An assessment of Pressurized Metered-Dose Inhaler use in countries in Europe and the rest of the world

Rationale: The European Chemicals Agency is reviewing proposed legislation for a class ban of per- and polyfluoroalkyl substances (PFAS) molecules from 2026, based on chemical structure, which would encompass currently used propellants in pressurized metered dose inhalers (pMDIs) and HFO1234ze(E); a next generation propellant with near zero global warming potential; which is non-persistent, non-bioaccumulative and non-toxic. As approximately 75% of pMDIs manufactured in the EU are exported to the rest of the world,¹ we sought to understand the potential impact of this draft legislation by assessing pMDI use as a proportion of all inhalers in 53 countries, spanning six geographical regions. Methods: Inhaler use was evaluated based on sales data from the IQVIA™ Quarterly MIDAS database (2021), as a surrogate of use. Data were compared by dose to prevent confounding from device actuation count differences, and the percentage of pMDI use calculated by country. Results: pMDI use accounted for 77% of inhalers across all countries (Table), representing the majority in 49 of the 53 countries analyzed. The highest pMDI use was observed in Latin America (87%) and North America (87%), followed by Africa (84%), the Middle East (74%), Europe (71%), and the Asia-Pacific region (70%). In 10 countries, pMDIs represented >90% of all inhaler use, demonstrating a high reliance. In 17 of the 20 European countries, pMDIs accounted for >50% of total inhaler use. Additionally, in France, Germany, Italy, Spain and Poland pMDIs contributed 70% of inhaler use. Conclusion: Restrictions in the manufacture and use of pMDI devices risk supply shortages and forced regimen switching, which is known to have variable outcomes and negatively impacts the physician/patient relationship.² It is important that any environmental legislation that impacts pMDIs considers the socioeconomic consequences emanating from a restriction of these essential medicines. Funding: AstraZeneca funded this analysis.