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Saxena D, Murugesan N, Evbayiro UD, Ngassa MK, Adrish M. Inhalational Drug Devices: Revisiting the Linchpin of Asthma Management. J Pers Med 2024; 14:867. [PMID: 39202058 PMCID: PMC11355058 DOI: 10.3390/jpm14080867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/10/2024] [Accepted: 08/14/2024] [Indexed: 09/03/2024] Open
Abstract
Asthma remains a prevalent condition among all age groups globally. First-line treatment requires the delivery of medications into the distal respiratory tract via inhalers. Using appropriate inhaler techniques is a significant challenge in achieving disease control. A variety of inhalers are available for treating asthma, and selecting the appropriate inhaler type for any given patient is crucial to achieving and maintaining symptomatic control. This review will discuss the anatomy and physiology behind drug delivery via inhalers, the types of inhalers currently available for use, nebulizers, and future directions in the delivery of inhaled medications for asthma.
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Affiliation(s)
- Damini Saxena
- Baylor College of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, 1 Baylor Plz, Houston, TX 77030, USA; (N.M.); (M.A.)
| | - Neveda Murugesan
- Baylor College of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, 1 Baylor Plz, Houston, TX 77030, USA; (N.M.); (M.A.)
| | - Uyioghosa D. Evbayiro
- Baylor College of Medicine, Section of General Internal Medicine, 1 Baylor Plz, Houston, TX 77030, USA; (U.D.E.); (M.K.N.)
| | - Marina K. Ngassa
- Baylor College of Medicine, Section of General Internal Medicine, 1 Baylor Plz, Houston, TX 77030, USA; (U.D.E.); (M.K.N.)
| | - Muhammad Adrish
- Baylor College of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, 1 Baylor Plz, Houston, TX 77030, USA; (N.M.); (M.A.)
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2
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Lough G, Bosnic-Anticevich S, Roche N, Usmani OS. Patient and Provider Perspectives Driving Inhaler Choice: Optimizing Sustainable Health Care. Chest 2024:S0012-3692(24)04577-X. [PMID: 38964671 DOI: 10.1016/j.chest.2024.06.3774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/22/2024] [Accepted: 06/10/2024] [Indexed: 07/06/2024] Open
Affiliation(s)
- Graham Lough
- Respiratory Effectiveness Group, Cambridgeshire, England.
| | | | - Nicolas Roche
- Pneumologie, Hôpital Cochin, AP-HP.Centre, Université de Paris, Institut Cochin, Paris, France
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3
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Wilkinson A, Woodcock A. High-quality and low-carbon asthma care go hand in hand. Eur Respir J 2024; 64:2400638. [PMID: 38991725 DOI: 10.1183/13993003.00638-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Alexander Wilkinson
- East and North Hertfordshire NHS Trust, Respiratory Department, Lister Hospital, Stevenage, UK
| | - Ashley Woodcock
- The University of Manchester, Division of Infection, Immunity and Respiratory Medicine, Manchester, UK
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Kainu A, Vartiainen VA, Mazur W, Hisinger-Mölkänen H, Lavorini F, Janson C, Andersson M. Successful Use of Easyhaler ® Dry Powder Inhaler in Patients with Chronic Obstructive Pulmonary Disease; Analysis of Peak Inspiratory Flow from Three Clinical Trials. Pulm Ther 2024; 10:133-142. [PMID: 38170393 PMCID: PMC10881915 DOI: 10.1007/s41030-023-00246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION There is increasing pressure to use environmentally friendly dry powder inhalers (DPI) instead of pressurized metered-dose inhalers (pMDI). However, correct inhalation technique is needed for effective inhaler therapy, and there is persistent concern whether patients with chronic obstructive pulmonary disease (COPD) can generate sufficient inspiratory effort to use DPIs successfully. The aims of this study were to find clinical predictors for peak inspiratory flow rate (PIF) and to assess whether patients with COPD had difficulties in generating sufficient PIF with a high resistance DPI. METHODS Pooled data of 246 patients with COPD from previous clinical trials was analyzed to find possible predictors of PIF via the DPI Easyhaler (PIFEH) and to assess the proportion of patients able to achieve an inhalation flow rate of 30 l/min, which is needed to use the Easyhaler successfully. RESULTS The mean PIF was 56.9 l/min and 99% (243/246) of the study patients achieved a PIF ≥ 30 l/min. A low PIF was associated with female gender and lower forced expiratory volume in 1 s (FEV1), but the association was weak and a statistical model including both only accounted for 18% of the variation seen in PIFEH. CONCLUSIONS Based on our results, impaired expiratory lung function or patient characteristics do not predict patients' ability to use DPIs in COPD; 99% of the patients generated sufficient PIFEH for successful dose delivery. Considering the targets for sustainability in health care, this should be addressed as DPIs are a potential option for most patients when choosing the right inhaler for the patient. TRIAL REGISTRATION Two of three included trials were registered under numbers NCT04147572 and NCT01424137. Third trial preceded registration platforms and therefore, was not registered.
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Affiliation(s)
- Annette Kainu
- Medzilla Oy, Helsinki, Finland
- Metropolia Proof Health, Metropolia University for Applied Sciences, Helsinki, Finland
| | - Ville A Vartiainen
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Pulmonary Medicine, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Witold Mazur
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Martin Andersson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Buttini F, Glieca S, Sonvico F, Lewis DA. Metered dose inhalers in the transition to low GWP propellants: what we know and what is missing to make it happen. Expert Opin Drug Deliv 2023; 20:1131-1143. [PMID: 37767756 DOI: 10.1080/17425247.2023.2264184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION The urgency to replace the propellants currently in use with the new sustainable ones has given rise to the need for investigation and reformulation of pMDIs. AREAS COVERED The reformulation requires in-depth knowledge of the physico-chemical characteristics of the new propellants, which impact the atomization capacity and the plume geometry. Among the investigated propellants, HFA 152a, due to its lower vapor pressure and higher surface tension compared to HFA 134a, deliver larger particles and has a higher solvent capacity toward lipophilic drugs. On the other hand, HFO 1234ze has properties more similar to HFA 134a, but showed lower reproducibility of the generated spray, indicating a possible high susceptibility to variation in the consistency of the dose delivered. In addition, the device components currently in use are compatible with the new propellants. This allowed promising preliminary results in the re-formulation of pMDIs by academia and pharma companies. However, there is little information about the clinical studies required to allow the marketing of these new products. EXPERT OPINION Overall, studies conducted so far show that the transition is technically possible, and the main obstacle will be represented by the investment required to put the product on the market.
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Affiliation(s)
- Francesca Buttini
- Food and Drug Department, University of Parma, Parma, Italy
- Interdepartmental Center for Innovation in Health Products, Biopharmanet_TEC, University of Parma, Parma, Italy
| | | | - Fabio Sonvico
- Food and Drug Department, University of Parma, Parma, Italy
- Interdepartmental Center for Innovation in Health Products, Biopharmanet_TEC, University of Parma, Parma, Italy
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6
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Usmani OS, Levy ML. Effective respiratory management of asthma and COPD and the environmental impacts of inhalers. NPJ Prim Care Respir Med 2023; 33:24. [PMID: 37393273 DOI: 10.1038/s41533-023-00346-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/14/2023] [Indexed: 07/03/2023] Open
Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital and St Mary's Hospital, London, UK.
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7
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Urrutia-Pereira M, Chong-Neto HJ, Winders TA, Solé D. Environmental impact of inhaler devices on respiratory care: a narrative review. J Bras Pneumol 2023; 48:e20220270. [PMID: 36651436 PMCID: PMC9747156 DOI: 10.36416/1806-3756/e20220270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Climate change is a huge and present threat to human health. This article aims to deepen the knowledge about the environmental impact of inhaler devices on their carbon footprint for patients and health professionals, providing information that allows a better choice of the type of device to be prescribed for the treatment of asthma and COPD. This narrative and nonsystematic review was carried out by searching databases (PubMed, Google Scholar, SciELO, and EMBASE) for articles published between 2017 and 2022, written in Portuguese or in English, using the search words "inhalation device" OR "environmental." The review showed that global warming cannot be addressed by focusing only on inhaler devices. However, the devices that we use to treat respiratory diseases such as asthma and COPD, which are diseases that are aggravated by climate change, are also causing that change. Therefore, health professionals, patient organizations, and industries should take a lead in health policies to offer affordable alternatives to inhalers containing hydrofluoroalkane.
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Affiliation(s)
| | | | - Tonya A Winders
- . Global Allergy and Airways Patient Platform, Vienna, Austria
| | - Dirceu Solé
- . Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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8
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Chakma M, Usmani O. Inhalers and the Environment: Pollution, Plastics and Policy. PNEUMON 2022. [DOI: 10.18332/pne/154608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Hatter L, Bruce P, Beasley R. A breath of fresh AIR: reducing the carbon footprint of asthma. J Med Econ 2022; 25:700-702. [PMID: 35574735 DOI: 10.1080/13696998.2022.2078573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
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10
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Pernigotti D, Stonham C, Panigone S, Sandri F, Ferri R, Unal Y, Roche N. Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries. BMJ Open Respir Res 2021; 8:e001071. [PMID: 34872967 PMCID: PMC8650484 DOI: 10.1136/bmjresp-2021-001071] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/17/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Inhaled therapies are key components of asthma and chronic obstructive pulmonary disease (COPD) treatments. Although the use of pressurised metered-dose inhalers (pMDIs) accounts for <0.1% of global greenhouse gas emissions, their contribution to global warming has been debated and efforts are underway to reduce the carbon footprint of pMDIs. Our aim was to establish the extent to which different scenarios led to reductions in greenhouse gas emissions associated with inhaler use, and their clinical implications. METHODS We conducted a series of scenario analyses using asthma and COPD inhaler usage data from 2019 to model carbon dioxide equivalent (CO2e) emissions reductions over a 10-year period (2020-2030) in the UK, Italy, France, Germany and Spain: switching propellant-driven pMDIs for propellant-free dry-powder inhalers (DPIs)/soft mist inhalers (SMIs); transitioning to low global warming potential (GWP) propellant (hydrofluoroalkane (HFA)-152a) pMDIs; reducing short-acting β2-agonist (SABA) use; and inhaler recycling. RESULTS Transition to low-GWP pMDIs and forced switching to DPI/SMIs (excluding SABA inhalers) would reduce annual CO2e emissions by 68%-84% and 64%-71%, respectively, but with different clinical implications. Emission reductions would be greatest (82%-89%) with transition of both maintenance and SABA inhalers to low-GWP propellant. Only minimising SABA inhaler use would reduce CO2e emissions by 17%-48%. Although significant greenhouse gas emission reductions would be achieved with high rates of end-of-life recycling (81%-87% of the inhalers), transition to a low-GWP propellant would still result in greater reductions. CONCLUSIONS While the absolute contribution of pMDIs to global warming is very small, substantial reductions in the carbon footprint of pMDIs can be achieved with transition to low-GWP propellant (HFA-152a) inhalers. This approach outperforms the substitution of pMDIs with DPI/SMIs while preserving patient access and choice, which are essential for optimising treatment and outcomes. These findings require confirmation in independent studies.
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Affiliation(s)
| | - Carol Stonham
- NHS Gloucestershire Clinical Commissioning Group, Brockworth, UK
| | - Sara Panigone
- Global Marketing, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Rossella Ferri
- Corporate Health Safety and Environment, Chiesi Farmaceutici SpA, Parma, Italy
| | - Yasemin Unal
- Global Medical Affairs, Chiesi Farmaceutici SpA, Parma, Italy
| | - Nicolas Roche
- Pneumologie, APHP Centre, Université de Paris, Paris, Île-de-France, France
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11
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Attar-Zadeh D, Lewis H, Orlovic M. Health-care Resource Requirements and Potential Financial Consequences of an Environmentally Driven Switch in Respiratory Inhaler Use in England. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:46-54. [PMID: 34616856 PMCID: PMC8460426 DOI: 10.36469/001c.26113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
Background: To reduce greenhouse gas emissions, national initiatives advocate the phasing down of respiratory inhalers that use a fluorinated gas as a propellant (pressurised metered-dose inhalers [pMDI]). Nevertheless, pMDIs continue to be an effective and common choice. Objective: To assess the potential financial impact of patients with asthma or chronic obstructive pulmonary disease (COPD) switching from pMDIs to dry powder inhalers (DPIs) in a representative primary care network (PCN) population of 50 000 and the English National Health Service (NHS). Methods: Epidemiological data were combined with current inhaler use patterns to estimate the resources and costs associated with this transition, varying patient acceptance scenarios. Results: Depending on the approach, resource requirements ranged from £18 000 - £53 000 for a PCN, and from £21 - £60 million for the English NHS. Discussion: Significant funds are needed to successfully manage targeted inhaler transitions, together with counselling and follow-up appointment with an appropriately skilled clinician to assess the patient's inhaler technique and ensure disease control. Conclusions: Targeted transition of inhalers must achieve a balance between environmental impacts, organisational factors, and patient requirements. The resources for managing a switch can be substantial but are necessary to appropriately counsel and support patients, whilst protecting the environment.
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12
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Usmani OS, Hickey AJ, Guranlioglu D, Rawson K, Stjepanovic N, Siddiqui S, Dhand R. The Impact of Inhaler Device Regimen in Patients with Asthma or COPD. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3033-3040.e1. [PMID: 33901714 DOI: 10.1016/j.jaip.2021.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
Many inhaler devices with varying handling requirements for optimal use are available for the treatment of asthma and chronic obstructive pulmonary disease (COPD). Patients may be prescribed different device types for reliever and maintenance medications, which may lead to confusion and suboptimal device use. We aimed to understand whether simplifying inhaler regimens by employing a single device type in patients who use multiple devices or prescribing a device with which a patient was already experienced could improve clinical and economic outcomes in asthma and COPD management. A targeted literature search was performed and additional articles were identified through hand searching citations within screened publications. A total of 114 articles were included in the final review. Findings suggest that simplifying inhaler regimens by applying the same type of inhaler for concomitant inhaled medications over time minimizes device misuse, leading to improved clinical outcomes and reduced health care use in patients with asthma or COPD. Physicians should consider a patient's suitability for a device and training needs when prescribing an inhaled medication and before changing the medication type or dose, especially when suboptimal treatment outcomes are observed. Further research is required to determine whether consistent use of the same device type is associated with better treatment adherence and persistence in patients with asthma or COPD. Nevertheless, this literature review identified clinical benefits and reduced health care use with simplified inhaler regimens.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, United Kingdom.
| | - Anthony J Hickey
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | - Rajiv Dhand
- Graduate School of Medicine, University of Tennessee, Knoxville, TN
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13
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Pritchard JN. The Climate is Changing for Metered-Dose Inhalers and Action is Needed. Drug Des Devel Ther 2020; 14:3043-3055. [PMID: 32801643 PMCID: PMC7410333 DOI: 10.2147/dddt.s262141] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/08/2020] [Indexed: 01/17/2023] Open
Abstract
Increases in global temperature are already having a significant impact on our climate. The hydrofluorocarbon (HFC) propellants used today in pressurized metered-dose inhalers (pMDIs) have global warming potential (GWP) many times that of carbon dioxide. Their use, together with all other emissive uses of HFCs, is being phased down under the Montreal protocol. This has prompted calls to switch patients to dry powder inhalers (DPIs). This paper presents a new analysis of the top 15 respiratory drug markets by drug class. It shows that a switch to DPIs would be economically feasible for most countries and most drugs. However, a wholesale switch of reliever medications, notably short-acting β-agonists, would lead to significant increases in the cost of these life-saving medications. Reviewing the evidence, whilst most patients are capable of using DPIs, the very young, very old and those undergoing an acute exacerbation still require a pMDI. Thus, there is a clinical and economic need to have both pMDIs and DPIs available. At the same time, it is projected that the reduction in non-medical uses of propellants is likely to give rise to a 5-fold increase in their cost for pMDI uses and is likely to hit the Western world in 2025. This may lead to a price increase in reliever medication that will make it unaffordable for the poorer communities in some markets. At the same time, opportunities to save money by developing new formulations using propellants with lower GWP, such as HFC 152a or HFO 1234ze(E), are described. Two companies have made this commitment, but neither currently have a strong presence in reliever medication. For them, or other companies, now is the time to act; 2025 is not far away in terms of product development timescales and the climate cannot wait.
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Wilkinson A, Hillman T, Hopkinson NS, Janson C, Smith J, Woodcock AA. Our patients and our planet-holistic considerations for inhaler choice. THE LANCET RESPIRATORY MEDICINE 2020; 7:e11. [PMID: 30823976 DOI: 10.1016/s2213-2600(19)30035-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Toby Hillman
- Consultant Respiratory Physician, University College London Hospitals NHS Foundation Trust, London, UK; Clinical Lead, Sustainability Programme, Royal College of Physicians, London, UK
| | | | - Christer Janson
- Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - James Smith
- University of Cambridge Department of Public Health and Primary Care, Cambridge, UK
| | - Ashley A Woodcock
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Sciences Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
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Panigone S, Sandri F, Ferri R, Volpato A, Nudo E, Nicolini G. Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment. BMJ Open Respir Res 2020; 7:e000571. [PMID: 32238349 PMCID: PMC7173981 DOI: 10.1136/bmjresp-2020-000571] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 01/19/2023] Open
Abstract
Patients with asthma and Chronic Obstructive Respiratory Disease (COPD) rely on three main device classes for inhalation therapy: metered-dose inhalers (MDIs), dry powder inhalers (DPIs) and soft-mist inhalers (SMIs). The carbon footprint (CF) of these inhalers differs with MDIs having a higher impact than DPIs and SMIs due to the propellant in MDIs. However, the certified CF of specific MDI products may differ significantly. MDIs still represent an essential option for many patients. Consequently, novel approaches shall be considered to balance environmental goals with patient health and well-being while maintaining a diverse range of choices for patients and physicians.
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Affiliation(s)
- Sara Panigone
- Corporate Marketing, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Rossella Ferri
- Corporate Health Safety & Environment, Chiesi Farmaceutici SpA, Parma, Italy
| | - Andrea Volpato
- Corporate Health Safety & Environment, Chiesi Farmaceutici SpA, Parma, Italy
| | - Elena Nudo
- Global Medical Affairs, Chiesi Farmaceutici SpA, Parma, Italy
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Keeley D, Scullion JE, Usmani OS. Minimising the environmental impact of inhaled therapies: problems with policy on low carbon inhalers. Eur Respir J 2020; 55:55/2/2000048. [PMID: 32108081 DOI: 10.1183/13993003.00048-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 01/27/2023]
Affiliation(s)
| | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
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