Abstract Rationale The environmental impact of pMDIs (pressurized metered-dose inhalers) is a global concern. Concurrently, clinical over-reliance on SABA (short-acting β2-agonist) inhalers, contrary to GINA recommendation, remains a major challenge. Recent US data (2020) shows a SABA-to-LABA/ICS dispensed ratio of approximately 2.0:1. In Brazil, 2025 forecast data (IQVIA) projects a SABA-to-LABA/ICS ratio of 2.48:1 (35.0M SABA vs 14.1M LABA/ICS units), suggesting a clinical scenario still significantly worse than the US. This study aimed to quantify the dual impact, clinical and environmental, of these divergent trends in the Brazilian market. Methods We performed two analyses using IQVIA® data. First, we analyzed the 2019-2025 (Forecast) sales trend of SABA, LABA/ICS, and isolated ICS units in Brazil to establish therapeutic ratios. Second, we modeled the carbon footprint (tCO2) in the formoterol/budesonide (LABA/ICS) category, comparing the Brazilian market, dominated by DPIs (Alenia® Aerocaps®), with the US market, dominated by pMDIs (Symbicort®), using emission data from the literature. Results Brazil’s SABA-to-LABA/ICS sales ratio is forecasted to be 2.48:1 in 2025 (35.0M SABA vs 14.1M LABA/ICS units). While this proportion shows a slight improvement from its 2.6:1 peak in 2023, the absolute volume of SABA pMDIs sales continues to grow. This ratio remains substantially higher than in the US (2.0:1). Conversely, in the maintenance therapy (LABA/ICS) category, Brazil’s preference for DPIs (Alenia® Aerocaps®) over the pMDI standard common in the US resulted in a potential environmental saving of 876,759 tons of CO2 per year (Figure 1). Conclusion Brazil faces a critical paradox. The country has demonstrated significant environmental leadership by adopting low-carbon DPIs for maintenance therapy. However, this success is overshadowed by a severe and persistent clinical problem: a SABA over-reliance that is proportionately worse than in the United States. This trend, which runs counter to all clinical guidelines, not only increases patient risk but also ensures that the largest volume of inhalers sold continues to be high-carbon pMDIs. Addressing SABA overuse in Brazil is therefore the single most critical intervention to align clinical best practices with environmental sustainability. Figure 1. Different carbon footprints for LABA/ICS combinations in Brazil and USA and Inhaler Sales Trend in Brazil, six years series. This abstract is funded by: Aché Laboratórios Farmacêuticos S.A.
Cancado et al. (Fri,) studied this question.