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The CFC transition: a practical guide

The transition from corticosteroid inhalers containing chlorofluorocarbons (CFCs) as propellants to CFC-free alternatives is now underway, but many health professionals have yet to address this issue within their practice. Sally Rose explains how you and your patients can make the change, with the help of some resources recently developed by Asthma UK

Sally Rose
RN BSc(Hons)
Asthma Nurse Specialist
Asthma UK

As most of us know, CFCs are harmful because they damage the earth's protective ozone layer. In 1987, countries worldwide negotiated the Montreal protocol and agreed to stop the use and manufacture of CFCs.(1) As a result, the UK developed a transition strategy to phase out CFCs used as propellants in metered-dose inhalers (MDIs).(2) Asthma reliever inhalers are now CFC-free, but some corticosteroid preventer inhalers still contain CFC propellants. Although no official date has been set, eventually these will also all be withdrawn.

Why is change happening now?
Two significant developments have accelerated the change to CFC-free corticosteroid MDIs. First, there was the launch of Clenil Modulite [Trinity-Chiesi] in 2006. This is a CFC-free beclometasone dipropionate (BDP) MDI, and is an alternative to the only other available CFC-free BDP MDI product, Qvar [Teva], which has been available for several years. Second, in 2007 GlaxoSmithKline discontinued CFC-BDP MDIs Becotide and Becloforte. As a result, some people with asthma have already changed to CFC-free inhalers, but many continue to be prescribed BDP MDIs containing CFCs. The advantage is perceived to be cost; CFC inhalers are generally cheaper than CFC-free ones. The problem is that when all CFC devices are withdrawn, many patients will need to change their device yet again - a confusing situation for patients and a potentially time-consuming one for health professionals. As Keeley puts it, when it comes to the CFC-free transition "we might as well get on with it."(3)

Asthma UK resources for the CFC-free transition
With the support of the General Practice Airways Group (GPIAG), Education for Health and the Pharmaceutical Services Negotiating Committee (PSNC), Asthma UK has developed a number of resources to help health professionals manage the transition to CFC-free corticosteroid inhalers. All the resources are free.* They are:

  • An A4 poster for the practice, inviting people with asthma to visit their asthma nurse or doctor if they are using an aerosol "press and puff" preventer inhaler.
  • A leaflet for patients called "Switching to CFC-free asthma inhalers" that contains the basic facts for patients facing the changeover.
  • A factfile called "CFC-free inhalers" that explains about the transition in more detail and is suitable for patients and health professionals.
  • A template letter for health professionals that invites people on CFC inhalers to an asthma review.
  • An A4 conversion table for health professionals, showing all the CFC-free and CFC-containing corticosteroid MDIs with their dose equivalents.
  • An A4 table for health professionals that outlines all the alternative CFC-free corticosteroid dry powder inhalers.


How to make the CFC transition in your practice

First, it is important that all health professionals in the practice and local pharmacists agree on how to approach the changeover. With the introduction of Medicines Use Reviews (MURs) pharmacists are ideally placed to talk to patients about the CFC-free transition, but their advice needs to be consistent with that adopted by the practice. It is also important to work with your primary care trust, which may have sent you details about how the transition should be managed in your area.
Display the Asthma UK CFC-free poster in the practice waiting room and at local pharmacies.
Search the practice register and identify all asthma patients who are currently prescribed a CFC corticosteroid. Bear in mind there will also be patients with other lung conditions on CFC corticosteroids as well. Table 1 lists the specific drugs to search for. They are also listed in the Asthma UK CFC-free factfile and in the conversion table.

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Those patients identified should have their record marked so that opportunistic intervention can be made in the event of any consultation made at the practice. Information given to patients  can be supported with an Asthma UK CFC-free leaflet or a copy of the factfile.
Along with the opportunistic strategy, a proactive approach is required using intervention management and administered changeover.(4) To make the task manageable, the patients identified above may be prioritised as follows:

Patients whose last prescription was for Becotide or Becloforte
Send an invitation letter, using the Asthma UK template, asking them to make an appointment, and enclose the Asthma UK CFC-free leaflet. Alternatively, change their repeat prescription on computer and attach an invitation letter and leaflet to their next requested prescription.

Patients due for an asthma review
Invite them for their review using the Asthma UK template letter or your own practice letter, and enclose a leaflet.

Patients on any other CFC corticosteroid MDI
As yet, there is no specific date by which all CFC corticosteroid MDIs must be withdrawn, although this is likely to happen before too long. There is therefore more time to work through this category of patients. Decide on a timeframe that is appropriate for your practice, then send out invitation letters and leaflets, or attach them to the patient's repeat prescription.

What changes need to be made?
If a patient is using their current CFC MDI correctly, a CFC-free MDI can be prescribed. Explain that the new device may look different, and that the spray may feel lighter, less cold, and may leave the device more slowly.
As stipulated in a memo from Professor Woods of the Medicines & Healthcare products Regulatory Agency (MHRA), CFC-free BDP MDIs must be prescribed by brand.5 This is because the two alternatives, Clenil Modulite and Qvar, are not equipotent. Clenil Modulite has a similar potency and lung deposition as CFC-BDP MDI, so can be prescribed at the same dose. But the Qvar particle is smaller, resulting in increased lung deposition and potency that is about 2-2.5 times greater. It should therefore be prescribed at approximately half the dose of a CFC-BDP MDI. Qvar is also available as Autohaler and Easi-Breathe devices. Please note that Qvar is not licensed for children under 12 years old.
Patients who use a spacer with their MDI should use a Volumatic [A&H] with Clenil Modulite, and an Aerochamber Plus [GlaxoSmithKline] with Qvar MDI.
If a patient's MDI technique is not very good, even with a spacer, it is advisable to switch them to an alternative device, such as the Autohaler [3M] or Easi-Breathe [IVAX], or one of the dry powder devices listed in the Asthma UK table of alternative devices.
There is currently no CFC-free MDI device containing budesonide, so patients who currently take Pulmicort [AstraZeneca] will eventually need to switch to a different corticosteroid or one of the budesonide dry powder inhalers.
For patients whose asthma is not well-controlled, a consultation about the CFC-free transition is an ideal time to review their asthma as a whole. Assessment of symptoms and adjustments to medication should be made using the stepwise approach outlined in the British Guideline on the Management of Asthma, and any changes should be followed up.(6) A written personal asthma action plan should be provided and agreed with the patient. Action plans are available from Asthma UK.
Any alterations to asthma treatments should be monitored carefully. Depending on the type of changes made, patients should either be given a follow-up appointment, or advised to come back if they experience any problems, such as increased symptoms.

Scenarios
The following two scenarios are examples of how you may implement the CFC-free transition for individual patients:

Scenario 1
Q: John is six years old. His asthma is triggered by pollen and he only needs his preventer inhaler in the summer months. Last summer he took two puffs of Becotide 50 mcg twice a day, through a Volumatic spacer. His mother has brought him to see you because she received a letter and a leaflet from you about changing his inhaler to a CFC-free device. What would you do?

A: Check with John's mother that his asthma is well-controlled. Explain that Becotide has been discontinued, so his preventer inhaler needs changing to a CFC-free device. Reassure her about the reasons for the withdrawal. Prescribe two puffs of Clenil Modulite 50 mcg twice a day. John can continue to take this through his Volumatic (Qvar is unsuitable because it is not licensed for under 12s). Explain to John and his mother that the new inhaler will look different and the spray may be delivered into the spacer at a different speed. Reassure John's mother that the medicine is the same. Ask her to come back if she notices any deterioration in her son's asthma as summer approaches.

Scenario 2
Q: Linda is 36 years old and has had asthma since childhood. She moved to your practice two months ago but has not yet attended the asthma clinic. She is currently taking two puffs of Beclazone 200 mcg twice a day and hasn't needed her reliever inhaler for several months. She has come to see you because she received an invitation from you for an asthma review, along with a leaflet about the CFC-free transition. What issues would you address concerning her asthma treatments?

A: Because Linda's asthma is so well controlled, suggest that she steps down her dose of corticosteroid.6 If she is happy with an MDI device and her technique is good, prescribe an equivalent of half her current dose of Beclazone - either as two puffs of Clenil Modulite 100 mcg twice daily, or as two puffs of Qvar 50 mcg twice daily. Explain the differences she can expect in her new inhaler, but reassure her that the active medicine is the same. Alternatively, after she demonstrates her MDI technique as part of the review, you may both agree that a different device would suit her. You may wish to use the Asthma UK conversion table and the table of alternative dry powder devices when choosing what to prescribe. Agree a written personal asthma action plan with Linda so she knows what to do if her asthma gets worse on the lower dose of corticosteroid. Arrange a follow-up appointment.

Conclusion
Using a consistent, planned approach, health professionals can address the transition to CFC-free corticosteroid inhalers with confidence. The Asthma UK resources described above will help both you and your patients make the changeover smoothly and effectively.

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*All these resources can be downloaded directly from the Asthma UK website www.asthma.org.uk. They are found in the "Health Professionals" area, under the tab "Materials to help you and your patients".

Free hard copies of both the poster and patient leaflet can be ordered by phone or email from the Asthma UK Supporter and Information Team on 08456 03 81 43 or at info@asthma.org.uk

Further support for patients and health professionals can be found by contacting an asthma nurse specialist at the Asthma UK Adviceline on 08457 01 02 03
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References

  1. Ozone Secretariat, United Nations Environment Programme. Montreal protocol on substances that deplete the ozone layer. New York: UNEP; 1987.
  2. Department of Health. UK transition strategy for CFC-based MDIs. London: DH; 1999.
  3. Keeley D. GPIAG Opinion No 9. Discontinuation of CFC-containing beclometasone metered dose inhalers - planning for change. Leeds: GPIAG; 2007.
  4. Cross S. Switching asthma patients to CFC-free inhalers. NiP 2006;33:36-39. Available from: http://www.nursinginpractice.com
  5. Woods K on behalf of the Medicines and Healthcare products Regulatory Agency. Beclometasone dipropionate pressurised metered dose inhaler. London: MHRA; 2006.
  6. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Revised edition 2007. Available from: http://www.brit-thoracic.org.uk/c2/uploads/asthma_fullguideline2007.pdf


Resources
Asthma UK
W: www.asthma.org.uk

Asthma UK Adviceline
T:  08457 01 02 03

BTS/SIGN British Guideline on the Management
of Asthma - Revised Edition 2007
W: www.brit-thoracic.org.uk