Pharmac under fire again over asthma inhaler

Controversial medicine inhaler Salamol has been linked with deteriorating control of asthma in a study that has unleashed fresh criticism of Pharmac.

Last year Pharmac planned to subsidise only one metered-dose salbutamol inhaler, Salamol, which would have forced more than 500,000 patients who used the Ventolin brand to switch or pay its full price.

After more than 700 complaints that Salamol was ineffective, tasted bad or that its spray got blocked, Pharmac backed down and kept subsidies on both - temporarily.

Ventolin's maker GlaxoSmithKline, after deciding against withdrawing the medicine, would not supply it at the new, lower subsidy, leaving patients to pay a part-charge of around $4 - in addition to the $3 to $15 prescription charge.

In today's NZ Medical Journal, Northland GP Dr Shane Reti reports on a study of 36 of his patients, acknowledging its weaknesses and concluding that Salamol was less effective than Ventolin.

"This could be due to several factors including true differences in active ingredient efficacy, physical differences in inhaler devices, and subject-related change anxiety."

In a related editorial, Auckland University paediatrician and asthma expert Professor Innes Asher says the new findings add to concerns about the clinical effectiveness of Salamol and urged more research.

She says Salamol inhalers are more likely to block, citing a university engineering department analysis showing their dispensing ports are less than half the size of those on the Ventolin devices.

"Many people do not clean their inhalers according to instructions. Those using Ventolin MDI appear to get away without washing them, and may not need to, whereas clearly some Salamol users do not."

Asthma NZ executive director Gerry Hanna said Salamol problems were still leading to hospital admissions for children and demanded Pharmac become less focused on price when changing drugs. The agency was again considering a sole supply contract for salbutamol, he said.

"Don't they ever learn?" he asked.

Asthma societies would be sent a copy of Dr Reti's study to renew the fight against subsidising only Salamol, he said.

Pharmac's medical director, Dr Peter Moodie, said Dr Reti's study was interesting, but he questioned its importance: "Half the patients seemed to have possibly poorly controlled asthma to start with."

He reiterated that Salamol was "bio-equivalent" to Ventolin and safe if the instructions were followed.

Inhaling Salamol, which has traces of alcohol, puts the user briefly over the breath-alcohol limit, a study found. A Christchurch Hospital study of 16 people concluded that "in all normal subjects their breath test was negative after three minutes and at least a five-minute wait post Salamol inhalation is necessary before roadside breath test ... otherwise a failed breath test is likely."

Pharmac said users simply needed to explain to police if they had used Salamol recently - or alcohol-containing cough mixture.


The results

* 36 asthma patients switched from Ventolin inhalers to Salamol for four weeks.
* 6 withdrew - 5 citing ineffectiveness of Salamol, 1 its unpleasant taste.
* 15 could not maintain Salamol alone, using Ventolin at some point. Of these, 10 cited Salamol's ineffectiveness, 1 an inhaler blockage.
* 14 of the 15 who stayed on Salamol had worse asthma stability (2 because of a chest infection).