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Home | Articles | Respiratory | Greener Inhaler Prescribing

Greener Inhaler Prescribing

Last updated 14th December 2022

The research on this topic applies most to adults with asthma. Some points may be generalisable to adults with COPD but discuss with Respiratory Specialist Nursing Team or your pharmacist if unsure.

 

Background

The NHS contributes around 6.1 mega-tonnes of CO2e towards UK greenhouse gas emissions, about 4% of the UK total. 3% of NHS greenhouse gas emissions come from inhaler prescribing1.

Environmental issues surrounding inhaler prescribing include lack of recycling facilities for inhalers and medication wasted due to ineffective technique, but the most significant contributor to emissions is the greenhouse gas effects of propellants used in metered dose (MDI) inhalers. This includes pressurised MDIs (pMDIs) and breath-actuated inhalers (BAIs). Dry powder (DPI) and soft mist (SMI) inhalers do not use these propellants and subsequently have a much smaller carbon footprint than MDIs.

Principles of Environmentally Friendly Inhaler Prescribing

  1. The use of rescue medication (SABA inhalers i.e. salbutamol) makes up 70% of inhalers used2, therefore the greenest way to prescribe inhalers is by taking a patient-centred approach which seeks to optimise asthma control and reduce the need for rescue medication. If a patient is well controlled with their current regime and device, it is not advisable to change it.
  2. If you prescribe salbutamol generically, the patient could be given anything from a Salbutamol Easyhaler, a DPI with a low carbon footprint, to Salbutamol CFC-free or Salamol, which are reasonably environmentally friendly MDIs, to Ventolin, a non-Formulary MDI which is very bad for the environment. When prescribing, prescribe by specific brand.
  3. It is a myth that DPIs are more difficult to use – in a small audit of asthma inhaler technique at DGRI, patients demonstrated perfect technique more often with DPIs than they did MDIs. MDIs require more coordination to deliver the drug properly than DPIs.Asthma & Lung UK have a resource of videos on how to use the various inhalers correctly.
  4. DPIs require patients to be able to take a short, fast inhalation and this has led to concerns by some that they are inappropriate for frailer patients. The only reliable test for whether your patient can use a DPI is by using a training device such as InCheck – speak to the Respiratory Specialist Nursing Team about this.
  5. Some are concerned that DPIs may be inadequate to deliver rescue medication when a patient is having acute symptoms. At present this is an evidence-free zone and it is important to bear in mind that DPIs are significantly better at drug delivery than using an MDI without a spacer3.
  6. The presence of a dose counter on an inhaler can reduce waste as it gives patients a guide to when they need to replace their inhaler. Many SABA and MDI inhalers do not have a dose counter.
  7. If your patient is on multiple inhalers, are they all the same type, or different? If a patient is on an MDI and a DPI, chances are they might thank you for switching them to two DPIs, bearing in mind points (1) and (4).
  8. At present there is no way of recycling spent inhalers4 so it is worth bearing in mind that a medication with a one puff once daily regime will use roughly four times less plastic and contribute less to landfill than a medication which is required two puffs twice daily. If you are increasing the dose of a particular inhaler for your patient, is there a stronger dose inhaler you could use? i.e. Budesonide Easyhaler 200microgram/dose TWO puffs TWICE daily has twice the carbon footprint of Budesonide Easyhaler 400microgram/dose ONE puff TWICE daily. It is likely your patient will have better compliance with an inhaler they need to replace less often too.
  9. For asthma patients, the Maintenance and Reliever Therapy (MART) regime is a regime that advocates that patients use one formoterol-containing combination inhaler both as a maintenance treatment and during exacerbations. It reduces the need for several inhalers and may improve asthma control, as patients receive the anti-inflammatory benefits of some inhaled steroid even during an exacerbation. This will become best practice for asthma prescribing in the next iteration of the BTS/SIGN guidelines, due in 2023. Discuss with the Respiratory Specialist Nursing Team if you think this may be suitable for your patient.
  10. NICE has provided an excellent patient decision aid for use when choosing and changing inhalers. This includes environmental considerations.
  11. Click the following link for videos on how to use the various inhalers correctly from Asthma.org.uk

Are Environmentally Friendy Inhalers More Expensive?

As the following table demonstrates, cheaper inhalers are not necesarily worse for the environment (though the opposite is sometimes true!).

CARBON FOOTPRINT AND FINANCIAL COST OF INHALERS USED IN ASTHMA
GREEN: Carbon footprint per inhaler <2 kgCO2e, use if clinically indicated
AMBER: Carbon footprint per inhaler 6-20 kgCO2e, use if lower carbon footprint inhaler unsuitable
RED: Carbon footprint per inhaler >34 kgCO2e, avoid using unless absolutely necessary
All table data from the Greener Practice Inhaler Prescribing Guideline and BNF

All devices featured in MDI and DPI/SMI columns are part of the NHS D&G Formulary April 2022
Cost/carbon footprint are given per month of inhaler use with exception of SABA inhalers which are given in cost/carbon footprint per inhaler
Use in conjunction with relevant treatment guidelines:
TG1 BTS/SIGN Asthma Treatment Guideline 2019 [pdf]
TG2 GINA 2022 asthma guideline (page 56 of Full Report features quick treatment algorithm for adults. BTS/SIGN guidance due to be brought in line with this in 2023)
TG3 NICE COPD in over 16s treatment algorithm

MDIDPI/SMINotes
SABA TG1 TG3

SALBUTAMOL CFC-FREE
12kg CO2e/inhaler
£1.50


SALAMOL
EASI-BREATHE (BAI)
12kg CO2e/inhaler
£6.30


SALBUTAMOL EASYHALER 100 & 200
0.6kg CO2e/inhaler
£3.31 and £6.63


This inhaler is non-formulary and should NOT be prescribed unless there is no other suitable option:

VENTOLIN EVOHALER
*(non-formulary)*
25.3kg CO2e/inhaler
£1.50


SAMA TG3

IPRATROPIUM BROMIDE CFC-FREE (ie ATROVENT)
One Puff FOUR TIMES DAILY
8.8kgCO2e/inhaler £3.33
----------
Two puffs FOUR TIMES DAILY
17.6kgCO2e/inhaler £6.66


LAMA TG1 TG2

SPIRIVA RESPIMAT (SMI)
TWO puffs ONCE daily
0.8kgCO2e/inhaler
£23.00

(if device used once)5
----------
0.2kgCO2e/inhaler
£23.00

(if one device refilled
6 times)5


Spiriva Respimat (tiotropium) is accepted for use in Scotland as an add-on maintenance bronchodilator in adults with asthma treated with a maintenance combination of medium dose ICS+LABA who experienced >1 severe exacerbations in the past year.
LABA+ICS Doses, costs and carbon footprints listed for
low TG1 TG2
medium TG1 TG2
high TG1 TG2 and/or
MART TG2 regimes.

Formulary inhalers marked F contain formoterol and are recommended as first-line as PRN inhalers as per GINA guideline, or as part of MART Regime

F LUFORBEC 100/6
ONE puff TWICE daily (LO)
5.6kg CO2e/month
£20.52

----------
TWO puffs TWICE daily plus FOUR puffs PRN (MART)
up to 22.4kg CO2e/month
up to £41.04


F FOSTAIR 100/6
ONE puff twice daily (LO)
5.6kg CO2e/month
£14.66

----------
TWO puffs twice daily (MED)
11.2kg CO2e/month up to £29.32



FOSTAIR 200/6
(asthma only)

TWO puffs TWICE daily (HI)
14.2kgCO2e/month
up to £29.32


F FOBUMIX EASYHALER
80/4.5

ONE or TWO puffs TWICE daily (LO) 0.2-0.4kgCO2e/month
£10.75-21.50

----------
160/4.5
ONE puff TWICE daily (LO)
0.2kgCO2e/month
£10.75

TWO puffs TWICE daily plus FOUR puffs PRN (MART)
up to 0.8kgCO2e/month
up to £43.00

----------
320/9
TWO puffs TWICE daily (HI)
0.4kgCO2e/month
£21.50


F DUORESP SPIROMAX
200/6

ONE puff TWICE daily (LO)
0.4kgCO2e/month
£13.98

----------
TWO puffs TWICE daily (MED)
0.8kgCO2e/month
£27.96

----------
400/12
ONE puff TWICE daily (MED)
0.4kgCO2e/month
£13.98

----------
TWO puffs TWICE daily (HI)
0.8kgCO2e/month
£27.96




F FOSTAIR NEXTHALER
100/6

ONE puff TWICE daily (LO)
0.4kgCO2e/month
£14.66

----------
TWO puffs TWICE daily (MED)
0.8kgCO2e/month
£29.32


These inhalers are both non-Formulary and should NOT be prescribed unless there is no other suitable option:

SYMBICORT pMDI
100/3 and 200/6
*(Non-Formulary)*

ONE to TWO puffs TWICE daily (LO)
18-35kg CO2e/month
£7 and £14


FLUTIFORM 125 pMDI
*(Non-Formulary)*

TWO puffs TWICE daily
35kg CO2e/month
£28.00


ICS (Low Dose) TG1 TG2

SOPROBEC 200micrograms
ONE puff twice daily
5kg CO2e/month
£3.63


KELHALE 100micrograms
ONE puff twice daily
5.2kg CO2e/month
£1.56


BECLOMETASONE EASYHALER 200micrograms
ONE puff TWICE daily 0.2kgCO2e/month
£4.48


BUDESONIDE EASYHALER 200micrograms
ONE puff TWICE daily
0.2kgCO2e/month
£5.31


ICS (Medium Dose) TG1

SOPROBEC 200micrograms
TWO puffs twice daily
10kg CO2e/month
£7.26


KELHALE 100micrograms
TWO puffs twice daily
10.4kg CO2e/month
£3.12


BECLOMETASONE EASYHALER 200micrograms
TWO puffs TWICE daily
0.2kgCO2e/month
£8.98


BUDESONIDE EASYHALER 400micrograms
ONE puff TWICE daily
0.2kgCO2e/month
£5.31


ICS (High Dose) TG1

SOPROBEC 250micrograms
ONE to TWO puffs FOUR TIMES daily
10-20kg CO2e/month
£7.26-14.52


KELHALE 100micrograms
TWO puffs FOUR TIMES daily
20.8kg CO2e/month
£6.24


BECLOMETASONE EASYHALER 200micrograms
TWO puffs FOUR TIME daily
0.8kgCO2e/month
£17.96


BECLOMETASONE EASYHALER 400micrograms
TWO puffs TWICE daily
0.4kgCO2e/month
£10.62


LABA+LAMA TG3

ANORO ELLIPTA
ONE puff ONCE daily 0.7kgCO2e/month
£32.50


SPIOLTO RESPIMAT
TWO puffs ONCE daily
0.8kgCO2e/month
£32.50

(if device used once)4
----------
0.2kgCO2e/month
£32.50

(if device refilled 6 times)4


ICS+LABA+LAMA TG3

TRIMBOW 87/5/9
TWO puffs TWICE daily
14.2kg CO2e/month
£44.50


TRIMBOW NEXTHALER 88/5/9
TWO puffs TWICE daily 0.9kgCO2e/month
£44.5


TRELEGY ELLIPTA 100/62.5/25
ONE puff ONCE daily
0.8kgCO2e/month
£44.5


References

  1. Delivering a ‘Net Zero’ National Health Service
  2. How to Reduce the Carbon Footprint of Inhaler Prescribing – A Guide for Healthcare Professionals in the UK (Asthma UK & British Lung Foundation)
  3. Spacers also have a carbon cost, and this is greater for Volumatic than AeroChamber devices. Spacers cannot be recycled. If prescribing a pMDI however, use of a spacer is essential for adequate drug delivery.
  4. This may change, so it’s important to encourage patients to return their used inhalers to the pharmacy.
  5. According to manufacturer instructions, a Respimat inhaler can be refilled with cartridges up to 6 times before a new device is recommended.

Links

  1. NHSD&G Guidance on Inhalers for Adults with Asthma
  2. NICE Patient Decision Aid – Inhalers for Asthma
  3. BTS/SIGN asthma treatment algorithm 2019
  4. GINA 2022 Asthma Guideline (page 56 of Full Report features quick treatment algorithm for adults)
  5. SIGN/NICE Visual Summary Algorithm COPD Treatment in Adults
  6. Greener Inhaler Prescribing Guideline
  7. Asthma & Lung UK: videos on inhaler technique

Content by Dr Katie Percvial