The transition to CFC-free inhalers

In an article exclusive to Family Medicine's website, Dr Vincent McGovern highlights why, in his opinion, healthcare professionals should be making the transition to CFC-free inhalers an urgent priority

[Click here for some case studies [case studies]]

Asthma poses a heavy burden on the NHS, although 90 per cent of the costs fall on GPs. Nevertheless, over 113,000 people are admitted to hospital for asthma each year, costing the NHS over £720 million¹. This excludes the costs of lost productivity and disability, which it is now estimated would bring the total cost to more than one billion pounds annually.

In the largest ever mass change in primary care medication, up to three million asthma patients are due to switch to CFC-free metered dose inhalers (MDIs) over the course of the next year or so. The switch will affect almost every asthma sufferer because salbutamol accounts for around 80 per cent of MDI short-acting beta agonist prescriptions and beclomethasone for over 70 per cent of MDI inhaled steroid prescriptions². The new CFC-free inhalers, reformulated using propellants known as HFAs, will be ozone friendly, but their characteristics can differ markedly from their more familiar CFC counterparts.

New inhalers

For example, in the case of Qvar, 3M Health Care¹s new CFC-free inhaled beclomethasone, changes to the propellant and the delivery device have resulted in the drug being released as extra fine particles. The data on 3M¹s product suggests that this reformulation has lead to enhanced lung deposition and an improved lung distribution profile³. As a result, clinical trials indicate that patients taking Qvar can achieve the same symptom control as conventional CFC beclomethasone, but at half the daily dose^4,51.

Because of this, I believe that all of us involved in managing asthma, doctors, specialists and practice nurses, should utilise the chance to optimise care by taking a proactive approach to managing the CFC transition, otherwise it could leave prescribers and the health service paying a high clinical and economic price.

Under both EU and UK transition strategy guidelines, the use of CFCs in a drug product containing salbutamol or beclomethasone will no longer be needed when two alternative CFC-free MDI products containing the same drug are available from two different companies6. So, in this country, with the marketing of Airomir and Ventolin Evohaler, the clock is already ticking for patients on CFC MDIs containing salbutamol (Allen & Hanburys ceased production of CFC Ventolin at the end of August).

Conflicting advice

However, some health authorities and NHS Executive regional offices are providing conflicting advice over when to switch, for example by suggesting that transition should not take place until CFC availability is exhausted. In my view, there is no advantage in holding back from switching patients until the last minute. To do so would be a recipe for potential chaos. Failure to anticipate the problem and start addressing it now, will lead to unnecessary pressure on work loads for hospital doctors and GPs, less time to educate patients properly and a last minute rush in demand for new CFC-free inhalers as the CFC versions are phased out.

Furthermore, the use of a planned transition protocol makes clinical and financial sense. A report published by the School of Health and Related Research (ScHARR) at the University of Sheffield says that the NHS could face a multi-million pound increase in the drug bill for managing the transition⁷. The report examines two transition scenarios: the first, the minimum change scenario, examines the situation if only five per cent of generic users cannot switch to CFC-free equivalents and so require dry powder inhalers (DPIs ) or a more costly alternative. In this scenario the cost associated with the broncodilator transition ranges from £170,000 for a patient switched to the 3M CFC free salbutamol inhaler, to just under £4 million for patients switched to terbutaline DPI. The cost of steroid transition alone could reach around £2 million to £3 million if patients were switched from BDP to fluticasone and budesonide MDIs respectively.

However the steroid transition need not increase costs. The report states that switching a patient to the 3M CFC-free BDP Qvar, could actually save money. According to the authors, ³carefully managed, this transition offers scope for cost-savings, where feasible, by transition to generics or cheaper branded therapies².

I would advocate early transition by using CFC-free replacements as they become available in order to allow adequate time for patient consultation and to minimise the potential impact of inadequate compliance if transition is rushed. Liaison between primary and secondary care is essential. For example, it would be highly undesirable for a patient to be discharged from hospital with CFC-free MDIs without adequate education and without informing the primary care team that the switch has been made.

Patient education

Patients, therefore, need to have the transition explained to them before they receive their first CFC-free formulation. They should understand that the change is for environmental reasons only. The new HFA-propelled devices will have a different taste and sensation in the mouth compared with conventional inhalers⁸. The inhaler may also be different in size, weight and shape, so it is essential that doctors and asthma nurses exploit this opportunity to check inhaler technique, as well as to review and improve treatment. For patients who are switched to 3M¹s CFC free BDP, they may need additional information about the lower dose of their medication. In my opinion, although some patients will need more information about the dose reduction, the transition will be easy for the patients, because they will continue to take the same number of puffs each day but from a reduced strength of inhaler.

If the transition is managed carefully, patients will receive the advice, reassurance and appropriate self-management plans they need and should make the switch without too much anxiety. Early transition, by using CFC-free inhalers as they become available, can help both prescribers and patients to minimise disruption and workload. More importantly, it gives the opportunity to review and optimise individual patient treatment and therefore potentially reduce the overall asthma costs including those associated with hospital admissions.

Vincent McGovern is a GP, Belfast

References

1 The value of medicines: Asthma, ABPI 1998
2 IMS Medical Data Index, Vol 3, Quarter 4, 1995
3 Leach CJ. Improved delivery of inhaled steroids to large and small airways. Respir Med 1998: 92 (Suppl A); 3-8
4 Davies, R.J., Stampone, P., O'Connor, B.J., Hydrofluoroalkane-134a beclomethasone dipropionate extrafine aerosol provides equivalent asthma control to chlorofluorocarbon beclomethasone dipropionate at approximately half the daily dose, Respir Med 1998; 92 (suppl A): 23-31
5 Gross G, Thompson P, Chervinsky P, Vanden Burgt J. HFA-134a BDP 400mcg as effective as CFC-BDP 800mcg for the treatment of moderate asthma. Chest 1999; 115: 343-351
6 European Commission. European Community: Strategy for the Phaseout of CFCs in Metered dose inhalers. January 1998 7 Slack R, Ward S, McCabe C, Peters J, Akehurst R. The Transition to CFC-Free Inhalers, ScHARR University of Sheffield 1998, 10-12 8 Tansey I. Changing to CFC-Free inhalers: the technical and clinical changes. Pharmaceutical J 1997; November 29

Click here for some case studies [case studies]