The prescription of multiple anticoagulant therapy (e.g. double or triple therapy with anticoagulants and antiplatelet agents) is complex and associated with an increased risk of bleeding. Patients often use these combinations temporarily, for example after acute coronary syndrome, percutaneous coronary intervention, or concomitant atrial fibrillation and stent implantation (1). European and Dutch guidelines therefore emphasize that double or triple therapy is never indicated for life, but always has a limited treatment period, depending on the clinical situation and the individual balance between the risk of bleeding or an ischemic event (1).

In practice, however, it appears that these drugs are regularly used for too long or are continued without a current indication, which significantly increases the risk of serious, preventable bleeding. For example, research in Dutch pharmacies showed that 14— 23% of patients who used dual anticoagulation no longer had a valid indication (2). During hospitalization, it was found that more than 40% of patients with multiple anticoagulant therapies used these combinations incorrectly (3). This risks bleeding complications, and thus unnecessary hospital admissions (4), but also contributes to unnecessary costs and environmental impact.

To prevent this, clear communication during dismissal and transfer is crucial. Explicitly sharing the indication and the intended treatment duration with primary care (general practitioner and pharmacist) enables follow-up care providers to continue treatment responsibly or to stop it in time. This contributes to medication safety, reduces the risk of complications and prevents unnecessary drug use.

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.

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.