By Ms Ravijyot Saggu, Clinical Pharmacist, Chief Pharmaceutical Officers Fellow and Chair of the UKCPA Respiratory Committee
Metered dose inhalers (MDIs) are widely used by patients with respiratory conditions such as asthma and who often have insufficient inspiratory flow to maximally benefit from this device. MDI’scontain propellant gases that have highcarbon emissions that are harmful to the environment. The gases become trapped in the earth’s atmosphere for many years causing the planet to heat up. This climate crisis is a health crisis, dangerous for all species.
Reducing MDI use is a way to address this, where clinically appropriate, in discussion with patients. In some cases, this might mean changing from a higher to lower carbon MDI, or to a dry powder inhaler (DPI) or soft-mist option which emits far less carbon and will be more suitable to the individual’s inspiratory ability. To do this safely requires the time, expertise and shared decision making(supported by resources) which pharmacists are ideally placed to provide.
More sustainable healthcare
The green agenda provides an opportunity to improve respiratory care whilst reducing environmental impact and MDI use. More sustainable care is achievable by better disease control, increased medicine adherence, less waste and preventing respiratory exacerbationsincluding associated GP or hospital visits. Patients should be empowered, informed and involved in decisions about their care and especially as part of this agenda.
Here are some top tips to optimise asthma care sustainably:
1. Blanket device switching is not recommended. Individual shared decision making and patient review are vital to jointly decide the most suitable device/switch. Insufficiently supported switching can de-stabilise patients and not all can change to an alternative device. Factors to consider include inspiratory flow, inhaler technique and ability, including Salbutamol (over)use disease control, adherence and revisiting the diagnosis. Remember to prescribe by brand & device
2. Explain the carbon context, for example two puffs of Ventolin MDI is like a 175mile car trip (London to Sheffield) versus same dose from Ventolin accuhaler (DPI) is equal to just a four mile trip.
3. The preventer inhaler should be used regularly as directed (in asthma this is usually steroid containing) which should result in less reliever use (usually Salbutamol, often missing a dose counter). If the patient requires this three or more times a week, refer them for a GP review as may requiring further investigation, referral or alternative therapies for more severe asthma.
4.Strategies to reduce frequent repeat prescribing include: a MART treatment approach, use of refillable inhalers if available, awareness of how long an inhaler should last to avoid overuse (many inhalers include a dose counter) and if appropriate, prescribing a higher strength inhaler to last longer and use less puffs per dose e.g using 1 puff of 200mcg instead of 2puffs of 100mcg (however, must counsel carefully to avoid inadvertent accidental extra dosing)
5. Sign posting/safety netting – provides decision making support and further information. Where the device has been changed, follow up, review and reassure, and refer onwards where necessary.
6. Safe disposal/recycling: Ensure patients know they should return inhalers to pharmacies for safe disposal/recycling and should not put them in with household waste.
7. Note: use MDIs via spacer device and discuss their use and care.
Pharmacy teams can impact the climate crisis
Whether prescribing, reviewing, counselling or part of a shared decision-making discussion, pharmacy teams in all sectors are well placed to streamline formularies and deliver high quality respiratory care that aligns with the net zero agenda and improves patient outcomes. Implementing the above measures and involving the patient in decisions can improve adherence, disease control and reduce MDI use. See also https://www.greenerpractice.co.uk/high-quality-and-low-carbon-asthma-care/ for a toolkit to support this in general practice.
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