WHO FOOD Toxicological evaluation of

ADDITIVES certain veterinary drug

SERIES: 49 residues in food

Prepared by the fifty-eighth meeting

of the Joint FAO/WHO Expert
Committee on Food Additives
(JECFA)

The summaries and evaluations contained in this book are, in most cases,
based on unpublished proprietary data submitted for the purpose of the
JECFA assessment. A registration authority should not grant a registration
on the basis of an evaluation unless it has first received authorization for
such use from the owner who submitted the data for JECFA review or has
received the data on which the summaries are based, either from the owner
of the data or from a second party that has obtained permission from the
owner of the data for this purpose.

World Health Organization, Geneva, 2002

IPCS—International Programme on Chemical Safety

This publication is a contribution to the International Programme on
Chemical Safety.

The International Programme on Chemical Safety (IPCS), established

in 1980, is a joint venture of the United Nations Environment Programme
(UNEP), the International Labour Organisation (ILO), and the World
Health Organization (WHO). The overall objectives of the IPCS are to
establish the scientific basis for assessing the risk to human health and
the environment from exposure to chemicals, through international peer-
review processes, as a prerequisite for the promotion of chemical safety,
and to provide technical assistance in strengthening national capacities
for the sound management of chemicals.

The Inter-Organization Programme for the Sound Management of

Chemicals (IOMC) was established in 1995 by UNEP, ILO, the Food
and Agriculture Organization of the United Nations, WHO, the United
Nations Industrial Development Organization, and the Organisation for
Economic Co-operation and Development (Partici-pating Organizations),
following recommendations made by the 1992 United Nations
Conference on Environment and Development to strengthen cooperation
and increase coordination in the field of chemical safety. The purpose of
the IOMC is to promote coordination of the policies and activities pursued
by the Participating Organiza-tions, jointly or separately, to achieve the
sound management of chemicals in relation to human health and the
environment.

The summaries and evaluations contained in this book are, in most cases,
based on unpublished proprietary data submitted for the purpose of the
JMPR assessment. A registration authority should not grant a registration
on the basis of an evaluation unless it has first received authorization for
such use from the owner who submitted the data for JMPR review or has
received the data on which the summaries are based, either from the
owner of the data or from a second party that has obtained permission from
the owner of the data for this purpose.

WHO Library Cataloguing-in-Publication Data

Toxicological evaluation of certain veterinary drug residues in food /

prepared by the fifty-eighth meeting of the Joint FAO/WHO Expert
Committee on Food Additives (JECFA)
(WHO food additives series ; 49)

1 .Drug residues - toxicity 2.lvermectin - analogs and derivatives

3.lvermectin - toxicology 4.Tiabendazole - toxicology 5.Cefuroxime -
toxicology 6. Veterinary drugs - toxicology 7.Food contamination
8.Risk assessment I.Joint FAO/WHO Expert Committee on Food
Additives. Meeting (58th: 2002 : Rome, Italy) II.Series
ISBN 92 4 166049 X (NLM classification: WA 712)
CONTENTS

Preface v

Anthelmintic agents
Doramectin 1
Tiabenzadole (thiabenzadole) 11
Antimicrobial agents
Cefuroxime 27

Annexes
Annex 1 Reports and other documents resulting from
previous meetings of the Joint FAO/WHO
Expert Committee on Food Additives 65
Annex 2 Abbreviations used in the monographs 75
Annex 3 Participants in the fifty-sixth meeting of the
Joint FAO/WHO Expert Committee on
Food Additives 77
Annex 4 Recommendations on compounds on the agenda
and further toxicological studies and information
required 81
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 PREFACE

The monographs contained in this volume were prepared at the fifty-eighth

meeting of the Joint FAO/WHO Expert Committee on Food Additives (JECFA),
which met at FAO Headquarters in Rome, Italy, 21-27 February 2002. These
monographs summarize data on the safety of residues in food of selected veterinary
drugs reviewed by the Committee.
The fifty-eighth report of JECFA will be published by the World Health
Organization in the WHO Technical Report Series. Reports and other documents
resulting from previous meetings of JECFA are listed in Annex 1. Abbreviations
used in the monographs are listed in Annex 2. The participants in the meeting are
listed in Annex 3 of the present publication.
JECFA serves as a scientific advisory body to FAO, WHO, their Member States,
and the Codex Alimentarius Commission, primarily through the Codex Committee
on Food Additives and Contaminants and the Codex Committee on Residues of
Veterinary Drugs in Foods, regarding the safety of food additives, residues of
veterinary drugs, naturally occurring toxicants, and contaminants in food. Commit-
tees accomplish this task by preparing reports of their meetings and publishing
specifications or residue monographs and toxicological monographs on substances
that they have considered.
The monographs contained in this volume are based on working papers that
were prepared by working groups before the meeting. A special acknowledgement
is given at the beginning of each monograph to those who prepared these working
papers. The monographs were edited by E. Heseltine, Lajarthe, 24290 St Leon-
sur-Vezere, France.
The preparation and editing of the monographs included in this volume were
made possible through the technical and financial contributions of the Participating
Organizations of the International Programme on Chemical Safety (IPCS), which
supports the activities of JECFA.
The designations employed and the presentation of the material in this
publication do not imply the expression of any opinion whatsoever on the part of
the organizations participating in the IPCS concerning the legal status of any
country, territory, city, or area or its authorities, or concerning the delimitation of its
frontiers or boundaries. The mention of specific companies or of certain
manufacturers' products does not imply that they are endorsed or recommended
by those organizations in preference to others of a similar nature that are not
mentioned.
Any comments or new information on the biological or toxicological properties
of the compounds evaluated in this publication should be addressed to: Joint WHO
Secretary of the Joint FAO/WHO Expert Committee on Food Additives, International
Programme on Chemical Safety, World Health Organization, Avenue Appia, 1211
Geneva 27, Switzerland.

-v-
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ANTHELMINTIC AGENTS
This page intentionally left blank
 DORAMECTIN

First draft prepared by

Dr Pamela L Chamberlain
Center for Veterinary Medicine
Food and Drug Administration, Rockville, Maryland, USA

Explanation 3
Biological data 4
Toxicological studies 4
Special studies on the genetic basis for sensitivity to
the toxicity of avermectins 4
Collie dogs 4
Observations in Murray Grey cattle 5
Relative sensitivities of mice, rats, rabbits, dogs and non-
human primates to the toxicity of avermectins 5
Relative potencies of doramectin, ivermectin and
abamectin 6
Observations in humans 6
Polymorphisms in the human MDR-1 gene
coding for P-glycoprotein 6
Patients with onchocerciasis treated with ivermectin .... 7
Healthy volunteers treated with ivermectin 7
Comments 9
Evaluation 10
References 10

1. EXPLANATION
Doramectin is a member of the avermectin class of compounds, which includes
abamectin and ivermectin. It is a semisynthetic avermectin that has close structural
similarity to abamectin and ivermectin. It is used as an endoparasitic agent in non-
lactating cattle.
Doramectin was previously evaluated by the Committee at its forty-fifth meeting
(Annex 1, reference 119), when it established an ADI of 0-0.5 mg/kg bw on the basis
of a NOEL of 0.1 mg/kg bw per day for mydriasis in a 3-month study in dogs treated
by gavage and using a safety factor of 200. An additional safety factor of 2 was
applied because doramectin was not tested in CF-1 mice, which is the test animal
most sensitive to the neurotoxic effects of this family of drugs. In 1997, the Joint
FAO/WHO Meeting on Pesticide Residues (JMPR) concluded that the sensitivity to
avermectins of CF-1 mice was due to a genetic variation that causes reduced
expression of P-glycoprotein in the blood-brain barrier (FAO/WHO, 1998). The JMPR
further concluded that the results of studies with CF-1 mice were not appropriate for
establishing ADIs for avermectins.
P-glycoprotein was expressed in the brain and jejunum of all species studied. P-
glycoprotein is a cell membrane protein that acts to remove a wide variety of lipophilic

-3 -
4 DORAMECTIN

compounds from cells, including avermectins. In the capillary endothelium of the

central nervous system, it serves as a functional component of the blood-brain
barrier. In intestinal epithelium, P-glycoprotein can limit intestinal absorption of a
range of compounds.
The Committee at its fiftieth meeting (Annex 1, reference 134) accepted the
conclusions of the JMPR and considered that it was no longer necessary to apply
an additional safety factor of 2 for avermectins and milbemycins that had not been
tested in CF-1 mice. Doramectin was re-evaluated by the Committee at its present
meeting in order to determine whether removal of the additional safety factor of 2
was appropriate. On the basis of the Committee's decision taken at its fiftieth meeting,
the present Committee concluded that use of an additional safety factor of 2 in
establishing the ADI for doramectin was no longer necessary.
No new data were provided to the Committee. The literature was reviewed for
published information on the toxicity of avermectins considered relevant to this
evaluation. The Committee reviewed information on the mechanism of the toxicity
of ivermectin in a subpopulation of collie dogs and observations of its toxicity in a
subpopulation of Murray Grey cattle. The Committee also considered a published
review of the relative sensitivities of mice, rats, rabbits, dogs and non-human primates
to avermectins. The relative potencies of doramectin, ivermectin and abamectin
were also considered. The Committee examined information about variants of the
human gene that codes for P-glycoprotein and reviewed observations in humans.

2. BIOLOGICAL DATA
2.1 Texicological studies
2.1.1 Genetic basis for sensitivity to the toxicity of avermectins
(a) Collie dogs
The genetic basis for the sensitivity of collies to avermectins was studied in 13
clinically normal collies, previously identified as being sensitive or insensitive to
ivermectin. Seven animals were identified as sensitive after displaying typical clinical
signs of neurotoxicity, including depression, ataxia, mydriasis, salivation or drooling,
after receiving a single oral dose of 120 mg/kg bw. The objective of the study was to
determine whether altered gene expression of P-glycoprotein or a polymorphism of
the canine Mdr\ gene that codes for P-glycoprotein exists in avermectin-sensitive
collies. The sensitivity of the CF-1 mouse strain to the neurotoxic effects of avermectin
has been traced to a polymorphism of the murine Mdr 1 gene resulting in decreased
expression of P-glycoprotein (Umbenhauer et al., 1997).
The level of Mdrt expression was similar in sensitive and insensitive collies, as
determined by semi-quantitative reverse transcriptase polymerase chain reaction
(RT-PCR) analysis. Sequence analysis of canine Mdr1 by RT-PCR was conducted
on RNA isolated from blood leukocytes obtained from the sensitive and insensitive
collies and also from other breeds (one beagle, two golden retrievers and one
Staffordshire terrier cross-bred dog). Sequence analysis of clones from three
ivermectin-sensitive collies revealed an identical four-base pair deletion in the first
10% of the transcript. This deletion causes a frame-shift mutation resulting in the
production of a truncated, non-functional protein. The same four-nucleotide deletion
was detected in all samples from ivermectin-sensitive collies, which were also
DORAMECTIN 5

homozygous for the deletion. Insensitive collies had a heterozygous genotype, with
one mutant allele and one wild-type allele. Blood samples from all the other breeds
showed homozygosity for the wild-type. The investigators concluded that their study
provided evidence that the sensitivity of collies to ivermectin results from a frame-
shift deletion of four base pairs in the canine Mdrt gene (Mealey et al., 2001).

(b) Observations in Murray Grey cattle

Murray Grey cattle on one farm in the central tablelands of New South Wales,
Australia, were reported to be sensitive to the toxicity of avermectin B1. The first
cases were noted in October 1985, in 50 Murray Grey heifers aged 18-26 months
treated with avermectin B1 at an estimated dose of 175-200 mg/kg bw by injection.
Three of the heifers died within 2 days of treatment.
Two weeks later, 144 Murray Grey cattle aged 4-18 months and weighing 200-
450 kg were treated with avermectin B1 at an estimated dose of 120-200 mg/kg bw
by injection. The numbers of males and females treated were not stated. Within
48 h of treatment, three steers weighing 400-450 kg developed severe neurological
signs, and all three were slaughtered for necropsy. A fourth steer in this group showed
mild neurological signs and was slaughtered 19 days after treatment.
A field trial was conducted on this farm with 208 Murray Grey cattle, comprising
90 steers that had been treated with avermectin B1 1-2 months earlier and a second
group of 118 cattle that had not been treated previously. The animals were weighed
and treated with the recommended therapeutic dose (200 mg/kg bw) or injected
with the vehicle only. One steer in the group that had not been treated previously
developed neurological signs 42 h after treatment and was slaughtered for necropsy.
Brain, spinal cord, liver, kidney, lung, heart, spleen, intestines, skeletal muscles,
adrenals, lymph nodes and peripheral nerves from the four initial cases, the case
found in the field trial and one normal treated animal were examined macroscopically
and histologically. No pathological changes were found that would explain the severe
neurological syndromes observed. The concentrations of avermectin B1 in plasma
and/or serum, liver, brain and spinal cord from the five clinically affected animals
and the normal animal were assayed by high-performance liquid chromatography
with fluorescence detection. The average concentration of avermectin B1a was
56 mg/ml in brain tissue from affected animals and 4 mg/ml in brain tissue from the
normal animal.
Two additional field trials were undertaken with Murray Grey cattle in other areas
of New South Wales and in Victoria. A total of 83 cattle were treated with at least
twice the normal therapeutic dose of avermectin B1. No adverse reactions occurred.
The authors stated that no other incidents of toxic effects of avermectins have been
reported in Murray Grey cattle. They also noted that the farm on which the adverse
reactions were seen had maintained a virtually closed herd for approximately 15 years
(Seaman etal., 1987).

2.1.2 Relative sensitivities of mice, rats, rabbits, dogs and non-human

primates to the toxicity of avermectins

The relative sensitivities of the central nervous system in mice, rats, rabbits,
dogs and non-human primates to avermectins have been reviewed (Lankas &
Gordon, 1989). The studies conducted with ivermectin addressed acute toxicity in
mice, rats, dogs and rhesus monkeys treated orally; short-term studies of toxicity in
6 DORAMECTIN

rats, dogs and rhesus monkeys; and studies of developmental and reproductive
toxicity in mice, rats and rabbits. The studies with abamectin given by oral
administration comprised long-term studies of toxicity and carcinogenicity in mice
and rats, a 1-year study of toxicity in dogs and a study in rhesus monkeys given
single doses.
The authors concluded that clear species differences exist in the sensitivity of
the central nervous system to the toxicity of avermectin, rodents being the most
sensitive. A dose of 0.2 mg/kg bw in mice and slightly higher doses in rats resulted
in clinical signs of central nervous system toxicity, comprising tremors and ataxia,
while these doses caused no adverse effects in rabbits, dogs or rhesus monkeys.
The authors described a study of acute toxicity in which groups of two male and
two female rhesus monkeys were given abamectin or ivermectin at single oral doses
of 0.2, 0.5,1, 2, 8,12 or 24 mg/kg bw. The time between administration of the next
higher dose to the same group of monkeys was 2-3 weeks. The authors noted that
the minimum single oral dose of ivermectin or abamectin that was toxic (2 mg/kg
bw) was approximately 10-fold greater than the human clinical dose of ivermectin.
Emesis was the only toxic effect observed in rhesus monkeys after an oral dose of
ivermectin of 2 or 8 mg/kg bw; the clinical signs of toxicity observed after a dose of
24 mg/kg bw were emesis, mydriasis and sedation. The authors compared the effect
at 8 mg/kg bw with effects seen in a child (age and sex not stated) after the apparently
accidental ingestion of approximately 8 mg/kg bw. The toxic effects observed in the
child were emesis, mydriasis and sedation. In view of the similarity of the toxic
effects observed in rhesus monkeys and the child, the authors proposed that rhesus
monkeys are an appropriate model for predicting the acute toxic effects of ivermectin
in humans. The NOELfor acute effects after administration of abamectin or ivermectin
to rhesus monkeys was 1 mg/kg bw.
The review of the developmental and reproductive toxicity of ivermectin included
the results of studies conducted in mice, rats and rabbits. The reported NOELs for
maternal toxicity in mice, rats and rabbits were 0.1, 5 and 3 mg/kg bw per day,
respectively. The reported NOELs for developmental toxicity in mice and rabbits
were 0.2 and 1.5 mg/kg bw per day, respectively. A NOEL of 0.2 mg/kg bw per day
was reported for neonatal and developmental toxicity in a multigeneration study in
rats (Lankas & Gordon, 1989).

2.1.3 Relative potencies of doramectin, ivermectin and abamectin

The Committee evaluated the relative potencies of doramectin, ivermectin and
abamectin by comparing the NOEL values reported in evaluations by the Committee
at its firty-fifth meeting, the JMPR in 1997 and Lankas and Gordon (1989). The
studies of reproductive and developmental toxicity in rats and rabbits and the 90-
day studies of toxicity in dogs, all treated orally, were the only ones in which all three
compounds could be compared. On the basis of these data, the Committee concluded
that the potency of these compounds was similar.

2.2 Observations in humans

2.2.1 Polymorphism in the human MDR1 gene coding for P-glycoprotein

In a study of 461 white volunteers in Germany (294 men and 167 women aged
18-65), DNA samples were analysed for polymorphisms in the MDR1 gene by
DORAMECTIN 7

polymerase chain reaction-restriction fragment length polymorphism assays. Eleven

polymorphisms of MDR1 were identified in this population. The author stated that
16 polymorphisms were identified. The polymorphism identified in exon 26 of the
MDR1 gene is associated with a specific alteration in drug transport. Volunteers
with this polymorphism showed enhanced uptake of an oral dose of digoxin and a
steady-state concentration that was 38% higher than that in volunteers without this
polymorphism. The difference was statistically significant. Quantitative
immunohistochemistry and western blot analysis were used to analyse the level of
expression of P-glycoprotein in the duodenum of the volunteers. A correlation was
found between decreased expression of P-glycoprotein and the polymorphism in
exon 26. Thus, both the expression level and the functionality of P-glycoprotein are
affected by this polymorphism. Controlled clinical trials and in-vitro studies are needed
to determine the clinical relevance of other polymorphisms of the MDR1 gene. Data
on the distribution of MDR1 polymorphisms in populations of other ethnic origins
are not available (Hoffmeyer et al., 2000; Cascorbi et al., 2001).

2.2.2 Patients with onchocerciasis treated with ivermectin

Ivermectin has been administered to several million patients in Africa and Latin
America for the treatment of onchocerciasis. A WHO report (WHO, 2001) stated
that in 2000 alone, over 23 million people were treated. The reported adverse
reactions in treated patients are allergic or inflammatory responses resulting from
the killing of microfilarariae, referred to as the 'Mazotti reaction' (Pacque et al., 1989).
No cases of acute central nervous system toxicity have been reported after treatment
of patients for onchocericasis.
When ivermectin was first distributed in 1987 to selected populations for the
treatment of onchocerciasis, the drug sponsor contraindicated its use in pregnant
women, mothers who were breastfeeding infants under 3 months of age, children
under 12 years of age and people with active disease of the central nervous system,
such as meningitis or epilepsy. These contraindications were listed as it was not
known with certainty whether the blood-brain barrier of neonates and those with
central nervous system disease would prevent entry of ivermectin. It was also
unknown whether the placenta could prevent transfer of ivermectin to the fetus. The
sponsor's evaluation of information that had become available since 1987 caused
them to change the original list of contraindications. The new information includes
elucidation of the genetic basis for the sensitivity of the CF-1 mouse, identification
of P-glycoprotein in the human placenta and in the human fetus from week 28 of
gestation (Cordon-Cardo et al., 1989), the finding of no significant risk to the fetuses
of pregnant women who had been inadvertently treated with ivermectin (Pacque et
al., 1990) and the demonstration that ivermectin is safe for patients with epilepsy
(Kipp et al., 1992). As a result, use of ivermectin in pregnant or epileptic patients is
now permitted, and treated mothers can breastfeed infants as young as 1 week of
age (Brown, 1998). The usual dose administered to humans for the treatment of
onchocerciasis is 150 ng/kg bw once every 12 months (Anon, 1999).

2.2.3 Healthy volunteers treated with ivermectin

The pharmacokinetics of orally administered ivermectin was studied in 12 healthy
male (race not stated) volunteers aged 18-50 years. A single therapeutic dose of
8 DORAMECTIN

12 mg (150-200 fig/kg bw) as a tablet resulted in an average maximal time to peak

plasma concentration of 3.6 h, an average maximal plasma concentration of 46 ng/ml
and an average area under the plasma concentration-time curve of 880 ng/h per
ml. No clinical adverse effects were reported (Edwards et al., 1988).

3. COMMENTS
The genetic basis for the sensitivity of collie dogs to the neurotoxic effects of
ivermectin was studied in four males and three females previously identified as
sensitive to ivermectin and in six which showed no increased sensitivity. Sensitive
animals were identified as those that exhibited typical clinical signs of toxicity to the
central nervous system after receiving ivermectin at an oral dose of 120 jig/kg bw.
The levels of P-glycoprotein expression were similar in sensitive and insensitive
test animals; however, a specific variant of the gene coding for P-glycoprotein was
identified in the sensitive animals that caused production of a severely truncated,
non-functional form of P-glycoprotein. The Committee noted that the sensitivity of
CF-1 mice to the toxicity of avermectins has also been linked to a variant of the
gene responsible for expression of P-glycoprotein. When the levels or functionality
of P-glycoprotein are reduced, avermectin compounds may penetrate the blood-
brain barrier and may be more extensively absorbed by the gastrointestinal tract.
Sensitivity to the toxicity of avermectin B^ was observed in a herd of Murray
Grey cattle in Australia in 1985. Eight of 312 cattle treated with ivermectin at a
therapeutic dose of 120-200 ^ig/kg bw by injection showed symptoms of
hypersensitivity. The average concentration of avermectin B1a in brain tissue from
the affected animals was 56 ng/kg, while that in brain tissue from a normal animal
was 4 ng/kg. No adverse reactions occurred in 83 additional Murray Grey cattle
from other areas of Australia that were tested for sensitivity to avermectins by treating
them with at least twice the normal therapeutic dose of avermectin 61.
The Committee evaluated the relative potencies of doramectin, ivermectin and
abamectin by comparing the NOEL values reported for reproductive and
developmental toxicity in rats and rabbits and in 90-day studies of toxicity in dogs
treated orally. These were the only studies with which such a comparison could be
made. On the basis of these data, the Committee concluded that the potencies of
these compounds are similar.
Eleven variants of the human gene coding for P-glycoprotein were identified in a
sample population of 461 white volunteers in Germany. One of the variants was
correlated with decreased levels of P-glycoprotein expression in the duodenum.
Volunteers with this variant gene showed enhanced bioavailability of an oral dose of
digoxin, with a steady-state concentration that was 38% higher than in volunteers
without the variant gene. The difference was statistically significant. Whether this
variant could result in enhanced bioavailability of orally administered avermectins is
unknown. Studies of variations in the gene coding for P-glycoprotein in populations
of other ethnic groups have not been reported. The Committee noted that, although
the effects resulting from variation in the human gene coding for P-glycoprotein are
modest, the evidence to date does not exclude the possibility that a subpopulation
of humans sensitive to the toxic effects of avermectins may exist.
DORAMECTIN 9

Ivermectin has been administered to several million human patients in Africa

and Latin America since its introduction in 1987 as the main treatment for
onchocerciasis at a recommended dose of 150 ng/kg bw administered once every
12 months. The adverse reactions that have been observed in treated patients have
been described as allergic or inflammatory responses resulting from killing of
microfilariae, referred to as the 'Mazotti reaction'. No signs of acute central nervous
system toxicity have been reported. Ivermectin is now considered safe for use in
pregnant women, on the basis of the finding of P-glycoprotein in human placentae
and in human fetuses by week 28 of gestation and the absence of adverse effects
to the fetus when pregnant women were inadvertently treated with ivermectin.
The pharmacokinetics of orally administered ivermectin was studied in 12 healthy
male volunteers of unspecified race. A single dose at a therapeutic level of 12 mg
(150-200 |ig/kg bw) resulted in an average maximal plasma concentration of 46 ng/ml
and an average time to maximum concentration in plasma of 3.6 h. No adverse
clinical signs were reported.

4. EVALUATION
An ADI for doramectin of 0-1 u.g/kg of bw was established on the basis of a
NOEL of 0.1 mg/kg bw per day for mydriasis in a 3-month study in dogs treated by
gavage, with a safety factor of 100. The Committee noted that removal of the twofold
safety factor resulted in an ADI that still provided an adequate margin of safety for
all other toxicological end-points of doramectin. The Committee also noted that the
resulting ADI for dormectin is 150-200 times lower than the human therapeutic
dose of the related compound ivermectin.
The Committee took special note of the available information on reduced
expression of P-glycoprotein in humans, which results in increased bioavailability of
substrates for this transporter. However, the effects on the bioavailability of
avermectins and their ability to penetrate the blood-brain barrier are unknown. The
Committee recommended that human populations continue to be monitored for
possible genetic predisposition to sensitivity to avermectins.

5. REFERENCES
Anon. (1999) Product information for Stromectol® , ivermectin tablets. In: Physicians' Desk
Reference (electronic version), PDR® Electronic Library Medical Economics Company Inc.,
Montvale, NJ. URL: www.pdrel.com.
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systemic availability of ivermectin after administration as capsule, tablet, and oral solution.
Eur. J. din. Pharmacol., 35, 681-684.
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FAO/WHO (1998) Pesticide residues in food—1997. Report of the Joint Meeting of the FAO
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Gerloff, T., Roots, I., Eichelbaum M. & Brinkmann, U. (2000) Functional polymorphisms of
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H.R. (1989) Community-based treatment of onchocerciasis with ivermectin: Acceptability
and early adverse reactions. Bull. World Health Org., 67, 721-730.
Seaman, J.T., Eagleson, J.S., Carrigan, M.J. & Webb, R.F. (1987) Avermectin 61 toxicity in a
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Umbenhauer, D.R., Lankas, G.R., Pippert, T.R., Wise, L.D., Cartwright, M.E., Hall, S.J. &
Beare, C.M (1997) Identification of P-glycoprotein-deficient subpopulation in the CF-1 mouse
strain using a restriction fragment length polymorphism. Toxicol. Appl. Pharmacol., 146,
88-94.
WHO (2001) Programme for the Prevention of Blindness and Deafness, www.who.int/pbd/
oncho/oncho-brochure.pdf.
 TIABENDAZOLE (THIABENDAZOLE) (addendum)

First draft prepared by

M.E.J. Pronk and G.J. Schefferlie
Centre for Substances and Risk Assessment
National Institute for Public Health and the Environment
Bilthoven, The Netherlands

Explanation 11
Biological data 12
Biochemical aspects: Absorption, distribution and excretion 12
Toxicological studies 12
Acute toxicity 12
Short-term studies of toxicity 13
Reproductive toxicity 14
Multigeneration studies 14
Developmental toxicity 14
Observations in humans 16
Selection of relevant end-points 17
Mechanism of action 17
Clinical signs 18
Toxicity to specific organs 18
Effects on the kidney 18
Effects on the haematopoietic system 21
Developmental toxicity 22
Comments 22
Evaluation 24
References 24

1. EXPLANATION
Tiabendazole (thiabendazole) is a benzimidazole compound used both as a
broad-spectrum anthelmintic in various animal species and for the control of parasitic
infestations in humans. It was evaluated by the Committee at its fortieth meeting
(Annex 1, reference 104). An ADI of 0-100 u,g/kg bw was established on the basis
of reduced body-weight gain in a 2-year study in rats and reduced fetal weight in a
study of developmental toxicity in rats, by applying a safety factor of 100 to the
NOEL of 10 mg/kg bw per day. At its forty-eighth meeting (Annex 1, reference 128),
the Committee reviewed the results of supplementary studies that allowed it to confirm
its earlier evaluation. The NOELs in the 12-month study in dogs, the 2-year study of
toxicity in rats and the two-generation study of reproductive toxicity in rats were all
10 mg/kg bw per day, identical to the NOEL that had served as the basis for the ADI.
The Committee applied a safety factor of 100 and confirmed the ADI of 0-100 u,g/kg
bw established at its fortieth meeting.
As tiabendazole is also used as a fungicide in plant protection, its toxicity was
also evaluated by the 1970 and 1977 Joint FAO/WHO Meeting on Pesticide Residues
(JMPR) (FAO/WHO, 1971, 1978). At the 2000 JMPR (FAO/WHO, 2001), at which
the residue and analytical aspects of tiabendazole were evaluated, the Meeting

-11 -
12 TIABENDAZOLE

concluded that the toxicological profile of tiabendazole included effects of concern

that might indicate a need for an acute reference dose (RfD). The Meeting
recommended that tiabendazole be considered further by JECFA, which had
conducted the most recent toxicological assessment of this chemical.
The Committee did not receive new data for establishing an acute RfD for
tiabendazole. All the data considered had been evaluated and summarized previously
by the Committee, at its fortieth and forty-eighth meetings. Those data were re-
evaluated by the Committee at its present meeting, when it focused on aspects
relevant for establishment of an acute RfD. In addition, the Committee consulted
the literature for recently published information on the toxicity of tiabendazole and
considered those relevant for this evaluation.

2. BIOLOGICAL DATA
2.1 Biochemical aspects: Absorption, distribution and excretion
After oral administration to mice, rats, dogs and humans, tiabendazole is rapidly
absorbed (peak plasma concentrations within 3 h), followed by rapid elimination,
which is essentially complete within 1 day for humans and rats and 3 days for dogs
and mice. The half-time in humans is < 2 h. In humans, rats and mice, urinary
excretion predominated over faecal excretion. In dogs, the amount excreted in faeces
was somewhat greater than that in urine (Annex 1, reference 105; Tocco et al.,
1966). Given these toxicokinetics, accumulation in the body is not expected.

2.2 Toxicological studies

2.2.1 Acute toxicity
The acute toxicity of thiadibendazole is summarized in Table 1.
The study by Lankas (1981) was not evaluated previously by the Committee. At
doses ranging from 2200 to 11 000 mg/kg bw, the signs noted were decreased
activity, bradypnoea, ptosis and loss of righting reflex.
In the studies of Robinson (1964), the doses used were not specified. The toxic
signs were described as lethargy and stupor. No further details were given.
In the study with rabbits treated dermally (Blaszcak & Auletta, 1987), no toxic
signs were noted.
Table 1. Acute toxicity of thiabendazole

Species Sex Route LD50 Reference GLP/QA

(mg/kg bw)

Mouse Female Oral 3800 Robinson (1964) No

Rat Male Oral 3300 Robinson (1964) No
Rat Male and female Oral 4700-5100 Lankas (1981) Yes
Rat Male and female Inhalation3 3
> 400 mg/m Gurmanetal. (1981) Yes
Rabbit Not specified Oral 3800 Robinson (1964) No
Rabbit Male and female Dermal >2000 Blaszcak & Auletta (1987) No

GLP, good laboratory oractice; QA, quality assurance

a
Gravimetric concentration; 4 h exposure
TIABENDAZOLE 13

The rats treated by inhalation had squinted eyes, polypnoea and body-weight
loss (Gurman et al., 1981).

2.2.2 Short-term studies of toxicity

Rats
In a 13-week study of toxicity reviewed by the Committee at its fortieth meeting
(Annex 1, reference 105), groups of 10 male and 10 female Sprague-Dawley Crl:CD
BR rats received diets containing tiabendazole at concentrations intended to provide
a daily dose of 0, 10, 40, 160 or 320 mg/kg bw. The calculated mean intakes of
tiabendazole were 0, 9, 37, 150 and 300 mg/kg bw per day, respectively. Clinical
signs were recorded weekly, and haematological end-points were measured in
samples taken at weeks 6 and 13. The following observations may be relevant for
the acute toxicity of this compound. No effects were seen in controls or in animals at
the lowest dose. At 37 mg/kg bw per day, females showed an increased platelet
count at both weeks 6 and 13, and both sexes showed an increased incidence of
erythroid hyperplasia in the bone marrow. At the two higher doses, the following
dose-related changes were seen: an increase in the incidence of alopecia; a decrease
in erythrocyte count, haemoglobin concentration and erythrocyte volume fraction at
weeks 6 and 13; an increased frequency of abnormal erythrocyte morphology at
both times; an increase in platelet count at both times (only at week 13 in males at
150 mg/kg bw per day); and increased incidences of erythroid hyperplasia in bone
marrow and haemoglobin pigment in spleen.

The Committee at its previous meeting identified a NOEL of 9 mg/kg bw per day
on the basis of decreased body-weight gain and food intake in males, increased
liver weight and centrilobular hypertrophy, increased thyroid weight, follicular cell
hypertrophy and bone-marrow erythroid hyperplasia at doses of 37 mg/kg bw per
day and above. The effects on the haematopoietic system at both sampling times (6
and 13 weeks), together with the erythroid hyperplasia in bone marrow, were
indicative of anaemia and were considered potentially relevant for acute exposure.
The NOEL for these effects was 9 mg/kg bw per day (Myers & Lankas, 1990).

Dogs
In a 14-week study of toxicity reviewed by the Committee at its fortieth meeting
(Annex 1, reference 105), groups of four male and four female beagle dogs received
tiabendazole orally in gelatin capsules at a daily dose of 0, 35, 75 or 150 mg/kg bw.
Clinical signs were recorded twice daily, and haematological end-points were
measured at weeks 4, 8 and 12. The following observations may be relevant for
acute toxicity. No changes were seen in controls or those at the lowest dose. Animals
at the two higher doses showed dose-related increases in salivation and emesis,
the latter effect mainly during the first few weeks of the study. At the highest dose,
decreased erythrocyte count, haemoglobin and erythrocyte volume fraction were
seen, the effects being more frequent at weeks 4 and 8 than at week 12.
The Committee at its previous meeting identified a NOEL of 35 mg/kg bw per
day on the basis of histopathological changes in the gall-bladder. This effect was,
however, considered not relevant for assessing the effects of acute exposure. The
haematological findings at the first two sampling times may be indicative of anaemia
14 TIABENDAZOLE

and were considered potentially relevant for acute exposure. The NOEL for these
effects was 75 mg/kg bw per day (Batham & Lankas, 1990).

Groups of four male and four female beagle dogs received tiabendazole orally
in gelatin capsules at a daily dose of 0,10,40 or 160 mg/kg bw for 1 year in a study
of toxicity reviewed by the Committee at its fortieth meeting (Annex 1, reference
105). Clinical signs were recorded daily and haematological end-points were
measured in samples taken at weeks 4,12, 26 and 52. The following observations
may be relevant to the acute toxicity of this compound. No effects were seen in
controls or animals at the lowest dose. Animals at the highest dose showed emesis,
especially during the first 3 weeks and in females throughout the first half of the
study. Animals at the highest dose showed decreased erythrocyte count, haemoglobin
concentration and erythrocyte volume fraction and increased activated partial
thromboplastin time and platelet count throughout the study (weeks 4-52).
Histological examination showed a dose-related increase in the frequency of distal
tubule vacuolation in the kidney of females; a dose-related increase in haemosiderin
deposition in the spleen of females, with a very slight, not statistically significant
effect in males at all doses with no dose-response relationship; and a dose-related
increase in splenic erythropoiesis in animals at the two higher doses. Increased
bone-marrow erythropoiesis was seen only in females at the highest dose.
The Committee at its previous meeting identified a NOEL of 10 mg/kg bw per
day on the basis of (histopathological) changes indicative of haemolytic anaemia.
As haematological changes were observed throughout the study, all changes to the
haematopoietic system, including the histopathological changes, were considered
potentially relevant to acute intake as well. It was noted that the effects in spleen
and bone marrow seen after 53 weeks were not found in the 14-week study in dogs
(Lankas, 1993).

2.2.3 Reproductive toxicity

(a) Multigeneration studies
Rats
In a two-generation study of reproductive toxicity, groups of 33 male and 33
female Sprague-Dawley Crl:CD BR rats received diets containing tiabendazole
(purity, > 99%) at concentrations providing a dose of 0, 10, 30 or 90 mg/kg bw per
day (Wise & Lankas, 1992). This study was summarized by the Committee at its
forty-eighth meeting (Annex 1, reference 129). The only treatment-related findings
were effects on food consumption and body-weight gain, for which the Committee
previously identified a NOELof 10 mg/kg bw per day. These effects were considered
irrelevant for acute exposure.

(b) Developmental toxicity

Mice
Three studies of developmental toxicity were undertaken in pregnant JcUCR
mice. Tiabendazole (purity, 98.5%) was given orally as a suspension in olive oil by
gastric intubation. The animals were killed on day 18 of gestation. These studies
were summarized by the Committee at its fortieth meeting (Annex 1, reference 105).
TIABENDAZOLE 15

In the first experiment, mice were given a dose of 0, 700, 1300 or 2400 mg/kg
bw on days 7-15 of gestation. Maternal body-weight gain was decreased in a dose-
related fashion at all doses, and the mortality rate increased with increasing dose,
being 0/39 controls, 0/39 at the lowest dose, 5/39 at the intermediate dose and
24/39 at the highest dose. The weights of the liver, kidney, heart and spleen were
increased at all three doses. A dose-related increase in the frequency of resorptions
was seen at the two higher doses, and a dose-related decrease in fetal body weight
occurred at all doses. In the offspring, the incidence of cleft palate was increased in
a dose-related fashion at all doses, and the incidence of fusion of vertebral arches
and vertebral bodies was increased in offspring of dams at the two lower doses.
In the second experiment, animals were given a dose of 2400 mg/kg bw on a
single day between days 6 and 15 of gestation. The maternal mortality rates were
2/7,2/12,1/12,2/11,2/11,6/11,2/11,1/11,4/11 and 6/11 on days 6-15, respectively.
The rate of resorptions was increased and the fetal body weight decreased after
dosing on any day. Increased frequencies were seen of microencephaly and
exencephaly after treatment on day 6, 7 or 8; short or absent tail and anal atresia
after dosing on day 9; open eyelids after treatment on day 7,8,10,13 or 14; reduction
deformity of the limbs after dosing on day 9,10,11 or 12; cleft palate after dosing on
day 8, 9, 10, 11, 12 or 13; fusion of vertebral arches and vertebral bodies after
treatment on day 7, 8,9,10 or 13; and fusion of the ribs after dosing on day 7, 8 or 9.
In the third experiment, groups of 21-31 mice were given tiabendazole at a
single dose of 0, 30, 60, 62, 120, 130, 240, 270, 480, 560, 670, 800, 960, 1200,
1400, 1700, 2000 or 2400 mg/kg bw on day 9 of gestation. Maternal weight gain
was decreased at 1200 mg/kg bw, the maternal mortality rate was increased at
1700 mg/kg bw, and the weights of the liver, heart and kidney weight were decreased
at 1400 mg/kg bw. The resorption rate was increased at 1700 mg/kg bw, and the
fetal body weight was decreased at 60 mg/kg bw. The incidence of reduction deformity
of the limbs was increased at 480 mg/kg bw, and that of fusion of vertebral arches
and vertebral bodies and of ribs was increased at 240 mg/kg bw (Ogata et al.,
1984).

In a study of developmental toxicity, groups of 25 pregnant JcklCR mice were

given tiabendazole (purity, 99.8%) in olive oil by oral gavage at a dose of 0, 25,100
or 200 mg/kg bw per day on days 6-15 of gestation. The animals were killed on
day 18 of gestation. This study was evaluated by the Committee at its forty-eighth
meeting (Annex 1, reference 129). Dams at the two higher doses showed dose-
related decreases in food consumption and weight gain, and there were dose-related
decreases in the number of implantations and fetal body weight at these doses. An
increased incidence of delayed ossification was seen at all doses, but this was not
dose-related, and the number of affected litters was similar in all groups, including
controls. The NOEL was 25 mg/kg bw per day on the basis of the reduced number
of implantations at a maternally toxic dose (Nakatsuka et al., 1995).

Rats
In a study of developmental toxicity, groups of 25 pregnant Sprague-Dawley
Crl:CD BR rats received tiabendazole (purity, 98.9%) in 0.5% methylcellulose by
gavage at a daily dose of 0,10, 40 or 80 mg/kg bw on days 6-17 of gestation. The
animals were killed on day 20 of gestation. This study was evaluated by the
16 TIABENDAZOLE

Committee at its fortieth meeting (Annex 1, reference 105). The food consumption
and weight gain of the dams at the two higher doses were decreased in a dose-
related manner, and dams at the highest dose showed ptosis and regurgitation. A
dose-related decrease in fetal body weight was seen at the two higher doses. The
NOEL was 10 mg/kg bw per day (Wise, 1990).

Rabbits
In a study of developmental toxicity, groups of 18 pregnant New Zealand white
rabbits received tiabendazole (purity, 98.9%) in 0.5% methylcellulose by gavage at
a dose of 0, 24, 120 or 600 mg/kg bw on days 6-18 of gestation. The animals were
killed on day 29 of gestation. This study was evaluated by the Committee at its
fortieth meeting (Annex 1, reference 105). Dose-related decreases in food consump-
tion and weight gain were seen at the two higher doses, with a loss of body weight
at the highest dose. Four of 18 dams at the highest dose aborted. The mortality
rates were 2/18 controls (due to intubation errors), 0/18 at the lower dose, 0/18 at
the intermediate dose and 1/18 at the highest dose. A dose-related increase in the
rate of early and late resorptions was seen at the two higher doses, and fetuses at
these doses had dose-related increased incidences of domed head, hydrocephalus
and marked enlargement of the fontanelle. The NOEL was 24 mg/kg bw per day
(Hoberman, 1989).
In another study of developmental toxicity, evaluated by the Committee at its
fortieth meeting (Annex 1, reference 105), groups of 18 pregnant New Zealand
white rabbits received tiabendazole (purity, 98.6%) in 0.5% methylcellulose by gavage
at a dose of 0, 50, 150 or 600 mg/kg bw per day on days 6-18 of gestation. The
animals were killed on day 28 of gestation. Effects were seen only at the highest
dose; they comprised decreased maternal food consumption and weight gain,
increased rates of early and late resorptions, decreased fetal body weight and
increased incidences of variation in lung lobation and incompletely ossified
metacarpals. No evidence for compound-related fetal hydrocephaly was found. The
NOEL was 150 mg/kg bw per day (Lankas & Wise, 1991/1993).

2.3 Observations in humans

In a study with volunteers, 50 men aged 20-57 years received capsules containing
placebo and 50 received 125 mg of tiabendazole twice daily for 24 weeks. Neither
the study subjects nor the investigators were aware of who had received placebo. In
total, 36 men receiving tiabendazole and 41 receiving placebo completed the study.
One man was removed from the study at his own request because of daytime
sedation and markedly decreased energy. The other withdrawals were clearly
unrelated to the treatment. Weekly interviews were conducted to record side-effects.
General physical examinations and laboratory examinations (haematology,
measurement of cholesterol, glucose, urea, alkaline phosphatase, thymol turbidity,
bilirubin in serum and urine analysis) were carried out before the test and after 4,12
and 24 weeks. The haematological parameters measured were reported only as
'CBC' and haematocrit. Protein-bound iodine in serum and electrocardiographic
traces were evaluated only at the beginning and after 24 weeks of the study.
This study was previously summarized by the 1977 JMPR (FAO/WHO, 1978),
which noted that, under the conditions of the study, tiabendazole was well tolerated,
TIABENDAZOLE 17

and no effect on any of the parameters could be clearly ascribed to treatment. The
JMPR identified a NOEL of 3-4 mg/kg bw per day, which was confirmed by the
Committee at its fortieth meeting (Annex 1, reference 105). The following observations
may be relevant for the acute toxicity of tiabendazole, although the time of onset of
clinical signs was not specified. The men reported the following possible side-effects
(treated versus placebo): increased appetite (26/50 vs 30/50), flatulence (6/50 vs
3/50), nausea (4/50 vs 2/50), increased urinary frequency (3/50 vs 3/50) and sedation
(7/50 vs 5/50) (Colmore, 1965).

In a review of studies on the efficacy of tiabendazole against parasites in humans,

the standard therapeutic oral dose was 25 mg/kg bw twice daily for 1-4 days, although
higher doses were used in some studies. The incidences of minor transient side-
effects were generally 25-30% with the standard dose and higher with higher doses.
The effects comprised anorexia, nausea, vomiting and dizziness. Serious side-effects
were rare and comprised numbness, collapse, tinnitus, abnormal sensation in the
eyes, xanthopsia, enuresis, decreased pulse rate and systolic blood pressure and
transient rises in the frequency of cephalin flocculation and in aspartate aminotrans-
ferase activity (Campbell & Cuckler, 1969).

Side-effects in humans after therapeutic oral doses (not specified) of thiabenda-

zole were reported in another literature review. Common effects were dizziness (the
frequency ranging from < 5% to 80%, depending on dosage) and nausea and vomiting
(5-15%). Rarely observed side-effects included anorexia, abdominal pain, headache,
drowsiness, weariness, heartburn, diarrhoea or constipation, flatulence, blurring of
vision, xanthopsia, skin eruption, malodorous urine and vomiting of live Ascaris.
The extent to which these frequencies differed from those in untreated subjects is
unknown, although in two placebo-controlled studies dizziness was reported to be
approximately twice as common in tiabendazole-treated subjects as in placebo-
treated subjects (Cuckler & Mezey, 1966).

In a clinical case report, the following side-effects were reported in 14 of

23 patients with trichinosis who had received tiabendazole orally at a dose of
50 mg/kg bw in two daily doses for 10 days: nausea (11/23), retching (11/23), vomiting
(11/23), aversion to tablets (3/23), exanthema (3/23), impotence (2/23), diarrhoea
(1/23), liver damage (1/23), fever (1/23) and dizziness (1/23) (Hennekeuser et al.,
1969). Again, the incidence of side-effects in untreated patients was not reported,
and the extent to which these effects might have been influenced by the underlying
condition was not reported.

3. SELECTION OF RELEVANT END-POINTS

The end-points relevant to acute intake are identified below, on the basis of
guidance given by the Commission of the European Union (2001), the 2000 JMPR
(FAO/WHO, 2001) and van Raaij (2001).

2.1 Mechanism of action

The mechanism of action of tiabendazole is not clear, but it might involve inhibition
of the fumarate reductase system of worms, thereby interfering with their source of
18 TIABENDAZOLE

energy (Parfitt, 1999). As fumarate is a link in the citric acid cycle, which is a common
pathway in organisms, this possible mode of action of tiabendazole may also be
relevant in assessing the risks of humans after acute exposure. An indication of the
toxicity resulting from this mode of action may be found in the mitochondrial
dysfunction observed in the renal cortex of mice given a single oral dose of 1000 or
2000 mg/kg bw (see section 3.3.1).

3.2 Clinical signs

The studies of acute toxicity gave oral LD50 values above 2000 mg/kg bw, raising
no concern. The clinical signs described in these studies were relatively unspecific
(e.g. decreased activity), and the correlation with doses was not reported. It remains
unclear whether these signs were substance-specific or related to the dosing
procedure. They were therefore not considered in establishment of an acute RfD.
In the studies with repeated doses, the only specific clinical sign in rats (13-
week study) was alopecia, which was observed at the highest dose of 300 mg/kg
bw per day, with a NOEL of 150 mg/kg bw per day. However, the onset of this sign
was not earlier than after 5 or 6 weeks of treatment, and it is therefore not relevant
for acute exposure. It was noted that this effect was also reported in a 28-day study
in rats treated orally (summarized by the Committee at its fortieth meeting (Annex 1,
reference 105) but not available in the present dossier) at the highest dose of
800 mg/kg bw per day, but not at lower doses up to 200 mg/kg bw per day. In dogs,
the only treatment-related clinical signs were salivation and emesis. These effects,
particularly emesis, are considered relevant for acute exposure, because vomiting
is also a common side-effect in humans. The NOEL for emesis in dogs was 40 mg/kg
bw per day.
Common side-effects reported in humans after oral doses > 25 mg/kg bw twice
daily for 1-10 days comprised anorexia, nausea, vomiting and dizziness (data from
1966-69; no recent data available and often no control data for comparison). NOELs
could not be identified. In a placebo-controlled study in volunteers, a dose of 125 mg
of tiabendazole twice a day for 24 weeks (equivalent to 3.6 mg/kg bw per day for a
60-kg person) did not cause significant changes in subjective side-effects.

3.3 Toxicity in specific organs

3.3.1 Effects on the kidney
No effects on the kidney were found in the studies available to the Committee,
after repeated doses in rats or in the studies on reproductive and developmental
toxicity in rats and rabbits. In dogs, renal toxicity was observed in the 1-year study
(NOEL, 10 mg/kg bw per day) but not in the 14-week study at comparable doses. In
contrast, renal toxicity was observed after acute and short-term oral intake of
tiabendazole in mice. This effect was described in earlier evaluations by the
Committee, as well as in some published articles, but none of these studies was
submitted in the dossier.
In a short-term study of toxicity, mice were given tiabendazole at a dose of 0,
250 or 500 mg/kg bw per day by gavage for 1, 3, 5 or 7 days. Dose-related renal
toxicity was observed, which included tubule dilatation, degenerative desquamation,
cell infiltration, fibrosis and regeneration of tubule epithelium. Electron microscopy
TIABENDAZOLE 19

showed evidence of glomerular damage, such as flattening of the foot processes of

podocytes and oedematous changes in the mesangium in treated mice. No NOEL
could be identified (Tada et al., 1989).
Effects on the kidneys were also observed in one 13-week study in rats and
some of the long term (2-year) studies in rats that had been evaluated earlier by the
JMPR or JECFA but which were not available in the present dossier.

In a published report not previously evaluated by the Committee, male Crj:CD-1

(ICR) mice were given tiabendazole (purity, 98.5%) in olive oil as a single dose of 0,
250, 500 or 1000 mg/kg bw by oral gavage, and the kidneys were examined
histologically 1,3,5 or 24 h after dosing. The histological findings were desquamation
of degenerated cells in proximal tubules and production and release of apical
cytoplasmic blebs from epithelial cells into the proximal tubule lumen of treated
mice from 1 h onwards. Dilatation of proximal, distal and collecting tubules was
apparent in treated mice at 3, 5 and 24 h. Pre-treatment with inducers of the
microsomal mono-oxygenase system reduced the renal injury, while pre-treatment
with inhibitors of that system enhanced the effects, suggesting that the toxicity was
caused by the parent compound rather than by its metabolites. Pre-treatment with
inhibitors of organic cation or anion transport indicated that tiabendazole is
transported into tubule cells through the organic cation transport system for 1-5 h
after dosing. No NOEL could be identified (Tada et al., 1992).

Recovery from the nephrotoxicity of tiabendazole was reported in mice after a

single dose in a published report that had not previously been evaluated by the
Committee. Male and female Crj:CD-1 (ICR) mice were given a single dose of
tiabendazole (purity, 98.5%) suspended in olive oil at a dose of 0, 125, 250, 500,
1000 or 2000 mg/kg bw by oral gavage. The animals were necropsied 24 h thereafter.
Additional groups of mice were given single oral doses of 1000 or 2000 mg/kg bw
and necropsied 1, 2, 3, 5, 7 or 10 days after dosing in order to study recovery from
the effects. Further groups of mice were given a single oral dose of 0 or 2000 mg/kg
bw and were observed for 10 days to study the effect on the mortality rate. By 10 days
after administration of 2000 mg/kg bw, 30% of the females and 60% of the males
had died. Mice given 1000 or 2000 mg/kg bw showed higher serum urea nitrogen
and aspartate aminotransferase concentrations 24 h after dosing. At the same time,
mice given 250 mg/kg bw or more showed dose-dependent renal toxicity. Histological
examination showed desquamation of degenerated cells in the proximal tubules
and dilatation of proximal, distal and collecting tubules. Necrosis of proximal tubules
was observed at doses of 500 mg/kg bw and higher. The changes at 250 mg/kg bw
were slight, and the kidneys of mice treated at 125 mg/kg bw were not different from
those of control mice. In the recovery experiment, tiabendazole-treated mice had
higher urine volumes with higher concentrations of glucose, protein and sodium, in
particular during the first few days after administration. The serum urea nitrogen
concentrations returned to control levels within 3 and 7 days in mice given 1000 and
2000 mg/kg bw, respectively. The increased aspartate aminotransferase
concentration in all treated mice recovered to normal within 3 days. The increased
absolute and relative kidney weights had returned to control levels at 5 and 7 days,
respectively, but pale foci and rough surface were still observed in the kidneys at
the end of the study. The dilatation of tubules observed at both doses did not revert
during the 10-day observation period. Mitochondria! swelling was seen in proximal
20 TIABENDAZOLE

tubule epithelium during the first 2 days after treatment. Necrosis of proximal tubules
and desquamation of degenerated cells in proximal tubules were not observed after
7 and 10 days of recovery, respectively. Tissue repair processes (cell infiltration,
fibrosis, regeneration of tubules) started 3 days after exposure and were still apparent
in all animals 10 days after exposure. The Committee concluded that the
tiabendazole-induced renal toxicity was most frequent 2 or 3 days after dosing and
was followed by regeneration. The NOEL for renal toxicity was 125 mg/kg bw (Tada
etal.,1994).

In a 13-week study of toxicity, groups of male and female Crj:CD-1 (ICR) mice
received a diet containing 0, 0.8 or 1.6% tiabendazole (purity not reported). The
report was not included in the dossier and had not previously been evaluated by the
Committee. The doses were equivalent to 0, 1200 and 2400 mg/kg bw per day,
respectively. Anaemia and liver and kidney damage were the main effects at both
doses (Tada et al., 1996). The study was considered to be of less value than others
for determination of an acute RfD in view of its long duration and the high doses.

Another study of toxicity in mice was reported in a published paper that had not
previously been evaluated by the Committee. Male Crj:CD-1 (ICR) mice were given
diets containing 0, 0.8, 1.2 or 1.6% tiabendazole (purity, > 99%) for 44 weeks. The
doses were equivalent to 0, 1200, 1800 and 2400 mg/kg bw per day, respectively.
Neither haematological nor urine analyses were performed. Liver, kidney and gall-
bladder damage were the main effects at all doses (Tada et al., 2001). The study
was considered to be of less value than others for determination of an acute RfD in
view of its long duration and the high doses used.

The same group of investigators studied the structural alterations to mitochondria

in renal proximal tubule cells to determine the mechanism of the acute renal tubule
necrosis. The published paper had not previously been evaluated by the Committee.
Groups of male CRj:CD-1(ICR) mice were given tiabendazole in olive oil by oral
gavage at a single dose of 0, 1000 or 2000 mg/kg bw and were killed 3, 6 or 16 h
after dosing. The following end-points were determined: mitochondria! respiration,
the tiabendazole concentration in renal cortex and mitochondrial fraction (also at
0.5, 1 and 24 h), histochemical analysis of mitochondrial enzyme (NAD-linked
isocitrate dehydrogenase) and the concentration of ATP in the renal cortex.
Mitochondrial respiration was statistically significantly decreased in a dose-dependent
manner 6 and 16 h after dosing but not 3 h after dosing. When additional groups of
mice were treated with tiabendazole at 0, 250 or 500 mg/kg bw and killed 16 h later,
no effects on mitochondrial respiration were observed. The concentration of
tiabendazole in the renal cortex reached a maximum 1 h after dosing and declined
thereafter. The concentration in the mitochondrial fractions followed the same pattern.
Effects on the activity of NAD-linked isocitrate dehydrogenase (a marker enzyme of
mitochondria) were not observed 3 or 6 h after dosing, whereas significant inhibition
of this activity was observed 16 h after administration of 1000 or 2000 mg/kg bw.
Dilatation of tubules, observed at all times after administration of 1000 or 2000 mg/kg
bw, was observed mainly in the area where inhibition of NAD-linked isocitrate
dehydrogenase was found. Necrosis of renal tubules was not observed. The ATP
concentration in the renal cortex, determined only 16 h after a single oral dose of 0,
TIABENDAZOLE 21

500, 1000 or 2000 mg/kg bw, was significantly decreased at 1000 and 2000 mg/kg
bw but not at the lowest dose (Fujitani et al., 1998).

The results of the studies summarized above suggest that, after single doses of
tiabendazole to mice, the compound is taken up by tubule cells in the renal cortex
through the organic cation transport system and subsequently inhibits mitochondrial
respiration, leading to depletion of ATP and ultimately to necrosis of proximal tubule
cells. The reduced mitochondrial respiration may be due to inhibition of the fumarate-
reductase system, which is the putative mechanism of action of tiabendazole (Parfitt,
1999). Tada and colleagues have suggested that cell debris obstructs the tubules,
leading to dilatation. This explanation is not entirely consistent, because dilatation
was observed at lower doses than necrosis and lasted longer. Dilatation of proximal
tubules was observed at single doses of 250 mg/kg bw and higher. The lowest dose
of 125 mg/kg bw was therefore the NOEL for acute renal toxicity in mice.

3.3.2 Effects on the haematopoietic system

In both rats and dogs, a number of haematological parameters were changed

after repeated oral intake of tiabendazole, sometimes with related histopathological
changes in the spleen and bone marrow. Although the studies were of short duration
(13 weeks in rats and 14 and 53 weeks in dogs), the interim analysis of blood samples
(starting at week 4 or 6) showed haematological changes early in the study, which
were occasionally more frequent at earlier times than at the end of the study. The
related histopathological changes were also observed at doses at which haemato-
logical changes were not yet or no longer seen. The haematological and histopatho-
logical changes are indicative of anaemia, and, as these changes could have occurred
after one or a few doses, they were considered relevant to acute intake. The NOELs
for this effect in rats and dogs were 9 and 10 mg/kg bw per day, respectively.

In addition to the studies summarized above, the Committee at its fortieth meeting
reviewed three other studies of the same or shorter duration in rats treated by gavage.
These studies, which were not available at the present meeting, comprised two 4-
week studies with animals given tiabendazole at doses of 50-1600 mg/kg bw per
day and one 13-week study with rats given doses of 25-400 mg/kg bw per day. The
4-week studies also showed haematological changes (NOEL, 100 mg/kg bw per
day) and histopathological changes in the spleen and/or bone marrow (LOEL,
50 mg/kg bw per day). In the 13-week study, changes were observed in red blood
cell parameters, and histopathological changes were seen in the spleen (NOEL for
both effects, 25 mg/kg bw per day). As the studies could not be reviewed by the
present Committee, it could not verify whether the bone marrow was affected in the
13-week study.

It should be noted that in the study of Colmore (1965) with male volunteers, a
dose of 125 mg twice a day for 24 weeks (equivalent to 3.6 mg/kg bw per day for a
60-kg person) did not affect haematological parameters after 4, 12 or 24 weeks of
treatment. However, this study has a number of serious shortcomings: the
haematological parameters (other than haematocrit and 'CBC') investigated were
not specified; only one dose was tested, so that the dose-response relationship
22 TIABENDAZOLE

could not be investigated; and, more importantly, no histopathological examination

was carried out, while, in animals, this appeared to be a more sensitive indicator of
haematotoxicity than the haematological parameters.

2.4 Developmental toxicity

As short treatments are used in studies of developmental toxicity orteratogenicity
and because, in particular, teratogenic effects and resorptions may be induced by a
single dose within a certain (sensitive) period, effects on the fetus were considered
relevant for setting an acute RfD.
With regard to teratogenic effects, domed heads, hydrocephalus and marked
enlargement of fontanels were observed in one study in rabbits at doses of 120 mg/kg
bw per day and higher. The NOEL was 24 mg/kg bw per day. In another study in
rabbits, no such effects were observed at doses up to 600 mg/kg bw per day. The
NOEL in this study was 150 mg/kg bw per day, on the basis of an increased incidence
of malformations, which was seen relatively often in this species. In mice, the
teratogenic effects after a single exposure on day 9 of gestation consisted of deformed
limbs at doses of 480 mg/kg bw and higher (NOEL, 26 g/kg bw) and fusion of vertebral
arches, bodies and ribs at doses of 240 mg/kg bw and higher (NOEL, 130 mg/kg
bw). In rats, no teratogenic effects were observed.
Increased resorption rates were observed in mice and rabbits but not in rats. In
mice, the NOELs for this effect were 700 mg/kg bw per day when the dams were
exposed on days 7-15 of gestation and 1400 mg/kg bw when a single dose was
given on day 9 of gestation. In rabbits, the resorption rate was increased at doses of
120 mg/kg bw per day and higher. The NOEL for this effect was 24 mg/kg bw.
Another developmental effect that was observed consistently in all the laboratory
animal species tested was reduced fetal body weight. This effect is generally regarded
as nonspecific and secondary to maternal toxicity, and this would appear to be the
case for tiabendazole: decreased fetal body weight occurred at doses at which the
dams had reduced food intake and/or reduced weight gain. The reduction in fetal
body weight at doses that did not appear to induce concurrent maternal toxicity, as
observed in mice given tiabendazole only on day 9 of gestation, might also have
been secondary to maternal toxicity, as it is possible that the dams had normal
weights after the single dose (day 10 until time of death) but that the fetuses did not
recover their normal weights within that period.
On the basis of the effects considered relevant for acute intake, the overall NOEL
for developmental toxicity, including teratogenicity, was 24 mg/kg bw per day.

4. COMMENTS
The studies of the acute toxicity of tiabendazole given orally, which gave LD50
values > 2000 mg/kg bw, did not provide any indication of acute effects. The only
substance-specific clinical sign relevant for acute exposure in studies with single or
repeated doses was emesis in dogs (NOEL, 40 mg/kg bw per day). The common
side-effects reported in humans receiving therapeutic doses (> 25 mg/kg bw twice
daily for 1-10 days) included anorexia, nausea, vomiting and dizziness. However,
these effects were poorly described and did not allow identification of a NOEL. In a
study in volunteers, in which controls were given a placebo, a dose of 125 mg of
TIABENDAZOLE 23

tiabendazole twice a day for 24 weeks (equivalent to 3.6 mg/kg bw per day for a 60-
kg person) did not cause significant changes in subjective side-effects.
In the report of its fortieth meeting, the Committee noted renal injury in mice
given tiabendazole for 1-7 days. In a number of published papers, the renal toxicity
of tiabendazole in mice was investigated after single or repeated oral administration.
Although renal toxicity was observed in the studies with repeated doses, these studies
were considered of limited value for establishing an acute RfD because of the high
doses used (1200,1800 or 2400 mg/kg bw per day in the diet) and their long duration
(13-44 weeks). In the studies with single doses, mice received 0, 125, 250, 500,
1000 or 2000 mg/kg bw by gavage. Renal toxicity, mainly in the proximal tubules,
was observed at doses of 250 mg/kg bw and higher and consisted of histopathological
changes including mitochondrial swelling. The toxic effects were due to the parent
compound and were most severe 2-3 days after dosing; after that time, tissue repair
processes began. All the effects except tubule dilatation were either fully or partly
reversed within 10 days of administration. These studies showed that tiabendazole
is taken up by proximal tubule epithelial cells in the renal cortex and ultimately causes
necrosis of those cells. The lowest dose of 125 mg/kg bw was the NOEL for acute
renal toxicity in mice.
Haematotoxicity was observed in studies with repeated oral doses in rats and
dogs, lasting 4 and 13 weeks in rats and 14 and 53 weeks in dogs. Analysis of blood
samples from week 4 or 6 showed changes indicative of anaemia early in the studies,
and these were occasionally seen more often earlier than at the end of the study.
Related histopathological changes in the spleen and/or bone marrow were observed
at the same and lower doses. As it cannot be excluded that histopathological changes
indicative of anaemia could occur after one or a few doses, they were considered
relevant for assessing acute exposure. The NOELs in rats and dogs were 9 and
10 mg/kg bw per day, respectively.
In a study with volunteers, 50 men received an oral dose of 125 mg of tiabendazole
twice a day for 24 weeks (equivalent to 3.6 mg/kg bw per day for a 60-kg person),
and 50 other men were given a placebo. Tiabendazole did not affect haematological
parameters after 4, 12 or 24 weeks of treatment. However, owing to a number of
shortcomings, no NOEL could be identified in this study. In particular, it was not
possible to perform histopathological examinations, which in animals appeared to
provide more sensitive indicators of haematotoxicity than the haematological
parameters.
In a study of developmental toxicity in rabbits, changes related to hydrocephalus
were observed after oral doses of tiabendazole of 120 mg/kg bw per day and higher
(NOEL, 24 mg/kg bw per day). In another study with rabbits, no such effects were
observed at oral doses of up to 600 mg/kg bw per day (NOEL, 150 mg/kg bw per
day). In mice, teratogenic effects were observed after a single oral dose on day 9 of
gestation. They consisted of deformed limbs at doses of 480 mg/kg bw and higher
(NOEL, 270 mg/kg bw) and fusion of vertebrae and ribs at 240 mg/kg bw and higher
(NOEL, 130 mg/kg bw). Tiabendazole was not teratogenic in rats in doses up to 80
mg/kg bw, the highest tested.
Increased resorption rates were observed in mice and rabbits but not in rats. In
mice, the NOELs for this effect were an oral dose of 700 mg/kg bw per day when the
animals were exposed on days 7-15 of gestation and 1400 mg/kg bw when they
were given a single oral dose on day 9 of gestation. Rabbits showed increased
24 TIABENDAZOLE

resorption rates at oral doses of 120 mg/kg bw per day and higher, with a NOEL of
24 mg/kg bw.
The overall NOEL for developmental toxicity, including teratogenicity, was
24 mg/kg bw per day.

5. EVALUATION
Emesis and effects on the kidney, haematopoietic system and development were
considered relevant end-points for establishing an acute RfD. The most sensitive
effect was haematotoxicity, specifically histopathological changes in the spleen and
bone marrow indicative of anaemia, for which almost identical NOELs were found in
rats (9 mg/kg bw per day) and dogs (10 mg/kg bw per day). Using these NOELs and
a safety factor of 100, the Committee established an acute RfD of 100 u,g/kg bw, the
same value as the ADI. In view of the lack of appropriate data for this effect after
single doses, the acute RfD is based on data from studies of repeated administration
and hence may be conservative. The results of a study designed specifically to
generate data after a single dose might allow refinement of the estimated acute RfD.

6. REFERENCES
Batham, P. & Lankas, G.R. (1990) Thiabendazole—Fourteen-week oral toxicity study in the
beagle dog. Unpublished report No. TT #89-9010/84021 from Merck Sharp & Dohme
Research Laboratories, West Point, Pennsylvania, USA, and Bio-Research Laboratories,
Ltd, Senneville, Quebec, Canada. Submitted to WHO by Syngenta, Basel, Switzerland.
Blaszcak, D.L. &Auletta, C.S. (1987) Acute dermal toxicity study in rabbits. Unpublished report
No. 4004-86 from Bio/dynamics, Inc., East Millstone, New Jersey, USA. Submitted to WHO
by Syngenta, Basel, Switzerland.
Campbell, W.C. & Cuckler, A.C. (1969) Thiabendazole in the treatment and control of parasitic
infections in man. Texas Rep. Biol. Med., 27 (Suppl. 2), 665-692.
Colmore, J.P. (1965) Chronic toxicity study of thiabendazole in volunteers. Unpublished report
No. NDA 16-096 from University of Oklahoma, Medical Centre Oklahoma City, Oklahoma,
USA. Submitted to WHO by Syngenta, Basel, Switzerland.
Commission of the European Union (2001) Guidance for the Setting of an Acute Reference
Dose (ARfD). Draft guidance document 7199/VI/99 rev. 5 of 05/07/2001, Brussels.
Cuckler, A.C. & Mezey, K.C. (1966) The therapeutic efficacy of thiabendazole for helminthic
infections in man. Arzneimittelforschung, 16, 411-428.
FAO/WHO (1971) 1970 Evaluations of some pesticide residues in food. AGP: 1970/M/12/1.
WHO/Food Add/71.42, Rome.
FAO/WHO (1978J Pesticide residues in food—1977. Report of the Joint Meeting of the FAO
Panel of Experts on Pesticide Residues and the Environment and the WHO Expert Group
on Pesticide Residues. FAO Plant Production and Protection Paper 10 Rev., Rome.
FAO/WHO (2001) Pesticide residues in food—2000. Report of the Joint Meeting of the FAO
Panel of Experts on Pesticide Residues in Food and the Environment and the WHO Core
Assessment Group on Pesticide Residues. FAO Plant Production and Protection Paper
163, Rome.
Fujitani, T, Tada, Y. & Yoneyama, M. (1999) Effects of thiabendazole (TBZ) on mitochondrial
function in renal cortex of ICR mice. Food Chem. Toxicol., 37,145-152.
Gurman, J.L., Hardy, R.J., Voelker, R.W. & Davidson, J.L. (1981) Acute inhalation toxicity
study in rats. Unpublished report No. 284-129 from Hazleton Laboratories America, Inc.,
Vienna, Virginia, USA. Submitted to WHO by Syngenta, Basel, Switzerland.
TIABENDAZOLE 25

Hennekeuser, H.H., Pabst, K., Poeplau, W. & Gerok, W. (1969) Thiabendazole for the treatment
of trichinosis in humans. Texas Rep. Biol. /Wed, 27 (Suppl. 2), 581-596.
Hoberman, A.M. (1989) Thiabendazole—Oral developmental toxicity study in rabbits.
Unpublished report No. 013-029 (TT #89-9005) from Argus Research Laboratories, Inc.,
Horsham, Pennsylvania, USA. Submitted to WHO by Syngenta, Basel, Switzerland.
Lankas, G.R. (1981) Thiabendazole veterinary (lot ERM-211)—Acute oral toxicity study in
rats. Unpublished report No. TT #81-2691 from Merck Sharp & Dohme Research
Laboratories, West Point, Pennsylvania, USA. Submitted to WHO by Syngenta, Basel,
Switzerland.
Lankas, G.R. (1993) Thiabendazole—Fifty-three-week oral toxicity study in dogs. Unpublished
report No. TT #91-068-0 from Merck Research Laboratories, West Point, Pennsylvania,
USA. Submitted to WHO by Syngenta, Basel, Switzerland.
Lankas, G.L. & Wise, L.D. (1991/1993) Thiabendazole—Oral developmental toxicity study-
Rabbits. Unpublished report No. TT #90-734-0 from Merck Sharp & Dohme Research
Laboratories, West Point, Pennsylvania, USA. Submitted to WHO by Syngenta, Basel,
Switzerland.
Myers, B.A. & Lankas, G.R. (1990) Thiabendazole—A 14-week dietary toxicity study in rats.
Unpublished report No. TT #90-9002/284-169 from Merck Sharp & Dohme Research
Laboratories, West Point, Pennsylvania, USA, and Hazleton Laboratories America, Inc.,
Rockville, Maryland, USA. Submitted to WHO by Syngenta, Basel, Switzerland.
Nakatsuka, T, Matsumoto, H. & Ikemoto, F. (1995) Thiabendazole—Oral developmental toxicity
study in mice. Unpublished report No. TT #94-9818 from Banyu Pharmaceutical Co., Ltd,
Saitama-ken, Japan. Submitted to WHO by Syngenta, Basel, Switzerland.
Ogata, A., Ando, H., Kubo, Y. & Hiraga, K. (1984)Teratogenicity of thiabendazole in ICR mice.
Food Chem. Toxicol., 22, 509-520.
Parfitt, K., ed. (1999) Martindaie. The Complete Drug Reference, 32nd Ed., London:
Pharmaceutical Press.
van Raaij, M.T.M. (2001) Guidance document for setting an acute reference dose in Dutch
national pesticide evaluations. RIVM report 620555 002. National Institute of Public Health
and the Environment (RIVM), Bilthoven.
Robinson, H.J. (1964) Thiabendazole (preclinical evaluation). Unpublished report from Merck
Sharp & Dohme Research Laboratories, Rahway, New Yersey, USA. Submitted to WHO
by Syngenta, Basel, Switzerland, [only the part related to acute oral toxicity was provided]
Tada, Y., Yoneyama, M., Kabashima, J., Fujitana, T. & Nakano, M. (1989) Effects of
thiabendazole on the kidneys of ICR mice. Food Chem. Toxicol., 27, 307-315.
Tada, Y, Fujitani, T. & Yoneyama, M. (1992) Acute renal toxicity of thiabendazole (TBZ) in ICR
mice. Food Chem. Toxicol., 30,1021-1030.
Tada, Y, Fujitani, T. & Yoneyama, M. (1994) Thiabendazole (TBZ) nephrotoxicity and recovery
in ICR adult mice. Toxicology, 94, 41-55.
Tada, Y, Fujitani, T. & Yoneyama, M. (1996) Subchronic toxicity of thiabendazole (TBZ) in ICR
mice. Food Chem. Toxicol., 34, 709-716.
Tada, Y., Fujitani, T, Yano, N., Yuzawa, K., Nagasawa, A. & Yoneyama, M. (2001) Thiabendazole
induces urinary tract toxicity in male ICR mice. Toxicology, 162, 1-10.
Tocco, D.J., Rosenblum, C., Martin, C.M. & Robinson, H.J. (1966) Absorption, metabolism,
and excretion of thiabendazole in man and laboratory animals. Toxicol. Appl. Pharmacol.,
9, 31-39.
Wise, L.D. (1990) Thiabendazole—Oral developmental toxicity study in rats. Unpublished report
No. TT #90-713-0 from Merck Sharp & Dohme Research Laboratories, West Point,
Pennsylvania, USA. Submitted to WHO by Syngenta, Basel, Switzerland.
Wise, L.D. & Lankas, G.R. (1992) Thiabendazole - Two-generation dietary study in rats.
Unpublished report No. TT #90-733-0 from Merck Research Laboratories, West Point,
Pennsylvania, USA. Submitted to WHO by Syngenta, Basel, Switzerland.
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ANTIMICROBIAL AGENT
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 CEFUROXIME

First draft prepared by

Gladwin Roberts1 & Carl Cerniglia2
1
Chemical Products Assessment Section, Therapeutic Goods
Administration,
Department of Health and Aged Care, Canberra, Australia; and
2
National Center for Toxicological Research,
Food and Drug Administration, Arkansas, USA

Explanation 29
Biological data 30
Biochemical aspects 30
Absorption, distribution and excretion 30
Biotransformation 32
Toxicological studies 32
Acute toxicity 32
Short-term studies of toxicity 33
Genotoxicity 38
Reproductive toxicity 40
Multigeneration studies 40
Developmental toxicity 41
Peri- and post-natal toxicity 42
Special studies 43
Renal toxicity 43
Hepatic toxicity 44
Microbiological effects 45
Observations in humans 50
Comments 50
Evaluation 58
References 58

1. EXPLANATION
Cefuroxime is a cephalosporin antibacterial agent with activity against a range
of gram-positive and gram-negative bacteria. The chemical name of cefuroxime
sodium is sodium (Z)-(6f?,7R)-3-(carbamoyloxymethyl)-7-[2-(2-furyl)-2-(methoxy-
imino)acetamide]-8-oxo-5-thia-1-a2abicyclo[4.2.0]oct-2-ene-2-carboxylate. Its
structure is shown in Figure 1. The sodium salt is used in veterinary medicine for the
treatment of mastitis and is available in two formulations, both applied by
intramammary infusion: one for the treatment of clinical mastititis in lactating cattle
and the second for the treatment of sub-clinical mastitis in dry cows and to prevent
new infections during the dry period. Cefuroxime is also used in human medicine,
as eitherthe sodium salt or as the 1 -acetoxyethyl ester (known as cefuroxime axetil).
Cefuroxime has not previously been evaluated by the Committee.

-29 -
30 CEFUROXIME

Figure 1. Structure of cefuroxime sodium

2. BIOLOGICAL DATA
2.1 Biochemical aspects
2.1.1 Absorption, distribution and excretion
Hats
Groups of three Wistar rats were given [14C]cefuroxime sodium as a single
intravenous or intramuscular injection of 25 mg/kg bw or as an intravenous infusion
of 50 mg/kg bw over 40 min. The blood concentrations of radiolabel were highest
within 30 min of the end of administration and then rapidly declined, with initial half-
times of 0.5-1 h. By 24 h, the blood concentrations were < 10% of the respective
peak. It was distributed widely, kidney and liver having higher concentrations of
radiolabel than blood; particularly low concentrations were detected in the central
nervous system, muscle and fat. Dosing of female rats on day 18 of gestation resulted
in very low concentrations of radiolabel in fetal tissue and amniotic fluid. Relatively
high concentrations were detected in the milk of lactating rats, and the peak
represented 18% of blood concentrations after 1 h. About 80% of a parenteral dose
was excreted in urine, and the remainder was excreted in bile, predominantly during
the first 24 h. A portion of the radiolabel in bile was subject to enterohepatic
recirculation. Daily intramuscular injections for up to 14 days did not affect the kinetics
in blood or excretion in urine (Nanbo et al., 1979; Okumura et al., 1979).
In anaesthetized rats given a single intravenous injection of 20 mg/kg bw of
cefuroxime, the bioavailability in brain was 4.2% that in plasma, thus confirming the
low penetration of the blood-brain barrier (Tsai et al., 1999).
The absorption of cefuroxime axetil in the small intestine of anaesthetized rats
was investigated in situ by perfusion at a concentration of 12,59,120 or 200 nmol/l.
Absorption across the intestinal mucosa appeared to occur as a result of an active
transport mechanism. Some drug was hydrolysed in the lumen of the intestine, the
proportion increasing from 16 to 25% with increasing concentration (Ruiz-Balaguer,
etal., 1997).
In seven rats given a single dose of 2 mg of cefuroxime axetil by gavage, the
peak plasma concentration of cefuroxime was found at about 30 min. About 25-
CEFUROXIME 31

30% of the dose was bioavailable, and a similar amount was considered to have
been immediately excreted in the bile. The relatively low bioavailability appears to
be due to hydrolysis in the intestine, which reduces the amount of the ester available
for absorption, and hydrolysis in blood, which facilitates rapid excretion of cefuroxime
in the urine (Ruiz-Carretero et al., 2000).

Rabbits
Groups of four rabbits were given single intravenous or intramuscular injections
or twice daily intramuscular injections of cefuroxime at a dose of 25 mg/kg bw for
15 days. The peak blood concentrations were reached within 15 min after each
administration and then rapidly declined. About 75-80% of the drug was recovered
in urine within 24 h. No cefuroxime was detected in organs 24 h after the final dose
(Okumura et al., 1979).

Dogs
Three male beagle dogs were given a single intravenous injection of 25 mg/kg
bw [14C]cefuroxime sodium. The concentration of radiolabel in blood peaked
immediately after dosing and then decreased, with an initial half-time of 0.7 h. About
90% of the dose was excreted in urine; recovery of about 8% in faeces suggested
limited excretion in bile (Nanbo et al., 1979). In beagle dogs given an intramuscular
dose of 25 mg/kg bw cefuroxime, 4% of the dose was detected in bile; the
concentrations were maximal 1-2 h after administration and gradually decreased
thereafter up to 24 h (Okumura et al., 1979).

Plasma was taken from one male and one female beagle dog given cefuroxime
axetil by gavage at a dose of 100, 400 or 1600 mg/kg bw per day. Samples were
withdrawn after treatment for 1, 36, 169 and 188 days. Peak concentrations of
cefuroxime in plasma were found within 2 h of administration, and the bioavailability
was claimed to be proportional to the dose. Unchanged cefuroxime axetil was also
detected in the plasma of the female given 400 mg/kg bw per day and in both animals
at 1600 mg/kg bw per day, attaining a highest concentration representing about
10% of the peak. De-esterification led to formation of acetaldehyde and acetic acid
(Spurling et al., 1986).

Humans
Cefuroxime sodium was poorly absorbed through the gastrointestinal tract. After
oral administration of 1000 mg to two volunteers, only 1% of the administered dose
was recovered in urine, and the plasma concentrations were stated to be only just
measurable. When cefuroxime sodium was injected, at least 95% of the dose was
recovered in the urine, mainly in unchanged form (Foord, 1976).

Cefuroxime is widely distributed in the body, entering body fluids and tissues
when given at therapeutic concentrations. It crossed the placenta and has been
detected in breast milk (Parfitt, 1999). The concentrations of cefuroxime in
cerebrospinal fluid were about 10% of those in plasma (Mandell & Petri, 1996).
Injection of 750 mg of cefuroxime to women during pregnancy, labour or caesarean
32 CEFUROXIME

section resulted in significant concentrations in the amniotic fluid and umbilical blood
vessels and in plasma from the neonates (Craft et al., 1981; Phillipson & Stiernstedt,
1982).

Moderate amounts of cefuroxime axetil were absorbed after five oral doses of
125,250,500 x 2 and 1000 mg to 12 male volunteers. The bioavailability was about
36% in fasted individuals and 50% after food intake. A linear relationship was found
between the dose in fed subjects and both the area under the plasma concentration-
time curve and the peak plasma concentration. The peak plasma concentration
was 43% greater in fed subjects than in fasted subjects (Finn et al., 1987). Cefuroxime
axetil was hydrolysed in the intestinal mucosa and blood to yield cefuroxime; the
resulting concentrations in plasma were variable (Parfitt, 1999). The plasma half-
time was 1-2 h, the maximum plasma concentration after oral administration was
6.3 mg/l, and the degree of protein binding was 33-50% (Kalman & Barriere, 1990).
Cefuroxime was excreted primarily in urine (Williams & Harding, 1984), and secretion
by the renal tubules was responsible for 43-54% of the renal elimination (Foord,
1976). The kinetics was unaffected by repeated oral dosing for 7 days (Sommers et
al., 1984).

2.1.2 Biotransformation
Rats and dogs
Up to 97% of administered [14C]cefuroxime sodium remained unchanged in the
plasma and urine of rats and dogs treated parenterally. However, an unidentified
metabolite was detected in the bile of rats, which accounted for about 27% of the
material present, the remainder being unchanged parent drug (Nanbo et al., 1979).
In another study, in rats given cefuroxime by intramuscular injection, thin-layer
chromatography showed that the only compound present in urine, bile and plasma
was the parent. The metabolites produced in rats and dogs were not identified
(Okumura et al., 1979).

Humans
Cefuroxime axetil mixed with human blood in vitro was rapidly de-esterified to
cefuroxime, with a half-time of 3.5 min. Similarly, in 12 male volunteers given a
single oral dose of 1.5 g of cefuroxime axetil, hydrolysis of the ester was virtually
complete, and cefuroxime was the only compound detected in blood (Harding et al.,
1984). In 11 children given a single oral dose of 10, 15 or 20 mg/kg bw cefuroxime
axetil, the unchanged ester was found in the urine of only four subjects and accounted
for < 0.1% of the administered dose (Powell et al., 1991).

2.2 Toxicological studies

2.2.1 Acute toxicity
The studies of acute toxicity did not comply with good laboratory practice (GLP).
As shown in Table 1, cefuroxime was of low acute toxicity in mice and rats after oral
or parenteral administration and was slightly toxic in rabbits when administered
parenterally.
CEFUROXIME 33

Table 1. Results of studies of the acute toxicity of cefuroxime sodium in

male and female rodents

Species Route LD (mg/kg bw) Reference

Mouse Oral > 10 000 Tamuraetal. (1979)

Rat Oral > 10000 Tamuraetal. (1979)
Mouse Intraperitoneal > 10 000 Tamuraetal. (1979)
Rat Intraperitoneal ~ 10000 Tamuraetal. (1979)
Mouse Subcutaneous > 10 000 Capel-Edwards et al. (1979);
Tamuraetal. (1979)
Rat Subcutaneous > 10 000 Capel-Edwards et al. (1979);
Tamuraetal. (1979)
Mouse Intravenous 10400 Capel-Edwards et al. (1979);
Tamuraetal. (1979)
Rat Intravenous >8000 Capel-Edwards et al. (1979);
Tamuraetal. (1979)
Rabbit Intravenous > 1 500 Tamuraetal. (1979)
Mouse Intramuscular >2000 Tamuraetal. (1979)
Rat Intramuscular >2000 Tamuraetal. (1979)
Rabbit Intramuscular >300 Tamuraetal. (1979)

The only adverse effect seen after oral administration was diarrhoea. In animals
that died after parenteral injection, swelling of the caecum was the main effect seen
at autopsy, and destruction of cortical renal tubules was observed only in rats (Tamura
etal., 1979).

Two cats and four dogs were given a single intramuscular injection of 2 g/kg bw
cefuroxime sodium as a 40% solution in water. No signs of toxicity were seen, and
the only treatment-related effect was discomfort at the injection site, which persisted
for a few minutes after injection. Cynomolgus monkeys given 1.5-2.0 g/kg bw
intramuscularly showed slight loss of body weight, and some had diarrhoea (Glaxo
Laboratories Ltd, 1986; Capel-Edwards et al., 1979).

2.2.2 Short-term studies of toxicity

Rats
A series of studies that did not comply with GLP were conducted in rats given
cefuroxime sodium parenterally.

Groups of five male and five female CD rats received cefuroxime sodium in
0.9% saline solution intravenously at a dose of 0, 50,100, 200 or 400 mg/kg bw per
day for 29 (males) or 30 (females) days. Treatment had no effects on body weight,
general condition, haematological, blood biochemical or urinary end-points, organ
weights or lesions. As only a summary of this study was available, the absence of
findings could not be confirmed independently (Glaxo Laboratories Ltd, 1986).

Groups of eight male and eight female Charles River CD rats were given
cefuroxime sodium in 0.9% saline solution by subcutaneous injection at a dose of 0,
34 CEFUROXIME

100, 200, 400 or 800 mg/kg bw per day for 33 (males) or 34 (females) days. There
were no toxic signs, no effects on body-weight gain and no changes in urinary
parameters. Inflammation and ulceration at the injection site were noted in animals
at the highest dose. Haemoglobin concentration and erythrocyte volume fraction
were reduced in some animals given 200 mg/kg bw per day or more, although the
effect was significant only at the highest dose. The serum potassium concentration
was increased in females at 100 and 800 mg/kg bw per day. Lymphatic dilatation
and lymphocyte infiltration were seen in the colonic mucosa in some animals at
800 mg/kg bw per day. There were no significant effects at 100 mg/kg bw per day.
As only a summary of this study was available, the absence of findings cannot be
confirmed independently (Glaxo Laboratories Ltd, 1986).

Groups of 18 male and 18 female SD-JCL rats were given cefuroxime in distilled
water by subcutaneous injection at a dose of 200, 500 or 1500 mg/kg bw per day on
6 days per week for 35 days. A similar group of controls was given saline. An additional
group of six males and six females given the highest dose was retained for a 5-
week recovery period after the end of treatment. No deaths or signs of overt toxicity
were noted, and there were no effects on body-weight gain, water intake or urinary
end-points. A significant fall in erythrocyte count was seen in males at the highest
dose and in females at all doses. Significant decreases in haemoglobin concentration
and erythrocyte volume fraction were noted in animals of each sex given the highest
dose. An increase in leukocyte numbers occurred in males a 500 or 1500 mg/kg bw
per day.
Increased serum alanine aminotransferase activity was seen in animals of each
sex at 1500 mg/kg bw per day and increased alkaline phosphatase activity in males
at 500 and 1500 mg/kg bw per day. Bilirubin concentrations were decreased in all
groups of treated males and in females at 500 and 1500 mg/kg bw per day. A
significant increase in blood glucose concentration was seen in males at the two
higher doses, while significant decreases were seen in all groups of treated females.
The albumin concentration was decreased and the potassium concentrations were
increased in animals at 1500 mg/kg bw per day. At this dose, males showed
decreased liver weights. The weight of the kidney was increased in males, and
caecal swelling was seen in animals of each sex at the two higher doses of
cefuroxime. All the changes were fully or partially reversed on cessation of dosing.
No compound- related effects were found on histological examination. A NOEL was
not identified (Ito et al., 1979a).

Groups of 18 male and 18 female SD-JCL rats were given cefuroxime in distilled
water by intraperitoneal injection at a dose of 100, 300 or 1000 mg/kg bw per day on
6 days per week for 35 days. A similar group of controls was given saline. An additional
group of six males and six females at the highest dose was allowed a 5-week recovery
period after the end of treatment. No deaths or signs of overt toxicity were noted,
and there were no effects on body-weight gain or urinary end-points. Females at
1000 mg/kg bw per day had slightly increased water intake. Erythrocyte counts
were significantly decreased in males at the highest dose, and increased values
were found in females at 300 and 1000 mg/kg bw per day. The haemoglobin
concentration and erythrocyte volume fraction were not affected. Blood glucose
concentrations were decreased in males and blood urea nitrogen concentrations
CEFUROXIME 35

were decreased in females at 300 and 1000 mg/kg bw per day but with no dose-
response relationship. The potassium concentration was decreased in females at
300 and 1000 mg/kg bw per day and increased in males at 100 and 1000 mg/kg bw
per day. Caecal swelling was noted in animals at 300 and 1000 mg/kg bw per day.
There were no compound-related effects on organ weights or on histological
appearance. All changes were reversed on cessation of dosing. There were no
significant effects at 100 mg/kg bw per day (Ito et al., 1979a).

Groups of seven male and seven female CD rats were given cefuroxime sodium
in 0.9% saline by subcutaneous injection at a dose of 0,100, 300 or 900 mg/kg bw
per day for 91 days. The groups given the control and highest dose contained an
additional seven rats of each sex which were allowed a 21-day recovery period at
the end of dosing. There were no effects on general condition, blood biochemistry
or body weight. The groups given 300 and 900 mg/kg bw per day showed reduced
erythrocyte count, haemoglobin concentration and erythrocyte volume fraction.
Reticulocyte counts were slightly increased in male rats that had reduced erythrocyte
counts. Total leukocyte counts were increased in females at the two higher doses,
but the differential counts were unaffected. Prothrombin times were slightly increased
in animals of each sex given the highest dose and in males at 300 mg/kg bw per
day. Urine volume, urinary electrolyte excretion and water intake were increased
and specific gravity decreased in animals at 900 mg/kg bw per day. The spleen
weight was increased in females at 900 mg/kg bw per day, but the only pathological
findings were inflammation, haemorrhage and haemosiderin deposition at the
injection sites in rats at 300 and 900 mg/kg bw per day. The changes were reversed
at the end of the recovery period. There were no significant effects at 100 mg/kg bw
per day. As only a summary of this study was available, the findings cannot be
confirmed independently (Glaxo Laboratories Ltd, 1986).

Groups of 10 male and 10 female CD rats were given cefuroxime sodium in

0.9% saline by subcutaneous injection at a dose of 0, 50,150 or 450 mg/kg bw per
day for 26 weeks. Body-weight gain and general condition were unaffected, except
for localized swelling at the injection site. There were slight reductions in erythrocyte
volume fraction, haemoglobin concentration and erythrocyte counts, and increases
in reticulocyte counts in animals at 450 mg/kg bw per day. The serum protein
concentration was slightly decreased and sodium and potassium excretion was
increased in animals at 450 mg/kg bw per day. The only pathological changes were
those associated with physical damage and inflammatory reactions at the injection
site. There were no significant effects at 150 mg/kg bw per day. As only a summary
of this study was available, the findings cannot be confirmed independently (Glaxo
Laboratories Ltd, 1986).

Groups of 26 male and 26 female SD-JCL rats were given cefuroxime in distilled
water by subcutaneous injection at a dose of 100, 250 or 750 mg/kg bw per day on
6 days per week for up to 26 weeks. Simitar groups of controls were given saline.
Animals were killed after 3 months (eight rats of each sex) and 6 months (10 rats of
each sex) of treatment, and after a 3-month recovery period (eight rats of each sex).
There were no overt signs of toxicity and no significant effects on urinary end-points.
Body-weight gain was slightly depressed in males at 750 mg/kg bw per day despite
36 CEFUROXIME

a small increase in food intake. Erythrocyte count, haemoglobin concentration and

erythrocyte volume fraction were lower in females at all doses. Significant decreases
were seen in serum aspartate aminotransferase activity in males at all doses and in
females at 750 mg/kg bw per day and in bilirubin concentration in males at 250 mg/kg
bw per day and in males and females at 750 mg/kg bw per day. Slight decreases in
cholesterol, total protein and albumin concentration were seen in rats at the highest
dose. Kidney weights were increased in the groups given 250 or 750 mg/kg bw per
day, but the effect was not associated with pathological alterations. Caecal swelling
was seen in animals of each sex at 250 and 750 mg/kg bw per day after 3 and
6 months of treatment. None of these changes was seen at the end of the recovery
period. A NOEL was not identified (Ito et al., 1979b).

Groups of 26 male and 26 female SD-JCL rats were given cefuroxime in distilled
water by intraperitoneal injection at a dose of 50, 125 or 375 mg/kg bw per day on
6 days per week for 26 weeks. A similar group of controls was given saline. Animals
were killed after 3 months (eight rats of each sex) and 6 months (10 rats of each
sex) of treatment and after a 3-month recovery period (eight rats of each sex). There
were no overt signs of toxicity and no deaths that could be attributed to treatment.
Body-weight gain was unaffected; however, feed conversion was reduced at 3 months
in animals at 125 or 375 mg/kg bw per day, gradually returning to control levels
thereafter. There were no effects on urinary parameters. Leukocyte counts were
decreased in females at 125 and 375 mg/kg bw per day; at the highest dose, this
effect was associated with an increase in the ratio of neutrophils to lymphocytes. A
decreased total protein concentration in males at the highest dose was the only
consistent biochemical alteration. Caecal swelling was seen in animals of each sex
at 375 mg/kg bw per day at 3 months only, but no histopathological findings were
attributable to administration of the compound. The leukocyte counts remained low
during the recovery period, whereas all other changes were reversed to control
levels. No effects were seen at 50 mg/kg bw per day (Ito et al., 1979b).

Dogs
A series of studies that did not conform to GLP were conducted, in which dogs
were treated with cefuroxime sodium parenterally and with cefuroxime axetil by oral
administration.

Groups of two male and two female beagle dogs were given cefuroxime sodium
in 0.9% saline by intramuscular injection at a dose of 0, 60,180 or 540 mg/kg bw per
day for 10 or 11 days. All the dogs gained weight and remained in good health.
Haematological, blood biochemical and urinary end-points were unremarkable. The
weights of the liver and kidney relative to body weight were increased at 540 mg/kg
bw per day, but the lesions were limited to irritation at the injection site. As only a
summary of this study was available, the findings cannot be confirmed independently
(Glaxo Laboratories Ltd, 1986).

Groups of three male and three female beagle dogs were given cefuroxime
sodium in saline by subcutaneous injection at a dose of 0, 50 or 500 mg/kg bw per
day on 6 days per week for 5 weeks. One animal of each sex per group was allowed
a 4-week recovery period at the end of treatment. No overt toxicity was seen, but
CEFUROXIME 37

body-weight loss was seen in male dogs at 500 mg/kg bw per day. Haematological
and urinary analyses revealed no significant findings. The bilirubin concentration
was decreased in both groups of treated males, but the difference was seen before
the beginning of dosing. Organ weights and gross appearance were unaffected. At
the end of the recovery period, the end-points in control and treated animals were
similar. No effects were seen at 50 mg/kg bw per day (Ito et al., 1979c).

Groups of three male and three female beagle dogs were given cefuroxime
sodium in saline by intravenous injection at a dose of 0,25 or 250 mg/kg bw per day
on 6 days per week for 5 weeks. One animal of each sex per group was allowed a
4-week recovery period at the end of treatment. Body-weight loss was observed in
males at the higher dose. There were no signs of overt toxicity and no effects on
haematological, blood biochemical or urinary end-points, organ weights or
histopathological appearance. At the end of the recovery period, all parameters
were similar in control and treated animals. No effects were seen at 25 mg/kg bw
per day (Ito et al., 1979c).

Cefuroxime axetil was administered as an aqueous suspension to groups of

four male and four female beagle dogs twice daily by gavage for 27 weeks. The
equivalent doses of cefuroxime were 0, 100, 400 and 1600 mg/kg bw per day.
Additional groups of two males and two females given 0 or 400 mg/kg bw per day
were allowed a 3-week recovery period. Two dogs were killed during the study
because of intercurrent disease (polyarteritis). The only signs seen in the remaining
animals were occasional vomiting and salivation at the highest dose. Body-weight
gain was slightly retarded in the group at this dose. Ophthalmic, electrocardiographic
and urinary parameters were unaltered. At the highest dose, erythrocyte count,
haemoglobin concentration and erythrocyte volume fraction were lower and the
reticulocyte number was higher than in controls. Prolonged prothrombin and activated
partial thromboplastin times were observed in males at 1600 mg/kg bw per day, and
the concentration of coagulation factor VII was reduced in this group. Plasma total
protein, albumin and cholesterol concentrations were reduced and that of triglycerides
increased at 1600 mg/kg bw per day. The weight of the kidneys of males at this
dose was increased. No differences were seen between groups after the recovery
period. None of the macroscopic or microscopic findings was attributable to treatment.
The NOEL was 400 mg/kg bw per day (Spurling et al., 1986).

Groups of three male and three female beagle dogs were given cefuroxime
sodium by subcutaneous or intramuscular injection at a dose of 0, 50, 150 or
450 mg/kg bw per day for 6 months. The route of administration was varied during
the study to minimize the irritating effects of the injections. The compound was
initially given in saline, but distilled water was used as the vehicle from day 25.
Controls and dogs at 50 mg/kg bw per day were given intramuscular injections into
the hind legs, while animals at the higher doses received subcutaneous injections.
After 12 weeks of treatment, one animal at the highest dose developed a Heinz
body haemolytic anaemia and was killed after a further 2 weeks. Otherwise, the
condition and body-weight gain of dogs was generally good throughout the study.
Discomfort arose at the site of injection, particularly after the subcutaneous doses.
The mean corpuscular haemoglobin concentrations were slightly reduced in dogs
38 CEFUROXIME

at 150 and 450 mg/kg bw per day. Serum iron values were consistently reduced
(significant after 8 weeks), and serum iron binding capacity was increased in animals
at the highest dose throughout the study. Analyses of blood biochemistry, urine and
organ weights showed no compound-related effects. The only pathological changes
were inflammatory reactions at the injection sites in some treated dogs and changes
to the bone marrow and reticuloendothelial system consistent with severe haemolytic
anaemia in the animal killed at week 14. No effects were seen at 50 mg/kg bw per
day. As only a summary of this study was available, the findings could not be
confirmed independently (Glaxo Laboratories Ltd, 1986).

Monkeys
In a study that did not comply with GLP, groups of two male and two female
cynomolgus monkeys were given cefuroxime sodium in 0.9% saline by intramuscular
injection at a dose of 0,150 or 450 mg/kg bw per day for 28 days. No overt signs of
toxicity were seen, although some animals in each treated group produced softer
faeces than normal for a few days at the beginning of treatment. Animals at 450 mg/kg
bw per day showed transient reductions in erythrocyte count and haemoglobin
concentration (significant at day 7), with moderate leukocytosis (neutrophilia and
eosinophilia) in males only. These changes had largely reversed by the end of the
study. Blood biochemistry and urinary parameters showed no alterations, and there
were no compound-related effects on organ weights. Histological examination
revealed only inflammatory reactions at injection sites. As only a summary of this
study was available, the findings cannot be confirmed independently. A NOEL was
not identified (Glaxo Laboratories Ltd, 1986).

2.2.3 Genotoxicity
A battery of tests that complied with appropriate standards was conducted to
address the genotoxicity of cefuroxime sodium. The results are summarized in Table
2.
As expected, cefuroxime was toxic to the bacterial strains used in the mutagenicity
assays. Consequently, only relatively low concentrations of cefuroxime sodium could
be tested in these studies. The selected concentrations were based on the results
of tests for cytotoxicity. Negative results were obtained, except in the test for induction
of chromosomal aberrations in cultured human peripheral blood lymphocytes
obtained from one woman and one man. In this test, a positive result was seen in
the absence of the metabolizing system. Prolonged exposure, for 20-44 h, was
required to obtain a positive effect, and no chromosomal damage was observed
after exposure for 3 h. The aberrations were predominantly chromatid deletions,
with very few chromosome rearrangements. Although the aberration frequencies
were markedly higher than in controls, the magnitude of the response was less than
proportional to the concentration of cefuroxime. This may have been due to inhibition
of mitosis, which increased from 14% to 54% as the concentration was increased.
Nevertheless, these positive results obtained in vitro were not confirmed in a test for
micronucleus formation in vivo in mice receiving cefuroxime sodium at intraperitoneal
doses of up to 10 000 mg/kg bw.
Similar clastogenic effects were seen in cultured human lymphocytes treated
with two other cephalosporins, cephalonium (Marshall, R., 1995) and cephalexin
CEFUROXIME 39

Table 2. Results of tests for genotoxicity with cefuroxime sodium

End-point Test object Concentration Result Reference

Reverse S. typhimuriuml'M535, 0.0013-0.8 ng/ml Negative Ballantyne (1996)

mutation3 TA1537 ± S9
TA98 ± S9 0.0013-1.0 jig/ml Negative
TA100±S9 0.031 -0.5 jig/ml Negative

Reverse E. coli strains WP2 0.0013-0.8ng/ml Negative Ballantyne (1996)

mutation3 pKM101±S9
WP2 uvrA pKM 101 ± S9 0.00026-0.16 pig/ml Negative

Reverse S. typhimurium TA98, 0.05-2.0 |j.g/ml Negative Tweats(1977)

mutation" TA100, TA1535, TA1537,
TA15381S9

Gene Saccharomyces 100-5000 ng/m I Negative Tweats(1977)

conversion0 cerevisiae JD1± S9

Forward Thymidine kinase (tk) 140-4500 fig/ml Negative Fellows (1995)

mutationd locus in mouse lymphoma
L5178Y cells ±S9

Chromoso- Human peripheral blood 750-1500 ng/ml, Positive Marshall, A. (1996)

mal damage lymphocytes in culture 20 h exposure -S9
in vitrcf 2200-4500 jig/ml, Negative
3 h exposure + S9
480 u,g/ml, Positive
44 h exposure -S9
4500 u,g/ml, Negative
3 h exposure -S9

Chromoso- Micronucleus formation Two intraperitoneal Negative Tweats et al.

mal damage in bone marrow from doses of 100,1000 (1980)
in vivd CR/H female mice or 10000 mg/kg bw,
24 h apart

S9, 9000 x g supernatant of rat liver used for metabolic activation

3
Positive controls were 2-nitrofluorene for TA98; sodium azide for TA100 and TA1535; ICR-
191 forTAI 537 and /V-methyl-A/"-nitro-/V-nitrosoguanidine (MNNG) for £ co//in the absence
of S9; 2-aminoanthracene for all S. typhimurium and E. coli strains in the presence of S9.
b
Positive controls were 2-acetamidofluorene for TA98, methyl methanesulfonate for TA100,
MNNG for TA1535, 9-aminoacridine for TA1537 and hycanthone methanesulfonate for
TA1538 in the presence and absence of S9.
0
Positive controls were hycanthone methanesulfonate in the presence and absence of S9.
d
Positive controls were 4-nitroquinoline 1 -oxide in the absence of S9 and benzo[a]pyrene in
the presence of S9.
e
Positive controls were 4-nitroquinoline 1 -oxide in the absence of S9 and cyclophosphamide
in the presence of S9.
f
Positive control was adryamicin by intraperitoneal injection.
40 CEFUROXIME

(Riley, 1996). Another cephalosporin, ceftiofur sodium, did not induce reverse
mutation in bacteria, mutations in mammalian cells in vitro or micronuclei in vivo.
However, chromosomal damage was seen in Chinese hamster ovary cells after
exposure in vitro for 44 h, but not for shorter times (Aaron et al., 1995a). These data
on ceftiofur were reviewed by the Committee at its forth-fifth meeting and were
considered to be of no biological significance (Annex I, reference 120). Further
investigations suggested that the clastogenic effect of ceftiofur is associated with
inhibition of cell division (Aaron et al., 1995b).

2.2.4 Reproductive toxicity

A series of studies that did not conform to GLP were conducted with parenteral
administration of cefuroxime sodium.

(a) Multigeneration studies

Mice
Groups of 12 male and 30 female CRN mice were given cefuroxime sodium in
distilled water by subcutaneous injection at a dose of 800,1600 or 3200 mg/kg bw
per day. Controls were given 0.9% saline. After 60 days, each male was caged with
two or three female mice at the same dose When pregnancy was detected, the
female mice were re-housed. When most of the female mice were pregnant, the
males were killed. The females were divided into two approximately equal groups
per dose: one group was killed on day 18 of gestation, and the females in the other
group were allowed to deliver and rear their litters. The latter group received their
final dose on day 18 of gestation. Three weeks after the birth of the F-i pups, the F0
dams and all but one male and one female from each litter were killed. When the FI
pups were 4 weeks old, one male from one litter was selected and re-housed with
one female from another litter to give rise to the F2 generation. The FT dams and the
F2 pups were killed on postnatal day 21.
The only treatment-related sign during the study was subcutaneous swelling at
the site of injection. There were no treatment-related effects on body-weight gain,
conception rate, numbers of implantation sites or resorptions, numbers of live fetuses,
litter weights or the proportions of male mice in either generation. There were no
fetal abnormalities, and the body-weight gain and physical development of the pups
was unaffected. No reproductive effects were observed at any dose (Griffiths, 1975a).

Rats
Groups of 20 male and 20 female Sprague-Dawley rats were given cefuroxime
sodium in physiological saline by subcutaneous injection at a dose of 0,200,400 or
800 mg/kg bw per day. Males were treated from 60 days before and during mating,
while females were treated from 14 days before mating until day 7 of gestation. The
dams were killed on day 20 of gestation. Pain during drug administration was noted
in animals given the highest dose. Males at doses of 400 mg/kg bw per day and
above showed slight increases in food intake, and water intake was increased in all
treated groups. Body-weight gain was suppressed in treated females during the
latter part of gestation. There were no differences in conception rates or in the
numbers of corpora lutea, implantations, resorptions or live fetuses. Fetal body
CEFUROXIME 41

weights and the numbers of malformed fetuses were not influenced by treatment.
Neither fertility nor reproduction was affected at any dose (Otaka et al., 1979).

(b) Developmental toxicity

Mice
Groups of 10-17 pregnant female CRH mice were given subcutaneous injections
of cefuroxime sodium in 0.9% saline solution at a dose of 0, 800, 1600, 3200 or
6400 mg/kg bw per day on days 6-15 of gestation and killed on day 18 of gestation.
The animals remained in good condition, and there were no effects on body-weight
gain or the numbers of implantation sites, resorptions or live fetuses. Litter weights
and the sex ratio of fetuses were unaffected, and no fetal abnormalities were noted.
Fetal development was not affected at any dose (Troughton & Bartholomew, 1975a).

Rats
Groups of 30 pregnant Sprgaue-Dawley rats were given cefuroxime sodium in
physiological saline by subcutaneous injection at a dose of 0, 200, 400, 800 or
1600 mg/kg bw per day on days 7-17 of gestation. Twenty females in each group
were killed on day 20 of gestation, and the remaining 10 were allowed to deliver and
rear their pups for 21 days. Dams in the latter groups were killed on postnatal day
21, and the Fi offspring matured up to 10 weeks of age. One male and two female
FT rats per dam in each treatment group were mated; one of the two females was
killed on day 20 of gestation, and the other was allowed to deliver and rear the F2
pups for 3 weeks. Pain, bleeding and haematomas at the injection site were common
at the highest dose. Dams in all groups showed slight depression in body-weight
gain and increased water intake and caecal weight. In the phase at which
teratogenesis was examined, lower body weights were seen in FT fetuses at 800
and 1600 mg/kg bw per day, but this effect was not seen in full-term pups. No
effects were found on the numbers of implantations, resorptions or live fetuses, sex
ratios, the incidences of fetal abnormalities or postnatal development or reproductive
capacity in either generation. There were no effects on fetuses at 400 mg/kg bw per
day (Otaka etal., 1979).

Groups of 30 pregnant Sprgaue-Dawley rats were given cefuroxime sodium in

physiological saline by intravenous injection at a dose of 0, 200, 400 or 800 mg/kg
bw per day on days 7-17 of gestation. Twenty females in each group were killed on
day 20 of gestation, and the remaining 10 were allowed to deliver and rear their
pups for 21 days. Dams in the latter groups were killed on postnatal day 21, and the
Fi offspring matured up to 10 weeks of age. One male and two female FI rats per
dam in each treatment group were mated; one of the two females was killed on day
20 of gestation, and the other was allowed to deliver and rear the F2 pups for 3 weeks.
Twitching after injection was noted at doses of 400 mg/kg bw per day and above.
Slight depression in body-weight gain was seen in dams at the highest dose and
increased water intake and caecal weight in all treated groups. No effects were
found on the numbers of implantations, resorptions or live fetuses, sex ratios, the
incidences of fetal abnormalities or postnatal development or reproductive capacity
in either generation. There were no effects on fetuses at any dose (Otaka et al.,
1979).
42 CEFUROXIME

Rabbits
Groups of 5-11 pregnant Dutch rabbits were given cefuroxime sodium in 0.9%
saline by intramuscular injection at a dose of 0, 50, 100, 200 or 400 mg/kg bw per
day on days 6-18 of gestation and were killed on day 29 of gestation. Four does
given 400 mg/kg bw per day, one given 200 mg/kg bw per day and one given
100 mg/kg bw per day died during the study. The rabbits developed diarrhoea before
death, probably due to disturbances of the gut flora. Surviving does showed no
effects on body-weight gain, and there were no effects on the numbers of implantation
sites, resorptions or live fetuses. The incidence of fetal abnormalities was similar in
all groups. Fetal development was not affected at any dose (Troughton &
Bartholomew, 1975b).

Groups of 10 pregnant New Zealand white rabbits were given cefuroxime sodium
in physiological saline by intravenous or subcutaneous injection at a dose of 0, 25,
50,100 or 150 mg/kg bw per day on days 6-18 of gestation and were killed on day
28 of gestation. No deaths occurred during the study, and the body weights were
similar to those of controls. Caecal weight was increased in does at the highest
dose. No differences were seen in the numbers of implants, resorptions or live fetuses,
in the sex ratio, in fetal weights or in the incidences of fetal abnormalities in any
group. Fetal development was not affected at any dose (Furuhashi et al., 1979).

(c) Peri- and postnatal toxicity

Mice
Groups of 12-15 pregnant CRH strain mice were given cefuroxime sodium in
0.9% saline by subcutaneous injection at a dose of 0, 800,1600 or 3200 mg/kg bw
per day from day 16 of gestation to 23 days after parturition. The dams and pups
were killed on postnatal day 23. The severity of local tissue damage at the injection
site was dose-dependent. There were no effects on maternal body weight, length of
gestation or sex ratio. The litter sizes were reduced at 1600 and 3200 mg/kg bw per
day but with no dose-response relationship. Postnatal development of pups and
the proportion of pups successfully weaned were unaffected. There were no effects
on reproductive capacity at 800 mg/kg bw per day (Griffiths, 1975b).

Flats
Groups of 20 pregnant Sprague-Dawley rats were given cefuroxime sodium in
physiological saline by subcutaneous injection at a dose of 0,200,400 or 800 mg/kg
bw per day from day 17 of gestation to day 20 after parturition. The dams were killed
on postnatal day 21. One male and two female Fi offspring per dam in each group
were mated at 10 weeks of age; one of the two females was killed on day 20 of
gestation, and the other was allowed to deliver and rear the F2 pups for 3 weeks.
Body-weight gain and food and water intakes were increased in F0 dams in all groups
during lactation. No differences in gestation or parturition or in the numbers of
implantations or live pups, sex ratios or body weights of offspring were found in any
generation. Caecal weights at the time of weaning were increased in male and
female FI pups of dams at 400 and 800 mg/kg bw per day. Pre- and postnatal
CEFUROXIME 43

development, fertility and reproductive capacity were unaffected at any dose (Otaka
etal., 1979).

Rabbits
Groups of 10-16 pregnant Dutch rabbits were given cefuroxime sodium in 0.9%
saline by intramuscular injection at a dose of 0, 50, 100 or 200 mg/kg bw per day
from day 19 of gestation to 6 weeks after parturition. Surviving does and offspring
were killed on postnatal days 42-44; however, several deaths occurred before
parturition: one at the lowest dose, two at the intermediate dose and six at the
highest dose. The deaths were attributed to perturbation of the maternal gut flora
and secondary toxaemic effects on the liver. Another three does given 200 mg/kg
bw per day either aborted or lost their entire litters soon after parturition. There were
no effects on maternal body weight, length of gestation, sex ratio or litter size. The
weights of pups of does at the highest dose were consistently low at parturition and
throughout lactation, but their postnatal development and survival were unaffected.
There were no effects on offspring of does at 100 mg/kg bw per day (Griffiths, 1975c).

2.2.5 Special studies

(a) Renal toxicity
Studies on nephrotoxic potential that did not comply with GLP were carried out
in rats, rabbits and dogs.

Rats
Groups of 10 male and 10 female Sprague-Dawley JCL rats were given
cefuroxime sodium in distilled water as a single injection, either subcutaneously at
0,1000 or 3000 mg/kg bw or as intravenously at 0,500 or 1500 mg/kg bw. It was not
clear when the tests were conducted or when the animals were killed, but they were
probably killed 24 h after treatment. The specific gravity and sodium and potassium
content of urine were increased in females at 3000 mg/kg bw, and the urinary sodium
concentration was decreased in males at this dose. Decreased blood concentrations
of creatinine were seen in females, of potassium in males and of uric acid in males
and females, all at 3000 mg/kg bw. The blood concentrations of magnesium in females
at 1500 mg/kg bw and of urea nitrogen in both sexes at 500 and 1500 mg/kg bw
were increased. Renal function tests and histopathological examination of a range
of tissues revealed no treatment-related changes (Ito et al., 1979d).

Groups of 10 male and 10 female Sprague-Dawley JCL rats were given

cefuroxime sodium in distilled water by subcutaneous injection at a dose of 0, 800
or 1600 mg/kg bw per day or by intravenous injection at 0,400 or 800 mg/kg bw per
day for 1 week. The results of urine analysis were unremarkable. At 1600 mg/kg bw
per day given subcutaneously, the blood concentrations of glucose, protein and
albumin were decreased in males, those of creatinine and uric acid were decreased
in females, and that of sodium was increased in females. The blood urea nitrogen
concentration was increased at both intravenous doses, and the blood concentrations
of uric acid and sodium were increased at 800 mg/kg bw per day. Renal function
tests and histopathological examination of a range of tissues revealed no treatment-
related changes (Ito et al., 1979d).
44 CEFUROXIME

Rabbits
Groups of five male and five female New Zealand white rabbits were given
cefuroxime sodium in distilled water as a single intramuscular injection of 0,100 or
300 mg/kg bw. It was not clear when the tests were conducted or when the animals
were killed, but they were probably killed 24 h after treatment. The urinary chloride
concentration was increased in females at both doses. Tests for blood biochemistry
and renal function and histopathological examination of a range of tissues revealed
no treatment-related changes (Ito et al., 1979d).

Groups of five male and five female New Zealand white rabbits were given
cefuroxime sodium in distilled water by intramuscular injection at a dose of 0 or
100 mg/kg bw per day for 1 or 4 weeks. After 4 weeks of dosing, increased urine
volume associated with decreased sodium, potassium and chloride concentrations
were observed in treated females. Increased creatinine and phenolsulfonphthalein
clearance were seen in females treated for 1 week but not in those treated for
4 weeks. Blood biochemical and histopathological examination of a range of tissues
revealed no treatment-related changes (Ito et al., 1979d).

Dogs
Groups of three male and three female beagle dogs were given cefuroxime
sodium in distilled water as a single intravenous injection of 0 or 1000 mg/kg bw.
Urinary and blood analyses gave unremarkable results. Phenolsulfonphthalein
clearance was increased in treated females. Histopathological examination of a
range of tissues revealed no treatment-related changes (Ito et al., 1979d).

Groups of three male and three female beagle dogs were given cefuroxime
sodium in distilled water by intravenous injection at a dose of 0, 250 or 500 mg/kg
bw per day for 1 week. No treatment-related changes were found in the results of
urinary analysis or blood biochemistry, tests for renal function or histopathological
examination of a range of tissues (Ito et al., 1979d).

(b) Hepatic toxicity

Dogs
In a study that did not comply with GLP, two male beagle dogs were given
cefuroxime sodium in saline by subcutaneous injection at a dose of 0, 100 or
300 mg/kg bw per day for 10 days. One dog was given a single daily dose, while the
other was given three divided doses, 8 h apart. There were no effects on body
weight or general condition. Blood samples were taken 1, 4 and 8 h after injection
on the first and eighth days and 24 h after the initial dose on the first, second and
tenth days. The activities of alkaline phosphatase, alanine and aspartate aminotrans-
ferases, sorbitol dehydrogenase and glutamate dehydrogenase were not affected
at any time. No histopathological changes were observed in the liver. As only a
summary of this study was available, the findings cannot be confirmed independently
(Glaxo Laboratories Ltd, 1986).
CEFUROXIME 45

(c) Microbiological effects

Several studies were available on the effects of orally administered cefuroxime
on the faecal bacterial flora of humans. These studies were carried out according to
appropriate standards for study protocol and conduct.

Six healthy male volunteers aged 22-40 (weighing 70-86 kg) were given 10
oral doses of 60 mg of cefuroxime axetil, 8 h apart, for a total dose of about 8.5 mg/kg
bw. Bowel function was recorded, and faecal samples were collected for microbio-
logical analysis 2 days before and during treatment. Three of the six volunteers had
diarrhoea during the dosing period which lasted for 2 days. Another had mild
abdominal discomfort for 1 day. A decline in the number of Escherichia coli and
conforms (>2 log) was seen in the faeces of the three men who developed diarrhoea.
Similarly, there was a> 2 log-fold decrease in the number of Streptococcus faecalis
in two men with diarrhoea. S. faecalis could not be detected in the third. The count
of Candida spp. increased from 103to 109in two men with diarrhoea and to 105 in
the other. It had been shown previously that oral doses of cefuroxime and other
cephalosporins can increase the proportion of yeast (Candida albicans) in the
gastrointestinal flora (Thomakos et al., 1998). The number of Bacteroides spp.
declined from 1010 to 103and those of Peptostreptococcus and Peptococcusspp.
decreased from 1010to < 103 in two of the men with diarrhoea and to 5 x 106 in the
third. After cessation of dosing, the microbial counts returned to pre-treatment levels.
There were no effects on Clostridium spp. (Wise et al., 1984).

Oral administration of cefuroxime axetil at a dose of 250 mg twice daily for 4.5 days
to 10 healthy volunteers (five men, five women; mean age, 35 years) caused
gastrointestinal disturbances. One of the subjects developed a feeling of nausea,
and five reported a bloated feeling; seven reported soft faeces, and two detected a
change in odour. Diarrhoea developed in four volunteers, and six reported an
increased number of defaecations during a day. One woman developed vaginitis.
Bowel function returned to normal within 5 days of completing treatment. Decreased
total numbers of anaerobes and total aerobes were found in several individuals.
The number of Enterobacteriaceae was reduced or even nil in six persons. Those of
Streptococcus and Candida spp. were increased. Pseudomonas aeruginosa
appeared in the faeces of four persons during the treatment period. Clostridium
difficile and C. perfringenswere not detected in any faecal samples, and no clostridial
toxins were found. In three persons in whom Enterobacteriaceae were eliminated,
recolonization with the sensitive species E. coli, Citrobacter freundii or Klebsiella
ozaenae occurred. The populations of faecal flora returned to pre-treatment
proportions about 7 days after cessation of treatment (Leigh et al., 1990).

Treatment of eight patients for acute exacerbation of bronchitis with cefuroxime

axetil at a dose of 250 mg (~ 4.1 mg/kg bw) twice a day for 10 .days resulted in
reduced numbers of Staphylococci, Enterobacteriaceae and clostridial populations.
These returned to pre-treatment levels 14 days after cessation of treatment. C.
difficile appeared in three patients (Novelli et al., 1995). In another study, in which
15 recipients of liver transplants were given 6.3 g of cefuroxime (100 mg/kg bw),
46 CEFUROXIME

0.6 g of tobramycin and 0.5 g of nystatin three times daily for 19-21 days to suppress
the gut flora, only a few samples contained C. difficile. The diarrhoea induced by the
treatment was self-limiting (Hove et al., 1996).

Minimum inhibitory concentrations (MICs) have been reported for a range of

bacterial species.
Cefuroxime was included for comparison in a multicentre trial of agents against
more than 42 000 gram-positive and gram-negative organisms. This survey from
79 medical centres and community hospitals in the USA made it possible to establish
MIC5o and MIC90 values for Proteus mirabilis, P. vulgaris, Escherichia coll and
Enterococcus faecalis (Murray et al., 1994). These data and data for the same
organisms reported by Marshall, A. (1995) are shown in Table 3. The results are
based on an inoculum density of 107 CFU/ml. The two reports show closely similar
values.

MIC values for cefuroxime (sodium) against 100 bacterial strains, comprising 10
isolates of 10 genera derived from human gut isolates, were determined by an agar
dilution method (Table 4). The bacteria tested are usually considered the most
relevant and representative of human gut flora. Of the 10 groups tested, five genera
(Enterococcus spp., Lactobacillus spp., Bifidobacterium spp., Peptostreptococcus
spp. and Clostridium spp.) showed a strong inoculum effect (more than two antibiotic
dilutions) between the undiluted culture and a 10~2 dilution, and two genera
(Bacteroides spp. and Bifidobacterium spp.) showed an inoculum effect between
the 10~2 and 1O"4 dilutions. The information available indicates that the lowest relevant
MICso, at the highest inoculum level of 109 CFU/ml, was 8 ng/ml for Bifidobacterium
spp. (Marshall, R., 1995).

In a limited study of the susceptibility of 124 bacteria of aerobic origin isolated

from patients with spontaneous bacterial peritonitis, the MIC50 and MIC90 values for
E. coll were both 4 ng/ml, and the MIC50for Enterococcus spp. was > 16 pig/ml
(Saderetal.,1995).
In a study specifically designed to determine the effects of inoculum size on MIC
values, a clear inoculum effect was seen in several bacteria. Many cephalosporin
antibiotics have an inoculum effect, which may be related to drug deactivation or
metabolism (Goldstein et al., 1991). The significance of this observation is twofold.

Table 3. Minimum inhibitory concentrations (MICs) of clinical isolates

in two studies

Organism Murray et al. (1994) Marshall, A. (1995)

MIC50 MIC90 MIC50 MIC90

Escherichia coli 4 8(10942) 4 4(10)

Proteus mirabilis <2 4 (3 822) 1 2(7)
Proteus vulgaris >64 > 64 (341) 256 256 (3)
Enterococcus faecalis 32 32 (2 624) 8 256(10)

Numbers in parentheses are numbers of isolates studied.

CEFUROXIME 47

Table 4. Minimum inhibitory concentrations (MICs) of cefuroxime

against predominant intestinal microflora at three inoculum levels

Genus MIC50 (fig/ml)

Nominal 109 CPU Nominal 107 CPU Nominal 105 CPU

Escherichia coli 8 4 2
Proteus spp. 8 2 1
Enterococcus spp. 256 8 4
Lactobacillus spp. 128 4 1
Fusobacterium spp. 128 0.5 0.062
Bacteroides spp. >256 256 8
Bifidobacterium spp. 8 1 0.25
Peptostreptococcus spp. 128 4 1
Clostridium spp. 256 32 2
Eubacterium spp. 32 32 16

First, at high inocula, the activity of cefuroxime is greatly reduced; therefore, use of
MICs for concentrations of organisms lower than those found in vivo in the
gastrointestinal tract will result in overestimates of the potential of cefuroxime to
affect the microflora adversely. Secondly, the data show potential p-lactamase
production, which in vivo would lead to inactivation of cefuroxime. This conclusion is
supported by the work of Barry et al. (1977).

The effects of co-culture on the MIC and minimum bactericidal concentration of

cefuroxime against 10 combinations of bacteria from the human gastrointestinal
microflora were determined by agar dilution and by broth microdilution. The results
(Table 5) showed that the activity of cefuroxime was significantly reduced, by a
factor of up to 20, by co-culture as compared with monoculture. The relatively sensitive
Fusobacterium mortiferum strain became less susceptible when tested in co-culture
with a more resistant, p-lactamase-producing Proteus vulgaris strain. This was not
observed in all cases. The results also showed that the gut microrganisms can
protect themselves against the antimicrobial effects of cefuroxime, thus affording
protection of the overall gut ecosystem (Pridmore, 1996). Indeed, significant (3-
lactamase activity has been detected in human faeces (Nord et al., 1989). Particular
organisms are known to produce the enzyme, and some, like Bacteroides fragilis,
have strains that produce high concentrations (Cornick et al., 1990). In a study of
the p-lactamase activity in bacteria used to determine the MICs of cefuroxime, 21 of
the 100 strains representative of the human gut flora had intrinsic P-lactamase activity,
and a further eight isolates produced p-lactamase in the presence of cefuroxime
(Marshall, A., 1996).

Cefuroxime is unaffected by many of the common p-lactamases and is effective

against bacterial strains that are resistant to other p-lactam antibiotics. Cefuroxime
is stable to many bacterial p-lactamases, especially plasmid-mediated enzymes
that are commonly found in Enterobacteriaceae (Medical Economics Co., 2002).

A model was used to assess the effects of cefuroxime on bacteria representative

of the human gut flora in vitro under conditions that mimicked those in the human
48 CEFUROXIME

Table 5. Effect of co-culture of intestinal microflora on the microbiological activity

of cefuroxime

Organism Individual broth Individual MBC in co-culture

MIC (jig/ml) MBC (jig/ml) (ng/ml)

Bifidobacterium adolescentis 0.25 0.25 0.125

Bacteroides distasonis >256 >256 >256

Proteus vulgaris >256 >256 >256

Fusobacterium mortiferum 0.25 0.25 4

Enterococcus faecalis >256 >256 >256

Bifidobacterium spp. 4 256 >256

Enterococcus faecalis >256 >256 >256

Bifidobacterium spp. 16 32 64

Proteus mirabilis 16 32 16
Clostridium perfringens 4 64 16

Bacteroides distasonis 32 32 2
Peptostreptococcus spp. 1 2 2

Proteus vulgaris >256 >256 >256

Bifidobacterium spp. 1 2 2

Bacteroides uniformis >256 >256 >256

Peptostreptococcus magnus 1 1 2

Proteus mirabilis 32 128 128

Fusobacterium spp. 0.016 0.016 0.031

Peptostreptococcus asaccharolyticus 0.25 0.25 0.25

Fusobacterium spp. 0.016 0.016 0.031

MBC, minimum bactericidal concentration

gut. Two concentrations were used: one was based on the maximum concentration
of cefuroxime residues expected to be found in the human gut, and the second was
comparable to the MICs for cefuroxime against the respective human gut isolates.
The effects of cefuroxime were investigated against five groups of bacteria
(Clostridium sporogenes, Cl. difficile, Peptostreptococcus magnus, P. anaerobius,
and Bacteroides spp.) found in the human gut. The drug was added to sterile
anaerobic cooked-meat medium supplemented with pepsin and incubated
anaerobically at pH 2 and 37 °C for 1 h. After adjustment to pH 7 and the addition of
physiological levels of bile salts and pancreatin, the tester strain was added, and
the culture was incubated anaerobically for 18 h. The results are given in Table 6.

Eight of the 10 strains tested showed no pronounced change or increase in

viable count. The results obtained for 10 bacterial strains in this investigation suggest
CEFUROXIME 49

Table 6. Effects of cefuroxime on human intestinal microflora in vitro

Bacterial strain Cefuroximej Inoculum Total viable count (cfu/ml) Cefuroxime

concentration density • MIC (mg/ml)
(mg/ml) (cfu/ml) On After 18 h
inoculation incubation

Clostridium sporogenes 0 5.0 x10 6 9.8 x10 8

2 8.0 xlO 8 4.8 x10 6 8.1 x 107 2
4 5.1 x10 6 6.3 x10 6

Clostridium difficile 0 1.1 x10 6 6.4 x10 8

2 1.6X10 8
1.6x10 6 1.0x10 7 256
4 1.3x10 6 6.3 x 1 06

Peptostreptococcus 0 3.2 X10 8 3.9 x10 6 3.7 x10 6 0.5

magnus 2 3.7 x10 8 6.9 x10 7

Peptostreptococcus 0 4.8 xlO 8 6.0 x10 6 2.5 x10 8 1

anaerobius 2 5.1 x10 7 5.6 x 1 07

Bacteroides 0 1.2x10 6 7.6 x10 8

thetaiotaomicron 2 1.0 X10 8
6.0 x10 5 9.6 x10 7 256
256 6.5 x10 5 2.8 x10 7

Bacteroides spp. 0 7.2 x10 5 8.0 x10 8

2 1.5 X10 8 6.0 x10 5 4.5 x10 8 2
256 7.2 x10 5 <2.5x10 5

Lactobacillusspp.* 0 2.2 x10 6 6.3 x10 7

2 3.5 xlO 8
1.7x10 6 1.0x10 7 4
128 2.1 x10 6 <2.5x10 5

Lactobacillus spp. 0 3.4 x10 6 2.6 X10 8

2 4.0 X10 8
2.7 x10 6 2.1 x 108 256
128 2.2 x10 6 8.3 x10 7

Escherichia coll a 0 9.2 x10 6 1.1 x10 9

2 9.3 xlO 8 9.8 x 106 2.9 x 108 2
8 8.7 x10 7 8.7 x10 8

Escherichia coli 0 1.0x10 7 1.2x10 9

2 1.1 X10 9
7.7 x10 6 3.9 x10 8 4
8 1.0x10 7 1.9x10 8
a
Duplicate names indicate different strains/isolates.

that cefuroxime had no detectable effects at the concentrations used, which were
equal to or greater than those likely to be achieved in the human gut in vivo. Reduced
numbers of one strain of Bacteroides spp. and one strain of Lactobacillus spp. were
found, but in both cases only after exposure to very high concentrations (> 128 u,g/ml)
chosen as the geometric mean MIC against these organisms (Pridmore, 1995).
50 CEFUROXIME

2.3 Observations in humans

Published reviews of adverse effects in patients treated with cefuroxime sodium
and cefuroxime axetil at therapeutic doses indicate that these drugs are generally
well tolerated by adults and children. Gastrointestinal disturbances such as stomatitis,
nausea and diarrhoea, particularly after oral dosing, occur frequently and are due to
the effects of the drug on the colonic microflora. Administration by intramuscular
injection commonly causes irritation, thrombophlebitis and pain at the injection site.
Hypersensitivity reactions are relatively uncommon, and central nervous system
toxicity is rare. Increased liver enzyme activity and blood urea nitrogen concentration
and anaemia and other haematological abnormalities (i.e. eosinophilia, leukopenia,
neutropenia and positive Coombs test [antibodies to red blood cells}) have been
observed occasionally. These changes have been mild, asymptomatic and transient
and are regarded as clinically inconsequential (Smith & Le Frock, 1983; Perry &
Brogden, 1996). Pseudomembranous colitis is infrequent and occurs at a low
incidence (Parfitt, 1999).

High doses of cefuroxime were associated with the development of reversible

encephalopathy characterized by dulled sensibility or stupor, myoclonic jerks and
asterixis (negative myoclonus) in four patients. Three of the patients were over
60 years of age and had renal failure, and the condition arose after two to three
intravenous injections of 750 mg. The other patient had been given 125 mg of
cefuroxime axetil orally three times a day for 2 years and had then received a dose
of 6000 mg for 4 days. In each case, the condition resolved on cessation of treatment
(Herishanu et al., 1998).

A study was conducted in 106 women who received cefuroxime during the first
trimester of pregnancy. The women were enrolled prospectively and paired for age,
smoking habits and alcohol consumption. The daily dose of cefuroxime was 500-
1000 mg, and the duration of treatment was 5-10 days. The risk for spontaneous
abortion, fetal distress or malformations in neonates was not increased. The rate of
induced abortions was significantly higher in the treated group, but the number of
live births, the birth weights and postnatal motor development were similar in the
two groups (Berkovitch et al., 2000).

The case records of 78 women aged 19-38 years who had been treated with
cefuroxime during pregnancy were analysed retrospectively. Treatment had been
given during the first trimester to 13 women, during the second trimester to 19 women
and during the third trimester to 46 women. The physical and mental development
of the children born to these mothers was evaluated for 18 months after birth. No
abnormalities were detected (Manka et al., 2000).

3. COMMENTS
The Committee considered the results of studies on pharmacokinetics and
metabolism, acute and short-term toxicity, genotoxicity, fertility, reproductive and
developmental toxicity, toxicity to the kidney and liver, microbiological safety and
studies in humans. Many of the older studies were available as summary reports
CEFUROXIME 51

only and thus could not be assessed, nor was it possible to determine whether the
studies had been carried out according to appropriate standards for study protocol
and conduct. The newer studies on genotoxicity and microbiological activity were
carried out according to appropriate standards.

Toxicological data
Cefuroxime, when administered as cefuroxime sodium, was poorly absorbed
from the gastrointestinal tract of humans after oral administration. When injected
into rats and humans, cefuroxime was widely distributed throughout the body.
Metabolism was negligible in rats, dogs and humans; however, the Committee noted
that significant transformation occurred after intramammary treatment of cows with
cefuroxime sodium. Elimination occurred rapidly, largely in the urine, in rats, rabbits,
dogs and humans and also in food-producing animals. A small proportion was
excreted in the bile of rats and dogs. More absorption occurred after oral
administration of cefuroxime axetil in rats, dogs and humans. The ester was rapidly
hydrolysed in the intestinal mucosa and blood to yield cefuroxime, acetaldehyde
and acetic acid. Thus, the spectrum of toxicity of cefuroxime axetil in vivo would be
the same as that of cefuroxime.
In a study summarized in the residue monograph (FAO, 2002), which was
conducted according to good laboratory practice (GLP), eight lactating dairy cows
(weighing 402-599 kg) were given [14C]cefuroxime sodium by intramammary infusion
after each of three successive milkings at a nominal dose of 250 mg per quarter per
treatment, for a total dose of 3000 mg. Approximately 95% of the dose administered
to two of the cows held in metabolic cages was accounted for, with 78% in milk,
10% in urine, 4.6% in faeces and 2.4% in the cage wash. The concentration of
cefuroxime equivalent (0.10 mg/kg) in blood peaked 24 h after treatment and declined
steadily to 0.01 mg/kg at 196 h. The concentrations were higher in the plasma fraction
(0.13 mg/kg at 24 h) than in serum. The elimination appeared to follow a biphasic
model, suggesting distribution in a body compartment other than blood or plasma.
Elimination was primarily in milk (75-82%) and urine (6-14%). Parent compound
accounted for about 20% of the residue in urine, while the remaining residues were
in three unidentified polar fractions separated by liquid chromatography. Parent
compound also accounted for about 20% of the total residues in milk during and
immediately after treatment, declining to about 6% several days after treatment and
later to < 2%. The Committee considered that factors other than metabolism, such
as compound instability, might have accounted for much of this depletion from milk;
however, no data were available to confirm this hypothesis. At slaughter 7 days
after the third dosing, no antimicrobiologically active residues were extracted from
the kidney, the edible tissue with the highest concentration of radiolabelled residues.
About 60% of the radiolabel was extractable from kidney, but very little co-eluted in
chromatographic analysis with the parent compound.
Cefuroxime sodium was of low acute toxicity when given orally, and it was not
lethal at single oral doses of up to 10 000 mg/kg bw in mice and rats. The main
adverse effect seen was diarrhoea. Parenteral administration by the subcutaneous,
intramuscular, intraperitoneal or intravenous route of single doses of up to 2000 mg/kg
bw was also well tolerated in mice, rats, cats, dogs and cynomolgus monkeys. Rabbits
were the most sensitive to the acute toxicity of cefuroxime.
52 CEFUROXIME

In short-term studies of toxicity, rats were given parenteral doses of cefuroxime

sodium for periods of 29-91 days (50-1500 mg/kg bw per day) and 26 weeks (50-
750 mg/kg bw per day). Reductions in erythrocyte count, haemoglobin concentration
and erythrocyte volume fraction were observed consistently at doses of 100-
1500 mg/kg bw per day, and decreased serum protein concentrations were detected
in some studies in animals given doses of 375-1500 mg/kg bw per day. The only
pathological change, apart from inflammation and haemorrhage at the injection site,
was swelling of the caecum at doses of 250-1500 mg/kg bw per day. No effects
were seen at 50 mg/kg bw per day for 26 weeks.
Dogs were given cefuroxime sodium parenterally for periods of 10-35 days (50-
540 mg/kg bw per day) and 26 weeks (50-450 mg/kg bw per day). Body-weight loss
was observed at 250 and 500 mg/kg bw per day for 35 days, but body weight was
not affected at any dose during the 26-week study. Haemoglobin concentrations
were reduced at 150 and 450 mg/kg bw per day for 26 weeks, and lower serum iron
concentrations were found at 450 mg/kg bw per day. One animal given 450 mg/kg
bw per day developed severe haemolytic anaemia after 12 weeks. The pathological
changes in other dogs were restricted to inflammatory reactions at the injection site.
No effects were found at a dose of 50 mg/kg bw per day for 26 weeks.
Dogs were treated orally with aqueous solutions of cefuroxime axetil, providing
a dose of 0, 100, 400 or 1600 mg/kg bw per day as cefuroxime, for 27 weeks.
Treatment-related effects were seen only at 1600 mg/kg bw per day. Body-weight
gain was retarded. Erythrocyte count, haemoglobin concentration and erythrocyte
volume fraction were reduced, and the reticulocyte count was increased. Clotting
times were prolonged, the concentrations of coagulation factor VII and plasma total
protein, albumin and cholesterol were reduced, and the concentration of triglycerides
was increased. The weight of the kidneys was increased in males, but there was no
histological change attributable to cefuroxime. The NOEL was 400 mg/kg bw per
day.
Cynomolgus monkeys were given cefuroxime sodium by intramuscular injection
at a dose of 0,150 or 450 mg/kg bw per day for 28 days. Soft faeces were reported
in some animals in each treatment group, but no further details were available. At
the highest dose, the erythrocyte count and haemoglobin concentration were reduced
during the initial stages of the study. Inflammation at the injection site was the sole
pathological finding.
Assays covering an adequate range of genotoxic end-points were conducted
with cefuroxime sodium. The results were negative, with the exception of an assay
for chromosomal aberration in vitro in the absence of metabolic activation, but effects
were seen only after prolonged exposure. The Committee concluded that this result,
when taken in conjunction with the negative results in a test for micronucleus formation
in the bone marrow of mice treated intraperitoneally, was not of biological significance.
It concluded that cefuroxime does not pose a genotoxic hazard.
No long-term studies of toxicity were carried out with cefuroxime. The drug has
no significant genotoxic activity and is not chemically related to known carcinogens.
Furthermore, cefuroxime was poorly absorbed from the gastrointestinal tract. No
neoplastic or preneoplastic lesions were observed in 26-week studies in rats and
dogs given repeated parenteral doses. Under the circumstances, the Committee
concluded that studies of carcinogenicity were unnecessary.
Multigeneration studies of reproductive toxicity and peri- and postnatal toxicity
were carried out in mice (800-3200 mg/kg bw per day) and rats (200-800 mg/kg bw
CEFUROXIME 53

per day) treated subcutaneously. Fertility and reproduction in parental animals and
postnatal development of the offspring were unaffected at any dose. Developmental
toxicity was investigated in mice (800-6400 mg/kg bw per day) and rats (200-
1600 mg/kg bw per day) treated subcutaneously. There was no effect on fetal
development.
Rabbits received cefuroxime at intramuscular doses of 50-400 mg/kg bw per
day during gestation and/or until 6 weeks after parturition. A dose-related increase
in the mortality rate of dams was observed at all doses, with diarrhoea occurring
before death. This effect was probably due to disturbances of the gut flora, a
recognized phenomenon in rabbits given antimicrobial agents. There were no effects
on fetal development or postnatal growth and survival at any dose.
Special studies designed to identify potential renal toxicity were undertaken in
rats (given single doses of up to 3000 mg/kg bw and up to 1800 mg/kg bw per day
for 1 week), rabbits (given single doses of up to 300 mg/kg bw and 100 mg/kg bw
per day for 4 weeks) and dogs (given single doses of 1000 mg/kg bw and up to
500 mg/kg bw per day for 1 week). There was no evidence of renal toxicity.
In a special study to investigate hepatic toxicity in dogs, the concentrations of a
range of serum liver enzymes were not affected by doses of cefuroxime of 100 and
300 mg/kg bw per day for 10 days.
Humans treated with cefuroxime sodium or cefuroxime axetil have generally
shown few toxic side-effects. Gastrointestinal disturbances are frequent, particularly
after oral dosing, and irritation and pain commonly occur at sites of injection.
Hypersensitivity reactions are relatively uncommon, and central nervous system
toxicity is rare. Increased serum concentrations of liver enzymes and blood urea
nitrogen and anaemia and other haematological abnormalities are observed
occasionally. These changes are mild and are generally regarded as inconsequential.
In elderly patients with renal failure, which impedes the elimination of cefuroxime,
higher systemic concentrations have been associated with reversible encephalo-
pathy. Data from use during pregnancy, although limited, did not show any adverse
effects on the developing fetus or the neonate.
The most relevant study for determining a toxicological NOEL is the 27-week
study in dogs given cefuroxime axetil orally. Owing to the rapid conversion of the
axetil ester to cefuroxime, the effects observed are likely to be due to the latter.
Studies in which cefuroxime sodium was given by parenteral injection are less
relevant for assessing the acceptable intake of cefuroxime in food. Hence, the NOEL
for toxicity was 400 mg/kg bw per day. A safety factor of 100 was considered
appropriate in view of the existing database for a compound with a long history of
use. Therefore, an ADI of 0-4 mg/kg bw could be established on the basis of the
toxicological data.

Microbiological data
Oral administration of cefuroxime axetil at therapeutic doses of 2.5-8 mg/kg bw
per day to human patients or volunteers resulted in gastrointestinal disturbances.
The signs and symptoms included soft faeces, nausea, a bloated feeling and
diarrhoea. Further investigation showed that these overt signs were associated with
decreased numbers of bacteria or, in extreme cases, elimination of certain colonic
flora. In a few subjects, there was evidence of overgrowth of pathogenic bacteria or
yeasts, suggesting disruption of the protective barrier effect in the colon. The
54 CEFUROXIME

populations of colonic flora returned to normal within 7-14 days after cessation of
treatment.
Cefuroxime has been tested for its inhibitory activity against microorganisms
representative of the human colonic microflora. The most sensitive species were
Bifidobacterium spp., with an MICso value of 8 mg/ml at an inoculum density of 109
CFU/ml. It has been shown that the activity of cefuroxime is reduced when large
inocula are used or when two or more organisms are combined in co-culture, possibly
due to the production of p-lactamase. In an in-vitro model of the gut that mimics the
conditions found in the human colon, cefuroxime at very high concentrations inhibited
the growth of two of 10 co-culture combinations of bacteria from the human
gastrointestinal tract. These results indicate that the intestinal microflora can protect
themselves from the antimicrobial effects of cefuroxime, thus affording protection to
the overall gut ecosystem.
A decision-tree for evaluating the potential effect of veterinary drug residues on
human intestinal microflora was developed by the Committee at its fifty-second
meeting (Annex 1, reference 140) and is reproduced in Figure 1. At its present
meeting, the Committee used the decision-tree to answer the following questions in
its assessment of cefuroxime:

1. Does the ingested residue have antimicrobial properties?

Yes. The parent compound is present as a residue and has been shown to have
antimicrobial activity. Significant transformation occurred after intramammary
treatment of cows with [14C]cefuroxime sodium, but the degradation products were
not identified and their antimicrobial activity is unknown.

2. Does the drug residue enter the lower bowel by any route?
Yes. Cefuroxime sodium is poorly absorbed in mammals, including humans. As
approximately 1% of an oral dose of cefuroxime was absorbed systemically in
humans, most of an oral dose enters the intestines.

3. Is the ingested residue transformed irreversibly to inactive metabolites by chemical

transformation, metabolism mediated by the host or intestinal microflora in the
bowel and/or by binding to intestinal contents?
No specific information was available on the metabolism of cefuroxime by
intestinal microflora. Cefuroxime undergoes negligible metabolism in rats, dogs and
humans; however, intestinal microflora have the potential to deactivate cefuroxime,
as they have P-lactamase enzymes. As there was no direct evidence that cefuroxime
is metabolized to inactive metabolites by the intestinal microflora, it was assumed
that microbiological activity is retained in the human gastrointestinal tract.

4. Do data on the effects of the drug on the colonic microflora provide a basis to
conclude that the ADI derived from toxicological data is sufficiently low to protect
the intestinal microflora?
No. A number of studies, including those to establish MIC50 values, experiments
with co-cultures, investigations of p-lactamase activity and pH effects and studies
with volunteers, have indicated that cefuroxime may have adverse effects on the
intestinal microflora.
CEFUROXIME 55

5. Do clinical data from the therapeutic use of the class of drugs in humans or data
from in-vitro or in-vivo model systems indicate that effects could occur in the
gastrointestinal flora?
Yes. Gastrointestinal effects are the most commonly reported adverse reactions
to therapeutic use of cefuroxime in humans; they include diarrhoea, nausea, vomiting
and abdominal pain.

6. Determine the most sensitive adverse effect of the drug on the human intestinal
microflora.
The available data indicate that disruption of the colonization barrier is the main
concern with cefuroxime, rather than emergence of resistance. In clinical practice,
cefuroxime is used to treat patients with acute sinusitis, otitis media, chronic bronchitis
and skin and urinary-tract infections. Cefuroxime is active against many typical
aerobic gram-positive and gram-negative bacteria associated with these infections.
There is always concern about decreased susceptibility to antimicrobial agents with
increasing resistance; however, cefuroxime is not indicated for use against the
predominant anaerobic bacteria commonly associated with the human gastro-
intestinal tract, and the antimicrobial resistance of such organisms has not been
reported.

7. If disruption of the colonization barrier is the concern, determine the MIC of the
drug against 100 strains of predominant intestinal flora and take the geometric
mean MIC of the most sensitive genus or genera to derive an ADI using the
formula for estimating an ADI. Other model systems may be used to establish
an NOEC to derive an ADI.
An evaluation of the MIC50 values for relevant gastrointestinal microflora provides
a figure of 8 ng/ml for Bifidobacterium spp. This value can be used to calculate a
microbiological ADI, as follows:
MIC50 x MCC
Upper limit of ADI =
FA x SF x BW
where:
MIC50 = minimum inhibitory concentration for 50% of strains of the most sensitive
relevant organism. The MICso for the most sensitive relevant genus of the gut flora
was 8 ng/ml (8 |ig/g) for Bifidobacterium spp.
MCC = mass of colonic contents; a value of 220 g, determined by the Committee at
its forty-seventh meeting (Annex 1, reference 125), was used in the calculation.
FA = available fraction of the dose: the microbiologically active residue is cefuroxime.
As only about 1 % of an oral dose of cefuroxime was systemically absorbed in humans,
the fraction of the dose available to the gastrointestinal microflora is 100%. Thus,
the value in the equation is unity (1).
SF = safety factor: the magnitude of the safety factor depends on the quality and
quantity of the microbiological data available. A value of 1 is appropriate when
extensive relevant microbiological data are available, as is the case in the current
assessment. Thus, the safety factor should be unity (1).
Figure 1. Decision-tree for determining the potential adverse effects of residues of veterinary antimicrobial drugs on the human Intestinal
microflora
Assess the effects of veterinary drug residues, including metabolites, on the human intestinal microflora.

Yes No
Does the ingested residue have antimicrobial properties (recommendation 1(a))?

No Does the drug residue enter the lower bowel (e.g. with the food Yes Conclude that the drug residue will not affect the intestinal
bolus, by biliary circulation, and/or by mucosal secretion) microflora and use toxicological data to derive the ADI
(recommendation 1(b))? (recommendation 1(a)).

Conclude that the drug residue will not affect the Is the ingested residue transformed irreversibly to inactive metabolites by chemical Yes
No
intestinal microflora and use toxicological data to transformation, metabolism mediated by the host or by the intestinal microflora in the
derive the ADI (recommendation 1(b)). bowel, and/or by binding to intestinal contents (recommendations 1(c) and 1(d)).

Do data on the effects of the drug on the colonic Conclude that the drug residue will not affect the intestinal microflora and use
Yes microflora provide a basis to conclude that the ADI No toxicological data to derive the ADI (recommendations 1(c) and 1(d}).
derived from toxicological data is sufficiently low to
protect the intestinal microflora (recommendation 1(e))7

Conclude that the drug residue will not affect the Yes Do clinical data from therapeutic use of the class of drugs in humans or No
intestinal microflora and use toxicological data to data from in vitro or in vivo model systems indicate that effects could
derive the ADI (recommendation 1(e)). occur in the gastrointestinal microflora (recommendation 1(f))?

Determine the most sensitive adverse effect(s) of the drug on the Conclude that the drug residue will not affect the gastrointestinal
human intestinal microflora, including selection of drug-resistant microflora and use toxicological data to derive the ADI.
populations, disruption of the barrier to colonization or changes in the
metabolic activity of the microflora in the gastrointestinal tract that have
been specifically linked to adverse effects on human health.
 If emergence of antimicrobial If disruption of the colonization barrier is the concern, determine the
resistance is the concern, If the concern is change in a
MIC of the drug against 100 strains of the predominant intestinal
conduct tests in vitro (continuous specific enzymatic activity that is
flora, and take the geometric mean MIC of the most sensitive
culture of faecal inocula) or in directly linked to adverse effects
genus or genera to derive an ADI using the equation" developed at the
vivo (rodents inoculated with on human health, conduct tests in
forty-seventhmeeting of the Committee (Annex 1, reference 125).
human flora); challenge the vitro (continuous culture of faecal
Other model systems may be used to establish a no-observed-effect
model system with an antibiotic- inocula) or in vivo (rodents
concentration (NOEC) to derive an ADI (recommendation 2(b)).
resistant species and determine inoculated with human flora) to
A more realistic ADI can be derived by conducting tests in vitro
the concentration of the drug that determine the concentration of the
(continuous culture of faecal inocula) or in vivo (rodents inoculated
does not select for resistance or drug that does not alter that
with human flora). Challenge the model systems with appropriate
the antibiotic-resistant strain when specific enzymatic activity when
species (e.g. Clostridium difficile. Salmonella spp., Enterococcus spp.,
compared with absence of the compared with absence of the
Escherichis coli) and determine the concentration of the drug that
drug. Use the dose of the drug drug. Use the dose of the drug
does not alter the shedding characteristics of the organisms when
that has no effect to derive an that has no effect to derive an ADI
compared with absence of the drug. Use the dose of the drug that has
ADI (recommendation 2(d)). (recommendation 2(e)).
no effect to derive an ADI (recommendation 2(c)).

• The equation Is as follows:

MIC (pg/g) x Mass of colonic contents (g)
Upper limit of ADI (ug/kg of body weight) =
Fraction of oral dose bioavailable x Safety factor x Weight of human (kg)
where:
MIC50 = Minimum concentration of an antimicrobial drug that completely inhibits the growth of 50% of the cultures of a particular microorganism, as judged by
the naked eye, after a given period of incubation. For the purpose of the evaluation, the MIC50 value is the mean MIC50 for the strain(s) of the relevant
species tested. Alternatively, the lowest MICSO value for the most sensitive species can be used.
Although MIC50 values are usually expressed in micrograms per millilitre, they are expressed as micrograms per gram in this equation so that the ADI will be in
micrograms per kilogram. When the MIC50 value is converted to these units, it is assumed that the density of the experimental medium is 1 g/ml.
A value of 220 g is used for the mass of the colonic contents, and a value of 60 kg is used for the weight of an adult. The safety factor used to take account of
uncertainty about the amount and relevance of data available for review may range from 1 to 10. A value of 1 is used when extensive relevant microbiological
data are provided.
58 CEFUROXIME

BW = body weight: a value of 60 kg has been adopted for an adult.

Hence,
8 ng/g x 220 g
Upper limit of ADI =
1 x 1 x 60 kg

Upper limit of ADI = 29 ng/kg bw

4. EVALUATION
The Committee noted that there is significant transformation of cefuroxime in
cattle, which does not occur in laboratory animals or humans. The toxicological
activity of the majority of the residue has not been characterized. Therefore, the
Committee established a temporary ADI of 0-30 mg/kg bw on the basis of the MIC5o
for Bifidobacterium spp., pending the results of studies to (1) identify the residues in
milk and clarify whether the residues other than parent compound are due primarily
to metabolism or to non-metabolic decomposition of parent cefuroxime; and (2)
characterize the toxicological significance of non-parent residues in milk. This
information should be provided for evaluation in 2004. The ADI is based on a
microbiological end-point and is significantly lower than it would be if it were based
on a toxicological end-point. An extra safety factor was not applied to account for
the fact that the ADI is temporary, because the concern is the possible toxicity of the
transformation products rather then their antimicrobial activity.

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in male and female volunteers after fasting and after food. J. Antimicrob. Chemother., 13,
191-196.
62 CEFUROXIME

Wise, R., Bennett, S.A. & Dent, J. (1984) The pharmacokinetics of orally absorbed cefuroxime
compared with amoxycillin/clavulanic acid. J. Antimicrob. Chemother., 13, 603-610.
ANNEXES
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 ANNEX 1

REPORTS AND OTHER DOCUMENTS RESULTING FROM PREVIOUS

MEETINGS OF THE JOINT FAO/WHO EXPERT COMMITTEE ON
FOOD ADDITIVES

1. General principles governing the use of food additives (First report of the
Joint FAO/WHO Expert Committee on Food Additives). FAO Nutrition Meetings
Report Series, No. 15,1957; WHO Technical Report Series, No. 129,1957 (out
of print).
2. Procedures for the testing of intentional food additives to establish their
safety for use (Second report of the Joint FAO/WHO Expert Committee on Food
Additives). FAO Nutrition Meetings Report Series, No. 17,1958; WHO Technical
Report Series, No. 144, 1958 (out of print).
3. Specifications for identity and purity of food additives (antimicrobial
preservatives and antioxidants) (Third report of the Joint FAO/WHO Expert
Committee on Food Additives). These specifications were subsequently revised
and published as Specifications for identity and purity of food additives, Vol.
I. Antimicrobial preservatives and antioxidants, Rome, Food and Agriculture
Organization of the United Nations, 1962 (out of print).
4. Specifications for identity and purity of food additives (food colours)
(Fourth report of the Joint FAO/WHO Expert Committee on Food Additives).
These specifications were subsequently revised and published as Specifications
for identity and purity of food additives, Vol. II. Food colours, Rome, Food
and Agriculture Organization of the United Nations, 1963 (out of print).
5. Evaluation of the carcinogenic hazards of food additives (Fifth report of the
Joint FAO/WHO Expert Committee on Food Additives). FAO Nutrition Meetings
Report Series, No. 29,1961; WHO Technical Report Series, No. 220,1961 (out
of print).
6. Evaluation of the toxicity of a number of antimicrobials and antioxidants
(Sixth report of the Joint FAO/WHO Expert Committee on Food Additives). FAO
Nutrition Meetings Report Series, No. 31,1962; WHO Technical Report Series,
No. 228, 1962 (out of print).
7. Specifications for the identity and purity of food additives and their
toxicological evaluation: emulsifiers, stabilizers, bleaching and maturing
agents (Seventh report of the Joint FAO/WHO Expert Committee on Food
Additives). FAO Nutrition Meetings Series, No. 35,1964; WHO Technical Report
Series, No. 281, 1964 (out of print).
8. Specifications for the identity and purity of food additives and their
toxicological evaluation: food colours and some antimicrobials and
antioxidants (Eighth report of the Joint FAO/WHO Expert Committee on Food
Additives). FAO Nutrition Meetings Series, No. 38,1965; WHO Technical Report
Series, No. 309, 1965 (out of print).
9. Specifications for identity and purity and toxicological evaluation of some
antimicrobials and antioxidants. FAO Nutrition Meetings Report Series, No.
38A, 1965; WHO/Food Add/24.65 (out of print).
10. Specifications for identity and purity and toxicological evaluation of food
colours. FAO Nutrition Meetings Report Series, No. 38B, 1966; WHO/Food
Add/66.25.

-65-
ANNEX 1 66

11. Specifications for the identity and purity of food additives and their
toxicological evaluation: some antimicrobials, antioxidants, emulsifiers,
stabilizers, flour treatment agents, acids, and bases (Ninth report of the Joint
FAO/WHO Expert Committee on Food Additives). FAO Nutrition Meetings
Series, No. 40,1966; WHO Technical Report Series, No. 339,1966 (out of print).
12. Toxicological evaluation of some antimicrobials, antioxidants, emulsifiers,
stabilizers, flour treatment agents, acids, and bases. FAO Nutrition Meetings
Report Series, No. 40A, B, C; WHO/Food Add/67.29.
13. Specifications for the identity and purity of food additives and their
toxicological evaluation: some emulsifiers and stabilizers and certain
other substances (Tenth report of the Joint FAO/WHO Expert Committee on
Food Additives). FAO Nutrition Meetings Series, No. 43,1967; WHO Technical
Report Series, No. 373, 1967.
14. Specifications for the identity and purity of food additives and their
toxicologica! evaluation: some flavouring substances and non nutritive
sweetening agents (Eleventh report of the Joint FAO/WHO Expert Committee
on Food Additives). "FAO Nutrition Meetings Series, No. 44, 1968; WHO
Technical Report Series, No. 383, 1968.
15. Toxicological evaluation of some flavouring substances and non nutritive
sweetening agents. FAO Nutrition Meetings Report Series, No. 44A, 1968;
WHO/Food Add/68.33.
16. Specifications and criteria for identity and purity of some flavouring
substances and non-nutritive sweetening agents. FAO Nutrition Meetings
Report Series, No. 44B, 1969; WHO/Food Add/69.31.
17. Specifications for the identity and purity of food additives and their
toxicological evaluation: some antibiotics (Twelfth report of the Joint FAO/
WHO Expert Committee on Food Additives). FAO Nutrition Meetings Series, No.
45, 1969; WHO Technical Report Series, No. 430, 1969.
18. Specifications for the identity and purity of some antibiotics. FAO Nutrition
Meetings Series, No. 45A, 1969; WHO/Food Add/69.34.
19. Specifications for the identity and purity of food additives and their
toxicological evaluation: some food colours, emulsifiers, stabilizers,
anticaking agents, and certain other substances (Thirteenth report of the
Joint FAO/WHO Expert Committee on Food Additives). FAO Nutrition Meetings
Series, No. 46, 1970; WHO Technical Report Series, No. 445, 1970.
20. Toxicological evaluation of some food colours, emulsifiers, stabilizers,
anticaking agents, and certain other substances. FAO Nutrition Meetings
Report Series, No. 46A, 1970; WHO/Food Add/70.36.
21. Specifications for the identity and purity of some food colours, emulsifiers,
stabilizers, anticaking agents, and certain other food additives. FAO
Nutrition Meetings Report Series, No. 46B, 1970; WHO/Food Add/70.37.
22. Evaluation of food additives: specifications for the identity and purity of
food additives and their toxicological evaluation: some extraction solvents
and certain other substances; and a review of the technological efficacy of
some antimicrobial agents. (Fourteenth report of the Joint FAO/WHO Expert
Committee on Food Additives). FAO Nutrition Meetings Series, No. 48, 1971;
WHO Technical Report Series, No. 462, 1971.
23. Toxicological evaluation of some extraction solvents and certain other
substances. FAO Nutrition Meetings Report Series, No. 48A, 1971; WHO/Food
Add/70.39.
24. Specifications for the identity and purity of some extraction solvents and
certain other substances. FAO Nutrition Meetings Report Series, No. 48B,
1971; WHO/Food Add/70.40.
ANNEX 1 67

25. A review of the technological efficacy of some antimicrobial agents. FAO

Nutrition Meetings Report Series, No. 48C, 1971; WHO/Food Add/70.41.
26. Evaluation of food additives: some enzymes, modified starches, and
certain other substances: Toxicological evaluations and specifications
and a review of the technological efficacy of some antioxidants (Fifteenth
report of the Joint FAO/WHO Expert Committee on Food Additives). FAO
Nutrition Meetings Series, No. 50,1972; WHO Technical Report Series, No. 488,
1972.
27. Toxicological evaluation of some enzymes, modified starches, and certain
other substances. FAO Nutrition Meetings Report Series, No. 50A, 1972; WHO
Food Additives Series, No. 1, 1972.
28. Specifications for the identity and purity of some enzymes and certain
other substances. FAO Nutrition Meetings Report Series, No. 50B, 1972; WHO
Food Additives Series, No. 2, 1972.
29. A review of the technological efficacy of some antioxidants and synergists.
FAO Nutrition Meetings Report Series, No. 50C, 1972; WHO Food Additives
Series, No. 3, 1972.
30. Evaluation of certain food additives and the contaminants mercury, lead,
and cadmium (Sixteenth report of the Joint FAO/WHO Expert Committee on
Food Additives). FAO Nutrition Meetings Series, No. 51,1972; WHO Technical
Report Series, No. 505, 1972, and corrigendum.
31. Evaluation of mercury, lead, cadmium and the food additives amaranth,
diethylpyrocarbamate, and octyl gallate. FAO Nutrition Meetings Report
Series, No. 51 A, 1972; WHO Food Additives Series, No. 4, 1972.
32. Toxicological evaluation of certain food additives with a review of general
principles and of specifications (Seventeenth report of the Joint FAO/WHO
Expert Committee on Food Additives). FAO Nutrition Meetings Series, No. 53,
1974; WHO Technical Report Series, No. 539, 1974, and corrigendum (out of
print).
33. Toxicological evaluation of some food additives including anticaking
agents, antimicrobials, antioxidants, emulsifiers, and thickening agents.
FAO Nutrition Meetings Report Series, No. 53A, 1974; WHO Food Additives
Series, No. 5, 1974.
34. Specifications for identity and purity of thickening agents, anticaking
agents, antimicrobials, antioxidants and emulsifiers. FAO Food and Nutrition
Paper, No. 4,1978.
35. Evaluation of certain food additives (Eighteenth report of the Joint FAO/WHO
Expert Committee on Food Additives). FAO Nutrition Meetings Series, No. 54,
1974; WHO Technical Report Series, No. 557, 1974, and corrigendum.
36. Toxicological evaluation of some food colours, enzymes, flavour enhancers,
thickening agents, and certain other food additives. FAO Nutrition Meetings
Report Series, No. 54A, 1975; WHO Food Additives Series, No. 6, 1975.
37. Specifications for the identity and purity of some food colours, enhancers,
thickening agents, and certain food additives. FAO Nutrition Meetings
Report Series, No. 54B, 1975; WHO Food Additives Series, No. 7, 1975.
38. Evaluation of certain food additives: some food colours, thickening agents,
smoke condensates, and certain other substances. (Nineteenth report of the
Joint FAO/WHO Expert Committee on Food Additives). FAO Nutrition Meetings
Series, No. 55, 1975; WHO Technical Report Series, No. 576, 1975.
39. Toxicological evaluation of some food colours, thickening agents, and
certain other substances. FAO Nutrition Meetings Report Series, No. 55A,
1975; WHO Food Additives Series, No. 8, 1975.
ANNEX 1 68

40. Specifications for the identity and purity of certain food additives. FAO
Nutrition Meetings Report Series, No. 55B, 1976; WHO Food Additives Series,
No. 9, 1976.
41. Evaluation of certain food additives (Twentieth report of the Joint FAO/WHO
Expert Committee on Food Additives). FAO Food and Nutrition Meetings Series,
No. 1, 1976; WHO Technical Report Series, No. 599, 1976.
42. Toxicological evaluation of certain food additives. WHO Food Additives
Series, No. 10, 1976.
43. Specifications for the identity and purity of some food additives. FAO Food
and Nutrition Series, No. 1B, 1977; WHO Food Additives Series, No. 11, 1977.
44. Evaluation of certain food additives (Twenty-first report of the Joint FAO/
WHO Expert Committee on Food Additives). WHO Technical Report Series, No.
617, 1978.
45. Summary of toxicological data of certain food additives. WHO Food Additives
Series, No. 12, 1977.
46. Specifications for identity and purity of some food additives, including
antioxidant, food colours, thickeners, and others. FAO Nutrition Meetings
Report Series, No. 57, 1977.
47. Evaluation of certain food additives and contaminants (Twenty-second
report of the Joint FAO/WHO Expert Committee on Food Additives). WHO
Technical Report Series, No. 631, 1978.
48. Summary of toxicological data of certain food additives and contaminants.
WHO Food Additives Series, No. 13, 1978.
49. Specifications for the identity and purity of certain food additives. FAO
Food and Nutrition Paper, No. 7,1978.
50. Evaluation of certain food additives (Twenty-third report of the Joint FAO/
WHO Expert Committee on Food Additives). WHO Technical Report Series, No.
648, 1980, and corrigenda.
51. Toxicological evaluation of certain food additives. WHO Food Additives
Series, No. 14, 1980.
52. Specifications for identity and purity of food colours, flavouring agents,
and other food additives. FAO Food and Nutrition Paper, No. 12, 1979.
53. Evaluation of certain food additives (Twenty-fourth report of the Joint FAO/
WHO Expert Committee on Food Additives). WHO Technical Report Series, No.
653, 1980.
54. Toxicological evaluation of certain food additives. WHO Food Additives
Series, No. 15, 1980.
55. Specifications for identity and purity of food additives (sweetening agents,
emulsifying agents, and other food additives). FAO Food and Nutrition
Paper, No. 17, 1980.
56. Evaluation of certain food additives (Twenty-fifth report of the Joint FAO/
WHO Expert Committee on Food Additives). WHO Technical Report Series, No.
669, 1981.
57. Toxicological evaluation of certain food additives. WHO Food Additives
Series, No. 16, 1981.
58. Specifications for identity and purity of food additives (carrier solvents,
emulsifiers and stabilizers, enzyme preparations, flavouring agents, food
colours, sweetening agents, and other food additives). FAO Food and
Nutrition Paper, No. 19, 1981.
59. Evaluation of certain food additives and contaminants (Twenty-sixth report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 683, 1982.
ANNEX 1 69

60. Toxicological evaluation of certain food additives. WHO Food Additives

Series, No. 17, 1982.
61. Specifications for the identity and purity of certain food additives. FAO Food
and Nutrition Paper, No. 25,1982.
62. Evaluation of certain food additives and contaminants (Twenty-seventh
report of the Joint FAO/WHO Expert Committee on Food Additives). WHO
Technical Report Series, No. 696, 1983, and corrigenda.
63. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 18, 1983.
64. Specifications for the identity and purity of certain food additives. FAO Food
and Nutrition Paper, No. 28, 1983.
65. Guide to specifications General notices, general methods, identification
tests, test solutions, and other reference materials. FAO Food and Nutrition
Paper, No. 5, Rev. 1, 1983.
66. Evaluation of certain food additives and contaminants (Twenty-eighth report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 710, 1984, and corrigendum.
67. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 19, 1984.
68. Specifications for the identity and purity of food colours. FAO Food and
Nutrition Paper, No. 31/1, 1984.
69. Specifications for the identity and purity of food additives. FAO Food and
Nutrition Paper, No. 31/2, 1984.
70. Evaluation of certain food additives and contaminants (Twenty-ninth report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 733, 1986, and corrigendum.
71. Specifications for the identity and purity of certain food additives. FAO Food
and Nutrition Paper, No. 34, 1986.
72. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 20. Cambridge University Press, 1987.
73. Evaluation of certain food additives and contaminants (Thirtieth report of the
Joint FAO/WHO Expert Committee on Food Additives). WHO Technical Report
Series, No. 751, 1987.
74. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 21. Cambridge University Press, 1987.
75. Specifications for the identity and purity of certain food additives. FAO Food
and Nutrition Paper, No. 37, 1986.
76. Principles for the safety assessment of food additives and contaminants in
food. WHO Environmental Health Criteria, No. 70. Geneva, World Health
Organization, 1987 (out of print). The full text is available electronically at
www.who.int/pcs.
77. Evaluation of certain food additives and contaminants (Thirty-first report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 759, 1987 and corrigendum.
78. Toxicological evaluation of certain food additives. WHO Food Additives
Series, No. 22. Cambridge University Press, 1988.
79. Specifications for the identity and purity of certain food additives. FAO Food
and Nutrition Paper, No. 38, 1988.
80. Evaluation of certain veterinary drug residues in food (Thirty-second report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 763, 1988.
ANNEX 1 70

81. Toxicological evaluation of certain veterinary drug residues in food. WHO

Food Additives Series, No. 23. Cambridge University Press, 1988.
82. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41, 1988.
83. Evaluation of certain food additives and contaminants (Thirty-third report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 776, 1989.
84. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 24. Cambridge University Press, 1989.
85. Evaluation of certain veterinary drug residues in food (Thirty-fourth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 788,1989.
86. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 25, 1990.
87. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/2, 1990.
88. Evaluation of certain food additives and contaminants (Thirty-fifth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 789, 1990, and corrigenda.
89. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 26, 1990.
90. Specifications for identity and purity of certain food additives. FAO Food
and Nutrition Paper, No. 49, 1990.
91. Evaluation of certain veterinary drug residues in food (Thirty-sixth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 799, 1990.
92. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 27, 1991.
93. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/3, 1991.
94. Evaluation of certain food additives and contaminants (Thirty-seventh
report of the Joint FAO/WHO Expert Committee on Food Additives). WHO
Technical Report Series, No. 806,1991, and corrigenda.
95. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 28, 1991.
96. Compendium of Food Additive Specifications. Joint FAO/WHO Expert
Committee on Food Additives (JECFA). Combined specifications from 1st
through the 37th Meetings, 1956-1990. FAO, 1992 (2 volumes).
97. Evaluation of certain veterinary drug residues in food (Thirty-eighth report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 815, 1991.
98. Toxicological evaluation of certain veterinary residues in food. WHO Food
Additives Series, No. 29, 1991.
99. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/4, 1991.
100. Guide to specifications—General notices, general analytical techniques,
identification tests, test solutions, and other reference materials. FAO
Food and Nutrition Paper, No. 5, Ref. 2, 1991.
101. Evaluation of certain food additives and naturally occurring toxicants
(Thirty-ninth report of the Joint FAO/WHO Expert Committee on Food Additives).
WHO Technical Report Series No. 828, 1992.
102. Toxicological evaluation of certain food additives and naturally occurring
toxicants. WHO Food Additive Series, No. 30,1993.
ANNEX 1 71

103. Compendium of food additive specifications: Addendum 1. FAO Food and

Nutrition Paper, No. 52, 1992.
104. Evaluation of certain veterinary drug residues in food (Fortieth report of the
Joint FAO/WHO Expert Committee on Food Additives). WHO Technical Report
Series, No. 832, 1993.
105. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 31, 1993.
106. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/5,1993.
107. Evaluation of certain food additives and contaminants (Forty-first report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 837, 1993.
108. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 32, 1993.
109. Compendium of food additive specifications: Addendum 2. FAO Food and
Nutrition Paper, No. 52, Add. 2, 1993.
110. Evaluation of certain veterinary drug residues in food (Forty-second report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 851,1995.
111. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 33,1994.
112. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/6,1994.
113. Evaluation of certain veterinary drug residues in food (Forty-third report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 855,1995, and corrigendum.
114. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 34, 1995.
115. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/7, 1995.
116. Evaluation of certain food additives and contaminants (Forty-fourth report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 859, 1995.
117. Toxicological evaluation of certain food additives and contaminants. WHO
Food Additives Series, No. 35, 1996.
118. Compendium of food additive specifications: Addendum 3. FAO Food and
Nutrition Paper, No. 52, Add. 3, 1995.
119. Evaluation of certain veterinary drug residues in food (Forty-fifth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 864, 1996.
120. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 36, 1996.
121. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/8, 1996.
122. Evaluation of certain food additives and contaminants (Forty-sixth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 868,1997.
123. Toxicological evaluation of certain food additives. WHO Food Additives
Series, No. 37, 1996.
124. Compendium of food additive specifications, addendum 4. FAO Food and
Nutrition Paper, No. 52, Add. 4, 1996.
ANNEX 1 72

125. Evaluation of certain veterinary drug residues in food (Forty-seventh report

of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 876, 1998.
126. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 38, 1996.
127. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/9, 1997.
128. Evaluation of certain veterinary drug residues in food (Forty-eighth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 879, 1998.
129. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 39, 1997.
130. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/10, 1998.
131. Evaluation of certain food additives and contaminants (Forty-ninth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 884, 1999.
132. Safety evaluation of certain food additives and contaminants. WHO Food
Additives Series, No. 40, 1998.
133. Compendium of food additive specifications: Addendum 5. FAO Food and
Nutrition Paper, No. 52, Add. 5, 1997.
134. Evaluation of certain veterinary drug residues in food (Fiftieth report of the
Joint FAO/WHO Expert Committee on Food Additives). WHO Technical Report
Series, No. 888, 1999.
135. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 41, 1998.
136. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/11, 1999.
137. Evaluation of certain food additives (Fifty-first report of the Joint FAO/WHO
Expert Committee on Food Additives). WHO Technical Report Series, No. 891,
2000.
138. Safety evaluation of certain food additives. WHO Food Additives Series, No.
42, 1999.
139. Compendium of food additive specifications, addendum 6. FAO Food and
Nutrition Paper, No. 52, Add. 6, 1998.
140. Evaluation of certain veterinary drug residues in food (Fifty-second report
of the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, No. 893, in press.
141. Toxicological evaluation of certain veterinary drug residues in food. WHO
Food Additives Series, No. 43, 2000
142. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/12, 2000.
143. Evaluation of certain food additives and contaminants (Fifty-third report of the
Joint FAO/WHO Expert Committee on Food Additives). WHO Technical Report
Series, in press.
144. Safety evaluation of certain food additives and contaminants. WHO Food
Additives Series, No. 44, 2000.
145. Compendium of food additive specifications, addendum 7. FAO Food and
Nutrition Paper, No. 52, Add. 7, 1999.
146. Evaluation of certain veterinary drug residues in food (Fifty-fourth report of the
Joint FAO/WHO Expert Committee on Food Additives). WHO Technical Report
Series, in press.
ANNEX 1 73

147. Toxicological evaluation of certain veterinary drug residues in food. WHO

Food Additives Series, No. 45, 2000.
148. Residues of some veterinary drugs in animals and foods. FAO Food and
Nutrition Paper, No. 41/13, 2000.
149. Evaluation of certain food additives and contaminants (Fifty-fifth report of the
Joint FAO/WHO Expert Committee on Food Additives). WHO Technical Report
Series No. 901,2001.
150. Safety evaluation of certain food additives and contaminants. WHO Food
Additives Series, No. 46, 2001.
151. Compendium of food additive specifications: Addendum 8. FAO Food and
Nutrition Paper, No. 52, Add. 8, 2000.
152. Evaluation of certain mycotoxins in food (Fifty-sixth report of the Joint FAO/
WHO Expert Committee on Food Additives). WHO Technical Report Series No.
906, 2002.
153. Safety evaluation of certain mycotoxins in food. WHO Food Additives Series,
No. 47/FAO Food and Nutrition Paper 74, 2001.
154. Evaluation of certain food additives and contaminants (Fifty-seventh report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, in press.
155. Safety evaluation of certain food additives and contaminants. WHO Food
Additives Series, No. 48, in press.
156. Compendium of food additive specifications: Addendum 9. FAO Food and
Nutrition Paper, No. 52, Add. 9, 2001.
157. Evaluation of certain veterinary drug residues in food (Fifty-eighth report of
the Joint FAO/WHO Expert Committee on Food Additives). WHO Technical
Report Series, in preparation.
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 ANNEX 2

ABBREVIATIONS USED IN THE MONOGRAPHS

ADI acceptable daily intake

ATP adenosine triphosphate
bw body weight
CPU colony-forming units
Fo parental generation
F1 first filial generation
F2 second filial generation
FA available fraction of the dose
FAO Food and Agricultural Organization of the
United Nations
GLP good laboratory practice
IPCS International Programme on Chemical Safety
JECFA Joint FAO/WHO Expert Committee on Food
Additives
LD50 median lethal dose
LOEL lowest-observed-effect level
MBC minimum bactericidal concentration
MCC mass of colonic contents
MIC minimum inhibitory concentration
MNNG /V-methyl- N -nitro-A/-nitrosoguanidine
NAD nicotinamide adenine dinucleotide
NOEC no-observed-effect concentration
NOEL no-observed-effect level
QA quality assurance
RfD reference dose
RT-PCS reverse transcriptase polymerase chain reaction
S9 9000 x g microsomal frcation of rat liver
SF safety factor
WHO World Health Organization
w/v weight per volume

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 ANNEX 3

Joint FAO/WHO Expert Committee on Food Additives

Rome, 21-27 February 2002

Members

Professor A. Anadon, Department of Toxicology & Pharmacology, Faculty of

Veterinary Medicine, Universidad Complutense de Madrid, Madrid, Spain

Dr D.Arnold, Acting Director, Federal Institute for Health Protection of Consumers

and Veterinary Medicine, Berlin, Germany

Dr J. Boisseau, Director, National Agency for Veterinary Medicinal Products,

French Food Safety Agency, Fougeres, France (Chairman)

Professor A.R. Boobis, Section on Clinical Pharmacology, Division of Medicine,

Imperial College School of Medicine, Hammersmith Campus, London,
England

Dr R. Ellis, Food and Safety Inspection Service, United States Department of

Agriculture, Washington DC, USA

Dr K. Greenlees, Toxicology Team, Office of New Animal Drug Evaluation,

Center for Veterinary Medicine, Food and Drug Administration, Rockville,
Maryland, USA (Rapporteur)

Dr J.D. MacNeil, Center for Veterinary Drug Residues, Saskatoon Laboratory,

Canadian Food Inspection Agency, Saskatoon, Saskatchewan, Canada
(Rapporteur)

Dr J.G. McLean, Camberwell, Victoria, Australia (Vice-Chairman)

Dr E.S. Mitema, Department of Public Health, Pharmacology and Toxicology,

Faculty of Veterinary Medicine, College of Agriculture and Veterinary
Sciences, University of Nairobi, Kabete, Kenya

Professor J. Palermo-Neto, Department of Pathology, Faculty of Veterinary

Medicine, University of Sao Paulo, Sao Paulo, Brazil

Dr J.L. Rojas Martmez, Chief, Toxicology Section, National Laboratory of

Veterinary Services, Ministry of Agriculture and Animal Husbandry,
Heredia, Costa Rica

-77-
ANNEX 3 78

Dr S. Soback, Head, National Residue Control Laboratory, Kimron Veterinary

Institute, Beit Dagan, Israel

Dr R.W. Stephany, Head, Laboratory for Residue Analysis, National Institute

of Public Health and the Environment, Bilthoven, Netherlands

Secretariat
Dr C.E. Cerniglia, Director, Division of Microbiology, National Center for
Toxicological Research, Food and Drug Administration, Jefferson,
Arkansas, USA (WHO Temporary Adviser)

Dr P. Chamberlain, Division of Human Food Safety, Office of New Animal Drug

Evaluation, Centerfor Veterinary Medicine, Food and Drug Administration,
Rockville, Maryland, USA (WHO Temporary Adviser)

Dr A. Fernandez Suarez, National Institute of Agricultural Technology, Food

Technology Institute, Food Protection Division, Buenos Aires, Argentina
(FAO Consultant)

Dr L.G. Friedlander, Off ice of New Animal Drug Evaluation, Centerfor Veterinary
Medicine, Division of Human Food Safety, Residue Chemistry Team,
Food and Drug Administration, Rockville, Maryland, USA(FAOConsultant)

Dr J.L. Herrman, Scientist, International Programme on Chemical Safety,

WHO, Geneva, Switzerland (Joint Secretary)

Mrs E. Heseltine, Communication in Science, Lajarthe, 24290 St Leon-sur-

Vezere, France (Editor)

Mr M. Luetzow, Food Quality and Strandards Service, Food and Nutrition

Division, Food and Agricultural Organization of the United Nations,
Rome, Italy (Joint Secretary)

Dr K. Mitsumori, Laboratory of Veterinary Pathology, School of Veterinary

Medicine, Faculty of Agriculture, Tokyo University of Agriculture and
Technology, Tokyo, Japan (WHO Temporary Adviser)

Dr S.W. Page, International Programme on Chemical Safety, World Health

Organization, Geneva, Switzerland (WHO Staff)

Mrs M.E.J. Pronk, Center for Substances and Risk Assessment, National
Institute of Public Health and the Environment, Bilthoven, Netherlands
(WHO Temporary Adviser)
ANNEX 3 79

Dr P.T. Reeves, National Registration Authority for Agricultural and Veterinary

Chemicals, Kingston, Australian Capital Territory, Australia (FAO
Consultant)

Mr D. Renshaw, Food Standards Agency, London, England (WHO Temporary

Adviser)

DrG. Roberts, Manager, Chemical Products Assessment Section, Therapeutic

Goods Administration, Commonwealth Department of Health and Aged
Care, Woden, Australian Capital Territory, Australia (WHO Temporary
Adviser)

Dr F. Shojaee AliAbadi, Director, Food Quality Control Laboratory, Khatam Co.,

Tehran, Iran (FAO Consultant)

Dr S. Sundlof, Director, Center for Veterinary Medicine, Food and Drug

Administration, Rockville, Maryland, USA (Chairman, Codex Committee
on Residues of Veterinary Drugs in Foods)

Professor G.E. Swan, Professor of Pharmacology and Toxicology and Head of

Department of Paraclinical Sciences, Faculty of Veterinary Science,
University of Pretoria, Pretoria, South Africa (FAO Consultant)

ProfessorF.R. Ungemach, Institute of Pharmacology, Pharmacy and Toxicology,

Faculty of Veterinary Medicine, University of Leipzig, Leipzig, Germany
(WHO Temporary Adviser)
This page intentionally left blank
 ANNEX 4

RECOMMENDATIONS ON COMPOUNDS ON THE AGENDA AND

FURTHER INFORMATION REQUIRED

Anthelmintic agents
Doramectin
Acceptable daily intake: 0-1 mg/kg bw
Residues: The MRLs that were recommended at the
forty-fifth and fifty-second meetings (WHO
TRS 864, 1996, and WHO TRS 893, 2000,
respectively) were not reconsidered and
were maintained.

Ivermectin
Acceptable daily intake:
Residue definition:
0-1 mg/kg bw (established at the fortieth
meeting of the Committee (WHO TRS 832,
1993))
Ivermectin B1a

Recommended maximum residue limits (MRLs)3

Species Milk

Cattle 10

a
The MRLs that were recommended at the thirty-sixth and fortieth meetings of the
Committee (WHO TRS 799 (1990) and 832 (1993), respectively) were not
reconsidered and were maintained.

Tiabendazole (thiabendazole)

Acceptable daily intake: 0-100 jig/kg bw (established at the fortieth

meeting of the Committee (WHO TRS 832,
1993))
Acute reference dose: 100 mg/kg bw
Residues: The MRLs that were recommended at the
fortieth meeting (WHO TRS 832, 1993)
were not reconsidered and were
maintained.

-81-
ANNEX 4 82

Antimicrobial agents

Cefuroxime
Acceptable daily intake: 0-30 |tig/kg bw (temporary)a
Residue definition: Cefuroxime

Recommended maximum residue limits (MRLs)

Species Milk
(HP/kg)

Cattle 50b
a
Results of studies to (1) identify the residues in milk and clarify whether the residues
other than parent compound are due primarily to metabolism or to non-metabolic
decomposition of parent cefuroxime; and (2) characterize the toxicological
significance of non-parent residue in milk are required for evaluation in 2004.
b
The recommended MRL is temporary because the ADI is temporary.

Dihydrostreptomycin and streptomycin

Acceptable daily intake:
Residue definition:
0-50 ng/kg bw (group ADI for
dihydrostreptomycin and streptomycin
established at the forty-eighth meeting of
the Committee (WHO TRS 879, 1998))
Sum of the concentrations of
dihydrostreptomycin and streptomycin

Recommended maximum residue limits ( M

Cattle 200
Sheep 200
a
The MRLs that were recommended at the fifty-second meeting of the Committee
(WHO TRS 893, 2000) were not reconsidered and were maintained.

Lincomycin
Acceptable daily intake: 0-30 mg/kg bw (established at the fifty-
fourth meeting of the Committee (WHO
TRS 900, 2001))
Residue definition: Lincomycin
ANNEX 4 83

Recommended maximum residue limits (MRLs)8

Species Muscle Liver Kidney Fat Milk
(ng/kg) (mg/kg) (mg/kg) (mg/kg) (mg/kg)
Cattle 150
Pigs 200 500 1500 100
Chickens 200 500 500 100
a
The temporary MRLs for muscle, liver, kidney and fat of cattle and sheep that were
recommended at the fifty-fourth meeting of the Committee (WHO TRS 900, 2001) were
not extended.
b
The MRLs for fat that were recommended at the fifty-fourth meeting of the Committee
were maintained. A separate MRL of 300 mg/kg for skin with adhering fat in pigs was
recommended in order to reflect the high concentrations found in the skin of pigs. For
consistency, an MRL of 300 mg/kg for skin with adhering fat in chickens was also
recommended.

Neomycin
Acceptable daily intake: 0-60 mg/kg bw (established at the forty-seventh
meeting of the Committee (WHO TRS 876,1998))
Residues: Following a request by the Codex Committee on
Residues of Veterinary Drugs in Foods at its
Twelfth Session (ALINORM 01/31, paragraph 90)
the Expert Committee considered information on
the registration of injectable neomycin products as
well as how they were used with respect to Good
Practice in the Use of Veterinary Drugs. In
addition, a proposal from the sponsor to increase
the MRL in milk was considered. The Committee
noted that use of neomycin for injectable adminis-
tration had been withdrawn in some countries and
was under review in others. The Committee also
considered information on the toxicity of neomycin
in calves; however, it concluded that toxicity in
target animals represents an animal welfare issue
that falls outside its mandate. The Committee
concluded that there was insufficient justification
for changing the MRLs and maintained the MRLs
that were recommended at its forty-third, forty-
seventh, and fifty-second meetings (WHO TRS
855, 1995; WHO TRS 876,1998; and WHO TRS
893, 2000, respectively). The Committee recom-
mended that these MRLs be reviewed when the
toxicity of neomycin is re-evaluated in response to
the request of the Codex Committee on Residues
of Veterinary Drugs in Foods at its Thirteenth
Session (ALINORM 03/31, paragraph 18).
ANNEX 4 84

Oxytetracycline
Acceptable daily intake: 0-30 mg/kg bw (group ADI for tetracycline,
oxytetracycline and chlortetracycline;
established at the fiftieth meeting of the
Committee (WHO TRS 888, 1999))
Residue definition: Oxytetracycline, expressed as parent drug

Recommended maximum residue limits (MRLs)a

Species Muscle
(mg/kg)
Fish 200
a
The MRLs that were recommended in cattle, pigs, sheep, poultry, and giant tiger
prawn (Penaeus monodon) at the fiftieth meeting of the Committee (WHO TRS 888,
1999) were not reconsidered and were maintained. The MRL applies only to
oxytetracycline.

Thiamphenicol
Acceptable daily intake: 0-5 mg/kg bw (established at the fifty-
second meeting of the Committee (WHO
TRS 893, 2000))
Residues: The temporary MRLs in muscle, liver,
kidney and fat of pigs and muscle of fish
were not extended because the information
requested at the fifty-second meeting (WHO
TRS 893, 2000) was not provided.

Insecticides
Cyhalothrin
Acceptable daily intake: 0-2 mg/kg bw (temporary)a
Residue definition: Cyhalothrin

Recommended maximum residue limits (MRLs)b

Species Muscle Liver Kidney Fat Milk
(mg/kg) (mg/kg) (mg/kg) (mg/kg) (mg/kg)
Cattle 20 20 20 400 30
Pigs 20 20 20 400
Sheep 20 20 20 400
a
Results of appropriate studies to establish a no-observed-effect level (NOEL) for
neurobehavioral effects in laboratory animals are required for evaluation in 2004.
b
The recommended MRLs are temporary because the ADI is temporary. In addition,
results of the validation of the analytical method for sheep liver to demonstrate a limit of
quantification of 10 mg/kg are required for evaluation in 2004.
ANNEX 4 85

Cypermethrin
Acceptable daily intake: 0-50 mg/kg bw (established at the forty-
seventh meeting of the Committee (WHO
TRS876, 1998))
Residue definition: Cypermethrin

Recommended maximum residue limits (MRLs)a

Species Muscle Liver Kidney Fat
(mg/kg) (mg/kg) (mg/kg)
Sheep 20 20 20 200
a
The ADI established at the forty-seventh meeting (WHOTRS 876, 1998) was for a
45:55 cis:trans mixture. Information provided to the Committee at the present
meeting was for an 80:20 cis.trans mixture for topical use. Because the cis isomer is
more toxic than the trans isomer, the Committee compared the theoretical maximum
daily intake of the 80:20 cis:trans mixture with the ADI for a-cypermethrin, which
consists only of cis isomers.

a-Cypermethrin
Acceptable daily intake: 0-20 mg/kg bw (established at the forty-
seventh meeting of the Committee (WHO
TRS876, 1998))
Residue definition: a-Cypermethrin

Recommended maximum residue limits (MRLs)

Species Muscle Liver Kidney Fat Milk

(mg/kg) (mg/kg) (mg/kg) (mg/kg) (mg/kg)

Cattle 100 100 100 1000 100

Sheep 100 100 100 1000

Phoxim
Acceptable daily intake: 0-4 mg/kg bw (established at the fifty-
second meeting of the Committee (WHO
TRS 893, 2000))
Residue definition: Phoxim
ANNEX 4 86

Recommended maximum residue limits (MRLs)

Species Muscle Liver Kidney Fat Milk

(mg/kg) (mg/kg) (mg/kg) (mg/kg) (mg/kg)
Cattlea 50 50 50 400 10
Pigs 50 50 50 400
Goats 50 50 50 400
Sheep 50 50 50 400

Temporary MRLs, pending the receipt of information on a GLP-compliant study on

residue depletion in cattle, which is required for evaluation in 2004

Production aid
Melengestrol acetate
Acceptable daily intake:
Residue definition:
0-0.03 fig/kg bw (established at the fifty-
fourth meeting of the Committee (WHO
TRS 900, 2001))
Melengestrol acetate

Recommended maximum residue limits (MRLs)

Species Liver Fat

(MO/kg) (ng/kg)

Cattle 2 5