[en] BACKGROUND: The main types of commercially available inhalers for the management of asthma include dry powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs). The environmental impact of pMDIs, due to hydrofluorocarbon propellants, is a growing concern. OBJECTIVE: To conduct a carbon-utility analysis in mild asthma, comparing the clinical efficacy of DPIs versus pMDIs alongside their associated environmental impacts. METHODS: We performed a carbon-utility analysis using data from the Novel START trial, comparing 3 treatment strategies for mild asthma: as-needed budesonide/formoterol DPI, as-needed salbutamol pMDI, and maintenance budesonide DPI plus as-needed salbutamol pMDI. We calculated carbon dioxide equivalent (kgCO(2)e) emissions per quality-adjusted life year (QALY) gained. Results were compared to predefined willingness-to-emit thresholds based on health care CO(2)e emissions in the United States, the European Union, and the United Kingdom. RESULTS: As-needed budesonide/formoterol DPI had a yearly carbon footprint of 1.1 kgCO(2)e and a utility of 0.936, compared with 26.2 kgCO(2)e and 0.935 for as-needed salbutamol pMDI, and 17.3 kgCO(2)e and 0.944 for maintenance budesonide DPI plus as-needed salbutamol pMDI. Compared with budesonide/formoterol, budesonide plus salbutamol resulted in 2192 more kgCO(2)e per QALY gained, exceeding the US per capita kgCO(2)e emissions in the health care sector and its 2030 target values. As-needed salbutamol was associated with higher CO(2)e emissions and lower utilities than budesonide/formoterol. CONCLUSION: We applied to the asthma field a novel methodological approach to consider both the environmental impact and effectiveness of interventions. These findings indicate that as-needed budesonide/formoterol DPI is the preferred option when considering both carbon emissions and treatment effectiveness.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Vieira, Rafael José; MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal.
Duarte, Vítor Henrique; MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal.
Bognanni, Antonio; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada, Clinical Epidemiology and Research Center (CERC), IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy.
Gil-Mata, Sara; MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal.
Marques-Cruz, Manuel; MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal.
Pereira, Ana Margarida; MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal.
Chen-Xu, José; NOVA National School of Public Health, Public Health Research Centre, NOVA University Lisbon, Lisbon, Portugal, ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain.
Louis, Renaud ; Université de Liège - ULiège > Département des sciences cliniques > Pneumologie - Allergologie
Williams, Sian; International Primary Care Respiratory Group IPCRG, Edinburgh, United Kingdom.
Nadeau, Kari C; Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, Mass.
Haahtela, Tari; Skin and Allergy Hospital, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland.
Piggott, Thomas; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada, Department of Family Medicine, Queens University, Kingston, ON, Canada.
Fonseca, João A; MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal.
Antó, Josep M; ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain, Universitat Pompeu Fabra (UPF), Barcelona, Spain, CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
Schünemann, Holger J; Clinical Epidemiology and Research Center (CERC), IRCCS Humanitas Research Hospital, Humanitas University, Milan, Italy, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany.
Bousquet, Jean; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology, Berlin, Germany, Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany, ARIA, Montpellier, France.
Sousa-Pinto, Bernardo; MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal. Electronic address: bernardo@med.up.pt.
Shin, Y.H., Hwang, J., Kwon, R., Lee, S.W., Kim, M.S., Shin, J.I., et al. Global, regional, and national burden of allergic disorders and their risk factors in 204 countries and territories, from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Allergy 78 (2023), 2232–2254.
Global Initiative for Asthma. Global strategy for asthma management and prevention. https://www.ginasthma.org. (Accessed 22 October 2024)
Price, D., Bosnic-Anticevich, S., Briggs, A., Chrystyn, H., Rand, C., Scheuch, G., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med 107 (2013), 37–46.
Montoro, J., Antolin-Amerigo, D., Izquierdo-Dominguez, A., Zapata, J.J., Gonzalez, G., Valero, A., Impact of asthma inhalers on global climate: a systematic review of their carbon footprint and clinical outcomes in Spain. J Investig Allergol Clin Immunol 33 (2023), 250–262.
Papi, A., Haughney, J., Virchow, J.C., Roche, N., Palkonen, S., Price, D., Inhaler devices for asthma: a call for action in a neglected field. Eur Respir J 37 (2011), 982–985.
Hillman, T., Mortimer, F., Hopkinson, N.S., Inhaled drugs and global warming: time to shift to dry powder inhalers. BMJ, 346, 2013, f3359.
Starup-Hansen, J., Dunne, H., Sadler, J., Jones, A., Okorie, M., Climate change in healthcare: exploring the potential role of inhaler prescribing. Pharmacol Res Perspect, 8, 2020, e00675.
Piggott, T., Raja, M., Michels, C.T.J., Herrmann, A., Scahill, K.A., Darzi, A.J., et al. Considering planetary health in health guidelines and health technology assessments: a scoping review protocol. Syst Rev, 13, 2024, 163.
Beasley, R., Holliday, M., Reddel, H.K., Braithwaite, I., Ebmeier, S., Hancox, R.J., et al. Controlled trial of budesonide-formoterol as needed for mild asthma. N Engl J Med 380 (2019), 2020–2030.
Hatter, L., Holliday, M., Eathorne, A., Bruce, P., Pavord, I.D., Reddel, H.K., et al. The carbon footprint of as-needed budesonide/formoterol in mild asthma: a post hoc analysis. Eur Respir J, 64, 2024, 2301705.
Vieira, R.J., Sousa-Pinto, B., Bognanni, A., Yepes-Nuñez, J.J., Zhang, Y., Litynska, J., et al. Embedding patients' values and preferences in guideline development for allergic diseases: the case study of Allergic Rhinitis and its Impact on Asthma 2024. Clin Transl Allergy, 14, 2024, e12377.
Sadatsafavi, M., McTaggart-Cowan, H., Chen, W., Mark FitzGerald, J., Economic Burden of Asthma (EBA) Study Group. Quality of life and asthma symptom control: room for improvement in care and measurement. Value Health 18 (2015), 1043–1049.
Briggs, A., Nasser, S., Hammerby, E., Buchs, S., Virchow, J.C., The impact of moderate and severe asthma exacerbations on quality of life: a post hoc analysis of randomised controlled trial data. J Patient Rep Outcomes, 5, 2021, 6.
The United States of America Nationally Determined Contribution—reducing greenhouse gases in the United States: a 2030 emissions target. https://unfccc.int/sites/default/files/NDC/2022-06/United%20States%20NDC%20April%2021%202021%20Final.pdf. (Accessed 2 May 2025)
Update of the NDC of the European Union and its Member States. https://unfccc.int/sites/default/files/NDC/2023-10/ES-2023-10-17%20EU%20submission%20NDC%20update.pdf, 2023. (Accessed 2 May 2025)
United Kingdom of Great Britain and Northern Ireland's nationally determined contribution. https://unfccc.int/sites/default/files/NDC/2022-09/UK%20NDC%20ICTU%202022.pdf, 2022. (Accessed 2 May 2025)
U.S. Environmental Protection Agency. Greenhouse gas inventory data explorer. https://cfpub.epa.gov/ghgdata/inventoryexplorer/#iallsectors/allsectors/allgas/inventsect/all. (Accessed 2 May 2025)
Eurostat. Greenhouse gas emission statistics—emission inventories. https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Greenhouse_gas_emission_statistics_-_emission_inventories. (Accessed 2 May 2025)
National Atmospheric Emissions Inventory. Greenhouse gas emissions data. https://naei.energysecurity.gov.uk/node/87. (Accessed 2 May 2025)
Healthcare Without Arm. Health care's climate footprint. https://global.noharm.org/resources/health-care-climate-footprint-report, 2019. (Accessed 2 May 2025)
U.S. Census Bureau. 2023 National Population Projections Tables: main series. https://www.census.gov/data/tables/2023/demo/popproj/2023-summary-tables.html. (Accessed 2 May 2025)
Eurostat. Projected population of the EU for 2030. https://ec.europa.eu/eurostat/databrowser/view/proj_23np/default/table?lang=en. (Accessed 2 May 2025)
Census. National population projections: 2020-based interim. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2020basedinterim, 2021. (Accessed 2 May 2025)
Bertram, M.Y., Lauer, J.A., De Joncheere, K., Edejer, T., Hutubessy, R., Kieny, M.P., et al. Cost-effectiveness thresholds: pros and cons. Bull World Health Organ 94 (2016), 925–930.
Jiang, R., Janssen, M.F.B., Pickard, A.S., US population norms for the EQ-5D-5L and comparison of norms from face-to-face and online samples. Qual Life Res 30 (2021), 803–816.
Tirumalasetty, J., Miller, S.A., Prescott, H.C., DeTata, S., Arroyo, A.C., Wilkinson, A.J.K., et al. Greenhouse gas emissions and costs of inhaler devices in the US. JAMA 332 (2024), 1017–1019.
The European Parliament and the Council of the European Union. Regulation (EU) no 517/2014 of the European Parliament and of the Council of 16 April 2014 on fluorinated greenhouse gases and repealing regulation (EC) no 842/2006. Official Journal of the European Union, 2014, 195–230 Accessed May 2, 2025 http://data.europa.eu/eli/reg/2014/517/oj.
McAlister, S., Morton, R.L., Barratt, A., Incorporating carbon into health care: adding carbon emissions to health technology assessments. Lancet Planet Health 6 (2022), e993–e999.
Vieira, R.J., Sousa-Pinto, B., Herrmann, A., Antó, J., Williams, S., Bognanni, A., et al. A novel approach to consider planetary health in guideline development: a GRADE approach using the Allergic Rhinitis and its Impact on Asthma (ARIA) 2024-2025 guidelines as a case-study. J Allergy Clin Immunol Pract 13 (2025), 2600–2607.
Alonso-Coello, P., Schünemann, H.J., Moberg, J., Brignardello-Petersen, R., Akl, E.A., Davoli, M., et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ, 353, 2016, i2016.
