OTC asthma inhaler pros and cons

Getting an asthma inhaler over the counter (OTC) may seem like a great way to avoid the expense, time, and inconvenience of a visit to the doctor for prescription medications. They can also be convenient if you’re traveling and don’t have your prescription rescue inhaler with you—you can just stop into a local pharmacy to buy one without a prescription. 

OTC inhalers are approved by the U.S. Food and Drug Administration (FDA) for relief of mild, intermittent asthma symptoms, like wheezing, cough, shortness of breath, and chest tightness. But before you get too excited about them, serious concerns about these OTC inhalers are reason enough to leave them on the store shelf in most cases. We’ll explain why and offer our thoughts on OTC inhalers for asthma.

OTC inhalers for asthma

Epinephrine is the active ingredient in OTC inhaled medications for asthma. Although it’s available as a solution for use in nebulizer machines under the brand names Asthmanefrin and S2, it’s also available as an inhaler. Primatene Mist is the only handheld OTC inhaler approved in the United States for temporary relief of asthma symptoms.

Primatene Mist

You may have heard of epinephrine for its use in pen injectors taken for severe allergic reactions, such as a bee sting allergy. It’s available in an inhaled form as Primatene Mist, a brand-name product with no generic alternative. Primatene Mist is the only OTC inhaler for asthma. Like all other inhalers in the United States, Primatene Mist is produced using hydrofluoroalkane (HFA) as the propellant (the spray that moves the medicine out of the inhaler) rather than chlorofluorocarbons (CFC), which are harmful to the ozone layer. 

Primatene Mist was actually taken off the market in 2011 due to CFC use and not reintroduced until 2018 in the HFA form. It is approved and labeled for use in patients 12 and older who have been previously diagnosed with asthma. In other words, you should not try Primatene Mist for any symptoms unless a healthcare professional has diagnosed you with asthma.

The manufacturer of Primatene Mist, Amphastar Pharmaceuticals, points out a couple of nuances of the device within its detailed instructions. It recommends that the device be shaken and then sprayed into the air once prior to using it for an actual dose. The inhaler comes with a spray indicator on the device that counts down in groups of 20 doses, starting with 160 sprays when new to zero when it is empty. This feature is akin to a dose counter on many asthma counter inhalers available with a prescription.

Primatene Mist dosing

Dosage instructions for Primatene Mist are as follows:

• Take one puff from the inhaler and wait one minute. If there is no relief after the first minute, take a second puff. 
• Repeat every four hours as needed for mild asthma symptoms.
• Don’t take more than eight puffs in a 24-hour timeframe.

Primatene Mist side effects

The inhaled epinephrine in Primatene Mist can cause side effects that include the following: 

• Tachycardia (fast heartbeat)
• Arrhythmia (irregular heartbeat)
• Paradoxical bronchospasm
• Increased blood pressure
• Tremor
• Nervousness
• Insomnia
• Seizure
• Headache
• Dizziness
• Nausea

Primatene Mist drug interactions

Medications you should not take with Primatene Mist include the following:

• Alpha blockers
• Beta blockers
• Levothyroxine
• Monoamine oxidase inhibitors (MAOI)
• Serotonin/norepinephrine reuptake inhibitors
• Tricyclic antidepressants

Primatene Mist contraindications

You should not take Primatene Mist within two weeks of MAOI use. You should also avoid it if you have any of the following health conditions:

• Heart disease
• High blood pressure
• Diabetes
• Glaucoma
• Prostate hypertrophy
• Seizures
• Thyroid disease

Primatene Mist cost

The average retail price of Primatene Mist is about $52. Coupons can lower the cost.

Asthmanefrin and S2

Although not handheld inhalers, Asthmanefrin and S2 are nebulizer solutions sold in 0.5-milliliter vials for intended use with nebulizers—devices that turn the solution into a mist or vapor that is inhaled.

Asthmanefrin and S2 are approved as OTC products for the relief of mild asthma symptoms in patients ages 4 and older. Healthcare providers occasionally administer these products off-label for croup at even younger ages. 

Asthmanefrin and S2 have similar side effects, drug interactions, and contraindications as Primatene Mist. 

The average retail price of Asthmanefrin is about $42 for 30 vials, and the average retail price of S2 is about $76 for 30 vials.

What you should know before buying an OTC asthma inhaler

All of the products mentioned above rely on epinephrine as the active ingredient. Epinephrine stimulates adrenergic receptors in the body in a nonselective manner, meaning it activates alpha, beta-1, and beta-2 receptors. The desired effect is to stimulate the beta-2 receptors, relaxing the spasms in the smooth muscles surrounding the bronchial tubes and opening the airways. However, when used as a bronchodilator, epinephrine also stimulates alpha and beta-1 receptors, leading to potential adverse effects like tachycardia and elevated blood pressure.

The side effects are just part of the story as to why many asthma experts feel that OTC epinephrine inhalers are unsafe. Other concerns include overuse of the products when the patient should instead be using a prescription asthma controller medication under the care of a healthcare provider. Another fear is that it could lead to a misdiagnosis of heart disease, which can manifest as shortness of breath and mimic asthma. If someone uses an OTC epinephrine inhaler in this scenario, the untreated heart problem could worsen as a result.

Cumulatively, these concerns led the American Thoracic Society and the National Asthma Education and Prevention Program to recommend against OTC epinephrine inhalers. Despite the controversy, the FDA explained in a 2018 statement that patient access to OTC medications was a compelling reason for approving Primatene Mist for asthma relief. Taking the product only under the supervision of a healthcare provider and as part of an asthma management plan were cautionary notes in the FDA’s statement.

Alternatives to OTC inhalers for asthma

Fortunately, albuterol is an effective and safe alternative to OTC epinephrine inhalers for asthma. It is available in inhaler and nebulizer solution forms as a bronchodilator for people with asthma or chronic obstructive pulmonary disease (COPD). Albuterol Sulfate Hfa inhalers come with a counter in them that displays how many doses are left. Most importantly, albuterol is a selective beta-2 receptor stimulant with less risk of adverse heart and blood pressure effects than nonselective stimulants. 

The downside is that albuterol is available only with a prescription. Still, given the need to use beta agonist rescue inhalers in a comprehensive asthma treatment plan, any potential inconvenience of a call or visit to the doctor is worth it whenever possible. If the cost of albuterol is a concern, consider using a SingleCare discount card for a lower price.

Bottom line

Although it may seem like OTC asthma inhalers provide an accessible and affordable treatment option, they pose a risk of significant side effects and the likelihood of misuse if not guided by a healthcare professional. The best way to weigh the pros and cons of OTC asthma inhalers is to get your healthcare provider’s medical advice. Be sure also to keep your medical team updated on how often you use a rescue inhaler, whether it is OTC epinephrine or prescription albuterol.