Economics of "essential use exemptions" for metered-dose inhalers under the Montreal Protocol.

The Montreal Protocol on Substances that Deplete the Ozone Layer has led to rapid reductions in the use of ozone-depleting substances worldwide. However, the Protocol provides for "essential use exemptions" (EUEs) if there are no "technically and economically feasible" alternatives. An application that might qualify as an "essential use" is CFC-powered medical metered-dose inhalers (MDIs) for the treatment of asthma and chronic obstructive pulmonary disease (COPD), and the US and other nations have applied for exemptions in this case. One concern is that exemptions are necessary to ensure access to medications for low-income uninsureds. We examine the consequences of granting or withholding such exemptions, and conclude that government policies and private-sector programs are available that make it economically feasible to phase out chlorofluorocarbons (CFCs) in this application, thereby furthering the global public health objectives of the Montreal Protocol without compromising the treatment of patients who currently receive medication by means of MDIs.

Hydrofluoroalkane-134a beclomethasone as a dominant economic asthma therapy.

Inhaled corticosteroids for asthma treatment have become mainstay of therapy for patients with persistent asthma. Numerous inhaled corticosteroids are available but to date no prospective cost-effectiveness studies have been reported using exclusively US patients and costs. The purpose of this study was to examine the cost-effectiveness of HFA-bectomethasone (QVAR) compared to CFC-beclomethasone (Vanceril) using data from a year-long prospective randomized, open label, parallel multicenter trial. Eligibility criteria required patients to have been on a stable dose of CFC-BDP prior to enrollment. Patients were randomized to either HFA-BDP at approximately half their previous daily dose of CFC-BDP or to continue CFC-BDP Effectiveness data, in terms of symptom-free days (SFDs), were used in a cost-effectiveness analysis conducted from the viewpoint of managed care. Patients receiving HFA-BDP reported a greater increase (median = 22.1) in the number of SFDs than those receiving CFC-BDP (median = 14.3) (P = 0.03). Total costs of care were less for patients taking HFA-BDP (median = dollars 668) compared to CFC-BDP (median = dollars 977). The median incremental cost-effectiveness ratio was dollars -5.77 (95% CI: dollars -68.08 to dollars -4.08). The results of this analysis indicate that HFA-BDP was a dominant therapy (more effective, less costly) compared to CFC-BDP.

Using hydrofluoroether solvents to replace HCFC-141b, Part II.

The use of hydrochlorofluocarbon (HFC) solvents is banned from the end of 2001. Part of this article assessed the merits of using hydrofluoroethers as replacement solvents. Alternatives to HFCs are more expensive. Part II looks at how to reduce the cost of conversion.

Comparison of 4 analgesic agents for venipuncture.

This study compared pain on application, pain on venipuncture, cost, and convenience of 4 analgesic agents used for venipuncture. A convenience sample of 280 preoperative subjects was assigned randomly to 1 of 4 groups. Group 1 received 2.5% lidocaine--2.5% prilocaine cream (LPC) topically, Group 2 received dichlorotetrafluoroethane spray (DCTF), Group 3 received 0.5% lidocaine subcutaneously, and group 4 received normal saline with 0.9% benzyl alcohol (BA) subcutaneously. A 7-point verbal descriptor scale measured pain on application, and a 100-mm visual analogue scale measured pain on venipuncture. Cost was measured and compared on unit-dose basis. Convenience was measured with a questionnaire survey completed by the investigators. There was no significant difference (P < .05) among the groups for age, sex, ASA physical status, or difficulty of venipuncture. There was a significant difference in pain on application for all 4 agents (P < .05). The DCTF had the highest pain on application score (1.7 +/- 0.1), while the LPC had no pain on application (0.0 +/- 0). Lidocaine had a higher pain on application score (1.08 +/- 0.1) than the BA (0.52 +/- 0.1) but a lower score than DCTF. Lidocaine (1.3 +/- 0.3) was significantly less painful (P < .05) on venipuncture than LPC (2.18 +/- 0.3) and DCTF (2.5 +/- 0.3) but was not significantly different than BA (1.92 +/- 0.3). (All scores are given as mean +/- SEM.) There was a significant difference in cost and convenience among the 4 agents, with BA and lidocaine being the least expensive analgesic agents. Lidocaine, DCTF, and BA were equally convenient to use, while LPC was the least convenient, (P < .05). Lidocaine had low pain on venipuncture and low cost and convenience of use, but it was less than ideal in terms of pain on application. The BA had all the qualities of an ideal analgesic agent for venipuncture in this sample and should be considered as an analgesic agent for venipuncture.

Challenges in changing to non-chlorofluorocarbon inhalers in the treatment of asthma.

The chlorofluorocarbon (CFC)-based metered dose inhaler, which has been the mainstay of the management of obstructive lung diseases, will soon be phased out world wide and replaced by CFC-free devices. Patients will have to be changed to the devices in a co-ordinated manner to avoid any risk to their health and safety. The different shapes and aerosol delivery characteristics of the new inhalers, as well as their distinctive taste, could add to the levels of poor drug use already experienced in asthma. From previous change scenarios in disease management, the potential for unstable asthma control is a real possibility with all the attendant costs. By using the time available before CFC-based inhalers are withdrawn, there is an opportunity to enhance asthma management during this period of change.