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Cyklofosfamid : dokumentacja proponowanych dopuszczalnych wielkości narażenia zawodowego

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EN
Cyclophosphamide : documentation of proposed values occupational exposure limits (OELs)
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PL
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PL
Cyklofosfamid ma postać białego, drobnego, bezwonnego proszku (monohydrat), który pozbawiony wody krystalizacyjnej ma postać oleistej, półpłynnej substancji ciemniejącej pod wpływem światła. Cyklofosfamid działa cytostatycznie i immunosupresyjnie. Stosowany jest w leczeniu: ziarnicy złośliwej, chłoniaków złośliwych, szpiczaka mnogiego, przewlekłej białaczki limfatycznej, raka jajnika, nieoperacyjnego raka sutka oraz nabłoniaka oskrzeli. Jako środek immunosupresyjny cyklofosfamid jest stosowany w leczeniu: zespołu nerczycowego, liszaja rumieniowatego, reumatoidalnego zapalenia stawów, niedokrwistości immunohemolitycznych oraz podczas transplantacji nerek i szpiku. Lek podaje się doustnie w postaci tabletek lub drażetek oraz pozajelitowo po rozpuszczeniu substancji ex tempore w wodzie do wstrzykiwań. Stosuje się go również do perfuzji narządów, w których rozwija się nowotwór. Stosowany jest zarówno pojedynczo, jak i (najczęściej) w połączeniu z innymi lekami przeciwnowotworowymi. Podczas produkcji cyklofosfamidu głównymi drogami narażenia zawodowego są układ oddechowy i skóra. Skóra jest główną drogą narażenia personelu medycznego na cyklofosfamid, dlatego większość danych o poziomach narażenia w szpitalach dotyczy stężeń związku na powierzchni stołów, na których są przygotowywane preparaty dla pacjentów, a także obserwowanych stężeń cyklofosfamidu na skórze i w moczu personelu. Brak jest danych na temat zawodowego narażenia podczas produkcji cyklofosfamidu w Polsce. Nie ma informacji o tym, że cyklofosfamid jest w Polsce produkowany. Zgodnie z danymi, nadesłanymi przez zakłady pracy do Centralnego Rejestru Danych o Narażeniu na Substancje Chemiczne, ich Mieszaniny, Czynniki lub Procesy technologiczne o Działaniu Rakotwórczym w Łodzi, na cyklofosfamid było narażonych zawodowo w Polsce 1476 osób w 2001 r. Według raportu Krajowego Konsultanta w dziedzinie pielęgniarstwa onkologicznego w 2010 r. (dane niepełne, obejmujące jedynie 12 województw) liczba pielęgniarek w placówkach onkologicznych wynosiła łącznie 5077. Wartość LD50 po podaniu per os cyklofosfamidu szczurom wynosi 180 mg/kg mc., a w przypadku myszy 137 mg/kg mc. Leukopenia była głównym skutkiem działania cyklofosfamidu na układ krwiotwórczy u: myszy, szczurów i psów. Stwierdzono również zahamowanie czynności szpiku kostnego i spadek liczby płytek krwi. Związek u: myszy, szczurów i psów, powodował: martwicę pęcherza oraz nabłonka kanalików i miedniczek nerkowych, a umiarkowane uszkodzenia obserwowano również w wątrobie. Dane dotyczące działania toksycznego cyklofosfamidu na ludzi pochodzą od pacjentów leczonych tym związkiem. Cyklofosfamid u ludzi w warunkach narażenia ostrego powodował: uszkodzenie szpiku kostnego, krwotoczne zapalenie pęcherza, a także kardiomiopatię. Kardiotoksyczność wywoływana przez cyklofosfamid objawia się w szerokim zakresie – od małych zmian w ciśnieniu krwi, przez zmiany w EKG i niemiarowość do wtórnej kardiomiopatii ze zmniejszoną frakcją wyrzutową lewej komory (LVEF) i niewydolnością serca, zakończoną śmiercią, w bardzo rzadkich przypadkach. Najczęstszym skutkiem ubocznym terapii cyklofosfamidem chorób autoimmunologicznych (np. układowego tocznia rumieniowatego, artretyzmu reumatoidalnego, ziarniniaka Wegenera, chłoniaków nieziarniczych) jest działanie toksyczne na pęcherz moczowy. Zapadalność pacjentów na krwotoczne zapalenie pęcherza jest rzędu 12 ÷ 41% i skutek ten występował u pacjentów, którzy otrzymywali ponad 100 g leku doustnie w ciągu ponad 30 miesięcy. Za toksyczne działanie cyklofosfamidu na pęcherz jest odpowiedzialna akroleina, będąca jego metabolitem, natomiast przy dożylnym podawaniu leku zapalenie pęcherza jest niezwykle rzadkie. Innymi objawami stwierdzanymi u pacjentów otrzymujących cyklofosfamid były: retencja sodu i wody, zwłóknienie płuc, zaburzenia widzenia, pigmentacja paznokci, jednakże jego rola w tych przypadkach nie została wyjaśniona. Genotoksyczność cyklofosfamidu potwierdzono w wielu badaniach, prowadzonych w warunkach in vivo oraz in vitro na hodowlanych modelach zwierzęcych. Przeprowadzono znaczną liczbę badań właściwości cytogenetycznych cyklofosfamidu na: traszkach, gryzoniach, psach i naczelnych, uzyskując niezmiennie dodatnie wyniki. W wielu doniesieniach opisano tworzenie adduktów DNA u ludzi pod wpływem działania cyklofosfamidu. Międzynarodowa Agencja Badań nad Rakiem (IARC) uznała, że są wystarczające dowody na działanie rakotwórcze cyklofosfamidu na ludzi. Cyklofosfamid wywołuje u ludzi raka pęcherza i ostrą białaczkę szpikową. Uznano również, że są wystarczające dowody działania rakotwórczego tego związku na zwierzęta doświadczalne i sklasyfikowano cyklofosfamid jako Cyklofosfamid. Dokumentacja proponowanych dopuszczalnych wielkości narażenia zawodowego związek rakotwórczy dla ludzi (Grupa 1.). W Unii Europejskiej cyklofosfamid został zaklasyfikowany jako substancja rakotwórcza kategorii 1.A i mutagenna kategorii 2.B. Cyklofosfamid wpływa na rozrodczość u ludzi zarówno w okresie leczenia, jak i przez krótki czas po jego zakończeniu. Związek ten powoduje u ludzi zaburzenia płodności i zaburzenia miesiączkowania. Cyklofosfamid jest teratogenny dla wielu gatunków zwierząt, m.in. dla: szczurów, myszy, królików i naczelnych. Jest odpowiedzialny za: zniekształcenia i deformacje w układzie kostnym, tkankach miękkich oraz zwiększoną liczbę resorpcji, a rodzaj i częstość deformacji są ściśle zależne od czasu i wielkości dawki. Cyklofosfamid działa szkodliwe na zarodki i prowadzi do poronień. Narażenie na cyklofosfamid w pierwszym trymestrze ciąży może powodować takie liczne wady rozwojowe płodu, jak: uszkodzenia kośćca i podniebienia oraz zniekształcenia kończyn. Cyklofosfamid wchłania się: drogą inhalacyjną, z przewodu pokarmowego, z jamy otrzewnej i przez skórę. W przypadku narażenia zawodowego personelu medycznego skóra uważana jest za główną drogę wchłaniania. Zarówno w Polsce, jak i w innych państwach nie ustalono dotychczas wartości najwyższego dopuszczalnego stężenia (NDS) cyklofosfamidu w powietrzu na stanowiskach pracy ani wartości dopuszczalnego stężenia w materiale biologicznym (DSB) dla narażenia zawodowego. Za podstawę do wyprowadzenia wartości NDS przyjęto działanie rakotwórcze cyklofosfamidu na zwierzęta. Wykorzystano współczynnik nachylenia krzywej dawka-odpowiedź na poziomie 0,57 mg/kg mc./dzień dla nowotworów pęcherza obliczony na podstawie wyników całożyciowego narażenia szczurów na cyklofosfamid drogą pokarmową. Średnia dawka całożyciowa dla ryzyka 10-4 wynosi 1,754 - 10-4 mg/kg mc./dzień, co w warunkach narażenia zawodowego odpowiada stężeniu w powietrzu 0,01 mg/m3 i taką wartość postanowiono zaproponować jako wartość NDS. Wartość NDS cyklofosfamidu w obliczonej wysokości powinna chronić pracowników również przed białaczką i działaniem na rozrodczość. Zaproponowano również przyjęcie wartości dopuszczalnego stężenia w materiale biologicznym (DSB) w wysokości 1 μg cyklofosfamidu w całodobowej zbiórce moczu. Brak jest podstaw merytorycznych do ustalenia wartości najwyższego dopuszczalnego stężenia chwilowego (NDSCh). Zaproponowano dla cyklofosfamidu zastosowanie następującego oznakowania: Carc. 1A – substancja rakotwórcza kategorii 1.A, „skóra” – wchłanianie substancji przez skórę może być podobnie istotne, jak przy narażeniu drogą oddechową oraz oznakowanie literami „Ft” – substancja działająca szkodliwie na płód.
EN
Cyclophosphamide (monohydrate) is a fine white crystalline odorless powder The substance liquefies and becomes an oily semisolid mass when water is removed. It darkens on exposure to light. Cyclophosphamide an antineoplastic and immunosuppressant agent. It is used to treat malignant lymphoma, multiple myeloma, leukemia, breast and ovarian cancer, neuroblastoma and malignat neoplasms of the lung. Cyclophosphamide is also used as an immunosuppressive agent to treat autoimmune disorders such as rheumatoid arthritis, psoriatic arthritis and nephrotic syndrome (a kidney disorder) in children. It is increasingly being used as an inmunosuppressive agent following organ (kidney, bone marrow) transplantation. The drug may be administered orally in the form of tablets or intravenously following dissolution ex tempore in aqua for injections. It may also be used for perfusion of cancer-affected organs. In chemotherapy, it may be used alone, but more frequently is used concurrently or sequentially with other anticancer drugs. During manufacture of cyclophosphamide, skin and the respiratory system are the main routes of exposure. Since skin is the most important route of exposure of medical personnel, most of the reported exposure data include surface concentration of the compound in locations where the drug is prepared for treatment and cyclophosphamide concentration on the skin and in urine of the personnel. No data on occupational exposure during production of cyclophosphamide in Poland are available. It is not known whether cyclophosphamide is manufactured in Poland. According to the information in the Central Register of Exposure to Cancerogenic Compounds, Mixtures and Technological Processes, 1476 persons were occupationally exposed to cyclophosphamide in 2001 in Poland. In 2010, there were 5077 oncological nurses (incomplete data, 12 out of 16 voivodships). Oral LD50 for cyclophoshamide was 180 mg/kg bw for rats and 137 mg/kg bw for mice. In mice, rats and dogs the predominant haematologic effect was leucopaenia. Depression in bone marrow and thrombocytes was also reported. Cyclophosphamide causes a marked necrosis of the bladder and of the tubular and pelvic epithelium in mice, rats and dogs; moderate damage in liver was also observed. Toxicity data for humans are derived mostly from findings in patients treated with cyclophosphamide. The predominant haematological effect of cyclophosphamide is leucopaenia. Acute toxicity of cyclophosphamide may lead to bone marrow damage, hemorrhagic cystitis and cardiomyopathy. Cyclophosphamide induced cardiotoxicity may be pronounced as changes in blood pressure, abnormal EKG, arhythmia leading to secondary cardiomyopathy with lowered left ventricular ejection fraction (LVEF) and heart failure leading in isolated cases even to death. The most frequent side effect of treatment of autoimmune inflammatory diseases (e.g., systemic lupus erythematosus, systemic vasculitis, scleroderma, rheumatoid arthritis, Wegener's granulomatosis) is toxicity to the urinary bladder. Incidence of hemorrhagic cystitis was in the range 12 – 41% in patients receiving orally more than 100 g of the drug over 30 months and more. The bladder toxicity of cyclophosphamide is caused by the formation of acrolein, which is its metabolite; hemorrhagic cystitis is, however, extremely rare following intravenous administration. Another symptoms in cyclophosphamide-treated patients are sodium and water retention, pulmonary fibrosis, visual blurring, nail pigmentation but the causative role of cyclophosphamide in these effects is, however, not well established. Genotoxicity of cyclophosphamide has been confirmed in many tests in vivo, in vitro and on cultured animal models. Many studies have investigated the cytogenicity of cyclophosphamide in newts, rodents, dogs and non-human primates giving consistently positive results. There are numerous reports of DNA-adduct formation by cyclophosphamide in humans. The International Agency for Research on Cancer (IARC) has announced that there is sufficient evidence in humans for the carcinogenicity of cyclophosphamide. Cyclophosphamide causes cancer of the bladder and acute myeloid leukemia. There is also sufficient evidence in laboratory animals for the carcinogenicity of cyclophosphamide. Cyclophosphamide has been classified as carcinogenic to humans (Group 1). In the European Union, cyclophosphamide has been classified as carcinogenic category 1.A and mutagenic category 2.B. Cyclophosphamide has an influence on reproducibility in humans both during treatment and immediately afterwards. It causes fertility impairment and menstrual disorders. Cyclophosphamide is teratogenic to many animal species including rats, mice, rabbits and primates. It is responsible for a variety of musculoskeletal and other malformations and an increased number of resorptions, The type and frequency of malformations are strictly dose- and time-dependent. It is harmful to embryos and may lead to abortions. Exposure to cyclophosphamide in the first trimester of pregnancy may cause numerous congenital anomalies in fetuses, musculoskeletal malformations and deformations of limbs. Cyclophosphamide may be absorbed by inhalation, ingestion, from skin contact or from peritoneum. In the case of occupational exposure of health professionals, skin is considered the main route of exposure. Both in Poland and in other countries, neither occupational exposure level (OEL) in workplace air nor biological exposure index (BEI) has been established for occupational exposure to cyclophosphamide. The proposed OEL value for cyclophosphamide has been derived from its carcinogenicity to laboratory animals, namely from a cancer slope factor (CSF) of 0.57 (mg/kg/day)–1 for bladder cancer, calculated from lifetime oral exposure of rats. The mean dose for 1 10-4 excess lifetime cancer risk would be 1.754 10-4 (mg/kg/day)–1, which in the condition of occupational inhalation exposure is equivalent to air concentration 0.01 mg/m3 and this value is proposed as Time Weighted Average (TWA) OEL. The proposed OEL should protect employees against leukemia and reproductive toxicity, too. The proposed biological exposure index (BEI) is 1 μg of cyclophosphamide in a 24-hr urine sample. There are no grounds for establishing short-term exposure limit (STEL).
Rocznik
Tom
Strony
17--71
Opis fizyczny
Bibliogr. 323 poz., rys., tab.
Twórcy
autor
  • Instytut Medycyny Pracy im. prof. dr. med. Jerzego Nofera 91-348 Łódź ul. św. Teresy od Dzieciątka Jezus 8
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