Greening guide

Greening guide

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Nursing wards

Medicines

Medicine sustainability interventions

8 interventions to reduce excessive medicine use in hospitals and promote responsible prescribing

Clinical care

Paracetamol should be administered orally instead of intravenously

To treat postoperative pain, intravenous (IV) acetaminophen is usually administered. However, research shows that oral (PO) administration is equally effective and more sustainable in most patients. A systematic review of 14 studies shows that there is no convincing difference in the analgesic effect between IV and oral acetaminophen at different times after surgery (1). However, the environmental impact varies considerably: CO2 emissions from IV administration are up to 16x higher (2). Where an oral administration of 1 gram of acetaminophen from a blister results in the emission of approximately 38 grams of CO₂ eq., this can be up to 628 grams when administered IV, depending on the packaging and administration material (2).

In most patients, acetaminophen can be administered orally, as described in the NVZA Monograph 'Paracetamol' (3). The paracetamol challenge demonstrated that IV acetaminophen administration can be reduced by at least 25%, saving staff time, costs and environmental impact (4). These results underline deployment at a larger scale.

Clinical care

Administer antiemetics orally and/or rectally instead of intravenously

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).

Clinical care and outpatient care

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 (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.

Clinical care and outpatient care

Discontinuation of proton pump inhibitors without a current indication

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).

Outpatient care

Climate-aware prescription of inhalation medication

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.

Clinical care and outpatient care

Restrictive opioid prescribing with indication and intended treatment duration

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.

Clinical care

Sharing the indication and intended treatment duration of multiple anticoagulant therapies with primary care

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.

Clinical care

Treatment with oral antibiotics when bioavailability is good

Timely conversion from intravenous (IV) to oral antibiotics is an important intervention within appropriate and sustainable care. Within the national antimicrobial stewardship program, as developed by SWAB, it is recommended to re-evaluate the route of antibiotic administration daily and switch to oral therapy as soon as possible once the patient is clinically stable and oral intake is possible (1). Switching to oral therapy contributes to shortening hospital stays, reduces complications from IV administration such as line infections and phlebitis, decreases the time spent preparing and administering infusions, and reduces material usage (2).

The Dutch Healthcare Institute explicitly states in its improvement report on Lower Respiratory Tract Infections that, where possible, a switch to oral antibiotics should be made for community-acquired pneumonia (CAP) (3). This recommendation has been translated into a target of 80% IV-to-oral switch, as included in the implementation agenda for Healthcare Evaluation and Appropriate Use (4). The Antimicrobial Stewardship Monitor (AMSM), which provides feedback on prescribing behavior to local A-teams, shows that this target percentage is often not yet achieved in practice (5).

Besides CAP, there is increasing evidence for IV-to-oral switch in other indications. A systematic review shows that in clinically stable patients with osteomyelitis, bacteremia, and endocarditis, an early switch to oral antibiotics leads to a clinically equivalent, but safer treatment, including a shorter hospital stay (6). For bone and joint infections, it has been shown that oral therapy during the first six weeks of treatment is non-inferior to intravenous therapy (7). It also appears that in patients with cellulitis, a switch to oral treatment, once the spread of the infection has stopped, leads to a non-inferior treatment (8).

Timely switching to oral treatment offers not only clinical benefits but also sustainability gains. For example, for penicillin use in pneumonia, based on the baseline situation in Denmark, it has been shown that timely completion of oral treatment leads to a reduction in climate impact of approximately 56%, increasing to 94% with fully oral treatment (9). For ciprofloxacin, a recent study has shown that one oral dose has a climate impact of 12.6 grams of CO2-equivalent, while an IV dose corresponds to a climate impact of almost 900 grams of CO2-equivalent (10).

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