Predicted concentrations of antineoplastic drugs in the aquatic environment: The case of Ría de Vigo (NW, Spain)

The European Medicines Agency (EMA) mandates Environmental Risk Assessments (ERAs) since 2006 to determine potential risks of new marketed medicines. Drugs with a Predicted Environmental Concentration (PEC) in inland surface waters exceeding 0.01 μg L-1 require further environmental risk assessment. PEC may be refined based on prevalence data and/or based on the treatment regimen. In this study, based on EMA regulations, refined PEC of 108 antineoplastic drugs in coastal waters were determined based on the consumption in a coastal health area during 2021, identifying six drugs with potential environmental risk in surface waters (hydroxyurea, capecitabine, abiraterone, ibrutinib, imatinib and 5-fluorouracil) and two in marine ecosystem (hydroxyurea and capecitabine). Comparison of these refined PECs with data from marketing laboratories revealed significant disparities, suggesting the need for regular updates, especially with changes in drug indications or financing. Notably, the identified drugs are not yet on the main reference lists of emerging contaminants.

Knowledge and attitude about drug pollution in pharmacy students: A questionnaire-based cross sectional study

INTRODUCTION

The environmental impact of drugs or pharmaceuticals is an issue of growing concern. Healthcare professionals, and pharmacists in particular, are used to managing medicines, yet aspects about drug pollution are generally neglected in schools of pharmacy worldwide. Formation in this issue is essential to tackle the problem. In this study, we aimed to find out the degree of knowledge about the problem of pharmaceuticals in the environment and the attitude about the matter of pharmacy students at the University of the Basque Country.

METHODS

We conducted a pilot study (186 students) using an online questionnaire available in two languages (Basque and Spanish). The attitude scale was validated for Spanish. To improve participation, a combination of indirect and direct recruitment was applied in the final study.

RESULTS

Four hundred eighty-seven students participated in the final study (response rate: 65.8%). The final questionnaire contained a total of 25 questions: 13 (knowledge), eight (attitude), and three (opinion). The results showed that knowledge can be considered relatively poor, whereas attitude was generally positive, and students considered drug pollution to be a relevant issue in general and in pharmacy practice.

CONCLUSIONS

We believe there is an urgent need to include aspects about pharmaceuticals in the environment in pharmacy studies worldwide.

The antipsychotic drug olanzapine altered lipid metabolism in the common carp (Cyprinus carpio L.): Insight from the gut microbiota-SCFAs-liver axis

Olanzapine (OLA) is a common drug used to treat schizophrenia and has recently come under increasing scrutiny as an emerging contaminant. However, its impact on lipid metabolism in fish and its mechanisms of action are not well understood. In this study, common carp were exposed to 0, 10, 100, and 250 μM OLA for 60 days. The results indicated that OLA exposure increased weight gain, total cholesterol (TC), low-density lipoprotein (LDL), and triglycerides (TG) and decreased high-density lipoprotein (HDL). In addition, lipids accumulated in the liver of the common carp. To explore the underlying mechanisms of action, gut microbiota, short-chain fatty acids (SCFAs), liver transcripts, and genes related to lipid metabolism were measured. It was discovered that OLA exposure altered the common carp gut microbiota composition and increased the abundance of SCFA-producing bacteria. Correspondingly, this study showed that OLA exposure increased the levels of SCFAs, which are highly relevant to the development of lipid accumulation. Transcriptome sequencing results indicated that OLA exposure could change lipid metabolism signalling pathways, including steroid biosynthesis, the PPAR signalling pathway, asglycerophospholipid metabolism, glycerolipid metabolism, and fatty acid metabolic pathways of the common carp. Additionally, OLA exposure interrupted lipid metabolism by means of significant upregulation of lipid synthesis-related genes, including pparγ, srebp1, and fas. OLA exposure also resulted in significant lipolysis-related gene downregulation, including cpt, lpl, hsl, and pparα. The results of this study indicated that contamination of aquatic environments with OLA alters lipid metabolism in common carp. In addition, the underlying mechanism might be due in part to the modulation of the gut microbiota-SCFA-PPAR signalling pathway.

Drugs used during the COVID-19 first wave in Vitoria-Gasteiz (Spain) and their presence in the environment

The city of Vitoria-Gasteiz was one of the probable first entrances of the SARS-CoV2 in Spain, one of the worst affected countries in the world during the first COVID 19 wave. Driven by the urgency of the situation, multiple drugs with antiviral activity were used off label. Sadly, most of these treatments were of little or no benefit and thus, the number of patients suffering from COVID-19 attended in intensive care units (ICUs) multiplied. After being administered to patients, a variable proportion of these drugs reach the environment where they may have detrimental effects, although this aspect is usually ignored by healthcare professionals. In this study we measured the patterns of hospital drug use in the city of Vitoria-Gasteiz (Spain) during the first COVID-19 wave pandemic, focusing on those with antiviral activity and those used in the ICUs. Subsequently, we measured concentrations of selected drugs in the city's wastewater treatment plant influent and effluent and estimated the potential risk for the environment. The hospital use of certain antivirals and drugs used for sedo-analgesia were dramatically increased during the first wave (cisatracurium was multiplied by 25 and lopinavir/ritonavir by 20). A mean of 1.632 daily defined doses of hydroxychloroquine were used during the period of February-May 2020. In this study we report the first positive detection of hydroxychloroquine ever in the environment. We also show the second positive report of lopinavir. Low risk was estimated for hydroxychloroquine, lopinavir and ritonavir (Risk quotients (RQ) <1), and medium risk for azithromycin (RQ 0f 0.146).

Drug pollution & Sustainable Development Goals

The United Nations set "The 2030 Agenda for Sustainable Development," which includes the Sustainable Development Goals (SDGs), a collection of 17 global goals designed to be a "blueprint to achieve a better and more sustainable future for all". Although only mentioned in one of the seventeen goals (goal 3), we argue that drugs in general, and growing drug pollution in particular, affects the SDGs in deeper, not readily apparent ways. So far, the emerging problem of drug pollution has not been sufficiently addressed. Here, we outline and discuss how drug pollution can affect SDGs and even threaten their achievement.

Environmental pollution with psychiatric drugs

Among all contaminants of emerging interest, drugs are the ones that give rise to the greatest concern. Any of the multiple stages of the drug's life cycle (production, consumption and waste management) is a possible entry point to the different environmental matrices. Psychiatric drugs have received special attention because of two reasons. First, their use is increasing. Second, many of them act on phylogenetically highly conserved neuroendocrine systems, so they have the potential to affect many non-target organisms. Currently, wastewater is considered the most important source of drugs to the environment. Furthermore, the currently available wastewater treatment plants are not specifically prepared to remove drugs, so they reach practically all environmental matrices, even tap water. As drugs are designed to produce pharmacological effects at low concentrations, they are capable of producing ecotoxicological effects on microorganisms, flora and fauna, even on human health. It has also been observed that certain antidepressants and antipsychotics can bioaccumulate along the food chain. Drug pollution is a complicated and diffuse problem characterized by scientific uncertainties, a large number of stakeholders with different values and interests, and enormous complexity. Possible solutions consist on acting at source, using medicines more rationally, eco-prescribing or prescribing greener drugs, designing pharmaceuticals that are more readily biodegraded, educating both health professionals and citizens, and improving coordination and collaboration between environmental and healthcare sciences. Besides, end of pipe measures like improving or developing new purification systems (biological, physical, chemical, combination) that eliminate these residues efficiently and at a sustainable cost should be a priority. Here, we describe and discuss the main aspects of drug pollution, highlighting the specific issues of psychiatric drugs.

Environmental contamination by pet pharmaceuticals: A hidden problem

As the environmental risks of companion animal pharmaceuticals has been assumed to be low, currently, no data on the fate, behaviour or effect is required by the European Medicines Agency. This is in sharp contrast with what happens in farming animals, where ecotoxicological data is a pivotal part on the benefit-risk assessment for the marketing authorization of a new veterinary drug. Recently, concern about the environmental impacts from the indiscriminate prophylactic use of antiparasitic drugs in pets has arisen. Considering the notable increase of companion animals in Europe since 2010, our impression is that, effects and potential deleterious consequences of other therapeutic classes such as antimicrobials and psychotropic drugs are probably underrated. We believe that pets, as animals, should not be excluded from One Health's philosophy, and that authorities should incorporate environmental aspects in the benefit-risk assessment for drugs used in companion animals as well.

Ivermectin & COVID-19: Let's keep a One Health perspective

Despite uncertainty about its clinical benefit, ivermectin has been used for COVID 19, even in prophylaxis. The European Medicines Agency (EMA) has advised against its use for the prevention or treatment of COVID-19 outside randomised clinical trials. Although the potential negative environmental effects of ivermectin have been widely recognised when used in veterinary medicine, scarce attention has been devoted to the potential ecotoxicological impact of human use. We believe is time to include One Health's philosophy in our daily practice. In the specific case of ivermectin & COVID 19, environmental aspects should also be on the table.

Antipsychotics as environmental pollutants: An underrated threat?

The heterogeneous class of what we nowadays call antipsychotics was born almost 70 years ago with the serendipitous discovery of chlorpromazine. Their utilization is constantly growing because they are used to treat a diverse group of diseases and patients across all age groups: schizophrenia, bipolar disease, depression, autism, attention deficit hyperactivity disorder, behavioural and psychological symptoms in dementia, among others. They possess a complex pharmacological profile, acting on multiple receptors: dopaminergic, serotoninergic, histaminergic, adrenergic, and cholinergic, leading scientists to call them "agents with rich pharmacology" or "dirty drugs". Serotonin, dopamine, acetylcholine, noradrenaline, histamine and their respective receptors are evolutionary ancient compounds, and as such, are found in many different living beings in the environment. Antipsychotics do not disappear once excreted by patient's urine or faeces and are transported to wastewater treatment plants. But as these plant's technology is not designed to eliminate drugs and their metabolites, a variable proportion of the administered dose ends up in the environment, where they have been found in almost every matrix: municipal wastewater, hospital sewage, rivers, lakes, sea and even drinking water. We believe that reported concentrations found in the environment might be high enough to exert significant effect to aquatic wildlife. Besides, recent studies suggest antipsychotics, among others, are very likely bioaccumulating through the web food. Crucially, psychotropics may provoke behavioural changes affecting populations' dynamics at lower concentrations. We believe that so far, antipsychotics have not received the attention they deserve with regards to drug pollution, and that their role as environmental pollutants has been underrated.