Environmentally Friendly Asthma Inhalers May Increase Hospitalizations
Large VA study links dry powder inhalers to higher emergency visits in older asthma patients
A massive observational study in the US Veterans Health Administration found that switching asthma patients from metered-dose inhalers (MDIs) to dry powder inhalers (DPIs) led to increased hospitalizations and emergency department visits, raising questions about the trade-offs between environmental benefits and patient outcomes.
Study Details
In 2021, the Veterans Health Administration implemented a formulary change switching asthma patients from budesonide-formoterol MDIs to fluticasone-salmeterol DPIs. Although the shift was initially driven by cost considerations, it coincided with growing interest in environmentally friendly inhaler options that avoid aerosol propellants linked to climate change. The natural experiment created by this large-scale policy shift offered researchers an opportunity to examine real-world clinical outcomes of switching inhaler types in a population of over 260,000 adult asthma patients.
Methodology
Researchers conducted two analyses using data from 2018 to 2022:
Self-controlled case series (SCCS): Tracked 260,268 patients before and after the switch from MDIs to DPIs.
Matched cohort study: Compared 258,557 patients who switched with matched controls who did not switch.
They assessed rescue medication use, emergency department visits, and hospitalizations, focusing on asthma and respiratory complications.
Key Findings
While the DPI group had a 10% decrease in albuterol fills, several negative trends emerged:
24% increase in pneumonia-related hospitalizations
10% increase in respiratory-related hospitalizations
8% increase in all-cause hospitalizations
6% increase in respiratory-related ER visits
5% increase in all-cause ER visits
2% increase in prednisone fills
These results held up in both analytic models. Importantly, no differences in mortality were observed.
Implications for Practice
The study raises essential considerations for healthcare systems weighing environmental sustainability against patient safety. Key takeaways:
Device usability matters DPIs may be harder for older or sicker patients to use properly.
Non-medical switching can lead to worse outcomes if patients and clinicians aren’t adequately supported.
Flexible prescribing should be preserved when clinical outcomes differ significantly.
Clinicians should advocate for patient-centered approaches when formularies change and monitor for adverse impacts. Further investigation is needed to distinguish whether increased risks stem from the medication, the delivery method, or the transition process itself.