Medically reviewed on Sep 10, 2018
(sal ME te role)
- Salmeterol Xinafoate
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Aerosol Powder Breath Activated, Inhalation:
Serevent Diskus: 50 mcg/dose (28 ea, 60 ea) [contains lactose]
Brand Names: U.S.
- Serevent Diskus
- Beta2 Agonist
- Beta2-Adrenergic Agonist, Long-Acting
Relaxes bronchial smooth muscle by selective action on beta2-receptors with little effect on heart rate; salmeterol acts locally in the lung.
Systemic: Inhalation: Undetectable to poor
Hepatic; hydroxylated via CYP3A4
Feces (60%); urine (25%)
Onset of Action
Asthma: 30-48 minutes, COPD: 2 hours; Peak effect: Asthma: 3 hours, COPD: 2-5 hours
Time to Peak
Serum: ~20 minutes
Duration of Action
Special Populations: Hepatic Function Impairment
May lead to accumulation of salmeterol in plasma.
Use: Labeled Indications
Asthma/Bronchospasm: Treatment of asthma and the prevention of bronchospasm (only as concomitant therapy with a long-term asthma control medication, such as an inhaled corticosteroid), in patients 4 years and older with reversible obstructive airway disease, including patients with symptoms of nocturnal asthma.
Chronic obstructive pulmonary disease: Maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD) (including emphysema and chronic bronchitis).
Exercise-induced bronchospasm: Prevention of exercise-induced bronchospasm (EIB) in patients 4 years and older (monotherapy may be indicated in patients without persistent asthma).
Limitations of use: Salmeterol is not indicated for the relief of acute bronchospasm.
Hypersensitivity to salmeterol or any component of the formulation (milk proteins); monotherapy in the treatment of asthma (ie, use without a concomitant long-term asthma control medication, such as an inhaled corticosteroid); treatment of status asthmaticus or other acute episodes of asthma or COPD
Canadian labeling: Additional contraindications (not in U.S. labeling): Presence of tachyarrhythmias
Documentation of allergenic cross-reactivity for sympathomimetics is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.
Note: Do not use for the relief of acute bronchospasm.
Asthma/Bronchospasm (maintenance and prevention): Inhalation: One inhalation twice daily (~12 hours apart); maximum: 1 inhalation twice daily. Note: For asthma control, long acting beta2-agonists (LABAs) should be used in combination with inhaled corticosteroids and not as monotherapy.
COPD (maintenance): Inhalation: One inhalation twice daily (~12 hours apart); maximum: 1 inhalation twice daily
Exercise-induced bronchospasm (prevention): Inhalation: One inhalation at least 30 minutes prior to exercise; additional doses should not be used for 12 hours; should not be used in individuals already receiving salmeterol twice daily. Note: Because LABAs may disguise poorly controlled persistent asthma, frequent or chronic use of LABAs for exercise-induced bronchospasm is discouraged by the Asthma Guidelines (NAEPP, 2007).
Refer to adult dosing.
Note: Do not use for the relief of acute bronchospasm.
Asthma/Bronchospasm (maintenance/prevention) and exercise-induced bronchospasm (prevention): Inhalation: Children ≥4 years and Adolescents: Refer to adult dosing.
Dosing: Renal Impairment
There are no dosage adjustments provided in the manufacturer’s labeling.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied). Use with caution.
For oral inhalation route only. Before inhaling the dose, breath out fully; do not exhale into the Diskus device; activate and use only in a level, horizontal position. Inhale quickly and deeply through the Diskus; hold breath for about 10 seconds or for as long as comfortable and exhale slowly. Do not use with a spacer device or wash mouthpiece; Diskus should be kept dry. Discard device 6 weeks after removal from foil pouch or when the dose counter reads "0" (whichever comes first).
Some products may contain lactose; very rare anaphylactic reactions have been reported in patients with severe milk protein allergy.
Store at 20°C and 25°C (68°F and 77°F); excursions are permitted between 15°C and 30°C (59°F and 86°F). Protect from direct heat or sunlight. Store Diskus in the unopened foil pouch and only open when ready for use; stable for 6 weeks after removal from foil pouch.
Aprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
AtoMOXetine: May enhance the tachycardic effect of Beta2-Agonists. Monitor therapy
AtoMOXetine: May enhance the hypertensive effect of Sympathomimetics. AtoMOXetine may enhance the tachycardic effect of Sympathomimetics. Monitor therapy
Atosiban: Beta2-Agonists may enhance the adverse/toxic effect of Atosiban. Specifically, there may be an increased risk for pulmonary edema and/or dyspnea. Monitor therapy
Beta2-Agonists (Long-Acting): May enhance the adverse/toxic effect of other Beta2-Agonists (Long-Acting). Avoid combination
Beta-Blockers (Beta1 Selective): May diminish the bronchodilatory effect of Beta2-Agonists. Of particular concern with nonselective beta-blockers or higher doses of the beta1 selective beta-blockers. Monitor therapy
Beta-Blockers (Nonselective): May diminish the bronchodilatory effect of Beta2-Agonists. Avoid combination
Betahistine: May diminish the therapeutic effect of Beta2-Agonists. Monitor therapy
Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Exceptions: Cannabidiol. Monitor therapy
Ceritinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of ceritinib with a narrow therapeutic index CYP3A substrate (eg, alfentanil, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus) should be avoided when possible. Monitor therapy
Cocaine (Topical): May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Consider therapy modification
Conivaptan: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination
CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
CYP3A4 Inhibitors (Moderate): May increase the serum concentration of Salmeterol. Exceptions: Grapefruit Juice. Monitor therapy
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Salmeterol. Avoid combination
Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Monitor therapy
Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Fosnetupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination
Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Monitor therapy
Idelalisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination
Linezolid: May enhance the hypertensive effect of Sympathomimetics. Management: Reduce initial doses of sympathomimetic agents, and closely monitor for enhanced pressor response, in patients receiving linezolid. Specific dose adjustment recommendations are not presently available. Consider therapy modification
Loop Diuretics: Beta2-Agonists may enhance the hypokalemic effect of Loop Diuretics. Monitor therapy
Loxapine: Agents to Treat Airway Disease may enhance the adverse/toxic effect of Loxapine. More specifically, the use of Agents to Treat Airway Disease is likely a marker of patients who are likely at a greater risk for experiencing significant bronchospasm from use of inhaled loxapine. Management: This is specific to the Adasuve brand of loxapine, which is an inhaled formulation. This does not apply to non-inhaled formulations of loxapine. Avoid combination
Monoamine Oxidase Inhibitors: May enhance the adverse/toxic effect of Beta2-Agonists. Monitor therapy
Netupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Palbociclib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
QTc-Prolonging Agents (Highest Risk): QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying) may enhance the QTc-prolonging effect of QTc-Prolonging Agents (Highest Risk). Management: Avoid such combinations when possible. Use should be accompanied by close monitoring for evidence of QT prolongation or other alterations of cardiac rhythm. Consider therapy modification
QTc-Prolonging Agents (Moderate Risk): QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying) may enhance the QTc-prolonging effect of QTc-Prolonging Agents (Moderate Risk). Monitor therapy
Simeprevir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Stiripentol: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification
Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Monitor therapy
Tedizolid: May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics. Monitor therapy
Telaprevir: May increase the serum concentration of Salmeterol. Avoid combination
Thiazide and Thiazide-Like Diuretics: Beta2-Agonists may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Monitor therapy
Tipranavir: May increase the serum concentration of Salmeterol. Avoid combination
Tricyclic Antidepressants: May enhance the adverse/toxic effect of Beta2-Agonists. Monitor therapy
>10%: Central nervous system: Headache (13% to 17%), pain (1% to 12%)
1% to 10%:
Cardiovascular: Hypertension (4%), edema (1% to 3%)
Central nervous system: Dizziness (4%), sleep disorder (1% to 3%), anxiety (1% to 3%), migraine (1% to 3%), paresthesia (1% to 3%)
Dermatologic: Skin rash (1% to 4%), contact dermatitis (1% to 3%), eczema (1% to 3%), urticaria (3%), photodermatitis (1% to 2%), pallor
Endocrine & metabolic: Hyperglycemia (1% to 3%)
Gastrointestinal: Dyspepsia (1% to 3%), gastrointestinal infection (1% to 3%), nausea (1% to 3%), oropharyngeal candidiasis (1% to 3%), toothache (1% to 3%), xerostomia (1% to 3%)
Hepatic: Increased liver enzymes
Infection: Influenza (5%)
Neuromuscular & skeletal: Muscle cramps (≤3%), muscle spasm (≤3%), arthritis (1% to 3%), arthralgia (1% to 3%), muscle rigidity (1% to 3%)
Ophthalmic: Conjunctivitis (≤3%), keratitis (≤3%)
Respiratory: Nasal congestion (4% to 9%), bronchitis (≤7%), throat irritation (7%), tracheitis (≤7%; may be paradoxical), pharyngitis (≤6%), cough (5%), viral respiratory tract infection (5%), sinusitis (4% to 5%), rhinitis (4% to 5%), asthma (3% to 4%)
Miscellaneous: Fever (1% to 3%)
<1%, postmarketing, and/or case reports: Abdominal pain, agitation, aggressive behavior, anaphylaxis (some in patients with severe milk allergy), angioedema, aphonia, atrial fibrillation, bruise, cardiac arrhythmia, cataract, chest congestion, chest tightness, choking sensation, eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss), Cushing’s syndrome, Cushingoid appearance, decreased linear skeletal growth rate (children and adolescents), depression, dysmenorrhea, dyspnea, ecchymoses, edema (facial, oropharyngeal), eosinophilia, glaucoma, hypercorticoidism, hypersensitivity reaction (immediate and delayed), hypokalemia, hypothyroidism, increased intraocular pressure, irregular menses, laryngospasm, local irritation (larynx), myositis, oropharyngeal irritation, osteoporosis, otalgia, paradoxical bronchospasm, pelvic inflammatory disease, prolonged Q-T interval on ECG, restlessness, sinus pain (paranasal), stridor, supraventricular tachycardia, syncope, tremor, vaginitis, vulvovaginal candidiasis, vulvovaginitis, ventricular tachycardia, weight gain
Concerns related to adverse effects:
• Appropriate use: Do not exceed recommended dose; serious adverse events, including fatalities, have been associated with excessive use of inhaled sympathomimetics.
• Asthma-related deaths: [US Boxed Warning]: Long-acting beta2-agonists (LABAs) increase the risk of asthma-related deaths. Salmeterol should only be used in asthma patients as adjuvant therapy in patients who are currently receiving but are not adequately controlled on a long-term asthma control medication (ie, an inhaled corticosteroid). Monotherapy with an LABA is contraindicated in the treatment of asthma. In a large, randomized, placebo-controlled US clinical trial (SMART 2006), salmeterol was associated with an increase in asthma-related deaths (when added to usual asthma therapy); risk is considered a class effect among all LABAs. Data are not available to determine if the addition of an inhaled corticosteroid lessens this increased risk of death associated with LABA use; however, current guidelines recommend the use of an inhaled corticosteroid before adding a LABA (GINA 2015; NIH/NHLBI 2007). Assess patients at regular intervals once asthma control is maintained on combination therapy to determine if step-down therapy is appropriate and the LABA can be discontinued (without loss of asthma control), and the patient can be maintained on an inhaled corticosteroid. LABAs are not appropriate in patients whose asthma is adequately controlled on low- or medium-dose inhaled corticosteroids. In a more recent multicenter, randomized, double-blinded trial, the use of salmeterol and an inhaled corticosteroid (ie, fluticasone) combined in a single inhaler in a large number of children, adolescent, and adult patients with persistent asthma (non-life threatening and stable) did not increase the risk of serious asthma-related events compared with fluticasone alone; in addition, patients receiving fluticasone/salmeterol had fewer severe asthma exacerbations compared with patients receiving fluticasone alone (Peters 2016; Stempel 2016a; Stempel 2016b).
• Bronchospasm: Rarely, paradoxical bronchospasm, which may be life threatening, may occur with use of inhaled bronchodilating agents; this should be distinguished from inadequate response.
• Hypersensitivity reactions: Immediate hypersensitivity reactions (urticaria, angioedema, rash, bronchospasm, hypotension), including anaphylaxis, have been reported.
• Upper airway symptoms: There have been reports of laryngeal spasm, irritation, swelling (stridor, choking) with use.
• Asthma: Appropriate use: Do not use for acute bronchospasm. Short-acting beta2-agonist (eg, albuterol) should be used for acute symptoms and symptoms occurring between treatments. Do not initiate in patients with significantly worsening or acutely deteriorating asthma; reports of severe (sometimes fatal) respiratory events have been reported when salmeterol has been initiated in this situation. Corticosteroids should not be stopped or reduced when salmeterol is initiated. During initiation, watch for signs of worsening asthma.
• Cardiovascular disease: Use with caution in patients with cardiovascular disease (arrhythmia, coronary insufficiency, or hypertension); beta-agonists may cause elevation in blood pressure, heart rate and result in CNS stimulation/excitation. Beta2-agonists may also increase risk of arrhythmias and electrocardiogram (ECG) changes, such as flattening of the T wave, prolongation of the QTc interval, and ST segment depression.
• COPD: Appropriate use: Do not use for acute episodes of COPD. Do not initiate in patients with significantly worsening or acutely deteriorating COPD. Data are not available to determine if LABA use increases the risk of death in patients with COPD. Canadian labeling suggest concurrent use of oral or inhaled corticosteroids may not be necessary in COPD because the role of inhaled corticosteroids is less well established; concurrent use should be determined by the treating physician.
• Diabetes: Use with caution in patients with diabetes mellitus; beta2-agonists may increase serum glucose and aggravate ketoacidosis.
• Exercise-induced bronchospasm: Because LABAs may disguise poorly controlled persistent asthma, frequent or chronic use of LABAs for exercise-induced bronchospasm is discouraged by the NIH Asthma Guidelines (NIH, 2007).
• Hepatic impairment: Use with caution in patients with hepatic impairment. Salmeterol is predominantly cleared by hepatic metabolism, impairment of liver function may lead to accumulation of salmeterol in plasma.
• Hyperthyroidism: Use with caution in hyperthyroidism; may stimulate thyroid activity.
• Hypokalemia: Use with caution in patients with hypokalemia; beta2-agonists may decrease serum potassium, possibly through intracellular shunting. This effect is usually transient.
• Seizures: Use with caution in patients with seizure disorders; beta-agonists may result in CNS stimulation/excitation.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Pediatric: [US Boxed Warning]: LABAs may increase the risk of asthma-related hospitalization in pediatric and adolescent patients. In general, a combination product containing a LABA and an inhaled corticosteroid is preferred in patients <18 years of age to ensure compliance.
Dosage form specific issues:
• Lactose: Powder for oral inhalation contains lactose; very rare anaphylactic reactions have been reported in patients with severe milk protein allergy.
• Patient information: Patients must be instructed to use inhaled short-acting beta2-agonists (eg, albuterol) for acute asthmatic or COPD symptoms and to seek medical attention in cases where acute symptoms are not relieved or a previous level of response is diminished. The need to increase frequency of use of inhaled short-acting beta2-agonist may indicate deterioration of asthma, and medical evaluation must not be delayed. Salmeterol should not be used more than twice daily; do not use with other long-acting beta2-agonists.
FEV1, peak flow, and/or other pulmonary function tests; blood pressure, heart rate; CNS stimulation; serum glucose, serum potassium. Monitor for increased use of short-acting beta2-agonist inhalers; may be marker of a deteriorating asthma condition.
Pregnancy Risk Factor
Adverse events were observed in some animal reproduction studies. Beta-agonists have the potential to affect uterine contractility if administered during labor.
Uncontrolled asthma is associated with adverse events on pregnancy (increased risk of perinatal mortality, pre-eclampsia, preterm birth, low birth weight infants). Although data related to its use in pregnancy is limited, salmeterol may be used when a long-acting beta agonist is needed to treat moderate persistent or severe persistent asthma in pregnant women (NAEPP, 2005).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience rhinitis, pharyngitis, or rhinorrhea. Have patient report immediately to prescriber signs of high blood sugar (confusion, fatigue, increased thirst, increased hunger, polyuria, flushing, fast breathing, or breath that smells like fruit), signs of low potassium (muscle pain or weakness, muscle cramps, or an abnormal heartbeat), angina, tachycardia, abnormal heartbeat, severe anxiety, severe headache, seizures, passing out, severe nausea, vomiting, severe loss of strength and energy, insomnia, severe dizziness, tremors, difficulty breathing, wheezing, or severe cough (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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- Drug class: adrenergic bronchodilators
Other brands: Serevent Diskus