Asthma and COPD: medications and paying cash

Overview

Asthma is a long-term condition in which the airways swell and narrow, causing wheezing, coughing (often at night or early morning), shortness of breath and chest tightness; pollen, exercise, viral infections and cold air can set symptoms off, and many people with asthma also have allergies. COPD, which includes emphysema and chronic bronchitis, is lung damage that blocks airflow; in the United States cigarette smoking is its main cause, and breathlessness with activity, an ongoing cough that brings up mucus and wheezing come on gradually and worsen over time. Neither can be cured: asthma is managed, and COPD treatment eases symptoms and slows its progression, with quitting smoking part of the treatment.

The medicines fall into two groups. A quick-relief, or rescue, inhaler such as albuterol works fast and is used when symptoms appear or before exercise; needing it for symptoms on more than two days a week, not counting use before exercise, means asthma is not well controlled, so tell the prescriber. Controller medicines are taken every day, even when breathing feels fine: inhaled corticosteroids such as fluticasone, which can cause a hoarse voice or thrush (the labels advise rinsing the mouth and spitting after each dose); combination inhalers that add a long-acting bronchodilator (fluticasone with salmeterol, budesonide with formoterol, fluticasone furoate with vilanterol); anticholinergics for maintenance treatment of COPD, the long-acting tiotropium, aclidinium and umeclidinium and the short-acting ipratropium; and tablets, montelukast, zafirlukast and zileuton for asthma, theophylline for asthma and COPD, and roflumilast to reduce flare-ups in severe COPD with chronic bronchitis and a history of flare-ups. None of the controllers treats a sudden attack.

Montelukast carries an FDA boxed warning for serious mood and behavior changes, including suicidal thoughts: the FDA tells patients who notice agitation, depression, sleep problems or similar changes to stop taking it and contact a health care professional right away, and it advises using it for allergic rhinitis only when other medicines fail or are not tolerated. For asthma, a long-acting beta agonist (salmeterol, formoterol or vilanterol) is used only together with an inhaled steroid, because on its own it raises the risk of asthma-related death; the salmeterol-only inhaler carries a boxed warning saying so. Zafirlukast and zileuton can injure the liver, so zileuton needs regular liver blood tests, and pain in the upper right abdomen, itching or yellowing of the skin or eyes is reported to the prescriber right away; theophylline needs blood level checks because the gap between a helpful and a toxic dose is small. The device matters too: a spacer helps a spray inhaler get more medicine into the airways, each powder inhaler has its own way of breathing in, and only some have a dose counter, so ask the pharmacist to watch your technique.

Choosing between the options when you pay cash

An inhaler is a drug and a device, and a generic can replace a brand at the counter when the Orange Book rates it equivalent to that brand’s product, or when it is the brand’s own product sold under the generic name (an authorized generic, which the FDA treats as equivalent although the Orange Book does not list it); a rated generic can come in its own device, as Wixela Inhub does for Advair Diskus. Albuterol has rated generics, each rated to one brand (ProAir, Proventil or Ventolin), so substitution stays within that group. The Advair Diskus type (Wixela Inhub and others), Symbicort (Breyna and a Teva generic) and the tiotropium capsules for the HandiHaler have rated generics. Advair HFA, AirDuo RespiClick, Breo Ellipta, Arnuity Ellipta and Incruse Ellipta come under the generic name only as authorized generics, the brand’s own inhaler relabeled; GSK discontinued the Flovent HFA brand at the start of 2024, Flovent HFA and Flovent Diskus continue as authorized generics in every strength, and Flovent HFA also has one rated generic for its lowest strength. Spiriva Respimat, Symbicort Aerosphere and Tudorza Pressair have no rated generic, while Atrovent HFA gained one in 2026. Montelukast, zafirlukast, zileuton, theophylline and roflumilast come as generic tablets, so quotes turn on each pharmacy’s fee and markup.

Switching from one inhaler to another is a prescribing decision, not a counter substitution: strengths do not line up between devices (Advair Diskus 250/50 is not the same dose as Advair HFA 230/21), and the device has to suit the patient. If a quote is high, ask the prescriber whether an inhaler with a rated generic would suit you, and compare quotes for the same device, strength and number of inhalers, since several canisters come in more than one size.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Albuterol
  HFA metered-dose inhaler (Ventolin HFA and generics), Breath-actuated powder inhaler (ProAir RespiClick), Nebulizer solution in unit-dose vials (generic)
  Generic: Yes · Once a week
• Ipratropium
  HFA inhaler (Atrovent HFA and one generic), Nebulizer solution (generic), Nasal spray in two strengths (generic)
  Generic: Yes · Four times a day
• Fluticasone
  Inhalation aerosol (Flovent HFA and generics), Inhalation powder (Flovent Diskus and authorized generic), Inhalation powder, fluticasone furoate (Arnuity Ellipta)
  Generic: Yes · See the guide
• Fluticasone/Salmeterol
  Dry-powder inhaler (Advair Diskus, Wixela Inhub and other generics), HFA metered-dose inhaler (Advair HFA and its authorized generic), Inhalation-driven powder inhaler (AirDuo RespiClick and its authorized generic)
  Generic: Yes · Twice a day
• Budesonide/Formoterol
  HFA metered-dose inhaler (Symbicort, Breyna and generics), HFA metered-dose inhaler with its own strengths (Symbicort Aerosphere)
  Generic: Yes · Twice a day
• Fluticasone Furoate/Vilanterol
  Inhalation powder (Ellipta inhaler)
  Generic: No · Once a day
• Tiotropium
  Inhalation powder capsules with their own device (Spiriva HandiHaler and generic), Soft mist inhaler with cartridge (Spiriva Respimat)
  Generic: Yes · Once a day
• Aclidinium Bromide
  Dry-powder inhaler (Tudorza Pressair), Dry-powder inhaler with formoterol (Duaklir Pressair)
  Generic: No · Twice a day
• Montelukast
  Film-coated tablets (Singulair and generic), Chewable tablets (Singulair 5 mg and generic), Oral granules in single-dose packets (generic)
  Generic: Yes · Once a day
• Zafirlukast
  Film-coated tablets
  Generic: Yes · Twice a day
• Zileuton
  Extended-release tablets
  Generic: Yes · Twice a day
• Theophylline
  Extended-release tablets (12-hour and once-daily), Extended-release capsules (Theo-24), Oral solution
  Generic: Yes · See the guide

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Which of my inhalers is for sudden symptoms, and which do I take every day?
• Is there a rated or authorized generic of my inhaler, and can you dispense it on my prescription?
• Can you watch me use this device, and would a spacer help?
• If I take montelukast, which mood, sleep or behavior changes should make me call you right away?
• How often can I use my rescue inhaler before I should call?

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