Review ArticleClinical Review

Climate-conscious inhaler prescribing for family physicians

Samantha Green, Valeria Stoynova, Celia Culley, Alan Kaplan, Ilona Hale, Nicole Simms and Naba Khan
Canadian Family Physician June 2024; 70 (6) 381-387; DOI: https://doi.org/10.46747/cfp.7006381

Abstract

Objective To provide family physicians with prescribing and diagnostic strategies that can reduce carbon emissions associated with inhalers.

Sources of information This review is based on the authors’ experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed.

Main message There is growing acknowledgment of the substantial impact that inhalers have on climate emissions generated by the health sector. Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available. Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care and enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions. Family physicians may reduce carbon emissions associated with inhalers by reducing unnecessary inhaler prescribing; ensuring patients’ control of asthma and COPD is optimized; considering whether a more sustainable inhaler may be appropriate; optimizing dosing technique to reduce emissions and waste; and disposing of inhalers appropriately if possible.

Conclusion Family physicians may reduce carbon emissions associated with inhalers through the following strategies: confirming diagnosis, controlling disease, considering inhaler type, optimizing dosing technique, and encouraging appropriate disposal.

As the climate crisis deepens, environmental changes such as higher temperatures, drought, and wildfires increase allergens, ground-level ozone, and particulate matter air pollution, which in turn lead to increased rates of respiratory and cardiovascular disease. People with existing respiratory conditions are particularly vulnerable to health risks associated with a changing climate.1,2

While the health care sector will be tasked with responding to increases in respiratory disease, health care providers can also help reduce greenhouse gas (GHG) emissions originating from the health sector; the management of respiratory conditions in particular has an outsized carbon footprint.

Data published in 2018 indicate health care in Canada accounts for 4.6% of national GHG emissions3; Canadian health care GHG emissions are responsible for 23,000 years of life lost every year from disability or early death.3 An analysis of the National Health Service in England found about 70% of health system emissions arise from pharmaceuticals, medical equipment, and the rest of the supply chain.4 Medications make up 25% of total health care GHG emissions in Canada, the largest single category of emissions.3 Pressurized metered-dose inhalers (MDIs) contribute 3.1% of the emissions produced by the United Kingdom (UK) National Health Service5 and 22% of its primary care emissions.4 While Canadian data on the GHG emissions of MDI prescribing are not currently available, our inhaler prescribing patterns are similar to those in the UK (ie, similar proportions of MDIs and dry-powder inhalers [DPIs]).6 Metered-dose inhalers currently rely on hydrofluorocarbon (HFC) propellants, which are potent GHGs—up to 3000 times more potent than carbon dioxide.7 Most MDI emissions arise during their use (56% to 70%) and disposal (26% to 32%).8 Novel propellants with lower GHG emissions are under development,9 but are likely years away from widespread market adoption10 and there may be barriers to their uptake, including cost, coverage, and compatibility with particular medications.

Sources of information

This review is based on the authors’ experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed.

Main message

Dry-powder inhalers lack propellants and as a result have substantially lower carbon footprints than MDIs. Dry-powder inhalers have been found to produce higher environmental impacts than MDIs in some categories—such as marine eutrophication and freshwater acidification—but given the severity of the climate crisis, these impacts are arguably less important than climate impacts, making DPIs the current preferred option from an environmental standpoint. Moreover, more recent assessments indicate these other impacts, which arise during the manufacturing of DPIs, may be far less important than originally postulated.11

There is growing acknowledgment of the substantial impact that inhalers have on GHG emissions from the health sector. The Canadian Thoracic Society (CTS) and the British Thoracic Society each released position statements on climate change and inhaler choices in 2023 and 2022, respectively.12,13 British Columbia addresses the environmental impact of inhalers directly in its 2023 asthma recommendations.14 The National Institute for Health and Care Excellence in the UK also addresses inhalers and climate change in a patient decision aid published in 2022.15

Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available.16 Only 1 in 5 Canadians with respiratory disease is aware of the environmental impact of inhalers, yet a survey found that nearly 60% believe it is important to choose lower-carbon inhalers provided that the efficacy is similar.17

Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care that enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions.

Family physicians may reduce carbon emissions associated with inhalers through the following strategies (Figure 1)18,19:

  1. Confirm diagnosis: Reducing unnecessary inhaler prescribing will reduce its environmental impact.

  2. Control disease: Ensure patients’ asthma and COPD control is optimized.

  3. Consider inhaler type: For some patients, more sustainable inhalers may be appropriate.

  4. Optimize dosing technique: For any inhaler type, optimizing technique reduces emissions and waste.

  5. Dispose appropriately: Many inhalers end up in the regular waste stream, but there are opportunities for more sustainable disposal in some jurisdictions.

Figure 1.
Figure 1.

Strategies for family physicians to reduce carbon emissions associated with inhalers

Confirm diagnosis. Many patients labelled as having asthma or COPD have in fact been misdiagnosed.20-23 One-third of patients with physician-diagnosed asthma have no evidence of asthma on spirometry when weaned off their maintenance therapy, yet 79% of these patients are using inhalers.24 Similarly, 31% to 44% of patients diagnosed with COPD in primary care do not actually have the disease on objective testing.25,26 Increasing the use of objective diagnostic testing in patients with suspected asthma or COPD may considerably reduce unnecessary inhaler use and corresponding GHG emissions from MDIs27 and other environmental impacts from DPIs.28

In addition to the environmental harm of overprescribing inhalers, incorrect diagnosis may also cause patients to incorrectly label themselves as “sick”; may result in missing the actual diagnosis; could lead to unnecessary financial costs to patients or insurers; and can cause medication side effects.22

Objective testing can be challenging to obtain in some communities. Most patients do not require full pulmonary function testing; in-office spirometry is sufficient. In some provinces, in-office spirometry can be arranged through third-party organizations (eg, Asthma Research Group Windsor-Essex County Inc in Ontario; https://www.argi.on.ca).

Many patients are prescribed an inhaler for a viral or postinfectious cough, which are both self-limiting conditions that do not require treatment. A systematic review found that, in adults, an acute cough lasts a mean duration of 18 days, while patients expect a duration of 7 to 9 days.29 In children, an acute cough lasts 5 to 20 days.30 Systematic reviews of randomized trials using treatments ranging from inhaled steroids to oral agents conclude there is no evidence of benefit to treatment of postinfectious cough,31,32 highlighting its self-limiting nature.

The objective diagnosis of obstructive airway disease is so important that the CTS and Choosing Wisely Canada have issued 2 separate recommendations to that effect:

  • “Don’t initiate medications for asthma (eg, inhalers, leukotriene receptor antagonists, or other) in patients ≥6 years old who have not had confirmation of reversible airflow limitation with spirometry, and in its absence, a positive methacholine or exercise challenge test, or sufficient peak expiratory flow variability.”33

  • “Don’t initiate long-term maintenance inhalers in stable patients with suspected COPD if they have not had confirmation of post-bronchodilator airflow obstruction with spirometry.”33

Control disease. More than half of patients with asthma and COPD have inadequate disease control due to suboptimal controller inhaler regimens,34-36 resulting in excessive short-acting β-agonist (SABA) reliever inhaler use.37,38 Overuse of SABAs (>2 canisters per year) is a major contributor to inhaler emissions, since most SABAs are currently prescribed as MDIs. Moreover, patients with poorly controlled respiratory disease are more likely to require an emergency department (ED) visit or admission to hospital, which are carbon intensive. In the SABINA (SABA Use In Asthma) study done in the UK, suboptimal asthma control was associated with triple the carbon emissions of well-controlled disease regardless of the carbon footprint of the maintenance inhaler.39 In that study, 83% of SABA prescriptions were for patients overusing SABAs (ie, due to suboptimal asthma control). Improving adherence to guideline-based disease management could substantially reduce the carbon footprint associated with both asthma and COPD.6,40

The 2021 updated CTS asthma guideline recommends that budesonide-formoterol (a DPI) can be offered as an alternative reliever therapy to patients older than 12 years with well-controlled asthma who are taking SABA monotherapy.41 It also highlights a role for budesonide-formoterol in patients older than 12 years with poorly controlled asthma and who are taking SABA monotherapy and who have poor adherence to maintenance therapy despite asthma education and support. The Global Initiative for Asthma recommends budesonide-formoterol as a preferred reliever therapy to SABA alone.42

Part of the rationale for these recommendations is the long-recognized risk posed by SABA monotherapy in asthma. The regular use of a SABA can lead to downregulation of β-receptors, rebound hyperresponsiveness, and decreased response to bronchodilators. As such, even patients with seemingly mild asthma can be at risk of serious complications.42 Using 2 or more SABA canisters per year is associated with a 2-fold increase in ED visits and hospitalizations.43 Higher SABA use is also associated with increased mortality compared with patients using fewer than 2 canisters per year.44 The SYGMA (Symbicort Given As Needed in Mild Asthma) study demonstrated that using budesonide-formoterol as needed decreased the rate of severe exacerbation compared with SABA rescue monotherapy.45 One study found that inhaled corticosteroid use is 73% higher when patients are prescribed only 1 combination inhaler.46 Cost and coverage concerns remain a substantial barrier to implementing these recommendations more widely. Aligning asthma management with CTS guideline recommendations is an opportunity to reduce emissions through improved asthma control.

Consider inhaler type. Dry-powder inhalers and soft-mist inhalers have carbon footprints that are about 10 times lower than those of MDIs.47 Most emissions (50% to 90%) from DPIs arise during their production.8 Dry-powder inhalers have been shown to be clinically effective for most patients with respiratory conditions such as asthma and COPD.48,49 Studies evaluating a switch from MDIs to DPIs have shown that most patients remain on DPIs without loss of asthma control.50-52

Although MDIs represent more than 70% of inhalers sold, DPIs show similar efficacy and are often preferred by patients50,53-57 since they are generally easier to use and often contain dose counters. In 1 study, changing an MDI to a DPI halved the carbon footprint among people with asthma while improving their asthma control level.52 In some European countries, such as Sweden and Denmark, DPIs account for more than 80% of inhalers sold,58 suggesting that changing Canadian prescribing practices is feasible.

Educating patients about lower-carbon inhaler alternatives can empower them through shared decision making, which can contribute to better health outcomes.59 A forced switch is never appropriate; patients must be offered the choice.60 Some patients simply prefer MDIs.61 Device changes made without patient involvement can reduce patients’ confidence in their medication,62 and multiple changes to therapy are correlated with nonadherence.63 Nonadherence can lead to a loss of disease control, engendering both direct morbidity and mortality risks for patients, and can paradoxically increase GHG emissions through carbon-intensive events such as medical visits and hospitalizations for acute exacerbations.64

Some patients are unable to supply the inspiratory force required to dispense and disperse powder from a DPI adequately, either due to severe lung disease at baseline or due to an acute disease exacerbation.65 Preschool-aged children66,67 and elderly patients may also lack adequate inspiratory flow and coordination; neuromuscular weakness and cognitive impairment can also preclude the use of DPIs. Nevertheless, these concerns likely apply to only a small minority (<5%) of patients.65

Studies suggest that careful selection of the lowest-cost DPIs within each drug class can reduce overall costs compared with MDIs,68 but cost implications may vary according to patients’ insurance coverage and must be considered individually.

When MDIs are needed, providers can select MDIs with lower GHG emissions. The carbon intensity of an MDI varies by the type of HFC used, and it varies considerably with the volume of HFC used in each device.69 A low-volume HFC salbutamol MDI contains the GHG equivalent of driving 47.2 km in an average gasoline-powered vehicle, compared with a high-volume MDI, which can be the equivalent of driving up to 170 km (author calculation70-72) (Figure 2).19,73

Figure 2.
Figure 2.

Carbon footprint of metered-dose inhalers

Optimize technique. Inhalers are used incorrectly up to 71% of the time.74-78 Regardless of inhaler type, taking the time to ensure correct usage can reduce carbon emissions by improving disease control and reducing the chance of early disposal (ie, while the device still contains doses). Inhaler misuse is associated with poor disease control,74 which increases rescue MDI use, decreases quality of life, increases ED visits and hospitalizations, and increases the need for oral steroids and antibiotics.76,77,79 Inhaler misuse may be more common with MDIs compared with DPIs.50,80-83 Misuse of MDIs is even more common in older adults (79% make critical errors)83 and children (97% use them inappropriately).80 Due to a lack of dose counters, many patients cannot reliably identify when their MDI is empty84 and dispose of the inhaler too early or too late (ie, using it when it no longer contains any medication).

Providers can ensure proper inhaler technique by regularly demonstrating and reviewing technique with patients in clinic, referring patients to community respiratory therapists, or asking community pharmacists to review technique with patients. With MDIs, a spacer device improves drug delivery and therefore results in fewer actuations required for the relief of symptoms, which reduces carbon emissions85; moreover, improved drug delivery results in fewer exacerbation events, which are carbon intensive.

Dispose appropriately. A substantial portion (26% to 32%) of the GHG emissions from MDIs are released following disposal as the propellant continues to leak out even once the inhaler is “empty” of the active ingredient.8 We can encourage patients to return old inhalers to pharmacies for proper disposal, including licensed incineration. Licensed incineration at regulated temperatures results in thermal degradation of HFCs, resulting in by-products with lower global warming potential.85 Recycling also has the potential to reduce GHG emissions through the recovery of the propellant during the disposal phase.86 Depending on the province, some pharmacies accept inhaler returns and facilitate recycling and incineration (information available from https://healthsteward.ca) and patients should be encouraged to return their inhalers to pharmacies for proper disposal. Family physicians can also connect with their community pharmacies regarding inhaler disposal. Infrastructure and planning for disposal, particularly recycling, need improvement across Canada to support sustainability efforts.

Conclusion

Climate-conscious inhaler prescribing is a simple yet effective change that family physicians can make, which has the additional benefit of improving respiratory care for patients. Although practice change can sometimes be slow and challenging, resources are available to support more climate-conscious inhaler prescribing. CASCADES is a federally funded initiative that supports Canadian health care’s transition toward a climate-resilient, sustainable, and low-carbon health system. CASCADES has partnered with both patients and clinical leaders to develop resources to support providers in sustainable inhaler prescribing. Primary care resources include inhaler comparison charts with provincial coverage and cost information, template letters to patients, posters, electronic medical record resources, and inhaler technique videos. Materials are freely available online from https://cascadescanada.ca/action-areas/pharmacy-and-prescribing.

Notes

Editor’s key points

  • ▸ Increasing the use of objective diagnostic testing for suspected asthma and chronic obstructive pulmonary disease and improving adherence to guideline-based disease management may considerably reduce unnecessary inhaler use and the corresponding greenhouse gas emissions from metered-dose inhalers (MDIs).

  • ▸ Dry-powder and soft-mist inhalers have carbon footprints that are about 10 times lower than that of MDIs. Dry-powder inhalers have been shown to be clinically effective for most patients with respiratory conditions such as asthma and chronic obstructive pulmonary disease. Although MDIs represent more than 70% of inhalers sold, dry-powder inhalers show similar efficacy and are often preferred by patients, since they are generally easier to use and often contain dose counters.

  • ▸ Providers can ensure proper inhaler technique by regularly demonstrating and reviewing technique with patients in clinic, referring patients to community respiratory therapists, or asking community pharmacists to review technique with patients. With MDIs, a spacer device improves drug delivery and therefore results in fewer actuations required for the relief of symptoms, which reduces carbon emissions; moreover, improved drug delivery results in fewer exacerbation events. Patients can be encouraged to return old inhalers to pharmacies for proper disposal.

Footnotes

  • Contributors

    All authors contributed to conducting the literature review and to preparing the manuscript for submission.

  • Competing interests

    None declared

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.

  • La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de juin 2024 à la page e73.

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Climate-conscious inhaler prescribing for family physicians
Samantha Green, Valeria Stoynova, Celia Culley, Alan Kaplan, Ilona Hale, Nicole Simms, Naba Khan
Canadian Family Physician Jun 2024, 70 (6) 381-387; DOI: 10.46747/cfp.7006381
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