Targeted prescribing of proton pump inhibitors (as stomach protection)

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 (2). In short-term use, more than half of the patients appeared to have no indication (3); in chronic use, this figure is even 87% (4). Overtreatment with PPIs risks side effects, such as an increased risk of bone fractures and vitamin B12 deficiency, but also leads to unnecessary costs and environmental impact (2).

The NHG 'Stomach Disease (NL)' guideline and the NVMDL guideline 'Gastroesophageal Reflux Disease (NL)' provide recommendations to prevent overtreatment with PPIs (5.6). These guidelines recommend that patients with stomach problems or disorders with a temporary indication for PPIs should reduce a PPI within three months. Only patients with grade C and D4 reflux esophagitis, Barrett's oesophagus and Zollinger-Ellison syndrome should use a PPI for life (5 - 7). A PPI for stomach protection should be stopped when a patient stops taking the medication for which it was prescribed (8).

The Proton Pump Inhibitors Knowledge Paper (NL) explains the consideration for reducing or discontinuing proton pump inhibitors when using PPIs chronically (7). Reducing appears to be successful in approximately 40 - 70% of the patients, depending on the intervention that is chosen (9). In this way, any long-term side effects of PPIs can be prevented and costs and environmental impact can be saved (5 - 7).

Antiemetics, such as 5HT3 antagonists (e.g. ondansetron and granisetron) and dopamine antagonists (e.g. metoclopramide), are widely used in clinical care to prevent and treat nausea and vomiting, for example postoperatively or during chemotherapy. Research shows that antiemetics administered enterally (e.g., orally or rectally) at an equivalent dose usually have a similar effectiveness and safety to those administered intravenously (IV) (1-2).

The oral/rectal route contributes to greater comfort and autonomy. In addition, the use of oral/rectal medication is more cost-effective and sustainable, because fewer disposable materials are required than intravenous administration (3). In situations where oral administration is not feasible, such as severe nausea or vomiting, rectal administration may sometimes still be chosen. IV administration is only eligible if this is not possible. This is further detailed in the NVZA monographs (4-6).

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.