Trying to inhale: Asthma sufferers say CFC-free inhalers aren't as effective

Millions of asthma sufferers were forced to switch to a different quick-acting inhaler by Jan. 1, after an amendment to the Clean Air Act outlawed chlorofluorocarbons, or CFCs, an ozone-depleting chemical that delivered medication deep into the lungs. People with asthma and other breathing disorders now are prescribed more environmentally friendly hydrofluoroalkane-propelled inhalers.

The devices are just as effective as CFC inhalers, according to many medical experts, including a spokesman for the American College of Allergy, Asthma and Immunology. But differences in operation and sensation have led to confusion, experts said. The HFA inhalers deliver a softer mist, taste different and must be primed before use and cleaned more often.

The less forceful spray makes many users believe that the inhalers are not working, said Dr. Thomas Stern, a pulmonologist in Charlotte, N.C. He said it will take time for some people to adjust their expectations, but most of his patients have made the transition.

"The medication is exactly the same, the effectiveness is the same," said Dr. Clifford Bassett, assistant clinical professor of medicine at Long Island College Hospital, State University of New York. "The only difference is that the propellant has some mild qualitative differences."

Some users, however, are adamant that the inhalers don't work. The National Campaign to Save CFC Asthma Inhalers has collected more than 4,500 signatures as part of its drive to bring the old CFC inhalers back.

Arthur Abramson, an asthma patient in San Francisco who runs the group's Web site, SaveCFCinhalers.org, said patients are being forced to buy drugs that are less safe and less effective. He said he developed permanent tinnitus in his left ear after using an HFA inhaler.

"What they tell you is that everything is the same, just the propellant is different, and that is a lie," Abramson said. "The fact of the matter is, it is not the active ingredient albuterol that is causing the problems. It is the inactive ingredients, such as ethanol, and also the unique impurities."

The HFA propellant itself also appears to be causing problems for some people, he said.

Karen Riley, a spokeswoman for the Food and Drug Administration, said the agency has received more than 500 complaints about HFA inhalers, many of them about the ethanol. But she said one of the four FDA-approved HFA inhalers on the market, Ventolin, lacks the ingredient.

"There is an alternative available for patients who cannot tolerate or do not want ethanol in their albuterol inhaler," she said.

Three albuterol HFA inhalers are available in the U.S.: Ventolin, Proventil and ProAir. Another inhaler, Xopenex, contains a medicine similar to albuterol. Riley said each was approved based on research showing its safety and effectiveness.

All of the active and inactive ingredients are considered safe in the amounts found in the approved inhalers, she said.

Sandra Fusco-Walker, director of patient advocacy at Allergy and Asthma Network Mothers of Asthmatics, based in Virginia, said many inhaler users have not been given instruction on how to properly use the devices. She worries about asthmatics having problems but not consulting their doctors.

"If you need albuterol more than two times a week or wake up during the night, you need other medications," she said. "That's considered asthma out of control."

Maureen Damitz of the Respiratory Health Association said some patients are doubling up on medications when they don't have to.

Bassett, a spokesman for the American College of Allergy, Asthma and Immunology, said talking about inhaler concerns gives patients and doctors a chance to go over prevention strategies, asthma triggers, back-to-school measures and instruction on use of medications.

Many studies show that inhalers are commonly misused, Bassett said.

"If the medication is not used correctly," he said, "you're going to have a problem."

Critics of the inhalers say it's not their technique that's the problem, it's the inhalers.

Like a number of other users, Jane Malloy, who lives in Streamwood, Ill., now gets inhalers from outside the U.S. over the Internet. She's not comfortable with the idea, but she doesn't want to use HFA inhalers after coughing up blood and feeling a strange itchy feeling in her lungs after using one.

However, now that an international treaty on chlorofluorocarbons has gone into effect, even overseas sources of the older inhalers are drying up.

She is becoming worried as she watches her supply run out.

"I don't know what I am going to do," Malloy said. "I think I'm in a world of trouble."
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TIPS FOR TREATING ASTHMA

Follow manufacturer's instructions for use and cleaning.

Ask the pharmacist how to prime it.

Consider using a spacer if you are not well-coordinated or are unsure when to inhale.

Adhere to your asthma treatment plan.

When exercising, drink adequate fluids and allow for a period of warm up and cool down.

Get help if the cost is prohibitive. (HFA inhalers cost more.) Ask your doctor for discount coupons. Download coupons from manufacturer Web sites. Or contact drug-makers about free or discounted prices offered to lower-income patients. Check with Medicare and Medicaid about coverage eligibility.

For more information about HFA inhalers, go to acaai.org/public/Making_the_Switch or fda.gov/Drugs/ResourcesForYou/Consumers/QuestionsAnswers/ucm077808
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