How replacing a handful of patient inhalers saved almost 5,000 kg of CO2 equivalent

Awareness of the impact of human activity on our environment is growing, with heat waves, flash floods, wildfires and eco-activism regularly making headlines. The climate crisis is a health crisis and without urgent action the effects on our health and our planet will be devastating.

In 2020, the NHS revealed its ambition to become the world’s first carbon-neutral national health service. His report ‘Offer a “net zero” national health service‘ is interesting reading: the NHS accounts for around 4% of the UK’s total carbon emissions and around 25% of NHS emissions are attributed to medicines.

Around 3% of the NHS’ carbon footprint is produced from just one type of medicine – inhalers – the main driver being the propellant contained in pressurized metered dose inhalers (pMDIs).

To mobilize action in this area, NHS England has included two environmental sustainability indicators in the Primary Care Network (PCN)’ Investment and Impact Fund‘, which focus on reducing the percentage of pMDI as a proportion of all non-salbutamol inhaler prescriptions and reducing the average carbon output of all salbutamol inhalers prescribed.

A cultural shift in our prescribing habits could benefit the environment without compromising patient care

The UK is an exception in its use of pMDIs. Here they make up around 70% of the inhalers used, while in other parts of Europe, such as Scandinavia, they mostly rely on dry powder and soft-mist inhalers. Health outcomes in these regions are not dramatically different, suggesting that a cultural shift in our prescribing habits could benefit the environment without compromising patient care.

Julie Hyam, chief respiratory nurse, shared how she transformed prescribing over an 18-month period during a global pandemic. In an ideal world, we invite people into the GP’s office, have an open and honest discussion and, if they’re happy to do so, we assess their inhaler technique.

But we are living in a pandemic, with strict infection prevention controls and a cohort of patients who are rightly scared.

Hyam had spoken on the phone with suitable patients and agreed to a trial. She then sends an SMS to the UK asthma demonstration video and followed up with another call after a few weeks.

Patients are often very happy to try a different inhaler, as long as it is safe, effective, and they know they can go back if the change is not to their liking.

One particularly valuable piece of advice shared by Hyam was that she only prescribes one reliever inhaler. Many patients want spare inhalers; however, she thinks the single inhaler should go wherever they go, much like a cell phone.

Armed with this advice and a PowerPoint presentation, I ambushed my clinical colleagues in each of the practices of the North Oxfordshire Primary Care Network during their clinical meetings.

Many of them had heard of this problem before, but were shocked by the emission figures. I have personalized the facts by establishing that a 175 mile car journey (emissions equivalent to a pMDI) takes you from Oxford to Liverpool, while a DPI only produces emissions equivalent to a four mile journey, which, as I described, is only halfway to the next village.

I also brought some pMDIs to illustrate that the equivalent CO2 the emissions from three tiny inhalers combined weigh more than my own body weight.

I then contacted my PCN community pharmacies to inform and prepare them for the upcoming changes and “new drug service” referrals. Yasin Jussab, my community pharmacy PCN manager, has been invaluable as a sounding board and community pharmacy safety net assured me that the patients I changed would receive extra support and be discharged if they had any problems.

I then set to work to tackle the the most prolific prescribers of pMDI in PCN. I did a search of all registered patients aged 12 and over who were currently being prescribed a pMDI.

The reason for this wide age range was to make sure that I didn’t exclude people who might be able to use PGD, just because of an age limit or “frailty” label. It might need more nuance and caution, but I think it’s important to be inclusive.

I screened the first 20 patients, going over the practicalities of the changes I could make to our formulary and the authorization and indication restrictions. At this point, I felt familiar and comfortable enough with the switches to think on my feet. At the end of January 2022, I invited patients to make an appointment for a check-up to discuss the change of inhaler.

It is imperative that inhaler switching is a shared decision based on evidence, clinician experience and lived experience of the patient

It is imperative that inhaler switching is a shared decision based on evidence, the clinician’s experience and the lived experience of the patient. The most environmentally friendly inhaler is one that a patient uses correctly to stay healthy and out of hospital. Patients need to be actively involved in their care, which is why wholesale changes by letter or SMS are repugnant to me.

In my first two clinics, I saw 18 patients. Of these, 14 have agreed to try a low-carbon alternative and, so far, none have reported any difficulties. One patient declined because he felt his condition was well controlled and did not want to learn a new inhaler technique. The other three conversations resulted in a split decision that a trial was inappropriate at this time, but would be reassessed in the future.

Over the next 12 months, the 14 changes agreed could represent a saving of 4,740 kg of CO2e — about the same as 15 economy class flights from London to New York. And that’s just the beginning.

Top tips for healthcare professionals:

  • Tailor your message to your audience;
  • Assess whether ‘maintenance reliever therapy’ (MART) is appropriate – this may reduce additional reliever inhalers;
  • If you prescribe a rescue inhaler, do only one rescue inhaler at a time;
  • If you prescribe several inhalers, try to keep them the same so that the technique is the same;
  • In asthma, consider treatment with leukotriene receptor antagonists (LTRA);
  • Get the doses right for the patient, i.e. instead of beclometasone 100 mcg two puffs twice daily (lasts 50 days), prescribe beclometasone 200 mcg one puff twice daily ( lasts 100 days and halves emissions);
  • Local collaboration in action — find your local Greener Practice group here: Local Groups — Greener Practice;
  • Track your performance on OpenPrescription.

Brendon Jiang is a senior clinical pharmacist based in Oxfordshire and a member of the Royal Pharmaceutical Society’s Primary Care Expert Advisory Group.