So, even if you are unwilling to trade environmental benefit for cost, which I definitely get, the choice will not even exist in these types of cases, which is all very frustrating!

So there will only be the expensive version of Breztri (with longer patent protection and slower generic competition).

And this will be bad for patients, much like the CFC-to-HFA transition.

Breztri is a good example. Will likely be the first MDI with a novel propellant in the US. AstraZeneca will pull the older version once the newer one is released for financial rather than regulatory reasons (with no ban on the horizon).

I hear you. I think keeping prices down is absolutely a priority--and sadly not where we are headed. The switch to novel propellants will be so lucrative for manufacturers and, in a some cases, there will be no lower-cost version that remains on the market.

Thanks as ever to Gregg Furie for his work and collaboration on these issues.

But one thing is clear: Only structural reform, and not individual decisions by even committed physicians, can ensure that patients with chronic respiratory disease have access to safe, effective, sustainable, and affordable therapy.

There are no easy answers here. We discuss some policy solutions in the piece.

...Loss of product exclusivity through patent expiration currently poses a much greater risk to revenue than climate related risks.” As with the last propellant transition, patients may be caught in the middle.

Here’s how AsraZeneca described the financial upside it sees: “Transitioning to new low GWP propellants as part of our Ambition Zero Carbon strategy will mitigate the financial risks posed to our MDI-based respiratory portfolio (e.g. Symbicort)…

New low carbon-inhalers are now under development, but these will be expensive and may be on-patent into the 2030s/2040s. Manufacturers earned billions from the last propellant transition (CFCs to HFAs) and could earn even more during this next round.

Many also have links to the tobacco industry; Phillip Morris International purchased an inhaler manufacturer in 2020 despite uproar by physicians.

Metered-dose inhalers are potent greenhouse gas emitters. Dry powder inhalers are better for the environment but are not suitable for all patients and not always available on formularies.

Great to work on this piece with Samy Suissa, @akesselheim.bsky.social. Jerry Avorn, Max Russo, Sebastian Schneeweiss, and Shirley Wang. @portalresearch.org

Particularly given the added climate impact of metered-dose inhalers, health systems designing formularies and setting treatment guidelines may consider steps to increase use of fluticasone-umeclidinium-vilanterol relative to budesonide-glycopyrrolate-formoterol.