Reviews | The cruel irony of inhalers worsening climate change

Drought and extreme heat, both exacerbated by climate change, set the stage for peak fire conditions in the western United States. As wildfire season intensifies and smoke re-emerges as a serious health threat, experts are encouraging people to ready to smoke. This includes stockpiling air purifiers and filters and, for those with the most at-risk lung conditions, refilling medical devices like inhalers.

But what if the very devices being used to address the health effects of climate change were themselves contributing to the crisis?

This is the case with metered dose inhalers, which are prescribed to treat two of the most common respiratory diseases in the United States: asthma and chronic obstructive pulmonary disease. These inhalers use hydrofluorocarbon aerosol propellants to help deliver drugs to the lungs. Propellants are greenhouse gases that can trap heat roughly 1,500 to 3,600 times as well as carbon dioxide over 100 years.

The good news is that there are other inhalers that are effective, competitively priced, and may contain the same active ingredients, but aren’t as bad for the climate. One type of these devices, known as dry powder inhalers, are associated with far fewer emissions compared to traditional propellant-based devices. Replacing high-release inhalers with these or another type of inhaler called soft-mist inhalers could lead to better outcomes for patients and the planet.

The contribution of metered-dose inhalers to greenhouse gas emissions from the healthcare sector is significant. British researchers have estimated that they represent 3 to 4 percent emissions from its national health system. And UK-based global pharmaceutical giant GSK said it was responsible for 45% of the company’s carbon footprint. As a result, there has been an increasing effort in Britain and other European countries to reduce the environmental impact of asthma and COPD care resulting from these inhalers.

Despite the fact that in 2020 Americans used about 144 million metered-dose inhalers – the greenhouse gas equivalent of driving half a million cars for a year – the United States has generally ignored their contribution to global warming. Like us gradually reduce hydrofluorocarbon gases from other sectors of the US economy, the healthcare industry must do its part.

Sweden uses alternative dry powder inhalers at a higher rate than the US while achieving superior results in the treatment of asthma. And the Department of Veterans Affairs, which does a drug review when developing its national formcontracted for a preference dry powder asthma medicine. Still, there’s a catch: Some inhaled medications aren’t yet available in the United States in dry powder form or aren’t covered by insurance.

The US Department of Health and Human Services, which is committed to reducing carbon emissions in the healthcare sector, could help by encouraging the development and approval of affordable dry powder inhalers. Creating demand for non-propellant inhalers would persuade pharmaceutical companies to market more of them. And insurers and hospitals motivated to have an impact on climate change could send a signal by prioritizing low-climate warming inhalers over prescription drug formularies.

The United States could also improve health and reduce environmental impact through more efficient use of available inhalers. Asthma care here lags behind other high-income countries”. Black and Native American populations in the United States are more likely than white Americans to have asthma and suffer a disproportionate burden of asthma-related health complications and deaths. The origins of these disparities are linked in part to structural racismgreater exposure to air pollution and heat (themselves aggravated by climate change) and reduced access to routine care, leading to fewer preventive medication prescriptions.

Research has found that patients in Britain with poorly controlled asthma have a problem with asthma care carbon footprint about three times that of people with well-controlled asthma, likely due to overuse of propellant-based rescue inhalers and more frequent emergency room visits during asthma attacks. Achieving better asthma control requires treating more patients with inhalers to prevent flare-ups.

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As clinicians, we know that dry powder inhalers are not for everyone. These inhalers require patients to take deep breaths to draw in the medication; the very young, the very old, and those with severe lung disease can struggle with them. Fortunately, metered-dose inhalers with new propellants that have practically Nope or greatly reduced effects on global warming are under development. Such devices are urgently needed to provide a full range of inhaler options to patients and to minimize emissions.

We recognize that talking about environmentally friendly inhalers can stir up painful memories for healthcare providers who practiced in the 2000s. After the Montreal Protocol from 1987, older ozone-depleting thrusters were replaced with the current generation. Not only did the protocol protect the ozone layer, but it also prevented a substantial amount of global warming. However, pharmaceutical companies have taken advantage of this transition to place new versions of generic drugs under patent protection and, predictably, inhaler costs have skyrocketed.

This time we can and must do better. For now, patients should continue to use the inhalers prescribed to them. But the United States needs a more robust selection of generic alternatives to dry powder to reduce the impact on patients. And for those who continue to need metered-dose inhalers, policymakers and insurance companies need to protect patients from price hikes.

The US healthcare sector is a major contributor to climate change, accounting for approximately 8.5% domestic greenhouse gas emissions. Since its fundamental mission is to promote health and well-being, it must seize every opportunity to mitigate its effect on the climate.

Reducing emissions from inhalers is an opportunity to reduce the carbon footprint while improving respiratory disease. The smoke from the forest fire is already blowing towards us; let’s not add fuel to the fire.

Alexander S. Rabin is a Clinical Assistant Professor of Pulmonary and Critical Care Medicine at the University of Michigan. Gregg L. Furie is a primary care physician and medical director for climate and sustainability at Brigham and Women’s Hospital.

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