How One Commonly Used Asthma Inhaler is Damaging the Planet

[Bayard]

f there is any field of science that understands the doctrine of unintended consequences, it’s medicine. We rely on antibiotics to wipe out infections, and in the process breed a class of superbugs resistant to the drugs. We develop powerful medications that can control chronic pain, and in the U.S., have a nationwide addiction crisis to show for that breakthrough.

Now, it appears, we can add asthma control to the list pharmaceutical blowbacks we didn’t see coming. According to a new study published in BMJ Open, the familiar lightweight, pocket-sized aerosolized inhalers that make breathing easier for so many of the 235 million people worldwide who suffer from asthma may be choking the planet on a powerful greenhouse gas they release in the process.

The study, led by Dr. Alexander JK Wilkinson, a respiratory specialist with Britain’s National Health Service, focused on the 4.67 million people diagnosed with asthma in the United Kingdom, but it has implications for treatment worldwide, including in the U.S., where 22.6 million people (6.1 million of them children) are afflicted with the condition. The researcher compared the greenhouse gas emissions of aerosol pumps—known as metered dose inhalers (MDI)—with dry powder inhalers (DPI), which are shaped something like a hockey puck and are activated simply by inhaling. The two weren’t even close.

https://time.com/5717676/asthma-inhalers-and-climate/?utm_source=linkedin&utm_medium=social&utm_campaign=editorial&utm_term=health_environment&linkId=76570316

It looks like they are only talking about albuterol here. That's an emergency inhaler. I don't see how that could be producing this much methane. While I keep albuterol on hand, my twice a day inhaler is Symbicort, and works the same way, so not quite understanding this.

[vsrazdem]

1. This doesn't make sense as 3 or so years ago, all the inhalers were reformatted to comply with the

new carbon laws. We used to be able to get generic albuterol extremely cheap, with about a 5-10 copay with insurance. After they were reformulized they are now called ProAir and cost 50 to 70 with insurance. So if it doesn't help the environment, why was it reformulized in the first place. It has alway really chapped by butt that the people who can't breath, have to pay for changes to help the ozone.

[muriel_volestrangler]

2. The study is about England. Was this 'reformatting' worldwide?

The thing I've noticed is that the Time article talks about methane as the propellant, but the study talks of "d by two hydrofluoroalkane
(HFA) propellants; 1,1,1,2-tetrafluoroethane (HFA134a) and 1,1,1,2,3,3,3-heptafluoropropane (HFA227ea)", and not methane at all.

[vsrazdem]

3. No, I think it was only here in the US, and yes, all of the inhalers were reformatted, and I have

noticed that they do not work as well now. The propellant is not as strong to push the medication into the airways as the old one was. It probably didn't affect the Brand name inhalers much, but it sure did increase the cost of the generics.

[muriel_volestrangler]

5. The FDA says there was a transition from CFCs in 2008 because of ozone depletion

https://www.fda.gov/drugs/questions-answers/transition-cfc-propelled-albuterol-inhalers-hfa-propelled-albuterol-inhalers-questions-and-answers

but neither they nor Wikipedia talk about a more recent change.

[vsrazdem]

7. It might have been that long ago, but I can't for the life of me figure out why if they got to

charge new prices for the formulation, why the price has not gone down by now.

[muriel_volestrangler]

4. Not just about albuterol, I think

The study: https://bmjopen.bmj.com/content/bmjopen/9/10/e028763.full.pdf

"Two LABA/ICS MDIs (Symbicort MDI and Flutiform) use HFA227ea as a propellant, which has higher GWP of 3320. "

"Some reliever inhalers (eg, Ventolin) have a carbon footprint over 25 kg CO2 e per inhaler, while others use far less 1,1,1,2-tetrafluoroethane (HFA134a) (eg, Salamol) with a carbon footprint of <10 kg CO2 e per inhaler. 1,1,1,2,3,3, 3-Heptafluoropropane (HFA227ea) LABA/ICS inhalers (eg, Flutiform) have a carbon footprint over 36 kg CO2 e, compared with an equivalent HFA134a combination inhaler (eg, Fostair) at <20 kg CO2 e. "

[Blue_true]

6. So what are we supposed to do?

Let a good portion of 235 million people die fast?

This a perfect example of us not paying attention to the fights that we pick. If we go after inhalers to fight climate change, the right is going to roast us with the freebie that we gave them.

[muriel_volestrangler]

8. See Table 3 in the study

Where appropriate, switch from MDI to non-propellant inhaler
Change from large volume reliever (eg, Ventolin Evohaler) to small volume reliever (eg, Salamol)
Change from HFA227ea inhaler (eg, Flutiform or Symbicort MDI) to HFA134a inhaler
Recycle used MDIs
Return used inhalers to pharmacy after use
If there is no dose counter, ensure your patient knows how many doses the inhaler contains

It gives the estimated savings for each action there.

[Blue_true]

9. I have spent all day reading arcane technical papers.

I am not interested in finding a conclusion table that is buried within another arcane paper. Please spell out the goal as part of an OP when posting stuff like this, it really helps.

[muriel_volestrangler]

11. It's not my OP, but I did just spell it out

Those words above are not really complicated. They are the suggested actions from Table 3.

The goal is to cut down the greenhouse gas footprint of treating asthma in England. The effect will vary from country to country; it notes 70% of current English prescriptions use propellants, while only 10% in Scandinavia do. It does not, as far as I can tell, give figures for the USA, but we can see from posts in this thread that sometimes propellants are used, and sometimes it's the ones with higher warming potential.

[Blue_true]

12. Okay. Thanks. nt

[moriah]

14. That might work in the UK, but the "Salamol" isn't available in the US.

And as for the brands of albuterol rescue inhalers that *are* available in the US, at least ProAir HFA (the cheapest) is already using HFA134a. So is Advair HFA (which I take daily with a spacer, mists work better than powder for me).

I admit, because the price of albuterol, I keep my rescue inhaler in my purse and use liquid albuterol in a nebulizer when I'm sick enough to need it at home. It gets it more deeply in my lungs anyway, and some months of the year my doc has me do a nebulizer twice a day, before doing my Advair/Sprivia, to ensure the crud is out and the meds can absorb easier.

The one mist dosage inhaler I have that doesn't rely on a propellant is Spiriva Respimat, and it is just as expensive as Advair. The Respimat design is a way to deliver a mist in a handheld device without using a propellant, and if Advair had a formulation with that tech I'd use it as well, but the more we raise the price of basic rescue inhalers, the more patients will suffer and *not* have one on them at all times.

-----

I know people love the environment.

I also miss being to be able to breathe without paying nearly $50 per inhaler to do so.

[customerserviceguy]

10. This is like

bitching about the plastic straw, and ignoring the plastic cup and the plastic top that are on it.

I just saw an example of this a couple of weeks ago. We were staying at a Marriott Courtyard, and the in-room coffee setup had packets that contained short, thin wooden dowels to stir the coffee with, instead of the red or black plastic ones. The rest of the setup consisted of plastic bags containing the stirrers, that powered "creme" crap that no self-respecting person would put in their coffee, and that pink artificial sweetener that even restaurants have stopped carrying.

Also, the coffee itself was not a prepackaged permeable "pillow" in a plastic-and-foil bag, but it was a pillow inside of a mini-tray made of plastic, surrounded in even more plastic to encompass the pillow and the tray, and it was a single serving! At least the bigger pillows were surrounded by less plastic, and served two to four servings of coffee.

But those little wooden sticks showed Marriott's "green" side!

[Blue_true]

13. Yeah, one of my concerns was that we could endanger the lives of 235 million people

to save a few million when the earth is in full climate fury. We don't know anything about future scientific advances, but it can be surmised that a good part of 235 million people could die if we force certain inhalers off the market.

One person posted that Sweden use a small fraction of propellant in inhalers in that country. A good approach would be to look at what they did before taking action.

[Duppers]

15. "don't see how that could be producing this much methane"

Totally agree.

And I have a problem breathing particulates that's why I always turned down an offer for prescription for the dry powder inhalers. It just didn't make sense to me - why take a particulate into my lungs when that was part of what was bothering me was particulates?