Why your asthma inhaler is so expensive (in the US)
Why your asthma inhaler is so expensive (in the US)<br>It starts with the ozone hole...<br>Posted by ekr on 09 Jun 2026
A little under 10% of the US population suffers from<br>asthma. The good<br>news is we<br>have highly effective treatments. The bad news is that despite these<br>treatments being decades old, they're shockingly expensive in<br>the US as the result of a really bad interaction between<br>the ozone hole, the patent system, the way drugs get priced, and<br>the profit-seeking behavior of drug companies.
Note: This post is really just about the US; the situation<br>is different in other countries, which often have robust<br>price controls.
Asthma and Asthma Treatment #
Asthma is an inflammatory disease in which the patient's airways constrict,<br>often in response to some trigger such as exercise, allergy, or illness,<br>leading to difficulty breathing. There are two front-line treatments for<br>asthma:
β2-agonists such as albuterol/salbutamol<br>that induce the muscles of the airway to relax.
Corticosteroids such as fluticasone<br>that reduce inflammation in the airways.
These treatments work together, in that some β2-agonists<br>are quick acting and therefore can treat an asthma attack immediately,<br>whereas the corticosteroids reduce your susceptibility to asthma attacks<br>but are not useful to deal with one already in progress. It's quite<br>common for a patient to be on both classes of drugs, taking the<br>corticosteroid daily and then a β2-agonist as needed,<br>for instance before exercise or when they feel that they are having<br>trouble breathing.
These drugs can be delivered systemically but are most commonly<br>inhaled, so that they are delivered directly to the affected<br>tissues. There are at least three major inhalation routes, but<br>historically the most common is via what's called a metered-dose<br>inhaler<br>(MDI)<br>("puffer") which is basically a specialized kind of spray can that<br>lets you spray the drug right into your lungs.
These drugs are all quite old. The most common<br>β2-agonist, albuterol (in the US)/salbutamol<br>(elsewhere) was patented in 1966, the first inhaled corticosteroid<br>(beclomethasone) was<br>patented in 1976, and the most common inhaled corticosteroid<br>(fluticasone<br>propionate),<br>was patented in 1980, so the basic drug is long out of patent. Unfortunately,<br>this is not the end of the story.
Drug Naming #
When a drug is developed, it typically gets assigned (at least) two names:
An international nonproprietary name<br>which just describes the compound (e.g., fluticasone). INNs are assigned<br>by the World Health Organization according to a fairly complicated<br>system in which each class of drug has a "stem" prefix or suffix that helps<br>tell you what it is. For instance, "glucagon-like Peptide (GLP) analogues"<br>all end in "glutide".
A brand name, which is assigned by the manufacturer (e.g., Flovent) and<br>is designed to sound appealing.
When the drug is initially marketed, it will of course use the brand name,<br>but then generics will typically use the INN name, though the drug<br>may also still be sold under the brand name. For instance, you can<br>still buy Advil even though generic ibuprofen is widely available.
Some (mostly older) drugs will also have names in some older national<br>naming system. For example, the β2-agonist salbutamol<br>is known as "albuterol" in the US. Another example is the drug brand-named<br>Tylenol and called acetaminophen in the US, paracetamol outside the US, and
Name Brand and Generics #
The first thing you have to understand is the lifecycle of a drug.
When a new drug is first invented, the manufacturer will generally<br>file for a patent. As a result, once the drug is approved the<br>manufacturer will have some period of exclusivity during which<br>only they can sell the drug. Developing drugs is incredibly<br>expensive, as is the process of testing the drug to determine that<br>it is safe and effective. This system allows the initial inventor<br>to charge monopoly prices during the lifetime of the patent,<br>typically far in excess of the cost of manufacture, thus recouping much of the upfront<br>cost of developing the drug.[1]
Eventually, the patent on the drug will expire, allowing other<br>manufacturers to make the drug themselves, in what's called<br>a generic drug (the one made by the manufacturer is called the name brand drug).<br>Importantly, the FDA<br>allows those other manufacturers to get approval to market the<br>drug without repeating all the studies that the original inventor<br>did. Instead, they just have to go through what's called an<br>abbreviated new drug application (ANDA),<br>in which they demonstrate that the drug is "bioequivalent"<br>(roughly that it delivers the same active ingredient at the same<br>rate and dosage) as the original drug. This isn't to say that the<br>formulation is exactly the same—for instance, a generic tablet might<br>have different coatings or binders—but it's obviously<br>a lot easier to show bioequivalence than the original safety<br>and efficacy trial. Once the generic is approved, it...