Millions of people with asthma and other lung diseases will have to switch inhalers by the end of the year. And for many, the transition will not be smooth.
The change — mandated by the federal government in 2005, to take effect next Jan. 1 — is to comply with the 1987 treaty to protect the Earth’s ozone layer. It bans most uses of chlorofluorocarbons, or CFCs, which are used as propellants in many inhalers.
CFC-free inhalers have been available for more than a decade. But 4 million to 5 million users have yet to switch, according to the consumer advocacy group Allergy and Asthma Network Mothers of Asthmatics.
For one thing, the old inhalers cost much less — an average of $13.50, or one-third the price of a CFC-free inhaler, which uses propellants called HFAs (hydrofluoroalkanes). (CFC inhalers are generic; HFA inhalers are brand name.) People with asthma use an average of three or four inhalers a year, but some patients use one a month.
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Moreover, the new and old inhalers differ in feel, force, taste and how they are primed and cleaned. Advocates for people with asthma say doctors and patients have not been educated about the changes.
“What the government failed to do is to mandate anyone to tell patients and physicians this transition was happening,” said Nancy Sander, president of the asthma group. “There is no education, no monitoring of patients, no financial assistance to patients who have to pay higher prices for the new drugs.”
As a result, she and others say, there have been unnecessary fears about the newer inhalers, preventable trips to the emergency room and even some hoarding of CFC inhalers.
Callers to a hot line run by Sander’s group have complained that when they were switched to the new inhalers, the differences between the two types were never explained. Many thought that their device was broken or that their symptoms were not being relieved by the new inhalers.
Both types of inhalers use albuterol, a short-acting medication that can prevent an asthma attack when used preventively — before exercising, for example — or at the first sign of breathing trouble.
Even though there are important differences between the four brands of HFA inhalers, some insurers cover only one of the four. Advocates say the higher cost may keep patients from buying inhalers, force them to cut back on other medications or switch to a less effective over-the-counter inhaler that uses epinephrine.
Several members of Congress are asking the Bush administration to require insurers, including the Medicare and Medicaid programs, to cover the new inhalers equally.
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HFA vs. CFC inhalers
Studies show that HFA inhalers are as effective as CFC inhalers and have the same rate of side effects. But if they are not used properly, patients will not get adequate doses. There are three critical differences:
– HFA inhalers must be pumped four times to prime them — a number that was not so critical with the more forgiving CFC inhalers, said Dr. Leslie Hendeles, professor of pharmacy and pediatrics at the University of Florida. And each brand of the newer inhaler requires a different frequency of priming.
– HFA inhalers have a weaker spray. “It’s very soft so people think it’s not working,” said Dr. Stuart Stoloff, a family physician who is a member of a National Institutes of Health expert panel on asthma. They also require a slower inhale. “You have to take a nice slow, deep breath and hold it,” Sander said. If people worry that it’s not working, they may not take the second puff, may fail to wait the necessary 30 seconds between puffs or may take too many puffs.
– HFA inhalers need to be washed with warm water and air-dried once a week. The medication is stickier and will clog the hole, reducing the amount of medication the spray delivers.