Miguel Dibo, a pulmonary specialist at Brigham and Women's Hospital in Boston, sits in an exam room across from Joel Rubinstein, who has asthma. Rubinstein, a former psychiatrist, is about to undergo a medical checkup when he hears some surprising words about not only his health, but also the planet's.
Dibo explains that boot-type inhalers, which account for nearly 90% of the U.S. asthma drug market, not only save lives, they also contribute to climate change. Each puff from an inhaler releases hydrofluorocarbon gas, which is 1,430 to 3,000 times more potent than carbon dioxide, the most commonly known greenhouse gas.
“It never occurred to me,” Rubinstein said. “Especially these are small, small things.”
So Devo is offering some patients with asthma and other lung diseases a more environmentally friendly option: a gray plastic cylinder about the size and shape of a hockey puck filled with powdered medicine. It started. Patients inhale the powder into their lungs. There is no need to blow gas and there are no greenhouse gas emissions.
“We're using the same drug, but there are two different delivery systems,” Deebo says.
According to the most recent data released in 2020, patients in the United States receive about 144 million prescriptions for what doctors call metered-dose inhalers each year. The cumulative amount of gas released is equivalent to driving 500,000 gasoline cars. 1 year. Therefore, the benefits of moving from a gas inhaler to a dry powder inhaler may be even greater.
Hydrofluorocarbon gases contribute to climate change, increasing wildfire smoke and other types of air pollution, and lengthening allergy seasons. These symptoms can make breathing more difficult, especially for people with asthma or chronic obstructive pulmonary disease (COPD), and may increase the use of inhalers.
Devo is one of a small but growing number of American doctors determined to reverse what is considered an unhealthy cycle.
“There's only one Earth, and there's only one human race,” Devo said. “We need to do something because we are creating the problem for ourselves.”
So Devo works with patients like Rubinstein who are willing to switch to dry powder inhalers. Rubinstein initially said no to the idea because powder inhalers would be more expensive. Then his insurance company increased his copay for a metered-dose inhaler, so Rubinstein decided to try dry powder.
“Price is important to me,” says Rubinstein, who has spent years tracking health care and pharmaceutical spending in his professional role. His adjustment was to use more of his own lung power to inhale the medicine. “It's a very strange thing to blow powder into your mouth and into your lungs.”
But Rubinstein's new inhaler is working, and her asthma is under control. A recent study found that some patients in the UK using dry powder inhalers had better asthma control while reducing greenhouse gas emissions. In Sweden, where the majority of patients use dry powder inhalers, the incidence of severe asthma is lower than in the United States.
Rubinstein is one of a small number of U.S. patients who have made the transition. For a variety of reasons, only about a quarter of patients consider switching, Debo said. Dry powder inhalers are often more expensive than gas propellant inhalers. Dry powder may not be a good option for some, as not all asthma and her COPD patients have access to their medications in dry powder. Also, dry powder inhalers are not recommended for infants and elderly patients with reduced lung strength.
Also, some patients using dry powder inhalers worry that they are not getting the right dose without the noise of the spray. Some patients don't like having inhaler powder left in their mouth.
Deebo said the priority is to ensure patients have access to inhalers that they are comfortable using and can afford. However, we plan to continue offering dry powder options if needed.
Asthma and COPD patient advocacy groups are supporting further discussion about the link between inhalers and climate change.
“The climate crisis puts these people at higher risk for worsening and worsening disease,” said Albert Rizzo, chief medical officer of the American Lung Association. “We don't want drugs to be a contributing factor to that.”
Rizzo said efforts are being made to make metered dose inhalers more climate-friendly. The United States and many other countries are phasing out the use of hydrofluorocarbons, which are also used in refrigerators and air conditioners. This is part of a global effort to avoid the worst effects of climate change. But inhaler manufacturers are largely exempt from these requirements, allowing them to continue using the gas while exploring new options.
Some major inhaler makers have pledged to produce canisters with lower greenhouse gas emissions and submit them for regulatory review by next year. It is unclear when these inhalers will be available in pharmacies. Separately, the FDA is spending about $6 million on research into the challenges of developing inhalers with lower carbon footprints.
Rizzo and other lung experts worry that these changes could lead to higher prices. This is what happened in the early to mid-2000s when ozone-depleting chlorofluorocarbons (CFCs) were phased out of inhalers. Manufacturers changed the gas in metered-dose inhalers, nearly doubling the cost to patients. Currently, many of these redesigned inhalers are still expensive.
William Feldman, a pulmonologist and health policy researcher at Brigham and Women's Hospital, said these dramatic price increases come despite manufacturers already having the drug on the market. He said this was happening because the device was registered as a new product. The manufacturer then obtains a patent that blocks the production of competing generic drugs for decades. The Federal Trade Commission says it is cracking down on this practice.
After the CFC ban, “manufacturers made billions of dollars off inhalers,” Feldman said of the redesigned inhalers.
Doctors say that as the price of inhalers increased, patients inhaled less and had more asthma attacks. Greg Furey, medical director of climate and sustainability at Brigham and Women's Hospital, worries the same thing is about to happen again.
“While these new propellants are potentially very positive developments, there is also a significant risk that patients and payers will face significant cost increases,” Furey said.
Some major inhaler makers, including GSK, are already under intense scrutiny in the United States for allegedly price gouging. Sidney Dodson-Nice told NPR and KFF Health News that the company has a strong track record of making medicines available to patients, but the price of a more environmentally friendly inhaler the company is developing is He said it was too early to comment.
Developing affordable, effective and climate-friendly inhalers is important not only for patients but also for hospitals. The Agency for Healthcare Research and Quality recommends that hospitals looking to reduce their carbon footprint reduce emissions from inhalers. Some hospital administrators see switching to inhalers as a low-hanging fruit on a list of climate-change improvements hospitals can make.
But “it's not as simple as changing your inhaler,” said Brian Chesebro, medical director of environmental management at Providence, an Oregon hospital network.
Chesebro said climate impacts vary among metered-dose inhalers. Therefore, pharmacists should suggest inhalers with the lowest greenhouse gas emissions. He said insurers would also need to adjust their reimbursements to prioritize climate-friendly alternatives, and regulators could consider emissions when reviewing hospitals' performance.
Clinicians can make a big difference when it comes to inhaler emissions by starting with the question, “Does the patient in front of me really need an inhaler?” says Samantha Green, a family physician in Toronto. he said.
Mr Green, who is working on a project to make inhalers more environmentally sustainable, said research shows that a third of adults diagnosed with asthma may not have asthma at all. Stated.
“So it's easy to start there,” Green said. “Check to see if patients prescribed inhalers are actually benefiting from them.”
Green said patient education has a measurable effect. In her experience, patients are impressed when she learns that the exhaust gas emitted by about 200 puffs from one inhaler is equivalent to driving about 100 miles in a gasoline-powered car. Some researchers say switching to dry powder inhalers could be as beneficial for the climate as patients adopting a vegetarian diet.
St. Joseph Health Center, one of the hospitals in Green's health network, found that talking to patients about inhalers significantly reduced the use of metered-dose devices. In 6 months, the hospital had 70% of its patients using puffer fish, and 30% of them.
Green said patients who switch to dry powder inhalers generally continue to use their inhalers and appreciate using a device that is less likely to exacerbate the environmental conditions that inflame asthma.
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This article is the result of a partnership that includes WBUR, NPR and KFF Health News.
(KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of KFF's core operating programs, providing independent information on health policy research, polling, and journalism. It is the source.)
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