[Allergy & Asthma Corner]

We have reached the countdown for generic albuterol. By now many of you know generic albuterol inhalers will no longer be available for sale or manufacture as of December 31^st of this year. There are only a small number of people still carrying these soon to be extinct inhalers. Most people managing their asthma carry rescue inhalers that are branded: ProAir HFA, Proventil HFA, Ventolin HFA or Xopenex HFA. The FDA has given the makers of Maxair an additional year to convert their product to an HFA brand.

Why the forced switch to HFA containing inhalers? I covered this issue in an earlier posting (linked at the bottom).

Most asthma patients have adapted well to the new inhalers but some complaints continue to surface as more people make the switch. Sorry, there is not much you can do about the cost change. America has never had such a widely used generic medication disappear without another available generic replacement. This will be a financial burden on some people accustom to paying the 5-10 dollar generic co-pay. Some will now have to pay more than three times this price Ouch!

Here are some tips to assist you in this transition process:

-1 The new HFA inhalers require more frequent priming, not only at first time use, but also after certain periods of non-use. This differs for each inhaler. For example, ProAir HFA requires 3 priming sprays at first time use as well if not used for 2 or more weeks. Proventil HFA and Ventolin HFA require 4 priming sprays under the same circumstances. Other HFA inhalers have their own priming directions which you should be aware of. I address this in more detail in the link provided at the end of this posting

-2 The HFA inhalers should be cleaned periodically (I recommend once weekly to patients using their inhaler one or more times weekly). Cleaning instructions for most of them (check package insert) include pulling out the center canister and running warm water through the mouthpiece (not the canister which should be kept dry) and stem for 30 seconds. Then shake the mouthpiece well, and let stand overnight to dry.

Steps one and two will help to prevent you from getting a lower than expected dose of your inhaler

-3 Some money can be saved by taking advantage of coupons or discount cards that are often left with your doctor by drug reps. Ask about them. Even if your doctor doesn’t have one he/she should be able to get some by request. You can save a lot of money with these coupons which sometimes starts you out with a free inhaler.

-4 Review your overall treatment strategy with your asthma care provider. Your asthma is not well controlled if you are requiring daily or greater than 3 days/week reliever inhaler (albuterol, ProAir HFA or similar inhalant). Less need for reliever inhaler will reduce trips to the pharmacy for more asthma medication.

-5 Have your inhaler technique reviewed by your doctor or nurse three or more times a year in order to insure you are getting the medication where it needs to go (deep into the lung). See this link about inhaler technique.

Contrary to the belief of some, you are getting the same dose of albuterol in these new lighter puff inhalers as you were with the generic brands. The change to HFA aerosol inhalers is mandatory for your doctors and pharmacy. I don’t recommend tapping other sources outside of the U.S. in order to continue getting generic albuterol. It may save you some dollars but safety would be my concern.

Why the forced switch to HFA inhalers (and away from CFC brands)? (click here)

Here is the link to my previous posting on specific HFA inhalers: (click here)

There has been so much talk in the media about Serevent and Advair as well as other inhalers that contain Long Acting Beta Agonist (LABAs) which include Foradil and Symbicort. The package insert contains warnings about the risk of worsening asthma, possibly fatal, associated with these inhalers yet so many adults and children appear to be benefitting from them.

I remember a time when in the months from September to October I rarely had a moment’s rest between tending to the walking wounded asthma patients in my office and my own family anxiously awaiting my return home to treat their asthma flares (my wife and children have asthma).

Now, patients more often have home nebulizers, peak flow meters and action plans these days. This makes a considerable difference in the number of people requiring unscheduled office visits and emergency or urgent care evaluations, in my opinion. Although national health statistics regarding hospital admissions and sick visits to doctor’s offices and EDs have not improved, asthma death rates have gone down. I suspect the failure to see changes in hospital admissions and perhaps the number of asthma attacks is skewed towards those with poor access to care and limited educational resources.

Many asthma specialists continue to prescribe combination inhalers that have LABAs and agree with recent reports that these inhalers can be safely used with much to be gained in asthma control, when patients and parent are properly oriented to the medication.

Most of my patients respond well to combination inhalers (Advair and Symbicort). Many of them don’t relish the idea of ever going off but step-down measures are part of the initiative in managing asthma.

People should realize that most of the data used to support the need for warning labels on the LABAs came from one major study. The study was called the “SMART” study, which stood for Salmeterol (Serevent) Multicenter Asthma Research Trial. This study comprised over 26,000 patients across the United States. The SMART study is mentioned in the Black Box warnings on Serevent and Advair. I was one of many chief investigators for this study. The study had many flaws regarding conclusions drawn from it subsequently. I won’t detail them here.

In short, Serevent and Foradil should almost always be taken with a form of inhaled steroid. Advair and Symbicort are combination inhalers that have inhaled steroid plus Serevent or Foradil respectively. Realize that no studies on Advair (available since 2001) have shown increased risk of asthma related death. I am not aware of any studies on Symbicort showing increased risk of fatal asthma.

The most recent NIH asthma guidelines (updated in 2007) and World Health Organization asthma guidelines promote and support the continued use of long acting beta agonist (Serevent and Foradil) plus inhaled steroid in the management of moderate to severe persistent asthma.

This era in modern medicine offers many treatment options for doctors to assist their asthma patients in achieving good asthma control and minimizing impairment and risk (risk associated with severe asthma as well as risk of side effects from medication).

Have you been prescribed one of the above inhalers?

What has your experience been?