Drug class: Selective beta-2-Adrenergic Agonists

Medically reviewed by Drugs.com on Jun 10, 2024. Written by ASHP.

Introduction

Bronchodilator; relatively selective, short-acting β₂-adrenergic agonist.

Uses for Terbutaline

Bronchospasm in Asthma

Symptomatic management or prevention of bronchospasm in patients with reversible, obstructive airway disease (e.g., asthma).

The Global Initiative for Asthma (GINA) guidelines provide evidence-based recommendations for the management of asthma. A stepwise approach to treatment is recommended where specific drugs are added or adjusted through a series of steps (1 through 5) to achieve symptom control while keeping the patient on the lowest effective treatment.

The GINA guidelines state that IV terbutaline^{† [off-label]} (administered as an initial IV bolus dose followed by continuous IV infusion) may be used as an alternative to inhaled short-acting β₂-adrenergic agonist for the initial emergency department management of asthma exacerbations in children ≤5 years of age^{† [off-label]}.

Some experts have suggested use of oral β₂-adrenergic agonist therapy principally in patients unable to use inhaled bronchodilators (e.g., young children). However, oral administration is associated with slower onset of action and increased incidence of adverse effects.

Sub-Q terbutaline reserved for prehospital management of severe asthma exacerbations when inhaled β₂-selective agents are not readily available. Sub-Q terbutaline not used routinely for treatment of severe exacerbations of asthma in hospitalized patients.

Bronchospasm in COPD

Symptomatic management of reversible bronchospasm associated with chronic bronchitis and emphysema.

Role of oral β₂-adrenergic agonists in treatment of COPD limited.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) publishes an annual guideline on the comprehensive management of COPD. Terbutaline is not mentioned in the most recent (2023) guidelines.

Preterm Labor

Has been used for acute IV^{† [off-label]} or sub-Q therapy in selected women to inhibit uterine contractions in preterm labor^{† [off-label]} (tocolysis) and prolong gestation when beneficial.

Manufacturers and FDA warn that injection is not FDA labeled for and is contraindicated for prolonged tocolysis (beyond 48–72 hours), because of the potential for serious maternal cardiac effects and death. (See Preterm Labor under Cautions.)

Manufacturers and FDA also warn that oral tablets are not FDA labeled for and are contraindicated for acute or maintenance tocolysis, because efficacy not proven and safety concerns similar to injection. (See Preterm Labor under Cautions.)

Do not use terbutaline sulfate (injection or oral tablets) for maintenance tocolysis, particularly in the outpatient or home setting. (See Preterm Labor under Cautions.)

However, available data suggest that acute β-adrenergic agonist treatment may forestall labor for 48 hours, providing time for patients to be transferred to other (e.g., tertiary-care) facilities and/or receive corticosteroids to increase fetal lung maturation. Any other potential benefits of such drugs in prolonging pregnancy are unclear.

ACOG states that because of conflicting results, there is no clear first-line tocolytic agent.

Related/similar drugs

Dupixent, albuterol, methylprednisolone, dexamethasone, Symbicort, Breo Ellipta, Ventolin

Terbutaline Dosage and Administration

Administration

Administer orally or sub-Q.

Has been administered IV^{† [off-label]} to inhibit uterine contractions in preterm labor^† (tocolysis). Administration of sub-Q injection preparation by other routes (e.g., IV) or methods not recommended by manufacturer. (See Preterm Labor under Cautions.)

Oral Administration

Administer orally 3 times daily during waking hours, at approximately 6-hour intervals.

Sub-Q Administration

Inject into lateral deltoid area.

IV Administration†

Standardize 4 Safety

Standardized concentrations for IV terbutaline have been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. Because recommendations from the S4S panels may differ from the manufacturer’s prescribing information, caution is advised when using concentrations that differ from labeling, particularly when using rate information from the label. For additional information on S4S (including updates that may be available), see [Web].

dosing units differ from concentration units

Dosage

Available as terbutaline sulfate; dosage expressed in terms of sulfate salt.

Pediatric Patients

Bronchospasm

Asthma

Oral

Children or adolescents 12–15 years of age: 2.5 mg 3 times daily. Do not exceed total dosage of 7.5 mg within a 24-hour period.

Sub-Q

Hospitalized children ≤12 years of age^† with acute asthma exacerbation: 0.01 mg/kg has been given every 20 minutes for a total of 3 doses, then every 2–6 hours as needed.

Children or adolescents ≥12 years of age: 0.25 mg recommended by manufacturer. Repeat dose (0.25 mg) if substantial clinical improvement does not occur within 15–30 minutes. If no response within another 15–30 minutes, consider other therapeutic measures. Manufacturer states total dosage should not exceed 0.5 mg within a 4-hour period.

Hospitalized children or adolescents >12 years of age with asthma exacerbation: 0.25 mg every 20 minutes for a total of 3 doses suggested by some clinicians.

IV

For initial emergency department management of asthma exacerbations in children ≤5 years of age^†, terbutaline has been given as an IV bolus dose of 2 mcg/kg over 5 minutes, followed by continuous IV infusion^† of 5 mcg/kg/hour. Closely monitor the child and adjust dosage according to response.

Adults

Bronchospasm

Asthma

Oral

5 mg 3 times daily, given approximately every 6 hours during waking hours. If disturbing adverse effects occur, reduce dosage to 2.5 mg 3 times daily. Do not exceed total dosage of 15 mg within a 24-hour period.

Sub-Q

0.25 mg recommended by manufacturer. Repeat dose (0.25 mg) if substantial clinical improvement does not occur within 15–30 minutes. If no response within another 15–30 minutes, consider other therapeutic measures. Manufacturer states total dosage should not exceed 0.5 mg within a 4-hour period.

Hospitalized adults with asthma exacerbation: 0.25 mg every 20 minutes for a total of 3 doses suggested by some clinicians.

COPD

Oral

5 mg 3 times daily, given approximately every 6 hours during waking hours. If disturbing adverse effects occur, reduce dosage to 2.5 mg 3 times daily. Do not exceed total dosage of 15 mg within a 24-hour period.

Sub-Q

0.25 mg recommended by manufacturer. Repeat dose (0.25 mg) if substantial clinical improvement does not occur within 15–30 minutes. If no response within another 15–30 minutes, consider other therapeutic measures. Manufacturer states total dosage should not exceed 0.5 mg within a 4-hour period.

Preterm Labor†

IV†

Carefully adjust rate and duration of infusion according to patient’s response as indicated by uterine response, maternal BP, and maternal and fetal heart rates.

For acute tocolytic therapy, has been initiated at a dosage of 2.5–20 mcg/minute. Dosage may be increased gradually as tolerated at 10- to 20-minute intervals until desired effects achieved. Effective maximum dosages have ranged from 17.5–30 mcg/minute, although higher maximum dosages (e.g., 70–80 mcg/minute) used cautiously in some patients.

Injection is contraindicated for prolonged tocolysis (beyond 48–72 hours). (See Preterm Labor under Cautions and Preterm Labor under Uses.)

Sub-Q

0.25 mg every 0.3–3 hours has been recommended.

Temporarily discontinue if pulse rate is >120 bpm.

Injection is contraindicated for prolonged tocolysis^† (beyond 48–72 hours). (See Preterm Labor under Cautions and Preterm Labor under Uses.)

Prescribing Limits

Pediatric Patients

Bronchospasm

Asthma

Oral

Children 12–15 years of age: Maximum 7.5 mg within a 24-hour period.

Sub-Q

Children ≥12 years of age: Maximum: 0.5 mg within a 4-hour period.

Adults

Bronchospasm

Asthma

Oral

Maximum 15 mg within a 24-hour period.

Sub-Q

Maximum 0.5 mg within a 4-hour period.

COPD

Oral

Maximum 15 mg within a 24-hour period.

Sub-Q

Maximum 0.5 mg within a 4-hour period.

Preterm Labor†

IV^†

Effective maximum dosages have ranged from 17.5–30 mcg/minute; higher maximum dosages (e.g., 70–80 mcg/minute) used cautiously in some patients.

Injection is contraindicated for prolonged tocolysis (beyond 48–72 hours). (See Preterm Labor under Cautions and Preterm Labor under Uses.)

Sub-Q

Injection is contraindicated for prolonged tocolysis (beyond 48–72 hours). (See Preterm Labor under Cautions and Preterm Labor under Uses.)

Special Populations

Geriatric Patients

Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and potential for concomitant disease and drug therapy.

Cautions for Terbutaline

Contraindications

• Injection: Prolonged tocolysis^† (beyond 48–72 hours); do not use for maintenance tocolysis, particularly in the outpatient or home setting. (See Preterm Labor under Cautions and Preterm Labor under Uses.)

• Oral: Acute or maintenance tocolysis; do not use for maintenance tocolysis^†, particularly in the outpatient or home setting. (See Preterm Labor under Cautions and Preterm Labor under Uses.)

• Known hypersensitivity to sympathomimetic agents or any ingredient in formulation.

Warnings/Precautions

Warnings

Preterm Labor

Serious and sometimes fatal adverse effects, including increased heart rate, transient hyperglycemia, hypokalemia, cardiac arrhythmias, pulmonary edema, and myocardial ischemia, reported after administration in pregnant women. Increased fetal heart rate and neonatal hypoglycemia also may occur following maternal administration.

FDA has received postmarketing reports of maternal death and serious cardiovascular events associated with obstetric use. FDA has concluded that risk of serious adverse events outweighs any potential benefit to pregnant women receiving prolonged tocolysis with terbutaline injection (beyond 48–72 hours) or receiving acute or prolonged tocolysis with oral terbutaline.

Injection is not FDA labeled for and is contraindicated for prolonged tocolysis (beyond 48–72 hours). Oral tablets are not FDA labeled for and are contraindicated for acute or maintenance tocolysis. Do not use terbutaline sulfate (injection or oral tablets) for maintenance tocolysis, particularly in the outpatient or home setting. (See Preterm Labor under Uses.)

Report adverse events involving terbutaline to the FDA MedWatch program.

Acute or Worsening Asthma

Failure to respond to a previously effective dosage of terbutaline may indicate seriously worsening asthma. Reevaluate asthma therapy, giving special consideration to possible need for anti-inflammatory treatment (e.g., corticosteroids). Use of β-adrenergic agents alone not adequate to control mild to severe persistent asthma symptoms.

Cardiovascular Effects

Possible clinically important cardiovascular effects, including changes in BP, heart rate, and ECG (e.g., flattening of the T wave, prolongation of the QT_c interval, ST-segment depression).

Cautious use recommended in patients with cardiovascular disorders, including ischemic heart disease, coronary insufficiency, cardiac arrhythmias, and hypertension. May require drug discontinuance.

Nervous System Effects

Possible CNS stimulation (e.g., nervousness, tremor). Seizures reported rarely; did not recur following drug discontinuance.

Cautious use recommended in patients with seizure disorders and those unusually responsive to sympathomimetic amines

Sensitivity Reactions

Immediate hypersensitivity reactions and exacerbations of bronchospasm reported.

General Precautions

Endocrine and Metabolic Effects

Large IV^† doses may aggravate preexisting diabetes and ketoacidosis.

Use with caution in patients with diabetes mellitus or hyperthyroidism.

Possible hypokalemia; may increase risk of cardiovascular effects. Hypokalemia usually transient, not requiring supplementation.

Specific Populations

Pregnancy

Category C. Restrict use for relief of bronchospasm during labor to women in whom benefits clearly outweigh risks. (See Preterm Labor under Cautions.)

Lactation

Distributed into milk, but in amounts generally considered insufficient to affect nursing infants. Administer to nursing women only if potential benefits to woman outweigh possible risk to infant.

Pediatric Use

Safety and efficacy not established in children <12 years of age.

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults. (See Geriatric Patients under Dosage and Administration.)

Common Adverse Effects

Oral: Nervousness, tremor, headache, somnolence, palpitations, dizziness, tachycardia, nausea.

Sub-Q: Nervousness, drowsiness, tremor, headache, palpitations.

Drug Interactions

Specific Drugs

Terbutaline Pharmacokinetics

Absorption

Bioavailability

Oral: About 30-50%.

Sub-Q: Well absorbed.

Onset

Sub-Q: Measurable changes in expiratory flow rate occur within 5 minutes. Clinically important increases in FEV₁ occur within 15 minutes. Maximum effects occur within 30–60 minutes.

Oral: Measurable changes in pulmonary flow rate usually occur within 30 minutes. Substantial clinical improvement in pulmonary function occurs within 1–2 hours. Maximum effects occur within 2–3 hours.

Duration

Sub-Q: Clinically important bronchodilator activity may continue for 1.5–4 hours. Duration of clinical improvement similar to equivalent doses (mg for mg) of epinephrine.

Oral: Clinically important decreases in airway and pulmonary resistance may persist for ≥4 hours.

Distribution

Extent

Crosses placenta and distributes into milk. (See Preterm Labor under Cautions.)

Elimination

Metabolism

Partially metabolized in liver, principally to inactive sulfate conjugate.

Elimination Route

Following sub-Q administration, excreted principally as unchanged drug (60%) in urine.

Half-life

Sub-Q administration: Mean 5.7 hours.

Oral single-dose administration in patients with asthma: Approximately 3.4 hours.

Stability

Storage

Oral

Tablets

Tight, light-resistant containers at 15–30°C.

Parenteral

Solution for Injection

20–25°C. Protect from light by storing in original carton until use.

Actions

• Stimulates β-adrenergic receptors of sympathetic nervous system with little or no effect on α-adrenergic receptors.

• Less selective than relatively selective β₂-agonists (e.g., albuterol).

• No apparent preferential β₂-adrenergic effect following sub-Q administration in controlled clinical studies.

• Stimulates the production of cyclic adenosine-3′,5′-monophosphate (cAMP), which mediates numerous cellular responses, including bronchial smooth muscle relaxation and inhibition of release of mediators from mast cells in airways.

• Decreases resistance of airways.

• Relaxes uterine smooth muscle and inhibits uterine contractions.

Advice to Patients

• Importance of understanding proper storage and administration techniques.

• Importance of adherence to dosing schedules, including not exceeding the recommended dose or frequency of use unless otherwise instructed by clinician.

• If decreased effectiveness occurs and/or symptoms become worse, contact clinician immediately; do not increase dose or frequency of administration.

• Importance of using inhaled or other anti-asthma agents only as directed by clinician.

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.

• Importance of informing patients that serious adverse effects (e.g., maternal cardiac effects, death) reported after prolonged use to manage preterm labor^†. Importance of informing patients of serious situations where short-term use of the injection in the hospital setting may benefit a pregnant woman.

• Importance of informing patients that oral tablets should not be used either to treat preterm labor^† or prevent recurrent preterm labor^†.

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription (e.g., inhaled drugs, other antiasthma agents) and OTC drugs, as well as any concomitant illnesses.

• Importance of informing patients of other important precautionary information. (See Cautions.)

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

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