Blanket IIF target switch to powder inhalers could damage patient care, says expert

GPs should avoid wholesale switching of patients onto greener inhalers as incentivised in the investment and impact fund, because it risks damaging patient relationships and disease control, a leading respiratory expert has warned.

Speaking at Pulse Live, Professor Omar Usmani, professor of respiratory medicine at the National Heart and Lung Institute, said healthcare professionals needed to take an individualised approach rather than striving to hit a target.

‘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.’

He added that research he was presenting at the American Thoracic Society conference suggested this approach could be counterproductive.

‘We’ve looked at the evidence of when you do a blanket switch for non-clinical reasons, so economic or environmental, and actually what we found is it’s at a detriment to the doctor-patient relationship.

‘If I’m switching and patient and I’ve done it remotely, and the patient is unhappy, then they’re not going to adhere to that treatment. The concern is that asthma or COPD control will worsen and actually when you’re trying to save the environment, the reverse is happening because of increased presentations, hospital admissions, travelling time and increased resources,’ he said.

Metered dose inhalers account for 3% of the NHS’ overall carbon footprint and shared decision making on lower carbon alternatives is one of the steps being taken towards the goal for a net carbon neutral health service by 2040.

A total of 27 points has been included in the IIF for cutting the proportion of all non-salbutamol inhalers that are metered-dose inhalers (MDIs) in the over 12s with a threshold of between 35-44%.

It states that for most patients, MDIs do not confer any advantage over dry powder alternatives but that any decisions to switch should be clinically appropriate and done as part of shared decision making.

Another 44 points are available for prescribing lower carbon salbutamol MDIs and thereby reducing the PCNs carbon footprint.

A UK study of asthma patients published in February found that switching asthma patients from an MDI to a dry powder inhaler significantly reduced their carbon footprint without loss of asthma control.

The Primary Care Respiratory Society has called on all inhaler suppliers to publish the carbon impact of their devices and commit to a rapid transition to low carbon propellants from 2025 onwards.

Professor Usmani, who spoke at Pulse Live in London in April, added that while we all have a responsibility to address our carbon footprint and protect the environment, the greenest inhaler was the one that the patient is able to use effectively. The elderly and those with severe asthma will struggle with dry power inhalers, he said

‘People believe that devices are interchangeable on their pharmaceutical performance, and they’re not,’ he said. ‘Having patients better controlled with an inhaled corticosteroid following BTS or ERS guidelines will decrease the requirement on the blue inhaler and therefore, decrease the impact on the environment,’ he added.

He also recognised that the requirement as set out in the IIF was daunting for PCNs. ‘It requires investment and it requires resource and time. You can’t do this in 10 minutes.’

‘I have concerns with this blanket switch approach, I really do, and I might be a small voice in a very big pond. I am an environmental advocate, but I’m also a patient advocate.’

Work to reduce the carbon footprint of inhalers is part of a broader NHS policy to improve the use of inhalers overall for better patient outcomes.

An NHS spokesman said: ‘Clinicians are enabling patients to choose greener devices, including dry-powder inhalers, where it is clinically appropriate for them to do so and as part of a shared decision-making conversation with patients.’