With or without help from government policy: CAPhE is leading the charge of greener asthma treatment

Healthcare emissions outpace those of the airline industry.And those escalating emissions significantly impact patient health—leading some to choose lower-carbon inhalers where clinically appropriate.Pressurized metered-dose inhalers (pMDIs) use potent propellants that have a high greenhouse gas footprint, whereas dry-powered inhalers (DPIs) and newer low-impact propellant devices produce significantly fewer emissions. That’s why members of the Canadian Association of Pharmacy for the Environment (CAPhE) are leading the charge to improve access to greener inhaler options. Read: CAPhE raising awareness around environmental impact of medicationsIn an open letter sent to the Ontario Ministry of Health in November, signed by 120 pharmacists, physicians, nurses and health advocates, CAPhE requested government to remove a rule called LU Code 330, which makes it harder for patients to access a specific “smart” inhaler (budesonide–formoterol) that can safely be used for both daily maintenance and quick relief. Current rules only cover this inhaler for patients who are already on daily steroid therapy and still having symptoms. However, this doesn’t match current Canadian Thoracic Society (CTS) guidelines, which recommend it more broadly, including for people with mild asthma or those who struggle to take a daily inhaler.The letter also urged the ministry to review coverage for other ICS–LABA combination inhalers so pharmacists and prescribers can choose the right option without unnecessary barriers. “We’re trying to modernize the coverage of smart inhalers by removing the restriction,” says Tarek Hussein, director of content at CAPhE. “[This provides] support to pharmacists who are trying to work on switching when it’s appropriate, whether by prescribing or recommending to the prescriber.” (There had been no response from government as of press time.)Hussein says if the ministry does not respond, CAPhE will follow up and gather even more names. The association is also working on a project, in collaboration with the Canadian Pharmacists Association and funded by Choosing Wisely Canada, to develop an Inhaler Assessment Tool aimed at facilitating the appropriate switch from MDI to DPI. “We expect to launch it next March after testing it over the next few weeks in two different provinces,” says Hussein.Read: Exploring efforts to reduce single-use plastics in healthcareFor Dr. Samir Gupta, respirologist and clinician-scientist at the Li Ka Shing Knowledge Institute of St. Michael's Hospital in Toronto, the conversation around sustainable inhalers can’t happen without talking about evidence-based respiratory care more broadly.“There’s a lot of focus on swapping out high greenhouse gas inhalers for lower-carbon ones—and that helps,” he says. “But if we just did the things we’re supposed to do from a care perspective—stop misdiagnosing, get patients on the right puffers, reduce ER visits—we would save just as much on carbon emission as switching everyone to low-carbon devices.”Dr. Gupta leads the Electronic Asthma Management System (eAMS) project and its new pharmacy adaptation now being piloted in five community pharmacies. These tools integrate guideline-based prompts directly into workflow and include a “conversation aid” showing patients the carbon footprint of different inhaler options.“It’s a teachable moment,” he explains. “While we’re advising on therapy, why not also discuss the environmental footprint? Patients care about this. Providers care about this. They just need the tools.”In the meantime, updating Ontario’s policy would allow clinicians, including pharmacists, to fully implement CTS guidelines and streamline therapy using a single inhaler for both maintenance and rescue when clinically appropriate.The environmental stakes in doing so are substantial. The most commonly used pMDI has a carbon footprint roughly equivalent to driving 137 km. For eligible patients, switching to dry-powder inhalers—or to newer, lower-impact propellants—can dramatically reduce emissions without compromising outcomes.“It’s about green consciousness when we’re making clinical decisions,” Hussein says, emphasizing that safety and appropriateness always come first. Survey data emerging from Dr. Gupta’s lab supports this; most patients had no idea inhaler options differed in carbon footprint, but once informed, “the vast majority wanted to change,” he says. Many pharmacists indicated willingness as well—but noted they lacked the resources to do so safely and consistently.Innovation is accelerating, with or without policyDr. Gupta says industry is also recognizing that patients and providers care about the environment and are innovating accordingly. “AstraZeneca has produced the first zero-global warming potential propellant inhaler . . . already launched in the U.K. and under Health Canada review.”Still, he says, government policy will matter—particularly in motivating manufacturers to scale innovation and support proper recycling. His team’s research shows most inhalers are tossed in household recycling bins, where they end up in landfill. Pharmacies, he notes, are the natural home for improved take-back programs, which patients often don’t know exist.Pharmacists definitely want to do more when it comes to promoting sustainable inhalers, says Dr. Gupta. “It improves outcomes, helps the environment, and strengthens their business. It’s empowering for both providers and patients.”

With or without help from government policy: CAPhE is leading the charge of greener asthma treatment

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