Vasumathy Sivarajasingam is a GP in West London and an honorary clinical research fellow at Imperial College London. She is on Twitter: @vasu27765631
What has been happening?
Asthma is a common long-term condition affecting people of all ages. General practice plays a key role in providing good asthma care. Around 12% of the UK population have been diagnosed with asthma which takes up 2-3% of primary care consultations and 60,000 hospital admissions in a year. There have been more than 12,700 asthma deaths in England and Wales with an increase of a third in the last decade. Compared to European countries, the UK has one of the highest mortality rates from asthma.
About 70% of the inhalers prescribed in the UK are Short Acting Beta Agonist inhalers (SABA) – providing rapid relief of asthma symptoms without affecting the underlying inflammatory process. SABA inhalers are a key contributor to the total carbon footprint in the UK. Data from the National Review of Asthma Deaths estimates that two-thirds of asthma deaths in the UK are preventable and this is partly related to over-reliance on reliever inhalers and underuse of the preventer inhalers. SABA over-reliance is associated with increased hospitalisation and A+E visits, whilst increased preventer inhaler reduces asthma deaths.
. ..asthma deaths in the UK are preventable and this is partly related to over-reliance on reliever inhalers and underuse of the preventer inhalers
A multitude of inhalers are available on the market. They differ in the way they deliver the medication to patients’ lungs increasing the error rates of using these inhalers. Commonly prescribed inhalers (around 70%) in the UK are Metered Dose Inhalers (MDIs), which use propellants to deliver the medication and contain powerful greenhouse gases that are much more potent than carbon dioxide. Dry powder inhalers (DPIs) do not contain these propellant gases and hence have a much lower carbon footprint. That said, about 13% of the inhalers used in Sweden are MDIs and 90% of relievers are DPIs, yet their asthma death rates are lower compared to the UK.
Furthermore, Asthma UK estimates that around two-thirds of our patients are not receiving the three components of basic asthma care – an annual review, an inhaler technique check, and a Personalized Asthma Action Plan (PAAP). With sub-optimal technique more medicine will be swallowed, potentially resulting in increased systemic side effects, particularly with inhaled corticosteroids and less symptom control. This could result in an increase in dose, increase in side effects, escalation of treatment, possible increased hospital admission due to poor control and exacerbations, and increased cost of treatment.
If the patient uses a SABA inhaler alone, they are at higher risk for asthma-related death and urgent asthma-related healthcare, even if they have good symptom control. Suboptimal asthma care undoubtedly affects the quality of life of our patients living with asthma, with increased visits to the general practice or hospital admission due to poor control and exacerbations. Consequently, poor asthma care has a higher carbon footprint. Furthermore, asthmatic attacks increase the risks associated with the use of high-dose oral steroids, namely an increased risk of osteoporosis, diabetes, and cataract. Poorly controlled asthma can also result in increased prescription costs to the patient as a result of the escalation of treatment. Besides, there is a huge financial cost of asthma on society in the UK – the estimated cost of asthma care in the UK health service is at least £1.1 billion each year.
DPIs are as clinically effective and as cost-effective as MDIs. An annual asthma survey in the UK highlighted that 60% of patients would change their device for environmental reasons as long as the new inhaler was efficacious, easy to use, fitted their current routine and that they could change back if needed.
inicians should make the right diagnosis, and choose the right drug and the right inhaler device ensuring good technique to achieve optimal lung deposition.
So what now, given that suboptimal asthma care in the UK is increasing the morbidity and mortality of patients living with asthma coupled with rising asthma care-related carbon footprint? The focus should be on providing high-quality person-centered asthma care with low-carbon inhalers that are good for the patient and the environment. The ‘greenest’ inhaler is the device that the patient can and will use. Clinicians should make the right diagnosis, and choose the right drug and the right inhaler device ensuring good technique to achieve optimal lung deposition.
First, raise awareness among clinicians of the importance of consultations around asthma control. Patients should understand that asthma is an inflammatory disease of the airway lining which means that they should use a preventer inhaler regularly to reduce inflammation even when they feel well. Using the terminology ‘rescue’ inhaler rather than ‘reliever’ inhaler may reinforce the need for regular preventer inhalers to have better-controlled asthma. Good asthma control is when a patient uses no more than 2 reliever inhalers and on average 6 steroid inhalers per year, depending on the number of puffs.
Second, clinicians involved in asthma care should be familiar with the wide-ranging inhaler devices, know how they work, and be well-trained in inhaler technique. The NICE patient decision aid flow chart and Incheck inhaler device can be used to assist patients choose the inhaler as part of the shared decision-making process. Good inhaler technique is key. If a patient can take a slow, steady breath over 3-5 seconds, then consider a MDI, however, for a patient who can take a quick deep breath within 2-3 seconds then DPI is more appropriate. Where MDIs are needed, choose a brand and regime with care. Having an updated practice formulary with recommendations for low-carbon inhalers is helpful for clinicians during daily busy clinics.
Third, encourage patients to have an annual asthma check. This is a great opportunity to explore patients’ knowledge of asthma, what it means to have well-controlled asthma, and how their treatment works. Take this opportunity to assess the patient’s inhaler technique. This can be reinforced by signposting patients to resources such as the RightBreathe app and website, or the Asthma UK website. The asthma toolkit section on the GreenerPractice website also has useful information for clinicians and patients about how to care for asthma. Moreover, the PAAP can be updated and patients can be encouraged to return their used or unwanted inhalers to their local pharmacies for environmentally safe disposal.
Featured image: ‘Door carving’ taken by Andrew Papanikitas, 2021