This isn't widely available but GSK have given it to me so I'm sharing it. It shows the carbon-trust-certified carbon footprint of their inhalers.
Headline figures are:
30 days of seretide 250 evohaler (pMDI) = 20kgCO2e
30 days of relvar ellipta 92/22 = 750gCO2e
Full details including the breakdown of where the carbon costs are incurred is in the attached file
Hi Alexander - this is very helpful, thanks for posting it. This is a really nice teaching point which always gets my medical students excited - prescribing practices have a huge impact on the health sector's carbon outputs. In a sense, the doctor's pen is mightier than the stethoscope!
Adi
Thanks for sharing this. It is useful to see a specific example. I've been aware for a while that MDIs with the propellant gas they include have a much higher footprint but useful can now say we have a specific example which is 15x higher for the same active ingredients.
I've always assumed that the powder forms were more expensive than the MDI versions which would in part justify why they aren't more used. However I've just looked up these two forms of Seretide in the BNF online. This suggests that Seretide 500 Accuhaler costs- £40.92 per 60 doses while the Seretide 250 Evohaler costs - £59.48 per 120 doses. Given two doses of the Seretide 250 evohaler are equivalent clinically to one of the 500 Accuhaler it is fair to compare these prices and to my surprise the powder inhaler is cheaper.
Have I got this right? Surely if this is correct there should be a push nationally to shift everyone to the powder Seretide unless there is a clinical reason not to.
That said I'm aware that Seretide will not be the most used inhaler and it's things like Salbutamol which we really need to change over.
Has anyone done or seen a table comparing the equivalent powder and MDI inhalers by price?
At East and North Herts NHS Trust we pay £724 for a year of seretide 250 evohaler and £268 for a year of Relvar. It's a total no brainer.
I did some back of envelope calculations showing that if we (theoretically) used relvar instead of any other ICS/LABA pMDI (mainly fostair, flutiform and seretide evohaler) we could save about £150,000 and 20tCO2e a year.
P.S. no affiliation to GSK, but they're the only company who have published CO2e data. I expect other DPIs are similar.
A few years ago when Chair of a CCG we looked at this and came to the same conclusion - indeed we proposed change of use to a number of inhalers based on price and footprint. It was sabotaged to cost only and essentially we failed. So to get change you need the patients on board (and powder inhalers are less acceptable less convenient for them) as well as promoting the carbon agenda otherwise costs and convenience likely to win. Good luck
Derek Chase (retired GP!)
Up till November 2015, Seretide 250 evohaler was the second most costliest drug in the NHS (the first is Spririva), and Seretide 500 Accuhaler was the fourth most costliest drug. The two high dose Seretides together (as they are the same dose but slightly different licenses), cost the NHS £220 million.
James Smith suggested that since Seretide 250 evohaler costs £60 and the Accuhaler at the same dose costs £40, there should be a national switch (although one should also ask why the price differential acutally exists in the first place!). This was certainly the case several years ago with many CCGs advocating this. However, since the introduction of generic fluticasone/salmeterol, CCGs have preferred a switch to the pMDI generic for cost reasons.
The London Respiratory Team as part of their Responsible Respiratory Prescribing messages in 2011 (https://www.networks.nhs.uk/nhs-networks/london-lungs/responsible-respiratory-prescribing-rrp) brought to attention the high cost of these inhaled medications and introduced the high dose ICS safety card for patients using these inhalers as they are taking the equivalent of 2000micrograms beclomethasone dipropionate a day, highlighting the risks involved.
As these inhalers are not only the highest cost, but also the highest volume in terms of items, this suggests that many asthmatics must be at step 4 of the old BTS guidelines or above. This clearly cannot be the case. In addition, the evidence for the use of very high dose ICS in COPD (in which the accuhaler is used) is limited, especially when lower doses are equally effective using other licensed ICS/LABA combinations (BMJ 2012;345:e8204). Thus there is currently a huge overuse of high dose ICS which is not appropriate (http://www.practiceupdate.com/content/overtreatment-of-copd-with-inhaled-corticosteroids-implications-for-safety-and-costs-cross-sectional-observational-study/5534?trendmd-shared=1).
Thus rather than switching from one high dose ICS product to another (and this includes Relvar 184), the right thing to do is to assess the need for high dose ICS in each patient and see if a dose reduction or even withdrawal of ICS in certain COPD patients would be more appropriate.
Thus before we consider what is best for the environment, we should consider what is best for the patient first.
Vince Mak (Consultant Physician in Respiratory Integrated Care)
Totally agree. Unecessary inhalers are terrible for both patient and environment. The RRP work from London is brilliant.
I wonder if it is really true that DPIs are less convenient and acceptable. This paper suggests otherwise: http://www.currenttherapeuticres.com/article/S0011-393X(02)80055-8/pdf
The large majority of new devices are DPIs, suggesting industry might agree they're preferred by patients. These newer devices might also been even more acceptible to patients than those reviewed in the above paper. At the very least patients have more choice, making it more likely they can find an acceptible DPI. pMDIs as devices haven't really evolved at all.
Good to see Alexander's and Derek comments about acceptability. I missed these when I wrote my longer comment above. Sounds like there is still more debate to be had.
In a 2011 review 70% of inhaler sales in the UK were for pMDIs, but in every other European country assessed, pMDIs constituted fewer than 50% of inhaled medications sold. In Sweden it was only 10%.
http://www.resmedjournal.com/article/S0954-6111(11)00100-4/abstract
http://www.resmedjournal.com/article/S0954-6111(11)00100-4/abstract
Alexander is quite correct. The UK (and USA for that matter) is addicted to pMDIs whereas Europe mostly uses DPIs. The shocking truth with pMDIs is that 50-90% of patients cannot use a pMDI correctly in various studies, and what is worse, 90% of healthcare professionals who are meant to demonstrate correct use to patients, cannot do it themselves. Since only 12-15% of a pMDI dose actually gets into the lungs with best technique, you can imagine how little actually ends up in patients' lungs. With Seretide 250 evohaler, each puff is worth 50p. With poor technique and no spacer, most of the £60 the NHS spends on the inhaler (£720/yr) is wasted, which means most of the £140 million we spend on this a year, is wasted (the USA is far worse).
DPIs are not only easier to use with fewer critical errors (especially the newer ones on the market now), they have better delivery (up to 30% of the metered dose goes into the lungs). Therefore, patients maybe better controlled using far lower doses.
So is there something that the Swedish know that we do not? Personally, I do not think that any inhaler prescribed should be a pMDI, although I expect that we are going to continue to prescribe salbutamol as a pMDI as it is very cheap in terms of price (£1.50), but not in terms of carbon footprint. So there is a compelling case for the UK to break off its love affair with pMDIs for the sake of the patients, the NHS and the environment. A win-win-win situation!
Well. I'm convinced. This shift sounds like something which could be a great campaigning goal. I'd always been hesitant to push too hard because of my assumption that the prices would always work against the argument for DPI. I hadn't really appreciated that propellant based inhaler might be so inefficient due to poor technique.
Not sure what others think? Would a campaign for DPIs be approrpriate?
Would need to have a clear evidence based summary of the arguments for and against? Including the costs comparisons for different active ingredients.
Would need to work out the target audience? Prescribers? Patients? Policy Makers?
Would need to put appropriate medical caveats in so people remain on the appropriate care for their condition and aren't put off their necessary treatment or stigmatised if they need a pMDI.
Nonetheless I think there is something there. It would also be useful to think who might get behind this. There is a huge range from organisations focussed on care quality to professional groups to patient groups to environmental groups. Could make for an interesting collaboration?
Thoughts anyone?
Thanks James, Alex - and everyone for really helpful discussion.
It certainly sounds like things have moved on a bit in the last few years, both on relative costs of DPI vs MDI and evidence of acceptability to patients.
I'm going to dust off proposals for a Sustainable Specialties Fellowship on this topic, and start looking again at potential partners and funders.
Anyone interested in supporting this approach, please let me know!
Frances
Dr. Frances Mortimer, Medical Director, Centre for Sustainable Healthcare.
Thanks Frances
Getting the best value out of our inhaler spend in the NHS has been one of the reasons why I go to work in the mornings. So i would be happy to be involved in any future projects on inhalers.
Vince
Hi
I was wondering if anyone knows of a brief video clip explaining the environmental impact of inhalers? We have been asked by a local pharmaceutical committee, which would like to share it with their pharmacies.
Inge, Project Manager, Centre for Sustainable Healthcare
I'm not aware of any, but its a good idea! Another pandora's box is engaging patients in inhaler change due to their carbon footprint. A box I'd be keen to open at some point though!
Given the amount of interest in this very worthwhile topic, I wonder if the time is right for a working group of sorts to be assembled? From the perspective of the Sustainable Healthcare Education network (also hosted on this site), it'd really help us if a group could rapidly put together the data, link it to the big picture (CCG-level) and small picture (patient-level) impacts, and package it for dissemination. I would envision this going not only to educators, but also through social media to the people and organisations that CSH would normally hope to influence.
Any takers? I would be happy to coordinate as I don't have the capacity to develop the resource itself.
Thanks for the comment Vince. I agree we should eliminate inappropriate prescribing as much as we can and patient safety is paramount.
I hadn't realised there was a generic option so thanks for noting this. (It's been quite a while since I did any prescribing. I've been working in public health recently.)
I guess the key initial question from a carbon footprint perspective is how many people could reasonably be switched to a powder inhaler which was clinically appropriate and cheaper.
Once this is happening we can ask the more challenging question of whether we would ever pay more for a powder inhaler than an MDI equivalent. I suspect the NHS in it's current financial state wouldn't (and perhaps shouldn't?) but that this will increasingly be factored into the economy as carbon costs are taken into account through taxes or caps.
In the meantime I guess we are left focussing on reducing waste including inappropriate prescribing and switching where clinically appropriate cheaper options are available.
I am left wondering about a couple of things:
I don't know enough about pharmaceutical pricing to know how prices might change if there was a large scale shift (or commitment to shift) to powder based inhalers. I would have thought this might drive the prices for powder inhalers down. One would hope to a comparable level to their MDI counterparts or beyond.
I also don't know whether we are clear on the proportion of patients in which a shift to powder would be clinically appropriate and how acceptable to patients this would be.
Thanks for the interesting discussion. Because of the high footprint of HFCs (the propellants in MDIs) this is really important for the NHS carbon footprint and is probably one of the areas where we could make the biggest saving if we could make a change.