The Wild & Crazy World Of Inhalers

My wife had asthma as a kid and it has been coming back recently, usually when it’s time for the dog to have a bath. Every few weeks she gets a mild attack, and the last time it happened (during a snow storm) I asked her “well, can we do something about this instead of just waiting for it to pass? What did you do in the past?”

That resulted in my heading out to buy an over-the-counter (OTC) inhaler for mild cases such as hers—only to find out that at 4 out of 4 stores I visited, after being told the aisle in which I could find them, they were no longer stocked. None of the pharmacists seemed to have a clue as to why, though the last one believed they had been discontinued…but didn’t have any details. The only alternative? Being told that perhaps taking some medicines designed to treat a multitude of unrelated things might help, or taking the one product I could find (in only 1 of the 4 stores) that was supposed to treat asthma….which turned out to be a pill, subsequently took hours to kick in, and kept my wife up all night.

We had no idea why OTC inhalers were no longer available, just that they weren’t—and nobody seemed to know why. Even those who really should be in the know said it was a pretty mysterious thing and didn’t have any additional insight. To me, that felt like reaching out for a banister that had always been there—and finding it missing. It would only take escalation of a few conditions to turn that into a trip to the emergency room instead of just up to the drug store. I want to know why I can’t get that good hot salsa at my local grocery store anymore, but I really want to know why I couldn’t get my wife something she had previously relied on when she was short of breath and there was no decent substitute. Not only does the lack of communication feel insulting and make me resent those responsible, it’s downright dangerous. When they discontinued the contraceptive sponge, everyone knew it—where was the communication this time?

So I turned to my most reliable source of information—Crazy Aaron, who, before I ever even asked him, sent me an article he had read in “Spray – Technology & Marketing for the Aerosol Industry” (I kid you not), because he was intrigued by the human factors issues involved with the discontinuation of CFC emitting inhalers. You can’t make this stuff up.

Spray didn’t provide an answer as to why there are no new OTC inhalers (although the change from CFC is probably at the root of it), but it seems that the folks in charge of the change-over to the new HFA 134a-propelled prescription inhalers (buy stock!) missed a few opportunities when switching to the new product. New mandates were designed to improve the product, but resulted in a bit of a bumpy rollout (particularly for life-long users of the previous versions) due to a lack of understanding of the full needs and habits of the audience. Here’s what some good solid user-testing could have helped avoid/better manage:

1. Dose Counter

Older products would, as you got close to the last few doses, become noticeably weaker—an indicator to replenish. A new regulatory requirement states that every dose has to be the same strength and potency. Sounds good on the surface, but how do you know when it’s kicked? You don’t, until it is. We can all infer the dangers of that scenario. Suggestions included telling patients that they’d have to keep track of the doses they’d already used themselves (not so user-friendly). But chalk one up for GSK: they are (so far) the only ones to introduce an inhaler that has a built-in clicker on the side that tells you how many times you’ve used it.

2. Taste

Apparently, the old stuff that everyone was used to had a mild taste of “rubber or cabbage”. Not ideal, but it went with the turf and people had learned to deal. There are two kinds of formulations available now—one without alcohol in it (which is more tasteless than before and interestingly garners mixed reviews for that reason), and one that has 10% ethanol and produces a burning sensation at the back of the throat and can taste weird due to impurities in the alcohol. Feels like we could have done better here.

3. Speed/Energy

Older products would give patients a “punch” of “chilled” air that many of them equated to it “working” and getting into their lungs faster. The newer products deliver a slower moving plume of air with finer particles in it, which has been proven to be more effective. However, many patients think it’s weaker and not working as well as the old ones. Sounds like solid communication and training could be the answer for that one.

4. Finer Particles = Nozzle Blockage

Those finer particles mentioned above? They get the medicine to the lungs more effectively, but they’re more likely to clog the nozzle—so now patients have to regularly clean it to prevent that, which is something they never had to do before. Is there a mechanical fix here that was too cost prohibitive to undertake? Is there some alternative to adding additional maintenance chores?

Beyond that are a few other issues like storage (the new inhalers are more susceptible to moisture and can be rendered ineffective more quickly depending on the environment) and even electrostatic charges making doses less effective. Did they miss the boat entirely? Absolutely not—the negative feedback came from a minority of patients, and we all know that when it comes to pharmaceutical regulations, you can have your hands tied in so many ways that you’re lucky if you ever get a helpful product to market, let alone one that doesn’t have associated gripes. But, things like the dose clicker in particular are easy wins that some more focus on the psychological needs of the patient, not just the physiological, can achieve.

Oh, and I never did find out for sure why OTC inhalers seemed to have vaporized. Anyone have any idea?