Environmental Issues PCRS Position Statement

1. As a point of principle, we support initiatives to improve air quality, and minimise short- and long-term damage to the environment, particularly those with an impact on climate change resulting from greenhouse gases. However, we believe that a well-balanced and proportional approach to the contribution of inhalers to the much larger problem of global warming should be taken, bearing in mind that the NHS SDU estimates that only 4% of NHS greenhouse gas emissions are accounted for by inhaler usage, and only 3% of overall greenhouse gas emissions in the UK are accounted for by NHS activity.
2. We also support initiatives which seek to reduce the environmental causes of lung diseases, and also any which reduce or eliminate the factors which exacerbate existing lung disease.
3. The most recent BTS/SIGN guideline (2019) has introduced a statement about the global warming potential (GWP) of fluorinated gas propellants (HFCs) which are contained in pMDIs. We would prefer to see a broader statement about how to reduce the overall GWP contribution of asthma treatments. This would cover a variety of issues: early and accurate diagnosis with better education for HCPs diagnosing and managing respiratory disease, better patient education and adherence with preventer use in asthma, routine spacer use if using pMDIs, minimising propellant per dose where the change is acceptable to patients, recycling schemes for inhaler devices, switching from pMDIs to dry powder inhalers (DPIs) or soft mist inhalers (SMIs) where the change is clinically appropriate, safe and acceptable to patients. A multifaceted approach of this kind is more likely to be effective in reducing propellant use. Alternative low GWP propellants for pMDIs are also under development.
4. Propellant-free inhalers such as DPIs and SMIs do not contain propellants, so therefore have no global warming potential in comparison to pMDIs. PCRS supports measures to reduce potential harm to the environment from inhaler use. We are aware that there are countries where propellant-free inhalers make up a greater proportion of inhaler use than they do in the UK. We therefore support the use of DPIs and SMIs where a DPI or SMI is acceptable to the patient and has the same efficacy and safety profile for an individual patient.
5. Increased utilisation of reusable inhalers or their components presents a further opportunity for decreasing the environmental impact. We support the choice, where appropriate, for devices already on formulary and support further developments in this area.
6. Doing the right thing clinically for individual patients must remain the primary focus of clinicians. In the same way that a clinician may consider the cheaper product if efficacy and safety are equivalent, so clinicians should only take environmental impact into account in selecting an inhaler device with the patient, if all other factors are the same.
7. We do not support policies that advocate ‘blanket switching’ of patients from one inhaler type to another in a practice or an area. This is not patient-centred and there is clear evidence that this is not good practice.    Guidelines recommend that patients use inhalers that they have been trained to use correctly, which are chosen for their suitability to the individual, and that their inhaler technique be checked regularly.     We encourage any decisions about inhaler choice to be made on an individual basis between clinicians and patients.
8. It is very important that the role of pMDIs in respiratory emergencies is recognised and protected.  When patients have deteriorating control of their respiratory condition, they may lack the inspiratory effort required to deliver sufficient quantities of the medicine for adequate drug deposition. For this reason, we cannot support attempts to phase out the use of pMDIs altogether as this would be detrimental to patients needing to use inhalers when their control is poor and in emergencies. 
9. PCRS recognises that consideration of medication and recycling is a small part of the environmental picture in respiratory care. Wider aspects of care to avoid waste include competent clinicians making an early and accurate diagnosis so avoiding travel to unnecessary appointments and treatment with unnecessary medication, optimising inhaler technique, encouraging high value non-pharmacological treatments and supporting self-care.

See full statement for complete document and references