The environmental impact of inhaled therapy: making informed treatment choices

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 CO2 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 will examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives.

Inhaled therapy for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is characterised by progressive symptoms of productive cough, breathlessness, wheeze and exacerbations. Airway obstruction is detected by quality assured spirometry, and is defined as a Forced Expired Volume in one second / Forced Vital Capacity ratio <0.7. Inhaled therapy is the most effective treatment solution, with bronchodilators and inhaled steroids helping to improve symptoms, quality of life and lung function, while reducing risk of exacerbations. Bronchodilators are available as both monotherapy and as dual combination therapy. Inhaled steroids can be added to inhaled long-acting bronchodilators, but are not without significant complications, including pneumonia. Therefore, careful assessment of the phenotype of a patient with chronic obstructive pulmonary disease must be given before commencing any therapy that contains inhaled steroid and other treatments, such as flu vaccination, smoking cessation and pulmonary rehabilitation should be given due consideration.

Budesonide-Glycopyrronium-Formoterol Fumarate Dihydrate (Breztri Aerosphere)

CADTH recommends that Breztri Aerosphere be reimbursed by public drug plans for the treatment of chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema if certain conditions are met. Breztri Aerosphere should only be covered to treat patients who are not controlled on optimal dual inhaled therapy for COPD. Breztri Aerosphere should be reimbursed similar to Trelegy Ellipta. The price of Breztri Aerosphere should not exceed the drug program cost with the least-costly fixed-dose inhaled corticosteroid/long-acting muscarinic antagonist/long-acting beta2-agonist (ICS/LAMA/LABA) triple therapy combination for the same indication.