Guide to Over-the-Counter Inhalers for Asthma

Benefits and Risks of Primatene Mist and Asthmanefrin

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While many asthma inhalers are only available by prescription, two are available over the counter in the United States: Primatene Mist (epinephrine) and Asthmanefrin (racepinephrine).

Over-the-counter (OTC) asthma inhalers can help treat—but not prevent—acute asthma attacks. While not commonly recommended for the treatment of asthma, some people still turn to them because of their convenience and price point.

These inhalers can have benefits, but there are also risks—and they are not right for everyone. This article explores the pros and cons of these medications. It also wades into the controversy surrounding Primatene Mist and Asthamanefrin and what leading health experts say about the use of over-the-counter asthma inhalers.

Types of Over-the-Counter Inhalers

The two over-the-counter asthma inhalers currently sold in American drugstores—Primatene Mist and Asthmanefrin—are similar to each other and can provide temporary relief of asthma symptoms.

These medicines are approved for use by the U.S. Food and Drug Administration (FDA) to temporarily relieve symptoms of mild intermittent asthma. This is an uncommon asthma type that's considered the mildest form of the disease.

Primatene Mist

Primatene Mist is an over-the-counter asthma inhaler used for the relief of acute asthma symptoms. It contains a drug called epinephrine (adrenaline) that acts on the airways, causing them to dilate (widen). Epinephrine is the same drug used in EpiPen auto-injectors that are used to treat severe allergic reactions.

Primatene Mist was removed from the U.S. market in 2011 because it was manufactured with an aerosol propellant called chlorofluorocarbon (CFC) that was harmful to the ozone layer. It was later approved by the FDA in 2018 when it was manufactured with a new propellant called hydrofluoroalkane (HFA) that is used in many other asthma inhalers.

Recommended Dose

Primatene Mist is approved for adults and children 12 and over. The recommended dose is 1 to 2 inhalations, not to exceed 8 inhalations within a 24-hour period.

Primatene Mist is not intended for long-term use. Moreover, the FDA strongly recommends not using Primatene Mist unless you've been diagnosed with asthma. That's because other conditions can cause asthma-like symptoms but need to be treated differently.

Asthmanefrin

Asthmanefrin is a CFC-free inhaler that works similarly to Primatene Mist. It contains a drug called racepinephrine that has a similar action to epinephrine but tends to be potent.

Asthmanefrin was introduced as a cost-effective bronchodilator in 2012, after the discontinuation of Primatene Mist. While it appears to be useful in treating mild bronchoconstriction (narrowing of the airway), it is generally less able to treat bronchospasm (spasms of the airways).

Asthmanefrin is not delivered in a pressurized canister like Primatene Mist. Instead, it is sold in liquid form in a 30-count pack for use in a portable nebulizer machine. This is a device that turns liquid into a fine mist for inhalation.

This makes Asthmanefrin somewhat less convenient during an asthma attack than an HFA propellant like Primatene Mist.

Recommended Dose

Asthmanefrin is approved for use in adults and children 4 and over. The recommended dose is one to three inhalations every three hours, not to exceed 24 inhalations during a 24-hour period.

As with Primatene Mist, Asthmanefrin is not intended for long-term use and should only be used after you have been diagnosed with asthma by a healthcare provider.

Benefits

Over-the-counter inhalers like Primatene Mist and Asthmanefrin have certain benefits. To many people who use them, the first is cost.

Primatene Mist currently retails for around $35 a canister. A 30-count box of Asthmanefrin retails for about the same price.

The cost of prescription inhalers varies significantly, depending on the type of inhaler. Rescue inhalers with generic drugs may cost about the same as over-the-counter inhalers. Meanwhile, brand-name rescue inhalers like Proventil (albuterol) and Xopenex (levalbuterol) are about twice as much.

Then you have maintenance inhalers, which are used regularly to prevent asthma attacks from happening. Some of them cost $300 or more.

You also save money with over-the-counter inhalers because you don't need to see a healthcare provider to get a prescription. While that saves the cost of an office visit or co-pay, it may not be the best way to treat your asthma.

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Side Effects of Over-the-Counter Inhalers

otc asthma inhaler side effects
​Illustration by Emily Roberts, Verywell

Just like prescription medications, Primatene Mist and Asthmanefrin carry a risk of side effects.

Primatene Mist
  • Bad taste

  • Cough

  • Dizziness

  • Dry mouth

  • Headache

  • Nausea

  • Nervousness

  • Sore throat

  • Stomach ache

  • Sweating

  • Tremors

  • Trouble sleeping

  • Vomiting

Asthmanefrin
  • Appetite changes

  • Dizziness

  • Headache

  • Hyperactivity (particularly in children)

  • Nausea

  • Nervousness

  • Sinus pain

  • Sore throat

  • Sweating

  • Tremors

  • Trouble sleeping

  • Vomiting

Risks of Using an OTC Inhaler for Asthma

Self-treating any medical condition poses significant risks, including:

  • Misdiagnosis
  • Overdosing
  • Underdosing

With over-the-counter inhalers, there's another real concern: They can become less effective over time, but you may not realize that and keep relying on them in a crisis situation.

If this happens and you experience frequent attacks, your lungs can begin to change and become stiffer and stiffer as scar tissues develop. Over time, this can reduce your lung capacity, leaving you weak and breathless with even moderate activity.

When Rescue Inhalers Are Not Enough

If you use a rescue inhaler two or more times per week or more than two nights per month, you need to talk to a healthcare provider about starting asthma controller medications. These are inhaled, oral, or injectable drugs used regularly (sometimes daily) to help control asthma symptoms.

According to a 2017 study published in BMJ Open, people who use over-the-counter rescue inhalers are no more likely to have uncontrolled asthma than those who use prescription rescue inhalers. However, they are 70% more likely to require urgent asthma care within a year.

Conflicting Opinions

In their approval of the "new" Primatene Mist in 2018, the FDA assured the public that, as with all approved drugs, Primatene Mist underwent "a robust scientific review to ensure it can be used safely by patients." With that said, the FDA acknowledged that only a "narrow population" of people—namely those with mild intermittent asthma—would benefit.

Many health professionals do not agree.

In fact, the American College of Asthma, Allergy & Immunology, the American Association for Respiratory Care, the American Thoracic Society, and the National Association for Medical Direction of Respiratory Care do not believe that over-the-counter inhalers of any sort are safe for the treatment of asthma.

For its part, the National Institutes of Health do not include either Primatene Mist or Asthmanefrin in its Guidelines for the Diagnosis and Management of Asthma.

Summary

There are two over-the-counter inhalers available for the treatment of asthma in the United States. They are Primatene Mist, which contains epinephrine, and Asthmanefrin, which contains a similar drug called racepinephrine.

While both are approved for use by the FDA, over-the-counter inhalers are only intended for the short-term use of mild intermittent asthma. Most major health authorities, including the American Thoracic Society, advise against their use and contend that the risks of these inhalers (including an increased likelihood of a severe attack) outweigh the benefits.

A Word From Verywell

It is important to remember that over-the-counter inhalers do not have the same proven benefits as prescription inhalers. Moreover, in the end, they may not necessarily cost less than generic inhalers like albuterol or levalbuterol.

To make an informed judgment, speak with your healthcare provider first.

Frequently Asked Questions

  • Are over-the-counter inhalers safe?

    While there are no serious safety concerns with the drugs themselves, over-the-counter (OTC) inhalers may provide inadequate control of asthma symptoms. A 2017 study reported people using OTC inhalers are 70% more likely to require urgent asthma care than those using prescription inhalers.

  • How much do over-the-counter inhalers cost?

    Cost is a major draw of over-the-counter inhalers like Primatene Mist and Asthmanefrin, both of which cost around $35. The savings isn't what it used to be, though. You can now get prescriptions for generic albuterol inhalers for about the same cost, and they're the preferred treatment for asthma attacks.

  • Is Primatene Mist the same as albuterol?

    No. Primatene Mist contains epinephrine, the same drug used to treat severe allergy attacks. Albuterol is a short-acting bronchodilator that works by relaxing muscles of the airways, reducing spasms and improving breathing.

  • Can I use an over-the-counter inhaler for COPD?

    No. Likewise, over-the-counter inhalers are not indicated for allergies, bronchitis, or non-asthma coughs.

11 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. U.S. Food and Drug Administration. CDER conversation: safely using the newly available OTC asthma inhaler Primatene Mist.

  2. American Academy of Allergy, Asthma & Immunology. Asthma treatment & management.

  3. National Institutes of Health, U.S. National Library of Medicine: DailyMed. Primatene Mist - epinephrine inhalation aerosol.

  4. Sicherer SH, Simons FER. Epinephrine for first-aid management of anaphylaxis. Pediatrics. 2017;139(3):4006. doi:10.1542/peds.2016-4006

  5. Mondal P, Kandala B, Ahrens R, Chesrown SE, Hendeles L. Nonprescription racemic epinephrine for asthma. J Allergy Clin Immunol Pract. 2014;2(5):575-8. doi:10.1016/j.jaip.2014.02.014

  6. Mondal P, Kandala B, Ahrens R, Chesrown SE, Hendeles L. Nonprescription racemic epinephrine for asthma. J Allergy Clin Immunol Pract. Sep-Oct 2014;2(5):575-8. doi:10.1016/j.jaip.2014.02.014

  7. DailyMed. Asthmanefrin - racepinephrine hydrochloride solution.

  8. Royce SG, Cheng V, Samuel CS, Tang MLK. The regulation of fibrosis in airway remodeling in asthma. Mol Cell Endocrinol. 2012 Apr 4;351(2):167-75. doi:10.1016/j.mce.2012.01.007

  9. American Lung Society. Assess and monitor your asthma control.

  10. Reddel HK, Ampon RD, Sawyer SM, Peters MJ. Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey. BMJ Open. 2017;7(9):e016688. doi:10.1136/bmjopen-2017-016688

  11. National Institutes of Health, National Heart, Lung, and Blood Institute. Guidelines for the diagnosis and management of asthma 2007 (EPR-3).

By Pat Bass, MD
Dr. Bass is a board-certified internist, pediatrician, and a Fellow of the American Academy of Pediatrics and the American College of Physicians.