New Year, New Asthma Inhalers

Millions of people with asthma and other lung diseases who use inhalers like Albuterol that are propelled by chlorofluorocarbons, or CFCs, will have to switch to hydrofluoroalkane, or HFA inhalers by Wednesday, December 31st. Because CFCs have been deemed bad for the environment, this is welcome news for Mother Earth. However, those facing the transition are not overjoyed. The change, which goes into effect January 2009, will bring the U.S. into compliance with the 1987 treaty designed to protect the Earth’s ozone layer by banning most uses of CFCs, which are used in not only inhalers but in aerosol hairsprays and deodorants as well. And even though CFC-free inhalers have been available for over ten years, it is estimated that millions of users have yet to switch. Nancy Sander, president of Allergy and Asthma Network Mothers of Asthmatics, says one reason why the change has been met with such resistance is the failure of the government “to mandate anyone to tell patients and physicians that transition was happening,” and adds that “there is no education, no monitoring, no financial assistance to patients who have to pay higher prices for the new drugs.” As a result, there have been unnecessary fears about the use of the new inhalers, preventable trips to the emergency room and even stockpiling of CFC inhalers. Ms. Sander says callers to the group's hot line have complained that when they were switched to the new inhalers, no one explained the differences between the two types. Many thought their device was broken or that the new inhaler wasn’t relieving their symptoms. Studies have shown that HFA inhalers are just as effective as CFC inhalers; both types of inhalers use Albuterol, a short-acting medication that can prevent an asthma attack when used preventively. However, there are three critical differences between HFA and CFC inhalers: how they are primed and cleaned, the spray force and taste, and cost. HFA inhalers must be primed by pumping them four times, something that wasn’t so critical with the CFC inhalers, according to Dr. Leslie Hendeles, professor of pharmacy and pediatrics at the University of Florida. Each brand of HFA inhaler requires a different frequency of priming. And since the medication is stickier and will clog the hole and reduce the amount of medication delivered, HFA inhalers need to be washed with warm water and air dried once a week. HFA inhalers have a warm, soft mist that leads people to think it isn’t working, whereas CFC inhalers deliver a powerful force that feels as if the airway is being pushed open. The HFA mist has a distinct taste as well. Ms. Sander says the newer inhalers also require a slower inhale. Her fear is that if people worry that it isn’t working, they may not take the second puff, may not wait the necessary 30 seconds between puffs or may take too many puffs. Their anxiety may also rise, constricting their airways even further. There are four brands of HFA inhalers: Ventolin by GlaxoSmithKline, ProAir by Teva, Proventil by Schering-Plough and Xopenex by Sepracor. (Xopenex uses a different chemical, levalbuterol.) There are important differences among the brands, but some doctors simply write Albuterol HFA on the prescription, leaving the brand choice up to the pharmacist. Ventalin is the only one with a dose counter that helps the user keep track of how much medicine is left. ProAir is on many insurance companies’ approved medications lists, but has the softest spray. The cost? CFC inhalers are generic, costing between $5 and $25; HFA inhalers are brand-name, costing anywhere from $30 to $60. People with asthma use an average of three or four inhalers a year, but some patients use one per month. Advocates say the higher cost may keep patients from buying inhalers or force them to cut back on other medications or switch to a less effective over-the-counter inhaler that uses epinephrine. Manufacturers of HFA inhalers are providing assistance for those who cannot afford them; including giveaways, discount coupons, and assistant programs based on financial need. If you are in need of financial assistance, contact The Partnership for Prescription Assistance at 1-888-477-2669 or visit their website at www.pparx.org. Some insurers only cover one of the four HFA inhalers, but several members of Congress are urging the Bush administration to require the inhalers to be covered equally. Representative Steve Kagen, a Wisconsin Democrat and an allergy and asthma physician, said it is important “to make sure there’s as little co-pay as possible.” The FDA has also been stepping up educational efforts after a public meeting last month in which doctors and patients said most people were unaware of the transition. Deborah Henderson, an official at the Center for Drug Evaluation and Research said several public service announcements are expected by the end of this month.