Indacaterol

Indacaterol is an ultra-long-acting beta-2 agonist with 24-hour duration and onset within 5 minutes. It is licensed for COPD only.

Classification. Ultra-long-acting beta-2 agonist.

Mechanism. Beta-2 agonism with prolonged receptor binding.

Pharmacokinetics. Steady state within 12 to 15 days. Metabolised by CYP3A4 and UGT1A1; faecal excretion.

First-line, COPD maintenance. 150 micrograms once daily by inhalation. Maximum 300 micrograms once daily. In some regions only 75 micrograms is licensed.

Fixed combination. Indacaterol with glycopyrronium 85/43 micrograms once daily.

Titration. Increase to 300 micrograms only when symptoms persist. No loading dose.

Asthma. Not licensed; do not use.

Contraindications. Hypersensitivity; asthma monotherapy.

Serious adverse effects. Arrhythmia, hypokalaemia, hyperglycaemia, paradoxical bronchospasm.

Common adverse effects. Cough after inhalation (often brief), nasopharyngitis, headache.

Interactions. Beta-blockers; hypokalaemic drugs; QT-prolonging drugs.

Common prescribing errors. Using in asthma. Using as relief.

Special groups.

• Pregnancy: avoid unless needed. Breastfeeding: no data.

• Older adults: no adjustment.

• Kidney impairment: no adjustment. Liver impairment: no adjustment in mild to moderate; not studied in severe.

• East Africa: capsules contain lactose.

Formulations. Dry powder capsule for inhalation only; never swallow.

Baseline. Spirometry, heart rate, potassium if risk factors.

Monitoring. Symptoms, exacerbations, spirometry.

Stop and reduce rules. Stop for arrhythmia. Therapeutic drug monitoring is not used.

Referral and escalation. Escalate to combination or triple therapy for persistent exacerbations.