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2014-2015

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS

Stockholm County Council Contents Reducing Residues from Pharmaceuticals in Nature is Part Reducing Residues from Pharmaceuticals of the Environmental Work of in Nature is Part of the Environmental Work of Stockholm County Council...... 1 Stockholm County Council Impact of Pharmaceuticals on Contributing to the reduction of environmental the Environment...... 2 risks from pharmaceuticals is an important part How the Substances are Classified...... 2 of the environmental work of Stockholm County How to Read the Table...... 4 Council. According to the Environmental Challenge Substances which are Exempt 2016, the Council´s 2012-2016 Environmental from Classification...... 6 Programme, the Council is mandated to i.a. do The Precautionary Principle...... 6 preventive environmental health work. This invol- Tables A Alimentary Tract and ...... 7 ves fostering healthy inhabitants in an environ- ment with clean air and water. To reduce the most B Blood and Blood-Forming Organs...... 9 environmentally hazardous remains of medicinal C Cardiovascular System...... 10 products in the natural surroundings is therefore D Dermatologicals...... 13 an important part of the environmental work of the County Council. One aspect of this work is the G Genito- and Sex Hormones...... 14 assessment and classification of pharmaceuticals H Systemic Hormonal Preparations excl according to their impact on the environment. Sex Hormones and Insulins...... 16 The pharmaceuticals are classified both in terms J Anti-Infectives for Systemic Use...... 17 of their inherent capacity to affect the environment L Antineoplastic and Immunomodulating Agents..19 (environmental hazard), and as regarding the

M Musculo-Skeletal System...... 21 environmental risk posed by the pharmaceutical substances when used to their current extent. The N Nervous System...... 23 environmental hazard assessment was initiated in P Products, Insecticides 2003 by Environmental Department of the and Repellents...... 27 Stockholm County Council. During 2005, the clas- R Respiratory System...... 27 sification was extended to also cover an environ- S Sensory Organs...... 30 mental risk assessment carried out by The Swedish Association of the Pharmaceutical Industry (Lif). V Various...... 31 The classification system is used in considering the Reading tips...... 33 environmental impact of the pharmaceuticals on the Vocabulary...... 34 so called Wise List (Kloka Listan), a list of recom- Index...... 36 mended pharmaceuticals for common diseases in Stockholm County Council, issued by the Drug and What You as a Prescriber Can Do...... 52 Therapeutics Committee. Advice For Your Patient...... 53 The classification is also available at the website www.janusinfo.se/environment

January 2014 edition ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 1 Impact of Pharmaceuticals Environmental hazard expresses the inherent environmentally damaging characteristics of the on the Environment substance in the following terms:

The majority of all pharmaceuticals that patients persistence – ability to resist degradation in take are excreted in the urine, in unchanged condi- the aquatic environment. tion or as metabolites, and reach wastewater plants bioaccumulation – accumulation in adipose and sometimes even waterways and ground water. tissue of aquatic organisms. Medicines are often adapted to resist biodegrada- toxicity – the potential to poison aquatic tion and can therefore remain in the environment ­organisms. for a long time. Some pharmaceuticals have been found in low, but traceable contents in drinking Each of these characteristics is assigned a water, which is a warning sign that the current numerical value (0–3). The total of these values handling of pharmaceuticals may lead to health constitutes the PBT Index for the substance. The and environmental problems in the future. PBT Index can assume values in the interval 0–9. Access to healthy water is a prerequisite for good The hazard model was formulated by Stockholm health. Since society’s use of chemicals, including County Council and Apoteket AB (The National pharmaceuticals, is continuously growing, the risk Corporation of Swedish Pharmacies). Since 2006, is also increasing that these chemicals will return all information about persistence, bioaccumula- to us in our food and water supply through nature’s tion and toxicity is obtained from www.fass.se. ecocycle. We have little knowledge of the long-term More information is available at the non- effects that continuously supplied trace quantities commercial website Janusinfo, produced by the of pharmaceuticals and other chemicals could have Stockholm County Council: on our development, our ability to resist disease www.janusinfo.se/environment and our wellness in general. Therefore caution is Environmental risk refers to the risk of advisable. In other words, even if we currently do toxicity to the aquatic environment. Environmen- not have scientific proof that pharmaceuticals in tal risk is based on the ratio between predicted nature can cause health problems, it could be wise environmental concentration of the substance to reduce our unintentional exposure to them as in Swedish water systems (PEC) and the highest much as possible i.e. adhere to the Precautionary concentration of the substance that does not have Principle, see p.6. a harmful effect on the environment (PNEC). Information about the risk is obtained from How the Substances are Classified www.fass.se.

Pharmaceutical substances are assessed with Risk is specified as: respect to environmental hazard and environmental risk. When assessing a ’s environmental insignificant if pec/pnec ≤ 0,1 impact, consideration should be given to both en- low if pec/pnec > 0,1 – ≤ 1 vironmental hazard and environmental risk, as the moderate if pec/pnec > 1 – ≤ 10 terms express different properties of the substance. high if pec/pnec > 10

2 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 3 risk refers to toxic risk to the aquatic environment, the calculation based How to Read the Table on Swedish conditions and is given as insignificant, low, moderate or high. the substance can be found under several dif- ”Cannot be excl” means that the ma- ferent drug groups. For example, triamcinolon can be nufacturer has stated that the docu- found under “a Alimentary Tract and Metabolism” as mentary basis for assessment of risk is well as “D dermatologicals”. Substances indicated in insufficient. Information bold are included in “Kloka Listan 2014”, stockholm about environmental risks P (persistence) can county council’s “wise list” of recommended drugs can be obtained from ­assume the value 0 or 3 for ­common diseases (including recommendations for www.fass.se. For risk specialized care). ”exempt”, see p.6 B (bioaccumulation) can assume the value 0 or 3

T (toxicity) can assume the pbt index is a measure SUBSTANCE the value 0–3 of environmental hazard and RISK can assume all values from J Anti-infectives PBT P B 0–9 (the total of p-, b- and Antibacterials for systemic use T VOLUME IN DDD the t-value). The higher trimetoprim the value of a substance, erythromycin insignificant the greater its danger to 4 ofloxacin 3 0 1 the environment. amoxicillin insignificant insignificant 6 149 661 3 0 3 C 261 420 moderate 9* 3 3* 6 3 133 025 *(ASTERISK) after the 3 0 3 1 580 pbt index indicates that 953 571 volume in ddd, the assessment is uncertain C 272 984 The sales by prescrip- due to lack of data. tions and to hospitals in ddd (Defined Daily Two substances may have the same risk values but dif- Doses) of the substance ferent pbt values, but the risk assessment can also be in stockholm county different even if the pbt values are the same. council during one When assessing a medication’s environmental impact, year. consideration should be given to both environmental risk (Sep 2012–Aug 2013) and environmental hazard since bioaccumulation and Indicates ddd for persistence are not included in the risk assessment. C (combination drugs, 1 tablet = 1 ddd) E (drugs for external use, 1 gram = 1 ddd) ddd indicated for pharmaceuticals for external use and combined products is not based on the amount of an active substance and can therefore not be ­compared to the ddd for other drugs.

4 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 5 Substances which are Exempt SUBSTANCE RISK PBT P B T VOLUME IN DDD from Classification A Alimentary Tract and Metabolism Stomatological preparations The use of some pharmaceuticals in the groups insignificant 4* 3 0 1* 165 311 vitamins, , amino acids, peptides, E - proteins, carbohydrates, lipids, vaccines and chlorhexidine cannot be excl 6* 3* 0 3* - drugs based on herbs are not considered as a e 275 263 risk to the environment. That is the reason why cannot be excl - - - - - these substances have not been assigned Drugs for acid-related disorders environmental information even though they sodium bicarbonate exempt are listed on the website www.janusinfo.se/ environment. In this folder these substances are esomeprazole insignificant 1* 0 0 1* 4 046 556 C 78 848 only presented if they are recommended in the omeprazole insignificant 1* 0 0 1* 28 089 960 Wise List (Kloka Listan). The assessment is then ranitidine insignificant 3 3 0 0 644 652 expressed as ”exempt”. pantoprazole insignificant 4 3 0 1 883 344 insignificant 4* 3* 0 1 33 500 C 505 350 rabeprazole insignificant 5* 3* 0 2 2 954 The Precautionary Principle clarithromycin insignificant 6 3 0 3 59 076 C 17 248 According to the Precautionary Principle, lansoprazole cannot be excl 4 3 0 1 1 000 435 ­measures can be taken if there is reason to believe glycopyrronium cannot be excl - - 0 - 2 931 that a product or a method of production involves C 22 010 unacceptable risks to the health of human beings, alginic acid cannot be excl - - - - C 83 420 animals, plants and the environment – even if dimethicone cannot be excl - - - - 1 578 953 there is no definitive scientific proof of such an c 840 papaverine cannot be excl - - - - 413 560 effect. The precautionary principle is a part of C 8 600 EU law and is valid in all member countries. Drugs for functional gastrointestinal disorders

butylscopolamine insignificant 4 3 0 1 7 254 cannot be excl - - 0 - 25 068 C - cannot be excl - - 0 - 813 579 cannot be excl - - - - 109 866 and antinauseants insignificant 4 3 0 1 4 583 insignificant 6* 3 0 3* 6 028 cannot be excl - - 0 - - C 8 600 cannot be excl - - - - 1 055 6 3 0 3 118 624 9* 3 3* 3 40

6 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 7 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD

Drugs for repaglinide cannot be excl 4* 3 0 1* 335 764 psyllium exempt pioglitazone cannot be excl - - - - 172 215 lactulose exempt C 5 320 macrogol exempt Vitamins sodium picosulfate exempt alfacalcidol exempt karaya gum exempt colecalciferol exempt bisacodyl insignificant 5 3 0 2 121 282 docusate sodium cannot be excl 8* 3* 3 2* C - Mineral supplements sodium sulphate cannot be excl - - - - C - carbonate exempt ursodeoxycholic acid cannot be excl 392 973 potassium chloride exempt Antidiarrheals, intestinal antiinflammatory/antiinfective Anabolic agents for systemic use agents cannot be excl - - - - 75 insignificant 5 3 0 2 8 079 288 C 8 099 610 B Blood and Blood-Forming Organs insignificant 7* 3* 3 1 855 503 C 840 Antithrombotic agents sodium cromoglycate cannot be excl 3* 3* 0 0* 103 116 alteplase exempt cannot be excl 3* 3* 0 0 69 452 dalteparin exempt cannot be excl 6* 3 0 3* 2 128 687 enoxaparin exempt cannot be excl - - 0 - 5 381 008 sodium exempt E - tinzaparin exempt dimethicone cannot be excl - - - - 1 578 953 prasugrel insignificant 2 0 0 2 22 974 C 840 ticagrelor insignificant 2 0 0 2 268 702 cannot be excl - - - - 165 723 dabigatran insignificant 2* 0 0 2* 662 728 cannot be excl - - - - 710 974 tirofiban insignificant 3 3 0 0 170 warfarin insignificant 4 3 0 1 7 027 345 Antiobesity preparations, excl diet products rivaroxaban insignificant 6* 3 0 3* 503 951 orlistat insignificant 8 3 3 2 438 788 insignificant 7* 3 3* 1 205 sibutramine cannot be excl 6 3 0 3 - clopidogrel insignificant 8 3 3 2 3 306 532 Drugs used in dipyridamole low 8 3 3 2 1 372 650 insulin exempt C 253 920 liraglutide exempt cannot be excl 1* 0 0 1* 1 575 saxagliptin insignificant 2* 0 0 2* 58 765 ticlopidine cannot be excl 6* 3* 0 3 2 600 c - fondaparinux cannot be excl 6* 3* 0 3* 12 188 glibenclamide insignificant 3 3 0 0 1 660 466 eptifibatide cannot be excl - - 0 - 6 insignificant 4 3 0 1 11 758 820 acetylsalicylic acid cannot be excl - - - - 38 231 279 C 190 666 C 6 573 994 vildagliptin insignificant 4* 3 0 1* 7 665 Antihemorrhagics C 6 930 phytomenadione exempt sitagliptin insignificant 5 3 0 2 882 526 tranexamic acid exempt C 178 416 insignificant 6* 3 3* 0 1 825 222 Antianemic preparations acarbose cannot be excl 3 3 0 0 43 203 cyanocobalamin exempt glipizide cannot be excl 4* 3* 0 1* 298 780 darbepoetin alfa exempt

8 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 9 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD ferric carboxy- exempt insignificant 4 3 0 1 21 575 294 maltose hydrochlorthiazide insignificant 4* 3 0 1* 2 830 612 epoetin zeta exempt C 24 086 325 ferrous exempt insignificant 6 3 0 3 104 450 sulfate bendroflumethiazide cannot be excl 4* 3* 0 1 5 349 201 folic acid exempt C 193 113 iron 2+ and 3+ exempt bumetanide cannot be excl 4* 3* 0 1 66 772 Blood substitutes and perfusion solutions cannot be excl 4* 3* 0 1* 265 945 alanyl glutamine exempt C 7 708 633 potassium chloride exempt metolazone cannot be excl - - - - 17 650 sodium glycero- exempt cannot be excl - - - - 2 079 512 Vasoprotectives insignificant 3 3 0 0 24 C Cardiovascular System C, E 431 819 glucosamine cannot be excl 1 0 0 1 749 537 Cardiac U - lidocaine insignificant 3 3 0 0 24 cannot be excl - - 0 - 401 062 C, E 431 819 C, E - glyceryl trinitrate insignificant 6 3 0 3 1 403 569 framycetin cannot be excl - - 0 - E - E - prednisolone cannot be excl - - 0 - 5 381 008 dronedarone low 6 3 0 3 140 950 E - disopyramide cannot be excl 4* 3* 0 1* 145 395 cincocaine cannot be excl - - 3 - - isosorbide cannot be excl 4* 3* 0 1* 6 679 049 e - mononitrate sodium oleate cannot be excl - - - - - milrinone cannot be excl 4* 3 0 1* 482 Beta-blocking agents amiodarone cannot be excl 7* 3 3 1* 173 333 bisoprolol insignificant 4 3 0 1 4 596 898 etilefrine cannot be excl 8* 3 3* 2* 44 350 insignificant 4 3 0 1 85 505 epinephrine cannot be excl - - 0 - 155 304 carvedilol insignificant 6 3 0 3 699 922 C - metoprolol low 4 3 0 1 18 920 983 vernakalant cannot be excl - - 0 - 23 C 462 238 alprostadil cannot be excl - - - - 162 937 moderate 3 0 0 3 1 217 783 digoxin cannot be excl - - - - 1 725 731 atenolol cannot be excl 4* 3* 0 1* 3 820 508 cannot be excl - - - - 584 labetalol cannot be excl 6* 3* 0 3* 49 187 flecainide cannot be excl - - - - 306 185 sotalol cannot be excl 6* 3 0 3* 684 450 norepinephrine cannot be excl - - - - 29 895 esmolol cannot be excl - - - - 21 Antihypertensives Calcium-channel blockers moxonidine insignificant 5 3 0 2 87 579 insignificant 6 3 0 3 31 233 736 hydralazine cannot be excl 6* 3 0 3* 3 750 C 87 024 doxazosin cannot be excl 6* 3 0 3* 1 296 763 isradipine insignificant 9 3 3 3 151 150 cannot be excl 6* 3 0 3* 37 163 low 9 3 3 3 13 326 881 bosentan cannot be excl - - 0 - 19 012 C 462 238 diltiazem cannot be excl 4* 3 0 1* 652 285 torasemide insignificant 4 3 0 1 68 850 cannot be excl 4* 3* 0 1* 667 772

10 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 11 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD cannot be excl 5* 3 0 2* 264 469 D Dermatologicals lercanidipine cannot be excl - - - - 295 066 for dermatolocigal use Agents acting on the renin-angiotensin system insignificant 9 3 3 3 E 18 857 losartan insignificant 3 3 0 0 12 784 091 low 6* 3 0* 3 13 820 C 5 444 709 E - eprosartan insignificant 4 3 0 1 55 678 low - - - 3 E 10 544 C 41 188 cannot be excl 9 3 3 3 64 irbesartan insignificant 4 3 0 1 1 689 855 E - C 826 588 cannot be excl 9* 3* 3 3 521 948 valsartan insignificant 4 3 0 1 1 670 083 E - C 1 090 324 cannot be excl - - - - E - candesartan insignificant 4* 3 0 1* 19 576 160 Emollients and protectives C 3 630 730 glycerin exempt fosinopril insignificant 4* 3 0 1* 3 200 propylene glycol exempt telmisartan insignificant 5 3 0 2 370 909 exempt C 149 842 ramipril insignificant 6* 3 3* 0 17 748 627 Antipruritics incl , , etc C 238 282 lidocaine insignificant 3 3 0 0 24 enalapril cannot be excl 3* 3 0 0* 33 105 589 C, E 431 819 C 4 883 561 Antipsoriatics lisinopril cannot be excl 3* 3 0 0* 802 941 calcipotriol cannot be excl 9* 3 3 3* E - C 83 276 acitretin 9 3 3 3 67 242 captopril cannot be excl 4* 3 0 1* 299 534 and chemotherapeutics for dermatological use quinapril cannot be excl - - - - 50 340 penciclovir insignificant 3* 3 0 0* E - C 76 216 aciclovir insignificant 4 3 0 1 95 121 Lipid-modifying agents E - rosuvastatin insignificant 1 0 0 1 3 888 335 cannot be excl 3* 3* 0 0* E - fenofibrate insignificant 3 3 0 0 146 130 retapamulin cannot be excl 5* 3 0 2* E - atorvastatin insignificant 4 3 0 1 8 097 305 cannot be excl 6 3 0 3 12 873 fluvastatin insignificant 4 3 0 1 12 712 E - pravastatin insignificant 4 3 0 1 897 476 cannot be excl 6* 3 0 3* 5 493 bezafibrate insignificant 5 3 0 2 97 342 E - insignificant 6 3 0 3 1 498 336 cannot be excl 6* 3 0 3* 203 434 C 101 850 E 24 545 simvastatin low 4 3 0 1 31 493 813 oxytetracycline cannot be excl 6* 3* 0 3* - C 101 850 C, E - gemfibrozil low 5 3 0 2 233 259 imiquimod cannot be excl - - - - - cholestyramine cannot be excl 6* 3 0 3* 102 516 podophyllotoxin cannot be excl - - - - E - colestipol cannot be excl - - - - 26 960 , dermatological preparations triamcinolone insignificant 4* 3 0 1* 165 311 E - insignificant 9* 3 3 3* E -

12 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 13 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD low 5 3 0 2 9 459 810 atosiban cannot be excl - - - - 368 E - dinoprostone cannot be excl - - - - 6 772 cannot be excl 6 3 0 3 2 294 110 cannot be excl - - - - 21 492 C, E 11 002 800 cannot be excl - - - - 55 cannot be excl 9 3 3 3 E - cannot be excl - - - - 55 cannot be excl 9* 3 3* 3* 2 507 905 quinagolide cannot be excl - - - - 59 190 E - 9* 3 3* 3 130 929 hydrocortisone cannot be excl - - 0 - 401 062 Sex hormones and modulators of the genital system C, E - corionic gonado- exempt cannot be excl - - - - E - trophin Antiseptics and disinfectants insignificant 4 3 0 1 19 348 chlorhexidine cannot be excl 6* 3* 0 3* - C - E 275 263 insignificant 5 3 0 2 8 718 819 Anti- preparations C 744 072 benzoyl peroxide moderate 3 0 0 3 E - insignificant 5 3 0 2 C 5 566 680 clindamycin cannot be excl 6* 3 0 3* 254 308 insignificant 6* 3 0 3* 4 749 000 E 55 367 e - adapalene cannot be excl - - - - E - insignificant 6* 3 0 3* C 835 548 azelaic acid cannot be excl - - - - E - insignificant 8 3 3 2 - cannot be excl - - - - E - moderate 9 3 3 3 4 886 028 C 3 834 979 Other dermatological preparations high 9 3 3 3 C 20 466 535 insignificant 7 3 3 1 4 107 958 E - cannot be excl 4* 3* 0 1* E - cannot be excl 3 0 0 3 1 347 658 cannot be excl 7* 3 3* 1* E - cannot be excl 6* 3* 0 3* 1 717 834 cannot be excl - - - - E - cannot be excl 8 3 3 2 131 632 sulfide cannot be excl - - - - E - cannot be excl 9 3 3 3 1 115 762 cannot be excl - - - - 342 035 C 2 901 018 cannot be excl 9* 3 3 3* 30 580 G Genito-Urinary System and Sex Hormones C 711 480 cannot be excl 9* 3 3 3* 1 730 Gynecological anti-infectives and antiseptics C 10 129 784 clotrimazole insignificant 9 3 3 3 E 18 857 cannot be excl - - 0 - 982 632 econazole low - - - 3 E 10 544 cannot be excl - - 3 - 976 291 clindamycin cannot be excl 6* 3 0 3* 254 308 C 21 971 E 55 367 ulipristal cannot be excl - - 3 - 6 249 metronidazole cannot be excl 6* 3 0 3* 203 434 clomiphene cannot be excl - - - - 192 849 E 24 545 medroxy- cannot be excl - - - - 1 562 582 Other gynecologicals C 1 038 989 etonogestrel insignificant 6* 3 0 3* 4 749 000 cannot be excl - - - - 3 061 E - cannot be excl - - - - C 2 351 972 ethinylestradiol high 9 3 3 3 C 20 466 535 progesterone cannot be excl - - - - E 1 197 023 E - cannot be excl 7* 3 3* 1* 11 270

14 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 15 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD

Urologicals Calcium homeostasis sildenafil insignificant 2 0 0 2 559 030 cinacalcet insignificant 6 3 0 3 67 205 insignificant 2* 0 0 2* 501 965 alfuzosin insignificant 4* 3* 0 1 6 175 552 J Anti-Infectives for Systemic Use tadalafil insignificant 5 3 0 2 643 075 insignificant 6 3 0 3 160 384 Antibacterials for systemic use finasteride insignificant 7 3 3 1 4 107 958 trimethoprim insignificant 4 3 0 1 149 661 terazosin cannot be excl 6* 3 0 3* 476 340 C 261 420 cannot be excl 6* 3* 0 3* 944 398 nitrofurantoin insignificant 5 3 0 2 279 144 cannot be excl 8* 3 3 2* 76 440 erythromycin insignificant 6 3 0 3 133 025 vardenafil cannot be excl 9* 3 3 3* 54 014 clarithromycin insignificant 6 3 0 3 59 076 cannot be excl - - 0 - 2 322 832 C 17 248 alprostadil cannot be excl - - - - 162 937 meropenem insignificant 6 3 0 3 40 051 cannot be excl - - - - 187 323 telithromycin insignificant 9 3 3 3 10 ofloxacin insignificant 9* 3 3* 3 1 580 azitromycin low 6 3 0 3 86 066 H Systemic Hormonal Preparations excl ceftazidime low 6 3 0 3 3 229 Sex Hormones and Insulins pivmecillinam low 6 3 0 3 474 053 Pituitary and hypothalamic hormones and analogues sulfamethoxazole low 6 3 0 3 C 261 420 desmopressin exempt low 6 3 0 3 118 944 ganirelix exempt amoxicillin moderate 6 3 0 3 953 571 nafarelin exempt C 272 984 exempt ciprofloxacin moderate 6 3 0 3 617 156 E - Corticosteroids for systemic use gentamicin cannot be excl 6 3 0 3 12 873 triamcinolone insignificant 4* 3 0 1* 165 311 E - E - ampicillin cannot be excl 6* 3 0 3* 14 355 betamethasone cannot be excl 9* 3 3* 3* 2 507 905 aztreonam cannot be excl 6* 3* 0 3 353 E - cannot be excl 6* 3 0 3* 39 307 cannot be excl - - 0 - 38 441 cefuroxime cannot be excl 6* 3 0 3* 13 381 C - ceftibuten cannot be excl 6* 3* 0 3* 27 125 hydrocortisone cannot be excl - - 0 - 401 062 ceftriaxone cannot be excl 6* 3 0 3* 12 987 c, E - C - prednisolone cannot be excl - - 0 - 5 381 008 cloxacillin cannot be excl 6* 3 0 3* 110 145 E - clindamycin cannot be excl 6* 3 0 3* 254 308 cannot be excl - - 0 - 351 413 E 55 367 cannot be excl - - - - 327 900 ertapenem cannot be excl 6* 3 0 3* 2 556 cannot be excl - - - - 431 819 fusidic acid cannot be excl 6* 3 0 3* 5 493 therapy E - levothyroxine cannot be excl - - - - 19 477 059 imipenem cannot be excl 6* 3 0 3* 7 164 liothyronine cannot be excl - - - - 100 190 cilastatin cannot be excl 5* 3 0 2* thiamazole cannot be excl - - - - 646 730 ( inhibitor) Pancreatic Hormones metronidazole cannot be excl 6* 3 0 3* 203 434 exempt E 24 545

16 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 17 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD moxifloxacin cannot be excl 6* 3 0 3* 13 481 boceprevir insignificant 2* 0 0 2* 2 184 oxytetracycline cannot be excl 6* 3* 0 3* - insignificant 3 3 0 0 5 857 C, E - insignificant 3 3 0 0 270 cefotaxime cannot be excl 9* 3 3* 3* 58 771 insignificant 3 3 0 0 - daptomycin cannot be excl - - 0 - 149 ganciclovir insignificant 3 3 0 0 872 flucloxacillin cannot be excl - - 0 - 1 453 923 valganciclovir insignificant 3 3 0 0 20 335 phenoxymethyl- cannot be excl - - 0 - 3 256 728 insignificant 3* 3 0 0* 881 penicillin insignificant 4 3 0 1 11 350 tobramycin cannot be excl - - 0 - 7 113 C 366 450 C - aciclovir insignificant 4 3 0 1 95 121 roxithromycin cannot be excl - - - 1* 2 250 E - norfloxacin cannot be excl - - - 3 20 850 entecavir insignificant 4 3 0 1 44 640 amikacin cannot be excl - - - - 1 853 insignificant 4 3 0 1 46 088 cefadroxil cannot be excl - - - - 93 639 C 371 640 cefalexin cannot be excl - - - - 1 404 insignificant 4 3 0 1 61 849 cannot be excl - - - - 1 389 103 ribavirin insignificant 4 3 0 1 31 629 levofloxacin cannot be excl - - - - 22 171 valaciclovir insignificant 4 3 0 1 312 871 linezolid cannot be excl - - - - 3 275 oseltamivir insignificant 4* 3 0 1* 6 570 lymecycline cannot be excl - - - - 1 176 099 insignificant 5 3 0 2 217 040 methenamine cannot be excl - - - - 1 235 894 insignificant 5 3 0 2 - netilmicin cannot be excl - - - - - insignificant 5* 3 0 2* 120 360 piperacillin cannot be excl - - - - 43 488 insignificant 6 3 0 3 117 517 tazobactam cannot be excl - - - - C 176 460 () insignificant 6 3 0 3 43 770 telaprevir insignificant 6* 3 0 3* 4 312 Antimycotics for systemic use insignificant 7 3 3 1 767 insignificant 6 3 0 3 2 770 zanamivir cannot be excl 3* 3 0 0* 205 insignificant 6 3 3 0 18 936 cannot be excl 4* 3 0 1* 4 429 insignificant 9 3 3 3 9 361 C 8 520 ketoconazole low 6* 3 0* 3 13 820 E - Immune sera and immunoglobulins cannot be excl 4* 3* 0 1 187 903 immunoglobulin exempt cannot be excl - - - - 4 917 anti-d flucytocine cannot be excl - - - - 4 cannot be excl - - - - 4 895 L Antineoplastic and Immunomodulating Agents Antimycobacterials insignificant 4 3 0 1 133 480 Antineoplastic agents C - insignificant 1 0 0 1 - rifampicin cannot be excl - - - 0* 87 490 insignificant 1 0 0 1 - C - erlotinib insignificant 3 3 0 0 - rifabutin cannot be excl - - - - 3 570 insignificant 3 3 0 0 - insignificant 3 3 0 0 - Antivirals for systemic use insignificant 5 3 0 2 - insignificant 1 0 0 1 378 insignificant 5 3 0 2 - insignificant 1* 0 0 1* 30

18 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 19 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD gefitinib insignificant 5* 3 0 2* - cannot be excl - - - - - insignificant 5* 3* 0 2 - cannot be excl - - - - - insignificant 6 3 0 3 - cannot be excl - - - - - sunitinib insignificant 6* 3* 0 3 - cannot be excl - - - - - insignificant 9 3 3 3 - cannot be excl - - - - - nilotinib insignificant 9 3 3 3 - cannot be excl - - - - - dasatinib insignificant 9* 3 3 3* - cannot be excl - - - - - insignificant - - - 3 - cannot be excl - - - - - sorafenib low 9 3 3 3 - Endocrine therapy cannot be excl 1* 0 0 1* - leuprorelin exempt cannot be excl 2* 0 0 2* - letrozole insignificant 4 3 0 1 332 920 cannot be excl 2* 0 0 2* - anastrozole insignificant 5* 3 0 2* 803 642 cannot be excl 2* 0 0 2* - insignificant 6 3 0 3 1 197 292 cannot be excl 3* 3* 0 0* - insignificant 6* 3 0 3* 1 324 215 cannot be excl 4* 3* 0 1* - abiraterone low 3 0 0 3 10 560 cannot be excl 4* 3 0 1* - low 3* 0 0 3* 29 939 cannot be excl 5 3 0 2 - cannot be excl - - 0 - 29 288 mitomycin cannot be excl 6 3 0 3 - cannot be excl - - - - 67 830 cannot be excl 6 3 0 3 - cannot be excl - - - - 1 562 582 cannot be excl 6* 3* 0 3 - C 1 038 989 cannot be excl 6* 3 0 3* - 9 3 3 3 30 cannot be excl 6* 3 0 3* - cannot be excl 6* 3 0 3* - Immunostimulants cannot be excl 6* 0 3 3* - mifamurtide cannot be excl - - - - - cannot be excl 9* 3 3* 3* - Immunosuppressants cannot be excl - - - 2* - adalimumab exempt cannot be excl - - - - golimumab exempt cannot be excl - - - - - exempt cannot be excl - - - - - ciclosporine insignificant 4 0 3 1 131 246 cannot be excl - - - - - leflunomide insignificant 5 3 0 2 77 620 cannot be excl - - - - - everolimus insignificant 8 3 3 2 23 756 brentuximab vedotin cannot be excl - - - - - mycophenolic acid moderate 6 3 0 3 213 572 cannot be excl - - - - - cannot be excl - - - - 742 446 cannot be excl - - - - - cannot be excl - - - - 2 221 070 cannot be excl - - - - - tacrolimus cannot be excl - - - - 342 035 cannot be excl - - - - - epirubucin cannot be excl - - - - - M Musculo-Skeletal System estramustine cannot be excl - - - - - cannot be excl - - - - - Antiinflammatory and antirheumatic products cannot be excl - - - - insignificant 4 3 0 1 23 370 cannot be excl - - - - - insignificant 4 3 0 1 53 560 cannot be excl - - - - - insignificant 4* 3 0 1* 2 043 1766 cannot be excl - - - - - misoprostol insignificant 4* 3* 0 1 33 500 cannot be excl - - - - - C 505 350

20 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 21 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD low 4 3 0 1 7 744 751 pamidronic acid insignificant 4* 3* 0 1* 4 305 low 5 3 0 2 192 823 etidronic acid insignificant 5 3 0 2 - glucosamine cannot be excl 1 0 0 1 749 537 C 2 240 cannot be excl 4* 3 0 1* 1 967 496 zoledronic acid insignificant 5* 3 0 2* 2 404 E - risedronic acid insignificant 6* 3* 0 3 608 384 cannot be excl 5* 3 0 2* 14 138 C - cannot be excl - 3 - - 4 412 946 C, E 624 897 N Nervous System auranofin cannot be excl - - - - 3 850 cannot be excl - - - - 2 189 840 Anaesthetics E 16 450 lidocaine insignificant 3 3 0 0 24 cannot be excl - - - - 11 170 C, E 431 819 cannot be excl - - - - 314 865 prilocaine insignificant 4 3 0 1 - cannot be excl - - - - 69 180 C, E - sodium aurothiomalate cannot be excl - - - - 2 083 ropivacaine insignificant 4 3 0 1 - cannot be excl - - - - - low 6 3 0 3 - 4 3 0 1 68 556 cannot be excl 4 3 0 1 617 900 excl inj liquid Topical products for joint and muscular pain mepivacaine cannot be excl 4* 3* 0 1* - diethylaminosalicylate cannot be excl 1* 0 0 1* E 321 C 54 133 ketoprofen cannot be excl 4* 3 0 1* 1 967 496 cannot be excl 4* 3 0 1* - E 1 467 985 bupivacaine cannot be excl 5* 3* 0 2* - ibuprofen cannot be excl - - - - 2 189 840 C - E 16 450 epinephrine cannot be excl - - 0 - 155 304 Muscle relaxants C - atracurium cannot be excl 2* 0 0 2* - cannot be excl - - - - - cisatracurium cannot be excl 2* 0 0 2* - cannot be excl - - - - E - baclofen cannot be excl 3* 3 0 0* 400 216 cannot be excl - - - - - mivacurium cannot be excl 3* 3 0 0* - cannot be excl - - - - 12 400 cannot be excl - - 0 - 78 153 cannot be excl - - - - - C 112 805 cannot be excl - - - - - rocuronium cannot be excl - - 0 - - cannot be excl - - - - - cannot be excl - - - - 396 965 thiopental cannot be excl - - - - - suxamethonium cannot be excl - - - - - Antigout preparations insignificant 3 3 0 0 7 164 allopurinol cannot be excl 6 3 0 3 1 747 779 insignificant 3 3 0 0 C 1 453 probenecid cannot be excl - - - - 82 000 insignificant 4 3 0 1 96 869 Drugs for treatment of bone diseases C 6 315 472 calcium carbonate exempt insignificant 4 3 0 1 235 176 denosumab exempt insignificant 4 3 0 1 896 620 ibandronic acid insignificant 2 0 0 2 507 107 insignificant 6* 3 0 3* 806 130 clodronic acid insignificant 4 3 0 1 4 802 C 210 964 alendronic acid insignificant 4* 3 0 1* 3 589 579 low 5 3 0 2 18 497 727 C 85 960 C 6 419 677

22 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 23 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD low 7 3 3 1 C 13 925 pramipexole insignificant 4 3 0 1 301 766 fentanyl cannot be excl 4 3 0 1 617 900 ropinirole insignificant 4 3 0 1 221 698 excl inj liquid benserazide insignificant 5 3 0 2 C 928 981 cannot be excl 4* 3 0 1* 436 171 entacapone low 5* 3 0 2* 69 289 cannot be excl 5* 3* 0 2* 20 283 C 254 111 cannot be excl 9* 3 3 3* 16 565 carbidopa cannot be excl 5* 3* 0 2* C 1 183 091 scopolamine cannot be excl - - 0 - - selegiline cannot be excl - - 0 - 120 664 C 8 600 cannot be excl - - - 2* 225 376 acetylsalicylic acid cannot be excl - - - - 38 231 279 rasagiline cannot be excl - - - 3* 166 376 C 6 573 994 cabergoline cannot be excl - - - - 21 492 cannot be excl - - - - 13 623 tolcapone cannot be excl - - - - 3 367 cannot be excl - - - - 241 755 cannot be excl - - - - 283 780 C - bromocriptine 9* 3 3* 3 130 929 cannot be excl - - - - 86 047 Psycholeptics C 15 764 lithium exempt methylscopolamine cannot be excl - - - - C 8 600 olanzapin insignificant 2 0 0 2 2 045 972 cannot be excl - - - - 751 404 insignificant 4 3 0 1 167 019 C 8 600 palperidone insignificant 4 3 0 1 173 622 cannot be excl - - - - 1 143 469 insignificant 5 3 0 2 102 441 C 120 301 insignificant 5 3 0 2 630 888 papaverine cannot be excl - - - - 413 560 zolpidem insignificant 5 3 0 2 8 930 134 C 8 600 insignificant 5* 3 0 2* 979 474 cannot be excl - - - - 1 491 insignificant 6 3 0 3 551 905 cannot be excl - - - - 2 242 848 insignificant 8* 3* 3 2 671 436 Antiepileptics low 9 3 3 3 439 148 zonisamide insignificant 1 0 0 1 59 514 cannot be excl 6* 3 0 3* 211 879 insignificant 3* 3 0 0* 2 305 710 cannot be excl 6* 3 0 3* 18 000 insignificant 4 3 0 1 1 167 875 cannot be excl 8* 3 3* 2* 95 lamotrigine insignificant 4 3 0 1 1 408 020 zopiclone cannot be excl 8* 3 3* 2* 17 448 676 insignificant 4* 3 0 1* 148 831 cannot be excl 9* 3* 3 3 175 263 topiramate insignificant 4* 3* 0 1 135 659 cannot be excl 9* 3* 3 3* 10 568 219 valproic acid insignificant 4* 3 0 1* 1 147 930 cannot be excl - - 0 - 2 427 691 retigabine insignificant 6 3 0 3 1 440 cannot be excl - - 0 - 698 felbamate cannot be excl 4* 3 0 1* 210 cannot be excl - - 3 - 335 858 oxcarbazepine cannot be excl 4* 3 0 1* 117 990 alprazolam cannot be excl - - - - 1 660 318 vigabatrin cannot be excl 4* 3* 0 1* 11 634 cannot be excl - - - - 20 209 ethosuximide cannot be excl - - - - 17 504 cannot be excl - - - - 2 572 760 fosphenytoin cannot be excl - - - - 6 385 cannot be excl - - - - 168 711 cannot be excl - - - - 779 653 cannot be excl - - - - 127 478 levetiracetam cannot be excl - - - - 764 749 melatonin cannot be excl - - - - 1 606 050 cannot be excl - - - - 414 313 cannot be excl - - - - 9 242 Anti-Parkinson drugs nitrazepam cannot be excl - - - - 1 200 655 levodopa insignificant 2 0 0 2 C 1 183 091 oxazepam cannot be excl - - - - 2 365 200

24 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 25 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD triazolam cannot be excl - - - - 78 441 cannot be excl 8* 3 3* 2* 33 964 zaleplon cannot be excl - - - - 89 964 cannot be excl - - 0 - 1 093 371 cannot be excl - - - - 83 805 ambenonium cannot be excl - - - - 9 472 cannot be excl - - - - 508 594 disulfiramum cannot be excl - - - - 413 100 Psychoanaleptics C - moclobemide insignificant 4 3 0 1 72 602 cannot be excl - - - - 2 763 venlafaxine insignificant 5 3 0 2 4 950 176 C 22 010 methylphenidate insignificant 5 3 0 2 7 473 723 pyridostigmine 6* 3* 0 3 100 595 insignificant 5 3 0 2 4 840 087 rivastigmine insignificant 5 3 0 2 319 617 P Antiparasitic Products, Insecticides and atomoxetine insignificant 6 3 0 3 371 043 Repellents fluvoxamine insignificant 6 3 0 3 18 916 duloxetine low 6 3 0 3 2 489 289 low 6 3 0 3 4 097 204 mefloquine insignificant 6 3 0 3 11 470 low 6 3 0 3 1 009 031 proguanil insignificant 6 3 0 3 - sertraline moderate 6 3 0 3 13 930 724 C 86 580 cannot be excl 6 3 0 3 12 664 lumefantrine insignificant 8 3 3 2 C 91 cannot be excl 6 3 0 3 4 187 artemether insignificant 9 3 3 3 C 91 cannot be excl 6* 3* 0 3* 1 192 294 metronidazole cannot be excl 6* 3 0 3* 203 434 citalopram cannot be excl 6* 3* 0 3* 13 809 518 E 24 545 donepezil cannot be excl 6* 3 0 3* 673 839 hydroxychloroquine cannot be excl 8* 3* 3 2* 120 636 escitalopram cannot be excl 6* 3* 0 3* 4 821 189 cannot be excl 9 3 3 3 874 cannot be excl 6* 3 0 3* 1 761 486 C 86 580 cannot be excl 9* 3 3 3* 75 323 cannot be excl - - 0 - 938 cannot be excl - - 0 - 860 549 chloroquine cannot be excl - - - - 23 081 cannot be excl - - 0 - 170 768 phosphate modafinil cannot be excl - - 0 - 144 121 cannot be excl - - - - 6 704 cannot be excl - - - - 32 689 Anthelmintics C - mebendazole cannot be excl 9* 3* 3 3 18 348 reboxetin cannot be excl - - - - 81 064 niclosamide cannot be excl - - - - 211 6 3 0 3 572 889 pyrvin cannot be excl - - - - 242 9 3 3 3 1 025 Ectoparasiticides, incl scabicides, insecticides and repellents Other nervous system drugs permetrin moderate 9 3 3 3 - acamprosate insignificant 3 3 0 0 196 825 benzyl benzoate cannot be excl - - - - C - insignificant 3 0 0 3 112 369 disulfiramum cannot be excl - - - - 413 100 insignificant 6 3 0 3 823 970 C, E - buprenorphine insignificant 6* 3 0 3* 806 130 C 210 964 insignificant 9 3 3 3 315 959 R Respiratory System cannot be excl 4 3 0 1 - Nasal preparations C 331 265 insignificant 4 3 0 1 51 700 cannot be excl 6* 3 0 3* 882 205 triamcinolone insignificant 4* 3 0 1* 165 311 C 3 357 090 E -

26 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 27 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD budesonide insignificant 5 3 0 2 8 079 288 beclomethasone cannot be excl 6* 3 0 3* 81 203 C 8 099 610 C 8 099 610 mometasone low 5 3 0 2 9 459 810 cannot be excl 6* 3 0 3* 316 080 E - ipratropium cannot be excl 6* 3 0 3* 736 412 sodium cromoglycate cannot be excl 3* 3* 0 0* 103 116 C 508 958 cannot be excl 5* 3* 0 2* 107 342 cannot be excl - - 0 - 146 679 fluticasone cannot be excl 6 3 0 3 2 294 110 Cough and cold preparations C, E 2 903 190 codeine insignificant 4 3 0 1 96 869 beclomethasone cannot be excl 6* 3 0 3* 81 203 C 6 315 472 C 8 099 610 ambroxol insignificant 5 3 0 2 278 ipratropium cannot be excl 6* 3 0 3* 736 412 insignificant 5 3 0 2 C 13 925 C 508 958 bromhexine cannot be excl 6 3 0 3 103 251 cannot be excl 7* 3 3 1* 13 063 C - C 1 938 guaifenesin cannot be excl - - 0 - 262 cannot be excl - - - - 3 551 C - C - cannot be excl - - - - 4 624 498 cannot be excl - - - - C 800 C - cannot be excl - - - - 976 180 cannot be excl - - - - C - C 19 900 cannot be excl - - - - C - cannot be excl - - - - C 800 noscapine cannot be excl - - - - 7 816 Throat preparations C 8 600 gramicidin cannot be excl - - - - 6 269 pentoxyverine cannot be excl - - - - - Drugs for obstructive airway diseases Antihistamines for systemic use insignificant 2 0 0 2 2 629 921 insignificant 6 3 0 3 15 insignificant 3 3 0 0 361 050 fexofenadine insignificant 6* 3 3* 0 433 165 insignificant 3 3 0 0 3 851 045 ebastine insignificant 8 3 3 2 892 710 insignificant 4 3 0 1 9 326 low 6 3 0 3 3 632 700 insignificant 4 3 0 1 978 158 cannot be excl 5* 3 0 2* 7 136 977 C 8 099 610 cannot be excl 9* 3 3 3* 2 915 010 budesonide insignificant 5 3 0 2 8 079 288 cannot be excl 9* 3* 3 3 833 816 C 8 099 610 cannot be excl 9* 3 3 3* 1 110 insignificant 5 3 0 2 377 580 acrivastine cannot be excl - - 0 - - C 2 903 190 cetirizine cannot be excl - - 0 - 3 844 354 mometasone low 5 3 0 2 9 459 810 cannot be excl - - - - - E - cannot be excl - - - - 26 466 cannot be excl 0* 0 0 0* 65 600 C 84 C - meclozine cannot be excl - - - - 152 585 sodium cromoglycate cannot be excl 3* 3* 0 0* 103 116 mizolastine cannot be excl - - - - - cannot be excl 4* 3 0 1* 3 253 297 C 507 020 cannot be excl 4* 3 0 1* 4 774 880 fluticasone cannot be excl 6 3 0 3 2 294 110 C, E 11 002 800

28 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 29 SUBSTANCE RISK PBT P B T VOLUME IN DDD SUBSTANCE RISK PBT P B T VOLUME IN DDD S Sensory Organs cannot be excl - - 0 - 898 850 C 3 357 090 Ophthalmologicals cannot be excl - - 0 - - aciclovir insignificant 4 3 0 1 95 121 C - E - cincocaine cannot be excl - - 3 - - levocabastine insignificant 4 3 0 1 51 700 E - dorzolamide cannot be excl 3* 3 0 0* 257 115 diclofenac cannot be excl - 3 - - 4 412 946 C 3 357 090 C, E 624 897 sodium cromoglycate cannot be excl 3* 3* 0 0* 103 116 povidone cannot be excl - 3 - - - cannot be excl 3* 3* 0 0* - acetazolamide cannot be excl - - - - 55 849 fusidic acid cannot be excl 6* 3 0 3* 5 493 azelastine cannot be excl - - - - 3 551 E - C - moxifloxacin cannot be excl 6* 3 0 3* 13 481 bibrocathol cannot be excl - - - - - pilocarpine cannot be excl 6* 3 0 3* 882 205 cannot be excl - - - - 434 400 C 3 357 090 C 3 357 090 cannot be excl 7* 3 3* 1* - cannot be excl - - - - 415 325 C - C 3 357 090 cannot be excl 8* 3 3* 2* C - carmellose sodium cannot be excl - - - - - cannot be excl 9* 3 3* 3 - chloramphenicol cannot be excl - - - - - apraclonidine cannot be excl - - 0 - 8 401 epinastine cannot be excl - - - - - atropine cannot be excl - - 0 - 25 068 cannot be excl - - - - 2 701 325 C - C 3 357 090 betaxolol cannot be excl - - 0 - 84 490 levofloxacin cannot be excl - - - - 22 171 brinzolamide cannot be excl - - 0 - 823 150 pegaptanib cannot be excl - - - - - C 3 357 090 cannot be excl - - - - - cannot be excl - - 0 - - cannot be excl - - 0 - - Otologicals dexamethasone cannot be excl - - 0 - 38 441 oxytetracycline cannot be excl 6* 3* 0 3* - C - C, E - emedastine cannot be excl - - 0 - - betamethasone cannot be excl 9* 3 3* 3* 2 507 905 fluorescein cannot be excl - - 0 - - E - C - hydrocortisone cannot be excl - - 0 - 401 062 hydrocortisone cannot be excl - - 0 - 401 062 C, E - C, E - chloramphenicol cannot be excl - - - - - nepafenac cannot be excl - - 0 - - cannot be excl - - 0 - - V Various prednisolone cannot be excl - - 0 - 5 381 008 All other therapeutic products E - deferoxamine insignificant 1* 0 0 1* - cannot be excl - - 0 - - insignificant 4 3 0 1 - timolol cannot be excl - - 0 - 3 444 535 insignificant 4* 3 0 1* - C 3 357 090 deferasirox insignificant 6 3 0 3 - tobramycin cannot be excl - - 0 - 7 113 naloxone cannot be excl 4 3 0 1 - C - C 331 265

30 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 31 SUBSTANCE RISK PBT P B T VOLUME IN DDD cannot be excl - - 0 - - Reading tips polystyrene sulfonate cannot be excl - - 0 - 32 044 • Pharmaceuticals in a Healthy Environment dexrazoxane cannot be excl - - - - 7 MistraPharma Research 2008-2011 Diagnostic agents This book – the fourth in an annual series – takes hexaminlevulinate cannot be excl - - - - stock of the first four years of the Swedish research Contrast media programme MistraPharma. Published in 2012. insignificant 3 3 0 0 - www.mistrapharma.se insignificant 3 3 0 0 - insignificant 3 3 0 0 - • Results from the Swedish National Screening insignificant 3 3 0 0 - insignificant 3 3 0 0 - Programme 2010. Subreport 3. Pharmaceuticals insignificant 4 3 0 1 - A screening study of 101 pharmaceuticals in waste- insignificant 4 3 0 1 - water, surface water and drinking water. IVL, cannot be excl 4* 3 0 1* - Swedish Environmental Research Institute 2011. amidotrizoic acid cannot be excl - - - - - www.ivl.se ferumoxsil cannot be excl - - - - - cannot be excl - - - - - • Environment and Pharmaceuticals cannot be excl------A publication containing facts and reflections about cannot be excl - - - - - how pharmaceutical products and pharmaceutical cannot be excl------residues can affect our environment and, as a cannot be excl - - - - - 4 3 0 1 - result, our health. Published in 2005 in collabora- tion between Apoteket AB, Stockholm County Council and Stockholm University. • Environmental Impact of Pharmaceuticals as well as Cosmetics and Hygiene Products The Swedish Medical Products Agency: report 2004. (Summary in English). www.lakemedelsverket.se • Fass.se The Swedish Association of the Pharmaceutical Industry’s website. www.fass.se

More reading tips are available at the non- commercial website www.janusinfo.se/environment

32 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 33 Vocabulary

ATC: (Anatomic Therapeutic Chemical classifica- PBT Index: the total of the values for persistence, tion system) a classification system for drugs i.a bioaccumulation and toxicity comprises the PBT used by WHO. The drugs are divided into 14 main Index of the substance. groups according to the organ or system on which PEC: (Predicted Environmental Concentration), they act and their chemical, pharmacological and predicted environmental concentration of the ­therapeutic properties. The same substance may substance. have several different ATC classifications if the Persistence: ability to resist degradation in the substance is a part of several groups and is being aquatic environment. The biodegradability is sold in combinations with other substances. assessed based on criteria for readily biodegrada- Bioaccumulation: accumulation in adipose tion according to the test guidelines (test 301) of ­tissue of aquatic organisms, according to the OECD or another equivalent test of biodegrada- OECD based on the partition coefficient ­ bility. n-octanol/water, Pow, in which substances with PNEC: (Predicted No Effect Concentration) the log Pow >4 are judged to be potentially bio­ highest concentration of the substance that does accumulating (OECD test 107 or 117). not have a harmful effect on the environment. DDD: (Defined Daily Doses), the DDD is the as- Toxicity: the potential to poison aquatic orga- sumed average maintenance dose per day for nisms. Toxicity for aquatic organisms is assessed a drug used for its main indication in adults. based on the results of toxicity tests including DDD:s are not established for all preparations. In ­three trophic levels; fish, Daphnia and algae ­Sweden, DDD:s are also used for estimating phar- (OECD test guidelines 203, 202 and 201, or equi- maceuticals for external use (1 gram = 1 DDD). valent). Data for the most sensitive organisms are This estimate is not based on the amount of an used in the assessment. active substance and can therefore not be compa- red to the DDD for drugs for internal use. Wise List: (Kloka Listan) a list of recommen- ded pharmaceuticals for common diseases in Environmental hazard: the inherent environ- Stockholm County Council. The Wise List takes mentally damaging characteristics of the sub- cost-effectiveness and environmental impact into stance in the following terms: persistence, bio­ account when comparing that are accumulation and toxicity (PBT). equally safe and equally suitable for the purpose, Environmental risk: refers to toxic risk to the based on scientific documentation. aquatic environment and is based on PEC/PNEC. Metabolite: any substance produced during metabolism (digestion or other bodily chemical processes). The term metabolite may also refer to the product that remains after a drug is broken down (metabolized) by the body.

34 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 35 Index Substance...... Page atazanavir...... 19 Substance...... Page atenolol...... 11 A atomoxetine...... 26 abacavir...... 19 atorvastatin ...... 12 abiraterone...... 21 atosiban ...... 15 acamprosate...... 26 atovaquone ...... 27 acarbose...... 8 atracurium ...... 22 acetazolamide ...... 31 atropine ...... 7, 30 acetylcysteine...... 29 auranofin...... 22 acetylsalicylic acid...... 9, 24 azathioprine...... 21 aciclovir...... 13, 19, 30 azelaic acid...... 14 acitretin...... 13 azelastine...... 28, 31 acrivastine...... 29 azitromycin...... 17 adalimumab...... 21 aztreonam ...... 17 adapalene...... 14 B alanyl glutamine ...... 10 baclofen...... 22 alendronic acid...... 22 bambuterol...... 28 alfacalcidol...... 9 ...... 28, 29 alfentanil ...... 23 bendroflumethiazide...... 11 alfuzosin...... 16 benserazide ...... 25 alginic acid...... 7 benzoyl peroxide...... 14 alimemazine...... 29 benzydamine...... 7 allopurinol ...... 22 benzyl benzoate...... 27 almotriptan...... 24 benzylpenicillin ...... 17 alprazolam...... 25 betamethasone ...... 14, 16, 31 alprostadil...... 10, 16 betaxolol...... 30 alteplase...... 9 bexarotene...... 20 ambenonium ...... 27 bezafibrate...... 12 ambroxol...... 29 bibrocathol...... 31 amfotericin...... 18 bicalutamide...... 21 amidotrizoic acid...... 32 bifonazole...... 13 amikacin...... 18 bimatoprost...... 31 amiloride...... 11 biperiden ...... 25 aminolevulinic acid ...... 20 bisacodyl...... 8 amiodarone ...... 10 bisoprolol...... 11 amitriptyline...... 26 bleomycin...... 20 amlodipine...... 11 boceprevir...... 19 amoxicillin...... 17 bortezomib...... 20 ampicillin ...... 17 bosentan...... 10 amsacrine...... 20 brentuximab vedotin...... 20 anagrelide...... 20 brimonidine...... 31 anastrozole...... 21 brinzolamide ...... 30 antazoline...... 30 bromhexine ...... 29 apraclonidine...... 30 bromocriptine...... 15, 25 aprepitant...... 7 budesonide...... 8, 28 argatroban...... 9 bumetanide ...... 11 aripirazol...... 25 bupivacaine ...... 23 artemether...... 27 buprenorphine...... 23, 26

36 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 37 Substance...... Page Substance...... Page bupropion...... 26 clarithromycin...... 7, 17 buspirone...... 25 clemastine...... 29 busulfan...... 20 clindamycin...... 14, 17 butylscopolamine...... 7 clobetasol...... 13 clobetasone ...... 14 C clodronic acid...... 22 cabazitaxel...... 20 clofarabine...... 20 cabergoline...... 15, 25 clometiazole...... 25 caffeine...... 26 clomiphene...... 15 calcipotriol...... 13 clomipramine...... 26 calcium carbonate...... 9, 22 clonazepam ...... 24 candesartan ...... 12 clonidine...... 10 capecitabine...... 20 clopidogrel...... 9 capsaicin...... 23 clotrimazole...... 13, 14 captopril...... 12 cloxacillin ...... 17 caramellose sodium...... 31 clozapine...... 25 carbachol ...... 30 codeine...... 23, 29 carbamazepine...... 24 colecalciferol...... 9 carbidopa...... 25 colestipol...... 12 carboplatin...... 20 corionic gonadotrophin...... 15 carboprost...... 15 cyanocobalamin...... 9 carvedilol ...... 11 cyclopentolate...... 30 caspofungin...... 18 cyclophosphamide...... 20 cefadroxil...... 18 cyproheptadine ...... 29 cefalexin...... 18 cyproterone ...... 15 cefotaxime...... 18 cytarabine...... 20 ceftazidime...... 17 ceftibuten...... 17 D ceftriaxone...... 17 dabigatran...... 9 cefuroxime...... 17 dacarbazine ...... 20 cetirizine...... 29 dalteparin...... 9 chlorambucil...... 20 daptomycin...... 18 chloramphenicol...... 31 darbepoetin alfa ...... 9 chlorcyclizine ...... 29 darifenacin...... 16 chlorhexidine...... 7, 14 darunavir ...... 19 chloroquine phosphate...... 27 dasatinib...... 20 chlorprothixene...... 25 daunorubicin ...... 20 chlorzoxazone ...... 22 deferasirox...... 31 cholestyramine...... 12 deferoxamine...... 31 ciclesonide ...... 29 denosumab...... 22 ciclosporine...... 21 desflurane...... 23 cilastatin...... 17 desloratadine...... 29 cinacalcet ...... 17 desmopressin...... 16 cincocaine...... 11, 31 desogestrel...... 15 ciprofloxacin...... 17 dexamethasone...... 16, 30 cisatracurium ...... 22 dexbrompheniramine ...... 28 cisplatin...... 20 dexchlorpheniramine...... 29 citalopram...... 26 dexibuprofen...... 22 cladribine...... 20 dexrazoxane...... 32

38 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 39 Substance...... Page Substance...... Page diazepam ...... 25 ertapenem ...... 17 diclofenac...... 22, 31 erythromycin ...... 17 didanosine ...... 19 escitalopram...... 26 dienogest...... 15 esmolol...... 11 diethylaminosalicylate...... 22 esomeprazole...... 7 digoxin...... 10 estradiol...... 15 diltiazem...... 11 estramustine...... 20 dimenhydrinate...... 29 estriol ...... 15 dimethicone...... 7, 8 ethinylestradiol ...... 14, 15 dinoprostone...... 15 ethosuximide...... 24 diphenhydramine...... 29 ethylmorphine...... 29 dipyridamole ...... 9 etidronic acid...... 23 disopyramide...... 10 etilefrine...... 10 disulfiramum ...... 27 etonogestrel...... 14, 15 docetaxel ...... 20 etoposide...... 20 docusate sodium ...... 8 etoricoxib...... 21 donepezil...... 26 etravirine ...... 19 dopamine...... 10 everolimus ...... 21 dorzolamide...... 30 exemestane...... 21 doxazosin...... 10 ezetimibe...... 12 doxorubicin...... 20 F doxycycline...... 18 famciclovir ...... 19 dronedarone...... 10 felbamate...... 24 droperidol...... 23 felodipine...... 11 drospirenone ...... 15 fenofibrate...... 12 duloxetine...... 26 fentanyl...... 23, 24 dutasteride...... 16 ferric carboxymaltose...... 10 dydrogesterone...... 15 ferrous glycine sulfate...... 10 E ferumoxsil...... 32 ebastine ...... 29 fesoterodine...... 16 econazole...... 13, 14 fexofenadine ...... 29 efavirenz...... 19 finasteride...... 14, 16 eletriptan...... 24 flecainide ...... 10 emedastine...... 30 flucloxacillin...... 18 enalapril...... 12 fluconazole...... 18 enoxaparin...... 9 flucytocine ...... 18 entacapone...... 25 fludarabine...... 20 entecavir...... 19 fludrocortisone...... 16 ephedrine...... 28 flumazenil...... 31 epinastine...... 31 fluocinolone...... 14 epinephrine ...... 10, 23 fluorescein ...... 30 epirubucin...... 20 fluorouracil...... 20 eplerenone...... 11 fluoxetine...... 26 epoetin zeta...... 10 flupentixol ...... 25 eprosartan ...... 12 fluphenazine ...... 25 eptifibatide...... 9 flutamide ...... 21 ergotamine...... 24 fluticasone ...... 14, 28 erlotinib ...... 19 fluvastatin...... 12

40 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 41 Substance...... Page Substance...... Page fluvoxamine...... 26 hydromorphone...... 24 folic acid...... 10 hydroxycarbamide...... 19 fomepizole...... 32 hydroxychloroquine...... 27 fondaparinux...... 9 hydroxyzine ...... 25 formoterol ...... 28 hyoscyamine...... 7 fosamprenavir ...... 19 I foscarnet...... 19 ibandronic acid...... 22 fosinopril...... 12 ibuprofen...... 22 fosphenytoin ...... 24 idarubicin...... 20 framycetin...... 11 ifosfamide...... 20 fulvestrant ...... 21 iloprost...... 9 furosemide...... 11 imatinib...... 19 fusidic acid...... 13, 17, 30 imipenem...... 17 G imipramine...... 26 gabapentin...... 24 imiquimod ...... 13 gadobutrol...... 32 immunoglobulin anti-d...... 19 gadodiamide ...... 32 indacaterol...... 28 gadopentetic acid ...... 32 indinavir...... 18 gadoteric acid...... 32 indometacin...... 22 gadoversetamide...... 32 infliximab...... 21 gadoxetic acid ...... 32 insulin...... 8 galanthamine...... 26 iobitridol...... 32 ganciclovir...... 19 iodixanol...... 32 ganirelix...... 16 iohexol ...... 32 gefitinib ...... 20 iomeprol...... 32 gemcitabine...... 19 iopromide...... 32 gemeprost...... 15 ioversol...... 32 gemfibrozil...... 12 ioxaglic acid...... 32 gentamicin...... 13, 17 ipratropium ...... 28, 29 glibenclamide...... 8 irbesartan...... 12 glimepiride...... 8 irinotecan...... 20 glipizide ...... 8 iron 2+ and 3+ ...... 10 glucagon...... 16 isoflurane...... 23 glucosamine...... 11, 22 isoniazid...... 18 glycerin...... 13 isosorbide mononitrate...... 10 glyceryl trinitrate...... 10 isradipine ...... 11 glycopyrronium ...... 7 itraconazole...... 18 golimumab...... 21 K gramicidin...... 28 karaya gum...... 8 granisetron...... 7 ketamine...... 23 guaifenesin...... 29 ketobemidone...... 24 H ketoconazole...... 13, 18 haloperidol...... 25 ketoprofen...... 22 heparin sodium ...... 9 ketorolac...... 21 hexaminlevulinate...... 32 ketotifen...... 30 hydralazine...... 10 hydrochlorthiazide...... 11 hydrocortisone...... 11, 14, 16, 30, 31

42 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 43 Substance...... Page Substance...... Page L mercaptopurine...... 20 labetalol...... 11 meropenem ...... 17 lactulose...... 8 mesalazine...... 8 lamivudine...... 19 metformin...... 8 lamotrigine...... 24 methadone...... 27 lansoprazole...... 7 methenamine...... 18 latanoprost...... 31 methotrexate...... 21 leflunomide ...... 21 methyl aminolevulinate...... 20 lercanidipine...... 12 methylergometrine...... 14 letrozole...... 21 methylphenidate...... 26 leuprorelin...... 21 methylprednisolone...... 16 levetiracetam...... 24 methylscopolamine...... 24 levocabastine...... 27, 30 metoclopramide...... 7 levodopa...... 24 metolazone...... 11 levofloxacin ...... 18, 31 metoprolol...... 11 levomepromazine ...... 25 metronidazole...... 13, 14, 17, 27 levonorgestrel ...... 15 mianserin ...... 26 levothyroxine...... 16 miconazole...... 13 lidocaine...... 10, 11, 13, 23 midazolam...... 25 linezolid ...... 18 mifamurtide...... 21 liothyronine...... 16 mifepristone...... 15 liraglutide...... 8 milrinone ...... 10 lisinopril ...... 12 miltefosine...... 20 lithium...... 25 minoxidil...... 14 lomustine...... 20 mirtazapine ...... 26 loperamide...... 8 misoprostol...... 7, 21 loratadine...... 29 mitomycin...... 20 lorazepam...... 25 mitoxantrone...... 21 lornoxicam...... 22 mivacurium...... 22 losartan...... 12 mizolastine...... 29 lumefantrine...... 27 moclobemide...... 26 lymecycline...... 18 modafinil ...... 26 lynestrenol...... 15 mometasone...... 14, 28 montelukast...... 28 M morphine ...... 24 macrogol...... 8 moxifloxacin...... 18, 30 mangafodipir...... 32 moxonidine...... 10 maprotiline...... 26 mupirocin...... 13 mebendazole...... 27 mycophenolic acid...... 21 meclozine...... 29 medroxyprogesterone...... 15, 21 N mefloquine...... 27 nabumetone...... 22 megestrol...... 21 nafarelin...... 16 melatonin...... 25 naloxone...... 26, 31 meloxicam...... 21 nandrolone...... 9 melperone ...... 25 naphazoline...... 30 melphalan...... 20 naproxen...... 22 memantine...... 26 naratriptan...... 23 mepivacaine...... 23 nedocromil...... 30

44 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 45 Substance...... Page Substance...... Page nelarabine...... 19 penciclovir...... 13 neostigmine...... 27 pentamidine...... 27 nepafenac...... 30 pentoxyverine...... 29 netilmicin...... 18 permetrin...... 27 nevirapine...... 19 perphenazine...... 25 niclosamide...... 27 pethidine ...... 24 nicotine...... 26 phenazone...... 23 nifedipine...... 12 phenoxymethylpenicillin...... 18 nilotinib ...... 20 phenylpropanolamine...... 28 nitrazepam...... 25 phenytoin...... 24 nitrofurantoin ...... 17 phytomenadione...... 9 nomegestrol...... 15 pilocarpine...... 26, 30 norepinephrine ...... 10 pimecrolimus ...... 14 norethisterone...... 15 pindolol...... 11 norfloxacin...... 18 pioglitazone...... 9 norgestimate ...... 15 piperacillin...... 18 nortriptyline...... 26 piroxicam ...... 22 noscapine...... 29 pivmecillinam...... 17 nystatin...... 8 pixantrone ...... 21 pizotifen...... 24 O podophyllotoxin...... 13 ofloxacin...... 17 polystyrene sulfonate ...... 32 olanzapin...... 25 posaconazole...... 18 olopatadine ...... 30 potassium chloride...... 9, 10 olsalazine...... 8 povidone...... 31 omeprazole...... 7 pramipexole...... 25 ondansetron...... 7 prasugrel...... 9 orlistat...... 8 pravastatin...... 12 orphenadrine...... 22 prednisolone...... 8, 11, 16, 30 oseltamivir ...... 19 prednisone...... 16 oxaliplatin...... 20 pregabalin ...... 24 oxazepam...... 25 prilocaine...... 23 oxcarbazepine ...... 24 probenecid...... 22 oxybutynin...... 16 prochlorperazine...... 25 oxycodone ...... 24 progesterone...... 15 oxymetazoline...... 28 proguanil ...... 27 oxytetracycline...... 13, 18, 31 propiomazine...... 25 oxytocin ...... 16 propofol...... 23 P propranolol...... 11 paclitaxel...... 20 propylene glycol...... 13 palonosetron ...... 7 pseudoephedrine...... 28 palperidone ...... 25 psyllium...... 8 pamidronic acid...... 23 pyridostigmin...... 27 pantoprazole...... 7 pyrvin ...... 27 papaverine...... 7, 24 Q paracetamol...... 23 quetiapine ...... 25 paroxetine ...... 26 quinagolide ...... 15 pegaptanib...... 31 quinapril...... 12 pemetrexed ...... 19

46 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 47 Substance...... Page Substance...... Page R solifenacin...... 16 rabeprazole ...... 7 sorafenib...... 20 raloxifene...... 15 sotalol...... 11 ramipril...... 12 spironolactone...... 11 ranitidine ...... 7 stavudine ...... 18 rasagiline ...... 25 sufentanil...... 23 reboxetin ...... 26 sugammadex ...... 31 remifentanil...... 23 sulfamethoxazole...... 17 repaglinide...... 9 sulfasalazine...... 8 retapamulin...... 13 sulindac...... 22 retigabine...... 24 sumatriptan ...... 23 ribavirin...... 19 sunitinib...... 20 rifabutin...... 18 suxamethonium...... 22 rifampicin...... 18 T riluzole...... 27 tacrolimus...... 14, 21 rimexolone...... 30 tadalafil...... 16 risedronic acid ...... 23 tamoxifen...... 21 risperidone...... 25 tazobactam...... 18 rivaroxaban...... 9 telaprevir ...... 19 rivastigmine...... 26 telithromycin ...... 17 rizatriptan...... 23 telmisartan...... 12 rocuronium...... 22 temozolomide ...... 19 ropinirole...... 25 tenoxicam...... 22 ropivacaine...... 23 terazosin...... 16 rosuvastatin ...... 12 terbinafine...... 13 roxithromycin...... 18 terbutaline...... 28 S testosterone...... 15 salbutamol...... 28 tetracycline...... 17 salicylic acid ...... 14 theophylline...... 29 salmeterol...... 28 thiamazole...... 16 saquinavir...... 19 thiethylperazine...... 29 saxagliptin ...... 8 thiopental...... 23 scopolamine...... 7, 24 tibolone ...... 15 selegiline...... 25 ticagrelor ...... 9 selenium sulfide...... 14 ticlopidine...... 9 sertindole...... 25 timolol...... 30 sertraline...... 26 tinidazole...... 27 sibutramine...... 8 tinzaparin...... 9 sildenafil...... 16 tioguanine ...... 20 simvastatin...... 12 tiotropium bromide...... 28 sitagliptin...... 8 tipranavir ...... 19 sodium aurothiomalate...... 22 tirofiban...... 9 sodium bicarbonate...... 7 tobramycin...... 18, 30 sodium cromoglycate...... 8, 28, 30 tolcapone...... 25 sodium glycerophosphate...... 10 tolterodine...... 16 sodium oleate...... 11 topiramate...... 24 sodium picosulfate...... 8 topotecan...... 20 sodium sulphate...... 8 torasemide...... 10

48 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 49 trabectedin...... 21 zolpidem...... 25 tramadol...... 24 zonisamide...... 24 tranexamic acid ...... 9 zopiclone ...... 25 travoprost...... 31 zuclopenthixol...... 26 tretinoin...... 14 triamcinolone...... 7, 13, 16, 27 triazolam...... 26 trihexyphenidyl ...... 25 trimethoprim...... 17 trimipramine...... 26 tropicamide ...... 31 tropisetron...... 7 U ulipristal...... 15 urea...... 13 ursodeoxycholic acid...... 8 V valaciclovir ...... 19 valganciclovir...... 19 valproic acid...... 24 valsartan...... 12 vardenafil...... 16 varenicline ...... 26 venlafaxine...... 26 verapamil...... 11 vernakalant...... 10 verteporfin...... 31 vigabatrin...... 24 vildagliptin...... 8 vinblastine ...... 21 vincristine...... 21 vindesine...... 21 vinflunine...... 21 vinorelbine...... 21 voriconazole...... 18 W warfarin ...... 9 X xylometazoline...... 28 Z zaleplon ...... 26 zanamivir ...... 19 zidovudine...... 19 ziprasidone...... 26 zoledronic acid...... 23 zolmitriptan...... 24

50 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 51 What You as a Prescriber Can Do Advice For Your Patient

• Follow “Kloka Listan” (the Wise List) – • Return unused medications to the pharmacy. environmental considerations are included. This is also important for used The Wise List is a list of recommended patches/vaginal rings since a lot of the pharmaceuticals for common diseases in estrogen remains in the patch/vaginal ring Stockholm County Council, issued by the after use. Avoid flushing them down the Drug and Therapeutics Committee. When toilet. Even can still contain active the Committee chooses to recommend a substance after being used. pharmaceutical, cost-effectiveness and environmental impact are taken into • Ask for refill packs. account, when comparing medications that are equally safe and equally suitable for the • Follow the enclosed instructions for using purpose. the medication carefully.

• Prescribe starter packs. • Return empty packages to the waste recycle • Do not prescribe more medications than can station. be used; if in doubt, repeating the prescrip- tion is preferable. • Use refills whenever possible. • Prescribe refill packs, if available. • Ask the representatives of the pharmaceu- tical manufacturers about environmental impact. • Learn more about which of “your” drugs have the largest environmental impact. If they are not recommended on the Wise List, can they be replaced by others which are? • Tell your patients to return medical patches, vaginal rings etcetera to the pharmacy after use (especially important for those contain- ing ).

52 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2014 e-mail: [email protected] about thePBTIndexandWiseList: Janusinfo’s editorialofficeforquestions You canalsocontact This informationiscontinuouslyupdated. www.janusinfo.se/environment by theStockholmCountyCouncil: commercial websiteJanusinfo,produced More informationisavailableatthenon- moreFor information pharmaceuticals. from impact environmental of negative risk the work-life to reduce daily your do in you can what on advice concrete provides folder The also substance. the of properties different elucidate terms these as risk, environmental and hazard environmental to both given be should consideration substance, extent. current at their used when substances pharmaceutical the by posed risk environmental the regarding as and hazard), (environmental environment the to affect capacity inherent their of terms in both assessed are pharmaceuticals The substances. pharmaceutical for ments assess- environmental the folder presents This When assessing the environmental impact of a impact environmental the assessing When in theenvironment. mentally straining pharmaceuticalsubstances and loweringthe levels ofthemostenviron- the environmentalriskfrompharmaceuticals environmental work.Thisincludesreducing ficient aswellconductinghealth-promotive way whichisclimateefficientandresource ef- The Councilhastocarryoutitsmandate ina

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