Asthma inhalers: Are long-acting beta-2 agonists (LABAs) safe?

Asthma inhaler medications called long-acting beta-2 agonists (LABAs) have been linked to dangerous asthma attacks — but these medications can be an effective treatment when used properly.

You may have heard about it on the news or noticed a warning on your asthma inhaler medication. Specific asthma inhalers called long-acting beta-2 agonists (LABAs) — such as Serevent, Advair or Foradil — may increase your risk of a life-threatening asthma attack. These medications are delivered via a dry powder inhaler or an aerosol inhaler and are used for long-term treatment of moderate and severe asthma.

You're not alone if you are concerned about the possible dangers of these asthma inhalers — and you may even wonder if you should stop using them. But don't change anything until you talk to your doctor. Even though LABAs have been linked to dangerous asthma attacks in some people, they're still an important treatment option for many people with moderate or severe asthma. When used correctly — combined with inhaled corticosteroids and monitored carefully — long-acting beta-2 agonist asthma inhalers reduce symptoms and are less likely to cause a dangerous reaction.

What are long-acting beta-2 agonists?

Long-acting beta-2 agonists (LABAs) are part of a group of asthma inhalers called bronchodilators. Used along with inhaled corticosteroids, LABAs reduce asthma symptoms and lessen the need for short-term "rescue" medication. They open up constricted airways for 12 hours or longer and are used to control moderate and severe asthma and to prevent nighttime symptoms. LABAs used to treat asthma include:

• Serevent Diskus. This medication contains the LABA salmeterol, administered with a disk-shaped inhaler device.
• Advair Diskus. This medication combines the LABA salmeterol and the inhaled corticosteroid fluticasone. Like Serevent, it's also delivered with a disk-shaped device.
• Foradil Aerolizer. This medication contains the LABA formoterol.
• Symbicort. This medication combines the LABA formoterol and the inhaled corticosteroid budesonide.

Why the concern?

A large recent study of salmeterol (Serevent) showed that people taking the medication, especially blacks, were at a higher risk of life-threatening asthma attacks or death than were people taking a placebo. The Salmeterol Multi-Center Research Trial (SMART), designed to test the safety of Serevent, had about 26,000 participants. It was stopped early because of safety concerns.

As a result of the study, the Food and Drug Administration (FDA) issued a public health advisory for LABA medications in 2005. It warns that these medications can cause a "small but significant risk in asthma-related deaths." The FDA also required the addition of new "black box" safety labels to these medications.

The warnings about LABas come at a time of heightened public concern about potentially dangerous drugs. Recently, problems with selective cyclooxygenase inhibitors (selective COX-2 inhibitors) led to the withdrawal of the pain medication Vioxx from the market because of dangerous side effects. But unlike with selective COX-2 inhibitors, the dangers of long-acting beta-2 agonists aren't so clear-cut.

Concerns over the risks of beta agonists aren't new. Since the 1970s, several studies have shown that short-acting beta agonists may increase the risk of serious or fatal asthma attacks in some people. But experts contend that severe reactions may be at least partly caused by the fact that in many studies, LABAs weren't always used in conjunction with inhaled corticosteroids or in the context of good medical care. When they're used correctly, the benefits of using LABAs appear to outweigh the possible risks for many people with moderate or severe asthma.

Do long-acting beta-2 agonists improve asthma symptoms?

Experts know these asthma inhaler medications work for people who have moderate or severe asthma — when they are combined with inhaled corticosteroids. People who used long-acting beta-2 agonists along with corticosteroids had fewer symptoms in clinical trials than did people who used only corticosteroids for long-term asthma control. Compared with participants who used corticosteroids only, people who took both medications:

• Woke up less often at night
• Had better lung function
• Had better health-related quality of life
• Used fast-acting "rescue" medications less often
• Had lower rates of asthma flare-ups (exacerbations)

Can these medications be used safely?

Current asthma treatment guidelines still recommend use of these asthma inhaler medications for people who have moderate or severe persistent asthma. However, these medicines should never be used as the only asthma treatment. Guidelines say these medications should be used on a regular schedule along with inhaled corticosteroids, which ease bronchial inflammation.

Some experts say that the SMART study results may exaggerate the risk of using LABAs to treat asthma because many study participants weren't using asthma medications properly. Less than 50 percent of SMART study participants took corticosteroids along with salmeterol — and many were using salmeterol as their only asthma treatment. An even smaller percentage of black study participants used inhaled corticosteroids along with salmeterol. Experts think not combining LABAs with inhaled corticosteroids may have contributed to the higher number of dangerous and fatal asthma attacks in this study and other studies.

While these medications can be effective in treating moderate or severe asthma, they don't work for everyone. Inherited traits may make some people who take these medications more likely to have an asthma attack.

The bottom line: Work with your doctor

According to James Li, M.D., an asthma specialist at Mayo Clinic in Rochester Minn., LABAs are an effective medication for many people with asthma — as long as they communicate with their doctor. "If you are taking a LABA to treat asthma, don't stop taking it if you have concerns. Check with your doctor. These are useful medications when they're used properly. LABAs should not be the only asthma controller medication you use — and they should only be used along with inhaled corticosteroids."

Dr. Li advises you to talk to your doctor about any concerns regarding your medication or your asthma symptoms. He also emphasizes the importance of regular checkups. "If you have asthma, check in with your doctor at least once a year — especially if you are taking medications to control your symptoms."

If you are taking a LABA, there are several things you can do to help keep your asthma under control — and avoid a dangerous flare-up:

• Don't stop or change the dose of any asthma medications on your own — always talk to your doctor first.
• Always take this medication along with an inhaled corticosteroid.
• If your asthma worsens, call your doctor or seek medical treatment.
• If you are taking LABAs and you have a sudden asthma attack, seek prompt emergency treatment.