You should probably stop using albuterol

A case study about why change is hard in medicine

I was scrolling through my favorite publication the other day and came across a headline that stopped me in my tracks.

(No horrific world news or celebrity gossip — it’s my favorite medical publication, New England Journal Clinician. Nerd out with me for a moment. It is the best roundup of medical research, perfect for a generalist like me who needs to stay on top of all the different specialties. Shout-out to Paul Sax, an editor there!)

Here’s what I found. Another Reason To Curtail Albuterol Overuse: Overuse Is Associated With Increased Major Cardiovascular Events.

Before you click away because it sounds boring and niche: Albuterol is an incredibly common medication.

There’s a decent chance you or someone you love has used it. It’s by far the most common inhaler prescribed to treat asthma and any respiratory conditions that even remotely resemble asthma. It’s given out like candy at urgent care and emergency rooms.

Photo by CNordic Nordic on Unsplash

I have an albuterol inhaler sitting under my own bathroom sink, from an emergency room visit with my son when he got influenza a few winters ago. (It was very scary. Yes, he was vaccinated, which almost certainly made his disease less severe! Yes, you too should get vaccinated for flu this fall!)

But albuterol isn’t considered the best treatment for wheezing. It hasn’t been the standard of care since 2019. And now, according to this study in the journal Thorax, albuterol is associated with excess risk for heart attack and stroke.

Yet albuterol is everywhere — in my patients’ backpacks and purses, on their medication lists, given to patients in emergency departments. In my own bathroom cupboard.

This kind of gap between scientific evidence and practice is common in medicine. The reality of clinical practice hasn’t caught up with the professional guidelines and research.

But why? What, exactly, is it that makes change so hard in health care?

First, let’s back up and define some terminology.

When I was in medical school, I learned that albuterol was always the first medication to prescribe if someone has asthma or is wheezing. (Another thing I learned in medical school: All that wheezes is not asthma!) Still, if someone is struggling to breathe, I always learned that albuterol is a pretty reasonable medication to try to help them feel better.

Albuterol is what’s called a short-acting beta-adrenergic receptor agonist. It’s usually administered via inhalation, in an inhaler or a liquid that can be nebulized in a machine that turns it into a kind of mist, which you can then breathe through a mask. (It comes in IV form in Europe, but for our purposes today, I’m talking about the inhaled and nebulized medication.)

Beta agonists trigger your “fight or flight” response. They’re used to treat asthma because they’re “bronchodilators,” which means they open up the lungs when someone is wheezing.

They also make your heart race and your blood vessels dilate, useful if you’re running from a lion. Less useful if you’re just trying to breathe comfortably on a warm, pollen-filled day.

Photo by Max van den Oetelaar on Unsplash

Over the last decade or so, the evidence has been piling up that albuterol maybe shouldn’t be our first-line treatment. It can actually increase the risk of recurrent asthma exacerbations and can cause negative cardiovascular side effects, like an increased risk of heart attack and stroke.

In 2019, the Global Initiative for Asthma (known as GINA) issued a major change from the practice I learned in medical school. They no longer recommended using albuterol at home as a first-line “rescue” medication – that is, to use when someone is wheezing. (Albuterol is still recommended as a rescue treatment in emergency settings, but just not for home use.)

Instead, GINA — probably the most influential international organization for asthma — recommended a combination of an inhaled steroid plus a long-acting beta agonist called formoterol. These are medications with brand names like Symbicort and Dulera, medications I had been taught were actually third in line, after my patients had tried albuterol and then inhaled steroids alone.

Turns out the inhaled steroid / long-acting beta agonist combination, when used to treat acute wheezing, actually helps prevent further asthma exacerbations.

But in 2019, I was still prescribing albuterol. Most doctors I know were, too. My patients were still showing up with albuterol canisters in their purses, telling me they had gotten the medication at an urgent care and could they have a new prescription, please?

To understand why so many doctors — like yours truly — were so slow on the uptake, I talked to a pulmonologist pal named Dr. Philip Dormish. He is a great sport about answering my niche questions about the lungs, and it turns out he also had a lot of thoughts about why this new scientific research has been so hard to put into action.

Here’s what he offered, paraphrased by me:

1. The transition away from a longstanding clinical practice is confusing to both doctors and patients. “But my albuterol works!” is a refrain I hear over and over again. It can feel scary to give up the status quo, even if there’s a potentially better option out there. (A related concern I often hear from patients: “The nebulizer machine is better than the pump!” I think there’s a perception that if they’re getting their medication via an expensive machine that you have to plug into a wall, it’s somehow better than a cartridge you can carry around in your backpack. There’s a cognitive bias in favor of technology, and also in favor of what’s already known…) Doctors are responsible for this, too. Many doctors – including me, up until pretty recently – aren’t aware of the new guidelines because, simply put, it’s hard to stay up-to-date on everything we need to know in clinical medicine.

2. Insurers won’t pay for the right medication. Most insurers will cover some combination of an inhaled steroid and long-acting beta agonist, but not always the right one. GINA guidelines recommend a combination of any steroid plus formoterol, because formoterol has the fastest onset of the long-acting medications. Many insurers simply won’t pay for this because they say, “Hey, we’ll only pay for this similar but not-exactly-right” medication.

3. Insurers and pharmacies can’t handle the idea that a medication could be used for two indications. The guidelines recommend these medications for both symptom relief (i.e. a puff when you’re wheezing) and prevention (people with more severe asthma can take it twice daily, every day, to prevent symptoms from occurring in the first place). But insurers will usually only pay for it as prevention. If patients are using it for both purposes, they run out of it faster.

4. Cost. Albuterol is usually pretty cheap. Combination inhalers sometimes aren’t, even when they’re supposedly “covered” by insurance.

So the conclusion I’ve been coming to, as I’ve been attempting to wrestle the albuterol out of my patients’ hands (kidding! kidding!), is that change is hard in health care.

It can be tough to put new science into practice, especially for generalists like me who need to stay updated on a huge breadth of clinical medicine.

But it doesn’t need to be.

It might be easier if we had a nationalized health system with unified clinical guidelines, so primary care doctors don’t have to go chasing down scientific papers in dozens of specialty journals.

It might be easier if we had universal pharmacy benefits, with a formulary of available medications that were available cheaply and consistently for everyone.

For now, I’ll be taking it one conversation at a time — talking to my patients, pharmacists, and unfortunately, yes, insurers — in the hopes that we can all breathe a little easier.

Have you ever made a change in the way you and your doctor approached a longstanding medical problem? How did it go? Did you wish you had stuck with the status quo?

Please join me and Cait Van Damm next week for a conversation about pelvic health, one of my many soapboxes as Your Doctor Friend. Add it to your calendar here.