Hot Topics Blog
In case you hadn’t noticed, today there is a general election in the UK. As ever, the NHS is the nation’s top priority, but for the first time the environment is also high on the agenda. While the public sees these as two separate issues, the truth is that they are intertwined.
Two quick examples:
- A very recent BMJ article showed an strong positive association between levels of fine particulate air pollution and hospital admissions for cardiovascular and respiratory disease as well as many other conditions, even with levels of exposure well below WHO guidance.
- Data shows that atmospheric temperature rises due to climate change has led to an increase in respiratory disease through a variety of mechanisms such as higher levels of pollen and mould for longer periods throughout the year. This is only set to increase further.
So, if climate change and the environment are medical issues then what can we do in primary care to make an impact? What can we do to benefit our patients?
Earlier in the year NB blogged about metered dose inhalers (MDI) accounting for 4% of all NHS carbon emissions. Inhalers are not the only area to address, but they are potentially an easy win and very much the purview of primary care. A paper in BMJ Open, published in October, showed that switching to DPIs could save money AND dramatically improve carbon emissions.
Unfortunately, the media reports had such a negative spin that patients with asthma felt justifiably indignant that global warming appeared to be placed on their shoulders. Despite this I believe that most patients using inhalers – this applies to both patients with asthma and/or COPD - where it is safe and they are physically able to, would be happy to try an alternative inhaler if a more environmentally friendly option were offered.
Using less MDIs might be an easy win, but inhalers are only a part of the picture. By thinking more broadly about the patient and their condition we truly can have it all: better health, better environment and better finances.
So here are a few suggestions for how to minimise the environmental impact in patients using inhalers:
1. Ensure the diagnosis is correct
- Between 33-50% of children and adults with an asthma label are ‘over-diagnosed’, either due to mis-diagnosis or resolution of their condition - unnecessary inhalers are lose-lose.
2. Maximise non-drug treatments
- Here are some of the greatest gain: smoking cessation, pulmonary rehab, simple exercise, even changing the route you walk/cycle to school, work, etc. to avoid polluting traffic.
3. Where possible prescribe dry powder inhalers.
- For excellent patient and clinician information see www.greeninhaler.org set up by Dr Alex Wilkinson, respiratory consultant and lead author of the aforementioned BMJ Open paper. An essential read, entirely free to access.
- DPIs will not be appropriate for every patient, blanket switching is not appropriate, and we also need to ensure there is no guilt attached to MDI use. A patient-led individualised decision is needed, but broadly speaking, the very young and old may struggle with DPIs, and patients need a decent inspiratory flow (my local CCG guidelines suggest >30L/min, which in the real world equates to… um…) but bear in mind that most COPD long-acting inhalers such as LABA+LAMA combinations are dry powder inhalers and effective.
- An important point is that during respiratory emergencies patients may lack the respiratory drive needed to use DPIs and so MDIs still play an important role here. Patients need to be aware of this. Manufacturers are aiming to make lower impact MDIs but these are still years away.
- In patients already using MDIs, if switching might be possible, consider asking at their next asthma/COPD review if they would consider using an alternative which is more environmentally friendly.
- The biggest barrier is clinicians. We need to change our prescribing habits and crucially make sure our excellent practice nurses are on board. As GPs we can get very de-skilled in inhaler prescribing – for a reminder of the available options and demonstrations of good inhaler technique for every individual inhaler have a look at www.rightbreathe.com
4. Make every inhaler count
- Ensure good technique and use of spacer with MDIs to maximise efficiency. A government report states that 50% of patients using MDIs do so incorrectly. They are inherently more difficult to use than DPIs which 80-90% of patients do correctly.
- Ensure people use all the doses in the inhaler – inhalers without dose counters (e.g. most salbutamol MDIs) are difficult to gauge as the active ingredient runs out well before the propellant. Either prescribe inhalers with integrated dose counters or encourage people to count how many doses they have used. If the inhaler is used regularly they can estimate the number of doses used from the number of puffs per day multiplied by the duration used. Interestingly, if you have an accurate enough scales (e.g. digital kitchen scales) you can weigh a Ventolin Evohaler inhaler to see how much medicine is left – click here.
5. Recycle the inhaler
- 99.5% of inhalers prescribed in the UK end up in the bin and go to landfill. That’s around 50 million in 2018. Not only is that a lot of plastic, they leach out the remaining propellant HFCs for years to come. You can’t put it in your normal recycling bin (!) but many pharmacies are part of a GSK run recycling scheme . You can find participating pharmacies here.
- If patients don’t use participating pharmacy start a collection at the practice and pass them on to a pharmacy that does.
As with any intervention, on an individual basis the benefits are comparatively small, but together general practice has the potential to make significant improvements to the environmental impact of healthcare in the UK. Inhalers are a simple place to start, let’s open the discussion with patients – they are interested, they want to help.
This is our first step, but there is much more we can do in practices – in 2020 we will look at simple changes practices can make which make them more environmentally friendly, sustainable AND potentially save money. Regardless of whichever government is in charge.
Merry Christmas and have a Happy New Year.
for a really insight comparison of inhaler carbon footprints click here.
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