What do Asthma and COPD inhalers have in common with Mexican food fast food?

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A 67 year old man came to see me recently, he had COPD, and found that it was getting harder to breathe. “I wanted to make sure that I’m on the right inhaler. My doctor switched me from Advair to Breo– is that better?

GSK would certainly say so, in fact their reps often do. Speaking with drug reps about their inhalers often makes me think of food. Actually I think of food quite often, but that’s more of a personal issue. Thinking of inhalers for COPD and asthma make me think of cheap Mexican food, specifically of the fast food variety. I think it has less to do with my poor dietary habits than the fact that I believe expensive inhalers have quite a lot in common with cheap Mexican food. 

Thinking about that patient’s question from the perspective of cheap Mexican fast food, switching from advair to Breo would be like ordering  one beefy rice burrito, only to be provided with two; but they would keep you full all day. Surely that’s an upgrade if there ever was one, and one which I endorsed. The problem though, and the real reason why he was asking, was not because he doubted the expertise of the prescribing physician but something else entirely. “It’s costing me $450 for 3 months. That’s more than triple what  the other one was. I guess I’ll pay for it if you think it’s worth it”

This was an especially unexpected twist, and not of the tasty cinnamon kind. No, that kind of dough busts straight out of the fast food genre into those fancy big-city restaurants, where it’s been said that they don’t even serve french fries. Like, you can’t even order them. 

But  again, I need to take this back to Taco Bell terms in order to wrap my mind around this. And to be clear I’m dumbing this down for my benefit not for yours, because if I can understand this, then certainly you can too. 

In the pulmonary world we have three classes of inhaled medications that are used in inhalers to treat COPD and asthma. Inhaled steroids, beta-agonists (albuterol), and anti-muscarinics (ipratropium).These three are the beans, meat and cheese, if you will, of our profession. These three chemical classes, released in the 1980’s in hand sized metered-dose  inhalers, revolutionized the treatment of asthma and COPD. The decades that followed brought further advancements in the form of long acting versions of these inhalers that could be taken twice daily instead of 4 or 5 times per day. 

I’m not much of a conspiracy theorist, but I do surmise that something happened  around that time. A pharmaceutical executive, I’m sure his name was Bob, got wind of a seminar that his fast food buddies had been attending. I can’t be sure exactly what it was called, but I’m guessing it was titled something like “Dramatically Expand Your Product Portfolio Using the Same Three Products” . With this newfound knowledge Bob moved his way up the corporate ladder, and found a way to make his company lots of money using the same three basic chemicals by putting them together in different ways. Over the years other pharma companies followed suit, sometimes combining a steroid with a beta agonist in one inhaler,  other times a beta agonist with an anti-muscarinic in another. Until one of Bob’s proteges, a maverick rebel thinker proposed the unimaginable. All three chemicals together in one inhaler. It was a shocking eureka moment, a veritable club sandwich of inhalers minus the toothpick, and it only took two and a half decades to get there. 

To their credit, Taco Bell, went beyond beans, meat and cheese, expanding their portfolio into rice, nacho fries, doritos taco shells other stuff. The pharma companies, unfortunately, have not. Rather than innovate and create new classes of chemicals, they choose instead to re-package and re brand their existing products to make them look like new ones. It’s no coincidence that new inhalers like Breo are coming on the market just as older brands like Advair lose their patent protection. Perhaps it’s surprising to you that there is greater innovation in America’s fast food industry than there is America’s pharmaceutical companies. It shouldn’t be, pharma companies often spend more on marketing then they do on research and development of new drugs. 

As for my patient, we decided not to go with the newer, more expensive inhaler. Sometimes the dollar menu’s the way to go. 

Deep Ramachandran, M.D. is a Pulmonary, Critical Care, Sleep Medicine physician, former CHEST Journal Social Media Editor, and co-Chair of ACCP Social Media Work Group. He blogs at Caduceusblog and the CHEST Thought Leaders Blog. He is on twitter @Caduceusblogger.