The transition to CFC-free inhalers

With the Y2K deadline nearly behind us, Dr Grevile Newson-Smith and Sian Watkin discuss the issues involved in the transition to CFC-free inhalers, which must be complete by 2003

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The introduction of CFC-free inhalers for many thousands of asthma patients in the UK is a huge undertaking. If handled with common-sense and a degree of sensitivity, however, it need not turn into a logistical nightmare.

In 1987 the United Nations faced growing international concern about the harm CFCs were causing to the environment and signed the Montreal Protocol1. The final agreement aims to ultimately eliminate 'ozone depleting' substances and when it came into force on 1 January 1989, 29 countries and the EEC had ratified it. This represented around 82 per cent of the world¹s consumption. In total 165 countries, of which well over 100 are developing countries, committed to phasing out CFCs by 1996.

The pharmaceutical industry was exempt from meeting this 1996 deadline to allow time for development of CFC-free metered dose inhalers (MDIs) and currently 96 per cent of all European CFC production is accounted for by MDIs. Transition to CFC-free MDIs must be completed by 2003 and thus GPs and patients need to start thinking about CFC-free medication.

The EU has developed its own CFC-free transition policy which exhorts national government bodies to develop their own local policies. In the UK the Department of the Environment, Transport and the Regions (DETR) has issued its consultation report Transition strategy for the phase out of CFC-containing MDIs for the treatment of asthma and COPD. The report states that Œa number of CFC-free MDIs are now available in the UK and we anticipate that it should be possible to complete the transition for most types of MDI in the next three years¹.

The transition will be spread over several years, with most CFC inhalers phased out by the year 20002. Some CFC-free inhalers, powered instead by HFAs (hydrofluoralkines) are already on the market (Ventolin Evohaler, Qvar, Airomir, Salbulin). In our fairly large practice (19000 patients, with eight full-time equivalent GP partners), we have now begun to address the issue of switching to these new devices. My list alone includes some 200 patients with asthma‹and almost without exception, their prescribed therapy includes some degree of inhaled beta-2 agonist therapy. It is quite clear, therefore, that any change to their medication is something that will require a good deal of thought. In my part of the country, at least, it has largely been left to individual GP practices as to how they will manage the switch to CFC-free inhalers. I suspect, though, that it will not be long before health authorities attempt to co-ordinate their own policies.

Because so many different inhalers are currently prescribed, we will want to make sure that the changeover to new CFC-free devices such as the Ventolin Evohaler is not a haphazard process. It would be nice to be able to switch the vast majority of our asthma patients at about the same time so as to avoid potential confusion for local pharmacies, medical professionals and patients.

There are now several CFC-free salbutamol inhalers available so it is rational to switch these patients now. As many as one in 10 prescriptions for salbutamol are already marked CFC-free by GPs in this area, and this momentum will doubtless continue apace. By contrast we do not yet have a range of inhaled steroid products available. GPs should plan to switch patients requiring inhaled corticosteroids when more choice becomes available.

Patients education

It will be important to counsel patients that they may notice some differences when using the new inhalers. There is not the sensation, for example, of a CFC-powered dose of salbutamol hitting the back of the throat and, due to the different propellant, and the taste may vary. The sound is also slightly different since the canister is at a different pressure, so patients will need to be reassured that they are, in fact, getting the required dose with each actuation.

Patients will understandably be worried if we prescribe them a new product and they do not know what to expect. In particular, we will have to pay very close attention to patients with high anxiety levels, for whom a lot of reassurance that they are still receiving the same and correct medication, will be necessary.

Indeed, GP partners will have to be briefed very thoroughly about the need for patient education, as will the nurses who run asthma clinics. Patient information leaflets explaining the need for a switch to CFC-free devices, as well as the practicalities of such a changeover, will be a vital part of this process.

We will also be emphasising that the introduction of the new inhalers is entirely for environmental reasons1, not because the current inhalers are in any way therapeutically inadequate. Indeed, we will stress that the CFC-free inhalers are no less beneficial than those they may have been using for the last 25-30 years. It will be helpful that the manufacturers have gone out of their way to make sure that the new devices look similar in terms of size, shape and colour.

Pharmacists

The degree of co-operation that GPs enjoy with their local community pharmacist will have a considerable bearing on how well the transition to CFC-free inhalers is achieved. More and more patients are now asking pharmacists for advice, and they will play an important role in reinforcing the messages about switching to CFC-free therapy.

Some confusion may result for both patients and doctors with the beclomethasone CFC-free products that are not equivalent. In order to prescribe these inhalers doctors will have to review patients¹ current medication and determine the correct dose of the new CFC-free product.

Once issues such as this have been resolved, there is no reason to suppose that the transition to CFC-free inhaled asthma therapy will not take place relatively smoothly, with beneficial environmental consequences for us all

Grevile Newson-Smith is a GP and Sian Watkin is a nurse, Slough, Berkshire

References

1 Montreal Protocol on Substances that Deplete the Ozone Layer; Intl Law Magazine 1987; September 16; 26: 1541
2 Department of Health. Phase out of CFC containing metered dose inhalers for the treatment of asthma and COPD. Health Service Circular HSC, 1998; 180; 23rd October

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