The main public health issue in this decision may be the side effects of the economics, not the drug chemistry. Multiple studies have shown that raising costs leads to poorer adherence to treatment. One study discovered that patients took 30 percent less antiasthma medication when their co-pay doubled. In the case of a chronic disease such as asthma, it is particularly difficult to get people to follow regular treatment plans. “Generally speaking, for any reason you don’t take medication, cost makes it more likely” that you do not, comments Michael Chernew, a health policy expert at Harvard Medical School.

Such choices to forgo medication could affect more than just the patients themselves. “For example,” Hendeles points out, “in a pregnant mother with untreated asthma, less oxygen is delivered to the fetus, which can lead to congenital problems and premature birth.” And considering that the disease disproportionately strikes the poor, what seemed to be a good, responsible environmental decision might in the end exact an unexpected human toll.

Note: The story was originially printed with the title, "Change in the Air".

7 Comments

1. 1. AANMA 02:58 PM 8/4/08

   Emily Harrison brings much needed attention to the uncharted and often confusing waters of the federally-mandated metered-dose inhaler (MDI) transition (Change is in the Air, August 2008). Because the federal mandate to eliminate CFCs from albuterol MDIs did not include patient and prescriber awareness and education programs, monitoring patient progress or the assurance of patient access to medications, it is understandable that she, along with millions of respiratory patients and their medical providers, arent really sure about the facts or how to transition safely.
   
   As the nationwide community-based nonprofit health organization dedicated to eliminating suffering and death due to allergies and asthma through education, advocacy, community outreach and research, AANMA has assembled MDITransitionTEAM, a working group of concerned patient and medical associations and companies to ask Congress to mandate the following emergency interventions:
   
   o National public, patient and clinician awareness and education campaigns  which could serve to educate the 40 million patients affected about critical changes to inhalers and their proper use (force of spray, priming and cleaning instructions, counting doses, proper inhalation technique, etc.)
   o A program to actively monitor patient progress  as we currently have no idea how many people have made the transition safely vs. those who object to or have had problems with the transition
   o Centers for Medicare and Medicaid Services to place HFA inhalers on the same co-pay tier as the CFC MDIs they are replacing. People rightfully object to being forced by the federal government to change inhalers AND pay higher prices. While pharmaceutical industry has helped by offering coupon and patient assistance programs  government has a responsibility to protect the lives of patients affected by the mandate.
   
   We have also created a Web site at www.aanma.org/MDITransition and a toll-free phone number 800-315-8056 where people can obtain accurate information about the inhaler transition and free educational resources.
   
   Sincerely,
   
   
   Nancy Sander
   President and Founder
   AANMA
   
   

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2. 2. Arthur Abramson 01:43 PM 8/11/08

   I have a lot of respect for Dr. Hendeles, since he is the only HFA MDI proponent I know of who has the honesty and courage to admit that the decision to ban CFC MDIs was based purely on politics- extremist environmental politics, to be exact. It never had anything to do with ozone depletion (FDA/EPA disinformation notwithstanding) since the amount of CFC emissions from MDIs is and always was too trivial to do any harm, as Dr. Gross pointed out. (Dr. Gross also deserves tremendous credit for having the courage to publicly change his position on the CFC albuterol ban. He asked tough, aggressive questions during the 1999 FDA PADAC meeting, but the answers he and his colleagues got from the FDA were very misleading, at best.) And the ban certainly was not based on medicine. It is inconceivable that there is a practicing allergist or pulmonologist in the U.S. (or anywhere else) who thinks that patient care will improve once CFC MDIs are banned.
   
   (It is worth noting that atmospheric concentrations of CFCs have been in a clear downward trend since 1994, and ozone concentrations in a key region of the stratosphere have held steady since 1997, after years of decline, according to two independent studies, and these trends were occurring while global ozone depleting substance/CFC emissions were far greater than peak global CFC MDI emissions ever were. We cite references for this on our petition to save CFC MDIs.)
   
   Contrast Dr. Hendeles' honesty with comments by some of his colleagues who still spread alarmist nonsense about the potential dangers of CFC MDI emissions, such as this unbelievable gem by a former president of the American College of Allergy, Asthma and Immunology:
   
   "This is really an environmentally driven pharmaceutical change," says Dr. Ira Finegold, chief of the Division of Allergy and Clinical Immunology at St. Luke's-Roosevelt Hospital Center in New York. "And it's a great idea. We're saving a lot of people from getting cancer." (Forbes, 7/7/08)
   
   With all due respect to Dr. Hendeles, however, his assertion that HFA MDIs are just as safe and effective as CFC MDIs is simply not correct. If you would like to read the comments of over 2,600 patients (including a number of MDs, PhDs, RRTs, and RNs) who know how to prime and clean their HFA MDIs, but who also know that HFA MDIs are not as safe and effective as CFC MDIs for all patients, visit our petition to save CFC MDIs below.
   
   Arthur Abramson
   The National Campaign to Save CFC Asthma Inhalers
   http://www.ipetitions.com/petition/saveCFCinhalers/
   or google: 'save cfc'

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3. 3. FDAsux 01:36 PM 8/12/08

   Please, it's a simple profit grab. Call a spade a spade.

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4. 4. valbino 09:06 PM 8/13/08

   My wife has asthma and must use two different medications in CFC based inhalers several times a day. Even then, she is basically struggling to breathe. When she tried using an HFA inhaler, it simply didn't work. She thought it was defective. Fortunately, she still had some of her old medication on hand. She reported this problem to her physician who is an asthma specialist. He confirmed both that the new HFA inhalers are more difficult to use and, even when used properly, do not work as well as the CFC units.
   
   The problem of finding the right propellant has been around for years. I find it hard to believe two things:
   
   1. This is the best we can do, namely provide a less effective substitute at triple the cost... and
   2. The government would make it more difficult for millions of asthma suffers to live simply because no one wants to face the obvious fact that withdrawing CFC inhalers from the market before a truly comparable alternative is available is the wrong thing to do.
   
   When you can't catch your breath, and you feel like you're drowning, you really don't want someone to throw you a defective life preserver. Unless you have asthma, you don't understand what this means.
   Is anyone at home at the FDA?
   

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5. 5. martyvickie 10:52 AM 8/27/08

   This sounds so irresponsible and callous. I have been an asthma sufferer my entire life. It's level of intensity comes and goes, but one time without accurate medication can kill you. My cousin died when she was 15 because she was not taken to the emergency room on time. Very sad.

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6. 6. Thalia506 02:14 AM 10/22/08

   Money counts, people don't. That's the bottom line. It is as simple as that. all the inhalers not just Albuterol have had to change over. How come the quality has not gone downhill in the other medications? am an Asthmatic and have COPD. I use two different in halers One works just fine. The new Albuterol is almost useless.

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7. 7. drawzlkl 10:52 PM 6/2/09

   Wanna know a trick? The generic (with CFC) is still available in Mexico, at around $3.50 USD per inhaler. That is one tenth of what my co-pay in the U.S. is. That means that $35.00 USD buys me 10 inhalers, or about a years' worth of medication, for the price of a single inhaler here in the U.S. Not to mention these non-CFC's just don't work as well.

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