Abstract
To the Editor:
Inhaled medications are essential in managing asthma and chronic obstructive pulmonary disease (COPD). Delivery systems include dry powder inhalers (DPIs), pressurized metered-dose inhalers (pMDIs), soft mist inhalers, and nebulizers. Historically, pMDIs used chlorofluorocarbon (CFC) propellants, contributing to ozone depletion. While pharmaceutical companies have transitioned to CFC-free pMDIs, there are now international efforts to phase down propellants with high global warming potential (GWP), with some governments and societies recommending switching from pMDIs due to their GWP. 1
Our Position
The Respiratory Effectiveness Group (REG) is a not-for-profit initiative established by international experts in real-life research in respiratory medicine. While we support environmental responsibility, inhaler choice should be personalized, balancing patient needs and environmental concerns. We strongly oppose switching an inhaler for nonmedical reasons without considering possible clinical consequences of a mismatch between the inhaler’s characteristics and the patient’s abilities and preferences.
A global study by REG, 2 surveyed 468 health care professionals (HCPs) and 270 asthma/COPD patients across 39 countries to understand how medical, technical, and environmental factors are prioritized when selecting an inhaler device. Our findings revealed that both HCPs and patients prioritize clinical considerations when prescribing or choosing an inhaler. Environmental concerns ranked low, despite awareness of the inhaler’s impact on climate change, underscoring the importance of tailoring inhaler selection to patient needs and promoting informed treatment decisions while transitioning towards newer, eco-friendly inhaler options as a progressive step towards more sustainable health care.
Personalized health care
Patients and HCPs should have the autonomy to jointly choose inhalers that best suit the medical needs, abilities, and preferences of patients. Personalized health care promotes better patient understanding and satisfaction, adherence, and overall outcomes. 3 Patients should be trained to use their inhaler correctly to avoid poorer disease control and over-reliance on reliever medication. 4 Patients can also be offered new inhaler technologies with smart features such as dose counters, medication reminders, and educational applications, which may improve adherence, technique, and health outcomes. 5 Abrupt, unaccompanied switching of inhaler type can lead to poor health outcomes requiring hospitalizations, which have a marked environmental impact. 4
Recycling
We advocate for responsible inhaler disposal and recycling to reduce environmental impact. Most HCPs and patients in our previous study lacked access to recycling programs. 2 Collaborative efforts between pharmaceutical companies and health care systems are needed to establish recycling initiatives.
Greener inhalers
We support the development and adoption of inhalers with lower GWP. Transitioning to greener inhalers should not mandate a switch in the type of inhaler a patient currently uses. Responsible choices support both patients and the planet. We must evaluate the environmental impact of any treatment, considering the overall impact. Industry advancements are expected to produce new pMDIs with lower emissions by 2025, making their environmental lifecycle impact comparable to that of current DPIs.
REG advocates for a balanced approach that considers patient-centered care, patient education, recycling, and adoption of greener inhalers. We oppose arbitrary switching of inhaler types for nonclinical reasons and advocate for prescribing the right inhaler for the right patient while considering environmental responsibility.
Footnotes
Acknowledgments
The authors would like to thank Dr. Graham Lough for his work on the first draft of the article, and the extended network of the Respiratory Effectiveness Group.
Authors’ Contributions
All authors reviewed and approved the article.
Author Disclosure Statement
O.S.U. received grants from AstraZeneca, Boehringer Ingelheim, Chiesi, Kindeva Drug Delivery and GlaxoSmithKline; Consulting fees from AstraZeneca, Cipla and Mereo Biopharma; Personal fees from Astra Zeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Mundipharma, Sandoz, Takeda, Cipla, Covis, Novartis, Orion, Menarini, UCB, Trudell Medical, Deva and Kamada. M.A.A. received personal fees from Sanofi, GlaxoSmithKline and Novartis; Meeting attendance fees from Sanofi, GlaxoSmithKline and AstraZeneca; Participation on advisory board with Sanofi, GlaxoSmithKline and AstraZeneca. ERS Assembly 5 head, President of International Society of Aerosols in Medicine, Chair of UK Inhaler Group. K.A. declares no conflict of interest. A.A. received consulting fees from GlaxoSmithKline, AstraZeneca, Sanofi/Regeneron and Viatrix; Speaker fees from GlaxoSmithKline, AstraZeneca and Viatrix. F.B. received grants from MSD; Consulting fees from Sanofi, AstraZeneca, Menarini International and GlaxoSmithKline; Speaker fees from AstraZeneca, GlaxoSmithKline, Chiesi, Menarini Group and Sanofi. G.W.C. received speaker fees from Menarini, AstraZeneca, CellTrion, Chiesi, Faes Farma, Firma, Genentech, Guidotti-Malesci, GlaxoSmithKline, HAL Allergy, Innovacaremd, Novartis, OM-Pharma, Red Maple, Sanofi-Aventis, Sanofi-Genzyme, Stallergenes-Greer and Uriach Pharma; Meeting attendance fees from Menarini, AstraZeneca, CellTrion, Chiesi, Faes Farma, Firma, Genentech, Guidotti-Malesci, GlaxoSmithKline, HAL Allergy, Innovacaremd, Novartis, OM-Pharma, Red Maple, Sanofi-Aventis, Sanofi-Genzyme, Stallergenes-Greer and Uriach Pharma. T. Lambert declares no conflicts of interest; T. Lapperre received grants from Chiesi and Genentech; Consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Sanofi and ALK; Meeting attendance fees from Sanofi and AstraZeneca; Participation on advisory board for Chiesi, Sanofi, AstraZeneca and GlaxoSmithKline. A.K. received consulting fees from ALK, AstraZeneca, Boehringer Ingelheim, Covis, Eisai, GlaxoSmithKline, Idorsia, Merck, Moderna, Pfizer, Sanofi, Trudel and Valeo; Speaker fees from ALK, AstraZeneca, Boehringer Ingelheim, Covis, Eisai, GlaxoSmithKline, Idorsia, Merck, Moderna, Pfizer, Sanofi, Trudel and Valeo; Boards/Societies of Family Physician Airways Group of Canada and Asthma Canada. M.M. received grants from Grifols; Consulting fees from AstraZeneca, Atriva Therapeutics, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, CSL Behring, Inhibrx, Ferrer, Menarini, Mereo Biopharma, Spin Therapeutics, Specialty Therapeutics, BridgeBio, Palobiofarma SL, Takeda, Novartis, Novo Nordisk, Sanofi/Regeneron, Zambon and Grifols; Speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Menarini, Kamada, Takeda, Zambon, CSL Behring, Specialty Therapeutics, Janssen, Grifols and Novartis; Meeting attendance fees from Novartis, Boehringer Ingelheim, Menarini and GlaxoSmithKline; Participation on data safety monitoring board for Moreo; NGP received grants from Capricare, Nestle, Numil and Vianex; Consulting fees from Abbott, Abbvie, Astra Zeneca, GlaxoSmithKline, HAL, Medscape, Menarini/Faes Farma, Mylan, Novartis, Nutricia, OM Pharma and Regeneron/Sanofi. C.K.R. received consulting fees from Sanofi and AstraZeneca; Speaker fees from AstraZeneca, GlaxoSmithKline, Novartis, Mundipharma, Boehringer Ingelheim, Organon, Teva, and Sanofi. N.R. received grants from Boehringer Ingelheim, Novartis, GlaxoSmithKline and Pfizer; Consulting fees from Boehringer Ingelheim, GlaxoSmithKline, AstraZeneca, Sanofi, Chiesi, Pfizer, Novartis, Teva, Bayer, Austral and Biosency; Speaker fees from Boehringer Ingelheim, GlaxoSmithKline, AstraZeneca, Sanofi, Chiesi, Pfizer, Novartis, Teva, Zambon, MSD and Menarini; Meeting attendance fees from Chiesi, AstraZeneca and GlaxoSmithKline; ERS Council Chair. J.B.S. received grants from Chiesi, GSK, Linde and Novartis; Speaking fees/advisory board from Air Liquide, Almirall, AstraZeneca, Boehringer Ingelheim, CHEST, Chiesi, CNPT, ERS, FTH, Gebro, Grifols, GlaxoSmithKline, IHME, Laminar Pharma, Linde, Lipopharma, Menarini, Mundipharma, Novartis, OMS/WHO, Pfizer, ResApp, RiRL, ROVI, SEPAR, Seqirus, WHO EUR, Takeda and Zambon.
Funding Information
This position statement was part of a research grant from AstraZeneca, Boehringer Ingelheim, Chiesi and Kindeva Drug Delivery.