‘Blanket switch’ to greener inhalers not recommended in prescribing guidance

The Scottish government has published a consultation on draft guidance emphasising that patients should only be switched to greener inhalers “if effectiveness, safety or adherence is not compromised”.
woman using dry powder inhaler

A Scottish government consultation on prescribing for respiratory illness has emphasised a ‘person-centred’ approach to prescribing more environmentally-friendly inhalers. 

The ‘Quality prescribing for respiratory illness 2024 to 2027 — draft guidance‘ consultation, published on 4 September 2023, says it does “not recommend a blanket switch” to dry powder inhalers (DPI), which do not use greenhouse gases as propellants.

The draft guidance follows NHS Scotland’s ‘Climate Emergency and Sustainability Strategy 2022–2026’, published on 16 August 2022, which advocated regular reviews of patients with asthma and chronic obstructive pulmonary disease who use metered-dose inhalers (MDIs) — which contain a propellant gas that could contribute to climate change — to help reduce emissions by 70% in the next six years.

In the draft guidance consultation, The Scottish government said that NHS Scotland’s emissions from inhaler propellants were the equivalent of 79,000 tonnes of carbon dioxide in 2020/2021, and that approximately 3% of NHS Scotland’s carbon footprint came from MDIs.

The new draft guidance, produced by the Scottish government, NHS Scotland and Experts by Experience, recommends prioritising reviews of patients who are overreliant on short-acting beta agonist (SABA) reliever inhalers, and that a switch to DPI inhalers can be considered if the patient is interested, has an adequate inspiratory flow and their condition has been stable for two years.

The draft guidance includes an illustration of the difference in carbon emissions from using a DPI instead of a MDI in car usage and tree-planting terms, which it suggests could be shared with patients. But it adds that “changes should only be made if effectiveness, safety or adherence is not compromised and this should be managed on a case-by-case basis, using a shared decision-making approach”.

Darush Attar-Zadeh, clinical fellow respiratory pharmacist at North West London Integrated Care Board and co-chair of the Taskforce for Lung Health medicines optimisation working group, welcomed the draft guidance’s emphasis on patient-centred reviews.

“We’ve heard of terrible scenarios where blanket switching of inhalers has occurred or GP websites have suggested doing ‘inhaler swaps’. This is bad for patients, as well as the environment and the healthcare system.

“If the person has poor inhaler technique for a new device, they can end up being hospitalised, GP admission rates go up, and the use of the emergency blue [SABA] inhaler can rise.”

In February 2022, respiratory experts raised concerns about an inhaler device switching programme in England, warning patients could suffer worse asthma control if they were not properly consulted about the switch. 

Laura Wilson, director for Scotland at the Royal Pharmaceutical (RPS), said that switching to greener inhalers “must be done on an individual basis, in consultation with the patient, to ensure a switch is both clinically appropriate and right for the patient”.

Other recommendations in the draft guidance include updating local formularies to highlight inhalers with lower carbon dioxide emissions, using the ScriptSwitch prescribing decision support tool to promote better asthma care and environmental messages to GP practices, and raising public awareness of good asthma care and the environmental impact of respiratory prescribing.

Sharon Pfleger, expert adviser on environmental sustainability policy at the RPS and consultant in pharmaceutical public health at NHS Highland, said: “Research has shown that countries with much higher DPI use than the UK also have fewer deaths from asthma.

“On a case-by-case basis, with shared decision making, using an MDI can lead to better asthma control for patients with a reduced need for reliever inhalers, so healthier lungs can also be greener lungs.”

On 3 August 2023, the UK government announced a £33m joint investment with Kindeva Drug Delivery, a company that is developing green inhalers. 

The Scottish government consultation is open until 31 October 2023.

Read more: Best practice principles for inhaler prescribing

Last updated
The Pharmaceutical Journal, PJ, September 2023, Vol 311, No 7977;311(7977)::DOI:10.1211/PJ.2023.1.196138

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