Serevent

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Serevent on Prescriptsy

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Serevent is the brand name for salmeterol, a long-acting beta2-agonist (LABA) bronchodilator manufactured by GlaxoSmithKline (GSK).

It is used for the regular maintenance treatment of asthma in adults and children aged 4 and over (always in combination with an inhaled corticosteroid) and for the maintenance treatment of chronic obstructive pulmonary disease (COPD) in adults.

Serevent is available as the Accuhaler (dry powder inhaler) and the Evohaler (pressurised metered-dose inhaler), each delivering salmeterol for twice-daily dosing.

This page provides a detailed clinical guide to Serevent, covering how it works, how to use it correctly, dosage instructions, side effects, important safety warnings, and how to obtain a prescription in the United Kingdom.

Important safety information about Serevent

• Serevent must never be used as the sole treatment for asthma. It must always be combined with an inhaled corticosteroid (ICS) preventer inhaler.
• Serevent is not a reliever inhaler. It takes 10 to 20 minutes to start working and cannot treat acute breathing difficulties. Always carry a separate short-acting reliever (such as salbutamol).
• If your asthma symptoms are worsening or your reliever use is increasing, see your GP or asthma nurse urgently.
• Do not stop your ICS preventer while continuing Serevent. If the ICS is discontinued, Serevent must also be stopped.
• Call 999 in an asthma emergency.

Understanding Serevent and its place in treatment

Serevent was introduced by GlaxoSmithKline in the early 1990s and was the first widely available LABA inhaler for asthma and COPD.

It represented a significant advance over short-acting bronchodilators by providing sustained airway opening for approximately 12 hours, reducing the need for frequent reliever use and improving symptom control, sleep quality, and exercise tolerance.

In asthma management, Serevent is positioned as add-on therapy for patients whose symptoms are not adequately controlled by an ICS alone.

NICE guideline NG80 and BTS/SIGN guideline SIGN 158 recommend adding a LABA at step 3 of the asthma treatment ladder when low-dose ICS is insufficient.

In COPD, salmeterol is one of several LABA options used as maintenance bronchodilator therapy.

Since Serevent's introduction, many prescribers have moved towards fixed-dose combination inhalers such as Seretide (fluticasone propionate/salmeterol) or Relvar Ellipta (fluticasone furoate/vilanterol), which combine the ICS and LABA in a single device.

This approach has the advantage of ensuring that the LABA cannot be taken without the ICS, addressing the critical safety concern about LABA monotherapy in asthma.

However, Serevent remains available and appropriate for patients who are already established on a separate ICS preventer and who prefer to use two separate inhalers, or for those using an ICS that is not available in a combination product with salmeterol.

How Serevent works

Salmeterol xinafoate, the active ingredient in Serevent, is a selective beta2-adrenoceptor agonist with a unique molecular structure.

The salmeterol molecule consists of a saligenin head group (the pharmacologically active portion that binds to the beta2-receptor) attached to a long lipophilic side chain.

This side chain inserts into the lipid bilayer of the cell membrane and acts as an anchor, holding the active head group in close proximity to the receptor.

This exosite binding mechanism is the key to salmeterol's prolonged duration of action; the molecule remains tethered near the receptor, repeatedly engaging and activating it over a period of approximately 12 hours.

When salmeterol activates the beta2-adrenoceptor, a cascade of intracellular events follows. The receptor is coupled to a stimulatory G-protein (Gs), which activates the enzyme adenylyl cyclase.

Adenylyl cyclase converts adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP).

Elevated cAMP activates protein kinase A (PKA), which phosphorylates several target proteins, including myosin light chain kinase, reducing its activity and causing smooth muscle relaxation.

The net result is bronchodilation, with opening of narrowed airways and improved airflow.

Salmeterol also has several non-bronchodilator effects that may contribute to clinical benefit. It inhibits the release of bronchoconstrictor mediators from mast cells, including histamine, leukotrienes, and prostaglandin D2.

It reduces airway oedema by decreasing microvascular permeability. It enhances mucociliary clearance, helping to remove mucus from the airways.

However, these effects do not equate to true anti-inflammatory activity, which is why salmeterol cannot replace an ICS in asthma management.

The critical safety message: never use Serevent alone for asthma

The most important safety message regarding Serevent and all LABAs in asthma is that they must never be used as the sole controller therapy.

This warning stems from the Salmeterol Multicenter Asthma Research Trial (SMART), a large US study published in 2006, which found a small but statistically significant increase in asthma-related deaths among patients randomised to salmeterol compared with placebo.

Critically, a substantial proportion of patients in SMART were not using concomitant ICS, and the risk appeared to be concentrated in this group.

Subsequent large safety trials, most notably the AUSTRI trial (2016, over 11,000 patients), specifically evaluated the safety of adding salmeterol to background ICS therapy.

AUSTRI found no increased risk of serious asthma-related events when salmeterol was used alongside ICS.

The FDA subsequently updated its guidance, and the MHRA and NICE have consistently recommended that LABAs should only be used in asthma in combination with an ICS.

The BNF and NICE NG80 both state this clearly.

For patients using Serevent as a separate inhaler, this means they must also use and adhere to their ICS preventer inhaler.

If the ICS is stopped for any reason, Serevent must also be stopped.

This is why many prescribers prefer combination inhalers such as Seretide, which physically combine the ICS and LABA and make it impossible to take one without the other.

Clinical evidence for Serevent

Salmeterol has been extensively studied in both asthma and COPD.

In asthma, studies have consistently shown that adding salmeterol to a low-dose ICS is more effective than doubling the ICS dose for improving lung function, symptom control, and quality of life.

The FACET and OPTIMA trials (with the related LABA formoterol) established the principle that adding a LABA is the preferred step-up strategy before increasing ICS dose, a recommendation now embedded in NICE NG80 and BTS/SIGN SIGN 158.

In COPD, the TORCH trial demonstrated that the combination of salmeterol and fluticasone propionate reduced exacerbation rates, improved FEV1, and improved health-related quality of life compared with placebo.

Salmeterol alone was also effective compared with placebo.

The trial established the ICS/LABA combination as a treatment option for COPD patients with frequent exacerbations, while also highlighting the pneumonia risk associated with ICS in COPD.

Serevent compared with other LABA inhalers

Several LABA inhalers are available in the UK.

Formoterol (available as Oxis Turbohaler and in combination products such as Symbicort) has a rapid onset (1 to 3 minutes) as well as a long duration (approximately 12 hours), making it suitable for both maintenance and MART regimens.

Salmeterol has a slower onset (10 to 20 minutes) and cannot be used as a reliever.

Indacaterol (Onbrez Breezhaler) is an ultra-LABA with 24-hour duration for once-daily dosing in COPD. Vilanterol (in Relvar Ellipta and Anoro Ellipta) is another ultra-LABA providing 24-hour bronchodilation.

The key distinguishing features of salmeterol are its long track record of clinical use, wide availability, and the extensive evidence base supporting its efficacy and safety when combined with ICS.

Its slower onset of action compared with formoterol means it is not suitable for MART regimens, which may be a disadvantage for patients who prefer a single-inhaler approach with as-needed dosing.

How to use the Serevent Accuhaler

The Serevent Accuhaler is a dry powder inhaler containing 60 pre-metered doses.

To use it, hold the device in one hand and slide the thumbgrip away from you until you hear a click to open it.

Slide the lever away from you until it clicks to load a dose. Hold the Accuhaler away from your mouth and breathe out gently.

Do not breathe out into the device, as moisture may affect the powder. Place the mouthpiece between your lips and breathe in steadily and deeply through your mouth.

Remove the device and hold your breath for approximately 10 seconds. Breathe out slowly. Close the Accuhaler by sliding the thumbgrip back. The dose counter shows remaining doses.

When the counter reaches 5, the numbers turn red, indicating you need a replacement. Ask your pharmacist or asthma nurse to check your technique if you are unsure.

How to use the Serevent Evohaler

The Serevent Evohaler is a pressurised metered-dose inhaler. Remove the mouthpiece cap and shake the inhaler thoroughly.

Hold it upright with your thumb on the base and index finger on top of the canister. Breathe out gently away from the inhaler.

Place the mouthpiece between your lips and begin to breathe in slowly and deeply. As you breathe in, press the canister down once to release a puff.

Continue breathing in slowly. Hold your breath for about 10 seconds. Each dose requires two puffs, so wait at least 30 seconds before repeating for the second puff.

A spacer device such as an AeroChamber or Volumatic may be used to improve delivery and is recommended for patients who find coordination difficult.

Good technique is essential for effective treatment.

Dosage and administration

For asthma (adults and adolescents 12 and over): 50 micrograms twice daily alongside an ICS. For children aged 4 to 11: 50 micrograms twice daily alongside an ICS.

For COPD (adults): 50 micrograms twice daily. Take doses approximately 12 hours apart. The Accuhaler delivers 50 micrograms per blister (one inhalation).

The Evohaler delivers 25 micrograms per actuation (two puffs per dose). Use a spacer with the Evohaler if coordination is difficult.

Side effects of Serevent

Common side effects are headache, tremor, and palpitations, which are beta2-agonist class effects and usually mild. Muscle cramps and throat irritation may occur.

Tachycardia, cardiac arrhythmias, and paradoxical bronchospasm are rare. Hypokalaemia may occur at high doses or in combination with potassium-depleting medicines.

Allergic reactions including rash, urticaria, and angioedema are very rare; call 999 for anaphylaxis. Hyperglycaemia may affect diabetic patients.

Report suspected adverse reactions to the MHRA at yellowcard.mhra.gov.uk .

Warnings and precautions

Never use Serevent as monotherapy for asthma. Always combine with an ICS. Not for acute relief. Carry a SABA reliever at all times. Contraindicated in salmeterol hypersensitivity.

Use with caution in thyrotoxicosis, cardiac disease, diabetes, and hypokalaemia. Avoid non-selective beta-blockers in asthma. Avoid potent CYP3A4 inhibitors (ritonavir, ketoconazole) unless benefit clearly outweighs risk.

Continue asthma treatment during pregnancy; poorly controlled asthma carries greater risk. Serevent is licensed for children aged 4 and over with asthma (with ICS).

Seek urgent help for worsening symptoms; call 999 in emergency.

How to get Serevent in the UK

Serevent is available on NHS prescription from your GP, asthma nurse, or an authorised online prescriber registered with the General Pharmaceutical Council (GPhC).

The standard NHS prescription charge in England is 9.90 pounds per item; prescriptions are free in Scotland, Wales, and Northern Ireland.

Generic salmeterol inhalers may also be available and can be prescribed if clinically appropriate.

Prescription prepayment certificates are available from the NHS Business Services Authority for patients who need multiple prescription items each month.

Your pharmacist can advise on correct storage and device replacement schedules.

Sources

• Serevent Accuhaler, Summary of Product Characteristics (EMC)
• Salmeterol, British National Formulary (BNF)
• Asthma: diagnosis, monitoring and chronic asthma management, NICE NG80
• Chronic obstructive pulmonary disease in over 16s, NICE NG115
• Salmeterol, NHS
• MHRA Yellow Card Scheme