<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>Isoflurane
Evaluation of the effects on reproduction, recommendation for classification
</pre>

====================================================================== Einde pagina 1 =================================================================

<br><br>====================================================================== Pagina 2 ======================================================================

<pre>Gezondheidsraad                              Voorzitter
Health Council of the Netherlands
Aan de Staatssecretaris Sociale Zaken en Werkgelegenheid
Onderwerp           : Aanbieding advies ‘Isofluraan’
Uw kenmerk          : DGV/MBO/U-932542
Ons kenmerk         : U-1038/AvdB/RA/543-A6
Bijlagen            :2
Datum               : 6 september 2002
Mijnheer de staatssecretaris,
Bij brief van 3 december 1993, nr DGV/MBO/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 lijst van voor de voortplanting vergiftige stoffen.
Op deze lijst komen stoffen die volgens de richtlijnen van de Europese Unie ingedeeld moeten
worden in categorie 1, 2 en 3 wat betreft effecten op de voortplanting en stoffen die schadelijk
kunnen zijn voor het nageslacht via de borstvoeding. De Gezondheidsraad is verzocht om voor
stoffen een classificatie volgens de EU-criteria voor te stellen.
      In dit kader bied ik u hierbij een advies aan over Isofluraan. Dit advies is opgesteld door de
Commissie Reprotoxische stoffen van de Gezondheidsraad en beoordeeld door de Beraadsgroep
Gezondheid en Omgeving. Ik heb deze publicatie heden ter kennisname aan de Minister van
Volksgezondheid, Welzijn en Sport en aan de Minister van de Volkshuisvesting, Ruimtelijke
Ordening en Milieu gestuurd.
Hoogachtend,
prof. dr JA Knottnerus
Bezoekadres                                                               Postadres
Parnassusplein 5                                                          Postbus 16052
2511 VX Den Haag                                                          2500 BB Den Haag
Telefoon (070) 3407520                                                    Telefax (070) 340 75 23
E-mail: A.vd.burght@gr.nl                                                 www.gr.nl
</pre>

====================================================================== Einde pagina 2 =================================================================

<br><br>====================================================================== Pagina 3 ======================================================================

<pre>Isoflurane
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. 2002/13OSH, The Hague, 6 september 2002
</pre>

====================================================================== Einde pagina 3 =================================================================

<br><br>====================================================================== Pagina 4 ======================================================================

<pre>The Health Council of the Netherlands, established in 1902, is an independent
scientific advisory body. Its remit is “to advise the government and Parliament on the
current level of knowledge with respect to public health issues...” (Section 21, Health
Act).
     The Health Council receives most requests for advice from the Ministers of Health,
Welfare & Sport, Housing, Spatial Planning & the Environment, Social Affairs &
Employment, and Agriculture, Nature Preservation & Fisheries. The Council can
publish advisory reports on its own initiative. It usually does this in order to ask
attention for developments or trends that are thought to be relevant to government
policy.
     Most Health Council reports are prepared by multidisciplinary committees of
Dutch or, sometimes, foreign experts, appointed in a personal capacity. The reports are
available to the public.
Preferred citation:
Health Council of the Netherlands: Committee for Compounds toxic to reproduction.
Isoflurane; Evaluation of the effects on reproduction, recommendation for
classification. The Hague: Health Council of the Netherlands, 2002; publication no.
2002/13OSH.
all rights reserved
ISBN: 90-5549-442-9
</pre>

====================================================================== Einde pagina 4 =================================================================

<br><br>====================================================================== Pagina 5 ======================================================================

<pre>    Contents
    Samenvatting 7
    Executive summary 8
1   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.  Isoflurane 13
2.1 Introduction 13
2.2 Human studies 13
2.3 Animal studies 16
2.4 Conclusion 17
    References 19
    Contents                       5
</pre>

====================================================================== Einde pagina 5 =================================================================

<br><br>====================================================================== Pagina 6 ======================================================================

<pre>  Annexes 23
A The committee 24
B Comments on the public draft 26
C Directive (93/21/EEC) of the European Community 27
D Fertility and developmental toxicity studies 33
E Abbreviations 37
  Contents                                           6
</pre>

====================================================================== Einde pagina 6 =================================================================

<br><br>====================================================================== Pagina 7 ======================================================================

<pre>Samenvatting
Op verzoek van de Minister van Sociale Zaken en Werkgelegenheid beoordeelt de
Gezondsheidsraad de effecten op de reproductie van stoffen waaraan mensen tijdens de
beroepsuitoefening kunnen worden blootgesteld. De Commissie Reproductietoxische
stoffen, een commissie van de Raad, adviseert een classificatie van reproductietoxische
stoffen volgens Richtlijn 93/21/EEC van de Europese Unie. In het voorliggende rapport
heeft de commissie isofluraan onder de loep genomen.
De aanbevelingen van de commissie zijn:
    Voor effecten op de fertiliteit meent de commissie dat er onvoldoende geschikte
    gegevens beschikbaar zijn. Zij adviseert daarom om isofluraan niet te classificeren.
    Voor effecten op de ontwikkeling is de commissie van mening dat er onvoldoende
    geschikte humane gegevens zijn en dat voldoende diergegevens laten zien dat
    isofluraan de ontwikkeling van het nageslacht niet schaadt. Zij adviseert daarom
    isofluraan niet te classificeren.
    Voor effecten tijdens lactatie, adviseert de commissie om isofluraan niet te
    kenmerken wegens onvoldoende geschikte gegevens.
Samenvatting                                                                             7
</pre>

====================================================================== Einde pagina 7 =================================================================

<br><br>====================================================================== Pagina 8 ======================================================================

<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 to classify compounds toxic to reproduction according to the Directive
93/21/EEC of the European Union. In the present report the committee has reviewed
isoflurane.
The committee’s recommendations are
    For effects on fertility, the committee recommends not to classify isoflurane due to
    a lack of appropriate human and animal data.
    For developmental toxicity, the committee is of the opinion that a lack of
    appropriate human data precludes the assessment of isoflurane and that sufficient
    animal data show that no classification is indicated
    For effects during lactation, the committee is of the opinion that a lack of
    appropriate data precludes the labeling of isoflurane.
Executive summary                                                                        8
</pre>

====================================================================== Einde pagina 8 =================================================================

<br><br>====================================================================== Pagina 9 ======================================================================

<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
        requested the Health Council of the Netherlands to classify compounds toxic to
        reproduction. The classification is performed by the Health Council’s Committee for
        Compounds Toxic to Reproduction according to the guidelines of the European Union
        (Directive 93/21/EEC). 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, 2 or 3) or labeled as ‘may cause
        harm to breastfed babies’ (R64).
1.2     Committee and procedure
        The present document contains the classification of isoflurane by the Health Council’s
        Committee for Compounds Toxic to Reproduction. The members of the committee are
        listed in Annex A. The first draft of this report was prepared by dr ir MEM Kuilman
        and ir DH Waalkens-Berendsen at the Department of Target Organ Toxicology of TNO
        Nutrition and Food Research, Zeist, The Netherlands, by contract with the Ministry of
        Social Affairs and Employment. The classification is based on the evaluation of
        published human and animal studies concerning adverse effects with respect to fertility
        and development and lactation of the above mentioned compound.
        Executive summary                                                                        9
</pre>

====================================================================== Einde pagina 9 =================================================================

<br><br>====================================================================== Pagina 10 ======================================================================

<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
                        effects (R63)
     No classification for effects on fertility or development
     Labelling for lactation:
                        May cause harm to breastfed babies (R64)
                        No labelling for lactation
    In 2002, the President of the Health Council released a draft of the report for public
    review. The individuals and organizations 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
    parental and developmental effects observed, their specificity and adversity, and the
    dosages 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
    considerations.
         If there is sufficient evidence to establish a causal relationship between human
         exposure to the substance and impaired fertility or subsequent developmental toxic
         effects 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).
    Executive summary                                                                                   10
</pre>

====================================================================== Einde pagina 10 =================================================================

<br><br>====================================================================== Pagina 11 ======================================================================

<pre>         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
         studies, need not necessarily lead to a category 2 classification.
         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
         occur 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 effects occur in the presence of maternal toxicity, they will be considered as a
         consequence 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
         reversibility 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 labeling substances for effects during lactation is also based
    on Directive 93/21/EEC. The Directive defines that substances which are absorbed by
    women and may interfere with lactation or which may be present (including
    metabolites) in breastmilk in amounts sufficient to cause concern for the health of a
    breastfed child, should be labeled with R64. Unlike the classification of substances for
    fertility and developmental effects, which is based on a hazard identification only
    (largely independent of the dosage), the labeling for effects during lactation is based on
    a risk characterization and therefore also includes consideration of the level of
    exposure of the breastfed child.
         Consequently, a substance should be labeled 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 concentration of a compound as potentially toxic to the breastfed
    child when this concentration is above an exposure limit for the general population, eg
    the acceptable daily intake (ADI).
*   Organisation for Economic Cooperation and Development
    Executive summary                                                                           11
</pre>

====================================================================== Einde pagina 11 =================================================================

<br><br>====================================================================== Pagina 12 ======================================================================

<pre>1.5 Data
    Literature searches were conducted in the on-line databases Toxline and Medline,
    starting from 1966 up to 2000. 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 of most recent reviews were consulted as well as several websites regarding
    (publications on) toxicology and health. References are divided in literature cited and
    literature consulted but not cited.
         The committee chose to describe human studies in the text, starting with review
    articles and, in addition, the studies are summarised in Annex D. Of each study the
    quality of the study design (performed 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 emphasizes 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 characterization,
    human exposure assessment and recommendations of other organizations.
*   for definitions see Tox95
    Executive summary                                                                          12
</pre>

====================================================================== Einde pagina 12 =================================================================

<br><br>====================================================================== Pagina 13 ======================================================================

<pre>Chapter 2
        Isoflurane
2.1     Introduction
         Name              :     Isoflurane
         Chemical name           1-chloro-2,2,2-trifluoroethyl difluoromethyl ether,
                                 2-chloro-2-(difluoromethoxy)-1,1,1-trifluoro ethane
         Other name        :     forane
         CAS-no            :     26675-46-7
         Use               :     anaesthetic gas (since 1979)
         Mol weight        :     184.50
         Chem formula      :     C3H2ClF5O
         Conversion factor :     1 ppm = 7.55 mg/m3 (101 kPa, 25ºC)
                                 1 mg/m3 = 0.13 ppm
                                 1% = 10000 ppm = 75500 mg/m3
2.2     Human studies
        Human studies are described in more detail in Tables 1 and 2 (annex D).
        Isoflurane                                                                   13
</pre>

====================================================================== Einde pagina 13 =================================================================

<br><br>====================================================================== Pagina 14 ======================================================================

<pre>Fertility
Peelen et al. (Pee99) reported that time to pregnancy was not affected in operation
chamber assistants (OR 0.9, 95% CI 0.6-1.4). In this study the concentrations of several
of anaesthetic gasses were measured; the maximal isoflurane concentration measured
was 120 mg/m3. However, in this study, the composition of the anaesthetic gas
mixtures, and the level and duration of exposure were not reported. Therefore, the
committee is of the opinion that this study is no reason for classification.
Development
Johnson et al. (Joh87) did not find an increase in spontaneous abortion in a case control
study among female veterinarians, veterinarian assistants and wives of male
veterinarians exposed to a mixture of anaesthetics. No information was available on the
concentration of the different anaesthetics.
     In contrast, Guirguis et al. (Gui90) found an increase in spontaneous abortions and
congenital anomalies among female hospital staff exposed to mixtures of anaesthetics
(concentration unknown) (abortions: OR 1.98, 95% CI 1.53-2.56; anomalies: OR 2.24,
95% CI 1.69-2.97) and wives of males hospital staff exposed to a mixture of waste
anaesthetics (abortions: OR 2.3, 95% CI 1.68-3.13; anomalies: OR 1.46, 95% CI
1.04-2.05). Odds ratios were adjusted for several confounders.
     Peelen et al. (Pee99) studied the effects of exposure to anaesthetic gasses on the
time to pregnancy, spontaneous abortions, preterm birth, low birth weight and
congenital anomalies in operation personal. An increased risk for spontaneous abortion
(OR 1.3, 95% CI 0.8-2.1), preterm birth (OR 1.9, 95% CI 1.2-3.0) and congenital
abnormalities (OR 1.6, 95% CI 0.9-2.9) was observed. After correction for alcohol use,
work circumstances and other occupational exposure, the OR for preterm birth was 1.4
(0.7-2.8) and the OR for congenital abnormalities 1.8 (1.0-4.1). Women present at the
beginning of operations or present at tonsil operations have higher risks for
spontaneous abortions (OR 1.6 (0.9-2.5)/ OR 1.9 (1.1-3.6) not corrected for
confounders) and preterm birth (OR 2.0 (1.2-3.4)/ OR 1.6 (0.8-2.0) not corrected for
confounders). In this study, the concentration of anaesthetic gasses was measured; the
maximal isoflurane concentration measured was 120 mg/m3.
     However, in the abovementioned studies, hospital staff was exposed to a mixture of
anaesthetic gasses. For that reason it was not clear if isoflurane caused the slight
increases in reproductive effects. Therefore, the committee is of the opinion that none
of the available studies could be used for classification purposes.
Isoflurane                                                                                14
</pre>

====================================================================== Einde pagina 14 =================================================================

<br><br>====================================================================== Pagina 15 ======================================================================

<pre>Lactation
Fisher et al. (Fis97) studied the human blood/air and milk/air partition coefficient (PC)
in human blood and human milk samples (n=10). The objective of this study was to
evaluate the potential chemical exposure of a nursing infant by ingestion of
contaminated milk from a mother who was occupationally exposed to vapours; To
estimate the infants’ exposure, a generic human pharmacokinetic (PB-PK) lactation
model was developed. The model was based on a 8-hour exposure period of the mother
to a constant (isoflurane) vapour concentration of 50 ppm (384 mg/m3). The
experimentally determined blood/air and milk/air PC values were used in the PB-PK
lactation model. The predicted amount of isoflurane ingested by a nursing infant over a
24-hour period was 0.336 mg in 0.92 l (0.37 mg/l). However, this model has not been
validated yet and the relevance of this exposure level to the development of the human
infant is unknown.
Isoflurane                                                                                15
</pre>

====================================================================== Einde pagina 15 =================================================================

<br><br>====================================================================== Pagina 16 ======================================================================

<pre>2.3 Animal studies
    Fertility and developmental toxicity studies with isoflurane in experimental animals are
    summarized in Tables 3 and 4, respectively.
    Fertility studies
    Male (C57B1/C3H)F1 mice were exposed by inhalation to air, 0.1 and 1% [7550 and
    75500 mg/m3] isoflurane for 4 h/day for 5 days (Lan81). After 28 days epididymal
    spermatozoa were evaluated for morphological changes. The percentage abnormal
    spermatozoa in both isoflurane-exposed groups was comparable to the control group
    (1.70 + 0.18 (1%), 1.20 + 0.24 (0.1%) versus 1.44 + 0.19 in the control). Mortality was
    not observed. General toxicity was not described in this study.
        No effects on pregnancy rate, number of implantation, resorptions or live foetuses
    were observed when untreated female Swiss/Webster mice were mated with males
    exposed to air, 0.1 and 0.4% [7550 and 30200 mg/m3] isoflurane 4h/day for 6 weeks
    prior to mating or when both males and females were treated 2 weeks prior to mating
    and during mating and gestation (Maz85a). No toxicity was observed; the exposure to
    the highest concentration resulted in light anaesthesia.
    Developmental toxicity
    After exposure of both male and female Swiss/Webster mice to 0.1 and 0.4% [7550 and
    30200 mg/m3] isoflurane 4h/day 2 weeks prior to mating and during mating and
    gestation no differences were found in the number of live foetuses per litter, the
    viability and lactation index and pup weight (Maz85a). In this study no toxicity was
    found; mice exposed to the highest concentration were slightly sedated.
        Exposure of female Swiss/Webster mice during GD 6-15 to 0.006, 0.06 and 0.6%
    [450, 4500 and 45000 mg/m3] isoflurane 4h/day did not result in any effects on litter
    size and sex ratio (Maz85b). However, at the highest concentration an increase in late
    resportions, a decrease in litter weight and skeletal ossification as well as an increase in
    cleft palate and renal pelvic cavitation was observed. Dams exposed to the highest
    concentration isoflurane showed ataxia followed by light general anaesthesia and a
    lower weight gain, partly due to a decreased litter weight.
        Mazze et al. (Maz86) found decreased foetal weight after exposure of Sprague
    Dawley rats from GD 8-10 or 14-16 to 1.05% [78750 mg/m3] isoflurane for 6 h/day by
    inhalation. Dams suffered from light general anaesthesia and decreased weight gain.
    Isoflurane                                                                                   16
</pre>

====================================================================== Einde pagina 16 =================================================================

<br><br>====================================================================== Pagina 17 ======================================================================

<pre>    Foetal weight was not affected after exposure of female rats exposed from GD 11-13 to
    1.05% isoflurane. The dams suffered from light general anaesthesia.
         Exposure of Sprague Dawley rats on GD 8 to 0.35% [26425 mg/m3] isoflurane for
    24h did not result in any effect on the number of implantations, live foetuses,
    resorptions, mean foetal body weight or sex ratio (Fuj87). Moreover, in external,
    visceral and skeletal examinations no differences were found. Maternal mortality was
    not observed, but the rats were slightly sedated during exposure and had lower body
    weights on GD 12, 14 and 16.
    Lactation
    No publications were available.
2.4 Conclusion
    Only one human study on effects on fertility was available which showed that the time
    to pregnancy was not affected in operation chamber assistants exposed to (mixtures of)
    anaesthetics (Pee99). However, the anaesthetic gases used and the concentrations were
    not specified.
         In an animal study, male mice were inhalatory exposed to high concentrations of
    isoflurane for 5 days and sperm morphology was studied 28 days after the last day of
    exposure (Lan81). No changes in sperm morphology were observed. However, as the
    spermatogenic cycle of mice takes 56 days, the exposure and latency periods of the
    experiment were too short to be able to detect effects on all stages of spermatogenesis.
    Inhalatory exposure of male Swiss/Webster mice mated with untreated females or
    treatment of both males and females to a maximum of 0.4% [30200 mg/m3] isoflurane
    did not result in reproductive effects (Maz85a).
         In conclusion, that committee is of the opinion that a lack of appropriate human
    and animal data precludes the assessment of isoflurane for fertility.
    Two out of three epidemiological studies reported developmental effects after exposure
    of (veterinarian) hospital staff to anaesthetic waste (Gui90, Pee99). However, the
    hospital staff was exposed to mixture of anaesthetics. Therefore, the committee is of
    the opinion that a lack of appropriate human data precludes the assessment of
    isoflurane for development
         In animals, effects on foetal weight were found in progeny of Sprague Dawley rats
    exposed inhalatory to 1.05% [78750 mg/m3] isoflurane (Maz86). Progeny of
    Swiss/Webster mice exposed to 0.6% [45000 mg/m3] isoflurane showed an increase in
    late resorptions, a decrease in litter weight and skeletal ossification, as well as an
    Isoflurane                                                                               17
</pre>

====================================================================== Einde pagina 17 =================================================================

<br><br>====================================================================== Pagina 18 ======================================================================

<pre>increase in cleft palate and renal pelvic cavitation (Maz85b). However, in both studies
maternal toxicity (weight loss) was observed. Two other studies in Swiss/Webster mice
and Sprague Dawley rats failed to show any effect of inhalatory exposure to a
maximum of 0.4% [30200 mg/m3] isoflurane on development (Maz85a, Fuj87).
     In view of these data, the committee is of the opinion that sufficient animal data
show that no classification for effects on development is indicated.
From the study of Fisher et al (a pharmacokinetic lactation model), an amount of 0.37
mg isoflurane per liter breast milk was predicted (Fis97). The committee is of the
opinion that this (predicted) isoflurane concentration in human breast milk can only be
used as an indication for the possible amount of the compound in breast milk, because
the model is not yet sufficiently validated. The committee concluded that a predicted
exposure level per se is not a sufficient basis for labeling isoflurane. No experimental
data are available about the concentration of isoflurane in human breast milk and about
the possible effects during lactation. In conclusion, the committee proposes not to label
isoflurane for effects during lactation because of a lack of appropriate data.
Proposed classification for fertility
Lack of appropriate human and animal data precludes assessment of isoflurane for
fertility.
Proposed classification for developmental toxicity
Lack of appropriate human data precludes assessment of isoflurane for development
and sufficient animal data show that no classification is indicated.
Proposed labelling for effect during lactation
Lack of appropriate data precludes assessment of isoflurane for labeling for effects
during lactation
Isoflurane                                                                                18
</pre>

====================================================================== Einde pagina 18 =================================================================

<br><br>====================================================================== Pagina 19 ======================================================================

<pre>       References
Fis97  Fisher J, Mahle D, Bankston L, Greene R, Gearhart J. Lactational transfer of volatile chemicals in breast
       milk. Am. Ind. Hyg. Ass. J. 1997; 58: 425-431.
Fuj87  Fujinaga M, Baden JM, Yhap EO, Mazze RI. Reproductive and teratogenic effects of nitrous oxide,
       isoflurane and their combination in Sprague-Dawley rats. Anesthesiology 1987; 67: 960-964.
Gui90  Guirguis SS, Pelmear PL, Roy ML, Wong L. Health effects associated with exposure to anaesthetic gases
       in Ontario hospital personnel. Br. J. Ind. Med. 1990; 47: 490-497.
Joh87  Johnson JA, Buchan RM, Reif JS. Effect of waste anesthetic gas and vapor exposure on reproductive
       outcome in veterinary personnel. Am. Ind. Hyg. Ass. J. 1987; 48: 62-66.
Lan81  Land PC, Owen El, Linde HW. Morphologic changes in mouse spermatozoa after exposure to inhalational
       anesthetics during early spermatogenesis. Anesthesiology 1981; 54: 53-56.
Maz85a Mazze RI. Fertility, reproduction and postnatal survival in mice chronically exposed to isoflurane.
       Anesthesiology 1985; 63: 663-667.
Maz85b Mazze RI, Wilson AI, Rice SA, Baden JM. Fetal development in mice exposed to isoflurane. Teratology
       1985; 32: 339-345.
Maz86  Mazze RI, Fujinaga M, Rice S, Harris SB, Baden JM. Reproductive and teratogenic effects of nitrous
       oxide, halothane, isoflurane, and endoflurane in Sprague-Dawley rats. Anesthiology 1986; 64:339-344.
Pee99  Peelen S, Roeleveld N, Heederik D, Kromhout H, de Kort W. Reproductie-toxische effecten bij
       ziekenhuispersoneel. Ministerie van Sociale Zaken en Werkgelegenheid 1999.
Tox95  Niesink RJM, de Vries J, Hollinger MA, eds, Toxicology, Principles and Applications, Boca Raton: CRC
       Press, 1995:385.
       References                                                                                                19
</pre>

====================================================================== Einde pagina 19 =================================================================

<br><br>====================================================================== Pagina 20 ======================================================================

<pre>       Literature consulted but not cited
Abb89a Abboud TK, Gangolly J, Mosaad P, Crowell D. Isoflurane in obstetrics. Anesth. Analg. 1989; 68:
       388-391.
Abb89b Abboud TK, D’Onofrio L, Reyes A, Mosaad P, Zhu J, Mantilla M, Gangolly J, Crowell D, Cheung M,
       Afrasiabi A, Khoo N, Davidson J, Steffens Z, Zaki N. Isoflurane or halothane for cesarean section:
       comparative maternal and neonatal effects. Acta Anaesthesiol. Scand. 1989; 33: 578-581.
Bac86  Bachman CR, Biehl DR, Sitar D, Cumming M, Pucci W. Isoflurane potency and cardiovascular effects
       during short exposures in the foetal lamb. Can. Aneasth. Soc. J. 1986; 33: 41-47.
Bai94  Baillot A, Brünner M, Diepenbrock F, Sander J. Belastung der Operationssaalluft mit Narkosegases in
       Abhängigkeit von Klimatechnik und Narkoseverfahren. Zbl. Hyg. 1994;195: 299-305.
Bie83  Biehls DR, Yarnell R, Wade JG, Sitar D. The uptake of isoflurane by the foetal lamb in utero: effect on
       regional blood flow. Can. Anaesth. Soc. J. 1983; 30: 581-586.
Bur85  Buring JE, Hennekens CH, Mayrent SL, Rosner B, Greenberg ER, Colton T. Health experiences of
       operating room personnel. Anesthesiology 1985; 62: 325-330.
Bus76  Bussard DA. Congenital anomalies and inhalation anesthetics. JADA 1976; 93: 606-609.
Byh98  Byhan C, Westphal K, Strouhal U. Mutterschutzgesetz und Kontamination des Personals im Aufwachraum
       und auf der chirurgischen Intensivstation durch Inhalationsanästhetika. Gesundheitswesen 1998; 60:
       586-591.
Coh75  Cohen EN, Brown BW, Bruce DL et al. A survey of anesthetic Health hazards among dentists. J. Am.
       Dent . Assoc. 1975; 2: 807-809.
Coh80  Cohen EN, Brown BW, Wu ML et al. Occupational disease in dentistry and chronic exposure to trace
       anesthetic gases. JADA 1980; 101: 21-31.
Cor74b Corbett TH. Inhalation anesthesia: an occupational hazard. Hospital Practice 1974; 9: 81-88.
Ebi94  Ebi KL, Rice SA. Reproductive and developmental toxicity of anesthetics in humans. Anesth. Toxicity
       1994; 175-198.
Fri88  Friedman JM. Teratogen update: anesthetic agents. Teratology 1988; 37: 69-77.
Fri96  Friedler G. Paternal exposures: impact on reproductive and developmental outcome. An overview.
       Pharmacology Biochemistry and Behavior 1996; 55: 691-700.
Har81  Hardin BD, Bond GP, Sikov MR, Andrew FD, Beliles RP, Niemeier RW. Testing of selected workplace
       chemicals for teratogenic potential. Scand. J. Work. Environ. Health 1981; 7: 66-75.
Hea98  Health Council of the Netherlands: Dutch Expert Committee on Occupational Standards (DECOS).
       Enflurane, Isoflurane and Cyclopropane. Den Haag: Health Council of the Netherlands, 1998; publications
       no. 1998/16WGD.
Hem8   Hemminki K, Vineis P. Extrapolation of the evidence on teratogenicity of chemicals between humans and
       experimental animals: chemicals other than drugs. Teratogenesis, Carcinog. Mutagen. 1985; 5:251-358.
Inf85  Infante PF, Tsongas TA. Anesthetic gases and pregnancy: a review of evidence for an occupational
       hazard. Occupational Hazards and Reproduction 1985: 287-294.
       References                                                                                              20
</pre>

====================================================================== Einde pagina 20 =================================================================

<br><br>====================================================================== Pagina 21 ======================================================================

<pre>Kal90 Källén B, Mazze RI. Neural tube defects and first trimester operations. Teratology 1990; 41: 717-720.
Ken77 Kennedy GL, Smith SH, Keplinger ML, Calandra JC. Reproductive and teratologic studies with
      isoflurane. Drug Chem. Toxicol. 1977-78; 1: 75-88.
Lan79 Land PC, Owen EL, Linde HW. Mouse sperm morphology following exposure to anesthetics during early
      spermatogenesis. Anesthesiology 1979; 51: S259.
Lau81 Lauwerys R, Siddons M, Misson CB et al. Anaesthetic health hazards among Belgian nurses and
      physicians. Int. Arch. Occup. Environ. Health 1981: 48:195-203.
Lee94 Lee EJE, Bongso A, Kumar A. Evaluation of inhalational anaesthetics on murine in vitro fertilization.
      Ann. Acad. Med. Singapore 1994; 23: 479-485.
Mai87 Maissin F, Mesz M, Roualdès G, Bataille B, Criscuolo JL. Hypotension à l’isoflurane pour cure
      d’anévrysme intracrânien en fin de grossesse. Ann. Fr. Anesth. Réanim. 1987; 6: 453-456.
Mar97 Marx T. Belastung des Arbeitsplatzes mit volatilen Anasthetika und Lachgas. Anasthesiol. Intensivmed
      Notfallmed Schmerzther 1997; 32: 532-540.
Mat91 Matt DW, Steingold KA, Dastvan CM, James CA, Dunwiddie W. Effects of sera from patients given
      various anesthetics on preimplantation mouse embryo development in vitro. J. in Vitro Fertil. Embryo
      Transf. 1991; 8: 191-197.
Plu86 Plummer JL, Hall PdelaM, Jenner MA, Ilsley AH, Cousins MJ. Effects of chronic inhalation of halothane,
      enflurane or isoflurane in rats. Br. J. Anaesth. 1986; 58: 517-523.
Raj89 Rajhans GS, Brown DA, Whaley D, Wong L, Guirguis SS. Hygiene aspects of occupational exposure to
      waste anaesthetic gases in Ontario hospitals. Ann. Occup. Hyg. 1989; 33: 27-45.
Rey98 Reynolds F. Effects of labour analgesia on the baby. Fetal and Maternal Med. Rev. 1998; 10: 45-59.
Ric93 Rice SA. Anaesthesia in pregnancy and the fetus: toxicological aspects. In: Reynolds F. Effects on the
      baby of maternal analgesia and anaesthesia. Saunders. 1993. 88-107.
Rod83 Rodier PM. Differential structural effects of three behavioral teratogens. In: Developments in the Science
      and Practice of Toxicology. 1983: 53-60. (Eds: Hayes AW, Schnell RC, Miya TS. Elsevier Science
      Publishers).
Ros73 Rosenberg P, Kirves A. Miscarriages among operating theatre staff. Acta Anaeast. Scand. 1973; 53: 37-42.
Shn65 Shnider SM, Webster GM. Maternal and fetal hazards of surgery during pregnancy. Am. J. Obst. Gynecol.
      1965; 92: 891-900.
Smi63 Smith BE. Fetal prognosis after anesthesia during gestation. Anesth. Analg. 1963; 42: 521-526.
Smi75 Smith S, Kennedy GL, Keplinger ML, Calandra JC. Reproduction and teratologic studies with halothane
      and forane. Toxicol. Appl. Pharmacol. 1975; 33: 124 (abstract).
Ste75 Stevens WC, Eger EI II, White A, Halsey MJ, Munger W, Gibbons RD, Dolan W, Sharge R. Comparative
      toxicities of halothane, isoflurane and diethyl ether at subanesthetic concentrations in laboratory animals.
      Anaesthesiology 1975; 12: 408-419.
Tra94 Tran N, Elias J, Rosenberg T, Wylie D, Gaborieau D, Yassi A. Evaluation of waste anesthetic gases,
      monitoring strategies, and correlations between nitrous oxide levels andhealth symptoms. Am. Ind. Hyg.
      Assoc. J. 55; 1994: 36-41.
      References                                                                                                   21
</pre>

====================================================================== Einde pagina 21 =================================================================

<br><br>====================================================================== Pagina 22 ======================================================================

<pre>Vai99 Vaillancourt C, Berger N, Boksa P. Effects of vaginal birth versus Caesarean section birth with general
      anesthesia on blood gases and brain energy metabolism in neonatal rats. Exp. Neurol. 1999; 160: 142-150.
War92 Warren JR, Shaw B, Steinkampf MP. Inhibition of preimplantation mouse embryo development by
      isoflurane. Am. J. Obstet. Gynecol. 1992; 166: 693-698.
      References                                                                                               22
</pre>

====================================================================== Einde pagina 22 =================================================================

<br><br>====================================================================== Pagina 23 ======================================================================

<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
                                                  23
</pre>

====================================================================== Einde pagina 23 =================================================================

<br><br>====================================================================== Pagina 24 ======================================================================

<pre>Annex A
      The committee
         BJ Blaauboer, chairman
         Toxicologist; Research Institute of Toxicology, Utrecht
         JN van den Anker
         Professor of pediatrics and pharmacology; The George Washington University
         Medical Center, USA
         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 medical genetics, paediatrician; UMC, Utrecht
         JHJ Copius Peereboom-Stegeman
         Toxicologist; Catholic University Nijmegen, Nijmegen
         AH Piersma
         Reproductive toxicologist; National Institute of Public Health and the
         Environment, Bilthoven
         N Roeleveld
         Epidemiologist; Catholic University Nijmegen, Nijmegen.
         DH Waalkens-Berendsen
         Reproductive toxicologist; TNO Nutrition and Food Research, Zeist
         PJJM Weterings
         Toxicologist; Weterings Consultancy BV, Rosmalen
      The committee                                                                   24
</pre>

====================================================================== Einde pagina 24 =================================================================

<br><br>====================================================================== Pagina 25 ======================================================================

<pre>    ASAM van der Burght, scientific secretary
    Health Council of the Netherlands, Den Haag
The first draft of the present document was prepared by MEM Kuilman and DH
Waalkens-Berendsen, from the TNO Nutrition and Food Research in Zeist, by contract
with the Ministry of Social Affairs and Employment.
Secretarial assistance: T van der Klugt.
Lay-out: J van Kan.
The committee                                                                      25
</pre>

====================================================================== Einde pagina 25 =================================================================

<br><br>====================================================================== Pagina 26 ======================================================================

<pre>Annex B
      Comments on the public draft
      A draft of the present report was released in 2002. The following persons and
      organisations have commented on the draft review:
          A Aalto
          Ministry of Social Affairs and Health, Finland
          RD Zumwalde
          National Institute for Occupational Safety and Health, USA
      Comments on the public draft                                                  26
</pre>

====================================================================== Einde pagina 26 =================================================================

<br><br>====================================================================== Pagina 27 ======================================================================

<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                                                         27
</pre>

====================================================================== Einde pagina 27 =================================================================

<br><br>====================================================================== Pagina 28 ======================================================================

<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 as 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 results 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 consequence of
     the other toxic effects, but where the evidence is insufficient to place the substance in Category 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                                                                28
</pre>

====================================================================== Einde pagina 28 =================================================================

<br><br>====================================================================== Pagina 29 ======================================================================

<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
headings 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
Directive (93/21/EEC) of the European Community                                                               29
</pre>

====================================================================== Einde pagina 29 =================================================================

<br><br>====================================================================== Pagina 30 ======================================================================

<pre>      interfere 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
      development, 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
      (teratogenic effects), functional defects, peripostnatal defects, and impaired postnatalmental or
      physical 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
animal 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 similar
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
levels 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
necessarily 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                                                                   30
</pre>

====================================================================== Einde pagina 30 =================================================================

<br><br>====================================================================== Pagina 31 ======================================================================

<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
appropriate.
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 evidence
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
studies 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 associated
with marked maternal toxicity. The route of exposue is also important. In particular, the injection of
irritant material intraperitoneally may result in local damage to the uterus and its contents, and the results
of such studies must be interpreted with caution and on their own would not normally lead to
classification.
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 possibility
that the effects may have been due to non-specific influences such as generalised toxicity cannot be
excluded.
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                                                                31
</pre>

====================================================================== Einde pagina 31 =================================================================

<br><br>====================================================================== Pagina 32 ======================================================================

<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
Reproduction’, 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
     potentially toxic levels in breast milk, and/or
b)   on the basis of results of one or two generation studies in animals which in- dicate the presence of
     adverse 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 into
     milk during lactation may be labelled with R33 and R64.
Directive (93/21/EEC) of the European Community                                                             32
</pre>

====================================================================== Einde pagina 32 =================================================================

<br><br>====================================================================== Pagina 33 ======================================================================

<pre>Annex       D
            Fertility and developmental toxicity
            studies
Table 1 Fertility studies in man.
authors exposure                  study type/data  study/comparation population      investigated effects remarks
                                  collection                                         and results
Pee99   Mixture: waste            Retrospective    427 pregnant females (age 22-37   No effect on time to Mixed exposure
        anaesthetics              survey           years) employed in anaesthesia/   pregnancy
        Concentration isoflurane  The Netherlands  1,010 pregnant females (age 22-37
        measured maximal 120      1990-1997/postal years) nurses employed in
        mg/m3; Employment in      questionnaire    department of orthopaedics,
        anaesthesia                                gynaecology or surgery
            Fertility and developmental toxicity studies                                                              33
</pre>

====================================================================== Einde pagina 33 =================================================================

<br><br>====================================================================== Pagina 34 ======================================================================

<pre>Table 2 Developmental toxicity studies in man.
authors exposure          study type/data      study/comparation population       investigated effects and     remarks
                          collection                                              results
Joh87   Mixture: waste    Case-control         278 spontaneous abortions and No statistically significant      Mixed exposure
        anaesthetics      USA/postal           stillbirths and 98 live birth with increase in spontaneous      Results adjusted
                          questionnaire        congenital abnormalities that      abortions                    for x-ray exposure
                          (additional          occurred to female veterinarians
                          questionnaire sent   and veterinarian assistants and
                          to senior female     wives of male veterinarians
                          veterinary           642 normal pregnancies chosen
                          assistants)          on a stratified random basis
Gui90   Mixture: waste    Retrospective        Exposed (n=6336) and               Significant increase in      Mixed exposure
        anaesthetics      study Ontario        non-exposed (n=2202) hospital      spontaneous abortion and     OR’s were
                          1981-1985/           staff and their or their wives     congenital abnormality       standardised for
                          questionnaire        pregnancies/children               among exposed females        age, smoking,
                                                                                  (OR 1.98, 95% CI             alcohol
                                                                                  1.53-2.56; OR 2.24, 95% CI   consumption,
                                                                                  1.69-2.97) and spouses of    previous abortion
                                                                                  exposed males (OR 2.3,       and occupation
                                                                                  95% CI 1.68-3.13; OR 1.46,
                                                                                  95% CI 1.04-2.05)
Pee99   Mixture: waste    Retrospective        427 pregnant females (age 22-37 Increased risk for abortion     Mixed exposure
        anaesthetics      survey               years) employed in                 preterm birth and congenital *Controlled for
        Concentration     The Netherlands      anaesthesia/1,010 pregnant         abnormalities                age, education,
        isoflurane        1990-1997/postal     females (age 22-37 years) nurses                                menstrual cycle,
        measured          questionnaire        employed in department of                                       life style and
        maximal 120                            orthopaedics, gynaecology or                                    circumstances
        mg/m3.                                 surgery                                                         during work.
        Employment in
        anaesthesia
             Fertility and developmental toxicity studies                                                                       34
</pre>

====================================================================== Einde pagina 34 =================================================================

<br><br>====================================================================== Pagina 35 ======================================================================

<pre>Table 3 Fertility studies in animals with isoflurane.
authors   species            experimental period/design     dose and route general toxicity      effects on reproductive    remarks
                                                                                                 organs and reproduction
Lan81     male               4h/day during 5 consecutive    0, 0.1 and 1%  no paternal           no change in percentage
          (C57B1/C3H)F week days sacrifice 28 days          [7550 and      mortality and         of abnormal
          1 mice (n=5)       after start of exposure; sperm 75500 mg/m3]   paternal toxicity
                             morphology of both cauda       isoflurane     described
                             epididymides                   inhalation
Maz85a    male               4h/day daily for 7 weeks       0, 0.1 and     all mice survived     no effects on male
          Swiss/Webster after 6 weeks treated males         0.4% [ 7550    and weight gain       fertility
          mice (n=15-24) were mated with untreated          and 30200      was identical for all all males became sire
                             females                        mg/m3]         groups                no effects on pregnancy
                             uterine content of females     isoflurane     exposure to highest   rate, number of
                             was examined on GD 18          inhalation     concentration         implantations, resorptions
                                                                           resulted in light     or dead in utero
                                                                           anaesthesia
Maz85a    male and           4h/day daily for 2 weeks       0, 0.1 and     all mice survived     no effects on fertility
          female             after 2 weeks males were       0.4% [ 7550    and weight gain       no effects were found on
          Swiss/Webster      mated with females of the      and 30200      was identical for all pregnancy rate, number
          mice (n=32-41)     same group                     mg/m3]         groups                of implantations, live
                             exposure was continued         isoflurane     exposure to highest   foetuses and resorptions
                             during mating and pregnancy    inhalation     concentration
                             uterine of two third of the                   resulted in light
                             females was examined on GD                    anaesthesia
                             18; one third of the females
                             littered and raised their pups
            Fertility and developmental toxicity studies                                                                         35
</pre>

====================================================================== Einde pagina 35 =================================================================

<br><br>====================================================================== Pagina 36 ======================================================================

<pre>Table 4 Developmental toxicity studies in animals with isoflurane.
authors species        experimental period/design         dose and   maternal toxicity     developmental toxicity        remarks
                                                          route
Maz85a male and        4h/day daily for 2 weeks           0, 0.1 and all mice survived     no differences in live
        female Swiss/  after 2 weeks males were mated     0.4% [     and weight gain was   foetuses/litter, viability
        Webster mice   with females of the same group     7550 and   identical for all     and lactation index and
        (n=32-41)      exposure was continued during      30200      groups                pup weights from PN1 to
                       mating and pregnancy               mg/m3]     exposure to highest   PN28
                       uterine of two third of the        isoflurane concentration
                       females was examined on GD 18      inhalation resulted in light
                       one third of the females littered             anaesthesia
                       and raised their pups
Maz85b female Swiss/ 4h/day on GD 6-15                    0, 0.006,  highest               no effects on litter size or  *in part
        Webster mice Caesarean section on GD 18           0.06 and   concentration:        sex ratio                     related to
        (n=23-31)                                         0.6% [453, lower weight gain*,   at highest concentration:     decreased
                                                          4530 and   ataxia followed by    decreased litter weight,      litter
                                                          45300      light general         increase in late resorptions, weight
                                                          mg/m3]     anaesthesia           cleft palate and renal
                                                          isoflurane                       pelvic cavitation,
                                                          inhalation                       decreased skeletal
                                                                                           ossification
Maz86   pregant        exposure 6h/day on                 0 and      I, II and III: light  I and III: decreased foetal
        Sprague        I. GD 14-16                        1.05%      anaesthesiaI and III: weight
        Dawley rats    II. GD 11-13                       [79275     decreased weight
        (n=39-50       III. GD 8-10                       mg/m3]     gain
        control,       screening for skeletal and soft    isoflurane
        21-25          tissue anomalies after Caesarean   inhalation
        isoflurane)    section
Fuj87   pregnant       exposure on GD 8 for 24 h          0 and      no maternal           no influence on number of
        Sprague        Caesarean section on GD 20         0.35%      mortality during      implantations, live and
        Dawley rats                                       [ 26425    exposure rats were    dead foetuses, resorptions,
        (n=40                                             mg/m3]     mildly sedated        foetal body weight and sex
        control, 30                                       isoflurane at GD12, 14 and 16    ratio
        isoflurane)                                       inhalation rats weighed less     no differences in external,
                                                                     than control rats     visceral and skeletal
                                                                                           abnormalities
            Fertility and developmental toxicity studies                                                                          36
</pre>

====================================================================== Einde pagina 36 =================================================================

<br><br>====================================================================== Pagina 37 ======================================================================

<pre>Annex E
      Abbreviations
      Abbreviations used:
      bw          =    body weight
      CI          =    confidence interval
      CNS         =    central nervous system
      d           =    day
      F           =    female(s)
      GD          =    gestation day
      i.p.        =    intraperitoneal
      IRPC        =    increased renal pelvic cavitation
      i.v.        =    intravenous
      M           =    male(s)
      n           =    number
      NOAEL       =    no adverse effect level
      OECD        =    Organisation for Economic Cooperation and Development
      OR          =    Odds ratio
      OT          =    Operating theatre
      PN          =    postnatal
      RR          =    relative risk
      Abbreviations                                                          37
</pre>

====================================================================== Einde pagina 37 =================================================================

<br><br>