How environmentally friendly is your DMT?

Barts-MS rose-tinted-odometer: ★★★★★
COP26 Land Green & Ocean Blue  #37328c #8cdc73

Did you know that the world will use between 8 billion and 10 billion syringes for COVID-19 vaccinations alone? Apart from this, the world uses approximately 16 billion syringes per year. Over half of these are used outside of the health care system each year by individuals with diabetes, migraines, allergies, infertility, arthritis, HIV, hepatitis, multiple sclerosis, osteoporosis, psoriasis, or other conditions. 

With COP26 top of mind do you ever consider the environmental impact of your DMT? I have simply assumed that because they are medicines and prescribed for a serious disease the environmental impact is justified. Could the environmental impact of injectable or intravenous therapies be another reason to embrace oral treatments? Or is the environmental impact related to the manufacturing process of oral treatments greater? 

Is this something that you would consider to be an important factor when making a decision about which DMT to choose? For example, would a lower environmental impact of a 6-monthly ocrelizumab infusion be a factor in choosing it over a monthly subcutaneous injection of ofatumumab?  After all, both of these DMTs are anti-CD20. Would you not want to choose the one with the lowest environmental impact?

Some of you may already be aware of our ClinicSpeak DMT decision aid we run to help pwMS make decisions about which DMT to start. Do you think we should include the environmental impact of the various DMTs on the list of factors to consider when making a decision?

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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust and are not meant to be interpreted as personal clinical advice. 

60 thoughts on “How environmentally friendly is your DMT?”

  1. Dominic – I am the worst person to describe myself. I'll leave that to my ex-supervisor Professor Roger Griffin who once said in a reference, "Dominic has a Nietzschean will to survive." I can't really top that.
    Dominic says:

    I think the ofatumumab/ocrelizumab example is over-simplifying the issue and is akin to comparing apples and oranges, if the frequency of dosing is the only point of comparison.

    How many other people and resources are involved with attending a hospital for ocrelizumab? The travel, the power consumption, the time of other staff, the time of the patient, as well as all the other disposable items etc versus a monthly one-off home administered quick hit?

    Moreover, I wonder how forthcoming the pharmaceutical companies will be about the environmental impact of drug development, manufacture and marketing costs?

    Any one-off therapy like HSCT, Alemtuzumab or Cladribine is likely to have a longer-term lower overall carbon footprint. Of course, if the climate impact of a DMT was part of the decision making variables then the most environmentally conscious short term choice is to go without.

    However, what is the long term environmental impact of disability; something we know is reduced by using a DMT?

    It is multi-faceted and cannot be reduced down to a single metric like syringe use. IMHO 😉

    1. Yep, I agree which is why I trying to get a study done by a health economist to drill down and find this information out. Would it be something that would affect your decision making? At the moment we are in the dark on this issue.

      1. Dominic – I am the worst person to describe myself. I'll leave that to my ex-supervisor Professor Roger Griffin who once said in a reference, "Dominic has a Nietzschean will to survive." I can't really top that.
        Dominic says:

        Agreed we are in the dark. I am not sure anything other than self-interest in my own long-term health outcomes first.

        An MS diagnosis suddenly forces unpleasant and never considered before choices onto one. It is a bit like leaving a burning house and deciding what to grab. I’d go for my daughter first, regardless of family pets. It is the need to make a sudden recalibration of relative worth.

        Not nice but I’d stand by my decision whilst acknowledging the dreadful downsides.

    2. I couldn’t agree more. There is so much plastic and other waste in health care that goes far beyond the syringes (another example is the plastic single-use speculums that are used for smear tests when previously metal reusable ones had been used). Aside from the environment costs, the disposal of waste must also cost hospitals and GP surgeries an absolute fortune.

  2. I’ll stop injecting Copaxone for my MS if MS researchers / neuros in their thousands stop flying round the world to attend ACTRIMS, ECTRIMS or well paid international lecture tours. I didn’t want MS, I didn’t want to inject myself (my neuro recommended Copaxone) and I don’t like it that the used syringes are heading to a landfill site. I find it slightly galling to be be seen as a contributor to global warming when I never had a choice!

    MSers are probably more environmentally friendly than most – many of us don’t drive or fly (cost and / or impact of disability). Many of us decide not to have children. Most of us die c.10 years earlier than the average life span – so big savings on water, food, energy consumption.

  3. I’d be amazed if this played a part in anyone’s thought process when considering which DMT to take. There are daily decisions in which the impact on the environment is a necessary consideration but in my view, this is not one of them. Not even close.

  4. Choice of DMT has been extremely important to me including thanks to this blog (thank you!). The main concern is mines is efficacy, I would have always gone for the drug available to me which would give me the best prognosis. I opted for alemtuzumab. Others may differ.

    Rightly or wrongly despite being an environmentalist in many ways in my life, this wouldn’t come into my decision about choice of DMT. I think drugs companies should be trying to make drugs in general as environmentally friendly as possible but this wouldn’t be something I would consider at a patient level in making a decision so critical to my health.

    I personally think that research on MS drugs specifically should be focused on the areas already identified by the blog.

  5. I’m on Tecfidera so feel guilty every time I throw out an empty pill packet.

    I also wonder what the impact on waste water of oral treatments is! I’m on hormonal contraception and I know that has an impact on waterways. I’m following the news from New Zealand where my family live. They use waste water testing there to detect whether COVID is present in an area. Even if there’s only one case in an area containing 300,000 people, the waste water testing can detect it.

  6. No, I do not. I just want the one that works the best….
    As Dom said in his comment.. disability probably has more of an impact on the environment in a negative way if you look at it like that.
    But honestly, I haven’t ever given it any thought. Maybe selfish. Maybe not.

  7. And also.. when I say works the best. I meant, works the best for me & my factors.
    I would not want to inject myself monthly/daily. I also don’t like taking tablets. So everyone will have a different choice based on personal preferences anyway. And environment, isn’t one of my factors.

  8. To use this metric, I’d also need comprehensive info on the manufacturing process, not just the administration of the drug. And, if a drug with less waste means more intervention for me in the future due to personal efficacy, it’s probably a wash anyhow. I absolutely get why this discussion is important, but I’m not sure it’s practical on an individual level as of yet. Unless the physician is well versed in the environmental impact of the manufacturing process, this might be more feel-good than do-good in practice. It is still something to mull over.

    I took alemtuzumab a few years back, so if the effects hold I guess that’s a solid environmental choice, since I am now on nothing at all.

  9. I’m an admirer of this blog. I’m concerned about the environment and the impact of climate change on the world population—way more than I am worried about the significant impact of my MS on myself and my family. But this is a ridiculous and disappointing question. No doctor should be asking a patient to consider the environmental impact of their treatment. And then present the question as a rosy opportunity for reflection. Give me a break.

    1. cathysrealcountrygardencom – France – I have a garden in France, which is not olive trees and jasmine, but much more like an English country garden. It is flowers and vegetables and wild bits and birds: not very big, but to me it is very beautiful.
      Cathy says:

      I agree. Worrying about falling apart is bad enough but now we have to worry about the cost of staying in one piece. There is only one answer to this and it is the answer we fight off thinking about every waking minute. This is blog has not contributed to the sum of human happiness in any way and I think this is where I stop checking in on this previously excellent blog for ever. So long and thanks for all the fish.

    2. “And then present the question as a rosy opportunity for reflection. “LOL! Indeed. More like a rosy opportunity for contemplating how much of a burden on the planet (and the family and tribe) chronically sick people are, with the end result of the deep dive of that contemplation being just a little more self-loathing and well-hidden but very real suspicions that I (the individual) DID something WRONG to “deserve” this. Even if a person rejects this line of thinking, if you’re even just a cultural Christian, these attitudes are part of the mental furniture we accumulate. Mix that in with the idea that I should always be able and willing to DO *something* to fix myself (master of my fate, etc) and the ensuing guilt cycle can be a toxic place in which to stew. Rightly or wrongly, most of us with MS struggle with some level of guilt already, but hey, now we get reminded that the insanely expensive meds we’re assured we simply MUST take, make us an even bigger burden on the environment. Give me a break too.

  10. Nice post
    The best impact one could make on the enviroment is our use of clean water
    The way we use clean water in the development world is all wrong
    The same clean water we use to drink is the same water we flush our feces wash our cars water our gardens
    All the under development world respect greatly clean water just beacause they dont have access to it
    As we do

  11. I might choose my next neuro on how environmentally friendly they are. I’d like to see a table setting out for each neuro: how many cars they own and the engine sizes; how many house they own; how many children they have; average flying miles per year etc.

    It looks to me, by this post, that you are bored. Please redirect your energy to EBV research etc. Please, no more silly posts. People with MS have drawn a short straw. They want a DMT which best limits brain tissue loss. Should they really be content to see their brain loss accelerate in order to save three lesser spotted mini sand turtles in the Maldives?

  12. Quick follow up. It’s troubling to think about how a clinician might be biased against or in favor of a given treatment (in any field of medicine) on account of the treatment’s environmental impact. Whether it’s a legitimate factor from a patient’s point of view is entirely down to the patient. But it absolutely must not factor into the prescribing clinician’s decision or advice.

  13. If you and your colleagues could come up with a “cure” (injection to kill off / control EBV) ie something that stopped MS in its tracks and encouraged some repair, then the environmental impact would be massive:

    No more syringes eg betaferon (plastic waste) or tablets
    No more blood tests (plastic waste)
    No more clinic visits (car journey)
    No more MS conferences (flights)
    No more MRIs (must take lots of power)
    No more adult nappies (land fill nightmare)
    No more house visits by MS nurses (car journey)

  14. Dominic hit the nail on the head. However, I still worry about environmental impact on most of everything I use. I recycle everything right down to the tiny foil wraps on top of my milk container under the plastic cap. But if I chose a med based just on environmental impact, I would not be here. 40 yrs T1d… How many syringes can you guess I’ve stuck myself with or lancets. The insulin med company solutions… Pen needles, pumps (which in my opinion use more plastic in the infusion sets and tubings). But the more I do to help with lessoning my impact, it seems the city inhabitants just make up for it. I watch on video every week 2 guys from my city out picking up thrown out needles from drug addicts. I am absolutely shocked at how many. When all my life I’ve had to do without so much to purchase my needles to take medicine to stay alive, and money to purchase empty needle containers for safety, It pees me off to no end seeing this. But as far as DMT and other types of meds & tests, it really boils down to the pharmaceutical companies, etc to start making changes at the top to reduce the environmental impact.

    1. cathysrealcountrygardencom – France – I have a garden in France, which is not olive trees and jasmine, but much more like an English country garden. It is flowers and vegetables and wild bits and birds: not very big, but to me it is very beautiful.
      Cathy says:

      Stay strong.

  15. Thinking about this some more, I consider myself an environmentalist but I would still choose based on which is the most effective, taking into account convenience to myself! I turned down Lemtrada because at the time I was needle phobic so hated the idea of an infusion and monthly blood tests.

    A more effective treatment might end up being more environmentally friendly over time too. I think if my disability worsens and I end up eating more prepackaged food for instance, which would have a worse impact, and also maybe needing more and different treatments etc etc. I’m certain that keeping as healthy as possible is better for the environment as well as health!

    I have an MSc in Food Policy and can go on for hours about the intersection of health, environment and economy…

  16. Feels like patients are getting pushed to use at home therapy’s to be less of a burden on the NHS due to ‘covid’ with treatments that can be taken at home, pills and self injectors

  17. What DMT?
    Please focus on finding a real therapy for the “real” MS.
    I’ll take a break from visiting this blog for a year. I have other stuff to read. I’ll pop by late 2022, hopefully there’s some real progress to read about then.
    Sincerely,
    Pragmatic PPMSer

  18. Find it difficult to believe this is being put forward as a serious suggestion.
    1. There are many ways in which all of us can reduce our carbon footprint/be far kinder on the environment which, if followed, will make a much bigger impact; making a vow to stop flying (completely!), stopping eating meat, buying sustainable clothing, to name but a few.
    2. MS treatment choice is difficult and stressful enough as it is … are we supposed to worry about yet another factor when making this choice, particularly when there are these far more effective things we can all do.
    Maybe now that it is clear that conferences can be hosted virtually, everyone who previously attended them in person by taking carbon heavy flights can be asked if they will take this into consideration before they agree to resuming to chalk up air miles again?!

  19. Hey no one mentioned that covid vaccine syringes will be disposed according to laws and policies governing hazardous waste sharps protocol in that jurisdiction. But this is VERY different from the lesser standards for sharps disposal for individuals witb pwms. My DMD pharmaceutical companies over the years (at request) would supply me with as many sharps container free of charge as I wanted. But my problem was finding where to dispose of container. ! Pharmacies and dr offices won’t take. In the US one must research proper disposal of full sharps container and it isn’t very clear. Bleach bottle in landfil??? Locate your own hazardous waste facility that will accept from consumer??
    Here’s an example of not so clear instructions given to consumers https://www.tceq.texas.gov/assets/public/comm_exec/pubs/gi/gi-418.pdf. If traveling by plane, how should one store used syringes safely in luggage? Some airports have sharps containers in bathroom, but if not, i would put cap back on needle and store in capped empty water bottle. (More than once I got a nice note inside my luggage from TSA that my luggage had been hand searched). I’m not comfortable with disposing in bleach bottle for the landfil, so I payed at my own expense for sharp containers to be disposed at hazardous waste facility. Ex of product https://www.sharpsassure.com/product-category/sharps/?gclid=EAIaIQobChMIno7Ckqn98wIVGIiGCh2sHg6DEAAYASAAEgJ94PD_BwE. Maybe. Maybe maybe pharmaceutical cos should be required to take on burden (environmentally and cost wise) of proper disposal of syringes . I like that idea better than adding the environmental impact of my dmt to the decision process. After all. Do we consider this when prescribing pills how its substrates end up in the water supply? Just throwing it out there…https://www.usgs.gov/special-topic/water-science-school/science/pharmaceuticals-water

  20. For crying out loud. Where did this guilt trip come from! PwMS have enough on their plate to deal with without trying to ‘save the planet’ too. In an ideal world maybe eco friendly choice would be an option but most people are stuck with the NHS. The healthcare provider should be making environmentally aware choices, not the patient on the receiving end. I’m all for patient choice but….this is a burden too far. Prof G. Stick to medicine it’s what you do best.

  21. This post makes me laugh, I wouldn’t consider myself in the position investigating environmental consequences of DMTs knowing it will be a negligible portion compared to other living aspects where I try to do my part.

    Sorry Prof G, have you really run out of things to do?

  22. I am a quant, so it depends on the weight you would give that factor in the final decision aid calculation 😉

    Intriguing question, particularly these days, but no, environmental impact is the least of my concerns regarding DMT selection.

  23. I am very concerned about the environment, but we are all living in The Matrix that we ALL created and now, alas, it’s pretty obviously set on “Juggernaut” at this point and we are stuck with it.

    The question I have, is why am I, the patient, supposed to be the one all concerned about environmental impact when I am presented with medications and treatments that all have a negative impact and were developed by people who made them, obviously, with no thought to their burden on the environment? Are the people who run and work at pharmaceutical companies nowadays suddenly all concerned about this? I doubt it. A lot. And putting the burden of concern and yes guilt, about that environmental impact on the patient is the cart before the horse.

    I take several prescriptions a month. Each one comes in a plastic bottle that would easily hold 3-4 times as many pills as they put in there. I would happily have my 90 day supplies in a single bottle of adequate size. In an ideal world we could re-use those bottles like we used to clean and reuse glass soda bottles (which of course are now all plastic). Am I as a patient supposed to second-guess my doctor and try to figure out which meds are similar, then decide which of those uses less packaging and demand to take that? I’m sure that will go over quite well in the actual clinic, most docs being so collaborative and all.

    Whether I am taking pills from endless plastic bottles, getting an infusion with the attendant travel, tubing, plastic bags, needles, etc, or injecting in the privacy of my own home, I cannot effect how drugs are packaged or marketed. (And don’t get me started about the sheer amount of useless Biogen swag and drug information in swanky packaging-heavy plasticized boxes that I never asked for but were sent to me and then went directly to the recycle. And I’m still not sure they COULD be recycled. Anyway, now I have TWO (they sent me the swag TWICE) new awkward poorly-designed hard PLASTIC pill-keepers taking up my precious space, that have no indication as to whether they are recyclable or not.). So when the pharmaceutical companies and the local pharmacies show that THEY are dedicated to reducing the environmental impact of what they PRESENT to us I might take this more seriously.

    The questions really needing answers here are: Why is knowing this important? Who, exactly, does it matter to what patients think about the environmental impact of their treatments? Will knowing this information impact how drugs are packaged and delivered to us? How will knowing this information actually benefit MS patients?

    And hey, I just thought of this: I wonder if cancer patients are being asked to ponder questions like these about THEIR meds….

    1. Karen,

      Couldn’t agree more. There’s enough going on in my MS life that I don’t need the additional burden of having to worry about the environmental impact of the therapies I take to try and control a disease I never asked for. I saw a sign at our local country park asking for volunteer to help clean up the river, lake and woodland ie clearing plastic bottles etc. I’d love to do this, but can’t- another loss thanks to MS. I do wonder if Prof G really understands the daily challenges faced by MSers. Despite being seriously ill, we are expected to challenge our neuro when he / she recommends an escalation approach to treatment and now make decisions on DMTs based on environmental issues rather than their efficacy. Mad world. Bring back the days when doctors prescribed the best treatments for their patients and patients trusted them. I don’t recall my mother having to deal with all these issues with her breast cancer. The consultant diagnosed her, treated her and followed her up during her recovery (20 years on she’s going strong). She trusted her implicitly and couldn’t praise her enough. If only neurology was like this!

  24. I would rather save the planet than myself,…(screw me) NOT! Putting that question in the list of factors to consider would diminish it’s credibility.

  25. For Pete ´s sake. Would you pose this question to a diabetic? MSers already contend with a complex multitude of decisions to make and you throw this onto the pile. Jeesh. Were you just checking to see if anyone was reading?

      1. How much plastic is used at ECTRIMS meetings maybe companies can plant some trees to off set carbon footprint of neurologists travels.:-)

      2. Same, I would say this post and his reaction now (dismissing all comments he doesnt like) is also expected from someone like Prof G who doesn’t really have any empathy to pwMS, which doesn’t bother me as he is not my neuro, but please stop acting like you care 🙂

      3. I think that’s deeply unfair and obviously untrue.
        Maybe not the most sensitive post but he’s allowed to raise questions

      4. I apologise for calling you have no empathy, I can take words from your colleagues and I know I am wrong. I’m sorry that you have to see these words when you actually cared about us.
        Please also understand the frustration wasn’t a result of one single post.
        I thank you for establishing this blog and for your knowledge and profession, it would not be the same without you and the blog, and of course more importantly all the hard work in the actual research.

  26. As both a person with MS and a nurse practitioner who cares for people with MS, I find this question to be infuriating. I am NOT willing to compromise efficacy for environmental friendliness. I will continue to make treatment decisions for my patients and for myself by looking for the best possible clinical outcome and would never jeopardize someone’s health in the name of reducing waste by a few vials or syringes.

  27. FFS – what a useless maundering waste of screen real estate this post is!

    How about using your expertise and brain power to come up with some real treatments for PPMS. I am heartily sick of the seemingly endless procession of “jump on the cash cow” RRMS treatments when those of us with PPMS are still basically out in the cold in most places in the world – either because the stats of ocrelizumab are too thin for regulatory authorities to let it past their gatekeepers or approve for funding sources.

    If those who have RRMS want to worry themselves about this issue then that’s fine by me (although from the other comments posted it’s pretty clear it’s waaaay down on a priorities list), but I have bigger things to worry about in my life full of ever increasing impairments than a hypothetical environmental footprint for a treatment which does not yet exist for me.

    1. Three reasons that come to mind:

      Wellness – “This involves establishing a sustainable lifestyle, protecting natural resources, and eliminating pollutants and excessive waste. … Environmental wellness also includes having respect for and awareness of your surroundings and playing an active role in your community”

      Marginal gains – we are only going to get to where we want to be in terms of the climate change agenda if we look at everything we do, including the medications we choose. Some people may be swayed by an environmental argument if one product is greener than another. Knowing the carbon footprint of one product will also prod or nudge other Pharma companies to calculate their footprint. If you don’t measure it you can’t change it. Leaving out medications and their production when calculating Pharma’s carbon footprint and your healthcare carbon footprint is not keeping with what others are doing.

      Healthcare – Healthcare including the NHS has made a pledge to reduce their carbon footprint. Why wouldn’t we look at medication as part of that pledge?

      1. I am a #1 George Monbiot fan. I was actually listening to his audiobook ‘Feral’ when I had my accident 🙁 My fault for wearing ear pods and concentrating on his endless wisdom. However, I don’t agree with ditching marginal gains; it makes sense and empowers individuals. Trying to target billionaires is something that the small man on the street finds hard, particularly when you have a corrupt government.

      2. No one is mentioning the real culprit which is uncontrolled population growth. As the world’s population increases so does the demand for food, clothes, cars, travel….. Advances in medicine have contributed to the population growth – lower child mortality and being able to keep older people alive (many people born today can get to 100). We need to come up with solutions to get back to a global population size which doesn’t result in global warming and rising sea levels. The expand or die philosophy adopted by most businesses and the mad obsession with consumption (new cars, phones, clothes….) must be thwarted.

      3. I do blame developing countries for uncontrolled population growth.

        https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiv687u8YH0AhUTXsAKHSxZB4QQFnoECCYQAQ&url=https%3A%2F%2Fwww.thelancet.com%2Farticle%2FS0140-6736(20)31522-1%2Fabstract&usg=AOvVaw0iU9zc1iUeVA9bZ_HImUpr

        But western aid agencies must take the blame as well. If you can’t feed em, don’t breed em. While China and India are the current biggest polluters, the continent of Africa will soon outstrip them.

      4. I remember watching a youtube documentary some years ago about food industry in the US and the documentary used China as an example “We cannot let the 1.2 billion Chinese eat the same way as Americans do”.

        Now there are more than 1.4 billion Chinese and they consume more and more meat now. The developing countries is definitely the problem, very alarming and have to be stopped. 😉

      5. Pharma need to think about it the same as other industries should, including recycling schemes.
        The waste produced worldwide in general is frightening, people need to stop and think about the amount of ‘stuff’ they buy, do they actually need it and how it will be disposed of later. And councils need to be upfront about where our ‘recycled’ fabrics end up. The textile mountains in Africa (our recycling!) are horrendous.
        This is such a huge and important topic, but sadly for a lot of people it is also an inconvenient one that is easier to ignore than acknowledge.
        I am not sure that pwms can make much difference with drug choice but I noticed that we can drop empty blister packets off at Superdrug for recycling by TerraCycle. It’s a start.

  28. Hmm. I take Tysabri every 28 days, x the last 12 years.
    I’ve lived off-grid (100% solar) for the last 38 years.
    I buy what little meat I do eat from a cattle rancher 10 miles down the road.
    What veg I don’t grow, I get from a farmer 8 miles down the road.
    My carbon footprint is dinky!
    I doesn’t freaking matter how bloody “green” I am when the DMD I’m taking is actually making a difference in my life!
    Let’s instead, concentrate our efforts in finding a CAUSE of MS, so we can find a CURE.

  29. Sorry to use this language, but this post is absurd.

    There aren’t enough PwMS in the world for this consideration to make a difference.

    Did anyone look into the environmental impact of Covid-19 vaccines? Obviously not! And for good reasons!
    If vaccines were selected with an eye on environmental impact, no country would allow the Moderna or Pfizer vaccines, with their requirements ultra-cold storage requirements.

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