The Scottish Government should ‘hang its head in shame’ for its plans to switch some patients to greener inhalers to address the climate emergency, an asthma charity has said.

NHS Scotland climate emergency and sustainability strategy: 2022-26, which was published last week, plans to reduce emissions from medical inhaler propellants (MDIs) by 70% in the next six years, owing to their environmental impact.

However, Martina Chukwuma-Ezike, chief executive of Asthma and Allergy Foundation, said that ‘the Scottish Government should hang its head in shame for even thinking about this’ over the ‘appalling’ plan, adding the strategy was ‘playing with people’s lives’.

If people end up going to hospital because of inadequate asthma treatment, this will lead to a bigger carbon footprint than if MDIs were prescribed, she argued.

She said: ‘I have asthma and I have an inhaler that works. If they take that away from me, I will be admitted to hospital almost every week. Even the cost of one admission will cost them more in terms of carbon emissions than if I used 20 inhalers in a year.’

Ms Chukwuma-Ezike was also doubtful that patients will only be switched following clinical review, raising concerns they will be pushed into switching.

Responding to the concerns, a Scottish Government spokesperson said: ‘New guidance will improve the way people control their asthma symptoms, meaning they are less reliant on reliever inhalers which contribute to higher carbon emissions.

‘Patients will be supported to switch to more environmentally friendly inhalers based on independent clinical judgement.’

And speaking at Pulse Live earlier in July, an event run by The Pharmacist sister publication Pulse, Professor Omar Usmani, professor of respiratory medicine at the National Heart and Lung Institute, warned healthcare professionals needed to take an individualised approach rather than striving to hit a target around green inhaler prescriptions.

He warned: ‘My fear is we’re going to get blanket switching without patients being seen, which will inevitably lead to worsening of asthma control and COPD control.’

Greener inhaler strategy

The strategy said that about 4.5m MDIs were dispensed in Scotland in 2020/21 for asthma and chronic obstructive pulmonary disease (COPD).

They accounted for more harmful emissions than the combined output from the entire NHS Scotland fleet of vehicles and waste disposal services, said the report.  This is because the propellants used in MDIs are powerful greenhouse gases.

Reducing emissions from MDIs was ‘essential to achieving our net-zero goals’, the strategy said, and was ‘an area where rapid reductions in emissions are achievable’.

The UK has a high proportion of MDI use (70%) compared with the rest of Europe (< 50%) and Scandinavia (10–30%).

This could be changed by switching patients from MDIs to dry powder inhalers (DPIs), which do not use propellant and so have a far lower carbon impact.

The strategy said that DPIs were suitable for many, though not all, patients – and that changes in prescribing practices would be instrumental in reducing emissions.

Changes could include regular reviews of patients who use MDIs and, as part of the review, considering a switch to DPIs. Then, where it is clinically appropriate, patients would be supported to switch to propellant-free options, it said.

The strategy pointed out that the existing British Guideline on the Management of Asthma supports this approach.

It states: ‘Prescribers, pharmacists and patients should be aware that there are significant differences in the global-warming potential of different MDIs and that inhalers with low global-warming potential should be used when they are likely to be equally effective.

‘Where there is no alternative to MDIs, lower volume HFA134a inhalers should be used in preference to large volume or HFA227ea inhalers.’

The Scottish Government said it will publish an updated Scottish Quality Respiratory Prescribing guide to help bring about changes in prescribing practices so that MDIs are only used where they are clinically necessary.

And, as there is a lack of awareness among both clinicians and the general public about how much MDIs contribute to the climate crisis, an awareness raising campaign is planned.

Health Boards in the north of Scotland are developing proposals for a pilot scheme which would capture the residual propellant and ensure its reuse.

In addition, pharmaceutical companies are working to develop low emissions propellant for MDIs.

In launching the new strategy, Scottish health secretary Humza Yousaf said that NHS Scotland is aiming to become a net-zero health service by 2040.

‘This will require unprecedented change in how we work,’ he said.

In February, a UK study showed switching an asthma patient from a metered dose to a dry powder inhaler significantly reduces their carbon footprint without loss of asthma control.