Inhaler Medication Reaction – Lightheadedness and Nausea with a Once Daily Bronchodilator

Inhaler Medication Reaction: What are the Alternatives?

Dear Dr. Mahler:

My doctor’s office asked me to try a ‘new’ inhaler – ANORO – which worked great for 2 days but I had a reaction when I first inhaled it – lighted-headed and nauseated.  That lasted for about 2 hours.  They will not let me continue on this .  Is there not something comparable?


Beverly from Avon, CT

Dear Beverly,

View of smooth muscle wrapping around the outside of the breathing tubes

An inhaler medication reaction to – Anoro Ellipta – with a feelings of lightheadedness and nausea is uncommon, but certainly can occur.

To answer your question, let’s first consider the anatomy of the the breathing tubes (airways). Smooth muscle wraps around the outside of the breathing tubes (see figure on right).  The smooth muscle can constrict which causes narrowing of the breathing tubes and reduces air flow. Certain medications can relax the smooth muscle allowing more air to move in and out during breathing.

Anoro Ellipta enables patients to breathe easier with two bronchodilators

Anoro Ellipta dry powder inhaler

Anoro Ellipta is a dry powder inhaler that contains two different classes of bronchodilators – one is called a long-acting beta-agonist and the other is called a muscarinic antagonist. These medications work in different ways to relax the smooth muscle that wraps around your breathing tubes (airways). By relaxing the smooth muscle, the tubes can open more (dilate) allowing more air to move during breathing.

Side effects can occur with any medication including inhalers. Fortunately, there are three other approved inhalers that are similar to Anoro as they also contain both classes of bronchodilators. Two of these are available at the present time – Stiolto Respimat and Bevespi Aerosphere.

Stiolto Respimat – a soft mist inhaler

Stiolto is a soft mist inhaler and releases a fine mist

Bevespi contains two different bronchodilators in a single device

Bevespi Aerosphere – a pressurized metered-dose inhaler

when you press down on the release button. The dose of Stiolto is two inhalations once a day. Bevespi is a metered-dose inhaler; the delivery system is the same as albuterol metered-dose inhaler. Bevespi delivers an aerosol after pressing down on the canister. The dose of Bevespi is two puffs twice a day about 12 hours apart.

I suggest that you contact your health care professional to ask about these other dual bronchodilators.


Donald A. Mahler, M.D.



When will Bevespi Aerosphere be Available for my COPD?

Bevespi Aerosphere – a Dual Bronchodilator

Dear Dr. Mahler:

When will bevespi aerosphere be available?
Kenneth from Orange, MA
Dear Kenneth:
Bevespi Aerosphere is an inhaler approved on April 25, 2016, by the U.S. Food and Drug Administration for use in those with COPD.
What is Bevespi Aerosphere?  It contains two different bronchodilators that act to relax muscles that wraps around breathing tubes. One medication is called glycopyrrolate – a muscarinic antagonsit – and the other medication is called formoterol – a beta agonist. The two medications are delivered using a unique co-suspension technology. It is to be used twice a day, 12 hours apart.
Bevespi contains two different bronchodilators in a single device

Bevespi is a pressurized metered-dose inhaler

AstraZeneca is the pharmaceutical company that makes Bevespi.  Current plans are that Bevespi will be available in the U.S. in early 2017.

Contact AstraZeneca

Here is information from their website. If you are in the United States and would like additional information regarding AstraZeneca products, or you are a third party with an offer of services for AstraZeneca, you can contact the AstraZeneca Information Center by phone at 1-800-236-9933 (Monday – Friday 8 a.m. – 6 p.m. ET, excluding holidays).

Why will it take that long?

For the past several years medical insurance companies decide which medications they will cover (pay for) and what medications they will not cover (pay for). These companies have contracts with health care programs like Medicare, Medicaid, Anthem Blue Cross, and many others. These contracts typically start in January and last one year.
It is common that insurance companies have new contracts for preferred bronchodilators each year. This may require those with COPD to change their medication(s) when scheduled to be refilled early in the year.  Either you agree to change or else you may have to pay full price out of pocket or have a higher co-pay.
Finally, there are two other dual bronchodilators currently available in the U.S. One is Anoro Ellipta™, a dry powder, and the other is Stiolto Respimat™, a fine mist.
Donald A. Mahler, M.D.

Tapering Pain Medications and Shortness of Breath

Tapering Pain Medications

Dear Dr. Mahler:

I am 72 yrs old. I have been on fentanyl and Norco for approx. 10 years for pain. I was born with a degenerative hip disease, had back surgery and was given this to help relieve pain. I was not told consequences of this. Now my Dr. Is lowering my dosage. I have been diagnosed with COPD had several bouts of breathing exacerbations-I now use Spiriva and it has helped until they lowered my RXs.

My question is, Could withdrawals cause my COPD to flare up? I seem to be having breathing trouble again. Appreciate any info you can give me. Thank you.

Anthony from Jackson, MS

Dear Anthony,

Both fentanyl and Norco (contains hydrocodone) are pain medications. They are called opioids that act on receptors in the body to relieve pain.  Opioids include opiates, an older term that refers to such drugs derived from opium, including morphine, and semi-synthetic and synthetic drugs, such as hydrocodone, oxycodone, and fentanyl.

Opium plant

Opium poppy. The Sumerians referred to it as “joy plant”

It appears that you are taking two similar pain medications for your chronic pain. So, it seems reasonable to reduce and hopefully stop one of these two medications.

In addition, opioids relieve breathing difficulty and are used in palliative care for persistent shortness of breath. So, it is possible that reducing your dose of either fentanyl or Norco is causing you some breathing difficulty rather than an actual exacerbation or flare-up.

You mentioned that you are taking Spiriva for COPD. This medication is a long-acting muscarinic antagonist. I suggest that you talk to you doctor and ask about adding a long-acting beta-agonist to Spiriva. This should open your airways even more and make it easier to breathe.

Anoro Ellipta enables patients to breathe easier with two bronchodilators

Anoro Ellipta dry powder inhaler

At the present time, there are four approved LABA/LAMA combinations in a single inhaler. However, only two of these – Anoro Ellipta and Stiolto Respimat – are currently available for use in the US.

Stiolto Respimat delivers a fine mist.

Stiolto Respimat delivers a fine mist.

Since you are currently using Spiriva (which is one of the two medications in Stiolto), it is quite reasonable for your doctor to stop Spiriva and to start Stiolto. You can also use albuterol inhaler as needed for quick relief of any shortness of breath.

Best wishes,

Donald A. Mahler, M.D.


New Inhaler – Bevespi – Approved for COPD

FDA approves new Dual Bronchodilator – Bevespi

On April 25, 2016, the United States Food and Drug Administration approved a new inhaler called Bevespi Aerosphere™ for long-term maintenance treatment for those with COPD.

Bevespi is a pressurized metered-dose inhaler

Bevespi is a pressurized metered-dose inhaler


What is Bevespi?  It contains two different bronchodilators that act to relax muscles that wraps around breathing tubes. One medication is called glycopyrrolate – a muscarinic antagonsit – and the other medication is called formoterol – a beta agonist. The two medications are delivered using a unique co-suspension technology. It is to be used twice a day, 12 hours apart.

Other Dual Bronchodilator Products Bevespi is the fourth dual bronchodilator in a single device approved in the United States.  Others dual bronchodilators in order of approval by the FDA are: Anoro Ellipta®, Stiolto Respimat®, and Utibron NeoHaler®. Studies show that using two different bronchodilators are more effective in improving how the lungs work and making it easier to breathe than one bronchodilator.

It is likely that Bevespi Aerosphere™ will be available in pharmacies later this year.


Are Powder or Spray Bronchodilators Better?

Dear Dr.Mahler:

My doctor has prescribed different inhalers for my COPD,  but I am not sure which ones work best for me. I have been tried on a couple different powder inhalers as well as various sprays. Of all the inhalers, Combivent seems to help me the most. I was diagnosed with COPD about 6 years ago, and still work 4 days a week at a pay booth collecting tolls. What are your thoughts?

Pete from Shelton, CT

Dear Pete,

The different inhaled medications and the different delivery devices can  be quite confusing for those with COPD and even health care providers. In fact, several new inhalers have been approved by the Food and Drug Administration this year.

Here is a simple (hopefully) way to think about inhaled bronchodilators.

First, bronchodilators relax the muscle that wraps around the breathing tubes to open them up and make it easier to breathe.

Second, there are two types of bronchodilators based on how they work: beta-agonists and muscarinic antagonists. It is not important for you to remember this information, but you should know that we frequently prescribe both types to gain the best benefit for your breathing.

Third, the medicines are either liquids or powders. The key thing is that the sprays from the liquid and the particles from the powder have to be inhaled deep into the breathing tubes to effectively open them up. If the spray or powder does not get into the lower parts of the lungs, it can not open the airways completely.

Fourth, these different bronchodilators are contained in various delivery devices. They are called metered-dose inhalers (puffers), soft mist inhalers, and dry powder inhalers.

Metered-dose Inhaler

Metered-dose Inhaler

Soft mist inhaler

Dry-powder Inhaler

Dry-powder Inhaler

The reason for the variety is that different pharmaceutical companies have developed the different inhaled bronchodilators, all of which are patented for a period of time.

Good inhalation technique (how you actually inhale the medication) is key to successful use. In my medical practice, I ask each individual how he/she uses the inhaler and whether the medication “makes it easier to breathe.” If the specific inhaler does not seem to help your breathing, the first thing to check is how you are inhaling the spray or powder. You should ask your health care provider or her/his nurse to watch you use the inhaler. If you are doing it correctly, then a trial of a different bronchodilator inhaler is reasonable.

So, there is no advantage of spray or powder bronchodilators. It is most important that you inhale the medication correctly.


Donald A. Mahler, M.D.



Utibron Neohaler Approved for COPD

Two Different Bronchodilators in one inhaler – Utibron Neohaler –  approved for COPD

On October 29, 2015, the US Food and Drug Administration approved a new inhaler called Utibron Neohaler for treatment of those with COPD. It is a combination inhaler containing two active ingredients: indacaterol (a long-acting beta2 agonist [called a LABA]) and glycopyrrolate (a long-acting muscarinic antagonist [called a LAMA]). These two medications work in different ways to open the breathing tubes (airways) to make it easier for those with COPD to breathe. The medications are supplied in a capsule containing dry powder for inhalation using the Neohaler. It is approved for use twice a day 1 2 hours apart.

It is the third dual bronchodilator combination inhaler approved in the US. The other two medications are Anoro Ellipta (also a dry powder) and Stiolto Respimat ( a fine mist). Both of these medications are used once daily in the morning.

Studies show that two bronchodilator medications in a single inhaler are more effective in opening the breathing tubes (improving breathing tests) and relieving shortness of breath than one bronchodilator. It is expected that dual bronchodilators will be used more widely to relieve shortness of breath and improve health-related quality of life in those with COPD.

My comment: Many physicians have been treating those with COPD with a combination of different  inhaled medications for some time. In the past, this required two different inhalers and, as a result, two separate co-payments for the individual. There are now three different dual bronchodilators available  in a single inhaler (Anoro, Stiolto, and Utibron) that provide treatment options for the unmet needs of individuals with COPD. I encourage you to discuss this information with your health care provider.

Bronchodilators and Glaucoma

Dear Dr. Mahler:

My father has chronic COPD, while also battling severe glaucoma. I know the most common treatment for COPD is an inhaler, however, most of those medicines are not compatible with those meds used to treat glaucoma.  So in essence, my father can either treat his breathing or eyesight?  To date, he has chosen to treat his eyes with proper medications.
What would be your recommendations for someone who battles both of these illnesses?

Thank you so much for your time and consideration.

Alice from Warner, NH

Dear Alice:

Is your father using any inhaled bronchodilators for his COPD? These medications are the mainstay of treatment for those with COPD by relaxing the muscle that wraps around breathing tubes, open the airways, and makes it easier to breathe.

There are two types or classes of bronchodilators – called

  1. beta-agonists
  2. muscarinic antagonists

The muscarinic antagonists (examples by brand name: Atrovent; Spiriva; Tudorza; Incruse) may increase the pressure inside the eye (intraocular pressure) and therefore make glaucoma worse. Doctors do not prescribe this type of bronchodilator if someone has glaucoma.

However, the beta-agonists do not affect the intraocular pressure and should otherwise by safe for your father to take. There are short-acting (examples of brand names:  ProAir; Proventil; Ventolin) and long-acting (examples of brand names: Arcapta; Formoterol; Serevent; Striverdi) beta-agonists.  The short-acting bronchodilators are used “as needed” and last about 4 hours. The long-acting bronchodilators are used as maintenance treatment either once (last 24 hours) or twice (last 12 hours) a day . Possible side effects of beta-agonists are shakiness, rapid heart rate, and nervousness. Most individuals with COPD are able to breathe better using a beta-agonist bronchodilator and tolerate the medicine without a problem.

I suggest that you and/or your father discuss this with his doctor. If he/she is not comfortable prescribing a beta-agonist bronchodilator for your father, then I would consider having your father see a pulmonary specialist.

Best wishes,

Donald A. Mahler, M.D.