15 Inhalers for COPD

Inhalers for chronic obstructive pulmonary disease (COPD) are a mainstay of treatment. These medications are inhaled through your mouth so they can directly reach your lungs.

If your healthcare provider prescribes an inhaler for COPD, it's important to know that different types of inhalers have different actions and uses. Some contain bronchodilators to open your airways or deliver a glucocorticoid (steroid) to reduce inflammation. Other inhalers offer a combination of drugs.

Types of COPD Inhalers

A COPD inhaler can contain either a single medication or a combination of ingredients. These medications work in different ways, and some inhalers contain combinations of different types of medications.

Medication Types

• Muscarinic antagonists contain a bronchodilator, which helps to open up your airways and increase airflow. Muscarinic antagonists may be short-acting (SAMAs) or long-acting (LAMAs). They are also called anticholinergics.
• Beta-agonists contain a different type of bronchodilator. Beta-agonists may be short-acting (SABAs) or long-acting (LABAs).
• Inhaled corticosteroids reduce inflammation in your airways.
• Combination inhaled medications contain two or three different drugs such as different bronchodilators or a bronchodilator and a corticosteroid.

Inhalers are meant to reduce airway constriction so that air can pass into your lungs more effectively as you breathe. You may be instructed to use your inhaler at scheduled times throughout the day and/or to also use an inhaler when you have a COPD exacerbation.

Some inhalers begin to have effects immediately, while others take longer to start working. Long-acting inhalers have lasting effects, while the effects of short-acting inhalers tend to wear off sooner.

Rescue and Maintenance Inhalers

Inhalers are also categorized by whether or not they help prevent symptoms or treat a COPD exacerbation.

• Preventers or maintenance inhalers are meant to be used daily over the long term to prevent symptoms and exacerbations. These medications are typically used once or twice daily at the same time each day.
• Relievers or rescue inhalers are used only in emergency situations. They provide immediate symptom relief and may be used up to a few times a day depending on your symptoms.

COPD inhalers have effects that overlap with other inhalers and medications, so rely on medical advice to avoid potentially dangerous side effects.

Device Types

Different types of inhalers deliver medication to the lungs in different ways:

• Metered dose inhalers (MDIs) contain liquid medication. The liquid becomes aerosolized when dispensed. To use one of these inhalers, you need to inhale at the same time as you push the button that dispenses the medication.
• Dry powder inhalers (DPIs) contain a powdered medication. When using one of these inhalers, you do not have to worry about timing, but you do have to be able to inhale deeply.
  

Inhaler Recommendations for COPD

It can be extremely confusing to understand the multiple different types and combination of inhalers available for COPD. However, they can be simplified by looking at current guidelines and using a few examples about when the various types are used alone or together.

When choosing the best inhaler or inhalers, healthcare providers will consider a few primary factors:

• Spirometry: Forced expiratory volume in 1 second (FEV1) describes the degree of airflow limitation. The GOLD Guide separates people into four different groups (A through D) based on FEV1 readings.
• Symptoms: Symptoms of either shortness of breath (dyspnea) or exercise intolerance are very important in selecting a COPD treatment. Shortness of breath can be described by the Modified Medical British Research Council dyspnea scale (mMRC dyspnea scale) or COPD Assessment Test (CAT). Exercise intolerance can be estimated using the six-minute walk test.
• COPD exacerbations: Different choices may be made for those who have one or more exacerbations per year and those who do not.

Co-existing conditions also play a role. Different choices may be considered if a person has a history of asthma or other medical concerns.

Advair

Advair is one of the most commonly used inhalers for the maintenance treatment of COPD. It is a combination of fluticasone, a corticosteroid, and salmeterol, a long-acting bronchodilator. Advair is used on a regular basis for the maintenance treatment of COPD and it is typically taken twice per day.

Advair is available as Advair Diskus, an inhaled powder, or Advair HFA, an aerosol inhaler. The dose is represented with two microgram (mcg) numbers and written as fluticasone mcg/salmeterol mcg per puff. The Diskus is available in doses of 100/50, 250/50, or 500/50, and the HFA is available in doses 45/21, 115/21, and 230/21.

Keep in mind that there are other dosing combinations for this medication as well.

Side Effects

When used for COPD, the most common side effects include pneumonia, fungal mouth infections, throat irritation, respiratory infections, headaches, and muscle aches.

Cost

Advair Diskus generally supplies one month of medication, with out-of-pocket prices ranging from approximately $100 for the generic version to $430 for the brand version.

The out-of-pocket cost of one canister of Advair HFA is about $400. There is no generic version of this form available.

Albuterol

Ventolin HFA, Proventil HFA, and Proair RespiClick (albuterol) are rescue inhalers used to help with urgent breathing problems. It contains albuterol, a short-acting beta-agonist.

Albuterol helps immediately relax the airways, making it easier to breathe. It is often used for managing sudden episodes of ​shortness of breath related to bronchospasm in both asthma and​ COPD.​​

This inhaler can be used about 15 to 30 minutes prior to exercise to prevent exercise-induced symptoms. And it can also be used for symptomatic relief taken as one or two inhalations every four to six hours.

Each brand of this medication comes in a package with instructions for use, as the doses are slightly different. For example, Ventolin HFA and Proventil HFA come in an aerosol canister containing 200 metered inhalations and fitted with a counter (a container with 60 doses is available for Ventolin HFA as well). Each inhalation delivers 90 mcg albuterol.

Because you might not use albuterol on a regular basis, it is recommended that you prime the inhaler. For example, you would prime Ventolin HFA by spraying three times in a direction away from your face if you haven't used it in over two weeks.

Side Effects

The most common side effects include headaches, tachycardia (rapid heart rate), pain, dizziness, sore throat, and runny nose.

Cost

The cost without insurance of a standard brand container, which provides 200 doses, is approximately $32, although it can cost more depending on the brand. Generic albuterol costs approximately $25 for the same supply of 200 doses.

Atrovent HFA

Atrovent HFA (ipratropium) is an anticholinergic bronchodilator. It's used in the maintenance treatment of chronic COPD, including bronchospasm, emphysema, and chronic bronchitis.

It can be taken as two inhalations of 17 mcg each. It is typically used three or four times per day. Atrovent HFA is supplied in a 12.9 g canister containing 200 doses.

Side Effects

Side effects of Atrovent HFA include bronchitis, COPD exacerbation, shortness of breath, and headaches.

Cost

The out-of-pocket cost of a canister containing a one-month supply is approximately $400 and there is no generic.

Bevespi Aerosphere

Bevespi Aerosphere is a combination of two long-acting bronchodilators, glycopyrrolate and formoterol. It is intended as a maintenance treatment for chronic COPD and is taken to help open airways and keep them open.

Bevespi Aerosphere is not a rescue inhaler and is not used to treat sudden COPD symptoms.

It is taken as two inhalations twice per day, each supplying 9 mcg of glycopyrrolate and 4.8 mcg of formoterol fumarate.

Side Effects

The most common side effects include urinary tract infection and cough.

Cost

The pressurized metered-dose inhaler contains a one-month supply of the medication and costs approximately $350, without insurance. There is no generic version.

Breo Ellipta

Breo Ellipta is a combination of fluticasone furoate, a corticosteroid, and vilanterol, a long-acting beta-agonist. Breo Ellipta is a once-daily maintenance medication for the treatment of airflow obstruction with COPD, including emphysema and chronic bronchitis.

The medication comes in two double-foil blister strips of powder formulation for oral inhalation. Each contains blisters that have either fluticasone furoate 100 mcg or vilanterol 25 mcg.

It is taken in doses of 25 mcg vilanterol/100 mcg fluticasone once daily.

Side Effects

Side effects include upper respiratory infections, headaches, and fungal mouth infection.

Cost

The cost of a standard package, which can serve as a two-month supply for some patients, is approximately $350. There is no generic version of this drug combination, although fluticasone furoate is available as a generic nasal spray.

Breztri Aerosphere

Breztri Aerosphere (budesonide, glycopyrrolate, formoterol fumarate) is a maintenance inhaler that contains an anticholinergic, a beta-agonist, and a corticosteroid.

This inhaler should be taken as two puffs twice a day.

Side Effects

Side effects of this medication can include fungal infections, pneumonia, immunosuppression, reduced adrenal function, sudden breathing problems, and allergic reaction.

Cost

A 30-day supply of this medication costs $645.14. There is no generic version available.

Brovana

Brovana (arformoterol) is a long-acting beta-agonist bronchodilator. It's used for long-term maintenance treatment in chronic COPD to relax the airways and make it easier to breathe.

It should be taken twice a day, in the morning and in the evening. It is available as a nebulizer solution at a dose of 15 mcg/2 milliliter (mL) to be used with a standard jet nebulizer with a face mask or mouthpiece, connected to an air compressor.

Side Effects

Side effects include chest pain and back pain, diarrhea, sinusitis, leg cramps, shortness of breath, rash, flu-like symptoms, leg swelling, and lung disease.

Cost

A standard package contains a two-month supply and costs approximately $1,000, or more, out-of-pocket. There is no generic version of Brovana.

Combivent Respimat

Combivent contains albuterol, a short-acting beta-agonist, and ipratropium, an anticholinergic. It is used in COPD as a second inhaler when symptoms are not controlled with a regular aerosol bronchodilator.

This medication is available as an aerosol metered-dose inhaler with a dose of 100 mcg albuterol/20 mcg ipratropium or as a nebulizer solution with a dose of 2.5 milligrams (mg) albuterol/0.5 mg ipratropium/3 mL of solution. It can be taken three or four times per day.

Side Effects

The most common side effects include upper respiratory infections, cough, bronchitis, headaches, and shortness of breath.

Cost

A standard inhaler generally includes a month supply and is expected to cost approximately $450. There is no generic version of this combination, although albuterol and ipratropium are both available separately in generic formulations.

Performomist

Performomist (formoterol) is a long-acting beta-agonist that is taken twice daily for the management of chronic COPD.

It is available in a solution for inhalation at a dose of 20 mcg/2 mL. The solution is used with a standard jet nebulizer with a facemask or mouthpiece connected to an air compressor. The inhalation solution should always be stored in the foil pouch and removed right before you will use it.

Side Effects

Side effects include diarrhea, nausea, throat infection, dry mouth, vomiting, dizziness, and trouble sleeping.

Cost

The cost of a standard solution, which includes a two-month supply, is about $1,000; there is no generic version.

Pulmicort

Pulmicort (budesonide) is a corticosteroid that helps reduce inflammation in the airways, making it easier for you to breathe. Pulmicort is used in the maintenance treatment of COPD.

This medication is available as an inhaled powder in doses of 90 mcg and 180 mcg or a nebulized suspension at doses of 0.25 mg/2 mL, 0.5 mg/2 mL or 1 mg/2 mL. It is usually taken twice per day.

Side Effects

Side effects include nasal congestion, upper respiratory tract infection, nausea, gastrointestinal (GI) infection, ear infection, and fungal mouth infection.

Cost

The price of a one-month supply is approximately $40, and there is no generic version.

Spiriva

Spiriva contains tiotropium, an anticholinergic bronchodilator. It opens and relaxes the airways, making it easier to breathe.

Spiriva (tiotropium) is used as a maintenance treatment for COPD, especially if bronchospasm is a major part of your disease. It is considered preventative for COPD exacerbations.

The inhaled solution comes in a dose of 1.25 mcg or 2.5 mcg and is taken as two inhalations once per day. It is also available in an 18 mcg powder-filled capsule to be used with a HandiHaler device, which is also taken as two inhalations once per day. 

Side Effects

Side effects include upper respiratory infection, cough, dry mouth, urinary tract infection, and heartburn.

Cost

The cost of a one-month supply is about $450, and there is no generic version.

Symbicort

Symbicort contains formoterol, a long-acting bronchodilator, and budesonide, a corticosteroid. It is used in the treatment of stable COPD and it is usually taken as two inhalations twice per day.

The dose is represented as budesonide mcg/formoterol mcg and it is available in doses of 80/4.5 and 160/4.5.

Side Effects

When used for COPD, the most common side effects include upper respiratory infections, fungal mouth infection, and bronchitis.

Cost

A one-month supply can range from $303–$346, without insurance. A generic version is also available.

Trelegy Ellipta

Trelegy Ellipta contains three active ingredients: fluticasone furoate (an inhaled corticosteroid), umeclidinium (a long-acting anticholinergic), and vilanterol (a long-acting beta-agonist). It is intended to open your airways, reduce inflammation, and improve lung function.

It is used for chronic COPD, especially for patients who have improved with fluticasone furoate and vilanterol, but need additional treatment for control of symptoms and prevention of exacerbations.

This medication is used once a day and comes as an inhaler containing two foil blister strips of powder (100 mcg fluticasone furoate; 62.5 mcg umeclidinium and 25 mcg vilantero).

Side Effects

The most common side effects include headaches, back pain, trouble swallowing, diarrhea, cough, throat pain, and GI infections.

Cost

The cost of one inhaler is approximately $580, and this combination is not available in a generic version.

Tudorza Pressair

Tudorza Pressair (aclidinium bromide) is a long-acting bronchodilator and is meant to be used twice daily. It is used for chronic COPD with bronchospasm. Like the other long-acting bronchodilators, it is not used as a rescue inhaler.

It is available as a dry powder metered-dose inhaler that delivers 400 mcg aclidinium bromide per inhalation.

Side Effects

Side effects include headaches, upper respiratory infection, and cough.

Cost

The cost of a device, which contains a one-month supply of medication, is about $360, and there is no generic version.

Xopenex

Xopenex (levalbuterol) is a short-acting beta-agonist bronchodilator that is used three or four times per day in one or two inhalations. It is used for the management of chronic COPD and it can be used as a rescue inhaler as well.

It is available as a 45 mcg aerosol or a nebulizer (0.31 mg/3 mL, 0.63 mg/3 mL, 1.25 mg/3 mL, or 1.25 mg/0.5 mL). Each inhaled dose of Xopenex HFA delivers 67.8 mcg of levalbuterol and 59 mcg of levalbuterol tartrate from the actuator mouthpiece. It is supplied in either a 15 g pressurized canister containing 200 doses or an 8.4 g canister containing 80 doses.

If you have not used the medication in three days, the manufacturer recommends that you spray four sprays in the air and away from your face to prime it.

Side Effects

Side effects include an increased risk of accidental injury, bronchitis, dizziness, pain, sore throat, runny nose, and vomiting.

Cost

The cost of a 24-day supply is about $24 for generic and $75 for the brand version.

Summary

There are many different inhalers available for COPD, including inhalers containing bronchodilators, corticosteroids, or a combination of these medications. Inhalers may work to prevent symptoms or to treat symptoms when they occur. Some inhalers contain metered doses of liquid medication while others contain dry powder medication.

Your healthcare provider will recommend an inhaler for you based on factors such as your symptoms and spirometry. If you have co-existing conditions, these may also factor into which COPD inhaler is right for you.