Vilanterol

Vilanterol is a once-daily long-acting beta-2 agonist available only in fixed combinations, with fluticasone furoate, with umeclidinium, or both.

Classification. Long-acting beta-2 agonist.

Mechanism. Selective beta-2 agonism with 24-hour effect.

Pharmacokinetics. CYP3A4 metabolism; faecal and urinary excretion.

First-line, COPD. Umeclidinium with vilanterol 55/22 micrograms once daily, or fluticasone furoate with vilanterol 92/22 micrograms once daily when exacerbations are frequent.

First-line, asthma. Fluticasone furoate with vilanterol 92/22 micrograms once daily; 184/22 micrograms for more severe disease in adults.

Specialist, triple therapy. Fluticasone furoate, umeclidinium and vilanterol 92/55/22 micrograms once daily.

Titration. Step up the corticosteroid strength if control fails. No loading dose.

Boxed-warning-level risk. Asthma-related death with LABA monotherapy; vilanterol is never given alone.

Contraindications. Hypersensitivity, including milk protein allergy.

Serious adverse effects. Arrhythmia, hypokalaemia, pneumonia in COPD, paradoxical bronchospasm.

Common adverse effects. Headache, nasopharyngitis, cough.

Interactions. Strong CYP3A4 inhibitors including ritonavir; beta-blockers; hypokalaemic drugs.

Common prescribing errors. Prescribing two LABA-containing inhalers together.

Special groups.

• Pregnancy: use if benefit outweighs risk. Breastfeeding: no data.

• Kidney impairment: no adjustment. Liver impairment: caution in moderate to severe disease.

Formulations. Multidose dry powder inhaler.

Technique. Rinse the mouth after use of products containing a corticosteroid.

Baseline. Spirometry, heart rate.

Monitoring. Exacerbations, symptoms, pneumonia signs.

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

Referral and escalation. Refer if exacerbations continue on triple therapy.