KISS: Green Inhaler Prescribing

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Thank you to the authors of this guide: Drs James Smith, Aarti Bansal, & Joe Barron-Snowdon, from Greener Practice; edits and inhaler costs by NB Medical. For FAQs and QI ideas see www.greenerpractice.co.uk. See the Traffic Light tables below for the relative carbon footprint of inhalers.

Inhalers account for 3-4% of the whole NHS carbon footprint. Metered dose inhalers (MDIs) use hydrofluoroalkanes (HFA) propellants which are potent greenhouse gases, 1000 – 3000 times more potent than carbon dioxide. In the UK approximately 70% of inhalers used are MDIs which is much higher than many other European countries, and most short acting beta-agonists (SABA) are prescribed as MDIs. Salbutamol accounts for the majority of the carbon footprint associated with inhalers.

KISS: How to Reduce Inhaler Carbon Footprint 

1. Optimize asthma and COPD care

  • The clinical and environmental harms of poor disease control will likely outweigh any benefits from the use of different inhalers. NB: on the Hot Topics course we have recently discussed:
    • Over-use SABA in asthma is extremely common and a marker of poor control and risk factor for exacerbation and death
      • Patients should need SABA no more than 3 times per week, or 2 inhalers per year. 
    • International asthma guidelines now recommend SABA monotherapy in mild asthma should be avoided and use of combined maintenance & reliever therapy using a formoterol LABA/ICS inhaler may be more appropriate as the drip-feed of steroid ↓ risk of exacerbation & long-term airway changes. 
    • Metered dose inhalers (MDIs) are most effective when used with spacers. Let's encourage patients to use these every time, not just when they have a flare of asthma.
  • Optimising asthma & COPD care will inevitably lead to ↓ salbutamol MDI inhaler requirement.

2. Use dry powder inhalers or soft mist inhalers as preferred choice when clinically appropriate

  • DPI and SMIs can be used as long as patients have sufficient inspiratory flow. This may be too low in certain groups, e.g. younger children and the very elderly, and during severe exacerbations, when MDI via a spacer is more appropriate.
  • Patient choice and clinical judgement remains crucial, NICE has a useful Patient Decision Aid.
    • Refer to your local guidance. Where DPIs or SMIs are not a recommended 1st line option engage with the local prescribing team about why and see if the guidelines can be updated.

3. If MDIs are needed choose a brand and regime to minimize carbon footprint

  • Avoid using branded Ventolin Evohaler 
    • Ventolin Evohaler has more than double the carbon footprint of other Salbutamol MDIs, e.g. Salamol. Prescribe by brand, not generic. Lower carbon MDI options such as Salamol or Airsalb are equivalent price. (NB: this does not apply to Ventolin Accuhaler, a DPI.) 
  • Prescribe inhaled corticosteroids to minimize the number of puffs required for the same dose.
    • For example, prescribe 1 puff of 200mcg Clenil twice a day rather than 2 puffs of 100mcg Clenil twice a day. This can effectively halve the carbon footprint of treatment.
  • Avoiding using MDIs containing HFA227ea when clinically appropriate
    • HFA227ea has a much higher carbon footprint than the HFA134a used in other MDIs. 
    • These are Flutiform and Symbicort MDI. (NB: not Symbicort Turbohaler which is a DPI.)

4. Ask patients to return all used inhalers to pharmacies for disposal

  • Inhalers should not be put into household waste as this allows release of remaining HFAs into the atmosphere. Incineration thermally degrades HFAs into far less potent greenhouse gases. Some pharmacies may have access to inhaler recycling which allows the plastics and gases to be recycled.

NB: cost is always a consideration for clinicians but DPIs are not always more expensive than MDIs. 

For many combination inhalers, the cheapest DPI equivalent may be cost-saving vs MDI, while some common brands such as Symbicort and Fostair have directly equivalent MDI and DPI versions at the same price. 

The cheapest salbutamol DPI is approx. 2x the price of the cheapest MDI (e.g. Ventolin 100 Evohaler MDI NHS indicative price Feb 2021 is £1.50 vs Easyhaler 100 DPI is £3.31) although still cheaper than many MDIs. Even then this cost is small in comparison to the £20-60 of many combination inhalers, while having a 10-30x smaller carbon footprint and dwarfed by savings from optimising care, reducing SABA overuse, consultations and treatment for exacerbations and hospitalisations.


Non-ICS Inhalers by Carbon Footprint
  Short Acting Beta Agonists (SABA) Long Acting Beta Agonists (LABA) Short Acting Muscarinic Antagonists (SAMA) Triple combination (ICS/LABA/LAMA)
Low Carbon Footprint (<1kg CO2e per inhaler) Use where clinically appropriate   Salbutamol: Salbutamol Easyhaler Salbulin Novolizer Ventolin Accuhaler   Terbutaline: Bricanyl Turbohaler   Formoterol: Foradil (DPI) Formoterol Easyhaler (DPI) Oxis Turbohaler (DPI)   Indacaterol: Onbrez Breezhaler (DPI)   Olodaterol: Striverdi Respimat (SMI)   Salmeterol: Serevent Accuhaler (DPI)   n/a Fluticasone Furoate / Umeclidinium / Vilanterol: Trelegy Ellipta (DPI)
High Carbon Footprint (10-20kgCO2e per inhaler) Use if low carbon footprint alternative not appropriate Salbutamol: Airomir AirSal Salamol   Airomir 100 Autohaler (BAI) Salamol 100 Easi-breathe (BAI) Formoterol: Atimos Modulite (MDI)   Salmeterol: Serevent Evohaler (MDI)   Multiple other manufacturers (MDI)   Ipratropium Atrovent MDI Beclometasone / Glycopyrronium / Formoterol: Trimbow (MDI)
Higher Carbon Footprint (28KgC02e) Salbutamol: Ventolin 100 Evohaler 100mcg          
All Long Acting Muscarinic Antagonists (LAMA) and LAMA/LABA inhalers have low carbon footprint (DPI or SMI)

 

Inhaled Corticosteroid (ICS) Inhalers by Adult Dose and Carbon Footprint
  ICS Low Dose Medium Dose High Dose #
Low Carbon Footprint (<1kg CO2e per inhaler) Use where clinically appropriate   Beclometasone
Beclomethasone Easyhaler 200mcg one puff twice a day 200mcg two puff twice a day n/a
Budesonide
Budesonide Easyhaler 200mcg one puff twice a day 400mcg one puffs twice a day* 400mcg two puffs twice a day
Pulmicort Turbohaler 200mcg one puff twice a day* 400mcg one puff twice a day* 400mcg two puffs twice a day
Budelin Novolizer 200mcg one puff twice a day 400mcg one puff twice a day 400mcg two puffs twice a day
Fluticasone proprionate
Flixotide Accuhaler 100mcg one puff twice a day 250mcg one puff twice a day 500mcg one puff twice a day
Mometasone
Asmanex Twisthaler 200mcg one puff twice a day 400mcg one puff twice a day n/a
High Carbon Footprint (10-20kgCO2e per inhaler) Use if low carbon footprint alternative not appropriate   Beclometasone
Clenil Modulite pMDI 200mcg one puff twice a day* 200mcg two puffs twice a day 250mcg two-to four puffs twice a day
Kelhale pMDI (extrafine) 100mcg one puff twice a day* 100mcg two puffs twice a day 100mcg four puffs twice a day
Qvar pMDI / Autohaler / Easi-Breathe (all extrafine) 100mcg one puff twice a day* 100mcg two puffs twice a day 100mcg four puffs twice a day
Soprobec pMDI 200mcg one puff twice a day* 200mcg two puffs twice a day 250mcg two or four puffs twice a day
Ciclesonide
Alvesco pMDI 160mcg one puff once a day* 160mcg two puffs once a day 160mcg two puffs twice a day
Fluticasone proprionate
Flixotide Evohaler 50mcg two puffs twice a day 250mcg one puff twice a day* 250mcg two puffs twice a day

# Only use after referring the patient to specialist care.

* Alternative regimes exist consisting of more puffs of lower strength per day.

For paediatric dosing please refer to the BNF.



ICS/LABA Combination Inhalers by Adult ICS Dose and Carbon Footprint
  ICS/LABA Low Dose Medium Dose High Dose #
Low Carbon Footprint (<1kg CO2e per inhaler) Use where clinically appropriate Beclometasone diproprionate (extrafine) with formoterol
Fostair Nexthaler 100/6 one puff twice a day 200/6 one puff twice a day* 200/6 two puffs twice a day
Budesonide with formoterol
Duoresp Spiromax Fobumix Easyhaler 160/4.5 one puff twice a day 320/9 one puff twice a day* 320/9 two puffs twice a day
Symbicort Turbohaler 200/6 one puff twice a day 400/12 one puff twice a day* 400/12 two puffs twice a day
Fluticasone proprionate with salmeterol
Seretide Accuhaler 100/50 one puff twice a day 250/50 one puff twice a day 500/50 one puff twice a day
Fusacomb Easyhaler n/a 250/50 one puff twice a day 500/50 one puff twice a day
Aerivio Spiromax AirFluSal Forspiro Stalpex Orbicel n/a n/a 500/50 one puff twice a day
Fluticasone furoate with vilanterol
Relvar Ellipta n/a 92/22 one puff once a day 184/22 one puff once a day
High Carbon Footprint (10-20kgCO2e per inhaler) Use if low carbon footprint alternative not appropriate Beclometasone diproprionate (extrafine) with formoterol
Fostair pMDI 100/6 one puff twice a day 200/6 one puff twice a day * 200/6 two puffs twice a day
Fluticasone proprionate with salmeterol
Combisal pMDI; Seretide Evohaler; (Other MDI brands exist) 50/25 two puffs twice a day 125/50 two puffs twice a day 250/25 two puffs twice a day
Highest Carbon Footprint (>35kgCO2e per inhaler) Avoid unless no appropriate alternative or switching is inappropriate clinically Flutiform MDI       50/5 two puffs twice a day 125/5 two puffs twice a day 250/10 two puffs twice a day
Flutiform K-haler     50/5 two puffs twice a day 125/5 two puffs twice a day 250/10 two puffs twice a day
Symbicort MDI     200/6 one puff twice a day 200/6 two puff twice a day n/a

# Only use after referring the patient to specialist care. 

* Alternative regimes exist consisting of more puffs of lower strength per day. 

For paediatric dosing please refer to the BNF.


Please Note: The above information was accurate on the date it is was written, 25th February 2021

Published on 25th February 2021