Do your kids have asthma?
What medicines do they take?
Kids with asthma basically get treated with five types of medications, including:
- inhaled short acting bronchodilators – albuterol nebulizer solution, levalbuterol nebulizer and HFA (Xopenex), ProAir HFA, ProAir Respiclick, Proventil HFA, Ventolin HFA
- oral steroids – prednisolone, prednisone
- inhaled steroids -Alvesco, Asmanex Twisthaler or HFA, Flovent HFA or Diskus, Pulmicort Respules, Pulmicort Flexhaler, QVAR RediHaler
- inhaled long acting bronchodilators
- montelukast (Singulair) – a leukotriene receptor antagonist that can help prevent asthma and allergy symptoms
Two of these, inhaled steroids and inhaled long acting bronchodilators, which are typically used in combination products (Advair, AirDuo, Dulera, and Symbicort), are commonly used every day to prevent asthma symptoms and asthma attacks.
How Kids Take Asthma Medications
Asthma is one of those conditions that should be a lot easier to control than it usually is.
Although many preventative medications are available, they typically have to be used every day and the medications have to be given with a nebulizer (takes time) or an inhaler (requires good technique).
Fortunately, younger kids who can’t yet learn to use an inhaler can get around this by using their inhaler with a spacer or a spacer with a mask.
How do spacers work with your child’s asthma inhaler?
The medicine from the inhaler goes in the spacer and then the child can just breath it in, not having to coordinate, or time when they breath, with when the medicine actually comes out of the inhaler.
What’s the problem?
More and more drug companies are switching to dry powder inhalers. These are great for older kids, who can easily master the necessary technique – a quick, deep breath. But they are still too hard to use for younger kids and can’t be used with a spacer.
“In a systematic review, the mean percentages of patients who used their inhalers without mistakes were 63% for metered dose inhalers (MDIs); 75% for breath-actuated MDIs; and 65% for dry powder inhalers (DPIs).”
Haughney et al. on Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs
Others are switching to breath-actuated aerosol inhalers that are also too difficult for younger kids to use (they must close their lips around the mouth piece and inhale deeply) and also can’t be used with a spacer.
The Redesigned QVAR Inhaler
While some companies still make two versions of their inhalers, a traditional metered dose inhaler (MDI) and a dry powder inhaler (DPI) or breath-actuated device, more and more have just one option.
QVAR, which has long had the popular inhaled steroid QVAR HFA in 40 and 80 mcg strengths, has now switched to a breath-actuated device.
While the availability of the QVAR RediHaler is good news, as some experts think that breath-actuated devices are better than coordinated devices, the bad news is that they dropped their older QVAR inhalers which could be used with a spacer.
Be careful that your pharmacy doesn’t switch your child from QVAR to QVAR RediHaler unless you think it is appropriate.
So what are your options if your child needs an inhaled steroid?
- Is your child old enough to learn how to use the QVAR RediHaler or a DPI inhaler, like Asmanex Twisthaler, Flovent Diskus, or Pulmicort Flexhaler? Online videos and demonstration devices can help teach your child.
- Is your child’s asthma under poor control, so that QVAR wasn’t a good option anymore anyway, in which case your child might need a step up to a combination inhaler that can be used with a spacer, such as Advair, AirDuo, Dulera, or Symbicort?
- Is your child’s asthma under such good control that your pediatrician might consider a step down off daily inhaled steroid therapy, so that you can stop using QVAR?
- Do you have a nebulizer and so can use budesonide (Pulmicort) respules instead?
Although the fact that it has “a spacer-free design” is being used as a selling point for the new QVAR RediHaler, that doesn’t help those kids who still need to use a spacer. For them, the easiest option is to simply switch to another brand of steroid inhaler that can still be used with a spacer.
These include Flovent HFA (44, 110, and 220mcg), Alvesco (80 and 160mcg), and Asmanex HFA (100 and 2000mcg). All are usually a little more expensive than QVAR though, which is what made QVAR popular. These other inhalers also might not be covered by your insurance plan or may require a coupon to make them affordable.
The Future of Asthma Inhalers
Now that the patents on HFA inhalers are expiring, instead of making inexpensive HFA inhalers, to keep drug prices high, drug companies are developing new delivery devices that they can patent. What’s surprising, is that QVAR is made by Teva, which traditionally makes “lower cost” generic medications.
“Daddy, why can’t they put my asthma medicine in a spray-can like they do hair spray?”
Stein et al. on The History of Therapeutic Aerosols: A Chronological Review
In 1955, a young girl asked her father a simple question and a few months later, the first MDI for asthma was developed.
Can asking a simple question about asthma inhalers get us such quick results today?
Why isn’t someone making inexpensive asthma inhalers?
Teva did recently get approval for their AirDuo brand and generic inhaler.
A combination of fluticasone propionate and salmeterol, AirDuo is similar to Advair. It is different in that the three strengths of AirDuo (55/14, 113/14 and 232/14 mcg) don’t exactly match the three strengths of Advair (45/21, 115/21 and 230/21 mcg), but at about 25% of the cost, few folks likely care. They might care that AirDuo is only available in a RespiClick version (a dry powder inhaler), and so can’t be used with a spacer.
Ironically, Teva’s AirDuo generic inhaler, a combination inhaler, is less much expensive than their QVAR inhaler, which only contains a steroid.
We will hopefully see more generic versions of more inhalers, including more that stay in a traditional non-breath-actuated, non-DPI form. And more asthma inhalers that are much less expensive.
What to Know About QVAR Being Redesigned
The redesign of QVAR and other asthma inhalers to breath actuated and dry powder versions can mean that they can’t be used with spacers and so can’t be used by infants, toddlers, preschoolers, and younger school aged children with asthma.
More on QVAR HFA Being Redesigned
- Here’s Why Your Asthma Inhaler Costs So Damn Much
- AAP – Asthma Medicines: Long-term Control
- AAP – Allergy and Asthma
- CDC – Know How to Use Your Asthma Inhaler
- NIH – Guidelines for the Diagnosis and Management of Asthma
- AAP – Asthma Guideline Implementation
- Asthma Medications
- QVAR RediHaler Video
- Show and Tell: Teaching Children with Asthma How To Use Asthma Devices
- How to use your inhaler
- Inhaled Medication Instructional Videos: Asthma
- CDC’s National Asthma Control Program
- Childhood Asthma Control Test for children 4 to 11 years old
- Help your child use their inhaler
- In-Check DIAL Inhaler Technique Training and Assessment Tool
- Study – Measurement of peak inspiratory flow with in-check dial device to simulate low-resistance (Diskus) and high-resistance (Turbohaler) dry powder inhalers in children with asthma.
- Review – Inhalation drug delivery devices: technology update
- Review – The History of Therapeutic Aerosols: A Chronological Review
- Study – Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs
- Generic Advair Coming in 2018: How You Can Save Now
- FDA Approves Xopenex HFA Generic for Asthma
- Teva Cares Foundation
Last Updated on May 27, 2019 by Vincent Iannelli, MD