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Blum K, FitzGerald R, Wilks MF, Barle EL, Hopf NB. Use of the benchmark-dose (BMD) approach to derive occupational exposure limits (OELs) for genotoxic carcinogens: N-nitrosamines. J Appl Toxicol 2023. [PMID: 36840679 DOI: 10.1002/jat.4455] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/29/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023]
Abstract
N-Nitrosamines are potent carcinogens and considered non-threshold carcinogens in various regulatory domains. However, recent data indicate the existence of a threshold for genotoxicity, which can be adequately demonstrated. This aspect has a critical impact on selecting the methodology that is applied to derive occupational exposure limits (OELs). OELs are used to protect workers potentially exposed to various chemicals by supporting the selection of appropriate control measures and ultimately reducing the risk of occupational cancer. Occupational exposures to nitrosamines occur during manufacturing processes, mainly in the rubber and chemical industry. The present study derives OELs for inhaled N-nitrosamines, employing the benchmark dose (BMD) approach if data are adequate and read-across for nitrosamines without adequate data. Additionally, benchmark dose lower confidence limit (BMDL) is preferred and more suitable point-of-departure (PoD) to calculate human health guidance values, including OEL. The lowest OEL (0.2 μg/m3 ) was derived for nitrosodiethylamine (NDEA), and nitrosopiperidine (NPIP) (OEL = 0.2 μg/m3 ), followed by nitrosopyrrolidine (NPYR) (0.4 μg/m3 ), nitrosodimethylamine (NDMA), nitrosodimethylamine (NMEA), and nitrosodipropylamine (NDPA) (0.5 μg/m3 ), nitrosomorpholine (NMOR) (OEL = 1 μg/m3 ), and nitrosodibutylamine (NDBA) (OEL = 2.5 μg/m3 ). Limits based on "non-threshold" TD50 slope calculation were within a 10-fold range. These proposed OELs do not consider skin absorption of nitrosamines, which is also a possible route of entry into the body, nor oral or other environmental sources. Furthermore, we recommend setting a limit for total nitrosamines based on the occupational exposure scenario and potency of components.
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Affiliation(s)
- Kamila Blum
- Environment, Health & Safety Department, GlaxoSmithKline, Munich, Germany.,Faculty of Science and Medicine, University of Geneva, Switzerland
| | - Rex FitzGerald
- Swiss Centre for Applied Human Toxicology (SCAHT) & Department of Pharmaceutical Sciences, University of Basel, Switzerland
| | - Martin F Wilks
- Swiss Centre for Applied Human Toxicology (SCAHT) & Department of Pharmaceutical Sciences, University of Basel, Switzerland
| | | | - Nancy B Hopf
- Swiss Centre for Applied Human Toxicology (SCAHT) & Department of Pharmaceutical Sciences, University of Basel, Switzerland.,Department for Occupational and Environmental Health, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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Jolly RA, Bandara S, Bercu J, Callis CM, Dolan DG, Graham J, HaMai D, Barle EL, Maier A, Masuda-Herrera M, Moudgal C, Parker JA, Reichard J, Sandhu R, Fung ES. Setting impurity limits for endogenous substances: Recommendations for a harmonized procedure and an example using fatty acids. Regul Toxicol Pharmacol 2022; 134:105242. [PMID: 35964842 DOI: 10.1016/j.yrtph.2022.105242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/29/2022] [Accepted: 07/25/2022] [Indexed: 11/28/2022]
Abstract
Endogenous substances, such as fatty, amino, and nucleic acids, are often purposefully used in parenterally pharmaceuticals, but may be present as impurities. Currently, no consensus guidance exists on setting impurity limits for these substances. Specific procedures are needed, as the amount and types of toxicity data available for endogenous substances are typically far less than those for other chemical impurities. Additionally, the parenteral route of administration of these substances is inherently non-physiological, resulting in potentially different or increased severity of toxicity. Risk Assessment Process Maps (RAPMAPs) are proposed as a model to facilitate the development of health-based exposure limits (HBELs) for endogenous substances. This yielded a framework that was applied to derive HBELs for several fatty acids commonly used in parenteral pharmaceuticals. This approach was used to derive HBELs with further vetting based on anticipated perturbations in physiological serum levels, impacts of dose-rate, and consideration of intermittent dosing. Parenteral HBELs of 100-500 mg/day were generated for several fatty acids, and a proposed class-based limit of 50 mg/day to be used in the absence of chemical-specific data. This default limit is consistent with the low toxicity of this chemical class and ICH Q3C value for Class 3 solvents.
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Wiesner L, Araya S, Lovsin Barle E. Identifying non-hazardous substances in pharmaceutical manufacturing and setting default Health-Based Exposure Limits (HBELs). J Appl Toxicol 2022; 42:1443-1457. [PMID: 35315528 DOI: 10.1002/jat.4323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 11/07/2022]
Abstract
Contract Development and Manufacturing Organizations (CDMOs) that manufacture large, diverse portfolio of chemical and pharmaceutical substances require pragmatic risk-based decisions with respect to the safe carry-over between different chemical entities, as well as for worker protection. Additionally, CDMOs may not have access to primary study data or data is generally lacking for a specific substance. While pharmaceuticals require the establishment of health-based exposure limits (HBELs) (e.g., occupational exposure limits, permitted daily exposure limits), the limits for non-hazardous substances could be set in a protective and pragmatic way by using default values, when internally required. Since there is no aligned definition provided by authorities, nor agreed default values for non-hazardous substances, we provide a decision tree in order to help qualified experts (such as qualified toxicologists) to identify the group of non-hazardous substances and to assign default HBEL values for specific routes of exposure. The non-hazardous substances discussed within this publication are part of the following subgroups: (I) inactive pharmaceutical ingredients, (II) pharmaceutical excipients or cosmetic ingredients, (III) substances Generally Recognized as Safe (GRAS), and (IV) food ingredients, additives and contact materials. The proposed default limit values are 1 mg/m3 for the OEL, and 50 mg/day for the PDE oral and IV (intravenous) route.
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Glogovac M, Paulson C, Lambert A, Winkler GC, Lovsin Barle E. Disease area and mode of action as criteria to assign a default occupational exposure limit. Regul Toxicol Pharmacol 2021; 122:104891. [DOI: 10.1016/j.yrtph.2021.104891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 12/06/2020] [Accepted: 02/09/2021] [Indexed: 12/22/2022]
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5
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Affiliation(s)
- Claudia Sehner
- Nonclinical Drug Safety, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Markus Schwind
- HSE Germany, Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany
| | - Gregor Tuschl
- Global Chemical and Preclinical Safety, Merck KGaA, Darmstadt, Germany
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Lovsin Barle E, Pfister T, Fux C, Röthlisberger D, Jere D, Mahler HC. Use of the permitted daily exposure (PDE) concept for contaminants of intravitreal (IVT) drugs in multipurpose manufacturing facilities. Regul Toxicol Pharmacol 2019; 101:29-34. [PMID: 30367903 DOI: 10.1016/j.yrtph.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/13/2018] [Accepted: 10/20/2018] [Indexed: 01/01/2023]
Abstract
A toxicological evaluation to determine the product specific permitted daily exposure (PDE) value is an accepted method to determine a safe limit for the carry-over of product residues in multipurpose manufacturing facilities. The PDE calculation for intravitreal (IVT) injection of small and large molecular weight (MW) drugs follows the guiding principles set for systemic administration. However, there are specific differences with respect to the volume administered with IVT administration, pharmacokinetic and pharmacodynamics (PK-PD) parameters and potential for toxicity. In this publication, we have proposed a method to derive PDEIVT in the presence of IVT dose. In the absence of an IVT dose we have a proposed default extrapolationof the systemic PDE for intravenous (IV) administration to the PDEIVT dose by applying a factor of 500 based on comparison of the volume of vitreous humour with the plasma volume, as well as provided examples for PK-PD and toxicity considerations.
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Jandard C, Hemming H, Prause M, Sehner C, Schwind M, Abromovitz M, Lovsin Barle E. Applicability of surface sampling and calculation of surface limits for pharmaceutical drug substances for occupational health purposes. Regul Toxicol Pharmacol 2017; 95:434-441. [PMID: 29288720 DOI: 10.1016/j.yrtph.2017.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 12/22/2017] [Accepted: 12/24/2017] [Indexed: 12/28/2022]
Abstract
Within the context of Occupational Hygiene (OH), surface sampling has been employed as a method to assess surface levels of Active Pharmaceutical Ingredients (APIs). There are potentially a number of reasons surface samples are collected including assessing potential health risks, housekeeping and cleaning effectiveness. There are no internationally accepted standards relating to collecting or interpreting surface samples for OH purposes. In the past, surface sampling results have been applied not only for estimating risks due to dermal contact, but also for other routes of exposure (e.g. inhalation, ingestion, etc). In this publication, we provide a decision tree to support the decision and value of performing surface sampling. For scenarios without conceivable skin exposure due to applied risk mitigation measures or for substances that do not penetrate the skin, surface sampling may not be needed. If the workers' health is determined to be at risk for systemic effects via skin, we propose to use the skin Permitted Daily Exposure (PDEskin), a safe skin dose independent of the exposure scenario that takes into consideration skin absorption properties of substances. For the purpose of OH monitoring, the likelihood of dermal exposure has to be understood before taking any samples, using both the PDEskin to calculate the surface limit and appropriate validated monitoring method for the surface.
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Affiliation(s)
| | | | - Maarten Prause
- Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland
| | | | - Markus Schwind
- Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany
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Prause M, Glogovac M, Barle EL. Group assessment of drug substances with same mechanism of action and safety profile for purpose of setting occupational exposure limits. Toxicol Lett 2017. [DOI: 10.1016/j.toxlet.2017.07.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Wiesner L, Prause M, Lovsin Barle E. Topical otic drugs in a multi-purpose manufacturing facility: a guide on determination and application of permitted daily exposure (PDE). Pharm Dev Technol 2017; 23:261-264. [PMID: 28535123 DOI: 10.1080/10837450.2017.1334665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Due to newly introduced EU GMP (Good Manufacturing Practice) guideline for Medicinal Products for Human and Veterinary use, product specific permitted daily exposure (PDE) for toxicological evaluation in multi-purpose facilities are required within a documented process for risk assessment. European Medicines Agency (EMA) guidance on setting PDE limits so far focused on systemic administration routes such as intravenous (IV), oral or inhalation. This article provides guidance on setting PDE values for risk management purposes in multi-purpose facilities for active pharmaceutical ingredients (APIs) applied as topical otic drugs to the outer ear canal. The therewith determined PDE otic, is used for the calculation of maximum safe carry-over (MSC) in manufacturing scenarios where a topical otic product is manufactured followed by another topical otic product.
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Affiliation(s)
- Lisa Wiesner
- a Novartis Pharma AG, Postfach , Basel , Switzerland
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Lovsin Barle E, Bizec JC, Glogovac M, Gromek K, Winkler GC. Determination and application of the permitted daily exposure (PDE) for topical ocular drugs in multipurpose manufacturing facilities. Pharm Dev Technol 2017; 23:225-230. [PMID: 28361586 DOI: 10.1080/10837450.2017.1312442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Limits for the carry-over of product residues should be based on toxicological evaluation such as described in the "Guideline on setting health based exposure limits for use in risk identification in the manufacture of different medicinal products in shared facilities". The toxicological evaluation should be performed also for locally administered drugs to ensure patient safety. Currently, there is no guidance on setting PDE for ocular drug substances in particular. The purpose of this investigation was to identify and describe a method for calculating a PDE value for topical ocular drugs (PDEocular). As an alternative method, extrapolation of a PDE for systemically administered drugs to a PDEocular is presented. These methods may be applied in cross-contamination risk assessments for manufacturing of topical ocular drugs. Similarly, the methods apply to systemically administered drugs, if their production precedes manufacturing of a topical ocular drug. We have examined pharmacokinetic (PK) properties of topical ocular drugs and compared them to the PK parameters of systemically administered drugs. Furthermore, we examined possible adverse effects of the carry-over in topical ocular drugs at therapeutic doses.
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Affiliation(s)
| | | | | | - Kamila Gromek
- a Novartis Pharma AG, Postfach , Basel , Switzerland
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Olson MJ, Faria EC, Hayes EP, Jolly RA, Barle EL, Molnar LR, Naumann BD, Pecquet AM, Shipp BK, Sussman RG, Weideman PA. Issues and approaches for ensuring effective communication on acceptable daily exposure (ADE) values applied to pharmaceutical cleaning. Regul Toxicol Pharmacol 2016; 79 Suppl 1:S19-27. [DOI: 10.1016/j.yrtph.2016.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
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12
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Hayes EP, Jolly RA, Faria EC, Barle EL, Bercu JP, Molnar LR, Naumann BD, Olson MJ, Pecquet AM, Sandhu R, Shipp BK, Sussman RG, Weideman PA. A harmonization effort for acceptable daily exposure application to pharmaceutical manufacturing – Operational considerations. Regul Toxicol Pharmacol 2016; 79 Suppl 1:S39-47. [DOI: 10.1016/j.yrtph.2016.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 06/01/2016] [Indexed: 02/01/2023]
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13
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Sargent EV, Flueckiger A, Barle EL, Luo W, Molnar LR, Sandhu R, Weideman PA. The regulatory framework for preventing cross-contamination of pharmaceutical products: History and considerations for the future. Regul Toxicol Pharmacol 2016; 79 Suppl 1:S3-S10. [PMID: 27230736 DOI: 10.1016/j.yrtph.2016.05.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/19/2016] [Indexed: 01/14/2023]
Abstract
Cross-contamination in multi-product pharmaceutical manufacturing facilities can impact both product safety and quality. This issue has been recognized by regulators and industry for some time, leading to publication of a number of continually evolving guidelines. This manuscript provides a historical overview of the regulatory framework for managing cross-contamination in multi-product facilities to provide context for current approaches. Early guidelines focused on the types of pharmaceuticals for which dedicated facilities and control systems were needed, and stated the requirements for cleaning validation. More recent guidelines have promoted the idea of using Acceptable Daily Exposures (ADEs) to establish cleaning limits for actives and other potentially hazardous substances. The ADE approach is considered superior to previous methods for setting cleaning limits such as using a predetermined general limit (e.g., 10 ppm or a fraction of the median lethal dose (LD50) or therapeutic dose). The ADEs can be used to drive the cleaning process and as part of the overall assessment of whether dedicated production facilities are required. While great strides have been made in using the ADE approach, work remains to update good manufacturing practices (GMPs) to ensure that the approaches are clear, consistent with the state-of-the-science, and broadly applicable yet flexible enough for adaptation to unique products and situations.
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Lovsin Barle E, Winkler GC, Glowienke S, Elhajouji A, Nunic J, Martus HJ. Setting Occupational Exposure Limits for Genotoxic Substances in the Pharmaceutical Industry. Toxicol Sci 2016; 151:2-9. [PMID: 27207978 PMCID: PMC4914798 DOI: 10.1093/toxsci/kfw028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In the pharmaceutical industry, genotoxic drug substances are developed for life-threatening indications such as cancer. Healthy employees handle these substances during research, development, and manufacturing; therefore, safe handling of genotoxic substances is essential. When an adequate preclinical dataset is available, a risk-based decision related to exposure controls for manufacturing is made following a determination of safe health-based limits, such as an occupational exposure limit (OEL). OELs are calculated for substances based on a threshold dose-response once a threshold is identified. In this review, we present examples of genotoxic mechanisms where thresholds can be demonstrated and OELs can be calculated, including a holistic toxicity assessment. We also propose a novel approach for inhalation Threshold of Toxicological Concern (TTC) limit for genotoxic substances in cases where the database is not adequate to determine a threshold.
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Affiliation(s)
| | | | | | | | - Jana Nunic
- Lek Pharmaceuticals D.D, Verovškova 57, 1526 Ljubljana, Slovenia
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Araya S, Winkler GC, Froehlicher M, Barle EL. Classified carcinogens: What is their potential risk for pharmaceutical manufacturing employees? Toxicol Lett 2014. [DOI: 10.1016/j.toxlet.2014.06.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Pfister T, Dolan D, Bercu J, Gould J, Wang B, Bechter R, Barle EL, Pfannkuch F, Flueckiger A. Bioavailability of therapeutic proteins by inhalation--worker safety aspects. ACTA ACUST UNITED AC 2014; 58:899-911. [PMID: 24958792 DOI: 10.1093/annhyg/meu038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A literature review and analysis of inhalation bioavailability data for large therapeutic proteins was conducted in order to develop a practical estimate of the inhalation bioavailability of these drugs. This value is incorporated into equations used to derive occupational exposure limits(OELs) to protect biopharmaceutical manufacturing workers from systemic effects. Descriptive statistics implies that a value of 0.05, or 5% is an accurate estimate for large therapeutic proteins (molecular weight ≥ 40kDa). This estimate is confirmed by pharmacokinetic modeling of data from a human daily repeat-dose inhalation study of immunoglobulin G. In conclusion, we recommend using 5% bioavailability by inhalation when developing OELs for large therapeutic proteins.
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Affiliation(s)
- Thomas Pfister
- 1.F. Hoffmann - La Roche Ltd, Group Safety, Security, Health and Environmental Protection, CH-4070, Basel, Switzerland
| | - David Dolan
- 2.Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA
| | - Joel Bercu
- 2.Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA
| | - Janet Gould
- 3.Bristol-Myers Squibb Company New Brunswick, NJ 08903 , USA
| | - Bonnie Wang
- 3.Bristol-Myers Squibb Company New Brunswick, NJ 08903 , USA
| | | | | | - Friedlieb Pfannkuch
- 5.Roche Pharma Research and Early Development Department, Roche Innovation Center Basel, CH-4070 Basel, Switzerland
| | - Andreas Flueckiger
- 1.F. Hoffmann - La Roche Ltd, Group Safety, Security, Health and Environmental Protection, CH-4070, Basel, Switzerland
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Winkler GC, Barle EL, Galati G, Kluwe WM. Functional differentiation of cytotoxic cancer drugs and targeted cancer therapeutics. Regul Toxicol Pharmacol 2014; 70:46-53. [PMID: 24956585 DOI: 10.1016/j.yrtph.2014.06.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/05/2014] [Accepted: 06/15/2014] [Indexed: 11/16/2022]
Abstract
There is no nationally or internationally binding definition of the term "cytotoxic drug" although this term is used in a variety of regulations for pharmaceutical development and manufacturing of drugs as well as in regulations for protecting medical personnel from occupational exposure in pharmacy, hospital, and other healthcare settings. The term "cytotoxic drug" is frequently used as a synonym for any and all oncology or antineoplastic drugs. Pharmaceutical companies generate and receive requests for assessments of the potential hazards of drugs regularly - including cytotoxicity. This publication is intended to provide functional definitions that help to differentiate between generically-cytotoxic cancer drugs of significant risk to normal human tissues, and targeted cancer therapeutics that pose much lesser risks. Together with specific assessments, it provides comprehensible guidance on how to assess the relevant properties of cancer drugs, and how targeted therapeutics discriminate between cancer and normal cells. The position of several regulatory agencies in the long-term is clearly to regulate all drugs regardless of classification, according to scientific risk based data. Despite ongoing discussions on how to replace the term "cytotoxic drugs" in current regulations, it is expected that its use will continue for the near future.
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Affiliation(s)
- Gian C Winkler
- Novartis Pharma AG NIBR, Postfach, CH-4002 Basel, Switzerland.
| | | | - Giuseppe Galati
- Patheon Inc., 2100 Syntex Court, Mississauga, Ontario L5N 7K9, Canada.
| | - William M Kluwe
- Novartis Pharmaceuticals Corporation, NIBR, One Health Plaza, East Hanover, NJ 07936-1080, USA.
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