110 - Deprescribing as a Decarbonisation Lever with Lisa-Marie Smale and Nicole Hunfeld

Most work on greener medication starts with the waste bin. This episode goes one step upstream, to the moment a medicine is prescribed at all, and in which form. Lisa-Marie Smale and Nicole Hunfeld explain what 63 Dutch doctors and pharmacists agreed to change about prescribing, why a tablet can beat a drip, and where a stop date gets lost on the way home.

About the guests: Lisa-Marie Smale is a pharmacist and postdoctoral researcher in sustainable medicine use at Erasmus MC in Rotterdam, and first author of the Delphi study behind this episode. Nicole Hunfeld is a clinical pharmacist at the Erasmus MC intensive care unit, chair of its green team and Associate Professor in Sustainable Healthcare. Both work in Samen de zorg vergroenen (Greening Healthcare Together), the Dutch national programme implementing sustainability measures in almost all 69 hospitals. Nicole was last on the show in episode 088.

Three things you'll take away:

Not treating beats switching. Visible medicine waste is the easy start, but the bigger gain sits before the prescription: up to 70% of guidelines say nothing about when to stop, so medicines run on because nobody asks whether they are still needed. A tablet beats a drip only when the dose is equivalent. Oral paracetamol has a far lower footprint than IV, but the switch only holds where bioavailability is high enough (a rule of thumb of 70 to 80%). By Nicole's account, her ICU went from a 25% target to a 50% cut within a month, with nurses in the lead. Follow the proton pump inhibitor home. One pill a day, often started inside a standard pain package, with no owner for the stop date. In Dutch primary care, roughly nine in ten are taken without a current indication.

References mentioned:

Smale EM, van der Giessen JL, Appels CWY, et al. Advancing sustainable medication use in healthcare: a Delphi study on (de)prescribing interventions. BMJ Open 2026;16:e115383: https://doi.org/10.1136/bmjopen-2025-115383 Samen de zorg vergroenen (Greening Healthcare Together), medication guide with the eight interventions: https://samendezorgvergroenen.nl/en/vergroeningsgids/geneesmiddelen Samen de zorg vergroenen, stopping proton pump inhibitors without a current indication: https://samendezorgvergroenen.nl/en/interventie/staken-van-protonpompremmers-zonder-actuele-indicatie Hunfeld, Tibboel, Gommers. The paracetamol challenge in intensive care. Intensive Care Medicine 2024: https://pure.eur.nl/ws/portalfiles/portal/174421991/s00134-024-07679-y.pdf Groene Zorg Alliantie, Duurzame Paracetamol Challenge: https://groenezorgalliantie.com/initiatief/duurzame-paracetamol-challenge/ Smale and Hunfeld. The clinical trade-offs of the "eco-pharma dilemma". Sustainable Chemistry and Pharmacy 2025: https://www.sciencedirect.com/science/article/abs/pii/S2352554125003559

Links:

Lisa-Marie Smale, Erasmus MC research portal: https://pure.eur.nl/en/persons/lisa-marie-smale/ Nicole Hunfeld, Erasmus MC: https://www.erasmusmc.nl/en/research/researchers/hunfeld-nicole Samen de zorg vergroenen: https://samendezorgvergroenen.nl/en

You might also enjoy:

Episode 088, Circular material flow of medication in the intensive care unit, with Nicole Hunfeld and Jasper Klasen (ESCH-R): https://carepathwayconsulting.com/podcast/podcast-episode-088/ Episode 109, What's Up With the Single-Useness? Inside Hospital Routines, with Heidi Annala: https://carepathwayconsulting.com/podcast/podcast-episode-109/ Episode 103, LCA in Surgery and Specialty-Level Carbon Literacy, with Anna Roe Rasmussen: https://carepathwayconsulting.com/podcast/podcast-episode-103/

Host links:

Joachim Almdal on LinkedIn: https://www.linkedin.com/in/joachim-espeland-almdal-017a6973/ Frederik van Deurs on LinkedIn: https://www.linkedin.com/in/frederikvandeurs/ Care Pathway Consulting: https://carepathwayconsulting.com

"In terms of circularity, not treating can provide bigger environmental gains than switching to another treatment. As long as it's still safe for the patient