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Human-use medicines are introduced into surface water throughout their entire life cycle, from manufacturing and consumption to improper disposal, resulting in negative effects on aquatic flora and fauna. Sustainability approaches have addressed this issue, proposing frameworks like the One Health approach. A revised definition of the rational use of medicines has also been proposed, taking into account their environmental sustainability. Building on this updated definition, this paper presents a decision-making flowchart to integrate the assessment of the impact of human medicines on surface water, outlining existing actions and proposing new ones. These actions are categorized into those with primary clinical benefits and those focused solely on environmental concerns. They include both upstream and downstream measures, such as implementing regulations similar to those in the EU and the USA, educating future healthcare practitioners, promoting green pharmacy innovations, and establishing proper disposal practices., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Antimicrobial resistance (AMR) is a global threat to human and animal health and well-being. To understand AMR dynamics, it is important to monitor resistant bacteria and resistance genes in all relevant settings. However, while monitoring of AMR has been implemented in clinical and veterinary settings, comprehensive monitoring of AMR in the environment is almost completely lacking. Yet, the environmental dimension of AMR is critical for understanding the dissemination routes and selection of resistant microorganisms, as well as the human health risks related to environmental AMR. Here, we outline important knowledge gaps that impede implementation of environmental AMR monitoring. These include lack of knowledge of the 'normal' background levels of environmental AMR, definition of high-risk environments for transmission, and a poor understanding of the concentrations of antibiotics and other chemical agents that promote resistance selection. Furthermore, there is a lack of methods to detect resistance genes that are not already circulating among pathogens. We conclude that these knowledge gaps need to be addressed before routine monitoring for AMR in the environment can be implemented on a large scale. Yet, AMR monitoring data bridging different sectors is needed in order to fill these knowledge gaps, which means that some level of national, regional and global AMR surveillance in the environment must happen even without all scientific questions answered. With the possibilities opened up by rapidly advancing technologies, it is time to fill these knowledge gaps. Doing so will allow for specific actions against environmental AMR development and spread to pathogens and thereby safeguard the health and wellbeing of humans and animals., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Pharmaceuticals treat and prevent diseases but can pose a risk to organisms, predominantly in aquatic environments. The use of pharmaceuticals is predicted to increase due to, among other factors, a growing and aging population and climate change. Therefore, it is important to develop mitigation strategies to prevent pharmaceutical residues from entering the environment. In Sweden, two public pharmaceutical web-based knowledge supports provide information on the environmental impact of pharmaceuticals., Objective: To explore stakeholder perspectives, use and future opportunities related to two webbased knowledge supports publicizing environmental information on pharmaceuticals., Methods: Stakeholders identified for their experience with the knowledge supports, pharmaceutical policy, and stakeholder collaboration were recruited using purposive and snowball sampling for semi-structured interviews. Interviews were conducted in person or via video calls. Respondents included twenty-one representatives from the pharmaceutical industry, regional and national authorities, academia, and an independent research institute. Interview transcripts were analyzed using content analysis., Results: Respondents valued having environmental information on pharmaceuticals publicly accessible on two well-known pharmaceutical knowledge supports. The knowledge supports have been used in Sweden and internationally. Perceived differences were recognized between the impact and perspectives of the two knowledge supports with a general preference for the Janusinfo knowledge support. The preference was especially identified regarding transparency and the use of the information in clinical practice. Barriers to impact were a lack of resources and decision-making criteria. Respondents believed that the impact and value of the knowledge supports could be improved with more authority involvement., Conclusion: Public knowledge support providing environmental information on pharmaceuticals has been valuable across sectors, especially, among Drug and Therapeutics Committees. We believe the results from this study could be useful for other countries interested in implementing a similar system., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Pharmaceuticals can reach the environment at all stages of their lifecycle and accumulate in the ecosystem, potentially reaching toxic levels for animals and plants. In recent years, efforts have been made to map and control this hazard. Assessing country-specific environmental risks could drive regulatory actions towards eco-friendlier drug utilization and disposal practices. By starting from a list of 25 environmentally hazardous pharmaceuticals developed by Region Stockholm, we integrated eco-toxicological and 2019-2021 Italian drug utilization data to estimate the environmental impact of pharmaceuticals in Italy. We calculated the risk as the ratio between the predicted environmental concentration (PEC) and the predicted no-effect concentration (PNEC). We found a high risk for levonorgestrel, ciprofloxacin, amoxicillin, azithromycin, venlafaxine, sertraline and diclofenac and a moderate risk for ethinyloestradiol, oestradiol and clarithromycin. This analysis can be periodically performed to identify the pharmaceuticals with the highest risk for the environment and ascertain if containment measures should be implemented., (© 2023 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)