Subcutaneous terbutaline as an alternative to aerosolized albuterol

To the Editor:

In their well-written and comprehensive article regarding contingency planning for the COVID-19 epidemic, Shaker et al¹ discuss the treatment of exacerbation of asthma. During the COVID-19 epidemic, asthmatics will continue to have exacerbations, frequently requiring emergency care in a physician's office, an urgent care center, or an emergency department of a hospital.

It is recommended that asthmatics continue to be managed according to asthma guideline–based recommendations.² Nebulizer use is discouraged unless essential during this pandemic because nebulized therapy is more likely to aerosolize SARS-CoV-2 and increase the risk of contagion. As such, asthma therapy delivered by a metered dose inhaler would be more appropriate in the health care setting.³ Nevertheless, some patients are so tight that using a metered dose inhaler, even with a spacer, might be problematic, particularly if they have uncontrolled coughing, have severe life-threatening asthma, or are uncooperative or unable to follow the directions required for a metered dose inhaler with a spacer.

A recent report⁴ demonstrated in a prospective study that 85 patients treated with subcutaneous terbutaline significantly improved after already receiving multiple albuterol treatments with either nebulized aerosol or albuterol metered dose inhaler. Terbutaline is readily accessible and inexpensive to use. This drug would obviate the need to use a nebulizer, thus decreasing the chance of spreading SARS-CoV-2 during this evolving pandemic.