sign in sign up
<<
Home , Dipyridamole, Tadalafil, Ticlopidine, Tropisetron

2009

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS

Stockholm County Council Contents

The environmental assessment of pharmaceuticals continues...... 1 Impact of on the environment. 2 How classification is made...... 2 To read the table...... 4 Reading tips...... 6 Tables A Alimentary tract and metabolism ...... 7 B Blood and blood forming organs...... 7 C Cardiovascular system ...... 8 D Dermatologicals ...... 10 G Genito-urinary system and sex hormones ...... 11 H Hormones excluding sex hormones ...... 12 J Anti-infectives ...... 12 L Antineoplastic and immunomodulating agents.14 M Musculo-skeletal system...... 15 N Nervous system...... 16 P Antiparasitic products, insecticides and repellents ...... 19 R Respiratory system...... 19 S Sensory organs...... 21 V Various ...... 21 Substances without environmental risk...... 22 Vocabulary...... 24 Precautionary Principle...... 25 Index ...... 26 What you can do...... 35

January 2009 edition The environmental assessment of pharmaceuticals continues Reducing the residues of medicinal products in the ground, water and air is one of Stockholm County &RXQFLO¶V¿YHPRVWLPSRUWDQWHQYLURQPHQWDO LVVXHV2XUYLVLRQLVWKDWFRXQW\FRXQFLORSHUDWLRQV VKRXOGQRWDGGDQ\HQYLURQPHQWDOO\KD]DUGRXV remains of medicinal products to the natural VXUURXQGLQJV7KHDLPLVIRUWKHOHYHOVRIWKHPRVW HQYLURQPHQWDOO\KD]DUGRXVPHGLFLQDOSURGXFWV LQHIÀXHQWVIURPZDVWHZDWHUSODQWVRULQVXUIDFH water to be lower in 2011 than in 2005. One aspect RIWKLVZRUNLVWKHDVVHVVPHQWDQGFODVVL¿FDWLRQRI medications according to their impact on the HQYLURQPHQW 7KHUHVXOWVRIWKHHQYLURQPHQWDODVVHVVPHQWRI a selection of drug compounds are displayed here. 7KHFODVVL¿FDWLRQLVEHLQJJUDGXDOO\H[WHQGHGDQG VXEVWDQFHVKDYHEHHQDGGHGWRWKLV\HDU¶VHGL- WLRQ&ODVVL¿FDWLRQLVPDGHRIERWKWKHPHGLFDWLRQ¶V LQKHUHQWDELOLW\WRDIIHFWWKHHQYLURQPHQW HQYLURQ- PHQWDOKD]DUG DQGWKHHQYLURQPHQWDOULVNSRVHG by the pharmaceutical substances when used to WKHLUFXUUHQWH[WHQW 7KHHQYLURQPHQWDOKD]DUGDVVHVVPHQWZDV initiated in 2003 by Stockholm County Council’s HQYLURQPHQWDOGHSDUWPHQW'XULQJWKHFODVVL ¿FDWLRQZDVH[WHQGHGWRDOVRFRYHUDQHQYLURQ mental risk assessment carried out by The Swedish Association of the Pharmaceutical Industry. 6WDUWLQJLQDOOGDWDLH±HQYLURQPHQWDO KD]DUGDVVHVVPHQWVSHUVLVWHQFHELRDFFXPXODWLRQ DQGWR[LFLW\±DUHREWDLQHGIURPWKHHQYLURQPHQWDO information published by The Swedish Association of the Pharmaceutical Industry on www.fass.se. By the year of 2010 all pharmaceuticals being mar- NHWHGLQ6ZHGHQZLOOEHHQYLURQPHQWDOO\DVVHVVHG according to The Swedish Association of the Pharmaceutical Industry. ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 1 Impact of medications on the environment The majority of all medications that patients take DUHH[FUHWHGLQWKHXULQHLQXQFKDQJHGFRQGLWLRQRU as metabolites, and reaches wastewater plants and VRPHWLPHVHYHQZDWHUFRXUVHVDQGJURXQGZDWHU Medications are often adapted to resist biodegrada- WLRQDQGFDQWKHUHIRUHUHPDLQLQWKHHQYLURQPHQW IRUDORQJWLPH6RPHPHGLFDWLRQVKDYHEHHQIRXQG in drinking water, which is a warning sign that the current handling of pharmaceuticals may lead to KHDOWKDQGHQYLURQPHQWDOSUREOHPVLQWKHIXWXUH Access to healthy water is a prerequisite for good health. Since society’s use of chemicals, including pharmaceuticals, is continuously growing, the risk is also increasing that these chemicals will return to us in our food and water supply through nature’s HFRF\FOH:HKDYHOLWWOHNQRZOHGJHRIWKHHIIHFWV that continuously supplied trace quantities of phar- PDFHXWLFDOVDQGRWKHUFKHPLFDOVFRXOGKDYHRQRXU GHYHORSPHQWRXUDELOLW\WRUHVLVWGLVHDVHDQGRXU ZHOOQHVVLQJHQHUDO7KHUHIRUHFDXWLRQLVDGYLVDEOH ,QRWKHUZRUGVHYHQLIZHGRQRWKDYHVFLHQWL¿F proof that pharmaceuticals in nature can cause health problems we should reduce our uninten- WLRQDOH[SRVXUHWRWKHPDVPXFKDVSRVVLEOH

How classification is made Pharmaceutical substances are assessed with UHVSHFWWRHQYLURQPHQWDOULVNDQGHQYLURQPHQWDO KD]DUG (QYLURQPHQWDOULVNUHIHUVWRDFXWHWR[LFULVNWR WKHDTXDWLFHQYLURQPHQW(QYLURQPHQWDOULVNLV EDVHGRQWKHUDWLREHWZHHQSUHGLFWHGHQYLURQPHQWDO FRQFHQWUDWLRQRIWKHVXEVWDQFH 3(& DQGWKHKLJKHVW FRQFHQWUDWLRQRIWKHVXEVWDQFHWKDWGRHVQRWKDYHD KDUPIXOHIIHFWLQWKHHQYLURQPHQW 31(& 

2 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 5LVNLVVSHFL¿HGDV INSIGNIFICANT if PEC/PNEC <0,1 LOW if PEC/PNEC 0,1–1 MODERATE if PEC/PNEC 1–10 HIGH if PEC/PNEC >10 The Swedish Association of the Pharmaceutical ,QGXVWU\EHJDQWRFRQGXFWHQYLURQPHQWDOULVN assessments of pharmaceuticals in 2005; these assessments are to include all medications by 2010. 7KHGUXJJURXSVWKDWKDYHEHHQDGGHGWRWKLV\HDU¶V HGLWLRQDUHSV\FKROHSWLFV 1 QDVDOSUHSDUDWLRQV 5 WKURDWSUHSDUDWLRQV 5 DQWLKLVWDPLQHV IRUV\VWHPLFXVH 5 DQWLWKURPERWLFDJHQWV % DQWLHSLOHSWLFV 1 DQWLSDUNLQVRQGUXJV 1 DQGSV\FKRDQDOHSWLFV 1%  (QYLURQPHQWDOKD]DUGH[SUHVVHVWKHLQKHUHQW HQYLURQPHQWDOO\GDPDJLQJFKDUDFWHULVWLFVRIWKH VXEVWDQFHLQWKHIROORZLQJWHUPV PERSISTENCE – ability to resist degradation in WKHDTXDWLFHQYLURQPHQW BIOACCUMULATION – accumulation in adipose tissue of aquatic organisms – the potential to aquatic organisms Each of these characteristics is assigned a numeri- FDOYDOXH ± 7KHWRWDORIWKHVHYDOXHVFRQVWLWXWHV WKH3%7LQGH[IRUWKHVXEVWDQFH7KH3%7LQGH[FDQ DVVXPHYDOXHVLQWKHLQWHUYDO ± 7KHKD]DUG model was formulated by Stockholm County Council and Apoteket AB. Since 2006 all information about SHUVLVWHQFHELRDFFXPXODWLRQDQGWR[LFLW\DUH obtained from www.fass.se. 0RUHLQIRUPDWLRQLVDYDLODEOHDWWKHQRQ commersial web site Janusinfo, produced by the 6WRFNKROP&RXQW\&RXQFLO www.janusinfo.se/environment

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 3 To read the table THE SUBSTANCEFDQEHIRXQGXQGHUVHYHUDOGLI- IHUHQWGUXJJURXSV)RUH[DPSOHPHWURQLGD]ROHFDQ be found under “A alimentary tract and metabolism” as well as “JDQWLLQIHFWLYHV´6XEVWDQFHVLQGLFDWHG LQEROGDUHLQFOXGHGLQ³.ORND/LVWDQ´ Stockholm County Council’s “Wise List” of recommended drugs IRUFRPPRQGLVHDVHV DQGDUHSUHVHQWHGLQWKHEHJLQ- ning of each section.

THE PBT INDEX is a measure SUBSTANCE RIHQYLURQPHQWDOKD]DUGDQG FDQDVVXPHDOOYDOXHVIURP J Anti-infectives ± WKHWRWDORIP, B and Antibacterials for systemic u the TYDOXH 7KHKLJKHU erythromycin WKHYDOXHRIDVXEVWDQFH amoxicillin s WKHJUHDWHULWVKD]DUGWR in m WKHHQYLURQPHQW trimetoprim o

ofloxacin insi insi

(*) AFTER THE PBT INDEX g indicates that the assessment is uncertain due to lack of data.

7ZRVXEVWDQFHVPD\KDYHWKHVDPHULVNYDOXHVEXW different PBTYDOXHVEXWWKHULVNDVVHVVPHQWFDQDOVR EHGLIIHUHQWHYHQLIWKHPBTYDOXHVDUHWKHVDPH:KHQ DVVHVVLQJDPHGLFDWLRQ¶VHQYLURQPHQWDOLPSDFWFRQVL- GHUDWLRQVKRXOGEHJLYHQWRERWKHQYLURQPHQWDOULVNDQG HQYLURQPHQWDOKD]DUGVLQFHELRDFFXPXODWLRQDQGSHUVLV- tence are not included in the risk assessment.

4 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 RISKUHIHUVWRDFXWHWR[LFULVNWRWKH DTXDWLFHQYLURQPHQWFDOFXODWHGEDVHG on SZHGLVKFRQGLWLRQVDQGLVJLYHQDV LQVLJQL¿FDQWORZPRGHUDWHRUKLJK ³&DQQRWEHH[FO´PHDQVWKDWWKH manufacturer has stated that the documentary basis for assessment RIULVNLVLQVXI¿FLHQW,QIRUPDWLRQ DERXWHQYLURQPHQWDOULVNV P PHUVLVWHQFH FDQ are obtained from DVVXPHWKHYDOXHRU www.fass.se. B BLRDFFXPXODWLRQ FDQ DVVXPHWKHYDOXHRU

T TR[LFLW\ FDQDVVXPH WKHYDOXH± RISK PBT P B T VOLUME IN DDD

se nsignificant 6 3 0326 3 244 oderate 6 3 1 0 3 187 403

ignificant 4 3 0316 1 324 C 274 060 gnificant 9* 3 3* 3 4863 C 198 734 VOLUME IN DDD, total sales in ''' GH- ¿QHGGDLO\GRVHV RIWKH substance in Stockholm County Council during one year. 2FW±6HSW

Indicates ''' for C FRPELQDWLRQGUXJVWDEOHW ''' E GUXJVIRUH[WHUQDOXVHJUDP ''' '''LQGLFDWHGIRUSKDUPDFHXWLFDOVIRUH[WHUQDOXVH and combined products is not based on the amount RIDQDFWLYHVXEVWDQFHDQGFDQWKHUHIRUHQRWEH compared to the ''' for other drugs.

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 5 Reading tips • The book “Environment and Pharmaceuticals”, published by Apoteket AB (the national Corpora- tion of Swedish Pharmacies), Stockholm County Council and Stockholm University. It is also available at the non commercial web site Janusinfo. www.janusinfo.se/imcms/GetDoc?meta_id=7241 • Swedish Environmental Protection Agency: The ability of municipal waste water treatment plants to handle pharmaceutical residues and other harm- ful substances, Report 5794, 2008 (Summary in English). www.naturvardsverket.se/Documents/ publikationer/620-5794-7.pdf • IVL: Woldegiorgis A, Green J, Remberger M, Kaj L, Brorström-Lundén E. Results from the Swedish scre- ening. Subreport 4: Pharmaceuticals, 2006. www3.ivl.se/rapporter/pdf/B1751.pdf • IVL: Andersson J, Woldegiorgis , Remberger M, Kaj L., Ekheden Y et al. Results from the Swedish Natio- nal Screening programme. Sub report 1 Antibiotics, Anti-inflammatory substances and Hormones, 2005. www3.ivl.se/rapporter/pdf/B1689.pdf • The Swedish Medical Products Agency: “ Environ- mental impact from pharmaceuticals as well as cos- metics and hygiene products”, report 2004 (Summary in English). www.lakemedelsverket.se/upload/Om%20LV/ publikationer/040824_miljouppdraget-rapport.pdf • The Swedish Association of the Pharmaceutical Industry’s web site Fass.se. www.fass.se/LIF/miljo_splash/index_en.jsp

6 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD A Alimentary tract and metabolism Stomatological preparations metronidazole insignificant 4 3 0 1 241 117 E 369 760 triamcinolone 4 3 0 1 226 104 E 675 690 Drugs for acid related disorders omeprazole insignificant 4 3 0 1 19 327 222 esomeprazole insignificant 4 3 0 1 3 247 692 C 18 977 lansoprazole insignificant 4 3 0 1 1 577 988 pantoprazole insignificant 4 3 0 1 1 081 219 rabeprazole insignificant 5* 3*0 2 5 014 ranitidine 3* 3*0 0* 2 068 822 and antinauseants 4 3 0 1 62 364 5* 3 0 2* 28 150 tropisetron 9* 3 3* 3 5 274 Antidiarrhoeals, intestinal anti-inflammatory/anti-infective agents budesonide insignificant 8 3 3 2 11 074 776 C 5 256 990 Antiobesity preparations orlistat 8 3 3 2 649 264 Drugs used in diabetes insignificant 5 3 0 2 8 214 307 C 226 604 glibenclamide insignificant 5* 3 0 2* 3 254 935 glimepiride insignificant 6 3 0 3 712 133 glipizide cannot be excl 4* 3*0 1* 302 290 repaglinide cannot be excl 4* 3 0 1* 416 036 pioglitazone cannot be excl – – – – 184 786 C 1 260

B Blood and blood forming organs agents insignificant 5 3 0 2 1 290 894 C 512 510 low 4 3 0 1 4 879 036 acetylsalicylic acid moderate 1 0 0 1 40 750 060 C10 696 786

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 7 SUBSTANCE RISK PBT P B T VOLUME IN DDD tirofiban insignificant 3 3 0 0 73 insignificant 5 3 0 2 1 949 818 insignificant 7* 3 3* 1 96 cannot be excl 6* 3*0 3* 7 164 cannot be excl 6* 3*0 3 9 365 eptifibatide cannot be excl – – 0 – 95

C Cardiovascular system Cardiac therapy glyceryl trinitrate 2 0 0 2 1 352 691 3 3 0 0 – C, E 1 142 397 amiodarone 9* 3*3 3 159 124 Antihypertensives moxonidine insignificant 4 3 0 1 76 802 hydralazine insignificant 5* 3 0 2* 17 989 doxazosin cannot be excl 6* 3 0 3* 903 990 cannot be excl 6* 3 0 3* 21 580 methyldopa cannot be excl – – – – 2 475 insignificant 4 3 0 1 24 745 112 hydrochlortiazide insignificant 4* 3 0 1* 2 829 837 C 22 393 342 bendroflumethiazide cannot be excl 4* 3 0 1* 6 559 787 C 186 489 cannot be excl – – – – 456 528 C 10 319 237 spironolactone cannot be excl – – – – 2 322 523 torasemide insignificant 4 3 0 1 64 633 eplerenone insignificant 6 3 0 3 59 050 bumetanide cannot be excl 4* 3 0 1* 79 336 Beta blocking agents metoprolol insignificant 4 3 0 1 16 377 224 C 772 946 insignificant 4 3 0 1 166 783 carvedilol insignificant 9 3 3 3 873 567 moderate 3 0 0 3 1 166 665 atenolol cannot be excl 4* 3*0 1* 6 098 446 labetalol cannot be excl 6* 3*0 3* 43 082 sotalol cannot be excl 6* 3 0 3* 1 219 039 esmolol cannot be excl – – – – –

8 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD

Calcium channel blockers amlodipine insignificant 6 3 0 3 12 366 352 C 70 336 isradipine insignificant 9 3 3 3 331 244 felodipine low 9 3 3 3 15 447 886 C 772 946 cannot be excl 5* 3 0 2* 645 828 diltiazem cannot be excl 6* 3 0 3* 877 544 Agents acting on the renin-angiotensin system losartan insignificant 3 3 0 0 6 313 398 C3 765 486 enalapril insignificant 3* 3 0 0* 20 988 241 C 2 472 408 ramipril insignificant 6 3 3 0 15 833 547 C 310 298 candesartan cannot be excl 4* 3 0 1* 11 667 221 C 2 465 062 eprosartan insignificant 3 3 0 0 140 588 C 92 498 cilazapril insignificant 4 3 0 1 281 551 C 169 995 irbesartan insignificant 4 3 0 1 2 120 748 C 962 416 valsartan insignificant 4 3 0 1 1 806 321 C 1 325 660 fosinopril insignificant 4* 3 0 1* 26 121 telmisartan insignificant 5 3 0 2 517 356 C 179 312 trandolapril insignificant 6* 3 0 3* C 23 786 lisinopril cannot be excl 3* 3 0 0* 1 108 437 C 201 770 captopril cannot be excl 4* 3 0 1* 674 868 quinapril cannot be excl – – – – 92 040 C 129 200 Lipid modifying agents simvastatin insignificant 4 3 0 1 49 116 867 atorvastatin insignificant 4 3 0 1 12 483 058 fluvastatin insignificant 4 3 0 1 317 057 pravastatin insignificant 4 3 0 1 2 368 970 rosuvastatin insignificant 4 3 0 1 1 533 030

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 9 SUBSTANCE RISK PBT P B T VOLUME IN DDD bezafibrate insignificant 5 3 0 2 130 366 ezetimibe insignificant 6* 3 0 3* 1 366 590 gemfibrozil low 5 3 0 2 340 983 cholestyramine cannot be excl 6* 3 0 3* 132 497 fenofibrate cannot be excl – – – – 153 290 colestipol cannot be excl – – – – 23 060

D Dermatologicals Antifungals ketoconazole moderate 9 3 3 3 3 300 E5 227 740 miconazole 9 3 3 3 482 510 C2 804 125 terbinafine 9* 3*3 3 514 459 E1 196 693 Antipruritics lidocaine 3 3 0 0 – C, E 1 142 397 Antipsoriatics acitretin 9 3 3 3 46 347 Antibiotics and chemotherapeutics metronidazole insignificant 4 3 0 1 241 117 E 369 760 fusidic acid insignificant 5 3 0 2 9 929 E 422 580 oxytetracycline 6* 3*0 3* 10 756 C, E 214 275 gentamicin 6* 3*0 3 7 150 E 135 820 Corticosteroids, dermatological preparations mometasone cannot be excl 9* 3 3 3* 6 536 335 E 5 745 400 triamcinolone 4 3 0 1 226 104 E 675 690 Anti-acne preparations clindamycin 6* 3*0 3* 227 463 E 696 170 Other dermatological preparations finasteride insignificant 8 3 3 2 2 386 452

10 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD G Genito-urinary system and sex hormones Gynecological anti-infectives and antiseptics metronidazole insignificant 4 3 0 1 241 117 E 369 760 Other gynecologicals 9 3 3 3 186 256 cannot be excl – – – – 30 330 Sex hormones and modulators of the genital system desogestrel insignificant 8* 3 3 2* 7 909 776 C 1 774 220 etonogestrel insignificant 8* 3 3 2* 3 106 000 C, E 1 249 668 high 6 0 3 3 6 146 354 C 3 778 265 ethinyl estradiol high 9 3 3 3 C 21 477 195 E 1 249 668 norethisterone cannot be excl 6 3 0 3 1 120 733 C 4 353 507 estriol cannot be excl 6* 3*0 3* 2 043 163 medroxy- cannot be excl – – – – 2 140 430 C 1 254 918 moderate 8 3 3 2 314 202 cyproterone cannot be excl 8 3 3 2 25 145 C 584 892 dydrogesterone cannot be excl 8 3 3 2 3 840 drospirenone cannot be excl 8* 3 3* 2 C 3 775 380 cannot be excl – – – – 675 608 Urologicals sildenafil insignificant 2 0 0 2 478 718 alfuzosin insignificant 4* 3*0 1 4 217 265 tadalafil insignificant 5 3 0 2 430 044 finasteride insignificant 8 3 3 2 2 386 452 tolterodine cannot be excl 6* 3*0 3* 1 672 203 solifenacin cannot be excl – – 0 – 1 054 322 vardenafil cannot be excl – – – – 67 794 darifenacin insignificant 6 3 0 3 388 948 terazosin cannot be excl 6* 3 0 3* 555 142 dutasteride cannot be excl 8* 3 3 2* 786 450 oxybutynin cannot be excl – – – – 119 062

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 11 SUBSTANCE RISK PBT P B T VOLUME IN DDD H Hormones excluding sex hormones Corticosteroids for systemic use triamcinolone 4 3 0 1 226 104 E 675 690

J Anti-infectives Antibacterials for systemic use trimetoprim insignificant 4 3 0 1 316 324 C 198 734 metronidazole insignificant 4 3 0 1 241 117 E 369 760 nitrofurantoin insignificant 5 3 0 2 207 166 erythromycin insignificant 6 3 0 3 326 244 sulfamethoxazole insignificant 6 3 0 3 C 198 734 pivmecillinam insignificant 6 3 3 0 380 999 amoxicillin moderate 6 3 0 3 1 187 403 C 274 060 ciprofloxacin cannot be excl 5 3 0 2 563 660 cefadroxil cannot be excl – – – – 148 309 phenoxymethyl- cannot be excl – – 0 – 3 300 748 penicillin flucloxacillin cannot be excl – – 0 – 1 125 283 cefepime insignificant 3 3 0 0 545 ceftriaxone insignificant 3 3 0 0 7 322 cefuroxime insignificant 3 3 0 0 98 996 ertapenem insignificant 3 3 0 0 1 233 cefotaxime insignificant 3* 3 0 0* 25 365 moxifloxacin insignificant 4 3 0 1 12 158 piperacillin insignificant 5 3 0 2 15 263 clarithromycin insignificant 6 3 0 3 62 938 C 18 977 levofloxacin insignificant 8* 3 3* 2 17 504 ofloxacin insignificant 9* 3 3* 3 3 486 telitromycin insignificant 9 3 3 3 80 tetracycline low 5 3 0 2 234 346 azitromycin low 6 3 0 3 48 517 ceftazidime low 6 3 0 3 10 205 imipenem cannot be excl 1* 0 0 1* 9 841 inhibitor insignificant 3* 3 0 0* ampicillin cannot be excl 3* 3 0 0* 11 374 meropenem cannot be excl 3* 3 0 0* 20 155 cannot be excl 4* 3 0 1* 27 196

12 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD norfloxacin cannot be excl 5* 3*0 2 118 125 aztreonam cannot be excl 6* 3*0 3 158 cloxacillin cannot be excl 6* 3 0 3* 91 879 amikacin cannot be excl – – – – 1 568 dicloxacillin cannot be excl – – – – 2 020 metenamine cannot be excl – – – – 1 295 961 gentamicin 6* 3*0 3 7 150 E 135 820 oxytetracycline 6* 3*0 3* 10 756 C, E 214 275 Antimycotics for systemic use, excluding griseofulvin fluconazole cannot be excl 4* 3*0 1 143 232 caspofungin insignificant 6 3 0 3 2 889 ketoconazole moderate 9 3 3 3 3 300 E5 227 740 amfotericin cannot be excl – – – – 46 114 Antimycobacterials isoniazid insignificant 4 3 0 1 122 900 C 345 Antivirals for systemic use acyclovir insignificant 4 3 0 1 97 601 E 180 219 stavudine insignificant 0 0 0 0 2 380 foscarnet insignificant 3 3 0 0 241 valganciclovir insignificant 3 3 0 0 10 080 didanosine insignificant 3* 3 0 0* 25 508 ribavirin insignificant 4 3 0 1 49 138 abacavir insignificant 4 3 0 1 22 396 C 68 490 lamivudine insignificant 4 3 0 1 63 368 C 68 490 oseltamivir insignificant 4 3 0 1 2 580 nevirapine insignificant 4 3 0 1 59 418 famciclovir insignificant 4* 3 0 1* 4 770 valaciclovir insignificant 4* 3 0 1* 187 073 zidovudine insignificant 4* 3 0 1* 14 095 C 68 490 atazanavir insignificant 5 3 0 2 136 240 indinavir insignificant 5 3 0 2 1 440 nelfinavir insignificant 6 3 3 0 100 saquinavir insignificant 7 3 3 1 1 530 insignificant 9 3 3 3 150 413 zanamivir cannot be excl 3* 3 0 0* 370

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 13 SUBSTANCE RISK PBT P B T VOLUME IN DDD amprenavir cannot be excl 4* 3 0 1* –

L Antineoplastic and immunomodulating agents Antineoplastic agents temozolomide insignificant 1 0 0 1 – hydroxycarbamide insignificant 3 3 0 0 – insignificant 3* 3*0 0 insignificant 5 3 0 2 – insignificant 5 3 0 2 – cladribine insignificant 5* 3*0 2 – capecitabine insignificant 6 3 0 3 – sunitinib insignificant 6* 3*0 3 – erlotinib insignificant 6* 3 0 3* – insignificant 9* 3 3 3* – doxorubicin insignificant – – – 2* – bortezomib insignificant –––3 – topotecan cannot be excl 1* 0 0 1* – busulfan cannot be excl 2* 0 0 2* – chlorambucil cannot be excl 2* 0 0 2* – melphalan cannot be excl 2* 0 0 2* – etoposide cannot be excl 3* 3*0 0* – carboplatin cannot be excl 4* 3*0 1* – mercaptopurine cannot be excl 4* 3 0 1* – cyclophosphamide cannot be excl 5 3 0 2 – tioguanine cannot be excl 6 3 0 3 – ifosfamide cannot be excl 6* 3 0 3* – methyl cannot be excl 6* 3 0 3* – aminolevulinate oxaliplatin cannot be excl 6* 3 0 3* – paclitaxel cannot be excl 6* 0 3 3* – docetaxel cannot be excl 9* 3 3* 3 – amsacrine cannot be excl – – – – – cannot be excl – – – – – bleomycin cannot be excl – – – – – cytarabine cannot be excl – – – – – clofarabine cannot be excl – – – – daunorubicin cannot be excl – – – – – epirubucin cannot be excl – – – – – estramustine cannot be excl – – – – – idarubicin cannot be excl – – – – – miltefosine cannot be excl – – – – – mitomycin 6 3 0 3 –

14 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD cisplatin 6* 3*0 3 – Endocrine therapy estradiol high 6 0 3 3 6 146 354 C 3 778 265 medroxyprogesterone cannot be excl – – – – 2 140 430 C 1 254 918 megestrol 9 3 3 3 490 9 3 3 3 940 738 Immunosuppressive agents everolimus 8 3 3 2 5 682 leflunomide 8 3 3 2 51 970

M Musculo-skeletal system Antiinflammatory and antirheumatic products insignificant 2 0 0 2 13 363 692 C, E 1 453 395 insignificant 4 3 0 1 8 332 510 C, E 10 015 675 low 4 3 0 1 3 441 193 cannot be excl – – – – 475 910 insignificant 4 3 0 1 22 511 insignificant 4 3 0 1 103 505 insignificant 5 3 0 2 1 240 417 glucosamine low 1 0 0 1 4 397 212 cannot be excl 5* 3 0 2* 169 105 cannot be excl 7* 3* 3 1 2 009 344 E 8 835 520 sodium- cannot be excl – – – – 6 875 aurothiomalate cannot be excl – – – – 14 050 4 3 0 1 132 740 Topical products for joint and muscular pain ibuprofen insignificant 2 0 0 2 13 363 692 C, E 1 453 395 diclofenac insignificant 4 3 0 1 8 332 510 C, E 10 015 675 diethylaminosalicylate cannot be excl 1* 0 0 1* E 956 200 ketoprofen cannot be excl 7* 3*3 1 2 009 344 E 8 835 520 Muscle relaxing drugs atracurium cannot be excl 2* 0 0 2* – cisatracurium cannot be excl 2* 0 0 2* –

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 15 SUBSTANCE RISK PBT P B T VOLUME IN DDD baclofen cannot be excl 3* 3 0 0* 361 225 cannot be excl 3* 3 0 0* – cannot be excl – – – – 212 482 suxamethonium cannot be excl – – – – – Antigout preparations moderate 6 3 0 3 1 612 681 probenecid cannot be excl – – – – 119 194 Drugs for treatment of bone diseases alendronic acid insignificant 6 3 0 3 3 396 149 C263 564 ibandronic acid insignificant 2 0 0 2 526 723 clodronic acid insignificant 4 3 0 1 18 528 pamidronic acid insignificant 4* 3*0 1* 2 605 etidronic acid insignificant 5 3 0 2 6 412 C 13 860 zoledronic acid insignificant 5* 3 0 2* 2 089 risedronic acid insignificant 6* 3*0 3 1 349 600 C 18 508

N Nervous system Anaesthetics lidocaine 3300 – C, E 1 142 397 prilocaine 4301 – cannot be excl 8* 3 3 2* 467 037 excl inj liquid ropivacaine 4 3 0 1 – 9 3 3 3 – insignificant 4 3 0 1 89 233 C 5 762 956 insignificant 4 3 0 1 723 763 low 5 3 0 2 24 494 039 C5 799 512 acetylsalicylic acid moderate 1 0 0 1 40 750 060 C10 696 786 cannot be excl – – – – 367 719 C192 232 cannot be excl – – – – 450 771 C44 823 insignificant 3 3 0 0 C 62 438 insignificant 3 3 0 0 9 012

16 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD insignificant 4 3 0 1 259 615 insignificant 6* 3 0 3* 34 563 low 7 3 3 1 C 51 803 cannot be excl 4* 3 0 1* 321 712 dextropropoxiphene cannot be excl 8* 3 3 2* 1 552 908 C 263 cannot be excl 8* 3*3 2* 21 718 fentanyl cannot be excl 8* 3 3 2* 467 037 excl inj liquid cannot be excl – – – – 1 549 cannot be excl – – – – 2 635 485 Antiepileptics insignificant 4 3 0 1 1 166 333 valproic acid cannot be excl 4* 3 0 1* 1 059 700 cannot be excl – – – – 647 861 zonisamide insignificant 1 0 0 1 34 960 insignificant 4 3 0 1 132 822 lamotrigine insignificant 4 3 0 1 894 241 oxcarbazepine cannot be excl 3 3 0 0 65 228 vigabatrin cannot be excl 4* 3*0 1* 13 046 ethosuximide cannot be excl – – – – 10 916 phenytoin cannot be excl – – – – 542 783 felbamate cannot be excl – – – – 338 fosphenytoin cannot be excl – – – – 5 941 Anti-Parkinson drugs benserazide insignificant 5 3 0 2 C 846 373 levodopa cannot be excl 2 0 0 2 C 986 275 carbidopa cannot be excl 5* 3*0 2* C 986 275 insignificant 4 3 0 1 266 057 entacapone low 5* 3 0 2* 120 608 C 139 902 selegiline insignificant – – 0 – 135 061 rasagiline cannot be excl – – – 3* 74 900 cabergoline cannot be excl – – – – 30 330 tolcapone cannot be excl – – – – 6 624 trihexyphenidyl cannot be excl – – – – 197 137 bromocriptine 9 3 3 3 186 256 Psycholeptics insignificant 8 3 3 2 728 840 zopiclone cannot be excl 8* 3 3* 2* 13 495 085 oxazepam cannot be excl – – 0 – 2 239 099 cannot be excl – – 3 – 384 479

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 17 SUBSTANCE RISK PBT P B T VOLUME IN DDD propiomazine cannot be excl – – – – 9 825 769 6* 3*0 3* 2 533 688 clometiazole insignificant 4 3 0 1 153 330 nitrazepam insignificant 4 3 0 1 1 366 562 palperidone insignificant 4 3 0 1 84 insignificant 5 3 0 2 93 942 zolpidem insignificant 5 3 0 2 8 337 012 aripirazol insignificant 6 3 0 3 212 976 olanzapin insignificant 6 3 0 3 1 315 301 insignificant 8* 3*3 2 575 272 insignificant 9 3 3 3 326 469 flunitrazepam cannot be excl 4 3 0 1 1 271 528 cannot be excl 4 * 3 0 1* 293 678 cannot be excl 6 3 0 3 159 421 fluphenazine cannot be excl 6* 3 0 3* 23 475 cannot be excl 8* 3 3* 2* 6 321 cannot be excl – –- 0 – 1 863 622 cannot be excl – – – 3* 1 388 flupentixol cannot be excl – – – 3* 171 937 cannot be excl – – – 3* 24 124 cannot be excl – – – 3* 434 459 cannot be excl – – – – 16 005 alprazolam cannot be excl – – – – 1 708 333 cannot be excl – – – – 128 936 cannot be excl – – – – 134 340 triazolam cannot be excl – – – – 100 795 zaleplon cannot be excl – – – – 299 390 Psychoanaleptics insignificant 5 3 0 2 1 711 479 venlafaxine insignificant 5* 3*0 2 4 007 271 insignificant 6* 3 0 3* 1 218 156 insignificant 8* 3 3 2* 3 826 282 citalopram insignificant 9* 3 3 3* 13 415 178 sertraline moderate 6 3 0 3 9 523 995 galanthamine 6 3 0 3 753 960 6 3 0 3 553 491 moclobemide insignificant 4 3 0 1 119 084 insignificant 6 3 0 3 119 347 fluvoxamine insignificant 6 3 0 3 52 981 insignificant 6* 3*0 3 1 731 896 paroxetine insignificant 6* 3 0 3* 1 882 889 escitalopram insignificant 9* 3 3 3* 3 058 558 fluoxetine low 6 3 0 3 3 214 993

18 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD low 9 3 3 3 219 666 cannot be excl 6 3 0 3 12 339 cannot be excl 9* 3 3 3* 72 574 modafinil cannot be excl – – – – 126 710 reboxetin cannot be excl – – – – 135 627 rivastigmine 5 3 0 2 215 895 6 3 0 3 17 421 9 3 3 3 1 338 Other nervous system drugs 6 3 0 3 175 900 pyridostigmine 6* 3*0 3 83 927 8* 3 3* 2 29 484

P Antiparasitic products, insecticides and repellents Antiprotozoals metronidazole insignificant 4 3 0 1 241 117 E 369 760 proguanil 4 3 0 1 12 900 C 71 105 artemether 7* 3 3* 1 – atovaquone 9* 3*3 3 316 C 71 105 Ectoparasiticides, including scabicides, insecticides, and repellents permetrin 9* 3*3 3 –

R Respiratory system Nasal preparations ipratropium insignificant 5* 3 0 2* 1 320 279 budesonide insignificant 8 3 3 2 11 074 776 C5 256 990 oxymetazoline cannot be excl 5* 3*0 2* 6 710 175 mometasone cannot be excl 9* 3 3 3* 6 536 335 E 5 745 400 levocabastine insignificant 5 3 0 2 314 063 sodium cromoglicate cannot be excl 3* 3 0 0* 270 704 fluticasone cannot be excl 6* 3 0 3* 1 773 537 fluticasone furoate cannot be excl 6* 3 0 3* 36 060 beclometasone cannot be excl 9* 3 3 3* 387 173

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 19 SUBSTANCE RISK PBT P B T VOLUME IN DDD triamcinolone 4 3 0 1 226 104 E 675 690 cannot be excl – – – – C 40 200 Throat preparations gramicidin cannot be excl – – – – 1 165 701 Drugs for obstructive airway diseases terbutaline insignificant 3 3 0 0 4 575 546 formoterol insignificant 4 3 0 1 1 049 636 C5 256 990 tiotropium bromide insignificant 4* 3 0 1* 2 861 770 salmeterol insignificant 5 3 0 2 529 890 ipratropium insignificant 5* 3 0 2* 1 320 279 budesonide insignificant 8 3 3 2 11 074 776 C5 256 990 salbutamol cannot be excl 4* 3 0 1* 2 791 132 C460 320 fluticasone cannot be excl 6* 3 0 3* 1 773 537 bambuterol insignificant 4 3 0 1 13 619 ephedrine cannot be excl 0* 0 0 0* 61 295 C 1 100 482 cannot be excl 1* 0 0 1* 265 744 montelukast cannot be excl 3* 0 0 3* 1 833 843 sodium cromoglicate cannot be excl 3* 3 0 0* 270 704 beclometasone cannot be excl 9* 3 3 3* 387 173 mometasone cannot be excl 9* 3 3 3* 6 536 335 E 5 745 400 cannot be excl – – 0 – 11 466 theophyllinate Cough and cold preparations cannot be excl – – – – C 3 134 668 noscapine cannot be excl – – – – 1 013 704 C 44 823 codeine insignificant 4 3 0 1 89 233 C 5 762 956 bromhexine insignificant 4* 3 0 1* 2 080 815 C 937 540 ambroxol insignificant 5 3 0 2 296 759 insignificant 5 3 0 2 C 325 957 cannot be excl – – – – C 294 554 guaifenesin cannot be excl – – 0 – 13 245 C 294 554 quillaia cannot be excl – – – – C 294 554 pentoxyverine cannot be excl – – – – 17 422

20 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 SUBSTANCE RISK PBT P B T VOLUME IN DDD

Antihistamines for systemic use loratadine low 3 0 0 3 7 293 410 clemastine cannot be excl 9* 3*3 3 864 568 cannot be excl – – – 3* 2 135 898 cetirizine cannot be excl – – 0 – 6 264 365 meclozine cannot be excl – – – – 541 568 desloratadine insignificant 5 3 0 2 4 657 318 insignificant 6 3 0 3 12 015 fexofenadine insignificant 6* 3 3* 0 577 608 ebastine insignificant 8 3 3 2 1 924 580 cannot be excl 9* 3 3 3* 9 132 acrivastine cannot be excl – – 0 – 27 032 cannot be excl – – – – 42 542 dexchlorfeniramine cannot be excl – – – – 160 565 mizolastine cannot be excl – – – – 6 400

S Sensory organs Ophthalmologicals fusidic acid insignificant 5 3 0 2 9 929 E 422 580 sodium cromoglicate cannot be excl 3* 3 0 0* 270 704 9* 3 3* 3 – Otologicals oxytetracycline 6* 3*0 3* 10 756 C, E 214 275

V Various Antidotes for , overdoses, etc naloxone 4 3 0 1 – Contrast media mangafodipir 4 3 0 1 –

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 21 Substances without environmental risk 7KHXVHRIYLWDPLQHVHOHFWURO\WHVDPLQRDFLGV SHSWLGHVSURWHLQHVFDUERK\GUDWHVOLSLGVYDFFLQHV and drugs based on herbes are not considered as DULVNWRWKHHQYLURQPHQW7KDWLVWKHUHDVRQZK\ WKHVHVXEVWDQFHVKDYHQRWUHFHLYHGHQYLURQPHQWDO information.

Example

B Blood and blood forming organs Antithrombotic agents Antihemorrhagics tranexamic acid aprotinin phytomenadione Antianemic preparations cyanocobalamin Blood substitutes and perfusion solutions sodium chloride

L Antineoplastic and immunomodulating agents Antineoplastic agents alemtuzumab rituximab trastuzumab Endocrine therapy buserelin leuprorelin triptorelin Immunostimulants filgrastim glatiramer interferon

22 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 lenograstim pegfilgrastim tasonermin

Immunosuppressive agents adalimumab anakinra basiliximab daclizumab efalizumab etanercept immunoglobulin infliximab muromonab

N Nervous system Psycholeptics lithium

R Respiratory system Drugs for obstructive airway diseases omalizumab Cough and cold preparations acetylcysteine

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 23 Vocabulary ATC: $QDWRPLF7KHUDSHXWLF&KHPLFDOFODVVL¿- FDWLRQV\VWHP DFODVVL¿FDWLRQV\VWHPIRUGUXJV 7KHGUXJVDUHGLYLGHGLQWRIRXUWHHQPDLQJURXSV according to the organ or system on which they act and their chemical, pharmacological and therapeutic properties. ATC is used by WHO. The VDPHVXEVWDQFHPD\KDYHVHYHUDOGLIIHUHQW$7& FODVVL¿FDWLRQVLIWKHVXEVWDQFHLVDSDUWRIVHYHUDO groups and is being sold in combinations with other substances. Bioaccumulation: accumulation in adipose tissue of aquatic organisms, according to the 2(&'EDVHGRQWKHSDUWLWLRQFRHI¿FLHQW n-octanol/water, Pow, in which substances with log Pow >3 are judged to be potentially bio- DFFXPXODWLQJ 2(&'WHVWRU  DDD: 'H¿QHG'DLO\'RVHV 7KH'''LVWKH DVVXPHGDYHUDJHPDLQWHQDQFHGRVHSHUGD\IRU a drug used for its main indication in adults. '''VDUHQRWHVWDEOLVKHGIRUDOOSUHSDUDWLRQV,Q 6ZHGHQ'''VDUHDOVRXVHGIRUHVWLPDWLQJSKDU- PDFHXWLFDOVIRUH[WHUQDOXVH JUDP '''  The estimation is not based on the amount of an DFWLYHVXVEVWDQFHDQGFDQWKHUHIRUHQRWEHFRP- SDUHGWRWKH'''IRURWKHUGUXJV Environmental hazard: WKHLQKHUHQWHQYLURQ- mentally damaging characteristics of the sub- VWDQFHLQWKHIROORZLQJWHUPVPersistence, Bio- accumulation and TR[LFLW\ 3%7 7KH6WRFNKROP County Council makes use of the information from the producer about PBT in order to create D3%7LQGH[ SOHDVH¿QGIXUWKHULQIRUPDWLRQRQ QH[WSDJH  Environmental risk: UHIHUVWRDFXWHWR[LFULVNWR WKHDTXDWLFHQYLURQPHQWDQGLVEDVHGRQ 3(&31(&

24 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 PBT-index: WKHWRWDORIWKHYDOXHVIRUPersistence, Bioaccumulation and TR[LFLW\FRPSULVHVWKH3%7 LQGH[RIWKHVXEVWDQFH PEC: 3UHGLFWHG(QYLURQPHQWDO&RQFHQWUDWLRQ  SUHGLFWHGHQYLURQPHQWDOFRQFHQWUDWLRQRIWKH substance. Persistence: ability to resist degradation in the DTXDWLFHQYLURQPHQW7KHELRGHJUDGDELOLW\LVDV- sessed based on criteria for ready biodegradation DFFRUGLQJWRWKH2(&'¶VWHVWJXLGHOLQHV WHVW  RUDQRWKHUHTXLYDOHQWWHVWRIELRGHJUDGDELOLW\ PNEC: 3UHGLFWHG1R(IIHFW&RQFHQWUDWLRQ WKH highest concentration of the substance that does QRWKDYHDKDUPIXOHIIHFWLQWKHHQYLURQPHQW Toxicity: the potential to poison aquatic orga- QLVPV7R[LFLW\IRUDTXDWLFRUJDQLVPVLVDVVHVVHG EDVHGRQWKHUHVXOWVRIWR[LFLW\WHVWVLQFOXGLQJ WKUHHWURSKLFOHYHOV¿VK'DSKQLDDQGDOJDH 2(&'WHVWJXLGHOLQHVDQGRUHTXL- YDOHQW 'DWDIRUWKHPRVWVHQVLWLYHRUJDQLVPVDUH used in the assessment.

Precautionary Principle According to the precautionary principle PHDVXUHVFDQEHPDGHLIWKHUHLVUHDVRQWREHOLHYH WKDWDSURGXFWRUDPHWKRGRISURGXFWLRQLQYROYHV unacceptable risks to the health of human beings, DQLPDOVSODQWVDQGWKHHQYLURQPHQW±HYHQLI WKHUHLVQRGH¿QLWLYHVFLHQWL¿FSURRIRIVXFKDQ effect. The precautionary principle is a part of (8ODZDQGLVYDOLGLQDOOPHPEHUFRXQWULHV

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 25 Index

Substance ...... Page abacavir ...... 13 acetylcysteine ...... 23 acetylsalicylic acid ...... 7,16 acitretin ...... 10 acrivastine ...... 21 acyclovir ...... 13 adalimumab ...... 23 alemtuzumab ...... 22 alendronic acid ...... 16 alfuzosin ...... 11 alimemazine ...... 21 allopurinol ...... 16 alprazolam ...... 18 ambroxol ...... 20 amfotericin ...... 13 amikacin ...... 13 amiloride ...... 8 amiodarone ...... 8 amitriptyline ...... 18 amlodipine ...... 9 amoxicillin ...... 12 ampicillin ...... 12 amprenavir ...... 14 amsacrine ...... 14 anagrelide ...... 14 anakinra ...... 23 aprotinin ...... 22 argatroban ...... 8 aripirazol ...... 18 artemether ...... 19 atazanavir ...... 13 atenolol ...... 8 atomoxetine ...... 18 atorvastatin ...... 9 atovaquone ...... 19 atracurium ...... 15 azitromycin ...... 12 aztreonam ...... 13 baclofen ...... 16 bambuterol ...... 20 basiliximab ...... 23 beclometasone ...... 19, 20 bendroflumethiazide ...... 8 benserazide ...... 17 benzylpenicillin ...... 12 bezafibrate ...... 10 bleomycin ...... 14

26 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 Substance ...... Page bortezomib ...... 14 bromhexine ...... 20 bromocriptine ...... 11,17 budesonide ...... 7,19, 20 bumetanide ...... 8 buprenorphine ...... 16 bupropion ...... 19 buserelin ...... 22 buspirone ...... 18 busulfan ...... 14 cabergoline ...... 11, 17 candesartan ...... 9 capecitabine ...... 14 captopril ...... 9 carbamazepine ...... 17 carbidopa ...... 17 carboplatin ...... 14 carvedilol ...... 8 caspofungin ...... 13 cefadroxil ...... 12 cefepime ...... 12 cefotaxime ...... 12 ceftazidime ...... 12 ceftriaxone ...... 12 cefuroxime ...... 12 cetirizine ...... 21 cetuximab ...... 22 chlorambucil ...... 14 chlorcyclizine ...... 20 chlorprothixene ...... 18 chlorzoxazone ...... 16 cholestyramine ...... 10 ...... 20 cilazapril ...... 9 ciprofloxacin ...... 12 cisatracurium ...... 15 cisplatin ...... 15 citalopram ...... 18 cladribine ...... 14 clarithromycin ...... 12 clemastine ...... 21 clindamycin ...... 10 clodronic acid ...... 16 clofarabine ...... 14 clometiazole ...... 18 clomipramine ...... 18 clonazepam ...... 17 clonidine ...... 8

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 27 Substance ...... Page clopidogrel ...... 8 cloxacillin ...... 13 clozapine ...... 18 codeine...... 16, 20 colestipol ...... 10 cyanocobalamin ...... 22 cyclophosphamide ...... 14 cyproheptadine ...... 21 cyproterone ...... 11 cytarabine ...... 14 daclizumab ...... 23 darifenacin ...... 11 dasatinib ...... 14 daunorubicin ...... 14 desloratadine ...... 21 desogestrel ...... 11 dexbrompheniramine ...... 20 dexchlorfeniramine ...... 21 dextropropoxiphene ...... 17 diazepam ...... 18 diclofenac ...... 15 dicloxacillin ...... 13 didanosine ...... 13 diethylaminosalicylate ...... 15 diltiazem ...... 9 dimenhydrinate ...... 21 diphenhydramine ...... 20 dipyridamole ...... 7 docetaxel ...... 14 doxazosin ...... 8 doxorubicin ...... 14 drospirenone ...... 11 duloxetine ...... 18 dutasteride ...... 11 dydrogesterone ...... 11 ebastine ...... 21 efalizumab ...... 23 efavirenz ...... 13 eletriptan ...... 17 enalapril ...... 9 entacapone ...... 17 ephedrine ...... 20 epirubucin ...... 14 eplerenone ...... 8 eprosartan ...... 9 eptifibatide ...... 8 ergotamine ...... 17 erlotinib ...... 14

28 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 Substance ...... Page ertapenem ...... 12 erythromycin ...... 12 escitalopram ...... 18 esmolol ...... 8 esomeprazole ...... 7 estradiol ...... 11,15 estramustine ...... 14 estriol ...... 11 etanercept ...... 23 ethosuximide ...... 17 ethylmorphine ...... 20 etidronic acid ...... 16 etinyl estradiol ...... 11 etonogestrel ...... 11 etoposide ...... 14 etoricoxib ...... 15 everolimus ...... 15 ezetimibe ...... 10 famciclovir ...... 13 felbamate ...... 17 felodipine ...... 9 fenofibrate ...... 10 fentanyl ...... 16, 17 fexofenadine ...... 21 filgrastim ...... 22 finasteride ...... 10, 11 flucloxacillin ...... 12 fluconazole ...... 13 flunitrazepam ...... 18 fluoxetine ...... 18 flupentixol ...... 18 fluphenazine ...... 18 fluticasone ...... 19, 20 fluticasone furoate ...... 19 fluvastatin ...... 9 fluvoxamine ...... 18 fondaparinux ...... 8 formoterol ...... 20 foscarnet ...... 13 fosinopril ...... 9 fosphenytoin ...... 17 furosemide ...... 8 fusidic acid ...... 10, 21 gabapentin ...... 17 galanthamine ...... 18 gemcitabine ...... 14 gemfibrozil ...... 10 gentamicin ...... 10,13

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 29 Substance ...... Page glatiramer ...... 22 glibenclamide ...... 7 glimepiride ...... 7 glipizide ...... 7 glucosamine ...... 15 glyceryl trinitrate ...... 8 gramicidin ...... 20 granisetron ...... 7 guaifenesin ...... 20 haloperidol ...... 18 hydralazine ...... 8 hydrochlortiazide ...... 8 hydroxycarbamide ...... 14 hydroxyzine ...... 18 ibandronic acid ...... 16 ibuprofen ...... 15 idarubicin ...... 14 ifosfamide ...... 14 imatinib ...... 14 imipenem ...... 12 imipramine ...... 19 immunoglobulin ...... 23 indinavir ...... 13 indometacin ...... 15 infliximab ...... 23 interferon ...... 22 ipratropium ...... 19, 20 irbesartan ...... 9 isoniazid ...... 13 isradipine ...... 9 ketoconazole ...... 10, 13 ketoprofen ...... 15 ketorolac ...... 15 ketotifen ...... 21 labetalol ...... 8 lamivudine ...... 13 lamotrigine ...... 17 lansoprazole ...... 7 leflunomide ...... 15 lenograstim ...... 23 leuprorelin ...... 22 levocabastine ...... 19 levodopa ...... 17 levofloxacin ...... 12 levomepromazine ...... 18 lidocaine ...... 8,10,16 lisinopril ...... 9 lithium ...... 23

30 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 Substance ...... Page loratadine ...... 21 lorazepam ...... 18 losartan ...... 9 mangafodipir ...... 21 maprotiline ...... 19 meclozine ...... 21 medroxyprogesterone ...... 11,15 megestrol ...... 15 meloxicam ...... 15 melphalan ...... 14 mercaptopurine ...... 14 meropenem ...... 12 melperone ...... 18 metenamine ...... 13 metformin ...... 7 methyl aminolevulinate ...... 14 methyldopa ...... 8 methylphenidate ...... 18 metoprolol ...... 8 metronidazole ...... 7,10,11, 12, 19 mianserin ...... 19 miconazole ...... 10 midazolam ...... 18 miltefosine ...... 14 mirtazapine ...... 18 mitomycin ...... 14 mivacurium chloride ...... 16 mizolastine ...... 21 moclobemide ...... 18 modafinil ...... 19 mometasone ...... 10,19, 20 montelukast ...... 20 morphine ...... 16 moxifloxacin ...... 12 moxonidine ...... 8 muromonab ...... 23 nabumetone ...... 15 naloxone ...... 21 naproxen ...... 15 naratriptan ...... 16 nelfinavir ...... 13 nevirapine ...... 13 nifedipine ...... 9 nitrazepam ...... 18 nitrofurantoin ...... 12 noretisterone ...... 11 norfloxacin ...... 13 nortriptyline ...... 19 noscapine ...... 20

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 31 Substance ...... Page ofloxacin ...... 12 olanzapin ...... 18 omalizumab ...... 23 omeprazole ...... 7 ondansetron ...... 7 orlistat ...... 7 oseltamivir ...... 13 oxaliplatin ...... 14 oxazepam ...... 17 oxcarbazepine ...... 17 oxybutynin ...... 11 oxymetazoline ...... 19 oxytetracycline ...... 10,13, 21 paclitaxel ...... 14 palperidone ...... 18 pamidronic acid ...... 16 pantoprazole ...... 7 paracetamol ...... 16 paroxetine ...... 18 pegfilgrastim ...... 23 pemetrexed ...... 14 pentoxyverine ...... 20 permetrin ...... 19 perphenazine ...... 17 pethidine ...... 17 phenazone ...... 16 phenoxymethylpencillin ...... 12 phenytoin ...... 17 phytomenadione ...... 22 pindolol ...... 8 pioglitazone ...... 7 piperacillin ...... 12 pivmecillinam ...... 12 pizotifen ...... 17 pramipexole ...... 17 pravastatin ...... 9 prilocaine ...... 16 probenecid ...... 16 prochlorperazine ...... 18 proguanil ...... 19 propiomazine ...... 18 propofol ...... 16 propranolol ...... 8 pyridostigmine ...... 19 quillaia ...... 20 quinapril ...... 9 rabeprazole ...... 7 raloxifene ...... 11

32 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 Substance ...... Page ramipril ...... 9 ranitidine ...... 7 rasagiline ...... 17 reboxetin ...... 19 repaglinide ...... 7 ribavirin ...... 13 riluzole ...... 19 risedronic acid ...... 16 risperidone ...... 17 rituximab ...... 22 rivastigmine ...... 19 rizatriptan ...... 17 ropivacaine ...... 16 rosuvastatin ...... 9 salbutamol ...... 20 salmeterol ...... 20 saquinavir ...... 13 selegiline ...... 17 sertindole ...... 18 sertraline ...... 18 sildenafil ...... 11 simvastatin ...... 9 sodium aurothiomalate ...... 15 sodium chloride ...... 22 sodium cromoglicate ...... 19, 20, 21 solifenacin ...... 11 sotalol ...... 8 spironolactone ...... 8 stavudine ...... 13 sulfamethoxazole ...... 12 sulindac ...... 15 sumatriptan...... 16 sunitinib ...... 14 suxamethonium ...... 16 tadalafil ...... 11 tamoxifen ...... 15 tasonermin ...... 23 telitromycin ...... 12 telmisartan ...... 9 temozolomide ...... 14 tenoxicam ...... 15 terazosin ...... 11 terbinafine ...... 10 terbutaline ...... 20 testosterone ...... 11 tetracycline ...... 12 theophylline ...... 20 thiethylperazine ...... 21

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 33 Substance ...... Page ticlopidine ...... 8 tinzaparin sodium ...... 22 tioguanine ...... 14 tiotropium bromide ...... 20 tirofiban ...... 8 tolcapone ...... 17 tolterodine ...... 11 topotecan ...... 14 torasemide ...... 8 tramadol ...... 17 trandolapril ...... 9 tranexamic acid ...... 22 trastuzumab ...... 22 triamcinolone ...... 7,10,12, 20 triazolam ...... 18 trihexyphenidyl ...... 17 trimetoprim ...... 12 trimipramine ...... 19 triptorelin ...... 22 tropisetron ...... 7 valaciclovir ...... 13 valganciclovir ...... 13 valproic acid ...... 17 valsartan ...... 9 vardenafil ...... 11 venlafaxine ...... 18 vigabatrin ...... 17 warfarin ...... 7 zaleplon ...... 18 zanamivir ...... 13 zidovudine ...... 13 ziprasidone ...... 18 zoledronic acid ...... 16 zolmitriptan ...... 17 zolpidem ...... 18 zonisamide ...... 17 zopiclone ...... 17 zuclopenthixol ...... 18

34 ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 WHAT YOU CAN DO • Follow “Kloka Listan” (Stockholm County Council’s “Wise List” of recommended drugs for common diseases). Always take cost- effectiveness and environmental impact into account when comparing medications that are equally safe and suitable for the purpose. • Prescribe starter packs. • Prescribe refill packs if available. • Encourage patients to return unused medications to the pharmacy. • Inform patients of the importance of also returning used patches to the pharmacy and avoiding flushing them down the toilet, since most of the estrogen remains in the patch after use. • After being used inhalers can still contain active substance. Ask the patients to read the enclosed instruction carefully and to bring these inhalators to the pharmacy. • Do not prescribe more medications than can be used; if in doubt, repeating the prescription is preferable. • Review and regularly reassess the patient’s total consumption of in order to reduce waste. • Learn more about which ones of “your” drugs have the largest environmental impact. Can they be replaced? • Please contact the representatives of the pharmaceutical manafacturers, if you do not find a certain substance in the table.

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 35

ENVIRONMENTALLY CLASSIFIED PHARMACEUTICALS 2009 37 medications. ULVNRIQHJDWLYHHQYLURQPHQWDOLPSDFWIURP what youcandoinyourdailyworktoreducethe from themanufacturers. StockholmCountyCouncilandbasedondata by 6ZHGLVK3KDUPDFLHV 7KHDVVHVVPHQWLVPDGH DQG$SRWHNHW$% 7KH1DWLRQDO&RUSRUDWLRQRI mulated in2003byStockholmCountyCouncil 7KHHQYLURQPHQWDOKD]DUGPRGHOZDVIRU DVVHVVHGIRUHQYLURQPHQWDOULVN PHGLFDWLRQVPDUNHWHGLQ6ZHGHQZLOOKDYHEHHQ assessment, beginningin2005.By2010all ,QGXVWU\FRQGXFWHGWKHHQYLURQPHQWDOULVN TheSwedishAssociationofthePharmaceutical sample ofpharmaceuticalsubstances. HQYLURQPHQWDOKD]DUGDVVHVVPHQWVIRUDVHOHFWHG 7KLVIROGHUSUHVHQWVWKHHQYLURQPHQWDOULVNDQG LQLWLDWLYHVFDQEHIRXQGDW 6WRFNKROP&RXQW\&RXQFLO¶VHQYLURQPHQWDO 0RUHFRPSUHKHQVLYHLQIRUPDWLRQDERXW This informationiscontinuouslyupdated. www.janusinfo.se/environment 6WRFNKROP&RXQW\&RXQFLO commercial websiteJanusinfo,producedbythe 0RUHLQIRUPDWLRQLVDYDLODEOHDWWKHQRQ information more For 7KHIROGHUDOVRSURYLGHVFRQFUHWHDGYLFHRQ release ofmedicationsinnature. environmental priorities,oneofwhich isthe petals representthecountycouncil’s topfive council’s environmentalinitiative.The five The floweristhesymbolofcounty www.sll.se -

www.soya.se