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InSight+ spoke with Dr Brett Montgomery about a “win-win” solution to improve asthma control for thousands of Australians while helping reduce the climate impact of asthma inhalers.
Dr Brett Montgomery is a GP and a senior lecturer at the University of Western Australia, and a member of the National Asthma Council (NAC) Guidelines Committee.
Dr Montgomery says he wants to see more Australians improving their asthma control with inhaled corticosteroids.
“Asthma affects about 1 in 10 Australians. Sadly, we see around 400 asthma deaths per year. There are real missed opportunities for better asthma control,” said Dr Montgomery.
“A lot of evidence, including recent Australian studies, shows that about one quarter of people with asthma have both poor asthma control, and use little or no inhaled corticosteroids,” he says.
He said that the asthma burden is worse for Indigenous Australians.
“Asthma is significantly more common in Aboriginal and Torres Strait Islander people than in other Australians, and a leading health burden among younger Aboriginal and Torres Strait Islander people. Culturally safe health care is an important part of making positive change,” said Dr Montgomery.
“But for Australians with asthma overall, there’s an opportunity to think, ‘How could we improve our asthma care, and also be greener?’”.
Pressurised Metered Dose Inhalers (pMDIs) often contain salbutamol. In Australia, salbutamol is only available in pMDI form, in the familiar blue inhalers. Salbutamol is the most commonly used short-acting beta-agonist (SABA), which opens the medium and large airways in the lungs, providing instant relief during an asthma attack.
Inhaled corticosteroids, a longer term medication, prevent asthma symptoms by reducing inflammation in the airways that carry oxygen to the lungs.
“People with better disease control rely less on salbutamol inhalers. If more people were using inhaled corticosteroid medicines, we would probably have fewer hospital admissions and, I suspect, fewer deaths,” says Dr Montgomery.
Dr Montgomery says that when alternative medications are prescribed in a dry powder inhaler, we can avoid the emission of propellants such as norflurane, a harmful greenhouse gas.
“We can have better asthma care, and greener asthma care, all at the same time,” says Dr Montgomery.
Asthma prevention – better than cure?
Dr Montgomery says that “while SABAs give quick relief, they can, if used on their own, leave patients at risk of exacerbations, hospitalisation or worse”.
“A challenge with the inhaled steroids is that they don’t work as quickly. But the pMDIs work quickly but are not as effective. They give people an immediate sense of relief. It’s quite extraordinary how quickly that happens,” says Dr Montgomery.
“The inhaled corticosteroid medicines do more good, though. You see the benefits when you’ve taken it for a while, and you notice your asthma symptoms are melting away,” he says.
More recently, we’ve seen a medication that combines the two and provides fast relief as well as preventive action.
“Inhalers that combine inhaled corticosteroids with the fast-acting beta-agonist formoterol offer new opportunities for better control. In recent years, evidence has shown that these can safely be used simply as needed by people with mild asthma. Several such inhalers are available as dry powder inhalers, which have much less environmental impact than pMDIs,” says Dr Montgomery.
Dr Montgomery says that making the switch to inhaled corticosteroids won’t be right for everyone, and health professional advice is crucial.
“The right device choice depends on many factors including age, dexterity, inspiratory ability and learning ability. Young children, especially under the age of 6, are best served by pMDIs and spacers. But for a large proportion of adolescents and adults, a dry powder inhaler will be appropriate,” he says.
“However, if a pMDI is the safest choice for a patient, people shouldn’t feel guilty about using it. When my son had viral induced wheeze as a toddler, I was very happy that he had pMDIs and a spacer to use,” says Dr Montgomery.
“But there’s an opportunity to think, how could we improve our asthma care, and also be greener?”
The greener road to health care
Greener inhalers are greener because they remove hydrofluorocarbon propellants from inhalers, which may reduce the health care sector’s impact on climate.
The NAC recently released new information to help health professionals make choices to reduce the environmental impact of asthma treatment. It’s part of a wider focus on reducing greenhouse gases produced in health care (here).
The first assessment of Australia’s health care carbon footprint, led by Associate Professor Arunima Malik (University of Sydney) in 2018, estimated that 7% (35 772 kilotonnes of carbon dioxide [CO2]) of Australia’s total emissions were due to health care. Anaesthetic gases, such as desflurane, are thousands of times more potent than CO2.
“Every inhaler has some kind of environmental impact. But over 90% of the carbon footprint of pressurized inhalers is from the hydrofluorocarbon propellants leaking into the atmosphere,” says Dr Montgomery.
“The most common in pMDIs is norflurane, which is about 1400 times more potent than carbon dioxide as a greenhouse gas. Even though there may only be a few grams of these chemicals in each inhaler, they have a disproportionate climate impact,” he says.
The greener inhalers, mostly dry powder inhalers, release medicine as a very fine powder to be inhaled, without using a propellant.
Most of the inhalers sold in Australia are pMDIs, whereas in Sweden, it is only about 13%.
“I would like to see better asthma outcomes, better asthma control, and more people be able to live lives unencumbered by asthma symptoms,” says Dr Montgomery.
“We can create better control and reduce our effect on the environment. Let’s seize this win-win.”
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pMDI inhalers such as Ventolin, Zempreon, and Asmol provide a gaseous rush of drug delivery which presents as psychological reinforcement, as the patient feels the inhaler is working correctly. Technique is especially important to the efficacy of asthma inhalers and as such, breath activated Sabas (and anything else) provide superior benefit here – and it reduces waste! To this point, transition away from V, Z and A inhalers can be best achieved through using breath activated puffers. However, cost is a significant factor here and given that one chemist discount model is responsible for around 25-30% alone of all pMDIs sold in Australia, it is a fallacy to suggest that any change is real world usage would occur at any substantial rate given that cost is a significant factor to good medication adherence and medicine access, generally. To make a difference, breath activated inhalers need to be the norm before and real change in therapy can occur – all it takes is spending time in a community pharmacy to understand that this is the scenario pharmacists deal with every day. Research is nice but real-world application is a completely different animal.
Should safe combined powerder combination inhalers be made available OTC at the same price as a salbutamol inhaler or removing salbutamol as an OTC other than for emergency pharmacist sale
Given the well intentioned deregulation of salbutamol inhalers in the interest of allowing consumer access for emergency situaitons (which many consumers take to mean long term self management) – that horse has bolted
It would seem that education by pharmacists is failing due to cost and convenience of self medicatoin
Should we be looking at a systemic solution that improves healthoutcomes
Dr. Brett Montgomery’s insights on improving asthma control while reducing the environmental impact of inhalers present a compelling vision for a “win-win” solution. His emphasis on increasing the use of inhaled corticosteroids, supported by robust evidence, highlights a critical opportunity to reduce hospitalizations, improve patient outcomes, and potentially save lives.
Equally important is his call to address disparities in asthma care, particularly for Indigenous Australians, where culturally safe healthcare approaches are urgently needed. By transitioning to greener inhaler options like dry powder inhalers, which minimize the use of harmful hydrofluorocarbon propellants, we can align asthma management with climate goals.
Dr. Montgomery’s balanced approach acknowledges the importance of personalized care, ensuring that device choice remains patient-centric while advocating for sustainable practices. His perspective is a timely reminder that health care can simultaneously prioritize better patient outcomes and environmental stewardship. Let’s embrace this opportunity to create meaningful change for both individuals and our planet.