Guess Who's Back, Back, Back, Back Again... Primatene!?!

If you kept rapping along with my mini-parody of Eminem’s Without Me, please don’t tell a friend about Primatene Mist… unless it’s to educate them on asthma treatment! Yes, you read that right: Primatene Mist, of all things, is back on the shelves in the United States.

And no, it hasn’t got any less problematic, in my opinion. It’s just no longer full of chlorofluorocarbons, more commonly known as CFCs, the propellant that was phased out of use and ultimately banned from use in inhalers by 2013.¹ What’s Primatene? It’s an over the counter (OTC) asthma inhaler of epinephrine “for temporary relief of mild symptoms of intermittent asthma."

This means people can (inadequately) treat their asthma without intervention of a doctor.

Should we use over the counter asthma inhalers?

As a Canadian, I have little reason to know about Primatene Mist. Yet, as a Canadian who also exists in the online asthma space, I’ve learned enough about Primatene to find its presence both scary and indicative of a larger problem.

Primatene Mist is not available in Canada (of which I approve). I even texted a doctor-friend about it, and she had no idea what Primatene was. Things Health Canada does not approve are not generally scary. However why things are not approved in Canada should, at least, be contemplated. They are also worth considering because sometimes the reasons are unfounded—that is, there is no real reason something is NOT approved in Canada when it is approved elsewhere.

Most importantly, the reason I find Primatene Mist inhaler scary is that asthma is not an over the counter disease. Not even mild intermittent asthma.

Questioning inhaler accessibility

There are a lot of things that can be treated over the counter: allergic rhinitis, for one. I can, to a large extent, even get behind OTC nasal steroids because the safety profile for both nasal andinhaled steroids is so good. Another condition that I’d agree is treatable over the counter without physician intervention is mild eczema. Even after entering the “dark and scary” world of Google, I could find cases of zero cases where these diseases in and of themselves have killed anybody.

Asthma, though, unfortunately, kills lots of people, many of whom just don’t have access to medication. This is why Primatene is sadly attractive in the United States. Per Consumer Reports, Primatene Mist retails for about $20 per 270 puffs (more than most inhalers!)³. This is often less—sometimes far less—than what a medication co-pay would be for many Americans, never mind the cost of the doctor’s visit that is also required to get the initial prescription.

Conversely, at my pharmacy in Canada, a Ventolin inhaler’s label cost has ranged from—at its highest—$17.50, to as low as $13. Per some web-sleuthing, the same inhaler (with a strap cap and counter, neither of which we have on rescue inhalers in Canada) averages $72.75, a price that went up dramatically after the re-patenting of all CFC-free inhalers in or before 2013. And that’s without mentioning the exorbitantly high cost of controller inhalers.

However, when you just need medicine, you are not necessarily taking into account that inhaled epinephrine (Primatene Mist, Asthmanefrin) is less effective than albuterol at both prevention and treatment of bronchospasm.³

Over the counter inhalers are telling

Primatene Mist is the sign of a bigger problem.

In the absence of Primatene Mist, 13,000 members joined 3 prominent Facebook groups “petitioning” to bring back the drug. Call it Facebook Warrior-ism if you will, but this could also be considered to be the sign of a larger problem in the US healthcare system—the only country I could find where Primatene is available. That problem is, as always, the problem of money.

When healthcare is treated like a business or commodity rather than a right, people become desperate and have little choice but to cut corners. More and more, the corner they have to cut is medicine, as prices skyrocket out of control.⁴ Primatene Mist may be the way some Americans cut corners in their asthma care—potentially avoiding two co-pays for their doctor visit and prescription, or avoiding paying out of pocket for these things depending on the circumstance.

We need to address the bigger problem

Over the counter treatments for chronic diseases are not management, they are imperfect stopgap solutions for survival and, to a lesser extent, quality of life. This is seen in not only Primatene Mist, but also older OTC insulins like NPH and Regular for those with insulin-dependent diabetes. There are reasons these medications are no longer first-line treatment—they work just “well enough” given new, more effective or safer treatments are available. They work just “well enough” for cases where all involved—patient, pharmacist, physician—know they should be treated by a doctor, not over-the-pharmacy-counter.

This is the reality when patient lives are commoditized, especially in developed nations without national pharmacare/prescription coverage strategies (like both the US and Canada). And when costs skyrocket or insurance is unavailable due to pre-existing conditions—as it still is in Canada—patients become endangered one way or another. They receive inadequate treatment, are unable to pay for what they need, or they're trapped with dependence on health insurance tied inextricably to their jobs with few—if any—outside options.

Primatene Mist may be back, but that still doesn’t make it an effective way to manage the unpredictable chronic disease that is asthma.

Have you treated your asthma with an over the counter inhaler like Primatene Mist?