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Review
. 2022 Jul 21;60(1):2102106.
doi: 10.1183/13993003.02106-2021. Print 2022 Jul.

The environmental impact of inhaled therapy: making informed treatment choices

Ashley Woodcock  1   2 , Kai M Beeh  3 , Hironori Sagara  4 , Simon Aumônier  5 , Emmanuel Addo-Yobo  6 , Javaid Khan  7 , Jørgen Vestbo  8   2 , Helen Tope  9
Affiliations
Review

The environmental impact of inhaled therapy: making informed treatment choices

Ashley Woodcock et al. Eur Respir J. .

Abstract

When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual or organisation is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of carbon dioxide equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered-dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives.

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Conflict of interest statement

Conflict of interest: A. Woodcock is co-chair of the Montreal Protocol Technology and Economic Assessment Panel, and member of the Medical and Chemical Technical Options Committee; has received compensation for consulting activities from GlaxoSmithKline, Novartis and Sandoz UK; and has received compensation for speaker activities from Novartis, GlaxoSmithKline and Teva. Conflict of interest: K.M. Beeh and/or the institution he represents has in the past 5 years received compensation for services on advisory boards or consulting activities from AstraZeneca, Berlin-Chemie, Boehringer, Chiesi, Elpen, GlaxoSmithKline, Mundipharma, Novartis, Pohl Boskamp, Sanofi and Teva; compensation for speaker activities in scientific meetings supported by AstraZeneca, Berlin-Chemie, Boehringer, Chiesi, Elpen, ERT, GlaxoSmithKline, Novartis, Pfizer, Pohl Boskamp, Sanofi and Teva; compensation for design and performance of clinical trials from AstraZeneca, Boehringer, GlaxoSmithKline, Novartis, Parexel, Pearl Therapeutics, Teva and Sterna. Conflict of interest: H. Sagara has received compensation for speaker activities supported by AstraZeneca, GlaxoSmithKline, Novartis and Sanofi. Conflict of interest: S. Aumônier is employed by ERM, a global sustainability consulting company that undertakes engagements with a wide range of public sector companies, including many in the healthcare sector and including Novartis. Conflict of interest: E. Addo-Yobo is employed by the Kwame Nkrumah University of Science and Technology, in the Dept of Child Health, School of Medicine and Dentistry, and is Honorary Consultant Paediatrician at the Komfo Anokye Teaching Hospital, Kumasi, Ghana with special interest in paediatric asthma and respiratory care and research; has received compensation as a resource person for asthma educational activities supported by AstraZeneca in Ghana. Conflict of interest: J. Khan and/or the institution he represents has received a research grant from NIHR UK for work on Smokeless Tobacco and Campaign for Tobacco Free Kids for a pilot study on looking at smoking policies at restaurants in Karachi, and is a member of the Medical and Chemical Technical Options Committee. Conflict of interest: J. Vestbo has received honoraria for presenting and/or advising from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Teva. Conflict of interest: H. Tope is employed by Planet Futures, a consulting business providing services to government, industry and other nongovernmental organisations on climate change, ozone-depleting substances and other environmental issues. As an independent expert, she co-chairs the Medical and Chemicals Technical Options Committee, which provides technical and economic advice, including on inhalers, to the Montreal Protocol. The views expressed herein are those of the co-authors and do not represent those of the Medical and Chemicals Technical Options Committee.

Figures

FIGURE 1
FIGURE 1
The stages involved in a cradle-to-grave life cycle assessment [2].
FIGURE 2
FIGURE 2
Carbon footprint (carbon dioxide equivalents (CO2-eq)) per month for a) FF/VI 92/22 μg DPI, SAL/FP 50/500 μg Accuhaler DPI (Diskus) and SAL/FP 25/250 μg pMDI (API included) [26], b) FORM/BDP 6/100 μg as NEXThaler DPI versus pMDI (API included) [27], c) disposable TIO Respimat SMI, IB/FEN Respimat SMI, IB/FEN HFC pMDI and IB HFC pMDI (API included) [28], and d) Breezhaler IND/GLY/MF devices (API included) [31]. SAL: salmeterol xinafoate; FP: fluticasone propionate; FF: fluticasone furoate; VI: vilanterol; DPI: dry powder inhaler; pMDI: pressurised metered-dose inhaler; API: active pharmaceutical ingredient; FORM: formoterol; BDP: beclometasone dipropionate; TIO: tiotropium; SMI: soft mist inhaler; IB: ipratropium bromide; FEN: fenoterol hydrobromide; HFC: hydrofluorocarbon; IND: indacaterol acetate; GLY: glycopyrronium bromide; MF: mometasone furoate.
FIGURE 3
FIGURE 3
The carbon footprint of inhalers referenced in a summary of different factors related to using inhalers and how they compare with each other in the National Institute for Health and Care Excellence (NICE) patient decision aid for inhalers for asthma ([60], p. 8). BAI: breath-actuated metered-dose inhaler; DPI: dry powder inhaler; pMDI: pressurised metered-dose inhaler. © NICE (2020) Patient Decision Aid: Inhalers for Asthma. Available from https://www.nice.org.uk/guidance/ng80/resources/inhalers-for-asthma-patient-decision-aid-pdf-6727144573. All rights reserved. Subject to Notice of Rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
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References

    1. Adedeji O, Reuben O, Olatoye O. Global climate change. J Geosci Environ Protect 2014; 2: 114. doi: 10.4236/gep.2014.22016 - DOI
    1. International Organization for Standardization (ISO) . ISO 14067:2018. Greenhouse gases – Carbon footprint of products – Requirements and guidelines for quantification. 2018. www.iso.org/standard/71206.html Date last accessed: 3 December 2021.
    1. Econometrica . Greenhouse gases, CO2, CO2e, and carbon: what do all these terms mean. 2012. https://ecometrica.com/greenhouse-gases-co2-co2e-and-carbon-what-do-all-... Date last accessed: 3 December 2021.
    1. Metting EI, Van Dijk L, El Messlaki H, et al. Development of a shared decision-making tool to support patients and their healthcare provider in choosing the best inhaler device. Eur Respir J 2018; 52: Suppl. 62, OA1643. doi: 10.1183/13993003.congress-2018.OA1643 - DOI
    1. Liew K, Wilkinson A. How do we choose inhalers? Patient and physician perspectives on environmental, financial and ease-of-use factors. Thorax 2017; 72: Suppl. 3, A235–A237.

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