Inhaler Guide:
British Columbia

Inhaler Carbon Emissions:

Low

Moderate

High

Instructions

1. Select indication:*

2. Add criteria:

Green inhalers only

Regular PhamaCare coverage
(Special Authority NOT required)

Available in hospital

Patient's Age:

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Quick Guide to Inhaler Switches

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Check out inhalerguide.ca for more info

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SABA

Bricanyl
Turbuhaler

terbutaline

Ventolin
‍Diskus

salbutamol

Teva-Salbutamol
MDI

salbutamol

Ventolin
MDI

salbutamol

ICS

Pulmicort
Turbuhaler

budesonide

Arnuity
Ellipta

fluticasone furoate

Flovent Diskus

fluticasone propionate

Aermony
Respiclick

fluticasone propionate

Asmanex
Twisthaler

mometasone furoate

Flovent
MDI

fluticasone propionate

Alvesco
MDI

ciclesonide

Qvar
MDI

beclomethasone dipropionate

ICS/LABA

Symbicort
Turbuhaler

budesonide +
formoterol

Breo Ellipta

fluticasone furoate + vilanterol

Wixela Inhub

fluticasone propionate + salmeterol

Advair Diskus

fluticasone propionate + salmeterol

Atectura Breezhaler

indacaterol +
mometasone

Advair MDI

fluticasone propionate
salmeterol

Zenhale MDI

mometasone +
formoterol fumarate

ICS/LAMA/LABA

Trelegy
Ellipta

fluticasone furoate + umeclidinium +
vilanterol

Enerzair
Breezhaler

indacaterol + glycopyrronium + mometasone

SABA

Bricanyl
Turbuhaler

terbutaline

Ventolin
Diskus

salbutamol

Teva-Salbutamol
MDI

salbutamol

Ventolin
MDI

salbutamol

SABA/SAMA

SAMA

Combivent
Respimat

ipratropium + salbutamol

Atrovent
MDI

ipratropium

LABA

Serevent
Diskus

salmeterol

LAMA

Spiriva
‍Respimat

tiotropium

Incruse
Ellipta

umeclidinium

Seebri
Breezhaler

glycopyrronium

Tudorza
Genuair

aclidinium

Spiriva
‍Handihaler

tiotropium

LAMA/LABA

Inspiolto
Respimat

tiotropium +
olodaterol

Anoro Ellipta

umeclidinium + vilanterol

Ultibro
Breezhaler

glycopyrronium + indacaterol

Duaklir Genuair

aclidinium + formoterol fumarate

ICS/LAMA/LABA

Trelegy
Ellipta

fluticasone furoate + umeclidinium + vilanterol

Breztri
‍Aerosphere

budesonide + glycopyrronium + formoterol

Disclaimer & About Us

Quick Guide to Inhaler Switches

High Emissions ~112.6 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Ventolin HFA (MDI)

generic versions: apo-sabutamol, sanis-salbutamol salbutamol 100 mcg/dose

Duration:

4-6h

Instructions:

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$20.29 for 200 doses

Covered

Very High Emissions ~139 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Zenhale HFA (MDI)

mometasone/formoterol fumarate 100/5; 200/5 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

two inhalation twice a day—dosage based on patient's asthma symptoms and severity (maximum dose: mometasone 200 mcg/formoterol 5 mcg twice daily)

Cost:

100/5 mcg: $128.94 for 120 doses | 200/5 mcg: $156.16 for 120 doses

Special Authority Required

Special Authority Link

Low Emissions

How to use a Diskus.pdf

Ventolin Diskus (DPI)

salbutamol 200 mcg/dose

Duration:

4-6h

Instructions:

one inhalation every 4 to 6 hours as needed (maximum 4 doses per day)

Cost:

$25.24 for 60 doses

Not covered

Not on hospital formulary (alternative: Bricanyl)

Low Emissions

How to use an Inhub.pdf

Wixela Inhub (DPI)

fluticasone propionate/salmeterol 100/50; 250/50; 500/50 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (Maximum dose: fluticasone propionate 1,000 mcg/day and salmeterol 100 mcg/day)

Cost:

100/50 mcg: $63.88 for 60 doses | 250/50 mcg: $71.31 for 60 doses | 500/50 mcg: $96.61

Special Authority Required

Special Authority Link

High Emissions ~112.6 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Ventolin HFA (MDI)

generic versions: apo-sabutamol, sanis-salbutamol salbutamol 100 mcg/dose

Duration:

4-6h

Adult Instructions:

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$20.29 for 200 doses

Covered

Low Emissions

How to use a Turbuhaler.pdf

Bricanyl Turbuhaler (DPI)

terbutaline 0.5 mg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

4-6h

Adult Instructions:

one inhalation every 4 hours as needed; if dose is ineffective may repeat after 5 minutes

Cost:

$23.88 for 120 doses

Covered

Low Emissions

How to use a Diskus.pdf

Ventolin Diskus (DPI)

salbutamol 200 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

4-6h

Adult Instructions:

one inhalation every 4 to 6 hours as needed (maximum 4 doses per day)

Cost:

$25.24 for 60 doses

Not covered

Not on hospital formulary (alternative: Bricanyl)

Low Emissions

How to use a Breezhaler.pdf

Ultibro Breezhaler (DPI)

glycopyrronium/indacaterol 50/110 mcg/dose

Duration:

24h

Instructions:

contents of 1 capsule inhaled once daily using Breezhaler device

Cost:

$103.06 for 30 doses

Special Authority Required

Special Authority Link

Not on hospital formulary (automatic change to Inspiolto)

Low Emissions

How to use a Genuair.pdf

Tudorza Genuair (DPI)

aclidinium bromide 400 mcg/dose

Duration:

12h

Instructions:

1 inhalation twice daily

Cost:

$74.09 for 60 doses

Special Authority Required

Special Authority Link

Not on hospital formulary (automatic change to Spiriva Respimat)

Low Emissions

How to use an Ellipta.pdf

Trelegy Ellipta (DPI)

fluticasone furoate/umeclidinium/vilanterol 100/62.5/25 mcg/dose

Duration:

24h

Instructions:

one inhalation once daily

Cost:

100/62.5/25 mcg: $174.56 for 30 doses

Special Authority Required

Special Authority Link

Low Emissions

How to use an Ellipta.pdf

Trelegy Ellipta (DPI)

fluticasone furoate/umeclidinium/vilanterol 100/62.5/25; 200/62.5/25 mcg/dose

Age Indication:

adults (≥18 years old)

Duration:

24h

Adult Instructions:

one inhalation once daily (maximum dose: fluticasone furoate 200 mcg/umeclidinium 62.5 mcg/vilanterol 25 mcg per day)

Cost:

100/62.5/25 mcg: $174.56 for 30 doses | 200/62.5/25 mcg: $190.20 for 30 doses

Not covered for Asthma

Low Emissions

How to use a Turbuhaler.pdf

Symbicort Turbuhaler (DPI)

budesonide/formoterol fumurate 100/6; 200/6 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

may be used as maintenance/controller only: 1-2 puffs twice a day (max: 4 puffs/day) or as part of a maintenance/controller PLUS reliever regimen (MART therapy): 1-2 puffs twice a day and 1 puff as needed (max 8 puffs/24 hours)—Individualize daily budesonide dose based on severity of symptoms

Cost:

100/6 mcg: $97.73 for 120 doses | 200/6 mcg: $121.10 for 120 doses

Special Authority Required

Special Authority Link

Moderate Emissions ~38.8 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Teva-Salbutamol HFA or Airomir (MDI)

must include "no substition" on the Rx for this lower carbon option salbutamol 100 mcg/dose

Duration:

4-6h

Instructions:

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$18.45 for 200 doses

Covered

Moderate Emissions ~38.8 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Teva-Salbutamol HFA or Airomir (MDI)

must include "no substition" on the Rx for this lower carbon option salbutamol 100 mcg/dose

Duration:

4-6h

Adult Instructions:

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$18.45 for 200 doses

Covered

Low Emissions

How to use a Respimat.pdf

Spiriva Respimat (SMI)

tiotropium bromide 2.5 mcg/dose

Duration:

24h

Instructions:

2 inhalations (5 mcg) once daily

Cost:

$75.47 for 60 doses

Covered

Low Emissions

How to use a Handihaler.pdf

Spiriva Handihaler (DPI)

tiotropium bromide 18 mcg/dose

Duration:

24h

Instructions:

Contents of 1 capsule inhaled once daily using HandiHaler device. Note: To ensure drug delivery, the contents of each capsule should be inhaled twice

Cost:

$76.18 for 30 doses

Special Authority Required

Special Authority Link

Low Emissions

How to use a Diskus.pdf

Serevent Diskus (DPI)

salmeterol 50 mcg/dose

Duration:

12h

Instructions:

one inhalation twice daily

Cost:

$96.08 for 60 doses

Special Authority Required

Low Emissions

How to use a Breezhaler.pdf

Seebri Breezhaler (DPI)

glycopyrronium bromide 50 mcg/dose

Duration:

24h

Instructions:

contents of 1 capsule inhaled once daily using Breezhaler device

Cost:

$74.09 for 30 doses

Special Authority Required

Special Authority Link

Not on hospital formulary. This will be interchanged to Spiriva Respimat in hospital.

High Emissions ~81.3 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Qvar HFA (MDI)

beclomethasone dipropionate 50; 100 mcg/dose

Age Indication:

adults and children ≥ 5 years

Duration:

12h

Adult Instructions:

use twice daily with an appropriate spacer device—dosage based on patient's asthma symptoms and severity (see below)

Cost:

50 mcg: $61.26 for 200 doses | 100 mcg: $106.85 for 200 doses

Covered

Hospital: Restricted to HIV / AIDS patients with highly active anti-retroviral therapy (HAART)

Low Emissions

How to use a Turbuhaler device.pdf

Pulmicort Turbuhaler (DPI)

budesonide 100; 200; 400 mcg doses

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg: $54.55 for 200 doses | 200 mcg: $96.11 for 200 doses | 400 mcg: $134.93 for 200 doses

Covered

Low Emissions

How to use an Ellipta.pdf

Incruse Ellipta (DPI)

umeclidinium bromide 62.5 mcg/dose

Duration:

24h

Instructions:

one inhalation once daily

Cost:

$70.40 for 30 doses

Covered

Low Emissions

How to use a Respimat.pdf

Inspiolto Respimat (SMI)

tiotropium/olodaterol 2.5/2.5 mcg/dose

Duration:

24h

Instructions:

2 inhalations (5/5 mcg) once daily

Cost:

$87.47 for 60 doses

Special Authority Required

Special Authority Link

Low Emissions

How to use a Diskus.pdf

Flovent Diskus (DPI)

fluticasone propionate 100; 250; 500 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg $48.75 for 60 doses | 250 mcg $73.26 for 60 doses | 500 mcg $107.84 for 60 doses

Covered

High Emissions ~67.4 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Flovent HFA (MDI)

fluticasone propionate 50; 125; 250 mcg/dose

Age Indication:

adults and children ≥ 12 months of age

Duration:

12h

Adult Instructions:

use twice daily with an appropriate spacer device—dosage based on patient's asthma symptoms and severity (see below)

Cost:

50 mcg: $48.74 for 120 doses | 125 mcg: $40.08 for 120 doses | 250 mcg: $66.92 for 120 doses

Covered

Low Emissions

How to use a Breezhaler.pdf

Enerzair Breezhaler (DPI)

mometasone/glycopyrronium/indacaterol 160/50/150 mcg/dose

Age Indication:

adults (≥ 18 years)

Duration:

24h

Adult Instructions:

contents of 1 capsule (indacaterol 150 mcg/glycopyrrolate 50 mcg/mometasone 160 mcg) inhaled once daily (maximum dose: 1 capsule/day)

Cost:

$133.16 for 30 doses

Special Authority Required

Special Authority Link

Not on hospital formulary

Low Emissions

How to use a Genuair.pdf

Duaklir Genuair (DPI)

aclidinium bromide/formoterol fumarate 400/12 mcg/dose

Duration:

12h

Instructions:

1 inhalation twice daily

Cost:

$85.51 for 60 doses

Special Authority Required

Special Authority Link

Not on hospital formulary (automatic change to Inspiolto)

Low Emissions

How to use a Diskus.pdf

Advair Diskus (DPI)

fluticasone propionate/salmeterol 100/50; 250/50; 500/50 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (Maximum dose: fluticasone propionate 1,000 mcg/day and salmeterol 100 mcg/day)

Cost:

100/50 mcg: $119.45 for 60 doses | 250/50 mcg: $149.78 for 60 doses | 500/50 mcg: $208.01

Special Authority Required

Special Authority Link

High Emissions ~58.2 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Atrovent HFA (MDI)

ipratropium 20 mcg/dose

Duration:

4-6h

Instructions:

one to two puffs every 4 to 6 hours as needed (maximum 12 doses/day)

Cost:

$36.43 for 200 doses

Covered

Low Emissions

How to use a Respimat.pdf

Combivent Respimat (SMI)

ipratropium/salbutamol 20/100 mcg/dose

Duration:

4-6h

Instructions:

one inhalation every 4 to 6 hours as needed (maximum: 6 inhalations/day)

Cost:

$48.70 for 120 doses

Covered

Not on hospital formulary

Low Emissions

How to use a Turbuhaler.pdf

Bricanyl Turbuhaler (DPI)

terbutaline 0.5 mg/dose

Duration:

4-6h

Instructions:

one inhalation every 4 hours as needed; if dose is ineffective may repeat after 5 minutes

Cost:

$23.88 for 120 doses

Covered

High Emissions ~48.8 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Alvesco HFA (MDI)

ciclesonide 100; 200 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

24h

Adult Instructions:

use once daily with an appropriate spacer device—dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg: $70.19 for 120 doses | 200 mcg: $108.93 for 120 doses

Covered

Hospital:Restricted to paediatrics OR to HIV / AIDS patients with highly active anti-retroviral therapy (HAART)

High Emissions

How to use an MDI.pdf

Breztri Aeroshpere HFA (MDI)

budesonide/glycopyrronium/formoterol fumarate 160/7.2/5 mcg/dose

Duration:

12h

Instructions:

2 inhalations twice daily; maximum dose: 2 inhalations twice daily

Cost:

$161.88 for 120 doses

Special Authority Required

Special Authority Link

Not on hospital formulary

Low Emissions

How to use a Breezhaler.pdf

Atectura Breezhaler (DPI)

mometasone/indacaterol 80/150; 160/150; 320/150 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

24h

Adult Instructions:

one inhalation once a day—dosage based on patient's asthma symptoms and severity

Cost:

80/150 mcg: $50.99 for 30 doses | 160/150 mcg: $61.01 for 30 doses | 320/150 mcg: $76.85

Special Authority Required

Special Authority Link

Not on hospital formulary (automatic change to Breo Ellipta)

Low Emissions

How to use an Ellipta.pdf

Breo Ellipta (DPI)

fluticasone furoate/vilanterol 100/25; 200/25 mcg/dose

Age Indication:

adults (≥18 years old)

Duration:

24h

Adult Instructions:

one inhalation once daily (maximum: 1 inhalation [fluticasone furoate 200 mcg/vilanterol 25 mcg] once daily)

Cost:

100/25 mcg: $129.17 for 30 doses | 200/25 mcg: $194.82 for 30 doses

Special Authority Required

Special Authority Link

Low Emissions

How to use a Twisthaler.pdf

Asmanex Twisthaler (DPI)

mometasone furoate 100; 200; 400 mcg doses

Age Indication:

adults and children ≥ 6 years

Duration:

24h

Adult Instructions:

one inhalation once or twice daily—dose is based on patient's asthma severity (see below)

Cost:

100 mcg: $56.44 for 30 doses* | 200 mcg: $56.90 for 60 doses | 400 mcg: $98.90 for 60 doses or $56.90 for 30 doses

Covered

Hospital: Restricted to HIV / AIDS patients with highly active anti-retroviral therapy (HAART)

Low Emissions

How to use an Ellipta.pdf

Arnuity Ellipta (DPI)

fluticasone furoate 100; 200 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

24h

Adult Instructions:

one inhalation once daily (maximum 200 mcg a day) — dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg: $67.80 for 30 doses | 200 mcg: $119.65 for 30 doses

Covered

Not on hospital formulary

High Emissions ~77.7 km driven by average gas-powered passenger vehicle

How to use an MDI.pdf

Advair HFA (MDI)

fluticasone propionate/salmeterol 125/25; 250/25 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

two inhalation twice a day—dosage based on patient's asthma symptoms and severity (Maximum dose: fluticasone propionate 1,000 mcg/day and salmeterol 100 mcg/day)

Cost:

125/25 mcg: $140.82 for 120 doses | 250/25 mcg: $195.31 for 120 doses

Special Authority Required

Special Authority Link

Not on hospital formulary (automatic change to Zenhale)

Low Emissions

How to use an Ellipta.pdf

Anoro Ellipta (DPI)

umeclidinium/vilanterol 62.5/25 mcg/dose

Duration:

24h

Instructions:

one inhalation once daily

Cost:

$116.16 for 30 doses

Special Authority Required

Special Authority Link

Not on hospital formulary (automatic change to Inspiolto)

Low Emissions

How to use a Respiclick.pdf

Aermony Respiclick (DPI)

fluticasone propionate 55; 113; 232 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

one inhalation twice daily, approximately 12 hours apart—dose is based on patient's asthma symptom and severity (see below)

Cost:

55 mcg: $32.07 for 60 doses | 113mcg: $49.46 for 60 doses | 232 mcg: $68.21 for 60 doses

Covered

Not on hospital formulary

DISCLAIMER: This website does not provide medical advice. The information, including but not limited to text, graphics, images, and other material contained on this website are for informational purposes only. This website is designed for reference by healthcare professionals working in British Columbia only. While we endeavour to keep this resource up to date, this website may not include all available inhalers or all information on each inhaler. Please refer to the product monographs before prescribing any inhalers. If you are a patient/member of the public, do not make any changes to your treatments based on information here.

Inhaler emissions: Carbon footprint data sourced from CASCADES— an initiative led by the University of Toronto Centre for Sustainable Health Systems. Inhaler footprint categorized by carbon emissions generated and is classified as:
‍
low: equivalent to ≤ 5km driven by average gas-powered passenger vehicle
moderate: equivalent to 5–40 km driven by average gas-powered passenger vehicle
high: equivalent to ≥ 40 km driven by average gas-powered passenger vehicle
‍
Drug prices/coverage: Inhaler costs are approximate and sourced from drugsearch.ca—a free online tool showing BC drug prices with dispensing fees. Prices are from August 2023. Inhaler coverage data is gathered from BC PharmaCare Formulary. Regular coerage refers to the BC Fair PharmaCare plan only.

Age indication: This resource follows BC Asthma Guideline and Canadian Thoracic Guideline recommendations for dry powder inhaler (DPI) use, whereby DPIs are only appropriate for children ≥ 6 years old with sufficient inspiratory force.
‍‍
About us: This material has been developed by the Planetary Health Steering Committee at Fraser Health. We welcome your feedback and inquiries via email at: Kevin.liang@fraserhealth.ca. It is important to note that there are no reported conflicts of interest or pharmaceutical funding involved in the creation and dissemination of this website.

Legend:
MDI = metered-dose inhaler
DPI = dry powder inhaler
SMI = soft mist inhaler
SABA = short-acting β2-agonist
SAMA = short-acting muscarinic antagonist
LABA = long-acting β2-agonist
LAMA = long-acting muscarinic antagonist
ICS = inhaled corticosteroid

Common Inhaler Switches:

Metered-dose inhalers (MDIs) are a significant contributor to health care’s climate emissions. They contain high levels of hydrofluorocarbons that, when released into the atmosphere, act as potent greenhouse gases.

Dry powder and soft mist inhalers (DPI and SMIs) do not contain propellants and have a substantially smaller carbon impact. Using shared decision-making, prescribers can counsel patients on the benefits and disadvantages of various inhalers, including their impact on climate change and consider switches to lower-carbon alternatives when appropriate. See below for three scenarios for inhaler switches.

Reliever Therapy

For safety, GINA no longer recommends SABA-only treatment for Step 1 in adults and adolescents with asthma. SABA-only treatment increases the risk of severe exacerbations, and that adding any ICS significantly reduces the risk. There is new evidence in children 12 years of age and adults that PRN budesonide/formoterol decreases exacerbations in comparison to PRN SABA, with different levels of evidence in those with very mild versus mild asthma
‍

Controller Therapy