Atrial Fibrillation: Which Inhalers Are Safe?

Which Inhalers Are Safe For Atrial Fibrillation?   

Dear Dr. Mahler:

What are the safest COPD inhalers for someone with atrial fibrillation, who is on Eliquis? Thank You.

Ingrid from High Point, NC

Dear Ingrid:

As you know, atrial fibrillation is an irregular heart rhythm. The upper chambers of the heart (called atria) do not beat in synchrony with the lower chambers (called ventricles). As a result, there is a risk for blood clots to form in the heart. Eliquis is a medication used to reduce the risk of blood clots from forming.

Atrial fibrillation is a common heart disease in COPD

The curved arrows in the right and left atrium (upper chambers) in atrial fibrillation indicate chaotic electrical activity.

In those with atrial fibrillation, the heart rate may be normal or, in some people, may beat fast without any apparent reason.

There are two different classes of bronchodilators. These are called beta-agonists and muscarinic antagonists. In general, beta-agonist bronchodilators are more likely to cause the heart to beat faster than muscarinic antagonists. However, both classes are considered safe for those with COPD. In my practice, I use both classes of bronchodilators in those who have atrial fibrillation and COPD.

You did not mention whether you are using any inhaler(s) at the present time. Most likely, your health care professional has prescribed albuterol (brand names are ProAir, Proventil, and Ventolin) which is a short-acting beta-agonist medication. This is typically used as needed for shortness of breath.

Have you noticed any change in your heart rate or felt any palpitations after you inhale albuterol or a long-acting bronchodilator? If so, you should discuss this with your health care professional.

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.


Donald A. Mahler, M.D.

Can Albuterol Cause Weight Loss? I Use Albuterol in Nebulizer 3x/day Along with Ventolin As Needed

Can Albuterol Cause Weight Loss?

Dear Dr. Mahler:

I continue to lose weight. 9 lbs in 6 months, more before that.  No apparent explanation so I am on the hunt to try to figure it out. I can’t get an appt with an endocrinologist for 3 months.

Have you heard of people with COPD losing weight from taking a lot of albuterol or just from having diminished lung capacity?

I use Albuterol in the nebulizer 3x day plus several puffs of Ventolin during the day. Along with Albuterol I use Budesonide inhalation 2xday as prescribed. I tried all of the other newer “2 in 1” bronchodilators, but either they didn’t work or I had side effects.
I’d appreciate your thoughts.

Sidney from Tacoma, WA

Dear Sidney:

I have not come across your question in my practice previously. To provide an answer to your question – Can Albuterol Cause Weight Loss? – I first summarize information about beta receptors in the body. Second, I review how albuterol works. Third, I include information based on a search of the medical literature on PubMed.

Beta Receptors

There are three types of beta-receptors in the body that work in different ways. Beta1 receptors are located mainly in the heart. When stimulated with a medication, heart rate increases and the heart pumps more blood. Beta2 receptors are located in the breathing tubes and in the blood vessels (arteries) that provide  blood to muscles in the arms and legs. When stimulated with a medication, the muscle that wraps around the breathing tubes relaxes allowing more air to go in and out of the lungs.  This makes it easier to breathe. Beta3 receptors are located in the fat (adipose) tissue of the body. When stimulated, there is break down of fat tissue (called lipolysis).

Muscarinic Receptors

In addition to beta receptors, there are muscarinic receptors located in the breathing tubes that work in a different way to allow more air to go in and out of the lungs. It is common to prescribe both beta2 and muscarinic antagonists because they dilate the airways be different mechanisms and work better than only one type of bronchodilator.

Albuterol Sulfate

Albuterol is a short-acting beta2-agonist bronchodilator. What does this mean? Short-acting means that it lasts for 3 – 4 hours, and then wears off. Beta2 means that is attaches to beta2 receptors – located in the breathing tubes and arteries of skeletal muscle –  and has minimal effect on beta1 and beta3 receptors. Bronchodilator means that it relaxes the smooth muscle that wraps around the breathing tubes to open them and make it easier for air to move in and out.

Smooth muscle wraps around the outside of the breathing tubes. This address Can Albuterol Cause Weight loss

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

In general, albuterol is used mainly as needed. This means either as rescue for sudden breathing attacks OR before doing an activity that is expected to cause some breathing difficulty. For maintenance therapy, long-acting bronchodilators are used to treat those with COPD because they keep the breathing tubes open from 12 – 24 hours. I assume that you were tried on long-acting bronchodilator medications and either they did not work for you, or you had side effects.

Can Albuterol Cause Weight Loss?

There is not a lot of medical information to answer your question completely. There is one study published in 1993 in the journal Thorax (Amoroso is first author) which showed a slight increase in metabolism in 10 healthy adults with four puffs of albuterol compared to a placebo over an hour.

A review of side effects of albuterol in listed the following side effects: 16 MAJOR side effects with shakiness and trembling as More Common, fast, irregular, pounding heart rate as Less Common, and 13 different reactions as Rare, none of which was weight loss. There were 11 MINOR side effects listed, again none of which included weight loss.

My Comments

Based on this information and my experience, I consider it very unlikely that your frequent use of albuterol in the nebulizer and by inhaler are causing your weight loss. Ideally, you would try using long-acting bronchodilators so that you would not need to use so much albuterol to breathe.

To know for sure about your concern, you would need to reduce albuterol use markedly. Obviously, that would require you to use long-acting bronchodilators to replace short-acting albuterol.

Finally, I support your effort to look for another reason for weight loss. I would start with your primary care provider, and then with an endocrinologist as you are planning.

Best wishes in finding an answer.

Donald A. Mahler, M.D.

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.


Is A Powder Inhaler or Spray Inhaler Better?

Powder Inhaler Versus Spray Inhaler: Is One Better For Breathing?

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.