The climate impact of medicines in the hospital sector: a scoping review

The climate impact of medicines in the hospital sector: a scoping review | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 11 June 2025 V1 Latest version Share on The climate impact of medicines in the hospital sector: a scoping review Authors : Katrine Bitsch Johansen 0009-0009-5782-0513 [email protected] , Peter Skov Esbech 0000-0001-8147-5515 , Johan Helland , Sidsel Arnspang Pedersen , and Zandra Ennis Authors Info & Affiliations https://doi.org/10.22541/au.174963974.47040519/v1 Published Basic & Clinical Pharmacology & Toxicology Version of record Peer review timeline 296 views 191 downloads Contents Abstract The climate impact of medicines in the hospital sector: a scoping review Supplementary Material References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Climate change poses a significant challenge for global health. The World Health Organization estimates 250,000 additional annual deaths between 2030 and 2050 due to global warming. The healthcare sector is a major contributor to greenhouse gas (GHG) emissions, accounting for approximately 4.4-5.5% of a country’s total carbon footprint, with medicines contributing 5–10%. Research on the climate impact of medicines is needed to identify areas for emission reduction. This scoping review aimed to provide an overview of existing literature on the climate impact of medicines in the hospital sector and identify knowledge gaps. A comprehensive literature search was conducted, with articles categorized based on the type of medicine or therapeutic area, enabling a structured mapping of current areas of evidence. The review followed PRISMA-ScR guidelines, searching PubMed and Embase for peer-reviewed articles published in the last 20 years that reported original data on GHG emissions from medicines in the hospital sector. Of the 2,986 studies identified, 33 were included. Most focused on emissions from inhaled anaesthetic gases (n=16), followed by inhaler therapies (n=6), healthcare systems or whole-hospital emissions (n=5), ophthalmology (n=3), surgical procedures (n=2), and other areas (n=2). The findings show that while certain areas, particularly anaesthetic gases and inhaler therapy, have been more researched the overall research on the climate impact of medicines in the hospital sector remains limited. Knowledge gaps persist across most therapeutic areas, highlighting the need for further systematic investigations to inform effective mitigation strategies and support climate-conscious decision-making in the hospital sector. The climate impact of medicines in the hospital sector: a scoping review Authors Katrine Bitsch Johansen 1 , Peter Skov Esbech 1 , Johan Fredrik Helland 1 , Sidsel Arnspang Pedersen 1 , Zandra Nymand Ennis 1 1 Center for research in sustainable medicine, Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark Corresponding author Katrine Bitsch Johansen, MD Department of Clinical Pharmacology Odense University Hospital Campusvej 55 5230 Odense M, Denmark E-mail: [email protected] Author e-mails Katrine Bitsch Johansen, e-mail: [email protected] Peter Skov Esbech, e-mail: [email protected] Johan Fredrik Helland, e-mail: [email protected] Sidsel Arnspang Pedersen, e-mail: [email protected] Zandra Nymand Ennis, e-mail: [email protected] Conflict of interest statement The authors declare no conflicts of interest Funding information No external funding was recieved Registration The protocol for this study was registered at the Open Science Framework, registration DOI: https://doi.org/10.17605/OSF.IO/TZWHB Keywords Climate impact, green medicine, healthcare sector Word count Abstract: 247 words Article body: 2010 words Tables: 0 (3 in appendix) Figures: 2 (1 in appendix) Abstract Climate change poses a significant challenge for global health. The World Health Organization estimates 250,000 additional annual deaths between 2030 and 2050 due to global warming. The healthcare sector is a major contributor to greenhouse gas (GHG) emissions, accounting for approximately 4.4-5.5% of a country’s total carbon footprint, with medicines contributing 5–10%. Research on the climate impact of medicines is needed to identify areas for emission reduction. This scoping review aimed to provide an overview of existing literature on the climate impact of medicines in the hospital sector and identify knowledge gaps. A comprehensive literature search was conducted, with articles categorized based on the type of medicine or therapeutic area, enabling a structured mapping of current areas of evidence. The review followed PRISMA-ScR guidelines, searching PubMed and Embase for peer-reviewed articles published in the last 20 years that reported original data on GHG emissions from medicines in the hospital sector. Of the 2,986 studies identified, 33 were included. Most focused on emissions from inhaled anaesthetic gases (n=16), followed by inhaler therapies (n=6), healthcare systems or whole-hospital emissions (n=5), ophthalmology (n=3), surgical procedures (n=2), and other areas (n=2). The findings show that while certain areas, particularly anaesthetic gases and inhaler therapy, have been more researched the overall research on the climate impact of medicines in the hospital sector remains limited. Knowledge gaps persist across most therapeutic areas, highlighting the need for further systematic investigations to inform effective mitigation strategies and support climate-conscious decision-making in the hospital sector. Introduction Climate change poses one of the most significant challenges of the 21st century. The World Health Organization (WHO) estimates that climate change will affect the health of many and could lead to a higher frequency and severity of heatwaves, wildfires, floods, tropical storms, and hurricanes. Additionally, the WHO estimates that climate change could result in approximately 250,000 additional deaths annually between year 2030 and 2050, due to a higher frequency of climate related diseases, such as undernutrition, malaria, diarrhea, and heat stress 1 . Given these facts, an urgent need for global action has arisen to both mitigate and adapt to the unfavorable effects of climate changes. The healthcare sector is a considerable contributor to the greenhouse gas (GHG) emissions worldwide. Globally, the healthcare sector on average contributes with 4.4-5.5% of a country’s total carbon footprint 2,3 . This statistic highlights the substantial environmental impact of the healthcare sector. Emissions come from a wide range of sources, including patient- and staff transport, facilities operations and administration. Other contributors include heating, water and electricity consumption, waste management as well as medicines and medical supplies 2-9 . It is estimated that medicines contribute between 5-10% of the total GHS emissions from the healthcare sector 2,3 . These numbers underscore the relevance of investigating the potential for reducing this emission burden. With this scoping review, we aimed to provide an overview of existing literature concerning the climate impact from medicines in the hospital sector, thereby highlighting both current knowledge and any gaps in existing literature. Methods This is a scoping review conducted in accordance with the “Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist” 10 . The study protocol was registered at the Open Science Framework. Information sources The databases PubMed and Embase were searched on December 12 th 2024. Keywords and MeSH terms were combined using Boolean operators, employing search terms such as ”Health Care Facilities, Manpower, and Services,” health AND ”Pharmaceutical Preparations,” “Anaesthetic Gas,” ”Pharmaceutical Preparation,” AND ”Carbon Footprint,” OR ”Greenhouse Gases,” OR “Eco-pharmaco-stewardship”. For details see Figure S1, Appendix. Eligibility criteria We defined the eligibility criteria prior to the literature search. Full-text peer-reviewed articles with original data on GHG emission related to the use of medicines in a hospital setting. To ensure that data were reasonably representative of contemporary clinical practice, we included literature published up to 20 years ago written in either English, Danish, Swedish or Norwegian (see Table S1, Appendix for detailed inclusion criteria). Study Selection The search strategy yielded n=3579 hits in total, identified from PubMed and Embase. Abstracts were exported to Covidence 11 . Duplicates were removed (n=593). Two independent reviewers screened the remaining n=2986 studies by title and abstract. In case of disagreement, conflicts were resolved through consensus and n=2874 abstracts were excluded. Subsequently, the remaining n=112 articles went through full-text review, from which further n=79 articles were excluded due to the reasons mentioned in the PRISMA flowchart (Figure 1), leaving n=33 articles eligible for inclusion. A full overview of the process is depicted in a PRISMA flowchart (see Figure 1). Data items and -charting The included articles underwent data extraction. We summarized the following information: lead author, year of publication, country, type of study (descriptive or comparative), drug, measured parameters, measurement methods and results. A risk of bias assessment was not deemed necessary for descriptive studies, as these studies aim to present observed data without testing specific hypotheses or interventions. Results Articles were grouped into six main categories: Volatile anaesthetic gases and/or drugs (n = 16), inhalers (n=6), total healthcare systems or whole-hospitals (n=5), ophthalmology (n=3), surgical procedures (n=2) and other (n=2). The included articles came from a variety of countries, with a notable majority originating from Europe, the USA and Australia. More than 80% of the included articles (n = 27) were published within the last 5 years (see Figure 2). The overall characteristics of the 33 articles are depicted in Table S2 (see Appendix). A more detailed review of the included articles is presented in Table S3 (see Appendix). Volatile anaesthetic gases and/or anaesthetic drugs The vast majority of articles belonged to the category concerning volatile anaesthetic gases and/or anaesthetic drugs (n=16) 12-27 . The most frequently reported data were related to sevoflurane (n=12), desflurane (n=11), isoflurane (n=7), nitrous oxide (n=5) and propofol (n=7). Most articles reported findings in CO2 equivalents (n=15). The geographical distribution of studies was as follows: Europe (n=8), Northern America (n=4), Australia (n=2), Taiwan (n=1) and an international collaboration between USA, Canada and the United Kingdom (n=1). Study designs varied, and findings were reported in a highly diverse manner. Three studies examined the shift from gas to propofol and its potential to reduce GHG emissions, reported in either absolute or relative terms 12-14 . One study investigated differences in GHG emissions and linked them to variations in sevoflurane consumption across hospitals 15 . Two studies measured the reduction in desflurane consumption over two years, demonstrating a decrease in GHG emissions 16,17 . One study explored sources of CO2 emissions and found that cooling sprays contributed significantly compared to the anesthesia itself 18 . One study examined nitrous oxide (N2O) loss 19 . Inhalers Articles in this category (n=6) focused on the comparative environmental impact of pressurised metered dose inhalers (pMDI), dry powder inhalers (DPI), and soft-mist inhalers (SMI), the climate impact of frequent use of short-acting β2 agonists (SABAs), and the potential emissions reductions from switching to lower impact inhalers 28-33 . Two studies reported on the GHG emissions of a high use of as-needed SABA 28,29 . One study calculated the different carbon footprints (including healthcare visits) of asthma patients, when following different treatment regimens 30 . Three studies estimated the different carbon footprints of the use of pMDI, DPI and SMI 29,31,32 . Three studies calculated the potential reduction of GHG emissions, when switching from high climate impact pMDIs to lower climate impact DPIs 29,32,33 . Total healthcare systems or whole-hospitals There were n=5 studies in this category 4,24,34-36 . All studies specified the specific emissions stemming from medicines use. The majority of the studies were conducted in Europe (n=3), others were conducted in China (n=1) and Canada (n=1). All studies were descriptive. One study compiled whole-hospital emissions 34 . Four studies focused on total healthcare systems 4,24,35,36 . Ophthalmology In total, there were (n=3) studies pertaining the GHG emissions of medicines used in ophthalmology 37-39 . One study examined GHG emissions relating to medicines used for intravitreal injections 37 . Two studies reported on the environmental impact of medicines used for a single day of cataract surgeries 38-39 . Surgical procedures There were n=2 studies examining surgical procedures 40,41 . One study calculated the carbon footprint of a typical tonsillectomy, including the proportion stemming from medicines 40 . One study described the different carbon footprints of perioperative pain management when using different formulations/administration methods, e.g. iv, oral liquid or tablet 41 . Other There were n=2 studies in this category 42,43 . They were both included in the category “other” because they did not fit into any of the prior categories. The two studies were vastly different. One study hypothesized how alternative dosing regimens of trastuzumab could potentially reduce GHG emissions 42 . One study conducted a life cycle analysis (LCA) on two mRNA-vaccines 43 . Discussion In this scoping review we identified 33 studies that examined the GHG emissions from medicines used in the hospital sector. Studies were widely distributed between different topics. Some studies were conducted within specific procedures while others described aggregated emissions for large populations or entire healthcare systems. A major strength of our review was including articles across all treatment areas. By doing this, we were able to provide a structured overview of all current areas of evidence. However, apart from a few studies within the same topic, our very broad inclusion made comparison across studies almost impossible due to the wide variation in study drugs, -design and -setting. Some studies purely were observational, while others were interventional. Additionally, findings in each study were reported in a highly diverse manner, complicating consistent reporting. Some studies reported end goals as a reduction of GHG emissions in absolute terms, while others reported it in relative terms. In the same way, some studies were able to use direct emissions tables for gasses, others conducted LCA, while others again used a spend-based (top-down) method to calculate GHG emissions. Within the last few years an increasing interest has arisen within this area of research, and multiple reviews have been conducted on the topic of the carbon footprint of health care. Both Rodríguez-Jimenéz and Keil conducted systematic reviews on the environmental impact of health services in general 44,45 , while Walsh did a review on the carbon footprint of primary healthcare 46 and Sijm-Eeken conducted a review seeking to identify the different methods/factors used to measure environmental impact in healthcare practice 47 . Our review falls in line with these, but provides a different angle focusing only on the GHG emissions from medicines. The different methods and reporting standards used throughout the articles also becomes an issue when considering the external validity of the included studies. Generally, procedures, marketed medicines, guidelines, populations and even healthcare systems differ widely across countries. Adding to this the different methods of calculating and reporting GHG emissions, transferability becomes almost impossible. This highlights an urgent need for international standards for reporting GHG emissions from medicines, especially for conducting LCAs but also when using spend-based methods. Despite these challenges, some of the reported data, for example for inhalers and anesthetic gasses, was reported for individual products or specific gasses and could be transferable to other populations. Furthermore, consensus across all studies was that medicines are a notable contributor to the emission burden from healthcare and most studies suggest interventions that could possibly reduce GHG emissions from medicine if implemented across other healthcare systems. Despite the growing interest in the environmental impact of medicines in the hospital sector, substantial knowledge gaps remain. The majority of the studies included in this review were conducted in high-income countries. The collective data pool therefore provide very limited insights into how climate impact from medicines and the healthcare sector vary globally due to different supply chains, prescribing patterns, accessibility of medicines and regulatory frameworks. Research in the conditions across multiple different income countries would give a wider perspective and help identify where the greatest room for emissions reductions lie. Most therapeutic areas are underrepresented in the current literature and many commonly used hospital medicines such as antibiotics, pain medicine, IV fluids, cardiovascular agents etc. are largely unexamined. There is a great need for data on other drug classes to help hospitals and policy makers reduce emissions more effectively, for example through medicine procurement and general treatment guidelines. To provide useful insights, future research should revolve around GHG emissions associated with the most frequently used hospital medicines. To make sure that hospitals and policymakers successfully integrate environmental metrics into procurement, procedures and clinical guidelines, research exploring and assessing the impact of climate-related interventions would also be beneficial in order to guide future change. As mentioned, inconsistencies in reporting units and methodologies hinder cross-study comparisons and external validity. There are initiatives working on developing international standards in measuring emissions. The Greenhouse Gas Protocol provide guidance in greenhouse gas accounting standards for governments and businesses 48 and the Pharma LCA Consortium, who’s main stakeholders are pharmaceutical companies, work towards a universal approach to assessing the environmental impact of medicines 49 . Though these are both promising initiatives, they do not provide any international standards for neither methods nor reporting for research articles. Conclusion While this scoping review offers an overview of the current research on the GHG emissions from medicines used in the hospital sector, it also highlights several challenges. The wide variation in study design, quantification methods, and reporting standards complicates comparisons and limits the transferability of findings across different healthcare settings. Despite these obstacles, our review underscores the important role that medicines play in the overall environmental impact of healthcare. Moving forward, there is a clear need for standardized methodologies and reporting frameworks to facilitate more consistent and comparable research. Additionally, there are substantial knowledge gaps, especially concerning the most commonly used hospital medicines. Future research should prioritize filling these gaps, exploring the potential for targeted interventions to reduce GHG emissions from medicines, thereby offering valuable insights for both hospitals, policymakers, medicine procurement and the broader healthcare community. Supplementary Material File (the climate impact of medicines in the hospital sector - a scoping review_figure s1.docx) Download 15.50 KB File (the climate impact of medicines in the hospital sector - a scoping review_figure1.docx) Download 46.17 KB File (the climate impact of medicines in the hospital sector - a scoping review_figure2.docx) Download 27.83 KB File (the climate impact of medicines in the hospital sector - a scoping review_table s1.docx) Download 15.89 KB File (the climate impact of medicines in the hospital sector - a scoping review_table s2.docx) Download 40.22 KB File (the climate impact of medicines in the hospital sector - a scoping review_table s3.docx) Download 50.62 KB References 1. 1. Climate change and health. World Health Organization; 2021. [cited 2025 March 28]. Available from: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health. 2. Pichler PP, Jaccard IS, Weisz U, Weisz H. International comparison of health care carbon footprints. Environ Res Lett. 2019;14(6):064004. https://doi.org/10.1088/1748-9326/ab19e13. Health care’s climate footprint. How the health sector contributes to the global climate crisis and opportunities for action. Health Care Without Harm. Green Paper Number One. Arup 2019.4. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental epidemiological analysis. PLoS Med 2018;15(7):e1002623. https://doi.org/10.1371/journal.pmed.10026235. Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE 11 2016;(6):e0157014. https://doi.org/10.1371/journal.pone.01570146. Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. The Lancet. Planetary Health 2018; 2 (1):e27-e35. https://doi.org/10.1016/S2542-5196(17)30180-8 7. Malik A, Padget M, Carter S, et. al. Environmental impacts of Australia’s largest health system. Resources Conservation and Recycling , 2021; 169 :105556. https://doi.org/10.1016/j.resconrec.2021.1055568. Nansai K, Fry J, Malik A, Takayanagi W, Kondo N. Carbon footprint of Japanese health care services from 2011 to 2015. Resources Conservation and Recycling , 2020; 152 :104525. https://doi.org/10.1016/j.resconrec.2019.1045259. Tennison I, Roschnik S, Ashby B, et. al. Health care’s response to climate change: A carbon footprint assessment of the NHS in England. The Lancet. Planetary Health , 2021; 5 (2):e84–e92. https://doi.org/10.1016/S2542-5196(20)30271-0 10. Tricco AC, Lillie E, Zarin W et. al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–73. https://doi.org/10.7326/m18-085011. Covidence - Better systematic review management. https://www.covidence.org/12. Chan KC, Cheng SY, Chang WJ, Chiu TW, Fan SZ, Hung MH. Trends in volatile anesthetic sevoflurane and desflurane usage and its impact on carbon emissions: A six-year audit at National Taiwan University Hospital (2018–2023). J Formos Med Assoc. 2024;S0929664624005084. https://doi.org/10.1016/j.jfma.2024.10.02113. Gasciauskaite G, Lunkiewicz J, Tucci M, et. al. Environmental and economic impact of sustainable anaesthesia interventions: a single-centre retrospective observational study. Br J Anaesth. January 2024;S000709122300692X. https://doi.org/10.1016/j.bja.2023.11.04914. Thiel CL, Woods NC, Bilec MM. Strategies to Reduce Greenhouse Gas Emissions from Laparoscopic Surgery. Am J Public Health. 2018;108(S2):158–64. https://doi.org/10.2105/ajph.2018.30439715. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health. 2017;1(9):e360–7. https://doi.org/10.1016/s2542-5196(17)30162-616. Dilger AE, Shelley J, Bergmark RW, Slutzman JE. Addressing Climate Health: A Practical Guide to Quantifying and Reducing Health Care‐Associated Emissions. Otolaryngol Neck Surg. 2024;170(3):981–6. https://doi.org/10.1002/ohn.60317. Zuegge KL, Bunsen SK, Volz LM, et. al. Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing With Cost Savings and Reduced Greenhouse Gas Emissions. Anesth Analg. 2019;128(6):e97–9. https://doi.org/10.1213/ane.000000000000377118. Sparke RE, Song A, Shelton CL, Patey SJ. Pentafluoropropane with tetrafluoroethane: a hidden greenhouse gas in regional anaesthesia. Br J Anaesth. 2024;133(6):1495–7. https://doi.org/10.1016/j.bja.2023.10.02819. Thomas MAF, Ward CJ, Sinnott ME, et. al. Nitrous Oxide Manifold and Other Reduction of Emissions (NoMoreGas): a multicentre observational study evaluating pre-utilisation loss of nitrous oxide. Br J Anaesth. 2024;133(6):1427–34. https://doi.org/10.1016/j.bja.2024.08.02720. Davies JF, Trajceska L, Weinberg L. The financial and environmental impact of purchased anaesthetic agents in an Australian tertiary hospital. Anaesth Intensive Care. 2023;51(2):141–8. https://doi.org/10.1177/0310057x22112929121. Droog W, Grace V, Droog L, et. al. Substantiating ‘green’ healthcare decisions: an explorative life cycle assessment study to identify differences in greenhouse gas emissions between general vs. regional anaesthesia for upper extremity surgery. Eur J Anaesthesiol. 2024;41(6):455–60. https://doi.org/10.1097/eja.000000000000198422. Hu X, Pierce JT, Taylor T, Morrissey K. The carbon footprint of general anaesthetics: A case study in the UK. Resour Conserv Recycl. 2021;167:105411. http://dx.doi.org/10.1016/j.rcradv.2021.20005323. Karlsson SL, Edman-Wallér J, Gudmundsson MV, Bentzer P, Moller PW. Bacterial contamination and greenhouse gas emissions: A randomised study of reuse versus single-use of infusion-set components for intravenous anaesthesia. Eur J Anaesthesiol. 2024;41(12):910–20. https://doi.org/10.1097/eja.000000000000206724. Keady T, Nordrum OL, Duffy O, et. al. Annual greenhouse gas emissions from inhaled anaesthetic agents in the Republic of Ireland. Br J Anaesth. 2023;130(1):e13–6. https://doi.org/10.1016/j.bja.2022.09.01925. Lehmann F, Schulz CM, Leicht D, et. al. Persistent use of nitrous oxide for anaesthesia in European hospitals despite its harmfulness to the climate – how emission taxation can achieve the coupling of cost-effectiveness and climate protection: observational study. BMC Health Serv Res. 2023;23(1):1392. https://doi.org/10.1186/s12913-023-10307-y26. Sherman J, Le C, Lamers V, Eckelman M. Life Cycle Greenhouse Gas Emissions of Anesthetic Drugs. Anesth Analg. 2012;114(5):1086–90. https://doi.org/10.1213/ane.0b013e31824f694027. Wyssusek K, Chan KL, Eames G, Whately Y. Greenhouse gas reduction in anaesthesia practice: a departmental environmental strategy. BMJ Open Qual. 2022;11(3):e001867. https://doi.org/10.1136/bmjoq-2022-00186728. Alzaabi A, Bell JP, Montero-Arias F, et. al. Greenhouse Gas Emissions from Respiratory Treatments: Results from the SABA CARBON International Study. Adv Ther. 2023;40(11):4836–56. https://doi.org/10.1007/s12325-023-02663-229. Vartiainen V, Woodcock AA, Wilkinson A, et. al. Thoughtful prescription of inhaled medication has the potential to reduce inhaler-related greenhouse gas emissions by 85%. BMJ Open Respir Res. 2024;11(1):e001782. https://doi.org/10.1136/bmjresp-2023-00178230. Hatter L, Holliday M, Eathorne A, et. al. The carbon footprint of as-needed budesonide/formoterol in mild asthma: a post hoc analysis. Eur Respir J. 2024;64(1):2301705. https://doi.org/10.1183/13993003.01705-202331. Tirumalasetty J, Miller SA, Prescott HC, et. al. Greenhouse Gas Emissions and Costs of Inhaler Devices in the US. JAMA September 2024;332(12):1017-1019. https://doi.org/10.1001/jama.2024.1533132. Wilkinson AJK, Braggins R, Steinbach I, Smith J. Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England. BMJ Open. 2019;9(10):e028763. https://doi.org/10.1136/bmjopen-2018-02876333. Ten Have P, Van Hal P, Wichers I, Kooistra J, Hagedoorn P, Brakema EA, mfl. Turning green: the impact of changing to more eco-friendly respiratory healthcare – a carbon and cost analysis of Dutch prescription data. BMJ Open. June 2022;12(6):e055546. https://doi.org/10.1136/bmjopen-2021-05554634. Lau I, Burdorf A, Hesseling S, Wijk L, Tauber M, Hunfeld N. The carbon footprint of a Dutch academic hospital—using a hybrid assessment method to identify driving activities and departments. Front Public Health. 22. 2024;12:1380400. https://doi.org/10.3389/fpubh.2024.138040035. Tennison I, Roschnik S, Ashby B, et. al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021;5(2):e84–92. https://doi.org/10.1016/s2542-5196(20)30271-036. Wu R. The carbon footprint of the Chinese health-care system: an environmentally extended input–output and structural path analysis study. Lancet Planet Health. 2019;3(10):e413–9. https://doi.org/10.1016/s2542-5196(19)30192-537. Di Felici F, Maestri F, Bodaghi B. The carbon footprint of French hospital ophthalmology consultations. Eye. 2024;38(16):3169–74. https://doi.org/10.1038/s41433-024-03257-038. Ferrero A, Thouvenin R, Hoogewoud F, et. al. The carbon footprint of cataract surgery in a French University Hospital. J Fr Ophtalmol. 2022;45(1):57–64. https://doi.org/10.1016/j.jfo.2021.08.00439. Pascual-Prieto J, Nieto-Gómez C, Rodríguez-Devesa I. The carbon footprint of cataract surgery in Spain. Arch Soc Esp Oftalmol Engl Ed. 2023;98(5):249–53. https://doi.org/10.1016/j.oftale.2023.01.00540. Cannon J, Tailor H, Douglas C. Carbon footprint of tonsillectomy. The Surgeon. 2024;22(4):242–7. https://doi.org/10.1016/j.surge.2024.06.00141. Davies JF, Trajceska L, Weinberg L. The financial and environmental impact of purchased anaesthetic agents in an Australian tertiary hospital. Anaesth Intensive Care. 2023;51(2):141–8. https://doi.org/10.1177/0310057x22112929142. Jacobson SI, Kacew AJ, Knoebel RW, Hsieh PH, Ratain MJ, Strohbehn GW. Alternative Trastuzumab Dosing Schedules Are Associated With Reductions in Health Care Greenhouse Gas Emissions. JCO Oncol Pract. 2023;19(9):799–807. https://doi.org/10.1200/op.23.0022743. Kurzweil P, Müller A, Wahler S. The Ecological Footprint of COVID-19 mRNA Vaccines: Estimating Greenhouse Gas Emissions in Germany. Int J Environ Res Public Health. 2021;18(14):7425. https://doi.org/10.3390/ijerph1814742544. Rodríguez-Jiménez L, Romero-Martín M, Spruell T, Steley Z, Gómez-Salgado J. The carbon footprint of healthcare settings: A systematic review. J Adv Nurs. 2023;79(8):2830–44. https://doi.org/10.1111/jan.1567145. Keil M, Frehse L, Hagemeister M, et. al. Carbon footprint of healthcare systems: a systematic review of evidence and methods. BMJ Open. Apr 2024 30;14(4):e078464. https://doi.org/10.1136/bmjopen-2023-07846446. Walsh SJ, O’Leary A, Bergin C, Lee S, Varley Á, Lynch M. Primary healthcare’s carbon footprint and sustainable strategies to mitigate its contribution: a scoping review. BMC Health Serv Res. Dec 2024 20;24(1):1630. https://doi.org/10.1186/s12913-024-12068-847. Sijm-Eeken M, Jaspers M, Peute L. Identifying Environmental Impact Factors for Sustainable Healthcare: A Scoping Review. Int J Environ Res Public Health. Sep 2023 12;20(18):6747. https://doi.org/10.3390/ijerph2018674748. Greenhouse Gas Protocol. World Resource Institute & the World Business Council for Sustainable Development. [cited 2025 March 28]. Available from: https://ghgprotocol.org/ 49. Pharma LCA consortium. Pharmaceutical Environment Group and the Sustainable Markets Initiative Health Systems Taskforce. [cited 2025 March 28]. Available from: https://peghub.org/lca50. Sustainable Healthcare Coalition. Sustainable Care Pathways Guidance. 2015. https://shcoalition.org/ sustainable-care-pathways-guidance/. Crossref Google Scholar Information & Authors Information Version history V1 Version 1 11 June 2025 Peer review timeline Published Basic & Clinical Pharmacology & Toxicology Version of Record 23 Jan 2026 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical pharmacology health policy pharmacotherapy prescribing therapeutics Authors Affiliations Katrine Bitsch Johansen 0009-0009-5782-0513 [email protected] Odense University Hospital View all articles by this author Peter Skov Esbech 0000-0001-8147-5515 View all articles by this author Johan Helland Odense University Hospital View all articles by this author Sidsel Arnspang Pedersen Odense University Hospital View all articles by this author Zandra Ennis Odense Universitetshospital View all articles by this author Metrics & Citations Metrics Article Usage 296 views 191 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Katrine Bitsch Johansen, Peter Skov Esbech, Johan Helland, et al. The climate impact of medicines in the hospital sector: a scoping review. Authorea . 11 June 2025. DOI: https://doi.org/10.22541/au.174963974.47040519/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.174963974.47040519/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fec2eb74ed306d3',t:'MTc3OTI4ODkyNw=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();