The Global Initiative for Asthma (GINA) has called on authorities and clinicians to be mindful of patient safety as well as that of the planet when considering use of ‘greener’ inhalers for asthma.
Control of the disease must remain the primary objective amid the quest for environmentally-friendly care, not only for patient outcomes but also because well-controlled disease “is best for the planet through minimisation of emergency health-care use and hospitalisations, which can themselves have a substantial environmental impact,” note authors of a paper published in The Lancet.
“Achieving this goal involves selecting the best treatment strategy and inhaler device for each patient and considering the global impact of regulatory changes on the safety of people with asthma,” they said.
The authors – including Professor Helen Reddel of the Woolcock Institute of Medical Research and the University of Sydney – stressed that the choice of inhaler should depend on several different factors, starting with consideration of which medication the patient needs to control symptoms and prevent exacerbations. It should then be determined which inhaler devices are available and how accessible they are.
A single combination inhaler would be the preferred option over multiple inhalers if more than one medication is needed, while age is also an important factor given that the majority of dry powder inhalers (DPIs) are not suitable for under-5-year-olds. The ability to correctly use the device should also be a critical part of the decision-making process.
At this point environmental implications should be taken into account, with reference to the carbon footprint of different inhalers and their impact, including those of their individual components, across the life-cycle from manufacture to disposal.
However, the authors also urged clinicians to be sensitive to creating so-called ‘green guilt’ in the patient, as this could impact adherence, exacerbations and the need for urgent care. User satisfaction is also important, as this will likely increase adherence and reduce the risk of worsening disease control, they said.
Crucially, following GINA recommendations for inhaler prescribing will also limit their impact on the environment as they address the current over-reliance on SABA pressurised metered-dose inhalers (pMDIs), the authors emphasised.
GINA recommends that all adults and adolescents with asthma should be given an anti-inflammatory reliever containing low-dose inhaled corticosteroid and either formoterol or SABA, “which markedly reduces the risk and frequency of severe exacerbations and urgent health care in adults and adolescents, compared with SABA alone, and reduces the risk of urgent health care compared with daily inhaled corticosteroid plus as-needed SABA”.
This approach most frequently uses DPIs devices and therefore has a lower carbon footprint than SABA-based treatment and also cuts back on the number of pMDIs used globally.
Disproportionate impact on poor countries
The authors also warned of potentially serious implications from planned legislation surrounding the use of greenhouse gases that could hit low- and middle-income countries (LMICs), where most global asthma deaths occur (96%).
The European Union is planning to amend its Fluorinated Gas Regulation by removing a long-standing exemption for medical fluorinated gases, instead proposing a step-down in their use and a ban on exporting pMDIs to countries that have not ratified the Kigali Amendment to the Montreal Protocol on Substances that Deplete the Ozone Layer.
GINA said it “fully supports” actions to reduce the use of harmful propellants and devices but noted that inhalers used in LMICs are predominantly pMDIs and therefore, an accelerated switch to new propellant formulations “could have severe immediate consequences in LMICs, and reverse the progress already made”.
“We urgently call on all individuals involved in regulatory discussions relevant to medical inhalers to prioritise the health of those within and beyond Europe – including people with asthma in LMICs, who already bear the brunt of the impact of climate change,” they stressed.