<b>Bijsluiter</b>. De hyperlink naar het originele document werkt niet meer. Daarom laat Woogle de tekst zien die in dat document stond. Deze tekst kan vreemde foutieve woorden of zinnen bevatten en de opmaak kan verdwenen of veranderd zijn. Dit komt door het zwartlakken van vertrouwelijke informatie of doordat de tekst niet digitaal beschikbaar was en dus ingescand en vervolgens via OCR weer ingelezen is. Voor het originele document, neem contact op met de Woo-contactpersoon van het bestuursorgaan.<br><br>====================================================================== Pagina 1 ======================================================================

<pre>Lithiumcarbonate and Lithiumchloride
Evaluation of the effects on reproduction, recommendation for classification
</pre>

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<pre>Aan de Staatssecretaris van Sociale Zaken en Werkgelegenheid
Onderwerp       :  aanbieding advies
Uw kenmerk      :  DGV/BMO-U-932542
Ons kenmerk     :  U 949/AB/jt/543-Z2
Bijlagen        :  1
Datum           :  3 mei 2000
Mijnheer de Staatssecretaris,
Bij brief van 3 december 1993, nr. DGV/BMO-U-932542, verzocht de Staatssecretaris
van Welzijn, Volksgezondheid en Cultuur namens de Minister van Sociale Zaken en
Werkgelegenheid om naast het afleiden van gezondheidskundige advieswaarden ook te
adviseren over andere onderwerpen ten behoeve van de bescherming van beroepsmatig
aan stoffen blootgestelde personen. In 1995 heeft de Staatssecretaris van Sociale Zaken
en Werkgelegenheid besloten tot het opstellen van een zogenaamde niet-limitatieve repro-
tox-lijst. Op deze lijst komen stoffen die volgens de richtlijnen van de Europese Unie in-
gedeeld moeten worden in categorie 1 of 2 wat betreft effecten op de voortplanting. De
Gezondheidsraad is verzocht om voor stoffen een classificatie volgens de EU-criteria
voor te stellen.
In 1996 heb ik hiervoor de Commissie Reproductietoxische stoffen ingesteld.
Hierbij bied ik u - gehoord de Beraadsgroep Gezondheid en Omgeving - de publikatie
van de commissie aan over lithiumcarbonaat en lithiumchloride. Deze publikatie heb ik
heden ter kennisname aan de Minister van Volksgezondheid Welzijn en Sport en aan de
Minister van Volkshuisvesting, Ruimtelijke Ordening en Milieubeheer gestuurd.
Hoogachtend,
w.g.
prof. dr JJ Sixma
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<pre>Lithiumcarbonate and Lithiumchloride
Evaluation of the effects on reproduction, recommendation for classification
Committee for Compounds toxic to reproduction,
a committee of the Health Council of the Netherlands
to
the Minister and State Secretary of Social Affairs and Employment
No. 2000/06OSH, The Hague, 3 May 2000
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<pre>Preferred citation:
Health Council of the Netherlands: Committee for Compounds toxic to reproduction. Li-
thiumcarbonate and Lithiumchloride; Evaluation of the effects on reproduction, recom-
mendation for classification. The Hague: Health Council of the Netherlands, 2000;
publication no. 2000/06OSH.
all rights reserved
ISBN: 90-5549-313-9
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<pre>    Contents
    Samenvatting 7
    Executive summary 8
    Scope 9
1.1 Background 9
1.2 Committee and procedure 9
1.3 Additional considerations 10
1.4 Labelling for lactation 11
1.5 Data 12
1.6 Presentation of conclusions 12
1.7 Final remark 12
2   Lithiumcarbonate and lithiumchloride 13
2.1 Introduction 13
2.2 Human studies 14
2.3 Animal studies 17
2.4 Overall conclusion 21
    References 24
    Contents                                5
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<pre>  Annexes 27
A The committee 28
B Comments on the public draft 30
C Directive (93/21/EEC) of the European Community 31
D Fertility and developmental toxicity studies 37
E Abbreviations 44
  Contents                                           6
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<pre>Samenvatting
Op verzoek van de Minister van Sociale Zaken en Werkgelegenheid beoordeelt de Ge-
zondheidsraad de effecten op de reproductie van stoffen waaraan mensen tijdens de be-
roepsuitoefening kunnen worden blootgesteld. De Commissie Reproductietoxische
stoffen, een commissie van de Raad, adviseert een classificatie voor reproductietoxische
stoffen volgens Richtlijn 93/21/EEC van de Europese Unie. In het voorliggende rapport
heeft de commissie lithiumcarbonaat en lithiumchloride onder de loep genomen.
De aanbevelingen van de commissie zijn:
    Voor effecten op de fertiliteit adviseert de commissie om lithiumcarbonaat en lithi-
    umchloride in categorie 3 (Stoffen die in verband met hun mogelijke voor de vrucht-
    baarheid van de mens schadelijke effecten reden geven tot bezorgdheid) te
    classificeren en met R62 (Mogelijk gevaar voor verminderde vruchtbaarheid) te
    kenmerken.
    Voor ontwikkelingsstoornissen, adviseert de commissie om lithiumcarbonaat en lithi-
    umchloride in categorie 1 (Stoffen waarvan bekend is dat zij bij de mens ontwikke-
    lingsstoornissen veroorzaken) te classificeren en met R61 (kan het ongeboren kind
    schaden) te kenmerken.
    Voor effecten tijdens de lactatie, adviseert de commissie om lithiumcarbonaat en li-
    thiumchloride tevens met R64 (Kan schadelijk zijn via de borstvoeding) te kenmer-
    ken.
Samenvatting                                                                             7
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<pre>Executive summary
On request of the Minister of Social Affairs and Employment, the Health Council of the
Netherlands evaluates the effects on the reproduction of substances at the workplace.
The Health Council's Committee for Compounds Toxic to Reproduction recommends a
classification for compounds toxic to reproduction according to Directive 93/21/EEC of
the European Union. In the present report the committee has reviewed lithiumcarbonate
and lithiumchloride.
The committee's recommendations are:
    For effects on fertility, the committee recommends to classify lithiumcarbonate and
    lithiumchloride in category 3 (Substances which cause concern for human fertility)
    and to label the compounds with R62 (Possible risk for impaired fertility).
    For developmental toxicity, the committee recommends to classify lithiumcarbonate
    and lithiumchloride in category 1 (Substances known to cause developmental toxici-
    ty in humans) and to label the compounds with R61 (May cause harm to the unborn
    child).
    For effects during lactation, the committee recommends that lithiumcarbonate and
    lithiumchloride should be labelled with R64 (May cause harm to breastfed babies).
Executive summary                                                                       8
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<pre>Chapter 1
        Scope
1.1     Background
        As a result of the Dutch regulation on registration of compounds toxic to reproduction
        that came into force on 1 April 1995, the Minister of Social Affairs and Employment re-
        quested the Health Council of the Netherlands to recommend a classification of com-
        pounds toxic to reproduction. The classification is performed according to the guidelines
        of the European Union (Directive 93/21/EEC) by the Health Council's Committee for
        Compounds Toxic to Reproduction. The committee's advice on the classification will be
        applied by the Ministry of Social Affairs and Employment to extend the existing list of
        compounds classified as toxic to reproduction (class 1 and 2) of the European Union.
1.2     Committee and procedure
        The present document contains the classification of lithiumcarbonate and lithiumchloride
        by the Health Council's Committee for Compounds Toxic to Reproduction. The mem-
        bers of the committee are listed in Annex A. The first draft of this report was prepared
        by Mrs ir IDH Waalkens-Berendsen at the Department of Neurotoxicology and Repro-
        duction Toxicology of the TNO Nutrition and Food Research Institute, Zeist, The
        Netherlands, by contract with the Ministry of Social Affairs and Employment. The clas-
        sification is based on the evaluation of published human and animal studies concerning
        adverse effects with respect to fertility, development and lactation of the above mentio-
        ned compound.
        Scope                                                                                     9
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<pre>    Classification and labelling was performed according to the guidelines of the European
    Union listed in Annex C.
     Classification for fertility and development:
     Category 1      Substances known to impair fertility in humans (R60)
                     Substances known to cause developmental toxicity in humans (R61)
     Category 2      Substances which should be regarded as if they impair fertility in humans (R60)
                     Substances which should be regarded as if they cause developmental toxicity in humans
                     (R61)
     Category 3      Substances which cause concern for human fertility (R62)
                     Substances which cause concern for humans owing to possible developmental toxic ef-
                     fects (R63)
     No classification for effects on fertility or development
     Labelling for lactation:
                     May cause harm to breastfed babies (R64)
                     No labelling for lactation
    In September 1999, the President of the Health Council released a draft of the report for
    public review. The individuals and organisations that commented on the draft report are
    listed in Annex B. The committee has taken these comments into account in deciding on
    the final version of the report.
1.3 Additional considerations
    The classification of compounds toxic to reproduction on the basis of the Directive
    93/21/EEC is ultimately dependent on an integrated assessment of the nature of all pa-
    rental and developmental effects observed, their specificity and adversity, and the dosa-
    ges at which the various effects occur. The directive necessarily leaves room for
    interpretation, dependent on the specific data set under consideration. In the process of
    using the directive, the committee has agreed upon a number of additional considera-
    tions.
         If there is sufficient evidence to establish a causal relationship between human expo-
         sure to the substance and impaired fertility or subsequent developmental toxic ef-
         fects in the progeny, the compound will be classified in category 1, irrespective the
         general toxic effects (see Annex C, 4.2.3.1 category 1).
         Adverse effects in a reproductive or developmental study, in the absence of data on
         parental toxicity, occurring at dose levels which cause severe toxicity in other stu-
         dies, need not necessarily lead to a category 2 classification.
    Scope                                                                                                  10
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<pre>         If, after prenatal exposure, small reversible changes in foetal growth and in skeletal
         development (e.g. wavy ribs, short rib XIII, incomplete ossification) in offspring oc-
         cur in a higher incidence than in the control group in the absence of maternal effects,
         the substance will be classified in category 3 for developmental toxicity. If these ef-
         fects occur in the presence of maternal toxicity, they will be considered as a conse-
         quence of this and therefore the substance will not be classified for developmental
         toxicity (see Annex C, 4.2.3.3 developmental toxicity final paragraph).
         Clear adverse reproductive effects will not be disregarded on the basis of reversibili-
         ty per se.
         Effects on sex organs in a general toxicity study (e.g. in a subchronic or chronic
         toxicity study) may warrant classification for fertility.
         The committee not only uses guideline studies (studies performed according to
         OECD standard protocols*) for the classification of compounds, but non-guideline
         studies are taken into consideration as well.
1.4 Labelling for lactation
    The recommendation for labelling substances for effects during lactation is also based on
    Directive 93/21/EEC. The Directive defines that substances which are absorbed by wo-
    men and may interfere with lactation or which may be present (including metabolites) in
    breast milk in amounts sufficient to cause concern for the health of a breastfed child,
    should be labelled with R64. Unlike the classification of substances for fertility and de-
    velopmental effects, which is based on a hazard identification only (largely independent
    of dosage), the labelling for effects during lactation is based on a risk characterisation
    and therefore also includes consideration of the level of exposure of the breastfed child.
         Consequently, a substance should be labelled for effects during lactation when it is
    likely that the substance would be present in breast milk in potentially toxic levels. The
    committee considers a compound as potentially toxic to the breastfed child when exposu-
    re to this compound via the milk results in an intake exceeding an exposure limit for the
    general population, e.g. the acceptable daily intake (ADI).
1.5 Data
    Literature searches were conducted in the on-line databases Toxline and Medline, star-
    ting from 1966 up 1995. Literature was selected primarily on the basis of the text of the
    abstracts. Publications cited in the selected articles, but not selected during the primary
    search, were reviewed if considered appropriate. In addition, handbooks and a collection
*   Organisation for Economic Cooperation and Development
    Scope                                                                                        11
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<pre>    of most recent reviews were consulted. References are divided in literature cited and lite-
    rature consulted but not cited. Before finalising the public draft the committee performed
    an additional literature search in Medline and Toxline for the period 1995 to 1997. The
    results of this search were no reason for the committee to adjust the recommendations.
         The committee chose to describe human studies in the text (summarised in Annex
    D), starting with review articles. Of each study the quality of the study design (perfor-
    med according to internationally acknowledged guidelines) and the quality of
    documentation are considered.
         Animal data are described in the text and summarised in Annex D.
1.6 Presentation of conclusions
    The classification is given with key effects, species and references specified. In case a
    substance is not classified as toxic to reproduction, one of two reasons is given:
         Lack of appropriate data preclude assessment of the compound for reproductive
         toxicity.
         Sufficient data show that no classification for toxic to reproduction is indicated.
1.7 Final remark
    The classification of compounds is based on hazard evaluation* only, which is one of a
    series of elements guiding the risk evaluation process. The committee emphasises that
    for derivation of health based occupational exposure limits these classifications should
    be placed in a wider context. For a comprehensive risk evaluation, hazard evaluation
    should be combined with dose-response assessment, human risk characterisation, human
    exposure assessment and recommendations of other organisations.
*   for definitions see Tox95
    Scope                                                                                       12
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<pre>Chapter 2
        Lithiumcarbonate and lithiumchloride
2.1     Introduction
         Name              :    lithium carbonate
         CAS-no            :    554-13-2
         Use               :    as alloying agent, as catalyst, as lubricant, as component of pottery glazes, in
                                psychiatric therapy
         Mol weight        :    73.89
         Chem formula      :    Li2CO3
         Name:             :    lithium chloride
         CAS-no            :    7447-41-8
         Use:              :    at manufacturing mineral waters, at soldering aluminium, in psychiatric the-
                                rapy
         Mol weight:       :    42.39
         Chem formula:     :    LiCl
        Lithium (Li+) is the active ingredient in the two substances mentioned above. The sub-
        stances will therefore not be discussed separately in the following text.
        Lithiumcarbonate and lithiumchloride                                                                     13
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<pre>2.2 Human studies
    Exposure of man to lithium predominantly occurs as a therapy for manic depression, of-
    ten in combination with other therapeutic substances. Lithium was registered for acute
    mania in 1960 (dose 1800 mg/day) and for maintenance therapy since 1970 (dose
    900-1200 mg/day) (Moo95). The committee concluded that in the earlier studies with li-
    thium, higher dosages were used and therefore these studies might be more useful for the
    hazard-based classification purposes.
         The human studies are summarised in Tables 1 and 2 (Annex D).
    Fertility
    Blay et al (1982) reported 2 cases of male sexual dysfunction associated with lithium
    therapy. After 1 month of therapy (serum levels were kept at 26-33 mg/l) the first pa-
    tient, age 42 years, reported loss of libido and impaired erection. After 3.5 months of tre-
    atment he was switched to a placebo treatment in a blind fashion for 2 weeks. On the
    second day of placebo treatment, his serum lithium level decreased to zero and there was
    normalisation of libido and sexual behaviour. The second patient, age 58 years, complai-
    ned about decreased libido and difficulty obtaining erection after start of treatment with
    lithium; serum lithium levels were kept at 18 mg/l. 2 Months after ceasing the lithium
    treatment, full remission occurred (Bla82).
         Levin et al (1981) studied the effects of lithium carbonate (serum levels of 22-52
    mg/l, dose unknown) on sperm function in 4 patients suffering from clinical depression
    and 9 controls. Three weeks of continuous therapy with lithium resulted in a significant
    decrease in sperm viability but no significant change in sperm count or motility were ob-
    served (Lev81).
    Lithium is supposed to cause hyperprolactinemia, thought to be associated with male in-
    fertility; for that reason the committee paid special attention to studies in which prolactin
    levels were measured.
         Lanng Nielsen et al. (1977) studied plasma prolactin (PRL) levels in a longitudinal
    study for 90 days. Manic-depressive patients (n=9) were examined before lithium treat-
    ment started and at various times during treatment (Lan77). No significant changes were
    found, nor could any correlation be established between lithium treatment and plasma
    prolactin. In a transversal study, plasma PRL levels were determined in 26 patients du-
    ring long-term (3 months to 20 years) lithium-treatment and in 16 control patients. The
    plasma PRL levels were not elevated in the treated patient compared with the controls.
    Lithiumcarbonate and lithiumchloride                                                          14
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<pre>       Ghadirian et al. (1992) studied the effects of lithium and lithium in combination with
  benzodiazepines in bipolar patients, 45 men and 59 women (Gha92). No relationship
  was found between serum lithium and plasma PRL or serum lithium levels and sexual
  dysfunction scores.
       In a study of Czernik (Cze79), levels of gonadotropin hormone (GH), thyroid stimu-
  lating hormone (TSH), PRL, follicle stimulating hormone (FSH), luteinising hormone
  (LH) and cortisol were measured in manic-depressive patients treated with lithium and in
  healthy patients before and after a combined treatment with insulin, thyroid releasing
  hormone (TRH) and luteinising hormone releasing hormone (LHRH). Baseline serum
  prolactin levels in lithium-treated patients were lower than in the controls, but the diffe-
  rence was not statistically significant.
       Tanimoto et al. (Tan81) studied the effect of TRH ( 0.5 mg/person) once administe-
  red before treatment with lithium and once administered at the end of a 3-4 weeks lithi-
  um carbonate treatment period (600-1800 mg lithiumcarbonate /day) on plasma TSH
  and PRL levels in patients with manic states and in controls. Basal plasma PRL concen-
  trations did not differ between the two groups and was not affected by lithium admini-
  stration to either group. In the controls and male patients, lithium had no effect on
  TRH-induced PRL response. In the female patients, lithium increased the TRH-induced
  PRL response.
       Goodnick et al. (Goo83) studied the effect of chronic lithium carbonate treatment
  (patients were treated with lithium until an adequate therapeutic lithium level of 30-55
  mg/l plasma was established) on apomorphine*-induced changes in serum prolactin and
  growth hormone following establishment of appropriate steady state lithium plasma le-
  vels in patients with primary affective disorder or schizoaffective illness. Baseline serum
  prolactin levels before and after lithium treatment were not significantly different (14.6 ±
  3.7 before and 16.4 ± 4.6 ng/ml after lithium treatment).
       Grof et al. (Gro85) studied the PRL response to insulin hypoglycemia in bipolar pa-
  tients treated with lithium and in healthy volunteers on and off lithium. No effect of lithi-
  um was observed on base-line prolactin response.
       Joffe et al. (Jof86) studied the responses to sequential stimuli with arginine (500
  mg/kg bw) and 90 minutes later with LHRH (100 µg/person) and TRH (500 µg/person)
  in 8 patients who were depressed before and after lithium carbonate treatment (1230 ±
  247 mg/day for at least 6 weeks). Plasma levels of LH, FSH, TSH, GH and prolactin
  were measured. Baseline prolactin plasma levels were increased by Li treatment and Li
  augmented the prolactin response to TRH. The authors discussed that their results about
  the effect of Li on base-line prolactin levels are in contrast to the results of 5 other stu-
* a dopamine agonist
  Lithiumcarbonate and lithiumchloride                                                          15
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<pre>dies (4 of these are described in this paper) which found unaltered baseline prolactin le-
vels with lithium treatment.
     Yatham (Yat94) studied the effect of buspirone (0.5 mg/kg orally), a 5HT agonist,
on prolactin release in 11 manic patients and 11 healthy controls. Six of the manic pa-
tients were treated with lithium (600-1500 mg/day for 3 weeks) where after the buspiro-
ne challenge was repeated. The baseline prolactin levels in manic patients were not
different compared to the controls and lithium treatment did not affect baseline prolactin
levels.
The studies concerning prolactin levels in lithium-treated men were ambiguous. Based
on these studies no conclusions concerning decreased human fertility can be drawn.
In vitro studies with human sperm were performed by Raoof et al (1989) and Shen et al
(1992) (Rao89) (She92). Both detected a negative effect on motility at concentrations
comparable with those reported in semen after oral administration.
Developmental studies
Lithium, administered as Li2CO3, was used in a 2-year study as a therapeutic and
prophylactic drug in 25 manic-depressive patients (male and female) in the Douglas
Hospital, Quebec, Canada in a dosage ranging from 300 to 1800 mg per day (blood le-
vel: 18-37 mg/l). In the first month blood levels were determined weekly, thereafter bi-
monthly. Apart from beneficial effects, diverse adverse effects were observed, among
them tremors, diarrhoea, skin rash, alopecia, mental confusion. One patient was preg-
nant during treatment and delivered a child with congenital malformations, bilateral club
feet and lumbar meningomyelocele (Vac70).
     Weinstein (1976) reported in the International Register of Lithium Babies about 166
patients who used lithium during pregnancy; 18 of these patients delivered malformed
children. The malformations were, among others, cardiovascular defects, including the
rare Ebstein's anomaly. Most of the pregnant patients, however, also received other
drugs for treatment. Moreover, the incidence of congenital malformations did not sub-
stantially exceed the expected incidence in a non-lithium population (Wei76).
     A medical birth registry program in Sweden identified 350 manic-depressive women
who had born a child in the period of 1973-1979. The number of perinatal deaths and
the incidence of heart defects was higher, gestational length shorter and the birth weight
lower than expected in a control population. 41 Mothers of these children had used only
lithium during pregnancy. The incidence of heart defects was high within this group; Eb-
stein's anomaly, however, was not among the defects (Käl83).
Lithiumcarbonate and lithiumchloride                                                       16
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<pre>         In 1977, the Danish Lithium Baby Register included 183 infants who had been ex-
    posed to lithium during the first trimester of gestation. Eleven percent of these had major
    congenital anomalies, the majority of which consisted of cardiovascular defects, inclu-
    ding a few cases of Ebstein's anomaly (4% of the total) (War88).
         A study on 50 lithium-using pregnant women in San Diego, USA, showed upon deli-
    very no cardiovascular malformations; one child had a lumbar meningomyelocele, and
    another had unilateral inguinal hernia (Cun89).
         The possibility of the use of lithium during pregnancy causing foetal hypothyroidism
    was reported in a Letter to the Editor (Rob90).
         An epidemiological study carried out between 1979 and 1991 in Canada and the
    USA. revealed no differences in the occurrence of congenital anomalies, particularly of
    cardiac malformations, between a lithium-exposed cohort and an unexposed cohort
    (Jac92).
         The teratogenic risk of therapeutic use of lithium was evaluated by Cohen et al
    (1994) who concluded that "the teratogenic risk of first-trimester lithium exposure was
    lower than previously suggested. The clinical management of women with bipolar disor-
    der who have childbearing potential should be modified with this revised risk estimate"
    (Coh94).
    Lactation
    Scialli (1992) reported excretion of lithium in breast milk, resulting in a milk lithium
    concentration of 40% of the maternal plasma levels (Sci92).
         Sykes et al. (1976) and Schou et al. (1973) noted concentrations of lithium in infant
    serum which were 10 to 50% of that found in maternal serum (Syk76, Sch73). The ef-
    fect of exposure to this amount of lithium in a neonate is minimal.
         Tunnessen and Hertz (1972) described a breast fed baby with serum lithium level of
    44 mg/l and a mother’s serum level of 111 mg/l manifesting cyanosis and floppy mus-
    cles along with electrocardiographic changes e.g.. T-wave inversions (Tun72). The
    symptoms resolved after the discontinuation of breastfeeding, however the authors did
    not specifically mention a repeat ECG.
2.3 Animal studies
    Tables 3 and 4 (Annex D) summarise the reproduction and developmental toxicity stu-
    dies with lithium in experimental animals.
    Lithiumcarbonate and lithiumchloride                                                        17
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<pre>Fertility
Banerji et al. (Ban83) injected adult male Sprague-Dawley rats intraperioneally (ip) with
LiCl (100 mg LiCl/kg bw, twice daily for 2 or 7 days) and examined the effect (by ra-
dioimmunoassay) on the levels of LH, FSH and PRL in plasma and pituitary homogena-
tes. No effect was observed on the concentrations of LH, FSH and PRL in the pituitary
homogenates after treatment with LiCl. Plasma LH was increased after 2 days and de-
creased after 7 days of LiCl treatment. No effect of LiCl treatment was observed on
FSH-plasma levels as well. Two days of LiCl treatment had no effect on PRL-plasma
levels whereas the level of PRL in plasma was statistically significantly decreased after
7 days of LiCl treatment compared to the control group (7 days ip injections of saline).
In the control group, the PRL-levels in plasma after 7 days were higher than after 2 days
of treatment (comparable to pituitary) whereas in the LiCl-treated group no increase was
observed. Four out of 20 animals that received lithium for 7 days died on the 6th day;
one rat of the controls died during treatment. A number of rats that received lithium for 7
days showed signs of polydipsia and polyuria.
     In a study of McIntyre et al., male Sprague-Dawley rats received saline or lithium
(ip, 2 mg/kg) once or for 14 consecutive days. No effect of Li was observed on PRL-le-
vels whereas PRL-levels after 14 days of saline or Li treatment were higher than those in
rats receiving only one ip injection (McI83).
     In a series of studies of Ghosh et al., the effect of LiCl on testicular activity was in-
vestigated (Gho91a, Gho91b). In the first study (Gho91a), immature Wistar rats (35
days old) were treated for 15, 20 and 25 days with LiCl (subcutaneously, 2.0 mg/kg, 8
rats per group) or distilled water (control group, 8 rats per group). After 15 days of tre-
atment, spermatogenesis was inhibited at stage VII of the seminiferous epithelial cycle
and serum levels of FSH, LH, PRL and testosterone were decreased. Longer treatment
resulted in a decrease of the weights of the accessory sex organs as well. In a second
comparable experiment, rats were treated with PRL just after LiCl treatment. This resul-
ted in a recovery of above described events (Gho91b). In both studies no effect on body
weight was observed. The serum lithium concentration were 20 mg/l, which is compara-
ble with the therapeutic level in man.
     Groups of 10 female Charles River albino rats were gavaged daily with doses of li-
thium carbonate solutions at levels of 0, 25, 75 or 150 mg/kg bw/day for 14 days before
mating. They were mated with male rats of the same strain which were treated with 0,
10, 25 or 50 mg/kg bw/day for 70 days. Mating pairs were formed within the low-, mid-
or high-dose groups. The pregnant females were allowed to litter and raise offspring up
to postnatal day 21, when they were sacrificed. Two high-dose females died during preg-
nancy. No differences were found in general maternal health or body weight; no differen-
ces were found in litter size, pup viability or in mean pup weight, except for postnatal
Lithiumcarbonate and lithiumchloride                                                           18
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<pre>day 21, when the high-dose pups body weights were statistically significantly lower than
in the other groups (Gra72).
     Groups of 11-12 swine were fed a diet containing 0 or 3000 mg Li2CO3/kg diet
(~120 mg/kg bw) during gestation. They were followed during gestation and up to day
21 of lactation. Maternal body weight was reduced from day 60 of gestation and on-
wards, reaching the level of statistical significance on gestation day 110. Postpartal body
weights were also reduced when compared to the controls. The number of pregnancies
and total number of piglets born per litter were slightly reduced; the mean number of live
born piglets, mean birth weight and survival at 21 day were statistically significantly re-
duced, and the number of mummies and stillborns was statistically significantly increa-
sed (Kel78).
     Mating pairs of 10 CFW (Carworth Farms) mice/group were offered drinking water
containing 0, 2000, 4000 or 8000 mg LiCl/l, starting from either 3 weeks or 6-8 weeks
of age. They were mated when they were 8-10 weeks. The mice offered 8000 mg/l did
not drink and died soon. Mice offered 4000 mg/l did drink, but less than the controls and
did not reproduce. Mice maintained on 2000 mg/l starting from 6-8 weeks of age did not
show adverse effects, but their reproduction capacity was reduced i.e.. the average time
between litters reduced and the total number of litters was reduced when compared to the
control pairs. Litter size was not affected, but preweaning pup mortality was statistically
significantly increased. In the mating pairs that were exposed to lithium from 3 weeks of
age the same effects were observed. Moreover, a statistically significantly high number
of pups showed delayed growth and development (Mro83). General toxicity and number
of animals per group was not described.
     Groups of 6-9 pregnant female Sprague-Dawley rats (Taconic Farms) were exposed
to 0, 80 or 160 mg natural lithium salts/kg bw/day via the drinking "water" (50% orange
juice) for 10 days after which they were mated with untreated males. Exposure conti-
nued during gestation and lactation up to postpartal day 28. The dams were monitored
for behaviour (nesting, nursing, grooming). Maternal behaviour was altered in both
groups: no grooming, little and short nursing; they did not cannibalise dead pups
(Sec86).
     Groups of 5 pregnant Sprague-Dawley albino mice were offered drinking water con-
taining 0 or 40 mg LiCl/l from mating up postpartal day 23, when the pups were weaned
and maintained on normal drinking water for a subsequent 14 days; then they were sacri-
ficed. In a similar experiment, exposure started immediately after delivery. In a third ex-
periment, female mice were exposed to 0 or 40 mg/l in drinking water for 2 weeks prior
to conception and during gestation. The new-borns were killed about one day after deli-
very. A reduction was recorded in the weights of the brain (significant), kidney (females:
significant), spleen (females only) and testis of the pups from experiments 1 and 2
(Mes86).
Lithiumcarbonate and lithiumchloride                                                        19
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<pre>Developmental toxicity
Groups of pregnant HaM/ICR mice (Charles River, Mass.) were treated with 200, 300
or 465 mg Li2CO3/kg bw/day by gavage from day 6 to 15 of gestation. They were killed
on gestation day 18. In the low-dose treated animals, no effects were observed. Treat-
ment with 300 mg/kg bw/day caused cleft palate in 11% of the animals. Treatment with
465 mg/kg bw/day resulted in a statistically significant increase in maternal and foetal
death and in 30% of the survivors cleft palate was found (Sza70).
     Groups of 20 pregnant Charles River albino rats were administered 0, 25, 75 or 150
mg Li2CO3/kg bw/day by gastric intubation from gestation day 5 through 15. They were
sacrificed on gestation day 20. Groups of 10 pregnant New Zealand White rabbits were
dosed orally with capsules containing 0, 25 and 40 mg Li2CO3/kg bw/day from gestation
day 5-18. On gestation day 28 the rabbits were killed. Six pregnant rhesus monkeys we-
re dosed with 0 or 25 mg Li2CO3/kg bw/day in capsules during organogenesis, from day
14 through 35 of gestation. The females were either delivered by caesarian section
around day 160 or they were allowed to litter naturally. All offspring was examined
thoroughly, the surviving monkeys also for postnatal (behavioural) development. Two
high-dose rats died, 3 high-dose rabbits refused to eat and eventually died, one low dose
group rabbit died. No differences were observed between control and dose groups in ma-
ternal fertility, body weight gain, number of implantation sites, litter size, litter weight,
foetal mortality and gross visceral or skeletal malformations or (for the monkeys) post-
natal development (Gra72).
     Groups of 15 - 25 malformation-prone strain 129 Sv/SL or A/J mice were injected
intraperitoneally with 0, 0.8, 1.6, 3.2 (or 5.0: Sv/SL mice only) mg Li2CO3/mouse on ge-
station day 8, 9 or 10, or on gestation day 12, 13 or 14, respectively. They were killed
on gestation day 18-19. The Sv/SL mice only showed malformations in the high dose
group (41.6%). These malformations consisted of fused ribs, vertebral defects, or exen-
cephaly. Most effects were found in animals exposed on day 9. The foetuses of the A/J
mice showed a high incidence of cleft lip and palate (16.4% in the control group). The
incidence of cleft lip and cleft palate in the lithium treated groups was 3.1-21.2%; no re-
lationship with the concentration of lithium dosed per animal was observed. Furthermo-
re, the day of administration did not influence these effects. (Smi82)
     Another group of 16 pregnant Sv/SL mice was offered drinking water containing 2
mg Li2CO3/ml from gestation day 1 though 18; they were killed at gestation day 18. The
chronically exposed mice produced only 2 litters, and a high percentage of resorptions.
The 6 resulting foetuses were grossly normal (Smi82).
     Groups of 11-20 pregnant Wistar rats were administered by gavage doses of 0, 50
or 100 mg Li2CO3/kg bw in agar from gestation day 6 to 15. They were killed on gesta-
tion day 20. Effects were found on the number of implantation sites, live foetuses and
Lithiumcarbonate and lithiumchloride                                                          20
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<pre>    foetal body weights which were slightly reduced in the low dose group and statistically
    significantly in the high dose group. The high dose group foetuses had congenital
    malformations such as reduced size, shortened limbs, and other deformities of the skele-
    ton. No differences in skeleton were observed in the low-dose group; no defects were ob-
    served at visceral examination in any of the foetuses (Mar86).
         Groups of pregnant albino rats were given intragastrically 0 or 7 mg Li2CO3/kg
    bw/day from gestation day 0 - 10. They were killed at term. The following defects were
    observed in the exposed offspring: growth retardation, cleft palate, brain liquification,
    hepatomegaly, digital abnormalities, hydrocephaly, cardiomegaly and syndactyly
    (Sha86).
         Groups of 6-9 female Sprague Dawley rats (Taconic Farms) were exposed to 0, 80
    or 160 mg natural lithium salts/kg bw/day via the drinking "water" (50% orange juice)
    for 10 days after which they were mated with untreated males. Exposure continued du-
    ring gestation and lactation up to postpartal day 28. The pups were followed for effects
    on body weight, physical landmarks, development of reflexes, and they were tested for
    open field activity. Adverse effects were present in both dose groups, the effects in the
    high dose group being more pronounced: pup body weight was decreased, the physical
    landmarks eye opening and pinna unfolding were delayed, as was the development of
    depth perception. In an open field activity test they showed lower spontaneous activity
    than the control offspring: the exposed pups were lethargic at 4 months of age (Sec86).
         Groups of 3-22 pregnant JBT/Jd mice were injected intraperitoneally with 0, 250,
    300, 310, 315, 320, 325, 330, 335, 340, 350 or 400 mg Li2CO3/kg bw on gestation day
    9. They were killed on gestation day 13. The defects found were various, and depended
    on dose level. They included a dose-related increase in number of dead foetuses, number
    of abnormalities and retardations. The abnormalities consisted a.o. of exencephaly, cra-
    niorachischisis, kinking of the spinal cord and dilatation of the 4th brain ventricle. These
    anomalies were concluded to be the result of the neurotropic effect of the drug (Jur88).
2.4 Overall conclusion
    Some case-reports suggest that Li induces libido and erection disturbances. In in vitro
    studies with human sperm, decreased motility was observed at the same concentration as
    is found in the semen of patients. Studies of plasma PRL levels in lithium-treated men
    were ambiguous. The committee concludes that the amount of evidence and the quality
    of the human studies is insufficient for a classification of Li for fertility.
         Fertility studies in animals were often carried out in such a way that the serum level
    of lithium in the tested animals was similar to that of treated human patients. Differences
    in sensitivity amongst species, however, resulted in general toxicity in most of the ani-
    mals, whereas at the same serum levels in man no signs of overt toxicity were observed.
    Lithiumcarbonate and lithiumchloride                                                         21
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<pre>Exposure below these levels hardly caused any effects in animals except for a reduction
in reproduction capacity in one study in the mice (Mro83). Ghosh et al. (Gho91a and b)
detected that the spermatogenesis was inhibited at stage VII of the seminiferous epitheli-
al cycle after subcutaneous injection of 2 mg LiCl/kg bw/day for at least 15 days.
     Based on the evidence in animal studies (Gho91a and b) the committee recommends
to classify lithiumcarbonate and lithiumchloride for fertility in category 3 (‘substances
which cause concern for human fertility’) and to label lithiumcarbonate and lithiumchlo-
ride with R62 (Possible risk of impaired fertility).
Women exposed to lithium during pregnancy in early studies were reported to give birth
to children with congenital malformations of extremities of limbs and central nervous
system or of the cardiovascular system in combination with hypothyroidism (Vac70,
Wei76, Käl83, War88). A more recent epidemiological study (Jac92), however, indica-
ted no differences in the occurrence of congenital malformations between a Li-exposed
and a control cohort. The committee is of the opinion that this discrepancy might be ex-
plained by relatively lower dosages used in the later studies when lithium was mainly
used for maintenance therapy (900-1200 mg/day) instead of treatment for acute mania
(1800 mg/day). Therefore, the absence of a teratogenic epidemiological risk found in
studies of a later date probably reflects the grown awareness of the clinicians and the
restrictive prescription of lithium at high doses during the first trimester of pregnancy.
     Lithium predominantly caused developmental effects when female animals were ex-
posed during the first part of pregnancy, before and/or during organogenesis, but expo-
sure before conception or after organogenesis also had effects.
     In view of the amount of evidence in earlier human studies, the committee recom-
mends to classify lithiumcarbonate and lithiumchloride in Category 1 (substances known
to cause developmental toxicity in humans) and to label lithiumcarbonate and lithium-
chloride with R 61 (may cause harm to the unborn child).
Lithiumcarbonate and lithiumchloride                                                       22
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<pre>Lithium ingested during lactation is found in breast milk in sufficient amounts to warrant
concern for the infant’s development. Therefore the committee recommends to label lithi-
umcarbonate and lithiumchloride with R 64 (May cause harm to breastfed babies).
Proposed classification for fertility
Category 3, R62.
Proposed classification for developmental toxicity
Category 1, R61.
Proposed labelling for effects during lactation
R64.
For the committee,
The Hague, 3 May 2000
dr ASAM van der Burght,                  dr BJ Blaauboer,
scientific secretary                     chairman
Lithiumcarbonate and lithiumchloride                                                       23
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<pre>       References
Ban83  Banerji TK, Parkening TA, Collins TJ, Rassoli A. Lithium-induced changes in the plasma and pituitary
       levels of luteinizing hormone, follicle stimulating hormone and prolactin in rats. Life Sciences 1983; 33:
       1621-1627.
Bla 82 Blay SL, Feraz MP, Calil HM. Lithium-induced male sexual impairment: two case reports. J Clin Psychi-
       atry 1982; 43: 497-498.
Coh94  Cohen LS, Friedman JM, Jefferson JJ, Johnson EM, Weiner ML. A reevaluation of risk of in utero expo-
       sure to lithium. JAMA 1994; 271: 146-150.
Cun89  Cunniff CM, Sahn DJ, Reed KL, Chambers CC, Johnson KA, Jones KL. Pregnancy outcome in women
       treated with lithium. Teratology 1989; 39: 447-448.
Cze79  Czernik A, Kleesiek K. Neuroendokrinologische Veränderungen unter Langzeitbehandlung mit Lithi-
       umsalzen. Pharmakopsychiatr Neuropsychopharmacol 1979; 12: 305-312.
Gha92  Ghadirian AM, Annable L, Bélanger RN. Lithium, benzodiazepines, and sexual function in bipolar pa-
       tients Am J Psychiatry 1992; 149: 801-805.
Gho91a Ghosh PK, Biswas NM, Ghosh D. Effect of lithium chloride on testicular steroidogenesis and gametoge-
       nesis in immature male rats. Acta Endocrinologica 1991; 124: 76-82.
Gho91b Ghosh D, Biswas NM, Ghosh PK. Studies on the effect of prolactin treatment on testicular steroidogene-
       sis and gametogenesis in lithium-treated rats. Acta Endocrinologica 1991; 125: 313-318.
Goo83  Goodnick PJ, Meltzer HY. Effect of subchronic lithium treatment on apomorphine-induced change in
       prolactin and growth hormone secretion. J Clin Psycopharmacol 1983;4: 239-243.
Gra72  Gralla EJ, McIlhenny HM. Studies in pregnant rats, rabbits and Monkeys with Lithium carbonate. Toxi-
       col Appl Pharmacol 1972; 21: 428-433.
       References                                                                                                 24
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<pre>Gro85 Grof E, Grof P, Brown GM. Effects of long-term lithium treatment on prolactin regulation. Adv Biochem
      Psychopharmacol 1985; 40: 81-87.
Jac92 Jacobson SJ, Jones K, Johnson K, Ceolin L, Kaur P et al. Prospective multicenter study of pregnancy out-
      come after lithium exposure during the first trimester. Lancet 1992; 339: 530-533.
Jof86 Joffe RT, Post RM, Ballenger JC, Rebar R, Gold PW. The effects of lithium on neuroendocrine function
      in affectively ill patients. Acta Psychiatr Scand 1986; 73: 524-528.
Jur88 Jurand A. Teratogenic activity of lithium carbonate: an experimental update. Teratology 1988; 38:
      101-111.
Käl83 Källén B, Tandberg A. Lithium and pregnancy. Acta Psychiatr Scand 1983; 68:134-139.
Kel78 Kelly KW, McGlone JJ, Froseth JA. Lithium toxicity in pregnant swine. Proc Soc Exp Biol Med 1978;
      158: 123-127.
Lan77 Lanng Nielsen J, Amdisen A, Darling S, Pedersen EB. Plasma prolactin during lithium treatment. Neu-
      rophychobiology 1977; 3: 30-34.
Lev81 Levin RM, Amsterdam JD, Winokur A, Wein AJ. Effects of psychotropic drugs on human sperm motility.
      Fertil Steril 1981; 55: 503-506.
Mar86 Marathe MR. Thomas GP. Embryotoxicity and teratogenicity of lithium carbonate in Wistar rat. Toxicol
      Lett 1986; 34: 115-120.
McI83 McIntyre IM, Kuhn C, Demitriou S, Fucek FR, Stanley M. Modulating role of lithium on dopamine tur-
      nover, prolactin release and behavioral supersensitivity following haloperidol and reserpine. Psychophar-
      macology 1983; 81: 150-154.
Mes86 Messiha FS. Lithium and the neonate: development and metabolic aspects. Alcohol 1986; 3: 107-112.
Moo95 Moore JA and an IEHR Expert Scientific Committee. An assessment of lithium using the IEHR evalua-
      tive process for assessing human developmental and reproductive toxicity of agents. Repro Toxicol 1995;
      9 (2): 175-210.
Mro83 Mroczka DL, Hoff KM, Goodrich CA, Baker PC. Effect of lithium on reproduction and postnatal growth
      of mice. Biol Neonate 1983; 43: 287-296.
Rao89 Raoof NT, Pearson RM, Tuerner P. Lithium inhibits human sperm motility in vitro. Br J Pharmac 1989;
      28: 715-717.
Rob90 Robert E, Francannet C. Comments on "Teratogen update on lithium" by J. Warkany Teratology 1990;
      42: 205.
Sch73 Schou M, Amdisen A. Lithium and pregnancy. III: lithium ingestion by children breast-fed by women in
      lithium treatment. BMJ 1973; 2 (5859):138
Sci92 Scialli AR. Breast milk. A clinical guide to reproductive and developmental toxicology 1992; 193-208.
Sec86 Sechzer, JA, Lieberman KW, Alexander GJ, Weidman D, Stokes PE. Aberrant parenting and delayed off-
      spring development in rats exposed to lithium. Biol Psychiatry 1986; 21: 1258-1266.
Sha86 Sharma A, Rawat AK. Teratogenic effecs of lithium and ethanol in the developing fetus.Alcohol 1986; 3:
      101-106.
She92 Shen MR, Yang R-C, Chen SS. Effects of lithium and haloperidol on human sperm motility in-vitro. J
      Pharm Pharmacol 1992; 44: 534-536.
      References                                                                                                25
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<pre>Smi82  Smithberg M, Dixit PK. Teratogenic effects of lithium in mice. Teratology 1982; 26: 239-246.
Syk76  Sykes PA, Quarrie J, Alexander FW. Lithium carbonate and breast feeding. BMJ 1976; 2(6047):1299.
Sza70  Szabo KT. Teratogenic effect of lithium carbonate in the foetal mouse. Nature 1970; 225: 73-75.
Tan81  Tanimoto K, Maeda K, Yamaguchi N, Chihara K, Fujita T. Effect of lithium on prolactin responses to
       thyrotropin releasing hormone in patients with manic state. Psychopharmacology 1981; 72: 129-133.
Tox95  Niesink RJM, de Vries J, Hollinger MA, eds. Toxicology, Principles and Applications, Boca Raton: CRC
       Press, 1995:385
Tun72  Tunnessen WW, Hertz CG. Toxic effects of lithium in newborn infants. A commentary. J Pediatr 1972;
       81:804-807.
Vac70  Vacaflor L, Lehman HE, Ban TA. Side effects and teratogenicity of lithium carbonate treatment. J Clin
       Pharmacol J New Drug 1970; 10(6): 387-389.
War88  Warkany J. Teratogen update: lithium. Teratology 1988; 38: 593-596.
Wei76  Weinstein MR. The international register of lithium babies. Drug Info J 1976; 10: 94-100. Yat94:Yatham
       LN. Buspirone induced prolactin release in mania. Biol Psychiatry 1994; 35: 553-556.
       Literature consulted but not cited
Ana93  Ananth J. Lithium during pregnancy and lactation. Lithium 1993; 4:231-237.
Bow98  Bowden CL. Key treatment studies of lithium in manic-depressive illness: efficacy and side effects. J
       Clin Psychiatry 1998; 59S: 13-19, (comments on pages 35-36)
Chi 97 Chisholm CA, Kuller JA. A guide to the safety of CNS-active agents during breastfeeding. Drug Saf
       1997; 17(2):127-142.
Dil97  Dillon AE, Wagner CL, Wiest D, Newman RB. Drug therapy in the nursing mother. Ostet Gynecol Clin
       N Am 1997; 24: 675-696.
Gho91c Ghosh PK, Biswas NM, Ghosh D. Effect of lithium chloride on spermatogenesis and testicular steroido-
       genesis in mature albino rats: duration dependent response. Life Sciences1991; 48: 649-657.
Mar92  Marken PA, Haykal RF, Fisher JN. Management of psychotropic-induced hyperprolactinemia. Clin
       Pharm 1992: 11: 851-856.
Pow93  Power AC, Dorkins CE, Cowen PJ. Effect of lithium on the prolactin response to D-fenfluramine in heal-
       thy subjects. Biol Psychiatry 1993; 33: 801-805.
Sch90  Schou M. Lithium treatment during pregnancy, delivery, and lactation: an update. J Clin Psychiatry 1990;
       51(10): 410-413.
Sin73  Singer I, Rotenberg D. Mechanisms of lithium action. New Engl J Medicine 1973; 289: 254-260.
Sch79  Schneider HPG, Leyendecker G. The normal and dysregulated human menstrual cycle. Adv Steroid Bio-
       chem Pharmacol 1979; 7: 23-50
       References                                                                                               26
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<pre>A The committee
B Comments on the public draft
C Directive (93/21/EEG) of the European Community
D Fertility and developmental toxicity studies
E Abbreviations
  Annexes
                                                  27
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<pre>Annex A
      The committee
         BJ Blaauboer, chairman
         Toxicologist; Research Institute of Toxicology, Utrecht
         JN van den Anker
         Professor of pediatrics and Neonatology; Erasmus University, Rotterdam
         AM Bongers, advisor
         Ministry of Social Affairs and Employment, The Hague
         HFP Joosten
         Toxicologist; NV Organon, Department of Toxicology and Drug Disposition, Oss
         D Lindhout
         Professor of Clinical Genetics/Teratology; Erasmus University, Rotterdam
         JHJ Copius Peereboom-Stegeman
         Toxicologist; Catholic University Nijmegen, Nijmegen
         AH Piersma
         Reproductive toxicologist; National Institute of Public Health and the Environment,
         Bilthoven
         A Stijkel
         Toxicologist; Environmental Awareness Foundation, ‘s-Graveland
         PJJM Weterings
         Toxicologist; Weterings Consultancy BV, Rosmalen
         ASAM van der Burght, scientific secretary
         Health Council of the Netherlands, The Hague
      The committee                                                                          28
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<pre>The first draft of the present document was prepared by IDH Waalkens-Berendsen, from
the TNO Nutrition and Food Research Institute in Zeist, by contract with the Ministry of
Social Affairs and Employment.
Secretarial assistance: E Vandenbussche-Parméus.
Lay-out: J van Kan.
The committee                                                                            29
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<pre>Annex B
      Comments on the public draft
      A draft of the present report was released in 1999 for public review. No organisations or
      persons have commented on the draft document.
      Comments on the public draft                                                              30
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<pre>Annex C
      Directive (93/21/EEC) of the European
      Community
      4.2.3         Substances toxic to reproduction
      4.2.3.1       For the purposes of classification and labelling and having regard to the present
                    state of knowledge, such substances are divided into 3 categories:
      Category 1:
      Substances known to impair fertility in humans
      There is sufficient evidence to establish a causal relationship between human exposure to the substance
      and impaired fertility.
      Substances known to cause developmental toxicity in humans
      There is sufficient evidence to establish a causal relationship between human exposure to the substance
      and subsequent developmental toxic effects in the progeny.
      Category 2:
      Substances which should be regarded as if they impair fertility in humans:
      Directive (93/21/EEC) of the European Community                                                         31
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<pre>There is sufficient evidence to provide a strong presumption that human exposure to the substance may
result in impaired fertility on the basis of:
     Clear evidence in animal studies of impaired fertility in the absence of toxic effects, or, evidence of
     impaired fertility occurring at around the same dose levels as other toxic effects but which is not a
     secondary non-specific consequence of the other toxic effects.
     Other relevant information.
Substances which should be regarded if they cause developmental toxicity to humans:
There is sufficient evidence to provide a strong presumption that human exposure to the substance may
result in developmental toxicity, generally on the basis of:
     Clear resuts in appropriate animal studies where effects have been observed in the absence of signs
     of marked maternal toxicity, or at around the same dose levels as other toxic effects but which are
     not a secondary non-specific consequence of the other toxic effects.
     Other relevant information.
Category 3:
Substances which cause concern for human fertility:
Generally on the basis of:
     Results in appropriate animal studies which provide sufficient evidence to cause a strong suspicion
     of impaired fertility in the absence of toxic effects, or evidence of impaired fertility occurring at
     around the same dose levels as other toxic effects, but which is not a secondary non-specific conse-
     quence of the other toxic effects, but where the evidence is insufficient to place the substance in Ca-
     tegory 2.
     Other relevant information.
Substances which cause concern for humans owing to possible developmental toxic effects:
Generally on the basis of:
     Results in appropriate animal studies which provide sufficient evidence to cause a strong suspicion
     of developmental toxicity in the absence of signs of marked maternal toxicity, or at around the same
     dose levels as other toxic effects but which are not a secondary non-specific consequence of the
     other toxic effects, but where the evidence is insufficient to place the substance in Category 2.
     Other relevant information.
Directive (93/21/EEC) of the European Community                                                              32
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<pre>4.2.3.2       The following symbols and specific risk phrases apply:
Category 1:
For substances that impair fertility in humans:
T; R60: May impair fertility
For substances that cause developmental toxicity:
T; R61: May cause harm to the unborn child
Category 2:
For substances that should be regarded as if they impair fertility in humans:
T; R60: May impair fertility
For substances that should be regarded as if they cause developmental toxicity in humans:
T; R61: May cause harm to the unborn child.
Category 3:
For substances which cause concern for human fertility:
Xn; R62: Possible risk of impaired fertility
For substances which cause concern for humans owing to possible developmental toxic effects:
Xn; R63: Possible risk of harm to the unborn child.
4.2.3.3       Comments regarding the categorisation of substances toxic to reproduction
Reproductive toxicity includes impairment of male and female reproductive functions or capacity and the
induction of non-inheritable harmful effects on the progeny. This may be classified under two main head-
ings of 1) Effects on male or female fertility, 2) Developmental toxicity.
1    Effects on male or female fertility, includes adverse effects on libido, sexual behaviour, any aspect
     of spermatogenesis or oogenesis, or on hormonal activity or physiological response which would in-
Directive (93/21/EEC) of the European Community                                                            33
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<pre>      terfere with the capacity to fertilise, fertilisation itself or the development of the fertilised ovum up
      to and including implantation.
2     Developmental toxicity, is taken in its widest sense to include any effect interfering with normal de-
      velopment, both before and after birth. It includes effects induced or manifested prenatally as well
      as those manifested postnatally. This includes embrytoxic/fetotoxic effects such as reduced body
      weight, growth and developmental retardation, organ toxicity, death, abortion, structural defects (te-
      ratogenic effects), functional defects, peri-postnatal defects, and impaired postnatal mental or physi-
      cal development up to and including normal pubertal development.
Classification of chemicals as toxic to reproduction is intended to be used for chemicals which have an
intrinsic or specific property to produce such toxic effects. Chemicals should not be classified as toxic to
reproduction where such effects are solely produced as a non-specific secondary consequence of other
toxic effects. Chemicals of most concern are those which are toxic to reproduction at exposure levels
which do not produce other signs of toxicity.
The placing of a compound in Category 1 for effects on Fertility and/or Developmental Toxicity is done
on the basis of epidemiological data. Placing into Categories 2 or 3 is done primarily on the basis of ani-
mal data. Data from in vitro studies, or studies on avian eggs, are regarded as ‘supportive evidence’ and
would only exceptionally lead to classification in the absence of in vivo data.
In common with most other types of toxic effect, substances demonstrating reproductive toxicity will be
expected to have a threshold below which adverse effects would not be demonstrated. Even when clear
effects have been demonstrated in animal studies the relevance for humans may be doubtful because of
the doses administrated, for example, where effects have been demonstrated only at high doses, or where
marked toxicokinetic differences exist, or the route of administration is inappropriate. For these or simi-
lar reasons it may be that classification in Category 3, or even no classification, will be warranted.
Annex V of the Directive specifies a limit test in the case of substances of low toxicity. If a dose level of
at least 1000 mg/kg orally produces no evidence of effects toxic to reproduction, studies at other dose le-
vels may not be considered necessary. If data are available from studies carried out with doses higher
than the above limit dose, this data must be evaluated together with other relevant data. Under normal
circumstances it is considered that effects seen only at doses in excess of the limit dose would not neces-
sarily lead to classification as Toxic to Reproduction.
Effects on fertility
For the classification of a substance into Category 2 for impaired fertility, there should normally be clear
evidence in one animal species, with supporting evidence on mechanism of action or site of action, or
chemical relationship to other known antifertility agents or other information from humans which would
Directive (93/21/EEC) of the European Community                                                                 34
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<pre>lead to the conclusion that effects would be likely to be seen in humans. Where there are studies in only
one species without other relevant supporting evidence then classification in Category 3 may be appropri-
ate.
Since impaired fertility may occur as a non-specific accompaniment to severe generalised toxicity or
where there is severe inanition, classification into Category 2 should only be made where there is eviden-
ce that there is some degree of specificity of toxicity for the reproductive system. If it was demonstrated
that impaired fertility in animal studies was due to failure to mate, then for classification into Category 2,
it would normally be necessary to have evidence on the mechanism of action in order to interpret whether
any adverse effect such as alteration in pattern of hormonal release would be likely to occur in humans.
Developmental toxicity
For classification into Category 2 there should be clear evidence of adverse effects in well conducted stu-
dies in one or more species. Since adverse effects in pregnancy or postnatally may result as a secondary
consequence of maternal toxicity, reduced food or water intake, maternal stress, lack of maternal care,
specific dietary deficiencies, poor animal husbandry, intercurrent infections, and so on, it is important
that the effects observed should occur in well conducted studies and at dose levels which are not associa-
ted with marked maternal toxicity. The route of exposure is also important. In particular, the injection of
irritant material intraperitoneally may result in local damage to the uterus and its contents, and the re-
sults of such studies must be interpreted with caution and on their own would not normally lead to classi-
fication.
Classification into Category 3 is based on similar criteria as for Category 2 but may be used where the
experimental design has deficiencies which make the conclusions less convincing, or where the possibili-
ty that the effects may have been due to non-specific influences such as generalised toxicity cannot be ex-
cluded.
In general, classification in category 3 or no category would be assigned on an ad hoc basis where the
only effects recorded are small changes in the incidences of spontaneous defects, small changes in the
proportions of common variants such as are observed in skeletal examinations, or small differences in
postnatal developmental assessments.
Effects during Lactation
Substances which are classified as toxic to reproduction and which also cause concern due to their effects
on lactation should in addition be labelled with R64 (see criteria in section 3.2.8).
Directive (93/21/EEC) of the European Community                                                                35
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<pre>For the purpose of classification, toxic effects on offspring resulting only from exposure via the breast
milk, or toxic effects resulting from direct exposure of children will not be regarded as ‘Toxic to Repro-
duction’, unless such effects result in impaired development of the offspring.
Substances which are not classified as toxic to reproduction but which cause concern due to toxicity
when transferred to the baby during the period of lactation should be labelled with R64 (see criteria in
section 3.2.8). This R-phrase may also be appropriate for substances which affect the quantity or quality
of the milk.
R64 would normally be assigned on the basis of:
a    toxicokinetic studies that would indicate the likelihood that the substance would be present in po-
     tentially toxic levels in breast milk, and/or
b    on the basis of results of one or two generation studies in animals which indicate the presence of ad-
     verse effects on the offspring due to transfer in the milk, and/or
c    on the basis of evidence in humans indicating a risk to babies during the lactational period.
     Substances which are known to accumulate in the body and which subsequently may be released in-
     to milk during lactation may be labelled with R33 and R64.
Directive (93/21/EEC) of the European Community                                                             36
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<pre>Annex D
      Fertility and developmental toxicity
      studies
      Fertility and developmental toxicity studies 37
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<pre>Table 1 Effects of lithium on human fertility.
authors  type of study/        dose/               experimental findings                                                   remarks
         no. of subjects/age   Route of exposure period
Lev81    male patients; n=4 serum Li 22-52         3 weeks      decreased sperm viability
         controls:volunteers; mg/l (oral)                       no effect on motility and count of sperm
         n=9
Tan81    2 male and 4 female 600-1800 mg           3-4 weeks    No effect of Li on PRL plasma levels
         patients (22-35 ye- Li2CO3/day per os
         ars old); 4 male and for 3-4 weeks
         4 female controls
         (24-38 years old)
Bla82    2 case reports, ma- serum Li              case 1: 3.5  case 1: after 1 month of Li use loss of libido and im-
         les age 42 years and case 1: 2.6-3.3      months case paired erection; after receipt of a blind placebo rapid
         58 years              mg/l case 2: 1.8    2: 7 months normalization of libido and sexual behaviour
                               mg/l (oral)                      case 2: after start of the Li treatment loss of libido and
                                                                difficulty in obtaining erection; after 2 months of use
                                                                spontaneously recovery from symptoms
Goo83    9 males (mean age     Li2CO3 until plas-               Baseline serum PRL levels were not affected by Li tre-
         28.3 years) and       ma level of 3-5.6                atment
         9 females (mean       mg/l (iv)
         age 33.3 years)
Gro85    12 control and 12     Li until plasma le-              No effect of Li on base-line PRL levels
         patients              vel was 2.2-3.3
                               mg/l
Jof86    8 patients (mean      1230 mg Li2CO3 /d at least 6     Li increased base-line levels of PRL and augmented a
         age 39.4 years)                           weeks        TRH-induced PRL response
Gha92    45 men and 59 wo- 300-2100 Li             mean: 6.7    No relationship between serum Li or plasma PRL le-
         men                   mg/day (orally)     years Li use vels and sexual dysfunction scores
         (mean age 45, range
         20-68)
Yat94    9 male and 2 female lithium, 600-1500 3 weeks          Li had no effect on base-line PRL levels
         patients and 11 con- mg/d in six pa-
         trols                 tients
            Fertility and developmental toxicity studies                                                                        38
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<pre>Table 2 Effects of lithium on human development.
authors     type of study/no. of     dose/Route of ex- experimental pe- findings                                     remarks
            subjects/age             posure            riod
Vac70       uncontrolled clinical 300-1800 mg/day pregnancy             bilateral club feet and meningomyocele in
            2-year study in 25 pa- (oral)                               lumbar region
            tients male and fema-
            le; 1 female became
            pregnant
Wei76       Birth Register of lithi- at least sometime first trimester  congenital malformations (11/166): 13 of
            um babies                during first tri- pregnancy        these involved the cardiovascular system and
            n=166                    mester (oral)                      of which 4 concern Ebstein's anomaly
Käl83       cohort study             (oral)            pregnancy        perinatal death, heart defects; Ebstein ano-
            female n=350                                                maly not detected
Cun89       female n=72              (oral)            pregnancy        4 spontaneous, 6 abortus provocatus, 1 still
                                                                        born, 1 lumbar meningocele and 1 unilateral
                                                                        inguinal hernia
Rob90       female case              750-1000 mg/day first trimester    hypothyroidism, lingual thyroid ectopy asso-
            report n=1               (oral)            pregnancy        ciated with atrial septal defect
Jac92       n=138/n=148              (oral)            pregnancy        no increased risk of congenital defects
            Fertility and developmental toxicity studies                                                                  39
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<pre>Table 3.1 Fertility studies with lithium in animals.
authors   species        route experimental      dose          findings                                  remarks
                                 period
Ban83     adult male     ip      twice daily for 0 and 100 mg no effects LH, FSH, PRL in pitiuitary,     4 out of 20 animals that
          Sprague                2 or 7 days     LiCl/kg bw    after 2 days plasma LH increased          received lithium for 7
          Dawley rats                                          after 7 days plasma decreased             days died on the 6th
          (n=20); age                                          no effect on plasma FSH after 2 and 7     day; one control animal
          50 days                                              days after 2 days no effect on plasma     died during treatment.
                                                               PRL level after 7 days decreased plasma   A number of rats that
                                                               PRL level                                 received lithium for 7
                                                                                                         days showed signs of
                                                                                                         polydipsia and polyuria
McI83     male Spra-     ip      once or 14 days 0 or 2 mg     no effect on serum PRL levels             general toxicity not
          gue Dawley                             Li/kg bw                                                described
          (n=6-9);
          230-260
          grams
Gho91a    Wistar rats sc         15, 20 or 25    0 and 2 mg    after 15 days:                            no effect on body
          (n=8) age 35           days            LiCl/kg bw/d; spermatogenesis was inhibited at stage    weights
          days                                   serum lithium VII of the seminiferous epithelial cycle,
                                                 concentration serum FSH, LH, PRL and testosterone
                                                 20 mg/l       levels were decreased
                                                               after 20 and 25 days:
                                                               spermatogenesis was inhibited at stage
                                                               VII of the seminiferous epithelial cycle,
                                                               serum FSH, LH PRL and testosterone
                                                               levels were decreased
                                                               decreased weight of accessory sex or-
                                                               gans
Gho91b Wistar rats sc            21 days         0 and 2 mg    PRL injection just after treatment with   no effect on body
          (n=8) age 90                           LiCl/kg bw/d, lithium resulted in a recovery of effects weights
          days                                   0.25 m/kg     mentioned in Gho91a
                                                 PRL treat-
                                                 ment just af-
                                                 ter lithium
                                                 treatment
             Fertility and developmental toxicity studies                                                                       40
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<pre>Table 3.2 Fertility studies with lithium in animals
authors  species            route      experimental peri-   dose            findings                                  remarks
                                       od
Gra72    Charles River      gavage     administration fe-   females: 0, 25, high dose group: 2 females died du-
         rat (males and     females;   males: 14 d prema-   75 or 150 mg ring gestation; d 21 pup body weight:
         females)           diet ma-   ting                 Li2CO3/kg       stat.sign. reduction
                            les        administration ma-   bw/d, males: 0,
                                       les: 70 d premating  10, 25 or 50
                                       sacrifice females:   mg Li2CO3/kg
                                       lactation d 21       bw/d
Kel78    swine (fema-       diet       administration: ge- 0, 3000 mg       reduction maternal body weight from
         les)                          station              Li2CO3/         gestation d 60, stat.sign. from d 110.
                                                            kg diet =       Stat.sign. reduction of no. of live
                                                            ~120 mg/kg      born, birth weight, survival d 21;
                                                            bw/d            stat.sign. increase mascerated foetuses
                                                                            and stillborn pups
Mro83    CFM mouse          drinking administration:        0, 2000, 4000 8000 mg: mice did not drink, died           general toxicity
         (males and fe-     water      from 3 or 6-8 w and or 8000 mg Li- 4000 mg: mice drank little, did not re-     and number of
         males)                        onwards              Cl/l            produce                                   animals per do-
                                                                            2000 mg from 6-8 w: time between          se group were
                                                                            litters stat.sign. increased, no. of lit- not described
                                                                            ters decreased; stat.sign. increase pre-
                                                                            weaning pup mortality
                                                                            2000 mg from 3 w: same as above +
                                                                            stat.sign. delay pup growth and deve-
                                                                            lopment
Sec86    Sprague-           drinking administration: 10     0, 80 or 160    80 or 160 mg: altered maternal beha-
         Dawley rat (fe- water         d                    mg natural Li   viour: no grooming, little and short
         males)                        premating through    salts/kg/d      nursing; dead pups were not canniba-
                                       postpartal d 28                      lized
Mes86    Sprague-           drinking administration:        0 or 40 mg Li-  exp.1+2 females: stat.sign. reduction
         Dawley mouse water            from mating          Cl/l            brain and kidney weight, reduction
         (females)                     (exp.1) or delivery                  spleen weight; pups: stat.sign. reduc-
                                       (exp.2) through                      tion brain, reduction kidney and testis
                                       postpartal d 23 sa-                  weight, induction L-ADH, L-C-
                                       crifice: PP d 37, or                 ALDH, (exp.1 only:) inhibition L-M-
                                       (exp.3): administra-                 T-LDH exp.3 pups: inhibition L-MT-
                                       tion 2 w premating                   LDH
                                       through d 1 after
                                       delivery; sacrifice:
                                       d 1 after delivery
             Fertility and developmental toxicity studies                                                                           41
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<pre>Table 4.1 Developmental toxicity studies with lithium in animals.
authors species            route            experimental period    dose             findings                           remarks
Sza70    Charles River     gavage           administration: gesta- 200, 300, 465    465 mg: stat.sign. increase in ma-
         mouse                              tion d 6-15            mg               ternal and foetal death, 30% cleft
                                            sacrifice: gestation d Li2CO3/kg/d      palate
                                            18                                      300 mg: 11 % cleft palate
                                                                                    200 mg: no effects
Gra72    Charles River rat gavage           rat administration:    rat: 0, 25, 75   high doses: 2 rats and 3 rabbits
         New Zealand                        gestation d 5-15, sa-  or 150 mg        died
         white rabbit      oral (capsules)  crifice: d 20          Li2CO3/kg bw     low doses: 1 rabbit died
         rhesus monkey     oral (capsules)  rabbit administration: rabbit: 0, 25 or No differences with controls in
                                            gestation d 5-18, sa-  40 mg/kg bw/d    maternal fertility, bw gain, im-
                                            crifice: d 28          Li2CO3/kg bw     plantation sites, litter size and
                                            monkey administra-     monkey: 0 or     weight, foetal mortality and vis-
                                            tion: gestation d      25 mg            ceral or skeletal malformations
                                            14-35, sacrifice: d    Li2CO3/kg bw
                                            160                    Li2CO3/kg/d
Smi82    129 Sv/SL or A/J i.p. injection    SV/SL: gestation d 8, 1x0, 0.8, 1.6     SV/SL: stat.sign. increase malfor- possible
         mouse                              9 or 10                or 5.0/3.2 mg    mations in high dose group only    maternal
                                            A/J: gestation d 12,   Li2CO3/mouse     (fused ribs, vertebral defects,    effects
                                            13 or 14                                exencephaly). Most effects upon    unknown
                                            sacrifice: gestation d                  exposure d 9
                                            18-19                                   A/J mice: not sign. increase in
                                                                                    higher dose groups, no effects re-
                                                                                    sulting from day of exposure
idem     129 Sv/SL mouse drinking water     administration: gesta- 2 mg             2 out of 16 females had viable
                                            tion d 1-18            Li2CO3/ml        foetuses; all 6 foetuses were
                                            sacrifice: d 18                         malformed
            Fertility and developmental toxicity studies                                                                       42
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<pre>Table 4.2 Developmental toxicity studies with lithium in animals.
authors species           route         experimental pe- dose            findings                                       remarks
                                        riod
Mar86 Wistar rat          gavage        administration:    0, 50, 100 mg low dose: slight effects on no. implantation   possible
                                        gestation d 6-15   Li2CO3/kg/d   sites, live foetuses, foetal bw                maternal
                                        sacrifice: gesta-                high dose: stat.sign. effects on no. implan-   effects un-
                                        tion d 20                        tation sites, live foetuses, foetal bw.        known
                                                                         High incidence of skeletal anomalies and
                                                                         malformations
Sha86 rat                 gavage        administration:    0, 7 mg       high incidence (>10%) of growth retarda-       possible
                                        gestation d 0-10 Li2CO3/kg/d     tion, cleft palate, brain liquification, hepa- maternal
                                        sacrifice: at term               tomegaly, digital anomalies                    effects un-
                                                                         lower incidence >10%) of hydrocephaly,         known
                                                                         cardiomegaly
Sec86 Sprague-            drinking      administration:    0, 80 or 160  Maternal effects related to behaviour
        Dawley rat        water         10 d premating     natural Li    Dose-related decrease in pup body weight,
                                        through postpar-   salts/kg/d    eye-opening, pinna unfolding, development
                                        tal d 28                         in depth perception, spontaneous activity
Jur88   JBT/Jd mouse      ip. injection administration:    0, 250-400 mg minimal maternal lethal dose: 300 mg/kg        possible
                                        gestation d        Li2CO3/kg     LD50: 440 mg/kg                                other ma-
                                        9sacrifice: gesta-               Dose-related effects on no. of dead foetu-     ternal ef-
                                        tion d 13                        ses, retardations, abnormalities (exencep-     fects
                                                                         haly, craniorachischisis, dilation of 4th      unknown
                                                                         ventricle)
d = day; i.p. = intraperitoneal
             Fertility and developmental toxicity studies                                                                          43
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<pre>Annex E
      Abbreviations
      Abbreviations used
      bw            body weight
      d             day
      F             female(s)
      FSH           follicle stimulating hormone
      GH            gonadotropin hormone
      i.p.          intraperitoneal
      i.v.          intravenous
      L-ADH         hepatic alcohol dehydrogenase
      L-C-ALDH hepatic cytoplasmatic aldehyde dehydrogenase
      LH            luteinizing hormone
      LHRH          luteinizing hormone releasing hormone
      L-MT-LDH hepatic mitochondrial lactate dehydrogenase
      M             male(s)
      n             number
      NOAEL         no adverse effect level
      OECD          Organisation for Economic Cooperation and Development
      Abbreviations                                                       44
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<pre>PN            postnatal
PP            post partum
PRL           prolatine
s.c.          subcutaneously
TRH           thyroid releasing hormone
TSH           thyroid stimulating hormone
Abbreviations                             45
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<br><br>