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Switching asthma patients to CFC-free inhalers

Sue Cross
RN BSc(Hons)
NPDip PGCE
Respiratory Nurse Biggleswade Bedfordshire
National Project Manager
General Practice Nursing Project
Working in Partnership Programme

Chlorofluorocarbons (CFCs) are used as coolants in fridges, solvents and the propellants in aerosols.(1) But, importantly for nurses, they are also used as the propellants in metered-dose inhalers (MDIs). And while they help patients with asthma, once CFCs are released into the atmosphere they release atoms of chlorine and bromine which destroy the ozone layer that protects the earth's surface from ultraviolet (UV) radiation. UV radiation is harmful to the eyes, damages the immune system and leads to the development of skin cancers.(3)
CFCs also act as greenhouse gases and contribute to global warning.
Most reliever inhalers are now CFC-free, but many preventer inhalers still contain CFCs. More than seven million prescriptions are issued for CFC-containing preventer inhalers each year. To respond to this crisis, in 1987 politicians from 24 countries and the European Economic Community negotiated the Montreal protocol on substances that deplete the ozone layer, which phased out the production and consumption of CFCs in developed countries from 1996.(4) Temporary exemptions have been allowed for items that are necessary for health, or for which there are no alternatives. This includes MDIs for asthma.
The UK put together a transition strategy in 1999, which sets out how the phase-out of CFCs in MDIs will be managed.(3) The aim is to make the transition as quick as possible, without jeopardising supplies to patients.
The UK will withdraw all CFC-containing inhalers once two alternative products containing beclometasone and at least one CFC-free MDI product for each of budesonide and fluticasone are available in an adequate range of doses.(5)
Certain other conditions need to be met, including adequate production and distribution capacity of CFC-free MDIs to meet the needs of all patients; an adequate range of doses and strengths to cover patient subgroups including children and the elderly; and comparable efficacy to the product-containing CFCs.
The health service circular Phase Out of CFC-Containing Metered-Dose Inhalers for the Treatment of Asthma and COPD,(6) published by the Department of Health in 1998, outlines the need for a coordinated transition involving all healthcare professionals.

What is the current picture in the UK?
More than five million people suffer from asthma in the UK, and more than seven million prescriptions are issued for CFC-containing preventer inhalers each year.(2) Most reliever inhalers, such as Ventolin, are already CFC-free. But many preventer inhalers, including Becotide™, (Allen and Hanburys) still contain CFCs.
There are only two CFC-free inhalers available on the market in the UK containing the active substance beclometasone dipropionate (BDP). Qvar®, produced by Ivax Pharmaceuticals, has been available for a number of years and Clenil® Modulite®, from Trinity-Chiesi Pharmaceuticals, was launched onto the UK market recently.
The alternative propellants developed to replace CFCs are the hydrofluoroalkanes (HFAs), which are hydrofluorocarbons (HFCs).(3) HFCs do not destroy ozone because they do not contain chlorine or bromine. They also contribute less to global warming.
There are three ways to administer the change-over to a CFC-free inhaler - intervention management, opportunistic changeover or administered changeover (see Box 1).(7) For intervention management, patients are invited to attend an asthma clinic or to see the practice nurse. During this appointment, the patient's medication is changed to a CFC-free MDI. Opportunistic changeover to a CFC-free MDI leaves the transition to take place during any appointment the patient makes with their GP or nurse. An administered changeover requires sending the patient a letter to tell them about the transition. The patient is then prescribed a CFC-free MDI for their next repeat prescription and they are advised to see their GP or practice nurse if they encounter any problems.

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Making the switch
Patients will need time to adapt to their new inhaler. Nurses should explain the reasons behind the switch to a CFC-free inhaler and reassure patients that there was nothing wrong with their original treatment. Patients should be told that their new CFC-free inhaler might taste and feel slightly different, but it is just as effective as their previous medication and contains the same active ingredient.
This is also an ideal opportunity to check inhaler technique and patient compliance. Extra information is useful for some patients, such as a leaflet with information on the transition, and posters displayed in the surgery to advise patients about the changes.
Nurses can also hold asthma clinics to explain the transition to several patients at once.
It is important to remember that switching a patient from a CFC-containing inhaler to a CFC-free inhaler could mean a dose change (see Table 1).

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For this reason, healthcare professionals should prescribe by brand, as instructed by the Medicines and Healthcare Products Regulatory Agency (MHRA).(8)
Qvar and Clenil Modulite, the two CFC-free BDP inhalers mentioned above, will require different approaches. They are not equipotent because the formulation of Qvar results in smaller particles and greater lung deposition when compared with Clenil Modulite. Clenil Modulite is dose equivalent to current CFC-containing BDPs and therefore it would be a straight switch. Qvar is 2-2.5 times more potent than current CFC-containing BDPs, so switching patients from Becotide or other CFC-containing inhalers to Qvar will involve changing the dose to approximately half. Qvar is available in Easibreathe, MDI and Autohaler devices
The MHRA's chief executive officer Professor Kent Woods, highlighted the importance of dosage and prescribing by brand in a memo to GPs, prescribing nurses and practice nurses in August 2006.(8) Prescriptions written using the generic name beclometasone dipropionate do not distinguish between CFC-containing and CFC-free formulations of BDP, and pharmacists can dispense either.
When prescriptions are written using the generic term beclometasone dipropionate CFC-free inhaler, the pharmacist can dispense Qvar or Clenil Modulite which, as discussed above, have different potencies.
Therefore, Professor Woods says, when a prescriber wants a patient to have a CFC-free formulation of BDP, that intention should be made clear by prescribing the product by brand name.
When patients are changed to an inhaler of a different potency to their existing therapy, this should be explained to them and titration to the appropriate dose to maintain control of the disease will need to be managed carefully.
Professor Woods adds that pharmacists who receive a generic prescription for a BDP pressurised MDI must establish whether a CFC-free product is required, and if so, which of the two available branded products should be dispensed.
Good communication between local prescribers and pharmacists will help smooth the transition and minimise the potential for mistakes.
Once a patient has been changed from a CFC-containing BDP inhaler to a CFC-free BDP inhaler, the patient should not switch from one CFC-free inhaler to the other unless advised to do so by their doctor.
When Becotide and Becloforte™ (Allen and Hanburys) are withdrawn from the UK market, patients using these medications will need to be switched to an alternative beclometasone treatment and inhaler. If patients are switched to a CFC-containing inhaler they might need to be switched again to a CFC-free inhaler once the government invokes the protocol. This creates the potential for confusion and additional workload for healthcare professionals. To avoid this confusion, it would make sense to switch now to CFC-free inhalers and avoid this additional step.

Conclusion
Nurses and other healthcare professionals can make sure the transition to CFC-free inhalers is safe and easy for patients, and in doing so protect patients' health and the environment.

References

  1. Air Pollution Information System. Ozone depletion. Available from: http://www.apis.ac.uk/overview/issues/overview_O3_depletion.htm
  2. NHS Health and Social Care Information Centre. Prescription costs analysis: England 2005. Leeds: NHS Health and Social Care Information Centre, Health Care Statistics.
    Available from: http://www.ic.nhs.uk/pubs/prescostanalysis2005
  3. Department of Health. UK transition strategy for CFC-based MDIs. London: DH; 1999.
  4. Ozone Secretariat, United Nations Environment Programme. Montreal protocol on substances that deplete the ozone layer. New York: UNEP; 1987.
  5. European Commission. European Community Strategy for the phaseout of CFCs in metered dose inhalers. European Commission; 1998. London: MHRA; 2006.
  6. Department of Health. Phase out of CFC containing metered dose inhalers for the treatment of asthma and COPD. HSC 1998/180. London: DH; 1998.
  7. Rannard A, Bundred P, Walley T, Bogg J. Managing the transition from CFC to CFC-free inhalers. Liverpool: Department of Primary Care, University of Liverpool; 1998.
  8. Medicines and Healthcare Products Regulatory Agency. Beclometasone dipropionate pressurised metered dose inhaler.