Your asthma or COPD inhaler is not available, and what to do

As reported in MedPage Today, the FDA announced the end for CFC-propelled inhalers. Of the seven inhalers with deadlines for removal, only three are still being made:

Flunisolide (Aerobid Inhaler System) on June 30, 2011
Albuterol and ipratropium combination (Combivent Inhalation Aerosol) on Dec. 31, 2013
Pirbuterol (Maxair Autohaler) on Dec. 31, 2013

The reason for this is because CFC’s are harmful for the environment, and the newer inhalers have to be replaced with a different, more environmentally friendly propellant called hydrofluoroalkane or HFA.

According to the FDA, “patients using the inhalers scheduled to be phased out should talk to their health care professional about switching to one of several alternative treatments currently available. Until then, patients should continue using their current inhaler medication.”

What you should do:

1. Albuterol. I still have patients that have their very old albuterol canisters, which are probably no longer effective. An important thing to know is that there is no longer any generic albuterol. More importantly, if your physician writes a prescription for albuterol, the pharmacist will likely give you ProAir, which may or may not be what your insurance prefers or what is least expensive for you.

This is because many of the chain pharmacies are getting a kick back from the makers of ProAir. Make sure your provider writes for the correct inhaler. All things being equal (same co-pay for patients), I recommend Ventolin HFA (because it is the only one with a dose counter) or Xopenex HFA, because of diminished side effects.

GlaxoSmithKline, makers of Ventolin HFA, sell a $9 inhaler, regardless of your insurance. Though the inhaler has fewer puffs in it, if you are using your inhaler that frequently, then your asthma is not under good control, and you should be on a different controller medication. Ask your doctor for Ventolin HFA 60 (they have to write the “60” part).

2. Maxair. Some patients love this drug, but it’s going away. Before January 2014, get another albuterol. See above and previous posts for advice.

3. Aerobid. I didn’t even realize they still made this medication. It is no more effective then other similar medications, probably less effective, possibly more side effects, and it tastes nasty. If you are on this medication, switch to another inhaled steroid. Good alternatives include Flovent, Pulmicort, Asmanex, and Alvesco.

4. Combivent. This will likely affect patients the most, since few patients are on Maxair or Aerobid, and there are far more chronic obstructive pulmonary disease (COPD) patients than asthmatics. It is very likely that before January, 2014, the makers of Combivent with come out with a Combivent HFA. However, there are reasons to consider switching now.

A few studies have come out which make me very concerned about using Combivent. One study published in the Annals of Internal Medicine looked at a VA population and found that patients taking ipratropium had significantly higher death rate — about 11%.

A second study was a meta-analysis published in JAMA that analyzed 14,783 patients with COPD and found that patients taking either ipratropium or tiotropium (Spiriva) or both had a 58% increase in cardiovascular death, heart attack or stroke when compared to patients taking other drugs (Advair, albuterol or placebo).

Though combined, these studies might cause safety concerns with the entire class of anti-cholinergic inhalers, the UPLIFT trial — a long-term, large randomized controlled trial (4 years, almost 6,000 patients) — which unfortunately failed to show that Spiriva could decrease that rate of lung function decline, did show about 10% relatively fewer deaths.

Though anti-cholinergic medicines may cause some harm, it appears that this is likely mainly for the short acting ipratropium and not for the long acting tiotropium. I would therefore recommend that COPD patients talk to their doctors about stopping their Combivent now and switch to a different controller medication (Advair, Symbicort, Spiriva) or switch to albuterol alone as a rescue medication.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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