Medicine sustainability interventions
Outpatient care
Climate-aware prescription of inhalation medication
Inhalation medications are used in the treatment of asthma and COPD. In the Netherlands, more than 1.4 million people use inhalation medications every year, including bronchodilators, such as short- and long-acting β2 sympathomimetics and parasympatholytics, and inhaled corticosteroids (1). There are various types of inhalers available, including dose aerosols, powder inhalers, and soft mist inhalers. These vary greatly in environmental impact because dose aerosols contain propellants, such as HFA-134a, which has a 1500 times stronger greenhouse effect than CO₂ (2).
In some countries, powder inhalers are already prescribed more often. For example, the proportion of dose aerosols is lowest in Sweden (± 10%), highest in England (± 70%) and around 50% in the Netherlands (2, 3). If the Netherlands were to follow the Swedish example, a significant amount of CO₂ emissions could be prevented (2, 3). This is feasible because powder inhalers and soft mist inhalers are an effective alternative for most adult asthma and COPD patients, provided the inhalation technique is used correctly (4). In addition, more and more dose aerosols based on more sustainable propellants will come on the market in the coming years. This can also reduce the greenhouse gas emissions of inhalation medication.
To encourage doctors and pharmacists to prescribe climate-friendly inhalation medication, the Tranmural guideline for climate-aware prescribing of inhalation medication was developed by the Health Institute in collaboration with GPs, pulmonologists, paediatricians, pharmacists and the Lung Fund (4). To make a real impact, the guideline still requires inclusion in local formularies, so that the large-scale, unnecessary use of environmentally harmful inhalation medications can be reduced.
Intervention
Give preference to climate-friendly inhalation medication (powder inhaler, soft mist inhaler or dose aerosol based on a more sustainable propellant) when starting therapy, or switch from a traditional dose aerosol to a climate-friendly inhaler*1.
Environmental impact
Measured in CO2-emissions by reducing the proportion (traditional*)2) dose aerosols back compared to climate-conscious inhalers, such as powder and soft mist inhalers or a dose aerosol based on a more sustainable propellant.
Working method
1. Determine the population and formulate a goal
- Inventory current policies in selected department/for selected patient group (s):
- Check to what extent local protocols and/or formularies already take sustainability into account.
- Use outpatient prescribing data from the EPD to evaluate what proportion of prescriptions a climate-friendly inhaler contains (inhaler toolkit (NL))?
- Formulate SMART goals together with (the green team of) the relevant department (s). For example, within six months, at least 70% of adult asthma patients will start using a climate-aware inhaler.
- The literature shows that Sweden has a low proportion of dose aerosols: this was only 13% in 2017 (2.3). In the Netherlands, this is approximately 50%, with a slightly higher proportion of dose aerosols being prescribed for the first time since 2024 (5). This can serve as a reference for setting achievable goals.
- Starting with a climate-friendly inhaler is preferred as the first step, as it presents fewer risks than changing well-adjusted patients.
- Keep in mind that within certain target groups, such as pediatrics, there is more often an indication for dose aerosols.
- The literature shows that Sweden has a low proportion of dose aerosols: this was only 13% in 2017 (2.3). In the Netherlands, this is approximately 50%, with a slightly higher proportion of dose aerosols being prescribed for the first time since 2024 (5). This can serve as a reference for setting achievable goals.
2. Implementation
This intervention can be performed in several ways depending on the hospital's preference (Table 1). A combination of different methods is also possible.
- During an outpatient consultation
- Presentation of climate-aware prescribing of inhalation medication, possibly in combination with a climate-aware month, in which you regularly remind colleagues in transmission of climate-conscious prescription of inhalation medication.
- Involve lung nurses as they often do the inhalation check and can thus assess which inhaler someone can use.
- If a switch is chosen, important points of attention (see also recommendations in the Climate-Aware Prescribing Guidelines for Inhalation Medication (NL):
- Asthma or COPD is stable
- The patient is well informed and motivated. Explain to patients the choice of a climate-aware inhaler, including the benefits for the environment and health, for example with the patient flyer.
- Good inhalation instruction and guidance by the (hospital and outpatient) pharmacy and lung nurses to ensure adherence and proper use.
2. Formulary
- Discuss the local prescribing policy and the place of more sustainable inhalers in the formulary committee.
- To support:
- Adjust the formulary where necessary so that climate-aware inhalers are preferred.
- Record preferred resources in the EPD, for example via order sets or preference lists, so that prescribers are automatically directed to climate-aware options.
- To support:
- Inform the prescribers and pharmacists of the department concerned and, if necessary, the Medicines Committee about the change, for example by briefly explaining the change during transfers and/or team meetings.
3. Monitoring and Evaluation
- Monitor implementation using (polyclinic) clinical prescriptions, see “How to evaluate a drug intervention” Hand inhaler toolkit. Discuss (interim) results regularly, for example (twice) monthly, during transfers, team meetings and/or teaching.
- Reflect on results in relation to the set goal, obstructing and promoting factors. Adjust interventions if necessary.
- At the end of the follow-up period, evaluate whether the goal (s) is/have been achieved and how the change is secured.
Provide (interim) results back to the implementation supervisor.
How is this measured?
The environmental impact of the intervention can be determined by an increase in the proportion of climate-friendly inhalation medications based on outpatient (starting) regulations, see “How to evaluate a drug intervention” Hand inhaler toolkit.
When successfully implemented?
Based on the reduction in the proportion of prescriptions of (traditional) dose aerosols compared to climate-friendly alternatives, as described in the previous section, determine when the implementation is considered successful, and reflect on the set goal.
Footnotes
*1: Various pharmaceutical companies are working to develop dose aerosols with more sustainable propellants (HFA-152a and HFO-1234ze) (6). Recently, the first new formulations for Trixeo Aerosphere (formoterol/glycopyrronium/budesonide combination therapy) and Riltrava Aerosphere (budesonide/glycopyrronium bromide/formoterol) for the treatment of COPD (7) came on the market; more are expected to follow. The list of more sustainable dose aerosols can be used for an up-to-date overview of dose aerosols based on more sustainable propellants.
Resources
- Foundation for Pharmaceutical Key Figures (SFK). 180,000 people use multiple types of inhalers. Pharmaceutical Weekly. 2021; PW51/52.
- Wichers IM, Pieters LI. Environmental impact of inhalers in the Netherlands and worldwide. Dutch Journal of Medicine. 2022; 166:E6718.
- Veldkamp R. Inhalation medication and environmental impact considerations in general practice. Utrecht: Level; 2022.
- Zorginstituut Nederland, CAHAG, De Groene Lung Doctor, KNMP, Lung Fund, NHG, NVALT, NVK. Trans-mural guideline for climate-aware prescribing of inhalation medication. April 9, 2025. Available at: https://www.zorginstituutnederland.nl/documenten/2025/04/09/transmurale-leidraad-klimaatbewust-voorschrijven-van-inhalatiemedicatie
- SFK. Shift from aerosol to powder inhaler. Pharmaceutisch Weekblad. 2025; 26. Available at: https://www.sfk.nl/publicatie/2025/farmacie-cijfers/verschuiving-van-aerosol-naar-poederinhalator.
- Drug Review Board. Environmental impact medicines. Pharmacotherapeutic Compass. [Internet]. Utrecht: Health Institute Netherlands. Accessed on: Aug 7, 2025. Available from: https://www.farmacotherapeutischkompas.nl/farmacologie/milieu-impact-geneesmiddelen
- European Medicines Agency (EMA). First reformulation of an inhaled medicine with an environmentally friendly gas propellant. Amsterdam: EMA; 2024 Feb 23. Accessed on: Aug 7, 2025. Available from: https://www.ema.europa.eu/en/news/first-reformulation-inhaled-medicine-environmentally-friendly-gas-propellant
Attachments
- Inhaler toolkit for environmental impact assessment — to follow
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