What to Know About Xopenex (Levalbuterol)

A rescue inhaler used to treat acute asthma and COPD symptoms

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Xopenex (levalbuterol) is a short-acting inhaled medication used to relieve acute symptoms of asthma and chronic obstructive pulmonary disease (COPD). The drug works by relaxing the smooth muscles in the airways of the lungs, usually within minutes. It is not used for the long-term control of symptoms but rather when there is a sudden episode of bronchoconstriction (narrowing of the airways).

Xopenex is available both as an aerosolized inhaler and in a solution form for use in a nebulizer machine.

A generic form of Xopenex, sold under the name levalbuterol, has been available since 2016.

a doctor helps a young patient use an inhaler
 Fat Camera / Getty Images


Xopenex is a short-acting beta-agonist (SABA) used for the first-line treatment of acute symptoms of reversible obstructive airway disease. This includes asthma, which is fully reversible, and COPD, which is partially reversible. Xopenex is not used for irreversible obstructive airway diseases like bronchiectasis.

Xopenex was approved by the U.S. Food and Drug Administration in 1999 as an alternative to the inhaled SABA albuterol (marketed under the brand names ProAir, Ventolin, and others). There are no other SABAs other than Xopenex or albuterol.

Xopenex vs. Albuterol

Xopenex contains only the active component of albuterol (called levalbuterol), not the inactive one (dextroalbuterol), which translates to certain benefits—not least of which is a lower drug dose.

With that said, Xopenex has not been shown to be any more or less effective than albuterol. Moreover, Xopenex has not been shown to have fewer side effects than albuterol despite acting more directly on the lungs.

Xopenex is offered in inhaled forms only, while albuterol is available as an inhalant, oral tablet, and oral syrup. With generic versions of both now available, the cost of Xopenex and albuterol is more or less the same.

Xopenex and albuterol are both useful drugs with similar actions. Because some providers believe that Xopenex has fewer side effects, it may be a reasonable option if you have any issue with albuterol.

Off-Label Uses

Xopenex is sometimes used off-label to treat exercise-induced bronchoconstriction (EIB), the narrowing of airways caused by excessive physical exertion. Although technically a form of asthma, EIB can occur both in people with asthma as well as elite athletes with no diagnostic evidence of asthma.

Before Taking

You are a candidate for Xopenex if you experience asthma attacks or acute exacerbations of COPD.

In people with mild intermittent asthma, Xopenex may be all that is needed to keep symptoms under control. In others, daily medications (such as long-acting beta-agonist and inhaled steroids) may be added to the treatment plan to ensure long-term control.

Your healthcare provider will assess your needs based on pulmonary function tests (PFTs) and imaging studies, as well as your general response to treatment.

Precautions and Contraindications

Xopenex should not be used in anyone with a known or suspected allergy to levalbuterol, albuterol, or any other ingredient in the medication.

Xopenex is known to affect heart rate and blood pressure, posing risks to people with pre-existing cardiovascular disorders. Levalbuterol is also known to act on the sympathetic nervous system and may affect glucose tolerance and thyroid function.

Because of this, Xopenex should be used with caution in people with the following pre-existing health conditions:

To avoid drug-related complications, people with diabetes, thyroid disease, or cardiovascular disorders should have their condition routinely monitored. Any increases in the frequency or severity of symptoms may warrant a dose adjustment or change of treatment.

Be sure to speak with your healthcare provider about the risks vs. benefits of using Xopenex if you are pregnant or planning to become pregnant. Use appears to be safe for mother and child during pregnancy, but it's important that you get personal advice from a healthcare provider.

It is unknown if Xopenex is passed through breast milk.


There are two forms of Xopenex: Xopenex HFA, the aerosolized form of levalbuterol, and Xopenex solution, the nebulized form.

Xopenex HFA is approved for adults and children 4 and over. It is available in a 15-gram (g) canister with 200 doses or an 8.4-g canister with 80 doses.

The recommend dose is the same for adults and children:

  • Take 2 inhaled doses (roughly 90 micrograms of levalbuterol) every four to six hours. For some, one inhaled dose of Xopenex HFA every four hours may be sufficient. Follow your healthcare provider's instructions.

Xopenex solution is approved for adults and children 6 and over. It is available in three premixed strengths: 0.31 milligrams (mg), 0.63 mg, and 1.25 mg. There is also a 1.25-mg concentrated that needs to be mixed with sterile normal saline.

The recommended dosage varies by age:

  • Adults and adolescents 12 and over: Start with a 0.63-mg dose administered three times daily (every six to eight hours) by nebulizer. The dosage can be increased if needed but should not exceed 1.25 mg three times daily.
  • Children ages 6 to 11: Start with a 0.31-mg dose administered three times daily (every six to eight hours) by nebulizer. The dosage can be increased if needed but should not exceed 0.63 mg three times daily.

As a general rule, the lowest possible dose able to improve breathing restriction should be used. If Xopenex is unable to provide relief at the prescribed dose, let your healthcare provider know before making a dose adjustment.

Never exceed the maximum recommended daily dosage. If Xopenex fails to provide relief at this dose, other medications will likely be needed to sustain long-term control of your asthma or COPD symptoms.

How to Take and Store

Because of its convenience and simpler dosing schedule, Xopenex HFA is often the preferred choice for first-time users. On the other, nebulizers are easier to use with younger children and allow for accurate dosing for people with severe COPD or asthma. Speak with your healthcare provider about the benefits and drawbacks of each.

Both can be stored at room temperature, ideally between 68 degrees F and 77 degrees F. Do not store in direct sunlight or use after the expiration date. Keep out of reach of children.

Using Xopenex HFA Inhaler

  1. Take the cap off the mouthpiece.
  2. Shake the canister for five seconds.
  3. If using the inhaler for the first time, it needs to be primed. To do so, spray it away from your face by depressing the canister top fully. Shake and repeat three more times.
  4. Once primed, exhale fully to empty the lungs.
  5. Holding the canister upright, place the mouthpiece in your mouth and close your lips tightly to create a seal.
  6. Depress the canister top fully in one movement as you simultaneously inhale.
  7. Remove the mouthpiece and hold your breath for 10 seconds.
  8. Shake and repeat steps 4 to 7, if needed.
  9. Replace the cap, pressing until you hear it snap.

Using Nebulized Xopenex Solution

  1. Open the pouch and remove one 3-milliliter (mL) vial.
  2. Check the vial. The liquid should be clear; if discolored, do not use it. Ensure that the dose is correct. The 0.31-mg dose has a green foil top, the 0.63-mg dose has a yellow foil top, and the 1.25 mg dose has a red foil top.
  3. Open the vial and pour the solution into the reservoir or cup on the nebulizer machine. If you are using the 1.25-mg concentration, mix it with sterile normal saline as per the manufacturer's instruction before pouring it into the machine.
  4. Connect the nebulizer to the face mask or mouthpiece.
  5. Put on the face mask or mouthpiece securely and turn on the machine.
  6. Relax and breathe in the nebulized mist until all of the solution is gone (between five and 15 minutes).
  7. Turn off the machine.
  8. Clean all of the parts of the nebulizer after each use.

Never mix another inhaled medication with Xopenex nebulized solution unless your healthcare provider tells you to.

Side Effects

Xopenex is considered safe for long-term use with few intolerable side effects.

The risk of side effects is dose-dependent, meaning that it increases in tandem with the dose or the frequency of dosing.


Common side effects of Xopenex HFA and Xopenex solution include:

  • Dizziness
  • Headache
  • Runny nose
  • Sore throat
  • Stomach upset
  • Nervousness
  • Tremors
  • Bronchitis
  • Rapid heart rate
  • Nausea and vomiting
  • Chest pains
  • Palpitations

Most of these side effects are mild and tend to resolve without treatment within an hour or so. Many will resolve fully as your body adapts to the medication.


There are few severe side effects associated with Xopenex. Of these, some are potentially life-threatening and require immediate medical attention.

One such condition is known as paradoxical bronchospasm in which an inhaled beta-agonist causes an unexpected worsening of symptoms. While the cause is poorly understood, paradoxical bronchospasm often occurs with the first use of a new canister or vial. It can be life-threatening.

It is also important to watch for signs of allergy. While rare, some people have been known to develop rash or hives after using Xopenex. The drug may also cause anaphylaxis which, if left untreated, can lead to shock and death.

When to Call 911

If breathing problems worsen after using Xopenex (or any other inhaled beta-agonist), call 911.

Likewise, seek emergency medical attention if allergy symptoms develop rapidly and are accompanied by shortness of breath, wheezing, irregular heartbeats, dizziness, and the swelling of the face or throat.

Warnings and Interactions

Xopenex can affect potassium levels and, in some cases, lead to hypokalemia—a condition in which low potassium causes weakness, fatigue, muscle cramps and stiffness, and tingling or numbness. It is important to let your healthcare provider know if you experience these symptoms as hypokalemia can increase the risk of cardiovascular side effects.

Do not take a potassium supplement in an effort to avoid hypokalemia unless your healthcare provider tells you to. Doing so can interfere with other medications you may be taking, including ACE inhibitors.

Drug Interactions

Xopenex is known to interact with certain drugs, either by increasing or decreasing drug concentrations of one or both drugs, or triggering severe side effects.

Among the drugs of concern are:

  • Beta-blockers, such as Coreg (carvedilol) or Tenormin (atenolol)
  • Digoxin
  • Diuretics, such as Lasix (furosemide) or Microzide (hydrochlorothiazide)
  • Epinephrine
  • MAOI antidepressants, such as Emsam( (selegiline) or Marplan (isocarboxazid)
  • Tricyclic antidepressants, such as amitriptyline or doxepin

In some cases, a dose adjustment or separation of doses by one to four hours may be enough to compensate for the interaction. In others, a change of treatment may be indicated. Others still may require no adjustment at all.

To avoid drug interactions, let your healthcare provider know about any and all drugs and supplements you take before starting Xopenex. This includes pharmaceutical, over-the-counter, nutritional, herbal, and recreational drugs.

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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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By Daniel More, MD
Daniel More, MD, is a board-certified allergist and clinical immunologist. He is an assistant clinical professor at the University of California, San Francisco School of Medicine and currently practices at Central Coast Allergy and Asthma in Salinas, California.