The Clean Air Act and an international environmental treaty have led to the phaseout of chlorofluorocarbon (CFC)-propelled inhalers by December 31, 2008. This change will have an enormous effect on the estimated 5 to 10 million U.S. children with asthma. Highlights of the FDA Public Health Advisory and news alert include the following:

• CFC inhalers are harmful to the environment because they deplete the ozone layer.
  
• Hydrofluoroalkane (HFA)-propelled albuterol inhalers will replace CFC inhalers, and healthcare professionals should transition patients now.
  
• Three HFA albuterol inhalers are approved by the FDA:
  

— Proair HFA Inhalation Aerosol

— Proventil HFA Inhalation Aerosol

— Ventolin HFA Inhalation Aerosol

• One HFA levalbuterol is approved by the FDA:
  

— Xopenex HFA Inhalation Aerosol

• Priming and cleaning instructions to prevent blockage differ for each of the four HFA devices and will require patient education.
  
• The FDA reports an adequate supply of HFA inhalers.
  

Comment: HFA-propelled albuterol inhalers are two to four times more expensive than CFC inhalers. Whether physicians decide to change patients from CFC albuterol inhalers to HFA inhalers or to increase use of inhaled corticosteroids (ICSs) will be interesting. In my reading of asthma guidelines and related editorials, I sense concerns that many children with asthma are undertreated — that is, maintained on β-2 agonists when ICSs would be more appropriate. The recent NIH asthma guidelines (JW Pediatr Adolesc Med Oct 31 2007) certainly imply that ICSs, rather than β-2 agonists or leukotriene inhibitors, are indicated for children with intermittent moderate-to-severe asthma and persistent disease.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine June 18, 2008