Over-the-counter inhalers: types, benefits and risks

While many asthma inhalers are available by prescription only, two are available over-the-counter in the United States: Primatene Mist (epinephrine) and Asthmanefrin (racepinephrine).

Over-the-counter (OTC) asthma inhalers can help treat, but not prevent, acute asthma attacks. Although not commonly recommended for the treatment of asthma, some people still turn to them due to their convenience and price.

These inhalers can have benefits, but there are also risks and they are not suitable for everyone. This article explores the pros and cons of these medications. It also addresses the controversy surrounding Primatene Mist and Asthamanefrin and what leading health experts are saying about the use of over-the-counter asthma inhalers.

Types of over-the-counter inhalers

The two over-the-counter asthma inhalers currently sold in US pharmacies — Primatene Mist and Asthmanefrin — are similar and may provide temporary relief from asthma symptoms.

These medications are approved by the US Food and Drug Administration (FDA) to temporarily relieve symptoms of mild intermittent asthma. It is an uncommon type of asthma that is considered the mildest form of the disease.

Primatene Mist

Primatene Mist is an over-the-counter asthma inhaler used for the relief of acute asthma symptoms. It contains a medicine called epinephrine (adrenaline) which acts on the airways, causing them to dilate (widen). Epinephrine is the same drug used in EpiPen auto-injectors which are used to treat severe allergic reactions.

Primatene Mist was pulled from the US market in 2011 because it was made with an aerosol propellant called chlorofluorocarbon (CFC) which was harmful to the ozone layer. It was later approved by the FDA in 2018 when it was made with a new propellant called hydrofluoroalkane (HFA) which is used in many other asthma inhalers.

Recommended dose

Primatene Mist is approved for adults and children 12 years and older. The recommended dose is 1 to 2 inhalations, not to exceed 8 inhalations in a 24 hour period.

Primatene Mist is not intended for long term use. Additionally, the FDA strongly recommends that you do not use Primatene Mist unless you have been diagnosed with asthma. This is because other conditions can cause symptoms similar to asthma, but need to be treated differently.

Asthmanefrin

Asthmanefrin is a CFC-free inhaler that works the same way as Primatene Mist. It contains a drug called racepinephrine which works similar to epinephrine but tends to be strong.

Asthmanefrin was introduced as a cost-effective bronchodilator in 2012, after Primatene Mist was discontinued. Although it appears to be useful in the treatment of mild bronchoconstriction (narrowing of the airways), it is generally less adept at treating bronchospasm (spasms of the airways).

Asthmanefrin does not come in a pressurized cartridge like Primatene Mist. Instead, it is sold in liquid form in a pack of 30 units for use in a portable nebulizer. This is a device that turns liquid into a fine mist for inhalation.

This makes Asthmanefrin a little less practical during an asthma attack than an HFA booster like Primatene Mist.

Recommended dose

Asthmanefrin is approved for use in adults and children 4 years of age and older. The recommended dose is one to three inhalations every three hours, not to exceed 24 inhalations in a 24 hour period.

As with Primatene Mist, Asthmanefrin is not intended for long term use and should only be used after being diagnosed with asthma by a healthcare professional.

Advantages

Over-the-counter inhalers like Primatene Mist and Asthmanefrin have some benefits. For many people who use them, the first is cost.

Primatene Mist currently sells for around $35 per cartridge. A box of 30 units of Asthmanefrin sells for about the same price.

The cost of prescription inhalers varies greatly depending on the type of inhaler. Rescue inhalers containing generic medications can cost about the same as over-the-counter inhalers. Meanwhile, branded rescue inhalers like Proventil (albuterol) and Xopenex (levalbuterol) are about twice as much.

Then you have maintenance inhalers, which are used regularly to prevent asthma attacks. Some of them cost $300 or more.

You also save money with over-the-counter inhalers because you don’t have to visit a health care provider to get a prescription. Although it saves the cost of an office visit or co-pay, it may not be the best way to treat your asthma.

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Side effects of over-the-counter inhalers

Artwork by Emily Roberts, Verywell

Just like prescription drugs, Primatene Mist and Asthmanefrin carry a risk of side effects.

Primatene Mist
  • Bad taste

  • Cough

  • Dizziness

  • Dry mouth

  • Headache

  • Nausea

  • Nervousness

  • Sore throat

  • Stomach ache

  • Sweat

  • Tremors

  • Sleeping troubles

  • Vomiting

Risks of using an over-the-counter asthma inhaler

Self-treating any medical condition poses significant risks, including:

  • Diagnostic error
  • Overdose
  • Underdosing

With over-the-counter inhalers, there’s another real concern: they may become less effective over time, but you may not realize this and continue to rely on them in a crisis.

If this happens and you have frequent attacks, your lungs may start to change and become more and more rigid as scar tissue develops. Over time, this can reduce your lung capacity, leaving you weak and short of breath even with moderate activity.

When Rescue Inhalers Are Not Enough

If you use a rescue inhaler two or more times a week or more than two nights a month, you should talk to a health care provider about starting asthma medications. These are inhaled, oral, or injectable medications used regularly (sometimes daily) to help control asthma symptoms.

According to a 2017 study published in BMJ open, people who use over-the-counter rescue inhalers are no more likely to have uncontrolled asthma than those who use prescription rescue inhalers. However, they are 70% more likely to need urgent asthma care within a year.

Conflicting opinions

When approving the “new” Primatene Mist in 2018, the FDA assured the public that, as with all approved drugs, Primatene Mist had undergone “rigorous scientific review to ensure that it is safe for use by patient”. That said, the FDA has acknowledged that only a “limited population” of people, namely those with mild intermittent asthma, would benefit.

Many medical professionals disagree.

In fact, the American College of Asthma, Allergy & Immunology, the American Association for Respiratory Care, the American Thoracic Society, and the National Association for Medical Leadership in Respiratory Care do not believe that over-the-counter inhalers of any so be sure. for the treatment of asthma.

For their part, the National Institutes of Health do not include Primatene Mist or Asthmanefrin in their Guidelines for the diagnosis and management of asthma.

Summary

There are two over-the-counter inhalers for the treatment of asthma in the United States. These are Primatene Mist, which contains epinephrine, and Asthmanefrin, which contains a similar drug called racepinephrine.

Although both are approved for use by the FDA, over-the-counter inhalers are only intended for short-term use for mild intermittent asthma. Most major health authorities, including the American Thoracic Society, advise against their use and argue that the risks of these inhalers (including an increased likelihood of a serious attack) outweigh the benefits.

A word from Verywell

It is important to remember that over-the-counter inhalers do not have the same proven benefits as prescription inhalers. Plus, in the end, they don’t necessarily cost less than generic inhalers like albuterol or levalbuterol.

To make an informed judgment, speak with your health care provider first.

Frequently Asked Questions

  • Are over-the-counter inhalers safe?

    Although there are no serious safety issues with the medications themselves, over-the-counter (OTC) inhalers may provide inadequate control of asthma symptoms. A 2017 study reported that people using over-the-counter inhalers are 70% more likely to need urgent care for asthma than those using prescription inhalers.

  • How much do over-the-counter inhalers cost?

    Cost is a major draw for over-the-counter inhalers like Primatene Mist and Asthmanefrin, both of which cost around $35. However, the savings are not what they used to be. You can now get prescriptions for generic albuterol inhalers for around the same price, and they are the treatment of choice for asthma attacks.

  • Is Primatene Mist the same as albuterol?

    No. Primatene Mist contains epinephrine, the same medicine used to treat severe allergy attacks. Albuterol is a short-acting bronchodilator that works by relaxing the muscles of the airways, reducing spasms and improving breathing.

  • Can I use an over-the-counter inhaler for COPD?

    No. Likewise, over-the-counter inhalers are not indicated for allergies, bronchitis, or non-asthmatic coughs.