MDIs to DPIs

Christelle Blunden's picture

Does anyone have an example of an audit or guideline review they have completed on the above which they are willing to share which I could use for inspiration to work with my practice and CCG on the issue?

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I would suggest reviewing the

Jerome Baddley CEnv MIEMA's picture

I would suggest reviewing the NICE Clinical Knowledge Summary on Asthma and the focus is asthma rather than COPD at this point.

I am not aware of any particular guidance on moving patients from one type of device to another, though actively switching patients is not encouraged. However NICE are developing a Shared Decision Aid to support patients and clinicians to make informed choices about equivalent inhalers with high and low environmental impacts. This could potentially be used at prescription or review.

At a CCG level, understanding how the carbon impacts of inhalers may be considered and displayed in local formularies would be very useful. I would be interested to hear your thoughts and experiences on this. Also ensuring that recycling and recovery boxes for old inhalers are present in all pharmacies and practices. There are industry run schemes that take back inhalers. Encouraging patients to return these, rather than put them in the rubbish is really important for reducing release of greenhouse gases.

Some patients manage their conditions better with and MDI, clearly this has to be the primary consideration. However DPIs have a far lower carbon impact than MDIs because of the propellant gases. Any measures to improve inhaler use and reduce overprescribing will reduce the impacts. Alerting patients, if both options are available and appropriate, to the relative carbon impact of DPI and MDI or different MDI regimes may mean that lower impact options are preferable.

Indeed, as climate change is of such a high concern to many people, providing patients with this information can help ensure that patient values and concerns are considered in their medication.

While all DPI are very low carbon impact, and all MDI are high carbon impact, some MDIs also have half the carbon impact of others. Particularly with two of the most common SABA options, Ventolin is very high compared to Salamol, which is just high. Single actuation inhalers rather than double actuation inhalers also result in lower gas emissions, so less carbon impacts per dose.

Kind regards

Jerome Baddley 
Head of Unit, Sustainable Development Unit (SDU)

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I have a few I could share

Alexander Wilkinson's picture

Dear Christelle,

I'm not aware of any guidelines to encourage large-scale switches or audits of this, although with rising awareness and passion about the evils of climate change I suspect many patients would be keen to switch if they knew the facts about inhalers' carbon footprints.

The BTS has a position statement on it:

https://www.brit-thoracic.org.uk/document-library/audit-and-quality-improvement/environment-and-lung-health/the-environment-and-lung-health/ see C3 in particular.

At Lister in Stevenage we've done

1. Survey of patient views:

https://thorax.bmj.com/content/72/Suppl_3/A235

2. Study showing 12% of patients admitted acutely had empty Ventolin metered dose inhalers (by empty I mean >200 doses used, making dosing unreliable)

https://thorax.bmj.com/content/73/Suppl_4/A193.2

3. Recycling project in which all inhalers returned to pharmacy are recycled (this saved us money and carbon). We also include information on recycling on all our patient information leaflets and posters in the respiratory clinics showing all the local pharmacies that will recycle inhalers.

4. Patient information leaflet explaining the pros/cons of different types of inhalers, including information on their carbon footprint (similar to NICE but better IMHO).

I've been meaning to calculate carbon savings from these initiative but haven't got around to it yet.

If you're keen to implement something like this in primary care and would like any specialist support I'd be delighted to help if I can. Also if you want any more detail on any of these projects let me know. I'm yet to convince my CCG that a project like this would be worthwhile.

Yours,

Alex

Respiratory Consultant, BTS lead on sustainable respiratory care

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