be dangerous in some children (see Cautions, below).

Excessive use is usually an indication of inadequately

controlled asthma and should be managed with a
prophylactic drug such as an inhaled corticosteroid.
The child and the child s carer should be advised to
seek medical advice when the prescribed dose of beta2
agonist fails to provide the usual degree of symptomatic
relief because this usually indicates a worsening of the
asthma and the child may require alternative medication (see Management of Chron
ic Asthma table, p. 133).
Children and their carers should be advised to follow
manufacturers instructions on the care and cleansing of
inhaler devices.
Nebuliser (or respirator) solutions of salbutamol and terbutaline are used for t
he treatment of severe acute
asthma both in hospital and in general practice. Children with a severe attack o
f asthma should have oxygen
if possible during nebulisation since beta2 agonists can
increase arterial hypoxaemia, see also section 3.1.5.
Oral Oral preparations of beta2 agonists may be used
for children if an inhaler device cannot be used but
inhaled beta2 agonists are more effective and have fewer
side-effects. A modified-release formulation of salbutamol may be of value in no
cturnal asthma as an alternative to modified-release theophylline preparations
(section 3.1.3), but an inhaled long-acting beta2 agonist
is preferable.
Parenteral Beta2 agonists can be given intravenously
in children with severe or life-threatening acute asthma.
Chronic asthma unresponsive to stepwise treatment
(see Management of Chronic Asthma, p. 133) may
benefit from continuous subcutaneous infusion of a
beta2 agonist, but this should be used only under the
supervision of a respiratory specialist; the evidence of
benefit is uncertain and it may be difficult to withdraw
such treatment once started.
Cautions Beta2 agonists should be used with caution
in diabetes monitor blood glucose (risk of ketoacidosis, especially when a beta2 a
gonist is given intravenously). Beta2 agonists should also be used with caution
in hyperthyroidism, cardiovascular disease, arrhythmias, susceptibility to QT-in
terval prolongation, and
hypertension. Interactions: Appendix 1 (sympathomimetics, beta2).
Hypokalaemia Potentially serious hypokalaemia may
result from beta2 agonist therapy. Particular caution is
required in severe asthma, because this effect may be
potentiated by concomitant treatment with theophylline
and its derivatives, corticosteroids, and diuretics, and by
hypoxia. Plasma-potassium concentration should
therefore be monitored in severe asthma.
Side-effects Side-effects of the beta2 agonists
include fine tremor (particularly in the hands), nervous
tension, headache, peripheral dilatation and palpitation.
Other side-effects include tachycardia, arrhythmias, peripheral vasodilation, my
ocardial ischaemia, and disturbances of sleep and behaviour. Muscle cramps and
hypersensitivity reactions including paradoxical bronchospasm (occasionally seve
re), urticaria, angioedema,
hypotension, and collapse have also been reported.
High doses of beta2 agonists are associated with hypokalaemia (see Hypokalaemia,
above).
FORMOTEROL FUMARATE
(Eformoterol fumarate)

Note For use in asthma only in children who regularly use

an inhaled corticosteroid, see notes above
Cautions see notes above
Pregnancy see p. 131
Breast-feeding see p. 131
Side-effects see notes above; nausea, dizziness, rash,
taste disturbances, and pruritus also reported
Indications and dose
Reversibl e airways obstruction (including
nocturnal asthma and prevention of exerciseinduced bronchospasm) in patients req
uiring
long-term regular bronchodilator therapy see also
Management of Chronic Asthma table, p. 133; for
dose see preparations below
Counselling Advise children and carers not to exceed
prescribed dose, and to follow manufacturer s directions; if a
previously effective dose of inhaled formoterol fails to
provide adequate relief, a doctor s advice should be obtained
as soon as possible
Formoterol (Non-proprietary) A
Dry powder for inhalation, formoterol fumarate
12 micrograms/metered inhalation, net price 120dose unit = 23.75. Counselling, administration
Brands include Easyhaler Formoterol
Dose
Chronic asthma
. By inhalation of powder
Child 6 12 years 12 micrograms twice daily
Child 12 18 years 12 micrograms twice daily, increased
to 24 micrograms twice daily in more severe airways
obstruction
Atimos Modulite (Chiesi) A
Aerosol inhalation, formoterol fumarate 12 micrograms/metered inhalation, net pr
ice 100-dose unit
= 30.06. Counselling, administration
Dose
Chronic asthma
. By aerosol inhalation
Child 12 18 years 12 micrograms twice daily, increased
to max. 24 micrograms twice daily in more severe airways obstruction
Foradil (Novartis) A
Dry powder for inhalation, formoterol fumarate
12 micrograms/capsule, net price 60-cap pack (with
inhaler device) = 23.38. Counselling, administration
Dose
Chronic asthma
. By inhalation of powder
Child 6 12 years 12 micrograms twice daily
Child 12 18 years 12 micrograms twice daily, increased
to 24 micrograms twice daily in more severe airways
obstruction
Oxis (AstraZeneca) A
Turbohaler(= dry powder inhaler), formoterol
fumarate 6 micrograms/inhalation, net price 60-dose
unit = 24.80; 12 micrograms/inhalation, 60-dose
unit = 24.80. Counselling, administration
Dose
Chronic asthma
. By inhalation of powder
Child 6 18 years 6 12 micrograms 1 2 times daily;

occasionally up to 48 micrograms daily may be needed

(max. single dose 12 micrograms); reassess treatment if
136 3.1.1 Adrenoceptor agonists BNFC 2014 2015
3Respiratory system
additional doses required on more than 2 days a week
(see also CHM advice above)
Relief of bronchospasm
. By inhalation of powder
Child 6 18 years 6 12 micrograms
Prevention of exercise-induced bronchospasm
. By inhalation of powder
Child 6 18 years 6 12 micrograms before exercise
Compound preparations
For compound preparations containing formoterol,
see Flutiform and Symbicort, section 3.2
SALBUTAMOL
(Albuterol)
Cautions see notes above
Pregnancy see p. 131
Breast-feeding see p. 131
Side-effects see notes above; also lactic acidosis with
high doses
Licensed use not licensed for use in hyperkalaemia;
syrup and tablets not licensed for use in children
under 2 years; modified-release tablets not licensed
for use in children under 3 years; injection and solution for intravenous infusi
on not licensed for use in
children under 12 years
Indications and dose
Acute asthma
. By aerosol or nebulised solution inhalation
See Management of Acute Asthma, p. 132
. By intravenous injection over 5 minutes (see also
Management of Acute Asthma, p. 132)
Child 1 month 2 years 5 micrograms/kg as a
single dose
Child 2 18 years 15 micrograms/kg (max.
250 micrograms) as a single dose
. By continuous intravenous infusion
Child 1 month 18 years 1 2 micrograms/kg/
minute, adjusted according to response and heart
rate up to 5 micrograms/kg/minute; doses above
2 micrograms/kg/minute should be given in an
intensive care setting
Exacerbations of reversible airways obstruction
(including nocturnal asthma) and prevention of
allergen- or exercise-induced bronchospasm, see
also Management of Chronic Asthma, p. 133
. By aerosol inhalation
Child 1 month 18 years 100 200 micrograms (1
2 puffs); for persistent symptoms up to 4 times
daily
. By inhalation of powder
See under preparations
. By mouth (but use by inhalation preferred)
Child 1 month 2 years 100 micrograms/kg (max.
2 mg) 3 4 times daily
Child 2 6 years 1 2 mg 3 4 times daily
Child 6 12 years 2 mg 3 4 times daily
Child 12 18 years 2 4 mg 3 4 times daily

Severe hyperkalaemia (section 9.2.1.1)

. By intravenous injection over 5 minutes
Neonate 4 micrograms/kg as a single dose; repeat
if necessary
Child 1 month 18 years 4 micrograms/kg as a
single dose; repeat if necessary
. By inhalation of nebulised solution (but intravenous injection preferred)
Neonate 2.5 5 mg as a single dose; repeat if
necessary
Child 1 month 18 years 2.5 5 mg as a single dose;
repeat if necessary
Administration for continuous intravenous infusion,
dilute to a concentration of 200 micrograms/mL with
Glucose 5% or Sodium Chloride 0.9%. If fluidrestricted, can be given undiluted t
hrough central
venous catheter [unlicensed]
For intravenous injection, dilute to a concentration of
50 micrograms/mL with Glucose 5%, Sodium Chloride 0.9%, or Water for injections
For nebulisation, dilute nebuliser solution with a suitable volume of sterile So
dium Chloride 0.9% solution
according to nebuliser type and duration of administration; salbutamol and iprat
ropium bromide solutions are compatible and can be mixed for nebulisation
Oral
Salbutam ol (Non-proprietary) A
Tablets, salbutamol (as sulfate) 2 mg, net price 28tab pack = 75.48; 4 mg, 28-tab pack = 77.26
Oral solution, salbutamol (as sulfate) 2 mg/5 mL, net
price 150 mL = 72p
Brands include Salapin (sugar-free)
Ventma x SR (Chiesi) A
Capsules, m/r, salbutamol (as sulfate) 4 mg (green/
grey), net price 56-cap pack = 8.08; 8 mg (white),
56-cap pack = 9.69. Label: 25
Dose
Chronic asthma (but see notes above)
. By mouth
Child 3 12 years 4 mg twice daily
Child 12 18 years 8 mg twice daily
Ventoli n (A&H) A
Syrup, sugar-free, salbutamol (as sulfate) 2 mg/5 mL,
net price 150 mL = 72p
Parenteral
Ventoli n (A&H) A
Injection, salbutamol (as sulfate) 500 micrograms/
mL, net price 1-mL amp = 38p
Solution for intravenous infusion, salbutamol (as
sulfate) 1 mg/mL. Dilute before use. Net price 5-mL
amp = 2.48
BNFC 2014 2015 3.1.1 Adrenoceptor agonists 137