combivent inhaler

Hi i just wondered as the combivent inhaler is no longer available after June what they were being changed to. I have received a letter from my surgery today asking to go next week to find an alternative to it. Was wondering what other inhalers are out there.Nikki xx

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I think the alternative would be to have Atrovent and Salbutamol separately?

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You will still be able to have the drug as its constituent parts - i.e. a salbutamol inhaler and an ipratropium inhaler.

Other suggestions put forwards for people with COPD is to switch to just one or the other, or a long-acting drug such as tiotropium (Spiriva) every morning, with salbutamol as required.

HTH,

CathBear.

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Is the Combivent neb being stopped aswell?? Just wondering if anyone knows??? Hope not

[Aisling30 in reply to Hidden]

no I use the Combuvent nebules when I am really bad which is very rarely thanks to the new Revlar Ellipta. I aldo udually have to take one puff of Atrovent now and again depending on how my chest is because you only take Revlar once per day!

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I take atrovent and salbutamol seperately as well as Seretide. Keep being told that atrovent is not for asthma, but it seems to work and my asthma nurse seems happy for me to carry on taking it. I am trying to reduce it at the moment, but very gradually. Apart from the pain of extra inhalers it seems to work well. Do you take any other meds? Is your for asthma?

[Aisling30 in reply to Hidden]

I think Atrovent is a very good inhaler for asthma,as Ventolin does nothing for me. One puff can do me 6 hours on a goid day!

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Combivent nebules aren't being discontinued - only the inhaler.

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Thanks everyone for your replies . i now have a Spiriva inhaler to take . Nikki xx

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Boehringer Ingelheim did this with Duovent a few years ago. They discontinued it due to CFCs without releasing a CFC free replacement. I find it completely disgraceful that they do this. At least when they discontinued Duovent they still had the similar Combivent available, but it looks like there isn't anything else with a combination of salbutamol and ipratropium bromide (Combivent) or fenoterol and ipratropium bromide (Duovent) available in the UK. Boehringer Ingelheim do produce a CFC free fenoterol/ipratropium bromide inhaler - called Berodual Respimat (respimat.com/com/Berodual/s... - but it's only available in Germany!

The Spiriva which the first poster has been prescribed as a replacement contains tiotropium, a long-acting bronchodilator very similar to ipratropium bromide (Atrovent). This is useless during an asthma attack as it takes too long to work, as I'm sure anyone who has used Atrovent can testify. You need a fast-acting bronchodilator too, such as salbutamol or fenoterol.

I have tried many inhalers and have found these medications in combination inhalers to be the best way of managing my asthma. The long acting ipratropium bromide and fast acting feneterol/salbutamol work much better for me than a steroid preventer and a salbutamol reliever or Atrovent/Salbutamol separately. A paper was also published in the BMJ recently stating that combination inhalers improve asthma control (bmj.com/cgi/content/extract....

It will be impractical to carry around Atrovent and salbutamol inhalers separately, and have to take a puff on each, so I hope something is done to rectify the situation. As far as I know there isn't a CFC free version of Atrovent so that will be discontinued soon too.

If you are a Duovent/Combivent user, and would like the Berodual Respimat to be available in the UK mention it to your doctor. Also email Boehringer Ingelheim at [e-mail] telling them you want it in the UK.

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Thank you for making us aware of the existence of this other product, Biff.

Firstly, I'm going to start by reassuring people who are worried that the Atrovent inhaler is going to be discontinued. The Atrovent inhaler is already CFC-free, so there is absolutely no danger of it disappearing off the market as the Montreal Protocol comes into force.

I'm a little puzzled by Biff's comments that Atrovent is ""useless in an attack because it takes too long to work"". Atrovent's onset of action is approximately 5-15 minutes - the same as salbutamol, and it is in fact frequently used by nebulisation during acute mod/severe attacks. It inclusion with salbutamol in the Combivent inhaler was with the purpose of prolonging the bronchodilation period of the salbutamol itself. Granted, not everyone will feel Atrovent is effective for them. Tiotropium (Spiriva), on the other hand, is not and never has been a treatment for acute attacks (and I would like to clarify that I did not suggest it as such); it is a maintainence therapy that may be suitable for those who are on maintainence treatment with Combivent (as compared to using it for reliever therapy).

I'm afraid, Biff, that you've quoted the BMJ paper completely out of context. That paper is concerning the use of the steroid and long-acting beta-2 agonist inhaler, commonly known as Symbicort, as both a preventative and relieving therapy. You cannot simply extrapolate the results of this study to Combivent, as Combivent contains no steroid component and as such does nothing to control the underlying inflammation leading to bronchospasm. The reason Symbicort used in this way (the SMART system) improves asthma control is that, as your reliever use increases, you increase your steroid dose - thus appropriately treating an increase in inflammation in the lungs.

CathBear

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Hi cathbear, thanks for your reply.

I was prescribed Atrovent when Duovent was discontinued a few years ago and didn't find it anywhere near as effective as Duovent or Combivent. I think it’s disgusting that a company can withdraw a medicine people rely on because of CFCs (it is still debatable that CFCs harm the Ozone Layer) without providing an alternative.

Using a combination inhaler – whether containing steroids or not – is better for controlling asthma in people who need to use a reliever daily as they will take the longer acting beta-agonist at the same time they feel the need to use their reliever. They then don’t need to remember to use a preventer every morning, which many people forget to take. I’ve also personally found steroid preventers don’t help me that much and make my breathing worse for several minutes after taking them. I’m not happy taking a steroid based medication on a regular basis over the long term either. I only use my Qvar on days that I think breathing might be a problem, mainly during the Summer. Like I say though, I don’t find it helps a great deal.

We need to lobby the relevant people to get Berodual Respimat available in the UK. I don’t know how many people used the Duovent? I used it ever since I was a first diagnosed with asthma as a child and would love to be able to have an inhaler with the same active ingredients again.

I don’t know how much weight Asthma UK have and if they would be able to lobby for us?

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Hi Biff,

I’m sorry to hear that you’ve had some problems since Duovent was withdrawn.

Like Cathbear, I’m a little puzzled by some of your assertions, and concerned that you may be under-treating your asthma, with potentially dangerous consequences. You comment that ‘using a combination inhaler – whether containing steroids or not – is better for controlling asthma in people who need to use a reliever daily as they will take the longer acting beta-agonist at the same time they feel the need to use their reliever’. I’m afraid that there is simply no evidence to support this statement.

First of all, Combivent contains no long-acting beta-agonist. Its active ingredients are salbutamol and ipratropium, both of which are (and will continue to be, for the foreseeable future) available as separate inhalers. There is no evidence to suggest that using these drugs as separate inhalers will result in worse control. Apart from the very slight inconvenience of carrying around two inhalers instead of one, this should be a very viable alternative for the minority who have been using Combivent and want to continue to take ipratropium as well as salbutamol in an acute attack.

There is a small amount of evidence that combination inhalers containing *steroid* and long-acting beta-agonist improve control, particularly if used in a flexible dosing regimen such as the Symbicort SMART system. However, as Cathbear has said, you cannot generalise this to combination inhalers containing entirely different active ingredients.

If you are needing to use your reliever daily, you are putting your health at risk by not taking regular inhaled steroids. There is evidence of an increased death rate in asthmatics who are over-reliant on beta-agonists without using steroids. Modern inhaled steroids are very safe and have a minimum of side effects. If you are finding that you are getting some paradoxical bronchospasm in the minutes after using your steroid inhaler, it may be that the propellant or the delivery device doesn’t suit you – it should be possible for your GP to find you an alternative that does not cause this effect. I’m not surprised that you currently find that steroid inhalers don’t help you much, if you are using them on an ad hoc basis when you feel your breathing might be a problem. The effect of steroids on damping down the inflammation in the lungs occurs after regular use, not after one-off use on a bad day.

I suggest you go back to your doctor and discuss your concerns. Hopefully you can find a way of managing your asthma that works for you and doesn’t put you at risk.

Em H

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Hi EmilyH, thanks for your concern.

I did use Qvar regularly for a few months but didn't find it helped much. It is only recently that steroid inhalers have been used. In the past people just used relievers to control their asthma. This is what I had done for many years until Duovent was discontinued. I might give it another go but I'm not happy taking a steroid based medication everyday on a long term basis.

I shouldn't have said that ipratropium bromide was a Beta2 agonist, it is actually an anticholinergic and is a maintenance drug that lasts several hours. It takes 30 minutes to an hour to start working though so is no good if you need to relieve symptoms quickly during an attack. I've used salbutamol on its own before during an attack but find the combination of salbutamol or fenoterol with ipratropium bromide to be more effective.

I will probably end up having to get separate ipratropium bromide and a salbutamol inhalers but it would be far more convenient to have them combined in one device. I just find it amazing that a company can stop producing a medicine many people rely on and are used to without providing a similar alternative. We need to lobby for Boehringer Ingelheim to produce a CFC free Combivent and to release the Berodual Respimat in the UK.

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Just to clear something up; the clinical pharmacology of ipratropium bromide (Atrovent) via inhalation:

Onset of action 5-30 minutes after inhalation.

Peak effect occurs at approximately 60-120 minutes.

Duration of action 3-8 hours.

Incidence of systemic side effects is extremely low following inhalation. There is no evidence that in the therapeutic dose range ipratropium has any adverse effect on sputum viscosity or volume.

Compared with salbutamol:

Bronchodilation usually starts within 3-5 minutes

Peak effects at 15-20 minutes.

Duration of effect is approximately 4 hours.

Both drugs are suitable for acute attacks, and augment each other. Neither can be classed as a preventer or should be used alone as a maintainence drug (when I mentioned this before I perhaps didn't make it clear that I meant maintainence in addition to regular steroid medication etc) - as EmilyH points out, over-use of a reliever medication without suitable preventative therapy is a risk for acute attacks and even sudden death from asthma, and is worrying.

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Hi Biff,

I’m afraid it’s not true to say that steroids are a recent treatment for asthma – the first recorded cases of using cortisone for asthma were reported in 1952 and the first use of inhaled beclomethasone occurred in 1972 (Brown HM, Storey G, George WH. Beclomethasone dipropionate: a new steroid aerosol for the treatment of allergic asthma. Br Med J. 1972 Mar 4;1(5800):585-90). There is abundant evidence for the safety and effectiveness of inhaled steroids in asthma, and considerable evidence for increased risk of death in people relying only on reliever medications. It is of course entirely up to you whether you use a steroid inhaler for your asthma – no-one can force you to do so – but the evidence overwhelmingly points in the direction of using one.

As Cathbear has already pointed out, ipratropium does not take 30 minutes to an hour to have an effect, it is much more rapid than that, which is why it is used via nebuliser in the emergency treatment of asthma. It is true to say that its maximal effect is felt within 30 – 60 minutes, which is perhaps where you are getting confused – similar is true of salbutamol, but both would be expected to have significant bronchodilatory effect within 5 – 15 minutes.

I find your thoughts on ipratropium a little contradictory – if you believe that it is ‘no good if you need to relieve symptoms quickly during an attack’, I am not sure why you believe that the combination of salbutamol and ipratropium is better in an acute attack than salbutamol alone.

Personally, I don’t believe that Boehringer Ingelheim have acted inappropriately – Combivent is an inhaler which is declining in use (as there is little evidence to support the use of ipratropium regularly in asthma) and it simply would not be economical for the drug company to pour resources into developing a new delivery device for a drug which is going to give diminishing returns. There *is* a viable alternative – using the two inhalers separately, which I really do not see as that inconvenient – so I am afraid it is not realistic to expect Boehringer Ingelheim to develop a CFC-free version. As I said before, they were *legally* obliged to stop producing CFC-containing inhalers, so there is really very little they can do about the issue.

I am sorry that you are unhappy with your current asthma treatment, but I am not sure that lobbying drug companies is the way forward. A constructive discussion with your GP about which treatments would be most appropriate would probably be a good idea.

Em H

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I don't know why the combination works better for me but it does. Maybe together they are more powerful. My experience of taking Atrovent and Ventolin individually didn't produce a quick relief of my symptoms. Combivent and Duovent relieve the symptoms in seconds.

The main point I was making about Boehringer Ingelheim isn't to produce a new inhaler, it is to provide the Berodual Respimat - which is available in Germany - to UK asthma sufferers too.

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I'm sure Boehringer would be only too happy to allow Berodual Respimat to be prescribed in the UK - more money for them! I imagine the ultimate decision would fall to the MHRA rather than the manufacturer.

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I am on Spriva, a blue capsual you put into a disc and inhale the powder. It seems a very old fashioned way. My friend has a Spriva inhaler that is a lot more better ie a spray. Could anyone explain why the differance, is it cost?

Sheila

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Just found these guidelines which the NHS are using in preperation for the discontinuation of Combivent.

elmmb.nhs.uk/search?q=combi... (top link under ""Assets"")

Apparently, Combivent is meant to be used for COPD rather than asthma. I only started using it a few years ago as it was the closest thing available to the Duovent, which I used since I was first diagnosed with asthma at around seven years old. I'm not sure why I was prescribed Duovent back then as most other kids had Ventolin, but I have tried Ventolin a few times in recent years and haven't found it as effective.

It's NICE (nice.org.uk/) who are responsible for providing pharmaceuticals to the NHS, so I guess it's NICE who need to be contacted. Berodual Respimat is the natural successor to Combivent and Duovent and I don't see why they can't provide it instead of providing two separate inhalers? Surely one inhaler would be cheaper than two?

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Biff, whilst NICE advise on the cost-effectiveness and appropriateness of the use of medications, they have absolutely nothing to do with the availability of medications or technology within this country. Steve is quite correct in that it is the MHRA who provide licences for medications to be used in this country - without an MHRA licence, a drug cannot be sold/prescribed in the UK. As regards the costing of the inhalers - I can't price up a Berodual Respimat because it's not available in this country, but the closest thing, the Spiriva Respimat, comes out at £37.21 (net cost to the NHS) a time; an atrovent MDI costs £4.21 and a salbutamol inhaler costs £1.50. The Berodual Respimat may be even more expensive than the Spiriva Respimat, because it contains two different drugs.

Jancy, inhalers are usually prescribed in terms of the appropriateness of the device and its delivery of medication to the patient on an individual basis. Whilst the Spiriva Handihaler may feel like an old-fashioned inhaler, it's only been around for a few years now. Some people get on better with the dry-powder inhalation, some prefer the aerosol. The Respimat is a very new delivery system, and its recommended dose (2 puffs in the morning) delivers roughly half the amount of drug you'd be getting from one capsule of the Handihaler. Working on this basis, if you wanted the full dose you were getting from the Handihaler, but wanted to use the Respimat, you'd need to have four puffs of the Repsimat each morning. On this basis, yes, it would work out more expensive; however I doubt that cost would be the main determiner of device in this case. Hope this helps and hasn't confused too much!

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I'm sure you are right about Berodual Respimat being more expensive as it's new and isn't manufactured in as large quantities as Ventolin and Atrovent. Hopefully it will be available in the UK at some point as carrying around and using two inhalers will be a pain in the arse.

Here's some info on ipratropium bromide and a beta2 agonist being more effective than a beta2 agonist alone:

clinicalevidence.bmj.com/ce...

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Unfortunately I don't have a subscription to BMJ Clinical Evidence, but from what you say the article probably covers the point we discussed earlier - ""(atrovent's) inclusion with salbutamol in the Combivent inhaler was with the purpose of prolonging the bronchodilation period of the salbutamol itself"". For most people, a beta-2 alone is sufficient for symptomatic relief, but there will be a niche of people who find the two necessary.

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I do have a subscription to BMJ Clinical Evidence. The article you cite concerns the use of ipratropium in addition to a beta-agonist in children being treated for severe exacerbations of asthma in A&E. I would be cautious about generalising this effect to adults suffering from mild to moderate exacerbations. In addition, the article has nothing to say about combination inhalers as opposed to two different inhalers or nebulisers.

While I am not disputing the fact that some people, including yourself, clearly do find the combination inhaler more effective, I don't believe there is enough evidence of a significant effect to influence national policy, especially as introducing the Berodual Respimat to the UK would probably increase costs to the NHS. I am afraid the very minor inconvenience of having to carry two inhalers is unlikely to influence the MHRA or NICE to change their policy, either - in terms of health economics, it simply doesn't make good sense.

Em H

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There are a good many posters to this message board who would love it if their daily carry-about medication was only two inhalers! Nebulisers, epi-pens, sub-cut infusions, tablets, oxygen cylinders; really, you are one of the luckier ones.

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Oh Steve, let me think for football (high risk cold air excitement, etc etc) that would be O2 cylinder (in its own bag with conserver), portable nebuliser, spare O2 cylinder in case of high flow nebbing needed, box of salbutamol nebules, couple of atrovent nebules, sub cut pump, spare syringe, needles, giving sets, small sharps bin, box of bricanyl (in case I go in they never have the damned stuff), epipen x 2, spare neb acorn and tubing, spare batteries, SATS monitor. No wonder my son says he gets back ache

Oh almost forgot anti-histamine tablets.

Bex

[KateMoss]

Bex & Steve - you beat me to it!

I too carry around in my large roomy handbag / small rucksack - Nebuliser, ventolin inhalers, 2 epipens, piriton, other spare meds, s/c bricanyl for emergency use, spare needles when using s/c ventolin syringe driver.

Oxygen and sometimes a wheelchair!

Perhaps if you want to mix the ventolin & Astrovent - use a spacer and put a squirt of each in quickly and inhale! (NOT a medically aproved method!!!) Oh but then you will have to carry a spacer....

Kate

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hmm have been watching this thread and am glad to see others feeling the same way I do. Biff some asthma suffers have no choice about the amount of inhalers or medical equipment they need to carry, even if they want to just pop out for 5 minutes. Although not on the same scale as some of the regular posters on this forum here is an example of the daily contents of my bag:

Aerochamber

Ventolin inhaler x 2

Atrovent inhaler

Bottle of Piriton syrup (can't have the tablets) + spoon / syringe

Spare Cetirizine tablets incase I need to increase my dose for an urticaria flare up

Small tube of Diprobase

Anapens / Epi-pens x 2

I would love to be able to leave the house with just my keys and one inhaler in my pocket but I know thats not going to happen!

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Yes, I would love to ditch the 5kg 50cm tall oxygen cylinder, among other paraphernalia, as well as the wheelchair, but as Sparkly Fairy says, it's not going to happen!

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maybe the mild/moderate asthmatics should stop being compared to the severe/brittle asthmatics, what may seem like a small amount of medication to carry around for a brittle astmatic might seem like a large amount to a milder asthmatic, but that does not mean that what they carry around is any less significant and it should not be a competition on who carrys around the most medication!

we all have asthma or know someone who has asthma on these boards and we should be supporting each other not having medication competitions!

Lejaya

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I don't think it should be perceived as a competition, and I don't think the recent posters intended it as such. I am sorry if my post gave that impression.

The point is more that since having to carry two inhalers is relatively easy in the scheme of things, it's unlikely to be a major influence in changing national policy to enable the use of a more expensive combination inhaler with no proven clinical advantage, which is the subject that has been under discussion.

In terms of health economics, the range of experience of other asthmatics *is* relevent, since that is one of the criteria used in the assessment of the effect on quality of life (and thus 'Quality Adjusted Life Years', the main outcome measure that health economics uses). It is common to compare the side effects and 'inconvenience' factor of a treatment to other treatments for the same condition. I know it seems harsh to apply economic thinking to quality of life issues, but that is the reality of treatment in the NHS, where there are limited resources.

I hope this explains things a little more clearly.

Em H

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Lejaya I have removed my post, it was supposed to be slightly tongue in cheek. You obviously have a very poor opinion of myself and Kate if you think either of us would ever try and start a drug competition.

Bex

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I didn't actually say any names when I wrote my post, I meant gernerally thats how some of the posts came across. and I also didn't mention wether experience was relevant or not I simply said that it is not right to compare mild/moderate asthmatics to severe brittle asthmatics because everyones asthma is different, and effects them differently.

I just think that everyone should be entitled to make their own opinions/statements etc without being compared to everyone else, but clearly I have offended people yet again so I will not post on here anymore

Lejaya

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Thank you, Bex, although I agree with Em and there was no need for you to do so.

In the grand scheme of things, changing from carrying around one inhaler to carrying around two is not a significant step - it is, after all, not a change in the medication that Biff requires, just a change in the way it is delivered.

There is a point in the T&Cs that mentions maintaining ""respect for other people"", and this is very much a two-way street. Bex, Kate, SF and Em were being tongue-in-cheek but also making a valid point; there has been a lot of circuitous discussion on this thread, and both Cathy and EmH have had to clear up the inaccuracies posted.

Bex, Kate, SF and Em have pointed out how bad things *can* be for an asthmatic, and I don't see how what they have posted can be construed in any other way; certainly I can't see that it is in any way competitive - they are merely pointing out the amount of meds they have to carry around, and letting Biff know that his situation isn't that bad after all - surely this is a good thing?

Lejaya - please reconsider; this is a discussion board so naturally people will tend to disagree with one another - if we all stopped posting when that happened there would be no-one left on the boards!

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Lejaya my response to this thread was by no means an attempt to compete with the users of this forum and I apologise if it came across that way. My asthma is not brittle and is much milder than many of my friends some of whom carry sub cut infusions or oxygen with them 24hrs a day.

I appreciate your view point but when I originally read this thread it upset me a little as the discussion seemed to focus around the inconvenience of carrying two inhalers. What I tried to do in my response was explain and raise awareness that for some of us it is a case of necessity to carry a fair amount of medication / equipment with us. I've actually been very upset by the suggestion that we are having a medication competition as that was definitely not what I was trying to achieve with my post.

I'm sorry if listing what I carry around in order to support my view point has caused you to think that I am trying to compete with other members here but I was trying to communicate my view point.

Recently there has been far too much reference to a division between severe and mild asthmatics on this forum and it is becoming increasingly difficult for those of us who either have or are close to someone with severe / brittle asthma to communicate our opinions without it being misinterpreted as a competition.

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Side issue my mind is rambling today but i find my wheelchair very useful for carrying all the stuff i have to carry around (allergy free snacks, toddler drink bottles, 3 sets of clothes nappies piriton neb epipens inhalers the list is endless) and end up walking....

I am currently carrying 3 spacers with 2 sizes of face mask and one without as my children have inconveniently chosen to grow at different rates and all need different sizes.

I am running sunday school today (first time in months and yes it's stupid and yes i still have a cast on my broken leg) and have just realised i will be taking a large handbag, baby bag and a tote full of craft stuff and cooler with packed lunch.How i am supposed to carry this on crutches i don't know. I am officially a bag lady.

In my circle of lots of mums even non asthmatics have to carry a lot of stuff.

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Hi folks,

I'm new to this forum - my mum has had asthma since she was 4 (a grand total of 67 years now!), but now has COPD - and she's really worried at the withdrawal of Combivent. I've had a read of this thread, and it seems that others find the same as my mum does - that for some reason, the combined inhaler works for her.

It's a massive shame that when my mum's medication has finally reached an even keel and her illness is actually being managed that everything is going to change again. She's worried with a Capital W.

Anyway, my sister has started a petition to see if something can be done to extend the manufacture period of Combivent until a replacement is found. If you'd like to sign it, here's the link:

petitions.pm.gov.uk/combivent/

I've no idea how much good these petitions do, but I don't see any harm in it, and if there's even a chance it can help keep my mum healthy for a while longer then heck, i'm all for it!

Wishing you all health,

Sam

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