Salmeterol Xinafoate and Trientine Hydrochloride

• Generic Name: salmeterol
• Dosage Forms: n.a.
• Other Brand Names: Serevent Diskus, Serevent

Salmeterol is used only concomitantly with long-term asthma controller therapy (e.g., inhaled corticosteroids) for treatment of asthma and prevention of bronchospasm in patients with reversible obstructive airway disease, including symptoms of nocturnal asthma.

Monotherapy with long-acting β2-adrenergic agonists (e.g., salmeterol) increases the risk of asthma-related death and may increase risk of asthma-related hospitalization in children and adolescents. Use of salmeterol for treatment of asthma without concomitant use of long-term asthma controller therapy (e.g., inhaled corticosteroids) is contraindicated. (See Boxed Warning and also Asthma-related Death and Life-threatening Events under Cautions.)

Salmeterol is used only as additional therapy in patients with asthma currently receiving long-term asthma controller therapy (e.g., inhaled corticosteroids) but whose disease is inadequately controlled with such therapy.

Salmeterol in fixed combination with fluticasone is used only in patients with asthma not responding adequately to long-term asthma controller therapy (e.g., inhaled corticosteroids) or whose disease severity warrants initiation of treatment with both an inhaled corticosteroid and a long-acting β2-adrenergic agonist.

Once asthma control achieved and maintained, assess patient at regular intervals and step down therapy (e.g., discontinue salmeterol) if possible without loss of asthma control, and maintain patient on long-term asthma controller therapy (e.g., inhaled corticosteroids).

Salmeterol is not a substitute for corticosteroids; corticosteroid therapy should not be stopped or reduced in dosage when salmeterol is initiated. (See Concomitant Anti-inflammatory Therapy under Cautions.)

Do not use salmeterol alone or in fixed combination with fluticasone in patients with asthma adequately controlled on low or medium dosage of inhaled corticosteroids.

In children and adolescents with asthma requiring addition of a long-acting β2-adrenergic agonist to an inhaled corticosteroid, generally use a fixed-combination preparation containing both an inhaled corticosteroid and a long-acting β2-adrenergic agonist to ensure compliance with both drugs.

When separate administration of long-term asthma controller therapy (e.g., inhaled corticosteroids) and a long-acting β2-adrenergic agonist is clinically indicated, take appropriate steps to ensure compliance with both drugs. If compliance cannot be ensured, a fixed-combination preparation containing both an inhaled corticosteroid and a long-acting β2-adrenergic agonist is recommended.

Salmeterol alone or in fixed combination with fluticasone not indicated for relief of acute bronchospasm. (See Deterioration of Disease and Acute Episodes under Cautions.)

Prevention of exercise-induced bronchospasm.

Use as a single agent for prevention of exercise-induced bronchospasm may be clinically indicated in patients without persistent asthma.

Use for prevention of exercise-induced bronchospasm may be clinically indicated in patients with persistent asthma; however, treatment of asthma should include long-term asthma controller therapy (e.g., inhaled corticosteroids).

Long-term symptomatic treatment of reversible bronchospasm associated with moderate to severe COPD (e.g., FEV1 less than 80% of predicted), including chronic bronchitis and emphysema.

Fixed combination with fluticasone as the inhalation powder (Advair Diskus) is used for maintenance treatment of airflow obstruction in COPD, including chronic bronchitis and/or emphysema; also used to reduce COPD exacerbations in patients with a history of exacerbations.

Not indicated for relief of acute bronchospasm. Use a short-acting inhaled β2-agonist intermittently (as needed) for acute symptoms of COPD. (See Deterioration of Disease and Acute Episodes under Cautions.)

• Generic Name: trientine
• Dosage Forms: n.a.
• Other Brand Names: Syprine, Clovique

Used to promote excretion of copper in patients with Wilson disease (hepatolenticular degeneration) who are intolerant of penicillamine (designated an orphan drug by FDA for this use). Manufacturer states that trientine should be used when continued treatment with penicillamine is no longer possible (e.g., because of intolerable or life-threatening adverse effects).

American Association for the Study of Liver Diseases (AASLD) recommends a chelating agent (penicillamine or trientine) for initial therapy of symptomatic patients. Penicillamine traditionally used as the chelating agent of choice, but is associated with many adverse effects. Trientine may be better tolerated and should be considered in patients who cannot take penicillamine.

Disease manifestations, particularly neurologic symptoms, may worsen during initial therapy.

Once symptoms and laboratory abnormalities stabilize with initial chelating therapy (typically after 2–6 months, but potentially up to 5 years), patients may continue on a lower dosage of the chelating agent or switch to zinc for maintenance therapy.

Because substantial morbidity and mortality can be prevented by treating asymptomatic/presymptomatic patients, AASLD and other experts recommend that such patients also be treated with a chelating agent (generally at a lower dosage than that used in symptomatic patients) or zinc.

Treatment is lifelong unless a liver transplant is performed. Discontinuance of therapy may result in clinical decompensation and/or death.

Use in conjunction with low copper diet.

Not recommended in the treatment of cystinuria or rheumatoid arthritis due to lack of efficacy in these conditions.

Not indicated for treatment of biliary cirrhosis.