Administer antiemetics orally and/or rectally instead of intravenously

Proton pump inhibitors (PPIs) are antacids that are frequently used. Pantoprazole (1.3 million users) and (es) omeprazole (1.2 million users) were among the top 3 most used medicines in 2023 (1). However, it appears that a large number of these drug users have no indication for PPI use (anymore) (2). With short-term use, more than half of the patients appeared to have no indication (3). Part of this is caused by starting PPIs as stomach protection without indication.

The NHG guideline “Prevention of stomach complications due to drug use (NL)” and the knowledge document proton pump inhibitors (NL) indicate that a PPI is indicated as stomach protection based on risk factors, such as age, ulcer or history of stomach complications, NSAID dosing, co-medication with an increased risk of stomach complications and comorbidities, such as rheumatoid arthritis, heart failure or diabetes (4 - 6). By prescribing PPIs based on risk factors for stomach protection, unnecessary PPI use can be reduced, thereby preventing environmental impact.

Inhalation medications are used in the treatment of asthma and COPD. In the Netherlands, more than 1.4 million people use inhalation medications every year, including bronchodilators, such as short- and long-acting β2 sympathomimetics and parasympatholytics, and inhaled corticosteroids (1). There are various types of inhalers available, including dose aerosols, powder inhalers, and soft mist inhalers. These vary greatly in environmental impact because dose aerosols contain propellants, such as HFA-134a, which has a 1500 times stronger greenhouse effect than CO₂ (2).

In some countries, powder inhalers are already prescribed more often. For example, the proportion of dose aerosols is lowest in Sweden (± 10%), highest in England (± 70%) and around 50% in the Netherlands (2, 3). If the Netherlands were to follow the Swedish example, a significant amount of CO₂ emissions could be prevented (2, 3). This is feasible because powder inhalers and soft mist inhalers are an effective alternative for most adult asthma and COPD patients, provided the inhalation technique is used correctly (4). In addition, more and more dose aerosols based on more sustainable propellants will come on the market in the coming years. This can also reduce the greenhouse gas emissions of inhalation medication.

To encourage doctors and pharmacists to prescribe climate-friendly inhalation medication, the Tranmural guideline for climate-aware prescribing of inhalation medication was developed by the Health Institute in collaboration with GPs, pulmonologists, paediatricians, pharmacists and the Lung Fund (4). To make a real impact, the guideline still requires inclusion in local formularies, so that the large-scale, unnecessary use of environmentally harmful inhalation medications can be reduced.

The most commonly used, high-acting opioids are morphine, fentanyl, oxycodone, and buprenorphine (1). In 2024, more than 1.1 million people received an opioid through the public pharmacy (2). Although the total number of benefits in kind fell slightly compared to 2023, the number of prescriptions from the hospital actually increased slightly (3). A first dose of a high-acting opioid included an average of 9 days of medication in 2024 (3), while acute pain due to trauma or surgery often requires only 48 hours of strong opioid pain relief (4). Prescribing opioids for too long increases the risk of dependence and also leads to unnecessary environmental impact.

Research shows that the amount of opioids that patients receive at discharge influences their actual use (5). As recovery progresses, the need for opioids decreases rapidly; four days are sufficient for most patients. This is in line with international recommendations that recommend a duration of 3 - 7 days (6-8). The guideline of the Dutch Association of Anesthesiology (NVA) also recommends appropriate use of opioids through restrictive prescribing (up to 7 days) tailored to the pain experienced (9).

Another bottleneck is that the intended treatment duration and indication of opioids at discharge or outpatient dispensing are not always explicitly stated or shared with patients and primary care providers. As a result, GPs and pharmacists often lack crucial information to continue treatment responsibly or to phase it out in time. This increases the risk of unnecessarily long use, and thus unnecessary environmental impact and risk of dependency.

Based on a recent opinion article This intervention has been selected in the NTvG by Kaal et al. This article recommends that there is more room for oral antibiotic initiation, but does not describe clinically tested interventions. This intervention will therefore be further developed on the basis of available scientific literature and will follow at a later date.