Medicines are designed to heal, but after they pass through the human body they can continue their journey into rivers, lakes, groundwater and oceans. A study of two Swedish regions shows how the committees that advise doctors on which medicines to prescribe are beginning to treat environmental damage as part of the same equation as patient safety, effectiveness and cost. By incorporating ecological information into prescribing guidelines, educating clinicians, monitoring prescription patterns and setting explicit targets for high-risk drugs, the regions of Gävleborg and Västernorrland have built a practical model for reducing pharmaceutical pollution without abandoning clinically necessary treatment. Their experience suggests that the environmental footprint of medicine could be reduced not only at the factory or wastewater-treatment plant, but also at the moment a prescription is chosen.
The study focuses on Drug and Therapeutics Committees, or DTCs, multidisciplinary groups typically made up of physicians, pharmacists, nurses and healthcare administrators. Their traditional role is to promote the “rational use” of medicines: giving patients drugs appropriate to their medical needs, at individually suitable doses, for long enough to work, and at the lowest reasonable cost. In Sweden, every one of the country’s 21 regions is required to have at least one such committee. These bodies develop formularies, advise policymakers and clinicians, analyze prescribing data and organize professional education across hospitals and primary-care centers. The new analysis argues that rational prescribing must now include a further consideration: the connection between human health, animals, plants and the shared environment.
That connection is increasingly difficult to ignore. Many active pharmaceutical ingredients are biologically potent by design, and some remain chemically stable after excretion. Conventional wastewater treatment can remove a proportion of these compounds, but not all of them. Residues may therefore reach aquatic ecosystems at concentrations capable of affecting sensitive organisms, particularly when exposure is continuous. Diclofenac, a widely used nonsteroidal anti-inflammatory drug, has become an emblematic example. The drug caused catastrophic declines in vulture populations in South Asia when birds fed on the carcasses of treated livestock and developed fatal kidney failure. Laboratory and field studies have also linked diclofenac exposure to damage in fish tissues, including the liver, kidneys and gills. Swedish authorities classify diclofenac and ciprofloxacin as river-basin-specific pollutants, while several hormones, including estradiol and ethinylestradiol, are also recognized as water contaminants.
The second environmental threat examined in the study comes from fluoroquinolone antibiotics, particularly ciprofloxacin and norfloxacin. These drugs can be persistent in aquatic environments and may exert antibacterial effects far below the concentrations used to treat patients. That matters because low-level antibiotic exposure can create evolutionary pressure favoring resistant bacteria. In effect, wastewater containing pharmaceutical residues may act as a diffuse training ground for microbes, selecting genetic variants able to survive future treatments. Fluoroquinolones also carry important clinical warnings. European regulators have restricted their use because of potentially disabling and long-lasting effects involving connective tissue, including tendon damage and increased risks associated with aortic complications. Unlike diclofenac, however, ciprofloxacin remains essential for some serious infections, including certain upper urinary-tract infections accompanied by fever. The goal is therefore not simple elimination, but precise, evidence-based use.
Researchers conducted an observational case study using official reports, regional and national agency websites, educational materials, communications, presentations and other documents published between 1988 and 2024. They reconstructed how the two DTCs developed environmental policies and compared those activities with sales data for diclofenac, ciprofloxacin and norfloxacin. Prescription and over-the-counter sales were obtained from the Swedish eHealth Agency and converted into kilograms of active substance per year. For systemic diclofenac, the analysis included tablets and capsules; topical products such as gels were assessed separately. Fluoroquinolone calculations covered the two products that were available in Sweden during the period. Measuring mass rather than simply counting prescriptions provides a closer approximation of the amount of pharmaceutical material entering the environment, although it still does not reveal how much was actually consumed or improperly discarded.
Gävleborg began considering the environmental consequences of medicines after a regional political decision in 2002. Over time, the policy became embedded in the region’s formulary, the list of medicines recommended to prescribers. Since 2019, the formulary has included environmental information for every listed drug when such information is available, and medicines with lower environmental impact may be favored when effectiveness, safety and cost-effectiveness are otherwise comparable. The guidance also identifies situations in which non-drug approaches could replace medication. Diclofenac received an explicit “anti-recommendation” in 2018, reflecting both its cardiovascular risks and its ecological effects. The committee also monitored prescribing by individual healthcare centers and hospital clinics, returned the results to clinicians and managers, and used comparisons between providers to encourage improvement.
Västernorrland took a similarly broad approach, beginning environmental work when its DTC was formed in 1997 and creating a dedicated “Pharmaceuticals and Environment” task force in 2021. Its measures included encouraging smaller starter packs for long-term therapies, reassessing treatments when benefits no longer outweighed risks, conducting medication reviews for older patients and promoting the return of unused medicines to pharmacies rather than flushing them into wastewater or placing them in household waste. The regional formulary emphasizes non-pharmacological alternatives such as cognitive behavioral therapy for some mental-health conditions and physiotherapy for some forms of pain. Environmental requirements have also been incorporated into medicine procurement, and the committee works with pharmacies, water and wastewater organizations and healthcare payers. Environmental representatives at healthcare providers receive specialized training, supported by a digital education course.
The prescribing data reveal substantial changes over the 25-year period. Systemic diclofenac sales rose during the first two decades and reached approximately 127 kilograms in Gävleborg and 137 kilograms in Västernorrland in 2011. They then declined rapidly. Over-the-counter systemic sales remained near 20 kilograms per year until 2020, when oral diclofenac was reclassified as prescription-only in Sweden because of cardiovascular concerns. The change did not produce a marked compensatory surge in topical diclofenac sales in either region. Topical products, introduced in 2005, increased for several years, particularly through over-the-counter channels, but their use also began to fall after 2016. The researchers caution that the trends cannot be attributed to the DTCs alone: national regulation, professional campaigns and changes in public awareness also influenced prescribing.
Fluoroquinolone use followed a different trajectory. In 2000, roughly 37 to 50 kilograms each of ciprofloxacin and norfloxacin were sold in each region. Norfloxacin use declined steadily until the product was removed from the Swedish market in 2020. Ciprofloxacin use initially increased as norfloxacin declined, then began falling after 2012, with an especially low level during the COVID-19 pandemic. Gävleborg introduced a fluoroquinolone prescribing target in 2003, while Västernorrland followed in 2005. The latter eventually specified that no more than 10 percent of urinary-tract-infection antibiotic prescriptions for women in primary care should be fluoroquinolones. Gävleborg set a target of fewer than five defined daily doses per 1,000 listed patients per day in primary care. These targets do not prohibit clinically justified treatment; they are intended to make unnecessary prescribing visible and reduce it.
The researchers say the Swedish experience offers a template for healthcare systems facing the same dilemma: how to preserve access to effective medicines while limiting their unintended ecological consequences. The approach begins with a technical challenge that remains unresolved—environmental information is missing for many active pharmaceutical ingredients. Reliable data on persistence, toxicity, bioaccumulation and effects on aquatic species are needed before committees can compare drugs meaningfully, and information about pollution from manufacturing is often absent even when risks from use have been assessed. Better environmental data could allow regulators and DTCs to distinguish drugs that are readily degraded from those that persist, accumulate or disrupt biological processes. Upstream decisions are especially important because wastewater treatment improvements, although necessary, cannot fully compensate for excessive or inappropriate use. The study does not prove that regional policies caused every observed decline, and sales do not equal consumption: medicines may remain unused in homes or be discarded incorrectly. Even so, it demonstrates how environmental stewardship can become part of everyday clinical decision-making, turning a prescription from a purely medical transaction into a One Health decision with consequences beyond the patient.
Subject of Research: Environmental sustainability in pharmaceutical prescribing and the role of Swedish Drug and Therapeutics Committees
Article Title: Promoting sustainable prescribing of medicines through Drug and Therapeutics Committees: experiences from two Swedish regions
Article References: Ericsson B, Ramström H, Lindahl U, Nekoro M, Villén J, Wettermark B. Promoting sustainable prescribing of medicines through Drug and Therapeutics Committees: experiences from two Swedish regions. Original research page
Image Credits: AI Generated
DOI: 10.1002/prp2.70279
Keywords: pharmaceutical pollution, sustainable prescribing, Drug and Therapeutics Committees, diclofenac, fluoroquinolones, antibiotic resistance, environmental health, Sweden
Tags: Drug and Therapeutics Committeeseco-friendly prescribing practicesecological considerations in prescribingenvironmental impact of medicinesenvironmentally conscious medication guidelinesmultidisciplinary healthcare teamspharmaceutical pollution reductionpharmaceutical waste managementprescription monitoring and targetsregional healthcare strategiessustainable prescribingSweden healthcare sustainability
