The environmental impact of inhalers for asthma: A green challenge and a golden opportunity

Abstract

The propellants in metered‐dose inhalers (MDIs) are powerful greenhouse gases, which account for approximately 13% of the NHS's carbon footprint related to the delivery of care. Most MDI use is in salbutamol relievers in patients with poorly controlled disease. The UK lags behind Europe in this regard, with greater reliance on salbutamol MDI and correspondingly greater greenhouse gas emissions, roughly treble that of our European neighbours. There has been a broad switch towards MDIs in asthma treatment in the UK over the last 20 years to reduce financial costs, such that the treatment for two‐thirds of asthma patients in the UK is dominated by salbutamol MDI. Strategies that replace overuse of reliever MDIs with regimes emphasising inhaled corticosteroids have the potential to improve asthma control alongside significant reductions in greenhouse gas emissions. Real‐world evidence shows that once‐daily long‐acting combination dry‐powder inhalers (DPIs) can improve compliance and asthma control, and reduce the carbon footprint of care. Similarly, maintenance and reliever therapy (MART), which uses combination reliever and inhaled steroids in one device (usually a DPI), can simplify therapy, improve asthma control and reduce greenhouse gas emissions. Both treatment strategies are popular with patients, most of whom would be willing to change treatment to reduce their carbon footprint. By focussing on patients who are currently using high amounts of salbutamol MDI and prioritising inhaled steroids via DPIs, there are golden opportunities to make asthma care in the UK more effective, safer and greener.

Barriers to green inhaler prescribing: ethical issues in environmentally sustainable clinical practice

“…13 The main reason behind the trend towards relying on MDIs in the UK is cost. 14 MDIs contain hydrofluorocarbon propellants which are powerful GHGs. For example, HFA-134a, which is found in most MDI inhalers, has a global warming potential of 1300.…”

“…It has been reported that two-thirds of patients' day-to-day asthma treatment is dominated by a short-acting beta agonist MDI. 14 What this means is i There is a third option which involves developing alternatives which contain propellants with lower global warming potentials. This is an important option because there are patients who are not able to use a DPI and so having an MDI with a lower carbon footprint would be useful.…”

“…This is not discussed further here because it will be years before they are prescribed in practice. See Wilkinson and Woodcock 14 for more. that many patients in the UK rely on short-acting beta agonists to manage their day-to-day symptoms rather than using regular preventer therapy to avoid symptoms in the first place and saving a short-acting beta agonist for acute illness.…”

“…In Sweden, for example, MDIs account for only 13% of inhaler prescriptions 13. The main reason behind the trend towards relying on MDIs in the UK is cost 14…”

Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London

“…15 In addition to the individual patient harm associated with excess prescription of SABA, the pMDIs (pressurized Metered-Dose Inhalers) are a major contributor to healthcare associated carbon footprint, and thereby global warming. 16 Hence reducing SABA over-prescribing is important both for individuals and for global health.…”