Epinephrine Inhaler vs Albuterol: Asthma Drugs Compared

When you have a diagnosis of asthma, it can be challenging to understand the best way to control your symptoms. To prevent your asthma, it's essential to have an active relationship with a healthcare provider who can help you establish a treatment approach that keeps your asthma well-controlled over the long term and also provides a practical option for quick relief of escalating symptoms. Two quick-acting medications that can bronchodilate the airway include epinephrine and albuterol. However, when comparing an epinephrine inhaler vs albuterol inhaler, it's essential to note that these medications are not interchangeable. One of these medications is considered far superior to the other when it comes to the management of acute asthma exacerbation symptoms. Read on to learn more about the difference between albuterol and epinephrine, and why it matters for your health.

What is epinephrine?

Epinephrine is a medication that activates both beta-adrenergic receptors and alpha-adrenergic receptors throughout your body. These receptors typically involve changes in the body consistent with the sympathetic response, also known as the fight-or-flight response. As such, inhaling epinephrine can help relax the smooth muscle cells of your airway (think: if you encountered a large animal in the wild and had to either run away or defend yourself, you would need extra air delivery and oxygen). Other sympathetic changes that epinephrine can induce include increased heart rate and increased blood pressure. While these changes can be helpful in some scenarios—such as when a person is going into shock or cardiac arrest—they are not always beneficial in an asthma attack, particularly if you have a pre-existing or undiagnosed heart condition. The reason is that epinephrine can put undue stress on the heart muscle. You may see epinephrine listed as "racemic epinephrine" or "racemic epi." These lists refer to the molecular orientation of the molecules (racemic epinephrine has two mirror-image isomers, while standard epinephrine has just the active L-epinephrine isomer). Studies have shown that there is no actual difference in efficacy between these two forms of epinephrine when used therapeutically. However, racemic epinephrine tends to be more expensive than standard epinephrine.

What is albuterol?

Albuterol is a short-acting beta2-adrenergic receptor agonist (SABA) that is a powerful "bronchodilator." This means that it can reverse the constriction of the tubular structures in the respiratory tract, specifically the bronchioles, thereby making breathing easier. Albuterol can help open up the airway when you're having a flare of asthma or chronic obstructive pulmonary disease (COPD), with increased wheezing, shortness of breath, chest pain, or coughing. The brand names of Ventolin, Ventolin HFA, Proventil, or ProAir are also known as albuterol inhalers. In addition to the inhaler form, albuterol is available in powder, nebulized, or oral form. Along with its clinical use in asthma and COPD, it is also prescribed to help prevent exercise-induced bronchospasm. Compared to epinephrine, albuterol more specifically targets the lungs because the majority of beta2-adrenergic receptors are found on the smooth muscle cells of the bronchioles. When you inhale albuterol, it helps relax the smooth muscles of the airway, thereby dilating or opening up the tubular structures that facilitate air movement in and out of the lungs, making albuterol the gold standard "bronchodilating" medication when compared to epinephrine. You may have heard of a "rescue inhaler" or "rescue medication," and this typically refers to albuterol therapy.

Why take epinephrine inhaler vs albuterol for treating asthma symptoms?

So, which is better, an albuterol or an epinephrine inhaler, and why? If you are experiencing trouble breathing due to asthma symptoms such as wheezing, coughing, or shortness of breath, you need help opening up your airway quickly. Both epinephrine and albuterol are bronchodilating medications, meaning they can quickly reduce airway constriction during an asthma attack by dilating the tubular structures of the respiratory tract. This can get you breathing easier. However, albuterol is recommended over epinephrine when it comes to a "rescue medication" or rescue inhaler for asthma symptoms. In fact, many medical associations specifically state that epinephrine is not recommended as a first choice for a rescue inhaler, and it does not appear in any national asthma guidelines or protocols.

What is the difference between albuterol and epinephrine?

Albuterol vs epinephrine inhaler—what's the difference? Albuterol and epinephrine are both bronchodilating medications. The difference between albuterol and epinephrine has clinical significance. You can see the breakdown of these two medications below.

	Epinephrine	Albuterol
Medication class	Epinephrine is a sympathomimetic catecholamine, and it is a non-selective alpha and beta adrenergic receptor agonist	Albuterol is a short-acting beta2-adrenergic receptor agonist
Clinical utility	Used for temporary relief of mild intermittent asthma symptoms; also used for treatment of airway edema in croup. Other forms of epinephrine have utility outside the scope of this direct comparison.	Used for relief of symptoms of acute asthma exacerbations, ranging from mild to severe; also used to prevent exercise-induced bronchospasms
Incorporation into asthma treatment guidelines	Not recognized in national asthma treatment guidelines	Fully incorporated into national asthma treatment guidelines
Availability	Epinephrine is available over the counter in inhaler or nebulized form	Albuterol is available by prescription only in all forms
Formulation	Used therapeutically in inhaler form, nebulizer form, nasal spray form and intramuscular (IM) or intravenous (IV) form	Used therapeutically in inhaler form, nebulizer form, and oral form
Typical dose	1 to 2 puffs every 4 hours as needed (not to exceed 8 puffs in 24 hours)	1 to 2 puffs every 4 to 6 hours as needed (not to exceed 12 puffs in 24 hours)
Half-life of medication	6 hours	1 hour
Age recommendations	For use in adults and children 12 years or older	For use in adults and children 4 years or older

Is epinephrine the same as albuterol?

No, when considering epinephrine inhaler vs albuterol, or racemic epi vs albuterol, it's important to understand that these medications are not the same. Both medicines are bronchodilators, which means they can help open up the airway when you're having symptoms like wheezing or shortness of breath. Both medications accomplish this by stimulating the beta2-adrenergic receptors on the smooth muscles of bronchioles. However, the medicines belong to two different categories of medication. They are not the same because, in addition to stimulating beta2-adrenergic receptors (which are located mainly in the lungs and to a lesser degree in the heart and elsewhere throughout the body), epinephrine also stimulates beta1-adrenergic receptors, as well as alpha receptors. This can cause other widespread effects throughout the body, including increasing blood pressure and heart rate. While epinephrine can be useful in other clinical situations, it's not as beneficial in asthma, and it can even be dangerous because it causes too much cardiac stimulation.

Is epinephrine as good as albuterol?

Compared to albuterol, epinephrine is less effective in treating asthma symptoms. Epinephrine was used historically to help with asthma symptoms before the development of albuterol, so there is precedent for its use as a rescue medication. However, since the development of albuterol, research has shown albuterol to be superior to epinephrine for asthma symptoms and to have a longer duration of effect than epinephrine. Epinephrine also causes more significant side effects compared to albuterol, including a more profound increase in blood pressure and heart rate, which can put unneeded stress on the heart muscle. While albuterol is considered to be a better medication than epinephrine for the treatment of urgent asthma symptoms, it's essential to know that neither medication is preferred for the long-term treatment of asthma, as neither of these medications has an anti-inflammatory effect.

What side effects are common between epinephrine and albuterol?

When analyzing the side effects of albuterol vs epinephrine for asthma, there are some similarities. This is due to the fact that both epinephrine and albuterol stimulate beta2-adrenergic receptors. These side effects include:

• Increased heart rate
• Jitteriness or tremulousness
• Nervousness (more common in children aged 2 to 6 years old)
• Insomnia
• Headache
• Low potassium (this comes from the stimulation of beta2-adrenergic receptors on skeletal muscle cells)
• Paradoxical bronchospasm (this can be a life-threatening emergency)

What side effects are not common between albuterol and epinephrine?

To understand the differences in side effects between epinephrine inhalers and albuterol, it is helpful to remember that, in addition to stimulating beta2-adrenergic receptors, epinephrine also stimulates beta1-adrenergic and alpha-adrenergic receptors. This causes a more profound sympathomimetic, or fight or flight, type of reaction. Due to its effect on beta1-adrenergic and alpha-adrenergic receptors, epinephrine can induce more vasoconstriction, or narrowing of blood vessels. This can help increase blood pressure, but it can also put undue strain on the heart muscle. Epinephrine also tends to cause more profound tachycardia (fast heart rate) compared to albuterol. Other side effects may include dilated pupils (which can be problematic for patients with known angle-closure glaucoma) and sweating.

How successful is epinephrine in treating asthma?

Epinephrine in the inhaled form is only FDA indicated to treat mild intermittent asthma symptoms temporarily. While it can help with bronchodilation, or opening up the airways to allow the easier passage of air, it is not as effective or as long-lasting as albuterol. If you are considering racemic epinephrine vs albuterol for the treatment of asthma, albuterol is a superior treatment and should be preferentially used.

How successful is albuterol in treating asthma?

As a stand-alone medication, or monotherapy, albuterol can be very successful in treating symptoms of an asthma exacerbation. It is recognized in national asthma treatment guidelines for the relief of periodic asthma symptoms. However, if you are having to use your albuterol inhaler to manage asthma symptoms more than twice a week, seek help from a medical provider. While albuterol is highly effective in treating asthma symptoms on an as-needed basis, it is not intended for daily use in controlling asthma symptoms. If you are relying on a rescue inhaler to address more frequent asthma symptoms, additional medication classes may be needed for better long-term control.

Is epinephrine better than albuterol for asthma treatment?

Put simply, no; epinephrine is not better than albuterol for asthma treatment. Using an epinephrine vs an albuterol inhaler for asthma symptoms can result in suboptimal treatment. Epinephrine inhalers are available over the counter, which can help if you have a barrier that prevents you from accessing albuterol, such as when traveling and not having an inhaler with you, or when your inhaler has run out and you can't get an immediate refill. However, epinephrine is not meant to be a bridge therapy, and it is only FDA indicated for temporary treatment of mild intermittent asthma symptoms. In fact, the manufacturer's own instructions state that if your asthma is not improved within 20 minutes of using the medication, you need to see a doctor.

Albuterol vs epinephrine for asthma: Related FAQs

 

Albuterol vs epinephrine for anaphylaxis: Which is better?

When the clinical question is whether to use albuterol or epinephrine for anaphylaxis, the answer is epinephrine, hands down. Epinephrine, in an injectable form (available in a self-injecting kit known as an EpiPen), is far superior to albuterol during an anaphylactic reaction. However, when it comes to albuterol vs epinephrine inhaler for anaphylaxis, neither drug is appropriate. Inhaled epinephrine should not be used for an allergic reaction; injectable epinephrine or epinephrine nasal spray is the standard of care.

Is epinephrine a bronchodilator?

Yes, epinephrine is a bronchodilator medication. This means it dilates, or widens the diameter, of the tubular structures in the respiratory tract known as bronchioles. It does this by stimulating the beta2-adrenergic receptors found on the smooth muscle cells that control the dilation and constriction of the airways.

Is epinephrine over the counter?

Yes, you can get epinephrine over the counter in an inhaler or nebulizer form. You may find this under the brand name of Primatene Mist (inhaler) or AsthmaNefrin (nebulizer solution). However, even though these medications are available over the counter, it's essential to take asthma medication in coordination with a medical provider. Over-the-counter epinephrine for asthma symptoms is not considered to be the standard of care.

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References

https://news.drgator.ufl.edu/2014/05/08/over-the-counter-medicine-not-the-best-option-for-asthma/

https://reference.medscape.com/drug/primatene-mist-epinephrine-inhaled-1000309

https://www.pharmacytimes.com/view/a-primer-on-the-newlyapproved-otc-asthma-inhaler-

https://pmc.ncbi.nlm.nih.gov/articles/PMC7051476/

https://www.primatene.com/otc-asthma-medicine.aspx

https://reference.medscape.com/drug/proventil-hfa-ventolin-hfa-albuterol-343426

https://www.lung.org/media/press-releases/fda-approval-primatene

https://www.ncbi.nlm.nih.gov/books/NBK482160/

https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf

https://www.primatene.com/news-and-views/how-to-use.aspx