacy and tolerability of both nebulized Ventolin and Brovana as a rescue medicines on 50 chronic obstructive pulmonary disease (COPD) patients in the acute care setting. (1)

The researchers concluded:

Our study has shown that both salbutamol and arformoterol are equally effective as a reliever medication as nebulizing solution in acute non-severe asthma. Improvement in PEFR was demonstrated in both the groups and following each dose of the drugs. The absolute increase in the PEFR after the first and the second dose were more with arformoterol than with salbutamol, but the increase in the PEFR after the third dose was similar with these two drugs. (1)

The researchers further explains why it is rapid acting when salbutamol, that active ingredient in Advair, is not:

Relatively, hydrophilic drugs such as salbutamol have a rapid onset of action due to their ability to reach the β2 receptor from the aqueous phase. Formoterol is a moderately lipophilic drug, about 300 times more than salbutamol. The aqueous portion rapidly activates the β2 receptor, whereas the lipophilic portion is taken up into the cell membrane from which it diffuses slowly to stimulate β2 receptor over a prolonged period. This accounts for rapid on set along with long duration of action of formoterol. Our study has also proved that arformoterol has a rapid onset of action. (1)

Many COPD experts now prescribe Brovana for twice a day, with Ventolin or Xopenex as needed in between.  Tiotropium Bromide (Spiriva) may also be prescribed for once a day use in combination with Brovana. (2)

References:

1. Das, Sibes K., Indranil Biswas, Arun K. Brandyopadhyay, Tapan D. Bairagya, and Somnath Bhattacharva, "A comparative study of efficacy and safety of aformoterol an salbutamol nebulization as rescue therapy in acute non severe asthma," Indian Journal of Pharmacology, 2011, July-August, 43 (4), pages 463-465
2. King, Paul T, "Review: Pharmacotherapy of Chronic Obstructive Pulmonary Disease: Focus on Aformoterol Tartrate," Clinical Medicine: Therapeutics, 2009:1, pages 1321-1327, study copy write by Libertas Academia

So why is Brovana feared by RTs, RT bosses and doctors?

Brovana (Aformoterol) is the latest medicine to be introduced to hospitals.  From my brief experience with it my fellow respiratory therapists are ignorant about it, and RT bosses fear it.  So the general consensus is to complain about it, and ignore the facts.

Yet this is nothing new among a medical profession that tends to be skeptical of new ideas and dogmatic of old ones.

For many years now Duoneb has been the medicine of choice for COPD patients, even when it's not truly indicated.  If someone has COPD, those patients get Duoneb every four hours (or at least QID) regardless of indication (Note: indications are rarely heeded in the hospital setting, at least when it comes to respiratory medicine).

So now we have this new medicine called Brovana.  A few of the wisest doctors are ordering it, and I'm not sure even they understand it.  Allow me to explain.  You see orders like the following:

Brovana BID, Duoneb Q6

I've observed twice a day my fellow RTs have been giving both Duoneb and Brovana.  So I question them:  "Do you not know what Brovana is?"

They say, "It's a long acting beta adrenergic."

I say, "It's also a rescue medicine."

They say, "No it's not. It's a LABA."

I say, "True, but it's also fast acting"

And this goes on and on, but you get the idea.  So I go to the physician, and he gives me the same defiance.  I go to the pharmacist, and he says, at least, "I'll look it up."

The bottom line here is that not only is Brovana a LABA, it's also fast acting, like Ventolin, like Duoneb, like Xopenex.  In fact, in Korea and Europe Symbicort (which has basically the same LABA in it) is used as a rescuemedicine (look it up).

Brovana should not be given at the same time as a rescue medicine.  When Brovana is given, a rescue medicine should be ordered PRN, and given only when needed, which is when rescue medicine should be used.

And this brings me to my other theory:  RT Bosses fear it.  In fact, even my coworkers fear it.  The other day I said, to my boss, "Why isn't Brovana on the new Order Set for COPD?" My boss ignored me, and my coworker said, "What are you trying to do, get us out of a job?"

So while Duoneb is habitually ordered by doctors for years, Brovana is a much better medicine.  If you give Brovana and Pulmicort BID, you should only need to give Duoneb as needed.  So you can see, there's a fallacy Brovana will put us out of a job.  Yet it's just another ignorant, selfish fallacy of the RT profession.

Yes, the RT Profession survived the first four stages of respiratory therapy while their demise would all result in the end of our profession.  The RT profession will survive, so we don't have to fear doing what is best for the patient just so we can keep our jobs.