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The use of medication contributes significantly to the total CO2 emission caused by the public health sector. Conservative estimates reveal that the amount of medication distributed by public pharmacies but is wasted unused equalizes a total amount of 100 million euro. Data regarding medication waste in hospitals is not yet available. Besides costs, wasting unused medication also has an enormous ecological impact. We analysed the stream of medication waste in our hospital and tried to reduce this by addressing the main causes. Our medication distribution process is mainly based on financial and quality based decisions, but should impact on planetary health not also be included? To realize this, though, both ecotoxicologic data as well as information related to environmental impact of medication production should be available and easily accessible.

The use of medication contributes significantly to the total CO2 emission caused by the public health sector. Conservative estimates reveal that the amount of medication distributed by public pharmacies but is wasted unused equalizes a total amount of 100 million euro. Data regarding medication waste in hospitals is not yet available. Besides costs, wasting unused medication also has an enormous ecological impact. We analysed the stream of medication waste in our hospital and tried to reduce this by addressing the main causes. Our medication distribution process is mainly based on financial and quality based decisions, but should impact on planetary health not also be included? To realize this, though, both ecotoxicologic data as well as information related to environmental impact of medication production should be available and easily accessible.

Pharmaceutical companies are under increasing scrutiny because of their strategy for gaining market access and reimbursement authorisation for novel drugs. The tool most often used is that of a randomised controlled trial (RCT) in a highly selected population that has a high chance of responding on the treatment but a low chance of developing side effects. This population differs to a large extent from real-life patients, who have diverging characteristics that can influence effectiveness and safety; these include co-morbidity, age and disease severity. The ultimate consequence is that evidence resulting from RCTs is not immediately transferable to clinical practice. This paper illustrates examples of drugs developed for rheumatoid arthritis and hepatitis C. We discuss research designs that can complement findings from RCTs, such as pragmatic trials, enriched trials, adaptive pathways, early access programs and patient registries. The aim is to stimulate debate among different stakeholders so that they answer the right question at the right time using a suitable research methodology.

To identify factors associated with appropriate knowledge about the indications for drugs prescribed to older patients on polypharmacy.Cross-sectional study.In a primary care setting, patients aged 60 years and over who were taking five or more prescribed drugs simultaneously were asked about their medication by conducting home interviews and postal questionnaires. Multiple logistic regression analysis was used to evaluate the association between medication knowledge and explanatory variables such as medication use, sex, age, residential status and educational level.Seven hundred and fifty-four participants, mean age 73.2 years, reported an average daily intake of nine (SD 3.0) prescribed drugs. Only 15% of the patients were able to recall the indication for each of their prescribed drugs. Variables that were negatively associated with correct reporting of all indications were: taking many prescribed drugs (≥ 10 vs. ≤ 5 drugs: odds ratio (OR) 0.05), age 80 years or over (vs. 60-69 years: OR 0.47) and male sex (vs. females: OR 0.53). Patients living with a partner were more knowledgeable than patients living alone (OR 2.11). We did not find an association with educational level.Among older patients using five or more prescribed drugs, there was little understanding of the indications for their drugs, especially among patients taking the highest number of drugs, patients aged 80 years or over, and men. Patients living independently with a partner were more knowledgeable than others.

The Dutch minister of Health, Welfare and Sport recently informed the Dutch Parliament that the current system of access to new medicines has failed because it is becoming too costly. She plans to tackle the pricing-problem within the current system by e.g. putting restrictions on patenting and market-protection of new medicines. In order to reform the system and to achieve rational pharmacotherapy, the government should do more. For example, the government could set up its own biotechnology companies, reject non-inferiority studies, and stop the rapid market access for new medicines when sound clinical evidence is lacking. Patients should be protected because they have the right, including during end-of-life care, to receive medicines that have been thoroughly evaluated.

There is increasing discussion in the Netherlands about the introduction of a threshold value for the costs per extra year of life when reimbursing costs of new drugs. The Medicines Committee ('Commissie Geneesmiddelen'), a division of the Netherlands National Healthcare Institute ('Zorginstituut Nederland'), advises on reimbursement of costs of new drugs. This advice is based upon the determination of therapeutic value of the drug and the results of economic evaluations. Mathematical models that predict future costs and effectiveness are often used in economic evaluations; these models can vary greatly in transparency and quality due to author assumptions. Standardisation of cost-effectiveness models is one solution to overcome the unwanted variation in quality. Discussions about the introduction of a threshold value can only be meaningful if all involved are adequately informed, and by high quality in cost-effectiveness research and, particularly, economic evaluations. Collaboration and discussion between medical specialists, patients or patient organisations, health economists and policy makers, both in development of methods and in standardisation, are essential to improve the quality of decision making.

It is not known if many existing medications can safely be used in children. For this reason the EU Paediatric Regulation came into force in 2007. When new medications are developed, pharmaceutical companies are obliged to produce a plan to research their use in children which must be approved by the regulatory authorities. Existing data on medications also had to be submitted. Review took place five years after the introduction of this regulation: of 682 medications, 476 plans were approved. In 206 of these medications this was unnecessary. By the end of 2011, research into 29 medications had been completed. The use of 10 of the 113 new, previously unregistered medications in children was approved, as was the case with 30 registered medications. Examination of existing data shows that results are often limited to changes in the 'Summary of Product Characteristics'. Many planned studies still have to be wound up, but in time the amount of information on safety and efficacy of new medications in children will increase greatly.

Patients with severe therapy-refractory immune-mediated inflammatory diseases (IMIDs) are increasingly treated with biologics. Since official practice guidelines for these rare diseases are lacking, these drugs are often prescribed off-label. However, treating physicians encounter difficulties and risks when prescribing drugs off-label. Access to these biologics for off-label indications is currently not well organized, which may result in suboptimal care. This also blocks innovation in patient care. In this article we introduce the recently initiated RUBRIC (Rational Use of Biologics in Refractory Immune-mediated inflammatory diseases Consortium) register. This national register documents the efficacy and safety of off-label biologic treatment in combination with the development of treatment protocols and practice guidelines. We believe that the results from this register will ultimately lead to a more evidence-based use of biologics in patients with rare IMIDs, which may also result in better access to these drugs. Ultimately, both the individual patient and the group as a whole will benefit.

Despite well-known differences in drug response between children and adults, dosing guidelines for children are usually developed by extrapolating the results from studies in adults. Instead of body weight, insight into the pharmacokinetics and pharmacodynamics of drugs should serve as the basis for dosing in children. In studies into drug dosing in children, the 'population approach' should be chosen to minimize the burden for the child. With a population approach, the covariates that affect the pharmacokinetics and pharmacodynamics of drugs can be identified in a covariate analysis; examples of covariates include body weight, age, degree of illness and genetic factors. Drugs that serve as a model for a specific elimination route provide the basis for individualized dosing guidelines for children.

Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse.What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist?Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use.Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%.Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.

Elderly patients are at an increased risk of developing adverse drug events due to polypharmacy, co-morbidity and changes in physiology. Often, pharmacotherapy in frail elderly patients is initiated based on randomized trials from which this population has been excluded. In such cases, the question when to stop a medication may be as important as when to start it. It is important to consider whether the patient is using Potentially Inappropriate Medications (PIM) that should be stopped. Checklists can be helpful in detecting PIM. A recent study has shown that Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria can identify clinically relevant PIM much better than the Beers criteria often used. These outcomes indicate that patient safety can be improved if clinicians use checklists such as the STOPP.

The Dutch Drug Bulletin (Geneesmiddelenbulletin) is a monthly journal with a unique approach which, after a hectic period in which its independence and even its right to exist were threatened, has now reached calm water The continued existence of the Dutch Drug Bulletin is now guaranteed, independently of the pharmaceutical industry, the government, professional organizations and patient organizations. Articles appear in the Dutch Drug Bulletin after extensive consultation among various experts. Conclusions are based on the published (and hence controllable) results of randomized, preferably double-blind, studies with an appropriate control group. Departures from these standards are made only in highly exceptional cases. The Dutch Drug Bulletin determines the place of new drugs amongst the already available drugs and compares their effectiveness and side effects with those of the standard therapy. This approach guarantees that dentists and physicians are kept up to date with respect to developments in the field of pharmacology, without the pharmaceutical industry or the government exerting any influence.