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Orlovic M, Tzelis D, Guerra I, Bar-Katz V, Woolley N, Bray H, Hanslot M, Usmani O, Madoni A. Environmental, healthcare and societal impacts of asthma: a UK model-based assessment. ERJ Open Res 2024; 10:00577-2023. [PMID: 39040585 PMCID: PMC11261382 DOI: 10.1183/23120541.00577-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 03/13/2024] [Indexed: 07/24/2024] Open
Abstract
Background This study aimed to assess the broader environmental, healthcare and societal impacts across the entire asthma pathway from diagnosis to treatment in the UK. Methods A comprehensive cost-of-illness framework was developed considering the effects of the full asthma patient pathway, including greenhouse gas emissions generated from inhalers, National Health Service (NHS) costs, health-related quality of life and productivity losses. The model was based on published literature and clinical expert opinion to accurately estimate, in monetary terms, the net present value of the asthma pathway impacts for 2022-2031. Results The estimated net present value of the environmental, healthcare and societal impacts of the asthma pathway was £47 billion over the 2022-2031 period in the UK. Loss of disease control was a key contributor to higher greenhouse gas emissions and NHS costs. In 2022, a patient with non-severe uncontrolled asthma was estimated to incur 22% higher NHS costs than a patient with controlled asthma, while generating 0.1 t more of CO2 equivalent emissions. In the same year, the total direct impacts per patient with severe asthma were four times higher than for a patient with non-severe controlled asthma, with 0.54 t CO2 equivalent of greenhouse gas emissions. Moreover, as much as 77% of the total economic impact was driven by worsening health-related quality of life and productivity impacts occurring when patients' symptoms were uncontrolled. Conclusions Uncontrolled asthma significantly impacts patients, the economy and the environment in the UK. Our results emphasise the need for a holistic approach in controlling asthma and should be carefully considered when developing policies to mitigate the overall burden of the disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Omar Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
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Luu B, Chinnadurai A, Choudhary O, Breede N, Fidler LM, Ryan CM, Khan MH, Lau AK, Blazer AJ, Wentlandt K, Rozenberg D. A comprehensive evaluation of online inhaler use techniques for obstructive airway disease. Respir Med 2024; 226:107607. [PMID: 38548142 DOI: 10.1016/j.rmed.2024.107607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/02/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Pulmonary inhaler therapy is a core treatment modality for >600 million individuals affected by obstructive airways disease globally. Poor inhaler technique is associated with reduced disease control and increased health care utilization; however, many patients rely on the internet as a technical resource. This study assesses the content and quality of online resources describing inhaler techniques. METHODS A Google search was conducted in April 2023 capturing the top 5 search results for 12 common inhaler devices. Websites were compared to product monographs for preparation/first use, inhalational technique, and post-usage/device care. They were also assessed using accepted quality metrics (GQS, DISCERN, JAMA Benchmark scores) and clinically relevant aspects based on the literature and consensus statements. RESULTS Websites regularly excluded critical steps important for proper inhaler technique. They performed best on information related directly to inhalation technique (average median score 78%), whereas steps related to preparation/first use (58%) or post-usage/device care (50%) were less frequently addressed. Median GQS, DISCERN, and JAMA Benchmark scores were 3 [IQR 3-4], 3 [IQR 2-4], and 1 [IQR 1-3], respectively. Clinically relevant factors were only addressed in about one-fifth of websites with no websites addressing smoking cessation, environmental considerations, or risk factors for poor technique. CONCLUSIONS This study highlights gaps in online resources describing inhaler technique, particularly related to preparation/first use and post-usage/device care steps. Clinically relevant factors were rarely addressed across websites. Improvements in these areas could lead to enhanced inhaler technique and clinical outcomes.
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Affiliation(s)
- Brandon Luu
- Department of Internal Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anu Chinnadurai
- Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Omer Choudhary
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Nikki Breede
- University Health Network, Toronto, Ontario, Canada
| | - Lee M Fidler
- University Health Network, Toronto, Ontario, Canada; Division of Respirology, Temerty Faculty of Medicine, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Clodagh M Ryan
- University Health Network, Toronto, Ontario, Canada; Division of Respirology, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Mohammad Hashim Khan
- University Health Network, Toronto, Ontario, Canada; Division of Respirology, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Ambrose K Lau
- University Health Network, Toronto, Ontario, Canada; Division of Respirology, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Alina J Blazer
- University Health Network, Toronto, Ontario, Canada; Division of Respirology, Temerty Faculty of Medicine, Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Department of Family and Community Medicine, Division of Palliative Care, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Division of Respirology, Temerty Faculty of Medicine, Toronto, Ontario, Canada.
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Arceneaux LS, Gregory KL. Climate change and its impact on asthma. Nurse Pract 2024; 49:25-32. [PMID: 38662493 DOI: 10.1097/01.npr.0000000000000174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT Earth's climate is changing at an unprecedented pace, primarily due to anthropogenic causes including greenhouse gas emissions. Evidence shows a strong link between climate change and its effects on asthma. Healthcare professionals must be educated to advocate for and lead effective strategies to reduce the health risks of climate change.
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Minootan Z, Wang H, Connaughton P, Lachacz K, Carrigy N, Ordoubadi M, Lechuga-Ballesteros D, Martin AR, Vehring R. On the Feasibility of Rugose Lipid Microparticles in Pressurized Metered Dose Inhalers with Established and New Propellants. AAPS PharmSciTech 2024; 25:82. [PMID: 38600288 DOI: 10.1208/s12249-024-02776-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/21/2024] [Indexed: 04/12/2024] Open
Abstract
Pressurized metered dose inhalers (pMDIs) require optimized formulations to provide stable, consistent lung delivery. This study investigates the feasibility of novel rugose lipid particles (RLPs) as potential drug carriers in pMDI formulations. The physical stability of RLPs was assessed in three different propellants: the established HFA-134a and HFA-227ea and the new low global-warming-potential (GWP) propellant HFO-1234ze. A feedstock containing DSPC and calcium chloride was prepared without pore forming agent to spray dry two RLP batches at inlet temperatures of 55 °C (RLP55) and 75 °C (RLP75). RLPs performance in pMDI formulations was compared to two reference samples that exhibit significantly different performance when suspended in propellants: well-established engineered porous particles and particles containing 80% trehalose and 20% leucine (80T20L). An accelerated stability study at 40 °C and relative humidity of 7% ± 5% was conducted over 3 months. At different time points, a shadowgraphic imaging technique was used to evaluate the colloidal stability of particles in pMDIs. Field emission electron microscopy with energy dispersive X-ray spectroscopy was used to evaluate the morphology and elemental composition of particles extracted from the pMDIs. After 2 weeks, all 80T20L formulations rapidly aggregated upon agitation and exhibited significantly inferior colloidal stability compared to the other samples. In comparison, both the RLP55 and RLP75 formulations, regardless of the propellant used, retained their rugose structure and demonstrated excellent suspension stability comparable with the engineered porous particles. The studied RLPs demonstrate great potential for use in pMDI formulations with HFA propellants and the next-generation low-GWP propellant HFO-1234ze.
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Affiliation(s)
- Zahra Minootan
- Donadeo Innovation Centre for Engineering (DICE), 9211 116 Street NW, Edmonton, Alberta, T6G1H9, Canada
| | - Hui Wang
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, T6G1H9, Canada.
| | - Patrick Connaughton
- Inhalation Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, Durham, North Carolina, USA
| | - Kellisa Lachacz
- Inhalation Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, Durham, North Carolina, USA
| | - Nicholas Carrigy
- Inhalation Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, Durham, North Carolina, USA
| | - Mani Ordoubadi
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, T6G1H9, Canada
| | - David Lechuga-Ballesteros
- Inhalation Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, Durham, North Carolina, USA
| | - Andrew R Martin
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, T6G1H9, Canada
| | - Reinhard Vehring
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, T6G1H9, Canada
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de Maack V, Tubeuf S, Desterbecq C, Dupras C. Beyond Advocacy: Human Health, the Environment, and Tradeoff Ethics. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:50-52. [PMID: 38394010 DOI: 10.1080/15265161.2024.2303164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
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Gupta S, Couillard S, Digby G, Tse SM, Green S, Penz E. Climate Change and Inhaler Selection in Patients With Respiratory Disease. Chest 2024; 165:503-506. [PMID: 38461016 DOI: 10.1016/j.chest.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Samir Gupta
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Simon Couillard
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Geneviève Digby
- Department of Medicine, Division of Respirology, Queen's University, Kingston, ON, Canada
| | - Sze Man Tse
- Faculté de Médecine, Université de Montréal, Montreal, QC, Canada; Department of Pediatrics, Division of Respiratory Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Samantha Green
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health, Toronto, ON, Canada; Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Erika Penz
- Division of Respirology, Critical Care and Sleep Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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Wilkinson AJK, Maslova E, Janson C, Radhakrishnan V, Quint JK, Budgen N, Tran TN, Xu Y, Menzies-Gow A, Bell JP. Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study. Thorax 2024; 79:thorax-2023-220259. [PMID: 38413192 DOI: 10.1136/thorax-2023-220259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/17/2023] [Indexed: 02/29/2024]
Abstract
BACKGROUND Poorly controlled asthma is associated with increased morbidity and healthcare resource utilisation (HCRU). Therefore, to quantify the environmental impact of asthma care, this retrospective, cohort, healthCARe-Based envirONmental cost of treatment (CARBON) study estimated greenhouse gas (GHG) emissions in the UK associated with the management of well-controlled versus poorly controlled asthma. METHODS Patients with current asthma (aged ≥12 years) registered with the Clinical Practice Research Datalink (2008‒2019) were included. GHG emissions, measured as carbon dioxide equivalent (CO2e), were estimated for asthma-related medication use, HCRU and exacerbations during follow-up of patients with asthma classified at baseline as well-controlled (<3 short-acting β2-agonist (SABA) canisters/year and no exacerbations) or poorly controlled (≥3 SABA canisters/year or ≥1 exacerbation). Excess GHG emissions due to suboptimal asthma control included ≥3 SABA canister prescriptions/year, exacerbations and any general practitioner and outpatient visits within 10 days of hospitalisation or an emergency department visit. RESULTS Of the 236 506 patients analysed, 47.3% had poorly controlled asthma at baseline. Scaled to the national level, the overall carbon footprint of asthma care in the UK was 750 540 tonnes CO2e/year, with poorly controlled asthma contributing excess GHG emissions of 303 874 tonnes CO2e/year, which is equivalent to emissions from >124 000 houses in the UK. Poorly controlled versus well-controlled asthma generated 3.1-fold higher overall and 8.1-fold higher excess per capita carbon footprint, largely SABA-induced, with smaller contributions from HCRU. CONCLUSIONS These findings suggest that addressing the high burden of poorly controlled asthma, including curbing high SABA use and its associated risk of exacerbations, may significantly alleviate asthma care-related carbon emissions.
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Affiliation(s)
| | | | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | - Jennifer K Quint
- National Heart Lung Institute, Imperial College London, London, UK
| | - Nigel Budgen
- Global Sustainability, AstraZeneca, Macclesfield, UK
| | - Trung N Tran
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | - Yang Xu
- BioPharmaceuticals Medical, AstraZeneca UK Ltd, Cambridge, UK
| | | | - John P Bell
- BioPharmaceuticals Medical, AstraZeneca Switzerland, Baar, Switzerland
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8
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Alzaabi A, Bell JP, Montero-Arias F, Price DB, Jackson DJ, Wang HC, Budgen N, Farouk H, Maslova E. Greenhouse Gas Emissions from Respiratory Treatments: Results from the SABA CARBON International Study. Adv Ther 2023; 40:4836-4856. [PMID: 37684493 PMCID: PMC10567885 DOI: 10.1007/s12325-023-02663-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023]
Abstract
INTRODUCTION Healthcare systems are looking to reduce their carbon impact. Short-acting β2-agonist (SABA) overuse (≥ 3 canisters/year) is common in asthma and linked to poor outcomes; however, its environmental impact remains unknown. As part of the CARBON programme, this study retrospectively quantified the carbon footprint of SABA and controller inhalers across all respiratory indications and SABA overuse in asthma in lower-middle-income countries (LMICs), upper-middle-income countries and high-income countries across Africa, Asia Pacific, Latin America and the Middle East. METHODS Two data sources were utilised to evaluate the carbon contribution of inhalers to respiratory care. To quantify greenhouse gas (GHG) emissions associated with total inhaler use across all respiratory indications, inhaler sales data were obtained from IQVIA MIDAS® (Q4/2018-Q3/2019) and compared by dose to prevent confounding from differences in canister actuation counts. GHG emissions associated with SABA overuse in asthma were evaluated using prescription and self-reported over-the-counter purchase data from the SABA use IN Asthma (SABINA) III study (2019-2020). Inhaler-related GHG emissions were quantified using published data and product life cycle assessments. RESULTS SABA accounted for > 50% of total inhaler use and inhaler-related emissions in most countries analysed. The total SABA-related emissions were estimated at 2.7 million tonnes carbon dioxide equivalents, accounting for 70% of total inhaler-related emissions. Among the countries, regions and economies analysed, per capita SABA use and associated emissions were higher in Australia, the Middle East and high-income countries. Most SABA prescriptions for asthma (> 90%) were given to patients already overusing SABA. CONCLUSIONS Globally, SABA use/overuse is widespread and is the greatest contributor to the carbon footprint of respiratory treatment, regardless of the economic status of countries. Implementing evidence-based treatment recommendations, personalising treatment and reducing healthcare inequities, especially in LMICs, may improve disease control and patient outcomes, thereby reducing SABA overuse and associated carbon emissions beyond SABA use alone.
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Affiliation(s)
- Ashraf Alzaabi
- Respiratory Medicine Division, Zayed Military Hospital, Abu Dhabi, United Arab Emirates.
| | - John P Bell
- BioPharmaceutical Medical, Medical Affairs Respiratory and Immunology, AstraZeneca, Baar, Switzerland
| | - Felicia Montero-Arias
- Servicio de Neumología, Hospital México, CCSS y Hospital Clínica Bíblica Santa Ana, San José, Costa Rica
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Science, University of Aberdeen, Aberdeen, UK
| | - David J Jackson
- Guy's Severe Asthma Centre, King's College London, London, UK
| | - Hao-Chien Wang
- Department of Medicine, National Taiwan University Cancer Center, Taipei City, Taiwan
| | - Nigel Budgen
- Global Sustainability, AstraZeneca, Macclesfield, UK
| | - Hisham Farouk
- International Medical, AstraZeneca, Dubai, United Arab Emirates
| | - Ekaterina Maslova
- BioPharmaceutical Medical, Medical Affairs Respiratory and Immunology, AstraZeneca, Cambridge, UK
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Pali-Schöll I, Hermuth-Kleinschmidt K, Dramburg S, Agache I, Mayerhofer H, Jensen-Jarolim E, Goshua A, Nadeau KC. An EAACI review: Go green in health care and research. Practical suggestions for sustainability in clinical practice, laboratories, and scientific meetings. Allergy 2023; 78:2606-2622. [PMID: 37584433 PMCID: PMC10543587 DOI: 10.1111/all.15836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/10/2023] [Accepted: 07/22/2023] [Indexed: 08/17/2023]
Abstract
Health care professionals (HCPs) and researchers in the health care sector dedicate their professional life to maintaining and optimizing the health of their patients. To achieve this, significant amounts of resources are used and currently it is estimated that the health care sector contributes to more than 4% of net greenhouse gas (GHG) emissions. GHG emissions adversely impact planetary health and consequently human health, as the two are intricately linked. There are many factors of health care that contribute to these emissions. Hospitals and research labs also use high amounts of consumables which require large amounts of raw materials and energy to produce. They are further responsible for polluting the environment via disposal of plastics, drug products, and other chemicals. To maintain and develop state-of-the-art best practices and treatments, medical experts exchange and update their knowledge on methods and technologies in the respective fields at highly specialized scientific meetings. These meetings necessitate thousands of attendants traveling around the globe. Therefore, while the goal of HCPs is to care for the individual, current practices have an enormous (indirect) impact on the health of the patients by their negative environmental impacts. There is an urgent need for HCPs and researchers to mitigate these detrimental effects. The installation of a sustainability-manager at health care facilities and research organizations to implement sustainable practices while still providing quality health care is desirable. Increased use of telemedicine, virtual/hybrid conferences and green chemistry have recently been observed. The benefits of these practices need to be evaluated and implemented as appropriate. With this manuscript, we aim to increase the awareness about the negative impacts of the health care system (including health care research) on planetary and human health. We suggest some easy and highly impactful steps and encourage health care professionals and research scientists of all hierarchical levels to immediately implement them in their professional as well as private life to counteract the health care sector's detrimental effects on the environment.
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Affiliation(s)
- Isabella Pali-Schöll
- The Interuniversity Messerli Research Institute of the University of Veterinary Medicine Vienna, Medical University Vienna and University Vienna, Vienna Austria
- Institute of Pathophysiology and Allergy Research; Center of Physiology, Pathophysiology and Immunology; Medical University Vienna, Vienna Austria
| | | | - Stephanie Dramburg
- Department of Pediatric Respiratory Care, Immunology and Intensive Care Medicine, Charité Universitätsmedizin – Berlin, Berlin, Germany
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Hanna Mayerhofer
- The Interuniversity Messerli Research Institute of the University of Veterinary Medicine Vienna, Medical University Vienna and University Vienna, Vienna Austria
- Institute of Pathophysiology and Allergy Research; Center of Physiology, Pathophysiology and Immunology; Medical University Vienna, Vienna Austria
| | - Erika Jensen-Jarolim
- The Interuniversity Messerli Research Institute of the University of Veterinary Medicine Vienna, Medical University Vienna and University Vienna, Vienna Austria
- Institute of Pathophysiology and Allergy Research; Center of Physiology, Pathophysiology and Immunology; Medical University Vienna, Vienna Austria
| | - Anna Goshua
- Stanford University School of Medicine, Stanford, CA
| | - Kari C. Nadeau
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
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Levy ML, Bateman ED, Allan K, Bacharier LB, Bonini M, Boulet LP, Bourdin A, Brightling C, Brusselle G, Buhl R, Chakaya MJ, Cruz AA, Drazen J, Ducharme FM, Duijts L, Fleming L, Inoue H, Ko FWS, Krishnan JA, Masekela R, Mortimer K, Pitrez P, Salvi S, Sheikh A, Reddel HK, Yorgancıoğlu A. Global access and patient safety in the transition to environmentally friendly respiratory inhalers: the Global Initiative for Asthma perspective. Lancet 2023; 402:1012-1016. [PMID: 37480934 DOI: 10.1016/s0140-6736(23)01358-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/12/2023] [Accepted: 06/27/2023] [Indexed: 07/24/2023]
Affiliation(s)
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keith Allan
- Department of Patient and Community Engagement, University Hospitals of Leicester, Leicester, UK
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matteo Bonini
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico A Gemelli-IRCCS, Rome, Italy
| | | | - Arnaud Bourdin
- Department of Respiratory Diseases, University of Montpellier, Montpellier, France
| | - Chris Brightling
- Institute for Lung Health, Leicester NIHR BRC, University of Leicester, Leicester, UK
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium; Departments of Epidemiology and Respiratory Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Alvaro A Cruz
- ProAR Foundation and School of Medicine, Federal University of Bahia, Salvador, Brazil
| | - Jeffrey Drazen
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Francine M Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine, Sainte-Justine University Health Centre, University of Montreal, Montreal, QC, Canada
| | - Liesbeth Duijts
- Department of Pediatrics, Divisions of Respiratory Medicine and Allergology and Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Hiromasa Inoue
- Department of Pulmonary Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Fanny W S Ko
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | - Refiloe Masekela
- Department of Paediatrics and Child Health, University of KwaZulu Natal, Durban, South Africa
| | - Kevin Mortimer
- Department of Paediatrics and Child Health, University of KwaZulu Natal, Durban, South Africa; Department of Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Cambridge Africa Department, University of Cambridge, Cambridge, UK
| | - Paulo Pitrez
- Pulmonology Department, Hospital Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - Aziz Sheikh
- Primary Care Research & Development and Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Helen K Reddel
- Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Gagné M, Karanikas A, Green S, Gupta S. Reductions in inhaler greenhouse gas emissions by addressing care gaps in asthma and chronic obstructive pulmonary disease: an analysis. BMJ Open Respir Res 2023; 10:e001716. [PMID: 37730281 PMCID: PMC10510936 DOI: 10.1136/bmjresp-2023-001716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/04/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Climate change from greenhouse gas (GHG) emissions represents one of the greatest public health threats of our time. Inhalers (and particularly metred-dose inhalers (MDIs)) used for asthma and chronic obstructive pulmonary disease (COPD), constitute an important source of GHGs. In this analysis, we aimed to estimate the carbon footprint impact of improving three distinct aspects of respiratory care that drive avoidable inhaler use in Canada. METHODS We used published data to estimate the prevalence of misdiagnosed disease, existing inhaler use patterns, medication class distributions, inhaler type distributions and GHGs associated with inhaler actuations, to quantify annual GHG emissions in Canada: (1) attributable to asthma and COPD misdiagnosis; (2) attributable to overuse of rescue inhalers due to suboptimally controlled symptoms; and (3) avoidable by switching 25% of patients with existing asthma and COPD to an otherwise comparable therapeutic option with a lower GHG footprint. RESULTS We identified the following avoidable annual GHG emissions: (1) ~49 100 GHG metric tons (MTs) due to misdiagnosed disease; (2) ~143 000 GHG MTs due to suboptimal symptom control; and (3) ~262 100 GHG MTs due to preferential prescription of strategies featuring MDIs over lower-GHG-emitting options (when 25% of patients are switched to lower GHG alternatives). Combined, the GHG emission reductions from bridging these gaps would be the equivalent to taking ~101 100 vehicles off the roads each year. CONCLUSIONS Our analysis shows that the carbon savings from addressing misdiagnosis and suboptimal disease control are comparable to those achievable by switching one in four patients to lower GHG-emitting therapeutic strategies. Behaviour change strategies required to achieve and sustain delivery of evidence-based real-world care are complex, but the added identified incentive of carbon footprint reduction may in itself prove to be a powerful motivator for change among providers and patients. This additional benefit can be leveraged in future behaviour change interventions.
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Affiliation(s)
- Myriam Gagné
- Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Aliki Karanikas
- Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Samantha Green
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir Gupta
- Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Murphy A, Howlett D, Gowson A, Lewis H. Understanding the feasibility and environmental effectiveness of a pilot postal inhaler recovery and recycling scheme. NPJ Prim Care Respir Med 2023; 33:5. [PMID: 36681666 PMCID: PMC9864496 DOI: 10.1038/s41533-023-00327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
All inhalers have an environmental impact; the majority are not recycled, with many disposed of inappropriately through domestic waste. To assess the feasibility of a method for recovering and recycling inhalers, Chiesi Limited (Chiesi) set up and funded 'Take AIR (Action for Inhaler Recycling)', a 12-month pilot postal scheme facilitated by community pharmacies across Leicester, Leicestershire, and Rutland, and hospitals in Leicestershire. All inhalers were accepted in the scheme. The recovered pressurised metered-dose inhalers (pMDIs) were dismantled and component parts recycled where possible; the remaining propellant gas was extracted for reuse in refrigeration and air conditioning industries. Other inhaler types were incinerated in an 'energy-from-waste' facility. From February 2021 to February 2022, 20,049 inhalers were returned; most (77%) were pMDIs. So far, Take AIR has saved the equivalent of an estimated 119.3 tonnes of carbon dioxide emissions from entering the atmosphere. Our experience demonstrates the feasibility and effectiveness of a postal inhaler recovery and recycling scheme, which could be used as a foundation to build future initiatives.
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Affiliation(s)
- Anna Murphy
- grid.269014.80000 0001 0435 9078University Hospitals of Leicester NHS Trust, Leicester, UK
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13
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Urrutia-Pereira M, Chong-Neto HJ, Winders TA, Solé D. Environmental impact of inhaler devices on respiratory care: a narrative review. J Bras Pneumol 2023; 48:e20220270. [PMID: 36651436 PMCID: PMC9747156 DOI: 10.36416/1806-3756/e20220270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Climate change is a huge and present threat to human health. This article aims to deepen the knowledge about the environmental impact of inhaler devices on their carbon footprint for patients and health professionals, providing information that allows a better choice of the type of device to be prescribed for the treatment of asthma and COPD. This narrative and nonsystematic review was carried out by searching databases (PubMed, Google Scholar, SciELO, and EMBASE) for articles published between 2017 and 2022, written in Portuguese or in English, using the search words "inhalation device" OR "environmental." The review showed that global warming cannot be addressed by focusing only on inhaler devices. However, the devices that we use to treat respiratory diseases such as asthma and COPD, which are diseases that are aggravated by climate change, are also causing that change. Therefore, health professionals, patient organizations, and industries should take a lead in health policies to offer affordable alternatives to inhalers containing hydrofluoroalkane.
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Affiliation(s)
| | | | - Tonya A Winders
- . Global Allergy and Airways Patient Platform, Vienna, Austria
| | - Dirceu Solé
- . Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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14
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Leraut J, Boissinot L, Hassani Y, Bonnet-Zamponi D, Le Gonidec P. [Reducing the environmental impact of inhalers dispensed in France. From diagnosis to sustainable action]. ANNALES PHARMACEUTIQUES FRANÇAISES 2023; 81:123-137. [PMID: 35944697 DOI: 10.1016/j.pharma.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/04/2022] [Accepted: 08/01/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES While inhaled drugs are mainly used to treat chronic respiratory diseases, they are also responsible for greenhouse gas (GHG) emission. To highlight this issue, a dispensed analysis and a carbon footprint evaluation of inhalers in France have been conducted. METHODS A national qualitative and quantitative analysis of dispensed inhalers in community pharmacies (CP) and hospitals (H) was conducted in France for 2019. A data review from the literature led to the determination of the inhalers carbon footprint, expressed in carbon dioxide equivalent (CO2e) during the inhaler life cycle. RESULTS Close to 40 million inhalers were dispensed by community pharmacies and one million by hospitals in 2019. It concerned three types of inhalers: metered-dose inhalers (MDI) [CP: 49%; H: 45%], dry powder inhalers (DPI) [CP: 47%; H: 51%], and soft mist inhalers (SMI) [CP: 4%; H: 4%]. According to the literature, MDI have the highest carbon footprint, ranging from 11 to 28 kgCO2e versus less than 1 kgCO2e for DPI/SMI. In 2019, the national carbon footprint of salbutamol (MDI), the most dispensed inhaler, was estimated to be over 310 million kgCO2e (CP+H) corresponding to more than 310,000 round-trip Paris-New York. CONCLUSIONS This study shows the involvement of MDI in GHG emissions. Taking actions as part of a global and coordinated approach to limit their environmental impact is possible and thus is a priority.
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Affiliation(s)
- J Leraut
- OMEDIT Île-De-France, 3, avenue Victoria, 75001 Paris, France.
| | - L Boissinot
- OMEDIT Île-De-France, 3, avenue Victoria, 75001 Paris, France
| | - Y Hassani
- OMEDIT Île-De-France, 3, avenue Victoria, 75001 Paris, France
| | | | - P Le Gonidec
- OMEDIT Île-De-France, 3, avenue Victoria, 75001 Paris, France
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15
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Häußermann S, Arendsen LJ, Pritchard JN. Smart dry powder inhalers and intelligent adherence management. Adv Drug Deliv Rev 2022; 191:114580. [PMID: 36273513 DOI: 10.1016/j.addr.2022.114580] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 01/24/2023]
Abstract
Adherence to inhaled treatments is a complex challenge for patients with chronic obstructive pulmonary disease (COPD) and asthma, it not only involves following the prescribed treatment plans but also administering the medications correctly. When using a dry powder inhaler (DPI), the inhalation flow is particularly critical. Patients frequently fail to use a rapid enough onset and fast enough inhalation when using DPIs. At the same time, there is increasing pressure on physicians to switch patients to DPIs, to minimise the environmental impact of pMDI propellants. This makes it critical to understand whether a patient will maintain or improve disease control by using their new inhaler correctly. However, it is challenging for health care professionals to understand how a patient behaves away from the clinic. Therefore, it would be beneficial to obtain real-world data through the use of monitoring tools, i.e., "smart inhalers". This paper reviews the technologies used to monitor DPIs, how effective they have been in a clinical setting, and how well these have been adopted by patients and health care providers.
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Drew J, Christie SD, Rainham D, Rizan C. HealthcareLCA: an open-access living database of health-care environmental impact assessments. Lancet Planet Health 2022; 6:e1000-e1012. [PMID: 36495883 DOI: 10.1016/s2542-5196(22)00257-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 08/17/2022] [Accepted: 10/18/2022] [Indexed: 06/17/2023]
Abstract
Anthropogenic environmental change negatively effects human health and is increasing health-care system demand. Paradoxically, the provision of health care, which itself is a substantial contributor to environmental degradation, is compounding this problem. There is increasing willingness to transition towards sustainable health-care systems globally and ensuring that strategy and action are informed by best available evidence is imperative. In this Personal View, we present an interactive, open-access database designed to support this effort. Functioning as a living repository of environmental impact assessments within health care, the HealthcareLCA database collates 152 studies, predominantly peer-reviewed journal articles, into one centralised and publicly accessible location, providing impact estimates (currently totalling 3671 numerical values) across 1288 health-care products and processes. The database brings together research generated over the past two decades and indicates exponential field growth.
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Affiliation(s)
- Jonathan Drew
- Department of Surgery (Neurosurgery), Dalhousie University, Halifax, NS, Canada.
| | - Sean D Christie
- Department of Surgery (Neurosurgery), Dalhousie University, Halifax, NS, Canada
| | - Daniel Rainham
- School of Health and Human Performance and the Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
| | - Chantelle Rizan
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK; Brighton and Sussex Medical School, Brighton, UK
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17
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Chakma M, Usmani O. Inhalers and the Environment: Pollution, Plastics and Policy. PNEUMON 2022. [DOI: 10.18332/pne/154608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Usmani OS, Bosnic-Anticevich S, Dekhuijzen R, Lavorini F, Bell J, Stjepanovic N, Swift SL, Roche N. Real-World Impact of Nonclinical Inhaler Regimen Switches on Asthma or COPD: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2624-2637. [PMID: 35750323 DOI: 10.1016/j.jaip.2022.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Switching inhaler regimens can be driven by poor disease control but also by nonclinical factors, such as cost and environmental impact. The consequences of switching for nonclinical reasons are largely unclear. OBJECTIVE To systematically review the real-world consequences of switching inhaler regimens for nonclinical reasons in asthma and/or chronic obstructive pulmonary disease patients. METHODS Embase, MEDLINE, EBM Reviews, and EconLit were searched to November 21, 2020. Conference searches and reference checking were also performed. Real-world studies of asthma and/or chronic obstructive pulmonary disease patients undergoing a switch in inhaler regimen for any reason apart from clinical need were included. Two reviewers screened and extracted data. Key outcomes included symptom control, exacerbations, and patient-doctor relationships. RESULTS A total of 8,958 records were screened and 21 studies included. Higher-quality (matched comparative) studies were prioritized. Five matched studies (6 datasets) reported on symptom control: 5 datasets (n = 7,530) with unclear patient consent reported improved disease control following switching, and 1 dataset (n = 1,648) with non-consented patients reported significantly worsened disease control. Three matched studies (5 datasets, n = 10,084) reported on exacerbation rate ratios; results were heterogeneous depending on the definition used. Two studies (n = 137) reported that switching inhaler regimens could have a negative impact on the doctor-patient relationship, especially when the switches were non-consented. Study quality was generally low. CONCLUSIONS Switching inhaler regimens is a complex issue that can have variable clinical consequences and can harm the patient-doctor relationship. Limited high-quality evidence was identified, and study designs were heterogeneous. A robust framework is needed to guide the personalized switching of inhalers.
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Affiliation(s)
- Omar S Usmani
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, UK
| | - Sinthia Bosnic-Anticevich
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Clinical Management, Woolcock Institute of Medical Research, Sydney, Australia
| | - Richard Dekhuijzen
- Faculty of Medical Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - John Bell
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | | | | | - Nicolas Roche
- Department of Respiratory Medicine, Cochin Hospital and Institute, APHP Centre University Paris Cité, Paris, France.
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19
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Carbon Footprints and Life Cycle Assessments of Inhalers: A Review of Published Evidence. SUSTAINABILITY 2022. [DOI: 10.3390/su14127106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Respiratory inhalers have a substantial impact on the carbon footprint of the healthcare sector. Environmental factors, including carbon footprints, are gaining importance in choosing inhalers once medical considerations have been addressed. This paper provides a review of the carbon footprint (CFP) and life cycle assessment (LCA) environmental profile of dry powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs). Despite methodological challenges, our analysis reveals that the CFP varies between DPIs ranging from 359 gCO2e per inhaler (Enerzair Breezhaler® DPI without digital companion 30-day pack) to 1250 gCO2e per inhaler (Seretide Accuhaler® 50/500) and from 6.13 gCO2e per dose (Enerzair Breezhaler® without digital companion 90-day pack) to 27 gCO2e per dose (Relvar Elipta 92/22). The breakdown of inhaler CFP by life cycle stage reveals that, although the use and end-of-life stages together contribute to most of the CFP of the MDIs, the largest contributions to the CFP of the DPI/SMI are made by the API and manufacturing stages of the life cycle. Although from a climate perspective our review aligns with the findings of Jeswani and Azapagic that DPIs have a lower CFP than pMDIs, we conclude that the performance against other environment impact categories depends on the design, choice of material and manufacturing process of the DPIs. The challenge of comparing the CFP of different inhalers can be made easier by the standardization of study boundaries and methods.
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20
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Brittain D, D’Andrea P, Gruen E, Hosoe M, Jain D, Jauernig J, Pethe A, Scosyrev E, Tanase AM, Tillmann HC. A Review of the Unique Drug Development Strategy of Indacaterol Acetate/Glycopyrronium Bromide/Mometasone Furoate: A First-in-Class, Once-Daily, Single-Inhaler, Fixed-Dose Combination Treatment for Asthma. Adv Ther 2022; 39:2365-2378. [PMID: 35072888 PMCID: PMC9122880 DOI: 10.1007/s12325-021-02025-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022]
Abstract
A novel, once-daily (o.d.), fixed-dose combination (FDC) of indacaterol acetate (IND), glycopyrronium bromide (GLY), and mometasone furoate (MF), delivered by the inhaler Breezhaler® device, is the first long-acting beta2-adrenergic agonist/long-acting muscarinic antagonist/inhaled corticosteroid (LABA/LAMA/ICS) therapy to be approved for maintenance treatment of asthma in adults inadequately controlled on LABA/ICS. The approval of IND/GLY/MF in the European Union (EU) also included an optional electronic sensor and smartphone (or other suitable device) application, making it the first “digital companion” that can be prescribed with an asthma medication. As a result, the European Medicines Agency included this approval as one of the “outstanding contributions to public health” (for Pneumology/Allergology) in their 2020 highlights report. Alongside IND/GLY/MF, an o.d. LABA/ICS FDC, IND/MF, was also developed and approved. This review outlines the unique strategy used in the accelerated development of IND/GLY/MF that combined various approaches: (1) selecting individual components with established efficacy/safety, (2) bridging doses to optimize efficacy/safety of IND/GLY/MF and IND/MF delivered via the Breezhaler® device, (3) developing IND/GLY/MF and IND/MF in parallel, and (4) submission for regulatory approval before formal completion of the pivotal phase III studies. IND/GLY/MF and IND/MF were combined in a single-development plan (PLATINUM program), which comprised four phase III studies: QUARTZ and PALLADIUM evaluated IND/MF while IRIDIUM and ARGON evaluated IND/GLY/MF. A unique feature was the inclusion of two LABA/ICS comparators in the pivotal IRIDIUM study—IND/MF as an internal comparator, and high-dose salmeterol xinafoate/fluticasone propionate (SAL/FLU) as a marketed comparator. In the ARGON study, IND/GLY/MF was compared against o.d. tiotropium (via Respimat®) plus twice-daily (b.i.d.) high-dose SAL/FLU (via Diskus®). As a result of this development strategy, the development and approval of IND/GLY/MF was accelerated by ca. 4 years as against what would be expected from a traditional approach, novel data were generated, and a unique optional digital companion was approved in the EU. A Video Abstract by Dr Dominic Brittain, Global Drug Development, Novartis. (MP4 228293 kb)
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21
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Wilkinson A, Maslova E, Janson C, Xu Y, Haughney J, Quint JK, Budgen N, Menzies-Gow A, Bell J, Crooks MG. Environmental Sustainability in Respiratory Care: An Overview of the healthCARe-Based envirONmental Cost of Treatment (CARBON) Programme. Adv Ther 2022; 39:2270-2280. [PMID: 35279810 PMCID: PMC9056443 DOI: 10.1007/s12325-022-02076-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/04/2022] [Indexed: 12/01/2022]
Abstract
Introduction Faced with the challenges of climate change, countries are seeking to decarbonise their economies. A greater understanding of what comprises the carbon footprint of care in healthcare systems will identify potential strategies for reduction of greenhouse gas (GHG) emissions. In respiratory care, the focus has been on preventer inhalers, thereby omitting contributions from other aspects such as healthcare resource utilisation (HCRU) and reliever inhaler use. The healthCARe-Based envirONmental cost of treatment (CARBON) programme aims to provide a broader understanding of the carbon footprint associated with respiratory care. Methods CARBON will quantify the carbon footprint of medications and HCRU among approximately 2.5 million patients with respiratory diseases from seven ongoing studies spanning more than 40 countries. Across studies, to obtain the carbon footprint of all inhaled, oral, and injectable medications, SimaPro life cycle assessment software modelling resource and energy consumption data, in addition to Ecoinvent® data sets and certified published studies, will be used. The carbon footprint of HCRU in the United Kingdom will be estimated by applying the methodology and data obtained from the Sustainable Healthcare Coalition Care Pathway Guidance. Planned Outcomes In asthma, CARBON studies will quantify GHG emissions associated with well-controlled versus not well-controlled asthma, the contribution of short-acting β2-agonist (SABA) reliever inhalers (and their potential overuse) to the carbon footprint of care, and how implementation of treatment guidelines can drive improved outcomes and footprint reduction. In chronic obstructive pulmonary disease (COPD), CARBON studies will assess the impact of exacerbation history on GHG emissions associated with HCRU and SABA use in subsequent years and estimate the carbon footprint associated with all aspects of COPD care. Conclusion CARBON aims to show that the principle of evidence-led care focused on improvement of clinical outcomes has the potential to benefit patients and the environment.
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Affiliation(s)
- Alex Wilkinson
- Respiratory Department, Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage, Hertfordshire, SG1 4AB, UK.
| | | | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | | | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
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22
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Bickhardt J, Czupalla C, Bader U. [Reduction of greenhouse gas emissions by inhaler choice in the therapy of asthma and COPD patients]. Pneumologie 2022; 76:321-329. [PMID: 35453159 DOI: 10.1055/a-1771-5292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The global warming potential of inhaled medication depends on the applied inhaler. Pressurised metered dose inhalers (pMDI) contain green-house gases (GHG) and are associated with a 10 to 40 times higher CO2-footprint than GHG-free dry-powder inhalers (DPI). AIM Feasibility and relevance of prescription conversion from pMDI to DPI were investigated in a pulmonology outpatient clinic regarding the CO2-footprint and the economic costs under real-world conditions. METHODS Based on exemplary therapy regimens of different intensity for three patients, the annual CO2-footprint and daily therapy costs were investigated. The effect of converting from pMDI to DPI on CO2-footprint and economic costs were calculated on the basis of prescriptions during the first quarter of 2020 compared to the first quarter of 2021. RESULTS Conversion of a pMDI-based inhalative therapy of exemplary asthma and COPD patients to a DPI-based therapy saved between 115 and 480 kg CO2 equivalents (CO2e) per year and patient depending on intensity of therapy and GHG used. A total of 184,297 and 164,165 defined daily doses (DDD) were prescribed by the clinic for 2,610 (January-March 2020) and 2,693 (January-March 2021) patients, respectively. The proportion of DPI prescribed increased from 49 to 78% of total inhaler prescriptions. The increase in prescriptions for single-agent inhaled corticosteroids from 19.8 to 74.1% of total inhaler prescriptions was particularly striking. Due to the conversion, emissions were reduced by 35,000 to 40,000 kg CO2e between January-March 2020 and January-March 2021 in our clinic. During the same period, there was no increase in costs compared to nationwide costs. The relation of prescribed DPI and pMDI in the same period did not change among the pulmonologists in Saxony nor nationwide in Germany. If all ambulant pulmonologists in Germany would prescribe 75% DPI, CO2-emissions could be reduced by 11,650 tonnes CO2e per quarter and 46,600 tonnes CO2e per year, respectively. CONCLUSION The type of inhalers can be converted from pMDI to DPI in a real-world setting. Thereby, a significant reduction of GHG emissions is possible without increased costs.
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Affiliation(s)
- Jakob Bickhardt
- Pneumologische Gemeinschaftspraxis Dres. Bickhardt/Bader, Dresden, Germany
| | - Cornelia Czupalla
- Verordnungs- und Prüfwesen, Kassenärztliche Vereinigung Sachsen, Dresden, Germany
| | - Uta Bader
- Pneumologische Gemeinschaftspraxis Dres. Bickhardt/Bader, Dresden, Germany
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How to Choose the Right Inhaler Using a Patient-Centric Approach? Adv Ther 2022; 39:1149-1163. [PMID: 35080761 PMCID: PMC8790222 DOI: 10.1007/s12325-021-02034-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
There are many different inhaler devices and medications on the market for the treatment of asthma and chronic obstructive pulmonary disease, with over 230 drug-delivery system combinations available. However, despite the abundance of effective treatment options, the achieved disease control in clinical practice often remains unsatisfactory. In this context, a key determining factor is the match or mismatch of an inhalation device with the characteristics or needs of an individual patient. Indeed, to date, no ideal device exists that fits all patients, and a personalized approach needs to be considered. Several useful choice-guiding algorithms have been developed in the recent years to improve inhaler–patient matching, but a comprehensive tool that translates the multifactorial complexity of inhalation therapy into a user-friendly algorithm is still lacking. To address this, a multidisciplinary expert panel has developed an evidence-based practical treatment tool that allows a straightforward way of choosing the right inhaler for each patient.
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Leving MT, Kocks J, Bosnic-Anticevich S, Dekhuijzen R, Usmani OS. Relationship between Peak Inspiratory Flow and Patient and Disease Characteristics in Individuals with COPD—A Systematic Scoping Review. Biomedicines 2022; 10:biomedicines10020458. [PMID: 35203667 PMCID: PMC8962311 DOI: 10.3390/biomedicines10020458] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 11/16/2022] Open
Abstract
Optimal delivery of medication via dry powder inhalers, the most commonly prescribed inhaler type, is dependent on a patient achieving a minimum level of inspiratory flow during inhalation. However, measurement of peak inspiratory flow (PIF) against the simulated resistance of a dry powder inhaler is not frequently performed in clinical practice due to time or equipment limitations. Therefore, defining which patient characteristics are associated with lower PIF is critically important to help clinicians optimize their inhaler choice through a more personalized approach to prescribing. The objective of this scoping review was to systematically evaluate patient and disease characteristics determining PIF in patients with chronic obstructive pulmonary disease (COPD). Medline, Cochrane and Embase databases were systematically searched for relevant studies on PIF in patients with COPD published in English between January 2000 and May 2021. The quality of evidence was assessed using a modified Grading of Recommendations Assessment, Development and Evaluation checklist. Of 3382 citations retrieved, 35 publications were included in the review (nine scored as high quality, 13 as moderate, nine as low, and four as very low). Factors correlating with PIF in >70% of papers included both patient characteristics (lower PIF correlated with increased age, female gender, shorter height, decreased handgrip and inspiratory muscle strength, and certain comorbidities) and disease characteristics (lower PIF correlated with markers of lung hyperinflation, lower peak expiratory flow [PEF] and increased disease severity). Other factors correlating with adequate/optimal or improved PIF included education/counseling and exercise/inspiratory muscle training; impaired physical function and errors in inhalation technique/non-adherence were associated with low/suboptimal PIF. In conclusion, clinicians should measure PIF against the simulated resistance of a particular device wherever possible. However, as this often cannot be done due to lack of resources or time, the patient and disease characteristics that influence PIF, as identified in this review, can help clinicians to choose the most appropriate inhaler type for their patients.
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Affiliation(s)
- Marika T. Leving
- General Practitioners Research Institute, 9713 GH Groningen, The Netherlands;
- Correspondence:
| | - Janwillem Kocks
- General Practitioners Research Institute, 9713 GH Groningen, The Netherlands;
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore 573969, Singapore
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, Sydney, NSW 2037, Australia;
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia
- Sydney Local Health District, Sydney, NSW 2050, Australia
| | | | - Omar S. Usmani
- National Heart and Lung Institute (NHLI), Imperial College London, London SW3 6LY, UK;
- Royal Brompton Hospital, London SW3 6NP, UK
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25
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Kponee-Shovein K, Marvel J, Ishikawa R, Choubey A, Kaur H, Ngom K, Fakih I, Swartz N, Schatzki T, Signorovitch J. Impact of choice of inhalers for asthma care on global carbon footprint and societal costs: a long-term economic evaluation. J Med Econ 2022; 25:940-953. [PMID: 35686860 DOI: 10.1080/13696998.2022.2088196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND While effective asthma control medications reduce the burden of asthma, a significant subgroup of these treatments, namely metered-dose inhalers (MDIs), produce substantial greenhouse gas (GHG) emissions, thus contributing to climate change. This study quantified the global climate impact (i.e. carbon dioxide equivalent [CO2e] emissions) and costs of long-term status quo asthma inhaler use versus alternative scenarios substituting MDIs with propellant-free dry powder inhalers (DPIs). METHODS Three scenarios were evaluated across 10-year (2020-2030) and 50-year (2020-2070) time horizons: A (status quo inhaler use), B and C (2% and 5% year-over-year substitution of MDIs with DPIs, respectively). Global inhaler volumes and costs at baseline were sourced from IQVIA, then projected using UN and WHO trends in per capita GDP, urbanization, and asthma population growth. Inhaler spending was assumed to fall by 90% following generic entry in 2030. The carbon footprint per inhaler and health damage factors for disability-adjusted life years (DALYs) were derived from literature. The US government's central and high-impact estimates for the social cost of carbon (SCC) were used to calculate emissions costs. RESULTS Over 50 years, scenario A resulted in 826 million tonnes of CO2e emissions globally, with an associated SCC between 21% and 65% of the projected global spending on asthma inhalers. In comparison, CO2e emissions were reduced by 38% and 58% in Scenarios B and C, respectively, and DALYs improved by 33 and 51%. Depending on SCC estimates, Scenarios B and C increased global costs by 7.3% and 16.5%, respectively (central SCC), or decreased costs by 4.2% and 2.6% (high-impact SCC) versus Scenario A. Over 10 years, Scenario A resulted in 97 million tonnes of CO2e emissions globally, with an associated SCC between 4.4% and 12.2% of projected spending. In comparison, Scenarios B and C were associated with 12% and 24% reductions in CO2e emissions and improvements in DALYs by 11.5% and 22.7%, respectively. CONCLUSIONS Global efforts by environmental and health-policy decision-makers to substitute currently available MDIs with DPIs for asthma control would result in substantial reductions in GHG emissions with manageable costs, or potential cost savings, depending on the SCC. Policies that decrease use of MDIs warrant global attention.
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Affiliation(s)
| | | | | | - Abhay Choubey
- Novartis Healthcare Private Limited, Hyderabad, India
| | - Harneet Kaur
- Novartis Healthcare Private Limited, Hyderabad, India
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Woodcock A, Beeh KM, Sagara H, Aumônier S, Addo-Yobo E, Khan J, Vestbo J, Tope H. The environmental impact of inhaled therapy: making informed treatment choices. Eur Respir J 2021; 60:13993003.02106-2021. [PMID: 34916263 PMCID: PMC9301054 DOI: 10.1183/13993003.02106-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/22/2021] [Indexed: 12/03/2022]
Abstract
When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual or organisation is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of carbon dioxide equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered-dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives. There is increasing interest regarding the carbon footprint of inhaled therapies; while efficacy, safety and patient preference should be prioritised, the increasingly available carbon footprint data may be factored into treatment decision makinghttps://bit.ly/3I6atV2
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Affiliation(s)
- Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK .,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Kai M Beeh
- Insaf Respiratory Research Institute, Wiesbaden, Germany
| | - Hironori Sagara
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University, Tokyo, Japan
| | | | - Emmanuel Addo-Yobo
- Department of Child Health, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Javaid Khan
- Section of Pulmonary and Critical Care Medicine, The Aga Khan University, Karachi, Pakistan
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Helen Tope
- Principal Consultant, Planet Futures, Melbourne, Australia
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Pernigotti D, Stonham C, Panigone S, Sandri F, Ferri R, Unal Y, Roche N. Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries. BMJ Open Respir Res 2021; 8:8/1/e001071. [PMID: 34872967 PMCID: PMC8650484 DOI: 10.1136/bmjresp-2021-001071] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/17/2021] [Indexed: 12/31/2022] Open
Abstract
Background Inhaled therapies are key components of asthma and chronic obstructive pulmonary disease (COPD) treatments. Although the use of pressurised metered-dose inhalers (pMDIs) accounts for <0.1% of global greenhouse gas emissions, their contribution to global warming has been debated and efforts are underway to reduce the carbon footprint of pMDIs. Our aim was to establish the extent to which different scenarios led to reductions in greenhouse gas emissions associated with inhaler use, and their clinical implications. Methods We conducted a series of scenario analyses using asthma and COPD inhaler usage data from 2019 to model carbon dioxide equivalent (CO2e) emissions reductions over a 10-year period (2020–2030) in the UK, Italy, France, Germany and Spain: switching propellant-driven pMDIs for propellant-free dry-powder inhalers (DPIs)/soft mist inhalers (SMIs); transitioning to low global warming potential (GWP) propellant (hydrofluoroalkane (HFA)-152a) pMDIs; reducing short-acting β2-agonist (SABA) use; and inhaler recycling. Results Transition to low-GWP pMDIs and forced switching to DPI/SMIs (excluding SABA inhalers) would reduce annual CO2e emissions by 68%–84% and 64%–71%, respectively, but with different clinical implications. Emission reductions would be greatest (82%–89%) with transition of both maintenance and SABA inhalers to low-GWP propellant. Only minimising SABA inhaler use would reduce CO2e emissions by 17%–48%. Although significant greenhouse gas emission reductions would be achieved with high rates of end-of-life recycling (81%–87% of the inhalers), transition to a low-GWP propellant would still result in greater reductions. Conclusions While the absolute contribution of pMDIs to global warming is very small, substantial reductions in the carbon footprint of pMDIs can be achieved with transition to low-GWP propellant (HFA-152a) inhalers. This approach outperforms the substitution of pMDIs with DPI/SMIs while preserving patient access and choice, which are essential for optimising treatment and outcomes. These findings require confirmation in independent studies.
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Affiliation(s)
| | - Carol Stonham
- NHS Gloucestershire Clinical Commissioning Group, Brockworth, UK
| | - Sara Panigone
- Global Marketing, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Rossella Ferri
- Corporate Health Safety and Environment, Chiesi Farmaceutici SpA, Parma, Italy
| | - Yasemin Unal
- Global Medical Affairs, Chiesi Farmaceutici SpA, Parma, Italy
| | - Nicolas Roche
- Pneumologie, APHP Centre, Université de Paris, Paris, Île-de-France, France
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A Systematic Review of Published Algorithms for Selecting an Inhaled Delivery System in COPD. Ann Am Thorac Soc 2021; 19:1213-1220. [PMID: 34856108 DOI: 10.1513/annalsats.202108-930oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Medication for treatment of COPD is available in many different delivery systems; however, national and international guidelines do not provide recommendations on how to select the optimal system for an individual patient. OBJECTIVES To perform a systematic review of published algorithms for inhaler selection in out-patients with COPD. METHODS PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were search for articles on inhaler selection published between January 1, 1990 and March 10, 2021. The results were reviewed for articles containing an algorithm for inhaler selection. The quality of publications containing an algorithm was assessed using the JBI SUMARI text and opinion critical appraisal checklist. Individual steps recommended in the algorithms and the order in which they were considered were extracted independently by the two authors using the JBI text and opinion data extraction tool. Textual syntheses and a table of factors included were used to appraise and compare algorithms. RESULTS The search identified 1016 publications. After removing duplicate studies (n = 409), 607 abstracts were examined. Nine different algorithms or hierarchical recommendations for device selection were identified. All nine publications were considered of good quality. Most algorithms contain only a few decision steps. There were significant differences between the algorithms. None of the algorithms have been validated. Three domains for factors included in the algorithms were identified: patient factors, device attributes, and HCP factors. Patient factors were considered most frequently (19 times) compared with device attributes (10 times) and HCP factors (7 times). Five specific attribute/factors with at least three rankings in different algorithms, were identified as key factors for device selection. CONCLUSION Although the algorithms generally provide step-by-step approaches based on a literature review and/or the experiences of the different authors, none were developed using item generation/reduction methodology nor included input from patients with COPD. There were considerable differences between the algorithms; however, the review identified key factors that should be considered by HCPs when selecting therapy. Registration: PROSPERO (CRD42021244475).
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Peché R, Attar-Zadeh D, Scullion J, Kocks J. Matching the Inhaler to the Patient in COPD. J Clin Med 2021; 10:jcm10235683. [PMID: 34884385 PMCID: PMC8658339 DOI: 10.3390/jcm10235683] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
Selecting the most appropriate inhalation device from the wide range available is essential for the successful management of patients with chronic obstructive pulmonary disease. Although choice is good for healthcare professionals, knowing which inhaler to prescribe is a complex consideration. Among the key factors to consider are quality of disease control, inhaler technique, inhaler resistance and inspiratory flow, inhaler design and mechanisms of drug delivery, insurance and reimbursement restrictions, and environmental impact. In this article, we offer a simple, practical tool that brings together all these factors and includes hyperlinks to other published resources from the United Kingdom, Belgium, and The Netherlands.
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Affiliation(s)
- Rudi Peché
- Department of Pneumology, Centre Hospitalier Universitaire de Charleroi, 6042 Charleroi, Belgium
- Correspondence:
| | - Darush Attar-Zadeh
- North Central London Clinical Commissioning Group (CCG), London N11 1GN, UK;
| | - Jane Scullion
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Janwillem Kocks
- General Practitioners Research Institute, 9713 GH Groningen, The Netherlands;
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore 409051, Singapore
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Damiański P, Kardas G, Panek M, Kuna P, Kupczyk M. Improving the risk-to-benefit ratio of inhaled corticosteroids through delivery and dose: current progress and future directions. Expert Opin Drug Saf 2021; 21:499-515. [PMID: 34720035 DOI: 10.1080/14740338.2022.1999926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) are known to increase the risk of systemic and local adverse effects, especially with high doses and long-term use. Hence, considerable resources are invested to improve pharmacokinetic/pharmacodynamic (PK/PD) properties of ICS, effective delivery systems and novel combination therapies to enhance the risk-to-benefit ratio of ICS. AREAS COVERED There is an unmet need for new solutions to achieve optimal clinical outcomes with minimal dose of ICS. This paper gives an overview of novel treatment strategies regarding the safety of ICS therapy on the basis of the three most recent molecules introduced to our everyday clinical practice - ciclesonide, mometasone furoate, and fluticasone furoate. Advances in aerosol devices and new areas of inhalation therapy are also discussed. EXPERT OPINION Current progress in improving the risk-to-benefit ratio of ICS through dose and delivery probably established pathways for further developments. This applies both to the improvement of the PK/PD properties of ICS molecules but also includes technical aspects that lead to simplified applicability of the device with simultaneous optimal drug deposition in the lungs. Indubitably, the future of medicine lies not only in the development of new molecules but also in technology and digital revolution.
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Affiliation(s)
- Piotr Damiański
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Grzegorz Kardas
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Michał Panek
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Piotr Kuna
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Maciej Kupczyk
- Clinical Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
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de Llano LP, Naval E, Mejía N, Domínguez-Ortega J. Inhaled indacaterol/glycopyrronium/mometasone furoate fixed-dose combination in moderate-to-severe asthma. Expert Rev Respir Med 2021; 16:1-15. [PMID: 34783265 DOI: 10.1080/17476348.2021.2005585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Fixed-dose long-acting beta2-agonist (LABA)/inhaled corticosteroid (ICS) combinations and add-on therapies as needed are the mainstay for maintenance therapy in asthma. However, more than 40% of patients have an inadequately controlled disease. The development of triple fixed-dose combinations consisting of long-acting muscarinic antagonist (LAMA)/LABA/ICS has paved the way for a new approach to reach therapeutic goals of an optimal control of symptoms and an effective prevention of future exacerbations. AREAS COVERED A search was conducted on PubMed (MEDLINE), using the MeSH terms [asthma] + [indacaterol] + [glycopyrronium] +[mometasone furoate] + [treatment], until October 2021. Original data from clinical trials, prospective and retrospective studies and reviews were selected. Clinical studies with IND/MF/GLY (Enerzair Breezhaler) are summarized, and its place in current asthma therapy is examined. EXPERT OPINION Triple therapy has been shown to be an effective and safe therapeutic option for asthma patients who remain uncontrolled despite ICS/LABA combination. The recently approved single-inhaler indacaterol/glycopyrronium/mometasone fixed dose combination has demonstrated to significantly reduce exacerbations, improve FEV1, symptoms and quality of life compared to ICS/LABA, including, salmeterol/fluticasone combination. Moreover, once-daily dosing may improve adherence.
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Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte, Lugo, Spain
| | - Elsa Naval
- Pneumology Service, Hospital Universitario de la Ribera, Alzira, Valencia, Spain
| | - Natalia Mejía
- Medical Affairs Department. Novartis Farmacéutica, Barcelona, Spain
| | - Javier Domínguez-Ortega
- Allergy Department, Hospital La Paz Institute for Health Research, Madrid, Spain.,Respiratory Disease Network Biomedical Research Centre (CIBERES), Madrid, Spain
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Wilkinson A, Woodcock A. The environmental impact of inhalers for asthma; a green challenge and a golden opportunity. Br J Clin Pharmacol 2021; 88:3016-3022. [PMID: 34719810 DOI: 10.1111/bcp.15135] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022] Open
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 our European neighbours'. There has been a broad switch towards MDIs in asthma treatment 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 can improve compliance, 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 dry-powder inhaler) 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 dry-powder inhalers, there are golden opportunities to make asthma care in the UK more effective, safer, and greener.
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Affiliation(s)
- Alex Wilkinson
- East and North Hertfordshire NHS Trust, Department of Respiratory Medicine Stevenage, Hertfordshire, UK
| | - Ashley Woodcock
- Manchester University NHS Foundation Trust, Greater Manchester, UK
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Attar-Zadeh D, Lewis H, Orlovic M. Health-care Resource Requirements and Potential Financial Consequences of an Environmentally Driven Switch in Respiratory Inhaler Use in England. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:46-54. [PMID: 34616856 PMCID: PMC8460426 DOI: 10.36469/001c.26113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
Background: To reduce greenhouse gas emissions, national initiatives advocate the phasing down of respiratory inhalers that use a fluorinated gas as a propellant (pressurised metered-dose inhalers [pMDI]). Nevertheless, pMDIs continue to be an effective and common choice. Objective: To assess the potential financial impact of patients with asthma or chronic obstructive pulmonary disease (COPD) switching from pMDIs to dry powder inhalers (DPIs) in a representative primary care network (PCN) population of 50 000 and the English National Health Service (NHS). Methods: Epidemiological data were combined with current inhaler use patterns to estimate the resources and costs associated with this transition, varying patient acceptance scenarios. Results: Depending on the approach, resource requirements ranged from £18 000 - £53 000 for a PCN, and from £21 - £60 million for the English NHS. Discussion: Significant funds are needed to successfully manage targeted inhaler transitions, together with counselling and follow-up appointment with an appropriately skilled clinician to assess the patient's inhaler technique and ensure disease control. Conclusions: Targeted transition of inhalers must achieve a balance between environmental impacts, organisational factors, and patient requirements. The resources for managing a switch can be substantial but are necessary to appropriately counsel and support patients, whilst protecting the environment.
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Walpole SC, Smith K, McElvaney J, Taylor J, Doe S, Tedd H. An investigation into hospital prescribers' knowledge and confidence to provide high-quality, sustainable respiratory care. Future Healthc J 2021; 8:e272-e276. [PMID: 34286197 DOI: 10.7861/fhj.2020-0251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The number and range of inhaler combinations and brand names has increased significantly over recent years, making prescribing more complex. Inhalers contribute 3% of the NHS's carbon footprint, therefore appropriate inhaler prescribing, use and disposal could contribute significantly towards the NHS's target of net zero carbon emissions by 2040. We developed a survey to assess prescriber knowledge of inhaled medications, inhalation devices and environmental impacts of inhalers. One-hundred and two secondary care prescribers from one NHS trust responded. Knowledge of the contents and device types of inhalers, and of the environmental impacts of inhalers was lacking. Only 9% of respondents discuss the environmental impact of inhalers with patients and 13% have discussed inhaler disposal with patients, but 46% of respondents expressed that they would educate patients about the environmental impacts of inhalers if they were provided with education and support to do so.
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Affiliation(s)
- Sarah C Walpole
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katherine Smith
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Jill Taylor
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Simon Doe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Hilary Tedd
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Sou T, Bergström CAS. Contemporary Formulation Development for Inhaled Pharmaceuticals. J Pharm Sci 2020; 110:66-86. [PMID: 32916138 DOI: 10.1016/j.xphs.2020.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/22/2022]
Abstract
Pulmonary delivery has gained increased interests over the past few decades. For respiratory conditions, targeted drug delivery directly to the site of action can achieve a high local concentration for efficacy with reduced systemic exposure and adverse effects. For systemic conditions, the unique physiology of the lung evolutionarily designed for rapid gaseous exchange presents an entry route for systemic drug delivery. Although the development of inhaled formulations has come a long way over the last few decades, many aspects of it remain to be elucidated. In particular, a reliable and well-understood method for in vitro-in vivo correlations remains to be established. With the rapid and ongoing advancement of technology, there is much potential to better utilise computational methods including different types of modelling and simulation approaches to support inhaled formulation development. This review intends to provide an introduction on some fundamental concepts in pulmonary drug delivery and inhaled formulation development followed by discussions on some challenges and opportunities in the translation of inhaled pharmaceuticals from preclinical studies to clinical development. The review concludes with some recent advancements in modelling and simulation approaches that could play an increasingly important role in modern formulation development of inhaled pharmaceuticals.
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Affiliation(s)
- Tomás Sou
- Drug Delivery, Department of Pharmacy, Uppsala University, Uppsala, Sweden; Pharmacometrics, Department of Pharmacy, Uppsala University, Uppsala, Sweden.
| | - Christel A S Bergström
- Drug Delivery, Department of Pharmacy, Uppsala University, Uppsala, Sweden; The Swedish Drug Delivery Center, Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Pritchard JN. The Climate is Changing for Metered-Dose Inhalers and Action is Needed. Drug Des Devel Ther 2020; 14:3043-3055. [PMID: 32801643 PMCID: PMC7410333 DOI: 10.2147/dddt.s262141] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/08/2020] [Indexed: 01/17/2023] Open
Abstract
Increases in global temperature are already having a significant impact on our climate. The hydrofluorocarbon (HFC) propellants used today in pressurized metered-dose inhalers (pMDIs) have global warming potential (GWP) many times that of carbon dioxide. Their use, together with all other emissive uses of HFCs, is being phased down under the Montreal protocol. This has prompted calls to switch patients to dry powder inhalers (DPIs). This paper presents a new analysis of the top 15 respiratory drug markets by drug class. It shows that a switch to DPIs would be economically feasible for most countries and most drugs. However, a wholesale switch of reliever medications, notably short-acting β-agonists, would lead to significant increases in the cost of these life-saving medications. Reviewing the evidence, whilst most patients are capable of using DPIs, the very young, very old and those undergoing an acute exacerbation still require a pMDI. Thus, there is a clinical and economic need to have both pMDIs and DPIs available. At the same time, it is projected that the reduction in non-medical uses of propellants is likely to give rise to a 5-fold increase in their cost for pMDI uses and is likely to hit the Western world in 2025. This may lead to a price increase in reliever medication that will make it unaffordable for the poorer communities in some markets. At the same time, opportunities to save money by developing new formulations using propellants with lower GWP, such as HFC 152a or HFO 1234ze(E), are described. Two companies have made this commitment, but neither currently have a strong presence in reliever medication. For them, or other companies, now is the time to act; 2025 is not far away in terms of product development timescales and the climate cannot wait.
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Keeley D, Scullion JE, Usmani OS. Minimising the environmental impact of inhaled therapies: problems with policy on low carbon inhalers. Eur Respir J 2020; 55:55/5/2001122. [PMID: 32461340 DOI: 10.1183/13993003.01122-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/11/2020] [Indexed: 12/27/2022]
Affiliation(s)
| | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
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