A new campaign to encourage GPs to make greener choices in asthma management is a win-win for patients and the planet.
By Cathy O’Leary
Perth GP Brett Montgomery admits he was worried when he first broached the subject of greener inhaler options with some of his asthma patients.
“I thought people might think I was weird and a bit of hippie – bringing up climate change and the environment in their consultation – but it’s gone OK,” he said.
Dr Montgomery does not need to be won over about a new resource to help GPs make greener asthma medicine choices, because he helped develop it.
The National Asthma Council Australia (NAC) recently released the information paper to guide GPs in choosing options that could reduce asthma symptoms, prevent severe exacerbations and at the same time improve the health of the environment.
It is the first statement from the group that outlines why prescribing pressurised metered-dose inhalers (pMDIs) have a much larger impact than other inhalers and provides practice points on how to minimise wastage while maintaining good asthma control.
Dr Montgomery, a member of the NAC’s guidelines committee, said good asthma control and greener inhaler choices could go hand in hand.
“Better asthma disease control often leads to less use of inhalers that contribute to greenhouse gas emissions and that’s good for patients and the planet,” he said. “This new information will help health professionals to understand how poorly controlled asthma contributes to a larger carbon footprint through inappropriate or unnecessary prescribing, dispensing and purchase of inhalers.”
According to the NAC, Australian studies have shown that high rates of poor asthma symptom control are associated with the under-use of inhaled corticosteroids (ICS) and over-reliance on short-acting beta2-agonists (SABAs).
Salbutamol delivered via pressurised metered-dose inhalers is by far the most common reliever medicine used in Australia, with more than five million prescribed inhalers dispensed every year, plus an estimated six million sold over the counter.
While all inhalers have an impact on the environment, pMDIs are much bigger players because they contain hydrofluorocarbon propellants, which are released during use and through leakage after disposal.
Annual Australian greenhouse gas emissions from SABA inhalers have been estimated to be equivalent to over 350,000 tonnes of carbon dioxide – as polluting as driving a petrol fuel car from Sydney to Perth more than 360,000 times.
On the other hand, dry powder inhalers and soft mist inhalers have a 100 to 200-fold lower carbon footprint than pMDIs.
The NAC, which publishes Australia’s major asthma guidelines, the Australian Asthma Handbook, is now partnering with other organisations to help reduce emissions from respiratory inhalers.
Dr Montgomery said the overuse of salbutamol pMDIs was the greatest concern.
He told Medical Forum that for some time other countries such as the UK had guidelines and journal articles that had been vocal on the environmental impact of respiratory inhalers, but Australia and some other countries were just catching up now.
“Some of the messaging is familiar about poor asthma control and the over-reliance on short-acting beta2-agonists that largely just relax the muscles in the airways, when there are other medicines that can do better settling down inflammation, not just the temporary muscle relaxation effect,” he said.
“But the nice thing about talking about the topic of the environmental effects of asthma treatment is that they’re not in tension with each other.
“It’s not like we’re saying we should use less of the polluting inhalers, even though they’re not as good for asthma control – it’s not like that, and I occasionally get that pushback from people.”
A win-win
Many people could get just as good asthma control with greener inhalers and might need less of their inhalers which meant less pollution.
“It’s a real win-win for patients and the environment if we get this right,” Dr Montgomery said.
“In Sweden, something like 90% of inhalers are not pressurised metered-dose – they are the greener types – and Australia is a long way behind that, with the majority used here being of the metered-dose inhaler type, often containing salbutamol, and it’s available over the counter as well as on prescription.
“It’s hard to believe this is an ongoing issue because many of us practitioners have spoken to our patients about this, but still when I see articles measuring the problem of poor asthma control, I keep being surprised by how bad it seems to be.”
Dr Montgomery said an article in the Medical Journal of Australia a few years ago revealed the results of a survey of people with asthma, randomly selected across the country rather than relying on data from general practice presentations. It found that about a quarter of Australians with asthma had both poor asthma control and had barely or never taken inhaled corticosteroids.
“We know that one in nine Australians have asthma, and every year about 400 people will die of asthma in this country, and people who have poor asthma control are surely over-represented among those people who die,” he said.
“Personally, I’ve change quite a few of my patients from traditional inhalers to greener ones and I anticipated more resistance than I received. One patient looked at me a bit sceptically, but I brought up an article published in the British Medical Journal – because then we didn’t have any Australian statement on it – and he could see it was legitimate so was happy to try this different puffer.
“Sometimes GPs think it will be harder than it is. It’s all about everyone doing their bit, and there is a slow process of normalising care of the environment, and that’s the spirit in which we’ve put out this statement.”
But Dr Montgomery stressed that it was not a ‘one size fits all’ model, nor was it about swapping everyone with asthma onto greener inhalers or apportioning blame. In the past he had defended the PBS listing of metered dose steroid inhalers for children, fighting for medicines that only came in metered doses, because they were entirely appropriate.
“I wrote an article a few years ago on this topic for a general audience and got a bit of blow back on social media, along the lines of ‘sure, fossil fuel companies are destroying our planet but let’s blame those people with asthma’ which certainly wasn’t my intent,” he said.
“This is not about blaming people with asthma for the state of our environment, and we know there are much bigger fish to fry, but it is an immense and urgent problem so every industry needs to look and see what they can do.”
The primary importance was always going to be choosing an appropriate device type for each patient, and the right device choice depended on many factors including age, dexterity, inspiratory ability and learning ability.
For many adolescents and adults, a dry powder inhaler, or soft mist inhaler, could be appropriate and avoid emitting the propellant gases of metered dose inhalers.
“It’s not about making people feel guilty, and for some people I’m not even going to bring up this issue in the conversation. If there’s a good reason for them to be on their medicine and it wouldn’t be wise for them to consider another option, then it’s not relevant to bring it up,” he said.
“If a pMDI is genuinely the safest choice for a patient, we should not make people feel guilty about using their inhaler, because this might make their disease control worse, which can be bad for people and the environment.
“And there are some people who are better served by the traditional metered-dose inhalers, particularly children under the age of six. We’re not suggesting there is anything wrong with using metered-dose inhalers in those kids when they’re needed and used with a spacer device.
“Some people have trouble inhaling quickly enough to manage the greener dry powder devices, because you need to be able to get air in quickly to sweep up the fine powder into your lungs. But an important point is that in asthma the main difficulty is breathing out, and most people with asthma can breathe in just fine.”
Dr Montgomery said that climate changes happening around the world would ultimately impact asthma.
Higher temperatures contributed to bushfire and smoke, and climate change seemed to be altering pollen seasons – lengthening and intensifying them – and that could be bad for some people’s asthma, as well as causing a lot of other bad health effects.
One of the ongoing challenges for doctors was managing patients with mild asthma, who often steered clear of preventive medications. But now combination therapies – including greener options – could help them.
“When I first started talking about this issue, I was thinking the way forward was to a move to greener inhalers rather than the old-fashioned ones – and that it is still true – but what has become even more clear in recent years is the idea of using combination inhalers – steroids and long-acting beta2-agonists – in mild asthma, as needed,” he said.
“There are many people out there who are very symptom-driven when it comes to their use of asthma medicines, so when they feel tight, they’ll take their puffer and for the rest of the time they kind of forget about it – they’re not that good on prevention.
“All doctors have been able to do for them is keep trying to persuade them to take them regularly, but now we have medicines that act as relievers but have steroids mixed in with them, and if we can use more of those then it’s a way of reaching people who have poor asthma control.
“In people who struggle to remember to take a puffer regularly as a preventer, if they’re taking these combination medicines, they’re getting a bit of the steroids to settle down the inflammation each time they reach for some symptom relief, and the nice thing is we can do it in a green way because some of them come in the new inhalers.
“But it’s a slightly difficult culture change because when I was a junior doctor, I was taught that if you’re using steroids, you must use them regularly – this was drummed into us – so this new way of using them purely as needed seems to be in defiance of what we were taught, yet there is good evidence for it.”
Dr Montgomery said that GPs could also make a greener choice, where appropriate, when starting people on an inhaler for the first time.
“The first step before prescribing is to try to be sure that the diagnosis is correct, as there is evidence that overdiagnosis of asthma is common. Ideally, diagnosis should be confirmed with spirometry or other lung function tests,” he said.
“Then, if there is no special reason to choose a pMDI, a good option could be choosing a less polluting choice, which in asthma is usually a dry powder inhaler. Teaching the patient how to use their new device is important whichever device is chosen.
“Sometimes changing inhalers can offer other advantages, such as eliminating the need to use a spacer and some patients who are appropriate for anti-inflammatory reliever therapy (using budesonide-formoterol as their only inhaler) appreciate the simplicity of only using a single inhaler.”
Dr Montgomery said important work was being done in Australia in this space, primarily via the National Health and Climate Strategy, to improve respiratory health outcomes and reduce greenhouse gas emissions from respiratory inhalers.
NAC’s practice points
Minimise wastage by reducing inappropriate or unnecessary prescribing, dispensing and purchase of inhalers:
- Confirm the diagnosis of asthma to target treatment effectively.
- Choose the best inhaler for the individual and train them to use it correctly.
- Aim for good asthma control to reduce patients’ requirement for salbutamol doses via pMDIs.
- Discourage excessive over-the-counter purchase of inhalers.
Think of the environment when prescribing – consider inhalers that contribute least to global warming, where suitable for the patient. If switching inhalers, train the person in correct inhaler technique.
Advise patients on safe disposal of used and unwanted inhalers.