The hidden cost of blanket inhaler switching

“Please don’t change my inhaler again — it took me months to get the hang of the last one.” That plea from a patient sums up the challenge at the centre of inhaler switching. The Primary Care Respiratory Society (PCRS) is clear: blanket switching of inhalers is a risk and negatively affects the patient’s disease control.^[1] Any change in device must be individual, clinically justified, supported with training and the patient should be actively involved in the decision-making process.

The risks associated with blanket switching of inhalers

Switching all patients in a practice or locality to a different inhaler for reasons such as cost or carbon targets may appear efficient, but it introduces significant clinical and financial risk.

Inhaler technique errors are widespread and strongly linked with poorer asthma and chronic obstructive pulmonary disease (COPD) outcomes.^[2] When patients receive a device they do not understand or cannot use properly, adherence declines, reliance on relievers increases, and the likelihood of exacerbations rises.^[3]

When selecting an appropriate inhaler for a patient, clinicians must work together and consider several key factors including:^[1] 

• Patient satisfaction
• Accommodating patient preferences
• Potential side effects
• Optimising clinical benefits
• Healthcare costs
• Environmental considerations

Mass switching also undermines shared decision-making, a core element of The National Institute for Health and Clinical Excellence (NICE) guidance,^[4],[5] and risks damaging trust, especially in patients who have worked hard to gain confidence with a particular device.

Switching inhalers to cheaper equivalent products is often advocated as a necessary cost saving measure, yet the impact on patient’s health and healthcare utilisation has not been measured.^[6] In reality, short-term unit-price reductions can be wiped out by the cost of poorly controlled respiratory disease which can lead to repeat consultations, additional prescriptions and emergency admissions. Concerningly, the cost of NHS hospital admissions for asthma ranges from £1,516 to £2,473 per night, while a year’s supply of preventer inhalers generally ranges from £5 to over £30 per unit, with some combined therapies costing more.^[7],[8]

When is a switch appropriate?

Switching can be clinically appropriate when done for the right reasons and with the right support. Examples include:^[4],[9],[10]

• The patient cannot use the current device correctly, despite training
• They cannot generate sufficient inspiratory flow for a dry-powder inhaler (DPI)
• Arthritis, tremor or cognitive impairment prevents correct pressurised metered dose inhaler (pMDI) use
• A lack of dose counter is leading to under-dosing
• The patient expresses an informed preference (including environmental preference)
• The switch improves control.

In every case, the switch should follow a structured review: confirm diagnosis and control, check adherence and reliever use, observe technique, and assess physical and cognitive ability to use alternative devices.^[4] The device must be appropriate for the patient.

How to switch appropriately

Shared decision-making and patient choice

Explain options, including remaining on the existing inhaler. Discuss carbon, cost, feel, usability, and dose counters. Record the decision process.

Right device, right patient

Match device to inspiratory flow, dexterity, cognition and preference.

Demonstration and check-back

Show the inhaler, then ask the patient to demonstrate it back. Provide written or video resources.

Follow-up and safety netting

Review within 4–6 weeks. Check symptoms, reliever use, technique and confidence. Reverse the inhaler switch if control worsens.

System coordination

Ensure formulary alignment, pharmacy stock, correct EPS coding and consistency across primary and secondary care.

Financial and value-for-money perspective

Medicines optimisation teams are under pressure to reduce spend and meet NHS net-zero goals.^[11] Switching to a lower-cost or lower-carbon inhaler can be justified, but only when clinically appropriate and supported. A device that is £2 cheaper per item is not a saving if it leads to one additional exacerbation, lost workdays, or urgent care attendance.

The cost of a COPD admission to the NHS can be up to £5,000 per patient each time.^[12] Inhaler device selection should take into consideration not only initial device cost but also the subsequent health care resource costs.^[13]

Appropriate, supported, patient-centred switching protects:

• Clinical outcomes – a study found that switching patients’ inhalers was associated with reduced exacerbations^[14]
• Patient experience – a need for HCPs to undertake consent during switching to support the innate principles of the doctor-patient relationship^[15]
• Sustainability goals – prescribing an inhaler that the patient uses regularly and correctly means that the patient will be controlled at the lowest effective dose, using less propellant^[16]
• NHS budgets – with switching potentially saving around £6 million annually.^[14]

Put more simply: the most cost-effective and ‘greenest’ inhaler is the one a patient can and will use correctly.^[16]

Key takeaways

When it comes to inhaler changes, the approach makes all the difference: blanket switching is a risk, while carefully supported, patient-centred switching delivers both clinical and financial benefits.

• Blanket switching is not clinically appropriate and rarely delivers financial benefit^[1] 
• Switching can deliver value and carbon benefit^[16] — but only when individualised, taught and followed up
• The cost of losing disease control outweighs any saving made by swapping devices without training.

Appropriate and individualised switching can protect patients, budgets and support sustainability goals.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi).  All content in this article is for informational and educational purposes only.  Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.

[1] Dayal, D. Leese, D. Primary Care Respiratory Society (PCRS). Blanket switching of inhaler types – why it is a bad idea. Available at: https://www.pcrs-uk.org/sites/default/files/resource/Blanket_switching_inhaler_types_2025.pdf

[2] Usmani OS, Lavorini F, Marshall J, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res. 2018 Jan 16;19(1):10

[3] Gregoriano C, Dieterle T, Breitenstein AL, et al. Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial. Respir Res. 2018;19(1):237

[4] NICE. Asthma: diagnosis and management (NG245). Updated November 2024. Available at: https://www.nice.org.uk/guidance/ng245/resources/asthma-diagnosis-monitoring-and-chronic-asthma-management-bts-nice-sign-pdf-66143958279109

[5] PCRS Position Statement – Inhaler Switching. Available at: https://www.pcrs-uk.org/sites/default/files/resource/2023-09-19-Position%20statement_Inhaler%20switching.pdf

[6] Bloom CI, Douglas I, Olney J, et al. Cost saving of switching to equivalent inhalers and its effect on health outcomes. Thorax. 2019;74(11):1078-1086

[7] NHS England. Respiratory high impact interventions. Available at: https://www.england.nhs.uk/ourwork/prevention/secondary-prevention/respiratory-high-impact-interventions/

[8] NHS Grampian. Inhaler costs. Available at: https://www.nhsgrampian.org/your-health/dont-waste-a-breath/facts/

[9] PCRS. Shared decision making for greener healthcare. Available at: https://www.pcrs-uk.org/sites/default/files/pcru/articles/2021-July-Issue-22-GHC_ChangingInhalersSharedDecisions.pdf

[10] Cataldo D, Hanon S, Peché RV, et al. How to Choose the Right Inhaler Using a Patient-Centric Approach? Adv Ther. 2022;39(3):1149-1163

[11] NHS England. National medicines optimisation opportunities 2024/25. Available at: https://www.england.nhs.uk/long-read/national-medicines-optimisation-opportunities-2023-24/

[12] Health Innovation North West Coast. Prevention of Admission for COPD. Available at: https://www.healthinnovationnwc.nhs.uk/media/Images/PACE%20copd%20case%20study%201.10.15.pdf

[13] Kemp L, Haughney J, Barnes N, et al. Cost-effectiveness analysis of corticosteroid inhaler devices in primary care asthma management: A real world observational study. Clinicoecon Outcomes Res. 2010;2:75-85

[14] Bloom CI, Douglas I, Olney J, D’Ancona G, Smeeth L, Quint JK. Cost saving of switching to equivalent inhalers and its effect on health outcomes. Thorax. 2019;74(11):1078-1086

[15] Usmani OS, Bosnic-Anticevich S, Dekhuijzen R, et al. Real-World Impact of Nonclinical Inhaler Regimen Switches on Asthma or COPD: A Systematic Review. J Allergy Clin Immunol Pract. 2022;10(10):2624-2637

[16] EMJ. The Greenest Inhaler: A Patient-centric Approach. Available at: https://www.emjreviews.com/respiratory/article/the-greenest-inhaler-a-patient-centric-approach/