Terbutaline has not been approved and should not be used for prolonged tocolysis (beyond 48 to 72 hours). In particular, terbutaline should not be used for maintenance tocolysis in the outpatient or home setting. Serious adverse reactions, including death, have been reported after administration of terbutaline to pregnant women. In mothers, these adverse reactions include increased heart rate, transient hyperglycemia, hypokalemia, cardiac arrhythmias, pulmonary edema, and myocardial ischemia. Increased fetal heart rate and neonatal hypoglycemia may occur as a result of maternal administration.
Asthma, refractory or severe exacerbation (alternative agent):
Note: Rarely used and based on limited data; may use in patients whose symptoms are refractory to standard therapy and who are in impending respiratory arrest. May also consider in patients with severe exacerbations who are unable to use inhaled bronchodilators (Long 2021). Do not use in combination with parenteral epinephrine (Fanta 2021).
SUBQ: Initial: 0.25 mg once; if severe symptoms persist after initial dose, may repeat every 20 minutes for a total of 3 doses (Long 2021; NAEPP 2007).
Asthma, intermittent symptom relief (alternative agent):
Note: An alternative short-acting beta agonist or rapid-onset long-acting beta agonist/inhaled steroid combination is preferred. Use on an as-needed basis (reliever therapy) rather than regularly scheduled (GINA 2022).
Metered-dose inhaler (0.5 mg/actuation) (Canadian product): Oral inhalation: One inhalation with spacer every 4 hours as needed; if dose is not effective after 5 minutes, may repeat. If second dose is not effective, consult health care provider immediately (maximum dose: 6 inhalations/day). Note: If adequate relief is not obtained with previously effective dose or duration of effect is <3 hours, patient should be reassessed promptly; may indicate worsening asthma (Fanta 2021; GINA 2022; manufacturer's labeling).
Extravasation management, sympathomimetic vasoconstrictors (off-label use; based on limited case reports): SUBQ:
Large extravasations: Infiltrate extravasation area using a solution of 1 mg diluted in 10 mL of 0.9% sodium chloride; volume of terbutaline solution administered varied from 3 to 10 mL (Stier 1999).
Small/distal extravasations: Infiltrate extravasation area using a solution of 1 mg diluted in 1 mL of 0.9% sodium chloride; volume of terbutaline solution administered varied from 0.5 to 1 mL (Stier 1999).
Premature labor (acute; short-term [≤72 hours] tocolysis) (off-label use):
IV: 2.5 to 5 mcg/minute; increased gradually every 20 to 30 minutes by 2.5 to 5 mcg/minute up to a maximum of 25 mcg/minute; decrease to the lowest effective dose once contractions are controlled (Mackeen 2014; Travis 1993).
SUBQ: 0.25 mg every 20 minutes to 3 hours; hold for pulse >120 beats per minute. Terbutaline has not been approved for and should not be used for prolonged tocolysis (beyond 48 to 72 hours) (ACOG 171 2016; Hearne 2000).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
(For additional information see "Terbutaline: Pediatric drug information")
Asthma, acute exacerbation:
Continuous infusion: Limited data available, optimal dose not defined, efficacy results variable: Children and Adolescents: Initial: IV bolus dose: 4 to 10 mcg/kg followed by continuous infusion of 0.2 to 0.4 mcg/kg/minute, titrate by 0.1 to 0.2 mcg/kg/minute increments as frequently as every 30 minutes based on patient response or toxicity. Usual maximum dose is 5 mcg/kg/minute; however, doses as high as 10 mcg/kg/minute have been described; monitor closely for adverse reactions (Bogie 2007; Carroll 2006; Doymaz 2018; Kambalapalli 2005; Singhi 2014; Stephanopoulos 1998).
Oral:
Children ≥12 and Adolescents <15 years: 2.5 mg three times daily; maximum daily dose: 7.5 mg/24 hours
Adolescents ≥15 years: 5 mg three times daily (approximately every 6 hours); reduce dose to 2.5 mg three times daily if side effects occur; maximum daily dose: 15 mg/24 hours
SubQ:
Children: Limited data available: SubQ: 0.01 mg/kg/dose every 20 minutes for 3 doses; may repeat every 2 to 6 hours as needed (NAEPP 2007)
Adolescents: SubQ: 0.25 mg/dose; may repeat every 20 minutes for up to 3 doses (NAEPP 2007)
Oral inhalation: Canadian labeling: Bricanyl Turbuhaler [Canadian product]: Children ≥6 years and Adolescents: 1 inhalation (0.5 mg) as needed; if not effective after 5 minutes may repeat dose. If second dose is not effective, consult health care provider immediately. Maximum daily dose: 6 inhalations/24 hours.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Injection, as sulfate:
Generic: 1 mg/mL (1 mL)
Solution, Injection, as sulfate [preservative free]:
Generic: 1 mg/mL (1 mL [DSC])
Tablet, Oral, as sulfate:
Generic: 2.5 mg, 5 mg
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Aerosol Powder Breath Activated, Inhalation:
Bricanyl Turbuhaler: 0.5 mg/actuation (1 ea)
IV: Use infusion pump.
Oral: Administer around-the-clock to promote less variation in peak and trough serum levels
Inhalation: Bricanyl Turbuhaler [Canadian product]: After removing lid, patient should hold inhaler upright and turn blue grip as far as it will go in one direction then turn it back to original position. Clicking sound indicates that inhaler is ready for use. Patient should exhale fully but not into the inhaler and then place mouthpiece gently between teeth, close lips around inhaler and inhale deeply. Inhaler should be removed from mouth prior to exhaling. Instruct patients to rinse mouth with water after each inhalation as some medication may stick to the inside of the mouth and throat. If inhaler is dropped or shaken, or if patient exhales into the inhaler after a dose is loaded, the dose will be lost and a new dose should be loaded and inhaled. Outside of mouthpiece should be cleaned once weekly with a dry tissue. Instruct patient to keep inhaler dry. First appearance of red mark in dose indicator (window underneath mouthpiece) indicates that 20 doses remain. When red mark reaches bottom of dose indicator no doses remain and Turbuhaler should be discarded.
SubQ: Extravasation management, sympathomimetic vasopressors (off-label use): Stop vesicant infusion immediately and disconnect IV line (leave needle/cannula in place); gently aspirate extravasated solution from the IV line (do NOT flush the line); remove needle/cannula; elevate extremity. Infiltrate extravasation area with terbutaline solution 1 mg diluted with 10 mL (large extravasation site) or 1 mg diluted in 1 mL (small/distal extravasation site) of 0.9% sodium chloride into extravasation site (Stier 1999).
Oral: May administer without regard to food; administer around-the-clock to promote less variation in peak and trough serum levels.
Parenteral:
Direct IV injection: Administer undiluted over 5 to 10 minutes
Continuous IV infusion: Administer via an infusion pump at a concentration ≤1 mg/mL (Bogie 2007; Murray 2014; Sinclair-Pingel 2006)
Inhalation: Bricanyl Turbuhaler [Canadian product]: To prepare inhaler prior to use, load dose by holding inhaler in upright position and turn blue grip as far as it will go in one direction and then turn it as far as it will go in the other direction. Prior to first use, this procedure should be done twice; with subsequent dosing, perform this procedure once. Clicking sound means inhaler is loaded with dose and ready for use. Place mouthpiece between teeth and close lips over mouthpiece. Inhale deeply and forcefully. Do not exhale through inhaler. If the Turbuhaler is dropped, shaken, or breathed into after it is loaded, the dose will be lost and a new dose will need to be loaded. When a red mark appears in the dose indicator window, 20 doses are left. When the red mark reaches the bottom of the window, the inhaler should be discarded.
Asthma/Bronchospasm: Prevention and reversal of bronchospasm in patients ≥6 years of age (Bricanyl Turbuhaler [Canadian product]) or ≥12 years of age with asthma and reversible bronchospasm associated with bronchitis and emphysema.
Extravasation management, sympathomimetic vasoconstrictors; Premature labor (acute; short-term [≤72 hours] tocolysis)
Brethine may be confused with Methergine
Terbutaline may be confused with terbinafine, TOLBUTamide
Terbutaline and methylergonovine parenteral dosage forms look similar. Due to their contrasting indications, use care when administering these agents.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Central nervous system: Nervousness, restlessness
Endocrine & metabolic: Decreased serum potassium, increased serum glucose
Neuromuscular & skeletal: Tremor
1% to 10%:
Cardiovascular: Hypertension, tachycardia
Central nervous system: Dizziness, drowsiness, headache, insomnia
Dermatologic: Diaphoresis
Gastrointestinal: Dysgeusia, nausea, vomiting, xerostomia
Neuromuscular & skeletal: Muscle cramps, weakness
<1%, postmarketing, and/or case reports: Cardiac arrhythmia, chest pain, hyperglycemia (preterm labor), hypokalemia (preterm labor), hypotension (preterm labor), ischemic heart disease (preterm labor), lactic acidosis (Smith 2019), myocardial infarction (preterm labor), paradoxical bronchospasm, pulmonary edema (preterm labor)
Hypersensitivity to terbutaline, sympathomimetic amines, or any component of the formulation
Injection: Additional contraindications: Prolonged (>48 to 72 hours) tocolysis, especially for maintenance in the outpatient setting
Oral: Additional contraindications: Acute or maintenance tocolysis
Bricanyl Turbuhaler [Canadian product]: Hypersensitivity to lactose; history of tachyarrhythmias; as tocolytic in patients at risk of premature labor or threatened abortion.
Concerns related to adverse effects:
• Bronchospasm: Rarely, paradoxical bronchospasm may occur with use of inhaled bronchodilating agents; this should be distinguished from inadequate response.
• Hypersensitivity reactions: Immediate hypersensitivity reactions (urticaria, angioedema, rash, bronchospasm) have been reported.
• Serious effects/fatalities: Do not exceed recommended dose; serious adverse events, including fatalities, have been associated with excessive use of inhaled sympathomimetics.
Disease-related concerns:
• Asthma: Appropriate use: When used as a bronchodilator, optimize anti-inflammatory treatment before initiating maintenance treatment with terbutaline. Do not use as a component of chronic therapy without an anti-inflammatory agent. Only the mildest form of asthma (Step 1 and/or exercise-induced) would not require concurrent use based upon asthma guidelines.
• Cardiovascular disease: Use with caution in patients with cardiovascular disease (arrhythmia or hypertension or HF); beta-agonists may cause elevation in blood pressure, heart rate and result in CNS stimulation/excitation. Beta2-agonists may also increase risk of arrhythmias.
• Diabetes: Use with caution in patients with diabetes mellitus; beta2-agonists may increase serum glucose.
• Glaucoma: Use with caution in patients with glaucoma; may elevate intraocular pressure.
• Hyperthyroidism: Use with caution in hyperthyroidism; may stimulate thyroid activity.
• Hypokalemia: Use with caution in patients with hypokalemia or taking concomitant drugs that cause hypokalemia; beta2-agonists may decrease serum potassium.
• Preterm labor: [US Boxed Warning]: Terbutaline is not FDA approved for and should not be used for prolonged tocolysis (>48 to 72 hours). Use for maintenance tocolysis should not be done in the outpatient setting. Adverse events observed in pregnant women include arrhythmias, increased heart rate, hyperglycemia (transient), hypokalemia, myocardial ischemia, and pulmonary edema. Heart rate may be increased in the fetus and hypoglycemia may occur in the neonate. Oral terbutaline is contraindicated for acute or chronic use in the management of preterm labor.
• Seizures: Use with caution in patients with seizure disorders; beta-agonists may result in CNS stimulation/excitation.
Dosage form specific issues:
• Bricanyl Turbuhaler [Canadian product]: Dry powder inhalers may contain lactose.
Other warnings/precautions:
• Patient information: Patients must be instructed to seek medical attention in cases where acute symptoms are not relieved or a previous level of response is diminished. The need to increase frequency of use may indicate deterioration of asthma, and treatment must not be delayed.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Risk C: Monitor therapy
Atomoxetine: May enhance the tachycardic effect of Beta2-Agonists. Risk C: Monitor therapy
Atomoxetine: May enhance the hypertensive effect of Sympathomimetics. Atomoxetine may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Atosiban: Beta2-Agonists may enhance the adverse/toxic effect of Atosiban. Specifically, there may be an increased risk for pulmonary edema and/or dyspnea. Risk C: Monitor therapy
Beta-Blockers (Beta1 Selective): May diminish the bronchodilatory effect of Beta2-Agonists. Of particular concern with nonselective beta-blockers or higher doses of the beta1 selective beta-blockers. Risk C: Monitor therapy
Beta-Blockers (Nonselective): May diminish the bronchodilatory effect of Beta2-Agonists. Risk X: Avoid combination
Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Cocaine (Topical): May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Risk D: Consider therapy modification
Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Risk C: Monitor therapy
Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy
Haloperidol: QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of Haloperidol. Risk C: Monitor therapy
Kratom: May enhance the adverse/toxic effect of Sympathomimetics. Risk X: Avoid combination
Linezolid: May enhance the hypertensive effect of Sympathomimetics. Management: Reduce initial doses of sympathomimetic agents, and closely monitor for enhanced pressor response, in patients receiving linezolid. Specific dose adjustment recommendations are not presently available. Risk D: Consider therapy modification
Loop Diuretics: Beta2-Agonists may enhance the hypokalemic effect of Loop Diuretics. Risk C: Monitor therapy
Loxapine: Agents to Treat Airway Disease may enhance the adverse/toxic effect of Loxapine. More specifically, the use of Agents to Treat Airway Disease is likely a marker of patients who are likely at a greater risk for experiencing significant bronchospasm from use of inhaled loxapine. Management: This is specific to the Adasuve brand of loxapine, which is an inhaled formulation. This does not apply to non-inhaled formulations of loxapine. Risk X: Avoid combination
Methacholine: Beta2-Agonists (Short-Acting) may diminish the therapeutic effect of Methacholine. Management: Hold short-acting beta2 agonists for 6 hours before methacholine use. Risk D: Consider therapy modification
Monoamine Oxidase Inhibitors: May enhance the adverse/toxic effect of Beta2-Agonists. Risk C: Monitor therapy
Ozanimod: May enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy
QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy
Solriamfetol: Sympathomimetics may enhance the hypertensive effect of Solriamfetol. Sympathomimetics may enhance the tachycardic effect of Solriamfetol. Risk C: Monitor therapy
Succinylcholine: Terbutaline may enhance the neuromuscular-blocking effect of Succinylcholine. Risk C: Monitor therapy
Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Risk C: Monitor therapy
Tedizolid: May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Theophylline Derivatives: Beta2-Agonists may enhance the adverse/toxic effect of Theophylline Derivatives. Specifically, sympathomimetic effects may be increased. Theophylline Derivatives may enhance the hypokalemic effect of Beta2-Agonists. Risk C: Monitor therapy
Thiazide and Thiazide-Like Diuretics: Beta2-Agonists may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor therapy
Tricyclic Antidepressants: May enhance the adverse/toxic effect of Beta2-Agonists. Risk C: Monitor therapy
Terbutaline crosses the placenta; umbilical cord concentrations are ~11% to 48% of maternal blood levels.
Terbutaline may affect uterine contractility; use caution if needed to control bronchospasm in pregnant patients.
Uncontrolled asthma is associated with adverse events in pregnancy (increased risk of perinatal mortality, preeclampsia, preterm birth, low-birth-weight infants, cesarean delivery, and the development of gestational diabetes). Poorly controlled asthma or asthma exacerbations may have a greater fetal/maternal risk than what is associated with appropriately used asthma medications. Maternal treatment improves pregnancy outcomes by reducing the risk of some adverse events (eg, preterm birth, gestational diabetes). Although short acting beta-2 agonists should be used to treat acute asthma exacerbations in pregnant patients, agents other than terbutaline are preferred (ERS/TSANZ [Middleton 2020]; GINA 2021).
Terbutaline injection has not been approved for and should not be used for prolonged tocolysis (beyond 48 to 72 hours). Oral terbutaline sulfate has not been approved and should not be used for acute or maintenance tocolysis. Terbutaline should not be used for maintenance tocolysis in the outpatient or home setting. Serious adverse reactions, including death, have been reported after administration of terbutaline to pregnant patients. Maternal adverse reactions include increased heart rate, transient hyperglycemia, hypokalemia, cardiac arrhythmias, pulmonary edema, and myocardial ischemia. Increased fetal heart rate and neonatal hypoglycemia may also occur. Terbutaline has been used in the management of preterm labor. Tocolytics may be used for the short-term (48 hour) prolongation of pregnancy to allow for the administration of antenatal steroids and should not be used prior to fetal viability or when the risks of use to the fetus or mother are greater than the risk of preterm birth (ACOG 171 2016).
Terbutaline is present in breast milk.
Terbutaline breast milk concentrations are similar to or higher than those in the maternal plasma. Based on information from four cases, exposure to the breastfed infant would be <1% of the weight-adjusted maternal dose. Adverse events were not observed in nursing infants (Boréus 1982; Lönnerholm 1982).
The manufacturer recommends that terbutaline be used in breastfeeding patients only if the potential benefit to the mother outweighs the possible risk to the infant.
Terbutaline is considered probably acceptable for use while breastfeeding (ERS/TSANZ [Middleton 2020]).
Serum potassium, glucose; intake/output; heart rate, blood pressure, respiratory rate; chest pain, shortness of breath; monitor for signs and symptoms of pulmonary edema (when used as a tocolytic); monitor FEV1, peak flow, and/or other pulmonary function tests (when used as bronchodilator). If used for extravasation management, monitor and document extravasation site.
Relaxes bronchial and uterine smooth muscle by action on beta2-receptors with less effect on heart rate
Onset of action: Oral: 30 to 45 minutes; SubQ: 6 to 15 minute; Inhalation: 5 minutes (maximum effect: 15 to 60 minutes)
Duration: Oral: 4 to 8 hours; Oral inhalation: 3 to 6 hours; SubQ: 1.5 to 4 hours
Absorption: 33% to 50%
Protein binding: 25%
Metabolism: Hepatic to inactive sulfate conjugates
Bioavailability: SubQ doses are more bioavailable than oral
Half-life elimination: 5.7 hours (range: 2.9 to 14 hours)
Time to peak, serum: SubQ: 0.5 hours
Excretion: Urine (60% as unchanged drug); feces
Solution (Terbutaline Sulfate Injection)
1 mg/mL (per mL): $1.56 - $23.64
Tablets (Terbutaline Sulfate Oral)
2.5 mg (per each): $5.44 - $13.73
5 mg (per each): $6.65 - $16.77
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