Minimising the environmental impact of inhaled therapies: problems with policy on low carbon inhalers

[Reducing the environmental impact of inhalers dispensed in France. From diagnosis to sustainable action]

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.

[Reduction of greenhouse gas emissions by inhaler choice in the therapy of asthma and COPD patients]

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.

Aerosolized drug delivery in awake and anesthetized children to treat bronchospasm

Bronchospasm is a common respiratory adverse event in pediatric anesthesia. First-line treatment commonly includes inhaled salbutamol. This review focuses on the current best practice to deliver aerosolized medications to awake as well as anesthetized pediatric patients and discusses the advantages and disadvantages of various administration techniques. Additionally, we detail the differences between various airway devices used in anesthesia. We highlight the unmet need for innovation of orally inhaled drug products to deliver aerosolized medications during pediatric respiratory critical events such as bronchospasm. It is therefore important that clinicians remain up to date with the best clinical practice for aerosolized drug delivery in order to prevent and efficiently treat pediatric patients experiencing life-threatening respiratory emergencies.

Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries

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.

Health-care Resource Requirements and Potential Financial Consequences of an Environmentally Driven Switch in Respiratory Inhaler Use in England

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.

The Climate is Changing for Metered-Dose Inhalers and Action is Needed

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.