Expert: Marc Rubin, RPh Asthma Educator - 2/16/2009

Question
QUESTION: I live in the rural Adirondacks (USA) at a boyscout camp (my fiance is the ranger). I have been taking Advair and Albuteral. The former has been used for about three years, the latter my entire life. My problem is that Albuteral has changed propellents and for some reason it doesn't work for me at all anymore and I am terrified to be honest. When they said Albuteral had changed, I thought it might have been a good thing, but it takes a long time to work (5-10 minutes) and only lasts close to an hour, if that. I have severe asthma and have no idea what to do now that the Albuteral has changed to make it "environmentally friendly." Why oil companies can get away with it but asthmatics can't is beyond me... anyway...

I had been consistently taking advair which works miracles and went to get it refilled but was informed that my yearly refill had expired. I have been without it for a little over a week and had an appointment today to have it filled but it probably won't be here until next week since I do it through the mail for a much cheaper price. Advair helps my asthma to no end, but it really seems like it has deteriorated what strength my lungs originally had. There isn't even anything that seems to trigger it anymore. I don't have to be exercising, cleaning, petting an animal... Just sitting in a room doing very little will trigger a serious asthma attack.

Any advice you could give regarding this new (ridiculous) albuteral inhaler and some other possibilities would be hugely appreciated. Thanks so much for your time and I look forward to your reply.

I would ask my doctor, but since I have only lived here for a year and been to only a couple of doctors, neither of which seemed too terribly concerned, I thought I would try another resource.

ANSWER: Hi Karen,

Sorry for the late reply ( I was at a medical conference and was not able to get online).

It seems as if neither the physicians office, nor the pharmacy took the time to acquaint you with how you need to adapt to the new product. Like everything in life, there are pro's and con's. Here is the rundown:
1) The new propellant does not destroy the ozone layer like the prior compound. This is important, since the ozone layer has developed large holes allowing increased radiation down to surface level. This increases the risk of skin cancer, as well as other genetic mutations on all life on the planet.
2) As you have found, the spray is warmer, and not as powerful, BUT, the mist is finer allowing better penetration deeper into the lungs.
3) The nozzle on the unit clogs up frequently. The guidelines for cleaning call for weekly separating the canister from the plastic, and running the nozzle under warm water, then allow to dry. If it gets plugged, you will get little or no mist. This is a common occurrence, and the cause of most failures.
4) Taste is different, even between brands.
5) It is important to inhale slowly beginning BEFORE you trigger the canister, and continue through the puff, to get the full benefit.
Also. look upwards as if you are looking at a clock on the wall. Better unobstructed airflow.

From your description, your asthma does not seem that it is in the level of control that is possible. How often were you using the albuterol prior to running out of Advair? More than twice a week in the daytime? Waking more than twice a night per month? It appears that the environment you are in has a lot more triggers than you may be aware of. It would be in your best interest to locate an asthma specialist in the area. Before I make any further suggestions, are you on any other medications taken on a daily basis?

There are some other options, but I need to first clarify what else you may be on.

I'll be able to respond to your answers Monday afternoon.

Sincerely,

Marc

---------- FOLLOW-UP ----------

QUESTION: I have since researched this "equally good" inhaler and as it turns out, the lack of effect this produces and the heaviness and pain I feel in my lungs when I inhale this isn't "imaginary" or due to my inability to use it properly. Apparently, the new propellents in these inhalers aren't "safe" and benign for ALL patients. What the doctors and pharmacists don't tell you is that these HFA inhalers contain ethanol, which CAN CAUSE bronchoconstriction, according to many scientists who have researched this medication, none of whom worked for the FDA or EPA of course. I have ALWAYS been a "tree-hugging hippie," as my friends always call me, and I am incredibly politically active (and intelligent, despite doctors' popular opinions) but to ban something that saves lives and improves the quality of life for over hundreds of millions of people globally and not replace it with a TRUE equivillant is absolutely appaulling, especially when the product that is being banned produces LESS THAN 0.1% of total cfc emissions. Why don't we ban hummers and insecticides and other "luxuries," THEN we can start to think about banning MEDICATIONS.

Also, to tell patients that their medication changed and that their suffering is for the betterment of the entire world's ozone layer is WRONG and IMMORAL.

"Former Surgeon General C. Everett Koop wrote that there is no comparison between the infinitesimal improvement in ozone depletion that would result from the FDA's ban and the direct impact of forced elimination of medications on American asthmatics." And he's not the only medical professional who shares this sentiment.

I even read the "Regulatory Impact Analysis" that the FDA created for the HFAs and the removal of CFC inhalers and it says, word for word "we (the FDA) are unable to assess or quantify specific reductions in future skin cancers and cataracts associated with these reduced CFC emissions (achieved by banning CFC MDIs)" The only thing they seem to know is the investment turnover and how this will "encourage more environmentally-friendly technologies." -which, don't get me wrong, I am ALL for, just not at the expense and detriment of millions of people. I am not only outraged by the banning of a medication that contributes "less than 0.1%" of the CFCs released into the atmosphere, but that doctors and pharmacists, MEDICAL PROFESSIONALS are either lying to their patients or aren't well-informed themselves. I don't mean to take this out on you personally, especially since I admire you for donating your time to free websites like this in order to help people, but you ARE a doctor and the advice you gave is the SAME, GENERIC advice that I found on every "woo for HFA inhaler" site I visited.

I really hope you don't take offense to this, I just hope that you can either look into this problem more deeply so that you can better inform future patients and make a difference, or hopefully feel badly for lying about the "safety" of these new inhalers and that the ONLY difference is in the propellent which has NO effect on the albuterol administered. The propellent CAN be dangerous, CAN render the medication useless, and ISN'T as good as CFC inhalers. Nor did its ban have anything to do with the environment. Beaurocrats and the "thugs in white coats" shifted money and lobbied the right people and WE have to suffer. It isn't right and it ISN'T in our heads.

Answer
Hi Karen,

Please let me know if you are able to get the Maxair, and let me know if this has resolved your problem.

Marc




Hi Karen,

Regardless of the politics involved, of which actions I myself am also subject to, we have had a large degree of success with the new product. That said, my medical philosophy has always treat the whole patient, and not just the disease. Furthermore, there are wide variations in patients, and one should never assume that one size fits all in the pharmaceutical world. I personally have a strong distaste for drug formularies that are created by insurance companies, since they are 85-90% motivated by money without regard to the individual variation I stated earlier.

That said, there are two options for you at present. Two inhalers have NOT been converted to HFA at this point. Maxair Autohaler uses Pirbuterol, a cousin of albuterol with the much the same profile, but may last up to 6 hours. What makes it unique is that it is breath-activated. You shake the unit, flip a lever, put it in your mouth and inhale. It automatically fires a soft puff. Go to : http://www.maxairautohaler.com/

Another Option is Combivent, an inhaler with albuterol plus ipratropine, an anticholinergic medication that takes a bit longer to have its' effect on broncho-dilation, and causes some airway drying. This product is commonly used in patients with COPD (Chronic Obstructive Pulmonary Disease), as well as in the emergency room setting for a severe asthma attack.

Two final notes, one, I am not a doctor, I am a pharmacist and a board certified asthma educator. Second, I understand your frustration, and therefore your rant, but you also failed to answer a single question that I presented to you. My ability to assess is based upon interaction with the patient I trying to help. While the information I presented you above should resolve your acute episodes, it fails to address the fact that your overall asthma control is not what I feel you may be able to achieve. For your personal evaluation to monitor your status, there is a bench marked test that you may want to refer to and save. Go to: http://www.asthmacontrol.com/

I hope this information helps you, and if you wish, I'd be happy to guide you further.

P.S: I'm also a nature lover. My home backs up to conservancy, with an occasional deer, fox or wolf plus a nice assortment of birds and waterfowl.

Sincerely,

Marc