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Green Inhaler Prescribing | Environmental Impact of Inhalers

This is the second of 3 videos starting with the climate crisis explained by a general practitioner, going into more detail about green inhaler prescribing and the environmental impact of inhalers. Switching your inhalers to an eco inhalers - which is a dry powder inhaler, can have a massive impact on reducing your carbon footprint!

1. MDIs Versus DPIs

When most of us reach for a first-line inhaler, we go for a metered dose inhaler or MDI. These deliver a mist of medications from a pressurised container using aerosol propellants called HFCs.

Unfortunately, these are powerful greenhouse gases that contribute to global warming.

In England alone, we prescribe around 50 million inhalers per year and 70% of these are MDIs. In fact, our addiction to MDIs is puffing out 3%-4% of the NHS carbon footprint and 15% of the Primary Care carbon footprint. This is so significant that reducing MDI use is a key part of the NHS net zero plan.

So what’s the alternative?

Enter, dry powder inhalers or DPIs! Without propellants, DPIs have a carbon equivalent impact that is around 10 to even 30 times less than MDIs. Plus, DPIs are often a viable alternative for many of our patients and in the right situation can represent a treatment that is best for both the patient and the planet.

2. Open Prescribing

Firstly, what inhalers are your practice prescribing? You can run analyses of your prescribing via your electronic patient record system, but if you are in England, you also have access to a lot of nifty data using

3. P - Practice

Think how as a practice you are going to tackle this?

  • Call in those on the really nasty MDI Flutiform & Symbicort first and try to switch them.

  • Next those on multiple SABAs per year – showing poor control.

  • Next those on mixed MDI and DPI and move to one type only?

4. P - Patients

First, technique.

The patient needs to actually be able to use the inhaler. DPIs need a short, deep inhalation over 2 to 3 seconds which could be too much for some patients. MDIs need a slow, steady inhale over 4 to 5 seconds, coupled with pressing the inhaler, which also could be too much for some patients!

Once you know which type of inhaler suits, stick to that type for all their inhalers to avoid confusion and optimise treatment. Yes, even if that means using MDIs +/- a spacer. And document why have you chosen a particular inhaler type, so next person knows your decision.

Second, regime.

A MART regime condenses multiple inhalers into one combined inhaler that acts as both preventer and rescuer. By just using one inhaler, this reduces waste and impact and happily they mostly come as low carbon DPIs too.

5. P - disPosal

Every inhaler is recyclable with the plastic and aluminium being reused and the gases sold to the refrigeration industry (so cool). Pharmacies previously collected inhalers for recycling under GSK’s “Complete the Cycle” scheme, but this finished in September 2020.

A recycling scheme is available via Tevascheme but is a paid-for service only available to pharmacists or dispensing practices who use Teva, so might not be suitable.

The next best option to recycling is actually incineration. Whilst this sounds awful, the high temperatures burn off the gases, making them safe, and some incineration plants can recover the metals used in the inhalers. Making sure that patients take their used inhalers to the pharmacy ensures they are at least incinerated and do not go into landfill where they gradually let off their remaining gases like sad party balloons.

So to sum up, MDIs are really bad for the environment but in the UK we prescribe lots of them. As prescribers, we have the power to change this. Work out your prescribing habits as a practice, identify suitable patients for potential switches, counsel them well and then enlist the help of your friendly pharmacist to aid with disposal.

Join the wave! - Part 1 - Climate Crisis Explained by GP


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