<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>www.healthcouncil.nl Innovation and the knowledge infrastructure Before we can harvest knowledge in the field of healthcare, we first need to ensure that the right seeds are sown. Healthy working conditions How can employees be protected against working conditions that could harm their health? Environmental health Which environmental influences could have a positive or negative effect on health? Healthy nutrition Which foods promote good health and which carry certain health risks? Prevention Which forms of prevention can help realise significant health benefits? Optimum healthcare What is the optimum result of cure and care in view of the risks and opportunities? Areas of activity Advisory Reports The Health Council’s task is to advise ministers and parliament on issues in the field of public health. Most of the advisory opinions that the Council produces every year are prepared at the request of one of the ministers. In addition, the Health Council issues unsolicited advice that has an ‘alerting’ function. In some cases, such an alerting report leads to a minister requesting further advice on the subject. Health Council of the Netherlands Cytarabine 2015/18 2015/18 Evaluation of the effects on reproduction, recommendation for classification Cytarabine Health Council of the Netherlands</pre>

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

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<pre>Aan de minister van Sociale Zaken en Werkgelegenheid
Onderwerp             : aanbieding advies Cytarabine
Uw kenmerk            : DGV/BMO/U-932542
Ons kenmerk           : U-791480/EvV/fs/543-K15
Bijlagen              :1
Datum                 : 23 juli 2015
Geachte minister,
Graag bied ik u hierbij het advies aan over de effecten van cytarabine op de vruchtbaarheid
en het nageslacht; het betreft ook effecten op de lactatie en via de moedermelk op de zuige-
ling. Dit advies maakt deel uit van een uitgebreide reeks waarin voor de voortplanting gif-
tige stoffen worden geclassificeerd volgens richtlijnen van de Europese Unie. Het gaat om
stoffen waaraan mensen tijdens de beroepsuitoefening kunnen worden blootgesteld.
Dit advies is opgesteld door een vaste commissie van de Gezondheidsraad, de Commissie
Classificatie reproductietoxische stoffen. Het is vervolgens getoetst door de Beraadsgroep
Gezondheid en omgeving van de Gezondheidsraad.
Ik heb dit advies vandaag ter kennisname toegezonden aan de minister van Volksgezond-
heid, Welzijn en Sport en, eveneens ter kennisname, aan de staatssecretaris van Infrastruc-
tuur en Milieu.
Met vriendelijke groet,
prof. dr. W.A. van Gool,
voorzitter
Bezoekadres                                                        Postadres
Parnassusplein 5                                                   Postbus 16052
2 5 11 V X D e n H a a g                                           2500 BB Den Haag
E - m a i l : p w. v a n . v l i e t @ g r. n l                    w w w. g r. n l
Te l e f o o n ( 0 7 0 ) 3 4 0 7 3 2 7
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<pre></pre>

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<pre>Cytarabine
Evaluation of the effects on reproduction,
recommendation for classification
Committee on the Classification of Reproduction Toxic Substances
of the Health Council of the Netherlands
to:
the Minister of Social Affairs and Employment
No. 2015/18, The Hague, July 23, 2015
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<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 and health
(services) research...” (Section 22, Health Act).
     The Health Council receives most requests for advice from the Ministers of
Health, Welfare and Sport, Infrastructure and the Environment, Social Affairs
and Employment, and Economic Affairs. 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.
                 The Health Council of the Netherlands is a member of the European
                 Science Advisory Network for Health (EuSANH), a network of science
                 advisory bodies in Europe.
This report can be downloaded from www.healthcouncil.nl.
Preferred citation:
Health Council of the Netherlands. Cytarabine - Evaluation of the effects on
reproduction, recommendation for classification. The Hague: Health Council of
the Netherlands, 2015; publication no. 2015/18.
all rights reserved
ISBN: 978-94-6281-029-7
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<pre>   Contents
   Samenvatting 9
   Executive summary 11
   Scope 13
.1 Background 13
.2 Committee and procedure 13
.3 Labelling for lactation 14
.4 Data 15
.5 Presentation of conclusions 15
.6 Final remark 16
   Cytarabine 17
.1 Introduction 17
.2 Human studies 19
.3 Animal studies 21
.4 Conclusions 29
   References 31
   Contents                       7
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<pre>  Annexes 37
A The Committee 39
B The submission letter (in English) 41
C Comments on the public draft 43
D Regulation (EC) 1272/2008 of the European Community 45
E Additional considerations to Regulation (EC) 1272/2008 57
F Fertility and developmental toxicity studies 59
  Cytarabine
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<pre>Samenvatting
In het voorliggende advies heeft de Gezondheidsraad cytarabine onder de loep
genomen. Cytarabine is een pyrimidine-nucleoside-analoog. Het wordt gebruikt
als cytostaticum, met name voor de behandeling van acute myeloïde leukemie.
Dit advies past in een reeks adviezen waarin de Gezondheidsraad op verzoek van
de Minister van Sociale Zaken en Werkgelegenheid de effecten van stoffen op de
voorplanting beoordeelt. Het gaat vooral om stoffen waaraan mensen tijdens de
beroepsuitoefening kunnen worden blootgesteld. De Subcommissie Classificatie
reproductietoxische stoffen van de Commissie Gezondheid en Beroepsmatige
blootstelling aan Stoffen (GBBS) van de Raad, hierna aangeduid als de commis-
sie, kijkt zowel naar effecten op de vruchtbaarheid van mannen en vrouwen als
naar effecten op de ontwikkeling van het nageslacht. Daarnaast worden effecten
op de lactatie en via de moedermelk op de zuigeling beoordeeld.
Op basis van verordening (EG) 1272/2008 van de Europese Unie doet de com-
missie een voorstel voor classificatie. Voor cytarabine komt de commissie tot de
volgende aanbevelingen:
• voor effecten op de fertiliteit adviseert de commissie cytarabine niet te classi-
     ficeren wegens onvoldoende geschikte gegevens
• voor effecten op de ontwikkeling adviseert de commissie cytarabine te classi-
     ficeren in categorie 1B (stoffen waarvan verondersteld wordt dat zij toxisch
     zijn voor de menselijke voortplanting) en te kenmerken met H360D (kan het
     ongeboren kind schaden)
Samenvatting                                                                        9
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<pre>  •  voor effecten op of via lactatie adviseert de commissie om cytarabine niet te
     kenmerken wegens onvoldoende geschikte gegevens.
0 Cytarabine
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<pre>Executive summary
In the present report, the Health Council of the Netherlands reviewed cytarabine.
Cytarabine is a pyrimidine nucleoside analogue that inhibits the synthesis of
DNA. It is used as an antineoplastic drug for the treatment of leukaemia,
especially acute non-lymphoblastic leukaemia. This report is part of a series, in
which the Health Council evaluates the effects of substances on reproduction, at
the request of the Minister of Social Affairs and Employment. It mainly concerns
substances to which man can be exposed occupationally. The Subcommittee on
the Classification of Reproduction Toxic Substances of the Dutch Expert
Committee on Occupational Safety (DECOS) of the Health Council, hereafter
called the Committee, evaluates the effects on the male and female fertility and
on the development of the progeny. Moreover, the Committee considers the
effects of a substance on lactation and on the progeny via lactation.
The Committee recommends classification according to regulation (EC) 1272/
2008 of the European Union. For cytarabine, these recommendations are:
• for effects on fertility, the Committee recommends not classifying cytarabine
    due to a lack of appropriate data
• for effects on development, the Committee recommends classifying
    cytarabine in category 1B (presumed human reproductive toxicant) and
    labelling with H360D (may damage the unborn child)
• for effects on or via lactation, the Committee recommends not labelling
    cytarabine due to a lack of appropriate data.
Executive summary                                                                 11
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<pre>2 Cytarabine</pre>

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<pre> hapter 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. This classification is performed by the Health
        Council’s Subcommittee on the Classification of reproduction toxic substances
        of the Dutch Expert Committee on Occupational Safety (DECOS). The
        classification is performed according to European Union Regulation (EC) 1272/
        2008 on classification, labelling and packaging (CLP) of substances and
        mixtures. The CLP guideline is based on the Globally Harmonised System of
        Classification and Labelling of Chemicals (GHS). The Subcommittee’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 reproductive
        toxicant (category 1A and 1B and 2) or compound with effects on or via
        lactation.
1.2     Committee and procedure
        This document contains the classification of cytarabine by the Health Council’s
        Subcommittee on the Classification of reproduction toxic substances, hereafter
        Scope                                                                             13
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<pre>    called the Committee. The members of the Committee are listed in Annex A. The
    submission letter (in English) to the Minister can be found in Annex B.
        In 2014, 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 C. The Committee has taken these comments into
    account in deciding on the final version of the report. The comments received,
    and the replies by the Committee, can be found on the website of the Health
    Council.
    The classification is based on the evaluation of published human and animal
    studies concerning adverse effects with respect to fertility and development as
    well as lactation of the above-mentioned compound.
    Classification for reproduction (fertility (F) and development (D)):
    Category 1              Known or presumed human reproductive toxicant (H360(F/D))
       Category 1A          Known human reproductive toxicant
       Category 1B          Presumed human reproductive toxicant
    Category 2              Suspected human reproductive toxicant (H361(f/d))
    No classification for effects on fertility or development
    Classification for lactation:
                            Effects on or via lactation (H362)
                            No labelling for lactation
    The classification and labelling of substances is performed according to the
    guidelines of the European Union (Regulation (EC)1272/2008) presented in
    Annex D. The classification of compounds 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 guideline necessarily leaves room for interpretation, dependent
    on the specific data set under consideration. In the process of using the
    regulation, the Committee has agreed upon a number of additional considerations
    (see Annex E).
1.3 Labelling for lactation
    The recommendation for classifying substances for effects on or via lactation is
    also based on Regulation (EC) 1272/2008. The guideline defines that substances
    which are absorbed by women and have been shown to 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, shall be classified
 4  Cytarabine
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<pre>    and labelled. Unlike the classification of substances for fertility and
    developmental effects, which is based on hazard identification only (largely
    independent of dosage), the labelling for effects during lactation is based on risk
    characterization and therefore, it also includes consideration of the level of
    exposure of the breastfed child.
        Consequently, a substance should be labelled for effects on or via lactation
    when it is likely that the substance would be present in breast milk at potentially
    toxic levels. The Committee considers a concentration of a compound as
    potentially toxic to the breastfed child when this concentration exceeds the
    exposure limit for the general population, e.g. the acceptable daily intake (ADI).
1.4 Data
    Literature searches were conducted in the on-line databases PubMed, Toxline
    and DART up to July 2012, and by searches on the Internet; an update was
    performed in TOXNET in September 2014. Literature was primarily selected on
    the basis of the text of the abstracts. Publications cited in the selected articles, but
    not retrieved 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 describes both human and animal studies in the text. The
    animal data are described in more detail in Annex F as well. Of each study, the
    quality of the study design (performed according to internationally
    acknowledged guidelines) and the quality of documentation is considered.
        In the assessment of the potential reproduction toxic effects of cytarabine, the
    Committee also used data on adverse effects related to its application as a
    therapeutic agent.
1.5 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 precludes assessment of the compound for
        reproductive toxicity
    • sufficient data show that no classification for toxic to reproduction is
        indicated.
    Scope                                                                                    15
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<pre>1.6 Final remark
    The classification of compounds is based on hazard evaluation (Niesink et al.,
    1995) only, which is one of a series of elements guiding the risk evaluation
    process.21 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.
 6  Cytarabine
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<pre> hapter 2
        Cytarabine
2.1     Introduction
        name                      : cytarabine
        IUPAC name                : 4-amino-1-[(2R,3S,4S,5R)-3,4-dihydroxy-5-(hydroxymethyl) oxolan-
                                    2-yl] pyrimidin-2-one
        CAS name                  : 2(1H)-pyrimidinone, 4-amino-1-β-D-arabinofuranosyl-
        CAS registry number       : 147-94-4
        synonyms                  : (arabinofuranosyl)cytosine; 1-(arabinofuranosyl)cytosine; 1-(β-D-
                                    arabinofuranosyl)- cytosine; 1-β-arabinofuranosylcytosine; 1-β-D-
                                    arabinofuranosylcytosine; 1-β-D-arabinosylcytosine; 4-amino-1-
                                    arabinofuranosyl-2-oxo-1,2-dihydropyrimidine; 4-amino-1-β-D-
                                    arabinofuranosyl-2(1H)-pyrimidinone; cytosine arabinoside;
                                    arabinocytidine; arabinosylcytosine; cytarabinoside
        molecular formula         : C9H13N3O5
        colour and physical state : Odourless, white to off-white crystalline powder
        structural formula        :
        molecular weight          : 243.2
        melting point             : 212-213 °C
        vapour pressure           :  1.1 x 10-9 Pa (estimated; at 25 °C)
        solubility                : soluble in water
        Log Poctanol-water        : -2.46 (estimated)
        Cytarabine                                                                                    17
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<pre>  use                       : cytarabine is an antineoplastic drug for the treatment of leukaemia,
                               especially acute non-lymphoblastic leukaemia. It is used in the
                               Netherlands and internationationally for induction therapy as well as
                               for consolidation therapy after the patient has achieved a complete
                               remission.
                               Route of administration is by injection or infusion (intravenous,
                               subcutaneous, intramuscular or intrathecal). A widely accepted form
                               of induction therapy includes standard-dose cytarabine 100-200
                               mg/m2 (i.e. 2.7-5.3 mg/kg body weight, assuming a surface area of
                               1.6 m2 for a 60-kg human), administered by continuous infusion for
                               seven days, combined with three days of intravenous administration of
                               anthracyclines (e.g. daunorubicin) or anthracenodianes, with or
                               without addition of other agents (e.g. etoposide, fludarabine or
                               cladribine). Consolidation therapy comprises treatment with
                               additional courses of intensive chemotherapy, usually with higher
                               doses of cytarabine (2-3 g/m2; i.e. 53-80 mg/kg body weight).28
  general toxicity          : Acute toxicity is low (reported LD50-values are: oral rat: >3,200
                               mg/kg, >5,000 mg/kg; oral mouse: 826 mg/kg, 3,150 mg/kg;
                               intravenous rat: >5,000 mg/kg; intravenous mouse >7,000 mg/kg;
                               intraperitoneal rat: 1,000 mg/kg, >5,000 mg/kg; intraperitoneal
                               mouse: 1,000 mg/kg, 3,379 mg/kg).
                               Cytarabine is mutagenic in vitro and clastogenic in vitro and in vivo.
                               The carcinogenic potential of cytarabine has not been fully evaluated.
                               In clinical use, adverse effects have included severe nausea and
                               vomiting, bone marrow depression, low white blood cell, red blood
                               cell and platelet counts, rash and hair loss, pain and redness of the
                               palms and feet, respiratory distress, and neurological effects such as
                               ataxia, dysphasia and nystagmus.
  mechanism                 : Cytarabine, a pyrimidine nucleoside analogue, is an antimetabolite
                               antineoplastic agent that inhibits the synthesis of DNA. Cytarabine
                               competes with deoxycytidine triphosphate for incorporation into DNA
                               during synthesis. Its actions are specific for the S-phase of the cell
                               cycle.
  kinetics                  : Following administration, cytarabine distributes into intracellular
                               compartments with a volume of distribution approximately equal to
                               body water. Its volume of distribution should therefore be
                               substantially increased in the pregnant patient. Cytarabine is rapidly
                               cleared from plasma, but the active metabolite (arabinofuranosyl-
                               cytosine triphosphate; Ara-CTP) is retained intracellularly (13-42% of
                               Ara-CTP 4 h after cytarabine administration). Accumulation of
                               cytarabine in non-pregnant patients does not appear to occur even
                               after successive doses. Approximately 80% of a cytarabine dose is
                               eliminated 36 h after administration with the majority of the dose
                               being excreted as uracil arabinoside. Cytarabine is approximately 13%
                               protein bound and readily penetrates the blood brain barrier (Wiebe &
                               Sipila).34 Foetal plasma concentrations of cytarabine were 56.7%
                               (+ 22.6%; n=6) of the maternal concentration, ninety minutes after an
                               intravenous injection (100 mg/kg) to mice on gestational day 18.5
                               (Van Calsteren et al.3).
  Data from HSDB19, unless otherwise noted.
8 Cytarabine
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<pre>2.2   Human studies
2.2.1 Fertility studies
      Data on the effects of cytarabine on human fertility are difficult to interpret for
      several reasons, including use of regimens involving multiple agents, case series
      with small sample sizes, lack of pre-chemotherapy assessment, and inadequate
      long-term follow up.
      Male fertility
      Lenz and Valley reviewed the risks of infertility after chemotherapy using a
      MEDLINE search of articles from 1966-1996.12 They concluded that male germ
      depletion probably occurs to some degree as a result of cytarabine therapy in
      acute leukaemia. No clear conclusions can be drawn, especially because all
      reported cases concerned combination therapy with other agents.
      Lendon et al. investigated testicular biopsies in 44 boys (27 prepubertal and 17
      pubertal) treated with various combination therapies for acute lymphoblastic
      leukaemia.11 Cytarabine, when exceeding 1 g/m2 (≈ 27 mg/kg body weight*),
      was associated with a statistically significant depression of the tubular fertility
      index in a multivariable model also including cyclophosphamide and the length
      of time between cessation of therapy and biopsy. The control group consisted of
      16 boys who died within three weeks of diagnosis.
      Some cases demonstrated that a man may be fertile and produce a normal child
      during chemotherapy for acute leukaemia with cytarabine in combination with
      other agents. These favourable reports remain anecdotal. Therefore they were not
      evaluated.
      Female fertility
      No relevant data are available.
      For a human adult, assuming a surface area of 1.6 m2 for a 60 kg human.
      Cytarabine                                                                          19
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<pre>2.2.2 Developmental toxicity studies
      Case-control or cohort studies
      Prospective or retrospective epidemiological studies examining the adverse
      effects of cytarabine during pregnancy are not available.
      Case studies
      Wiebe & Sipila reviewed 36 cases in which cytarabine was used in combination
      chemotherapy for the treatment of leukaemia in pregnancy.34 The authors
      concluded that cytarabine can be used safely in the second and third trimester,
      but its use resulted in several cases of fetal anomalies when used during the first
      eight weeks of gestation. However, in almost all cases cytarabine was given in
      combination with other drugs. In only one case cytarabine was administered
      alone (Wagner et al.33). The woman delivered an infant with obvious extremity
      and ear deformities.
      Caligiuri & Mayer reviewed 32 reported cases in which cytarabine was
      administered to pregnant women alone or in combination with other drugs.2 The
      32 pregnancies resulted in 18 normal infants (four of whom had first trimester
      exposure), two infants with congenital malformations (both with first trimester
      exposure) and several instances of neonatal distress resulting in one death and
      five therapeutic abortions. However, in almost all cases cytarabine was given in
      combination with other drugs. In only one case cytarabine was administered
      alone (Juárez et al.8). The woman was treated during the third trimester and gave
      birth at term. At the age of one year the infant born was normal.
      In a letter to the editor, Morgenstern briefly referred to a number of extra cases of
      administration of cytarabine to pregnant women.18 The original case reports were
      consulted.13,16,17,20,29,32 Six pregnancies were described. In all cases the pregnant
      women received cytarabine as part of combination chemotherapy. One woman
      elected to have her pregnancy aborted. The other pregnancies resulted in normal,
      healthy infants. The time point at which this was determined varies from birth till
      the age of four years.
 0    Cytarabine
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<pre>2.2.3 Lactation
      No human studies on effects of cytarabine during lactation are available.
           It is not known whether cytarabine is excreted in human milk.
2.3   Animal studies
      Fertility and developmental toxicity studies in laboratory animals are
      summarized in Annex F.
2.3.1 Fertility studies
      Male fertility
      Cytarabine was administered at single intraperitoneal dose levels of 0, 100, 150
      and 200 mg/kg body weight to groups of six male Swiss albino mice (Palo et
      al.23). Spermatocytic analysis was conducted 24 h and 4 wk post-treatment, and
      sperm morphology assays were conducted 8 wk post-treatment. Statistically
      significant and dose-dependent increases in the percentage of aberrant
      spermatogonial metaphases and chromosomal aberrations at 24 h post-treatment,
      and in the percentages of aberrant primary spermatocytes at wk 4 post-treatment
      were noted at all three dose levels. The percentage of abnormal sperm at wk 8
      post-treatment was, however, not statistically significantly affected.
      Female fertility
      No data are available.
2.3.2 Developmental toxicity studies
      No animal studies with oral administration of cytarabine are available.
      Structural defects
      Mice, intraperitoneal administration
      Cytarabine was administered intraperitoneally at doses of 0, 0.5, 2 or 8 mg/kg
      body weight/day to pregnant Swiss mice (13-15/group) on gestational days 6-15
      Cytarabine                                                                       21
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<pre>  (Ortega et al.22). All dams survived to their scheduled termination on gestational
  day 18, and there were no abortions or early deliveries. Maternal body weight
  gain and feed intake during the treatment period were statistically significantly
  reduced at 2 and 8 mg/kg body weight/day. Maternal body weight and gravid
  uterine weight was statistically significantly reduced at 8 mg/kg body weight/
  day. The number of early and late resorptions per litter was increased (p<0.001
  and p<0.05, respectively) and the number of life foetuses decreased (p<0.001) at
  8 mg/kg body weight/day. Only 4 out of 13 dams in this group contained one or
  more life foetuses on gestational day 18. No effects on implantations, resorptions
  or viability were noted at 0.5 and 2 mg/kg body weight/day.
      A dose-related and statistically significant decrease in foetal body weights
  occurred in all treatment groups. The number of stunted foetuses was increased
  (p<0.05) at 8 mg/kg body weight/day. External examination revealed phocomelia
  and short or absent tail in all foetuses of the 8 mg/kg body weight/day group.
      The total incidence of soft tissue defects was statistically significantly
  increased at 2 and 8 mg/kg body weight/day; cleft palate and dilatation of
  cerebral ventricles were the main findings.
      At 8 mg/kg body weight/day, skeletal malformations consisted of severe
  general retardation, incomplete ossification of the skull bones, fused and
  fragmented ribs, split vertebral arches, bifid vertebral centra and partial or
  complete absence of limb bones. At 0.5 and 2 mg/kg body weight, skeletal
  maturation was statistically significantly reduced (especially decreased numbers
  of ossified sacrococcygeal vertebrae as well as decreased percentage of foetuses
  with ossified calcaneus). Based on growth alterations, the NOAEL for maternal
  toxicity was placed at 0.5 mg/kg body weight/day. The developmental NOAEL
  was <0.5 mg/kg body weight/day.
  Cytarabine was administered intraperitoneally at single doses of 0, 2, 10, 25, 50,
  100 or 200 mg/kg body weight to 265 pregnant 1CR mice on gestational days 10,
  10.5, 11, 11.5, 12, 12.5, 13, 14 or 16 (Kochhar et al.10). Injection of the mother
  with levels up to 200 mg/kg body weight at any time between gestational days
  10.5 and 12 did not cause ‘any physical distress’. Embryo lethality depended on
  the dose level and stage of injection; e.g. a dose of 100 or 200 mg/kg body
  weight was completely embryo-lethal during gestational days 10.5-12, whereas 2
  or 10 mg/kg body weight produced hardly any resorption at any stage.
      Limb defects were induced during gestational days 10.5-12.5, not by
  treatment before or after this period. The effective dose was ≥10 mg/kg body
  weight. The dose of 2 mg/kg body weight was completely without effect. The
2 Cytarabine
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<pre>limb defects encountered were micromelia, phocomelia, hemimelia,
ectrodactyly, polydactyly and adactyly.
    Depending on the dose and time of injection, other defects included stunted
growth, cleft palate, fusions of the vertebral bodies and of ribs, shortened
abnormal tails, and micrognathia (both maxilla and mandible).
Cytarabine was administered intraperitoneally at single doses of 0, 10, 20 or 40
mg/kg body weight to pregnant CD-1 mice at various times from gestational day
10 till gestational day 12 (Manson et al.14). The dams were killed on gestational
day 18. The number of litters examined were 18 in controls and 2-4 in the
various groups at the various stages. No data on maternal toxicity were provided.
There was a dose-related increase in both forelimb and hindlimb malformations
(no statistics presented). Limbs were maximally sensitive to cytarabine between
gestational day 10 (9 p.m.) and gestational day 11 (9 a.m.). Malformations
(adactylous limbs with distally located blisters) ranged from 13%-100%,
depending on the dose and time of exposure.
Cytarabine was injected intraperitoneally at single doses of 0 or 30 mg/kg body
weight to groups of 4-12 pregnant CD-1 mice on gestational days 14 and 15
(Gray et al.7). No data on maternal toxicity were provided. Mortality in
cytarabine-exposed offspring was considerably increased due to a failure of the
lower incisors to develop. Many cytarabine-treated mice had narrow flattened
skulls and some mice had thin cerebral hermispheres (no further details were
given).
    In a second experiment, cytarabine was injected intraperitoneally at a single
dose of 0 or 30 mg/kg body weight to groups of 11-30 pregnant CD-1 mice on
gestational days 8-9, 10-11, 14-15 or 17-18.7 No data on maternal toxicity were
provided.
    No live pups were born to dams in the gestational days 8-9 and 10-11
treatment groups. All foetuses were resorbed in the gestational days 8-9 group,
while a few malformed pups were born in the gestational days 10-11 group
(p<0.01).
    Growth was retarded by 25% (not statistically significant) in offspring in the
gestational days 14-15 group and unaffected in the gestational days 17-18 group.
Cytarabine-exposed offspring showed increased locomotor activity and were
more aggressive (see ‘Cognitive effects’ below).
Cytarabine was injected intraperitoneally at a single dose of 0 or 5 mg/kg body
weight to groups of 8 or 12 pregnant mice on gestational day 10.5 (Rahman et
Cytarabine                                                                         23
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<pre>  al.25). Skeletal changes in offspring were evaluated on post-natal day 15 or 24.
  No data on maternal toxicity were provided. The body weights of newborns were
  similar in the treatment and control groups. In the treatment group, the incidence
  of external digit abnormalities (oligodactyly or polydactyly) of forelimbs and
  hindlimbs was about 50% and 20%, respectively, versus 0% in controls. The
  incidence of various abnormalities of carpal or tarsal bones (fusion, absence or
  deformation) was increased (no statistics presented) in the offspring of treated
  mice.
  Cytarabine was injected intraperitoneally at single doses of 0, 0.5, 1 or 2 mg/kg
  body weight to groups of 6 to 10 pregnant mice on gestational day 10.5 (Rahman
  et al.26). Skeletal changes in offspring were evaluated on post-natal day 15. No
  data on maternal toxicity were provided. The number of foetuses per dam and the
  body weights of newborns were similar in the treatment groups and controls. The
  relatively low doses induced carpal and tarsal bone abnormalities (mostly
  fusions, ranging from 19% in the low-dose group (p<0.01) to 88% in the high-
  dose group (p<0.01)), without producing any other external or skeletal
  abnormalities.
  Cytarabine was injected intraperitoneally at a single dose of 0 or 10 mg/kg body
  weight to pregnant Swiss Webster mice (22 or 24 animals per group) on
  gestational day 9 (Chiang et al.4). Dams were killed on gestational day 18. No
  data on maternal toxicity were reported. The incidence of resorptions and dead
  foetuses was statistically significantly increased to 20% in the treatment group
  (versus 5% in controls). The incidence of cleft palate and/or cleft lip was
  statistically significantly increased to 26% in the treatment group (versus 2.6% in
  controls). The length of the foetuses was statistically significantly decreased, and
  the incidence of minor skeletal variations (reduction of skeletal calcification)
  was increased (without statistical significance) in the treatment group.
  Cytarabine was injected intraperitoneally at single doses of 0, 5 or 7.5 mg/kg
  body weight to groups of 8-19 pregnant Jcl:ICR mice on gestational days 8, 9.5
  or 11 (Chiba et al.5). The offspring was killed on post-natal day 24. No data on
  maternal toxicity were provided. A 30% incidence of hip joint anomalies was
  observed only in the group exposed to 7.5 mg/kg body weight on gestational day
  9.5, though the increase was not statistically significant. The types observed were
  femoral shaft dysplasia, pseudo arthrosis of the femur, femoral head dysplasia,
  acetabular dysplasia, fusion between the femoral head and acetabulum and
4 Cytarabine
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<pre>pseudo arthrosis of the coxal bone. Of the newborns in this group, 23% showed
oligodactyly.
Rats, intraperitoneal administration
Cytarabine was injected intraperitoneally at single doses of 0, 15, 50, 100 or 200
mg/kg body weight to pregnant Wistar rats on gestational day 12 (Ritter et al.27).
Pregnancy was terminated on gestational day 20.
    The number of foetuses examined was 74-101 in the treatment groups and
477 in controls.
    No data on maternal toxicity were provided. The percentage of
malformations was 2% in controls, 16% in low-, 67% in mid- and 85% in high-
dose groups (no p-values reported). The principal external malformations were
ectrodactyly, brachydactyly, syndactyly, cleft palate, clubfoot and kinky tail.
Internal abnormalities (hydrocephalus, hydronephrosis, diaphragmatic hernia
and genital defects) occurred occasionally, particularly at high dosage.
CNS structural defects
Mice, intraperitoneal administration
Cytarabine was injected at 30 mg/kg body weight to pregnant Swiss ICR-JCL
mice as a single dose, on gestational day 13 (8 mice), or twice, on gestational
days 13 and 14 (16 mice) (Kasubuchi et al.9). Foetuses were examined within 24
h after the last injection. In addition, offspring of 6 mice were examined. No data
on maternal toxicity were provided.
    Within six hours after the first injection, pyknotic nuclei and nuclear debris
were found at the matrix layer surrounding the lateral ventricles. Most of the
matrix cells were killed by the treatment and had disappeared 24 h after the
second injection.
    Offspring examined after birth showed marked dilatation of the lateral
ventricles, especially in the parieto-occipital region. From post-natal day 15, all
offspring showed gradual increase of the cranial vault and subsequently died by
35 days of age.
Cytarabine was injected at a dose of 30 mg/kg body weight/day to pregnant
Swiss ICR-JCL mice on gestational days 13.5 and 14.5 (Shimada et al.30).
Foetuses of 6 mice were examined on gestational days 15, 16, 17 and 18. Five to
Cytarabine                                                                          25
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<pre>  seven offspring of 15 mice were killed on post-natal days 1, 3, 7, 10, 20, 30, 60
  and 120. No data on maternal toxicity were provided.
      Severe damage in the matrix layer occurred in embryonic brains examined on
  gestational day 15, but regenerated partly on gestational day 17. Offspring
  examined from post-natal day 20 showed pronounced microcephaly. In offspring
  examined on post-natal day 1, 3 or 5, abnormal clusters of young neurons were
  found on the surface of the developing cerebral cortex. After post-natal day 20,
  the clusters gradually became indistinct but some vestigial groups of neurons
  were observed even at post-natal day 120. The hippocampus of young mice
  showed severe cytoarchitectural abnormalities.
  Takano et al. examined the pathogenesis of grey matter heterotopia and
  microcephaly produced by cytarabine.31 A total of 12 pregnant ICR-strain mice
  were injected with 30 mg/kg body weight on gestational days 13.5 and 14.5 and
  the offspring were examined. Four other (saline-injected) pregnant mice served
  as controls. No data on maternal toxicity were provided. Cytarabine disturbed the
  DNA-replication and migration of neuroepithelial cells in the ventriculate zone
  (BrdU-labelling, p<0.001) on post-natal day 15.5. Nestin-immunoreactive radial
  glial fibres and calretinin-positive subplate fibres were disrupted. TUNEL-
  reaction (detection of cells containing fragmented DNA) was remarkable
  throughout the cerebral hemisphere (p<0.01). Subcortical heterotopia in the
  cingulate cortex and subependymal nodular heterotopia in the dorsolateral part of
  the lateral ventricles became detectable on post-natal day 1. On post-natal day
  32, microcephaly was apparent and subcortical heterotopia was observed to have
  increased in size. The authors concluded that cytarabine induces neuronal
  apoptosis throughout the cerebral hemisphere.
  Rats, intraperitoneal administration
  Cytarabine was injected at a single dose of 0 or 50 mg/kg body weight to
  pregnant rats of the Lister black and white hooded strain on gestational day 14
  (Adlard et al.1). At birth, litters were reduced to eight pups for follow-up. Effects
  of cytarabine were evaluated in offspring at birth, on post-natal day 25 and in
  adult (15 wk old) offspring. Depending on the effect investigated, group sizes
  varied between 11 and 39 offspring rats per group.
      No data on maternal toxicity were provided. The treatment resulted in
  statistically significant reductions in birth weight (-14%, p<0.001), brain weight
  at birth (-17%, p<0.001) and brain/body weight ratio (-9%, p<0.001). The brain
6 Cytarabine
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<pre>weight deficit at birth reflected a deficit in number of brain cells as assessed by
total DNA.
    At post-natal day 25, a 22% deficit in brain weight (p<0.001) with no
significant effect on body weight was noted. Adult, 15 wk old, male offspring of
treated mothers also showed microcephaly, in that brain weight was reduced by
15% (p<0.001) while body weight was normal.
    Adult offspring of treated mothers showed an impairment in discrimination
learning, when tested in a water T-maze (see ‘Cognitive effects’ below).
Cytarabine was injected at a dose of 0 or 280 mg/kg body weight/day to pregnant
Wistar-Imamichi rats on gestational day 15 and 5-8 male offspring were
examined on post-natal day 60 (Matsutani et al.15). No data on maternal toxicity
were provided. Terminal body weight was statistically significantly (15%)
reduced in the offspring of treated rats. The weight of the cerebral hemisphere,
brain stem and cerebellum statistically significantly decreased to 60%, 75% and
89% of controls, respectively. DNA content (mg/region) in the brain stem and
cerebellum decreased by 20% and 10%, respectively. Levels of norepinephrine,
dopamine and serotonin in the cerebral hemisphere showed a statistically
significant rise (almost two times the control value).
Mice and rats, subcutaneous administration
Cytarabine was injected at doses of 12.5, 25 or 50 mg/kg body weight/day to
pregnant ICR Swiss mice on gestational days 16, 17 and 18 and to pregnant
Sprague Dawley rats on gestational days 18, 19 and 20 (Percy24). Surviving
offspring (17-57 per group) were killed on post-natal day 10 or 20. No data on
maternal toxicity were provided. No data in concurrent controls were reported.
Mortality of offspring rats was high at 25 (24%) and 50 mg/kg body weight/day
(70%). Dose-related segmental cerebellar hyperplasia was noted in mice at 25
and 50 mg/kg body weight/day and in rats of all dose groups. Focal microcystic
renal cortical dysplasia was noted in mice at 25 and 50 mg/kg body weight/day
and in rats of all dose groups. Retinal dysplasia occurred in rats at 50 mg/kg body
weight/day.
Cytarabine                                                                          27
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<pre>  Cognitive effects
  Mice, intraperitoneal administration
  Cytarabine was injected at single doses of 0 or 30 mg/kg body weight to groups
  of 4-12 pregnant CD-1 mice on gestational days 14 and 15 (Gray et al.7). No data
  on maternal toxicity were provided. Cytarabine-exposed offspring (at least one
  animal per sex and per litter was tested) showed statistically significantly
  increased locomotor activity in a Figure-eight maze (hyperactivity) on post-natal
  day 22 (100% increase) and post-natal day 58 (43% increase). Cytarabine-
  exposed mice (85 days of age) were statistically significantly more aggressive (in
  a ‘latency to attack the intruder test’).
      In a second experiment7, cytarabine was injected intraperitoneally at a single
  dose of 0 or 30 mg/kg body weight to groups of 11-30 pregnant CD-1 mice on
  gestational days 8-9, 10-11, 14-15 or 17-18. No data on maternal toxicity were
  provided. No live pups were born to dams in the gestational days 8-9 and 10-11
  treatment groups. Offspring (n=12) in the gestational days 14-15 group showed
  statistically significantly increased locomotor activity in the Figure-eight maze
  test on post-natal day 22. Behaviour in offspring in the gestational day 17-18
  group was unaffected.
  Rats, intraperitoneal administration
  Cytarabine was injected at a single dose of 0 or 50 mg/kg body weight to
  pregnant rats of the Lister black and white hooded strain on gestational day 14
  (Adlard et al.1).
      No data on maternal toxicity were provided. Adult offspring of treated
  mothers (11 or 12 per group) showed an impairment in discrimination learning
  when tested in a water T-maze (p<0.01).
  Rats, subcutaneous administration
  Cytarabine was injected at a dose of 0 or 30 mg/kg body weight/day to pregnant
  Sprague Dawley rats on gestational days 19.5 and 20.5 (Elmer et al.6). This
  dosing regimen was chosen deliberately to investigate behavioural changes in the
  absence of severe anatomical lesions. Groups of 14-26 offspring were subjected
  to sensorimotor assessment on post-natal days 35 and 56. No data on maternal
  toxicity were provided. Disruption of the pyramidal cell layer in the
8 Cytarabine
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<pre>      hippocampus was noted in cytarabine-exposed offspring. On post-natal day 35
      no statistically significant neurocognitive changes were observed. On post-natal
      day 56, however, cytarabine-exposed offspring had lower acoustic startle
      amplitudes (acoustic startle test) (p<0.002) and diminished sensorimotor gating
      (prepulse inhibition of the acoustic startle response) (p<0.025).
2.3.3 Lactation
      No animal studies on effects of cytarabine during lactation were available.
2.4   Conclusions
2.4.1 Fertility
      The Committee proposes not classifying cytarabine for effects on fertility due to
      a lack of appropriate human and animal data.
2.4.2 Developmental toxicity
      Prospective or retrospective epidemiological studies examining the adverse
      effects of cytarabine during pregnancy are not available. Several case reports on
      cytarabine treatment for leukaemia in pregnancy indicated both successful and
      unsuccessful maternal and foetal outcomes.8,13,16,17,20,29,32,33 The data do not
      allow definite conclusions with respect to adverse perinatal outcomes or
      congenital malformations in humans. There are no animal studies available with
      oral administration of cytarabine. The rat and mouse studies with intraperitoneal
      or subcutaneous administration of cytarabine to pregnant rats or mice show a
      range of effects on development.1,4-7,9,10,14,15,22,24-27,30,31 Most studies did not
      report on maternal toxicity. However, the developmental effects observed in two
      mouse studies, that of Kochhar et al. and that of Ortega et al., are not considered
      to be a non-specific consequence of maternal toxicity.10,22 For effects on
      development, the Committee therefore recommends to classify cytarabine in
      category 1B (presumed human reproductive toxicant) and to label it H360D
      (may damage the unborn child).
      Cytarabine                                                                           29
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<pre>2.4.3 Lactation
      No human studies or animal studies on effects of cytarabine during lactation
      were available. The Committee therefore proposes not classifying cytarabine for
      effects on or via lactation.
      Proposed classification for fertility
      Lack of appropriate data precludes the assessment of cytarabine for effects on
      fertility.
      Proposed classification for developmental toxicity
      Category 1B, H360D.
      Proposed labelling for effects during lactation
      Lack of appropriate data precludes the assessment of cytarabine for effects on or
      via lactation.
 0    Cytarabine
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<pre>References
Adlard BP, Dobbing J, Sands J. A comparison of the effects of cytosine arabinoside and adenine
arabinoside on some aspects of brain growth and development in the rat. Br J Pharmacol 1975; 54(1):
33-39.
Caligiuri MA, Mayer RJ. Pregnancy and leukemia. Semin Oncol 1989; 16(5): 388-396.
Calsteren K van. Substantial Variation in transplacental transfer of chemotherapeuric agents in a
mouse model. Reproductive Sciences 2012; 18(1): 57-63.
Chiang H, Wu RY, Shao BJ, Fu YD, Yao GD, Lu DJ. Pulsed magnetic field from video display
terminals enhances teratogenic effects of cytosine arabinoside in mice. Bioelectromagnetics 1995;
16(1): 70-74.
Chiba K, Ishikawa H, Rahman ME, Endo A. Neonatal mouse hip joint and hindlimb anomalies
induced by prenatal exposure to Ara-C (Thesis). 1996.
Elmer GI, Sydnor J, Guard H, Hercher E, Vogel MW. Altered prepulse inhibition in rats treated
prenatally with the antimitotic Ara-C: an animal model for sensorimotor gating deficits in
schizophrenia. Psychopharmacology (Berl) 2004; 174(2): 177-189.
Gray LE, Jr., Kavlok RJ, Ostby J, Ferrell J, Rogers J, Gray K. An evaluation of figure-eight maze
activity and general behavioral development following prenatal exposure to forty chemicals: effects
of cytosine arabinoside, dinocap, nitrofen, and vitamin A. Neurotoxicology 1986; 7(0161-813; 0161-
813; 2): 449-462.
Juárez S, Cuadrado Pastor JM, Feliu J, González Barón M, Ordónez A, Montero JM. Association of
leukemia and pregnacy; clinical and obstetic aspects. Am J Clin Oncol 1988; 11(2): 159-165.
Kasubuchi Y, Wakaizumi S, Shimada M, Kusunoki T. Cytosine Arabinoside-Induced Transplacental
Dysgenetic Hydrocephalus in Mice. Teratology 1977; 16: 63-70.
References                                                                                          31
</pre>

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

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

<pre>0 Kochhar DM, Penner JD, McDay JA. Limb development in mouse embryos. II. Reduction defects,
  cytotoxicity and inhibition of DNA synthesis produced by cytosine arabinoside. Teratology 1978;
  18(1): 71-92.
1 Lendon M, Hann IM, Palmer MK, Shalet SM, Jones PH. Testicular histology after combination
  chemotherapy in childhood for acute lymphoblastic leukaemia. Lancet 1978; 2(8087): 439-441.
2 Lenz KL, Valley AW. Infertility after chemotherapy: review of the risks and strategies for prevention.
  J Oncol Pharm Pract 1996; 2(2): 75-100.
3 Manoharan A, Leyden MJ. Acute non-lymphocytic leukaemia in the third trimester of pregnancy.
  Aust N Z J Med 1979; 9(1): 71-74.
4 Manson JM, Dourson ML, Smith CC. Effects of cytosine arabinoside on in vivo and in vitro mouse
  limb development. In vitro 1977; 13(7): 434-442.
5 Matsutani T, Tamaru M, Hayakawa Y, Nagayoshi M, Nakahara T, Tsukada Y. A neurochemical study
  of developmental impairment of the brain caused by the administration of cytosine arabinoside
  during the fetal or neonatal period of rats. Neurochem Res 1983; 8(10): 1295-1306.
6 Maurer LH, Forcier RJ, Mcintyre OR, Benirschke K. Fetal group C trisomy after cytosine
  arabinoside and thioguanine. Ann Intern Med 1971; 75(5): 809-810.
7 Moreno H, Castleberry RP, McCann WP. Cytosine arabinoside and 6-thioguanine in the treatment of
  childhood acute myeloblastic leukemia. Cancer 1977; 40(3): 998-1004.
8 Morgenstern G. Cytarabine in pregnancy. Lancet 1980; 2(8188): 259.
9 National Library of Medicine (NLM), editor. Cytarabine. CASRN: 147-94-4. In: Hazardous
  Substances Data Bank (HSDB). Internet: http://toxnet.nlm.nih.gov. Consulted: June 24, 2015.
0 Newcomb M, Balducci L, Thigpen JT, Morrison FS. Acute leukemia in pregnancy. Successful
  delivery after cytarabine and doxorubicin. JAMA 1978; 239(25): 2691-2692.
1 Niesink R, de Vries J, Hoolinger M. Toxicology principles and applications. Boca Raton, FL, USA:
  CRC Press; 1995.
2 Ortega A, Puig M, Domingo JL. Maternal and developmental toxicity of low doses of cytosine
  arabinoside in mice. Teratology 1991; 44(4): 379-384.
3 Palo AK, Sahoo D, Choudhury RC. Cytosine arabinoside-induced cytogenotoxicity in bone marrow
  and spermatogonial cells of mice and its potential transmission through the male germline. Mutat Res
  2009; 673(1): 29-36.
4 Percy DH. Teratogenic Effects of the Pyrimidine Analogues 5-Iododeoxyuridine and Cytosine
  Arabinoside in Late Fetal Mice and Rats. Teratology 1976; 11: 103-118.
5 Rahman ME, Ishikawa H, Watanabe Y, Endo A. Carpal and tarsal bone anomalies in mice induced by
  maternal treatment of Ara-C. Reprod Toxicol 1994; 8(1): 41-47.
6 Rahman ME, Ishikawa H, Watanabe Y, Endo A. Carpal and tarsal bone development is highly
  sensitive to three antiproliferative teratogens in mice. Reproductive toxicology 1996; 10(6): 485-489.
7 Ritter EJ, Scott WJ, Wilson JG. Teratogenesis and Inhibition of Dna Synthesis Induced in Rat
  Embryos by Cytosine Arabinoside. Teratology 1971; 4: 7-14.
2 Cytarabine
</pre>

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

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

<pre>8 Robak T, Wierzbowska A. Current and emerging therapies for acute myeloid leukemia. Clin Ther
  2009; 31 Pt 2: 2349-2370.
9 Sears HF, Reid J. Granulocytic sarcoma: local presentation of a systemic disease. Cancer 1976;
  37(4): 1808-1813.
0 Shimada M, Abe Y, Yamano T, Ohta S, Yamazaki S, Ohya N. The pathogenesis of abnormal
  cytoarchitecture in the cerebral cortex and hippocampus of the mouse treated transplacentally with
  cytosine arabinoside. Acta Neuropathol 1982; 58(3): 159-167.
1 Takano T, Akahori S, Takeuchi Y, Ohno M. Neuronal apoptosis and gray matter heterotopia in
  microcephaly produced by cytosine arabinoside in mice. Brain Res 2006; 1089(1): 55-66.
2 Tobias JS, Bloom HJ. Doxorubicin in pregnancy. Lancet 1980; 1(8171): 776.
3 Wagner VM, Hill JS, Weaver D, Baehner RL. Congenital abnormalities in baby born to cytarabine
  treated mother. Lancet 1980; 2(8185): 98-99.
4 Wiebe VJ, Sipila PE. Pharmacology of antineoplastic agents in pregnancy. Crit Rev Oncol Hematol
  1994; 16(2): 75-112.
  Literature consulted but not used
  Abe Y, Yamano T, Shimada M, et al. Transplacental chemical induction of microcephalus in
  mice:Physical growth and motor development. Teratology. 1978; 18:150.
  Breithaupt H, Pralle H, Eckhardt T, von Hattingberg M, Schick J, Löffler H. Clinical results and
  pharmacokinetics of high-dose cytosine arabinoside (HD ARA-C). Cancer. 1982; 50: 1248-1257.
  Chiba K, Ishikawa H, Rahman ME, Endo A. Hip joint anomalies in mouse newborns induced by
  prenatal cytosine arabinoside treatment. Teratology. 1995; 52(4):38B.
  Claahsen HL, Semmekrot BA, van Dongen PW, Mattijssen V. Successful fetal outcome after
  exposure to idarubicin and cytosine-arabinoside during the second trimester of pregnancy--a case
  report. Am J Perinatol. 1998; 15(5): 295-297.
  Colbert N, Najman A, Gorin NC, et al. [Acute leukaemia during pregnancy: Favourable course of
  pregnancy in two patients treated with cytosine arabinoside and anthracyclines (author's transl)].
  Nouv Presse Med. 1980; 9(3): 175-178.
  Endo A, Sakai N, Ohwada K. Analysis of diurnal difference in teratogen (ara-C) susceptibility in
  mouse embryos by a progressive phase-shift method. Teratog Carcinog Mutagen. 1987;7(5):475-482.
  Erdogan D, Kadioglu D, Peker T. Demonstration of congenital anomalies in the joints of the
  forelimbs and hindlimbs caused by several pharmacological agents. Anatomia Histologia
  Embryologia 1996; 25(4): 263-267.
  Goto T, Endo A. Dose- and stage-related sex difference in the incidence of cytosine arabinoside
  induced digit anomalies in the mouse fetus. Teratology. 1987; 35: 35-40.
  Gray LE,Jr., Kavlock RJ. An extended evaluation of an in vivo teratology screen utilizing postnatal
  growth and viability in the mouse. Teratog Carcinog Mutagen. 1984; 4(5): 403-426.
  References                                                                                          33
</pre>

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

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

<pre>  Hashimoto Y, Mizutani M. Behavioral abnormality of rats with micrencephaly due to prenatal
  treatment with methylnitrosourea, methylazoxymethanol and cytosine arabinoside. Teratology. 1981;
  24(1): 32A.
  Ishikawa H, Omoe K, Endo A. Digit malformations induced by cytosine arabinoside (ara-C) in
  mouse fetuses: Relationship between the hour of the day (dg 10) of treatment and the incidence.
  Teratology. 1991; 44(6): 10B.
  Ishikawa H, Omoe K, Endo A. Growth and differentiation schedule of mouse embryos obtained from
  delayed matings. Teratology. 1992; 45(6): 655-659.
  Kasubuchi Y, Wakaizumi S, Shimada M, Nakamura T. Cytosine arabinoside induced microcephaly in
  mice. Teratology. 1973; 8: 96.
  Lemez P, Urbanek V. Chemotherapy for acute myeloid leukemias with cytosine arabinoside,
  daunorubicin, etoposide, and mitoxantrone may cause permanent oligoasthenozoospermia or
  amenorrhea in middle-aged patients. Neoplasma. 2005; 52(5): 398-401.
  Lobanov AV, Khokhlova ON, Zaraiskaia II, Murashev AN. [Somatic maturation and sensorimotor
  development of C57BL/6 mice prenatally exposed to cytosine arabinoside]. Zh Vyssh Nerv Deiat Im
  I P Pavlova. 2008; 58(1): 98-110.
  Marcickiewicz J, Chazan B, Niemiec T, et al. Microwave radiation enhances teratogenic effect of
  cytosine arabinoside in mice. Biol Neonate. 1986; 50(2): 75-82.
  Matsutani T. A neurochemical study of experimental microencephalic rat. J Toxicol Sci. 1984; 9(3):
  205-218.
  Matthews JH, Wood JK. Male fertility during chemotherapy for acute leukemia. N Engl J Med. 1980;
  303(21): 1235.
  Mikami T, Gotou M, Suzuki Y, Chiba T. Cerebellar Hypoplasia Produced by Cytosine Arabinoside in
  Rats.2. Teratology 1980; 22(1): 16A.
  Morishita S, Imai A, Kawabata I, Tamaya T. Acute myelogenous leukemia in pregnancy: Fetal blood
  sampling and early effects of chemotherapy. Int J Gynaecol Obstet. 1994;44(3):273-277.
  Müller J, Skakkebaek NE, Hertz H. Initiation of spermatogenesis during chemotherapy for leukemia.
  Acta Paediatr Scand. 1985; 74(5): 956-960.
  Newcomb M, Balducci L, Thigpen JT, Morrison FS. Acute leukemia in pregnancy: Successful
  delivery after cytarabine and doxorubicin. Jama J Am Med Assoc. 1978; 239: 2691-2692.
  Ohno M. Neuroanatomical study of somatomotor cortex in microcephalic mice induced by cytosine
  arabinoside. Brain Dev. 1984; 6(6): 528-538.
  Ohno M, Yamasaki S, Yamano T, Shimada M. A histochemical study of motor neurons and
  catecolaminergic fibers in the cerebral cortex of microcephalic brains. Teratology. 1984; 30(1): 9A.
  Ohno M. Brain pathology of microcephalic mouse with hyperactivity. Congenit Anom Kyoto. 2002;
  42(3): 239.
  Okagawa T, Suzuki F, Oohira A, Nogami H. Digital malformations produced in rats by successive
  administration of cytosine arabinoside. Teratology. 1981; 24(1): 20A.
4 Cytarabine
</pre>

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

<pre>Ono K, Takano T, Ohno M, Yamano T, Shimada M. Cytosine arabinoside-induced heterotopia in
mouse cerebrum and its synaptogenesis. Teratology. 2000; 62(3): 35A.
Ono-Yagi K, Ohno M, Iwami M, Takano T, Yamano T, Shimada M. Heterotopia in microcephaly
induced by cytosine arabinoside: Hippocampus in the neocortex. Acta Neuropathol. 2000; 100(4):
403-408.
Pawliger DF, McLean FW, Noyes WD. Normal fetus after cytosine arabinoside therapy. Ann Intern
Med. 1971; 74(6): 1012.
Pizzuto J, Aviles A, Noriega L, Niz J, Morales M, Romero F. Treatment of acute leukemia during
pregnancy:Presentation of nine cases. Cancer Treat Rep. 1980; 64: 679-683.
Plows CW. Acute myelomonocytic leukemia in pregnancy: Report of a case. Am J Obstet Gynecol.
1982; 143: 41-43.
Rahman ME, Ishikawa H, Endo A. Prenatal cytosine arabinoside treatment produces gestational
stage-related carpal and tarsal bone anomalies in neonatal mice. Teratology. 1994; 50(6): 18B.
Rahman ME, Ishikawa H, Endo A. High sensitivity of carpal and tarsal bones to teratogens.
Teratology 1995; 52(4): 15B.
Rahman ME, Ishikawa H, Watanabe Y, Endo A. Stage specificity of ara-C induced carpal and tarsal
bone anomalies in mice. Reprod Toxicol. 1995; 9(3): 289-296.
Scott WJ, Ritter EJ, Wilson JG. Studies on induction of polydactyly in rats with cytosine arabinoside.
Dev Biol 1975; 45(1): 103-111.
Shimada M. Congenital anomalies of central nervous system and neuronal plasticity. Congenital
Anomalies. 1989; 29(1): 31-40.
Stanimirova I, Michalik K, Drzazga Z, Trzeciak H, Wentzell PD, Walczak B. Interpretation of
analysis of variance models using principal component analysis to assess the effect of a maternal
anticancer treatment on the mineralization of rat bones. Anal Chim Acta. 2011; 689(1): 1-7.
Takahara M, Ogino T, Minami A, Kato H, Ohshio I. Experimental study on symphalangism.
Teratology. 1989; 40(6): 669.
Takano T, Sokoda T, Akahori S, Takikita S, Takeuchi Y. Nestin-immunoreactive radial glia in
experimental cortical dysplasia induced by cytosine arabinoside in mice. Congenit Anom (Kyoto).
2005; 45(4): A50.
Takano T, Sokoda T, Akahori S, Sawai C, Sakaue Y, Takeuchi Y. Experimental cortical dysplasia
induced by cytosine arabinoside in mice: BrdU and TUNEL immunohistochemistry. Congenit Ano m
(Kyoto). 2006; 46(4): A35.
Uderzo C, Locasciulli A, Marzorati R, et al. Correlation of gonadal function with histology of
testicular biopsies at treatment discontinuation in childhood acute leukemia. Med Pediatr Oncol.
1984; 12(2): 97-100.
Veneri D, Todeschini G, Pizzolo G, et al. Acute leukemia and pregnancy. case report. Clin Exp Obstet
Gynecol. 1996; 23(2): 112-115.
References                                                                                             35
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<pre>  Yamauchi H, Katayama K, Ueno M, Uetsuka K, Nakayama H, Doi K. Involvement of p53 in 1-beta-
  D-arabinofuranosylcytosine-induced rat fetal brain lesions. Neurotoxicol Teratol. 2004; 26(4): 579-
  586.
  Yucebilgin MS, Cagirgan S, Donmez A, et al. Acute myeloblastic leukemia in pregnancy: A case
  report and review of the literature. Eur J Gynaecol Oncol. 2004; 25(1): 126-128.
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<pre>A The Committee
B The submission letter (in English)
C Comments on the public draft
D Regulation (EC) 1272/2008 of the European Community
E Additional considerations to Regulation (EC) 1272/2008
F Fertility and developmental toxicity studies
  Annexes
                                                         37
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<pre>8 Cytarabine</pre>

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<pre>nnex A
     The Committee
     •   A.H. Piersma, Chairman
         Professor of Reproductive and Developmental Toxicology; Utrecht
         University, Utrecht and National Institute of Public Health and the
         Environment, Bilthoven
     •   D. Lindhout
         Professor of Medical Genetics, Paediatrician (not practising), Clinical
         Geneticist, University Medical Centre, Utrecht
     •   N. Roeleveld
         Reproductive Epidemiologist, Radboud university medical center, Nijmegen
     •   J.G. Theuns-van Vliet
         Reproductive Toxicologist, TNO Triskelion BV, Zeist
     •   D.H. Waalkens-Berendsen
         Reproductive Toxicologist, Zeist
     •   P.J.J.M. Weterings
         Toxicologist, Weterings Consultancy BV, Rosmalen
     •   P.W. van Vliet, Scientific Secretary
         Health Council of the Netherlands, Den Haag
     The first draft of the present document was prepared by Dr. B.A.R. Lina (TNO
     Triskelion BV, Zeist, the Netherlands), by contract with the Ministry of Social
     Affairs and Employment.
     The Committee                                                                   39
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<pre>  The Health Council and interests
  Members of Health Council Committees are appointed in a personal capacity
  because of their special expertise in the matters to be addressed. Nonetheless, it
  is precisely because of this expertise that they may also have interests. This in
  itself does not necessarily present an obstacle for membership of a Health
  Council Committee. Transparency regarding possible conflicts of interest is
  nonetheless important, both for the chairperson and members of a Committee
  and for the President of the Health Council. On being invited to join a
  Committee, members are asked to submit a form detailing the functions they
  hold and any other material and immaterial interests which could be relevant for
  the Committee’s work. It is the responsibility of the President of the Health
  Council to assess whether the interests indicated constitute grounds for non-
  appointment. An advisorship will then sometimes make it possible to exploit the
  expertise of the specialist involved. During the inaugural meeting the
  declarations issued are discussed, so that all members of the Committee are
  aware of each other’s possible interests.
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<pre>nnex B
     The submission letter (in English)
     Subject         : Submission of the advisory report Cytarabine
     Your reference  : DGV/BMO/U-932542
     Our reference   : U-791480/EvV/fs/543-K15
     Enclosure(s)    :1
     Date            : July 23, 2015
     Dear Minister,
     I hereby submit the advisory report on the effects of cytarabine on fertility and on
     the development of the progeny; it also concerns effects on lactation and on the
     progeny via lactation. This advisory report is part of an extensive series in which
     reproduction toxic substances are classified in accordance with European
     guidelines. This involves substances to which people may be exposed
     occupationally.
     The advisory report was prepared by a permanent Committee of the Health
     Council of the Netherlands, the Committee on the Classification of Reproduction
     Toxic Substances. The advisory report was consequently reviewed by the Health
     Council’s Standing Committee on Health and the Environment.
     The submission letter (in English)                                                   41
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<pre>  Today I sent copies of this advisory report to the State Secretary of Infrastructure
  and the Environment and to the Minister of Health, Welfare and Sport, for their
  information.
  Yours sincerely,
  (signed)
  Professor W.A. van Gool,
  President
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<pre>nnex C
     Comments on the public draft
     A draft of the present report was released in 2014 for public review. The
     following organisation and persons have commented on the draft document:
     • T.J. Lentz, J. Ma. National Institute for Occupational Safety and Health
         (NIOSH), Cincinnati, OH, USA.
     The comments received, and the reply by the Committee can be found on the
     website of the Health Council.
     Comments on the public draft                                               43
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<pre>4 Cytarabine</pre>

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<pre>nnex D
     Regulation (EC) 1272/2008 of the
     European Community
     3.7            Reproductive toxicity
     3.7.1          Definitions and general considerations
     3.7.1.1        Reproductive toxicity includes adverse effects on sexual function and fertility in adult
     males and females, as well as developmental toxicity in the offspring. The definitions presented
     below are adapted from those agreed as working definitions in IPCS/EHC Document No 225, Princi-
     ples for Evaluating Health Risks to Reproduction Associated with Exposure to Chemicals. For classi-
     fication purposes, the known induction of genetically based heritable effects in the offspring is
     addressed in Germ Cell Mutagenicity (section 3.5), since in the present classification system it is con-
     sidered more appropriate to address such effects under the separate hazard class of germ cell muta-
     genicity.
     In this classification system, reproductive toxicity is subdivided under two main headings:
     (a) adverse effects on sexual function and fertility;
     (b) adverse effects on development of the offspring.
     Some reproductive toxic effects cannot be clearly assigned to either impairment of sexual function
     and fertility or to developmental toxicity. Nonetheless, substances with these effects, or mixtures con-
     taining them, shall be classified as reproductive toxicants.
     Regulation (EC) 1272/2008 of the European Community                                                      45
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<pre>  3.7.1.2         For the purpose of classification the hazard class Reproductive Toxicity is differentiated
                  into:
  •     adverse effects
        •    on sexual function and fertility, or
        •    on development;
  •     effects on or via lactation.
  3.7.1.3         Adverse effects on sexual function and fertility
  Any effect of substances that has the potential to interfere with sexual function and fertility. This
  includes, but is not limited to, alterations to the female and male reproductive system, adverse effects
  on onset of puberty, gamete production and transport, reproductive cycle normality, sexual behaviour,
  fertility, parturition, pregnancy outcomes, premature reproductive senescence, or modifications in
  other functions that are dependent on the integrity of the reproductive systems.
  3.7.1.4         Adverse effects on development of the offspring
  Developmental toxicity includes, in its widest sense, any effect which interferes with normal devel-
  opment of the conceptus, either before or after birth, and resulting from exposure of either parent
  prior to conception, or exposure of the developing offspring during prenatal development, or postna-
  tally, to the time of sexual maturation. However, it is considered that classification under the heading
  of developmental toxicity is primarily intended to provide a hazard warning for pregnant women, and
  for men and women of reproductive capacity. Therefore, for pragmatic purposes of classification,
  developmental toxicity essentially means adverse effects induced during pregnancy, or as a result of
  parental exposure. These effects can be manifested at any point in the life span of the organism. The
  major manifestations of developmental toxicity include (1) death of the developing organism, (2)
  structural abnormality, (3) altered growth, and (4) functional deficiency.
  3.7.1.5         Adverse effects on or via lactation are also included in reproductive toxicity, but for
  classification purposes, such effects are treated separately (see Table 3.7.1 (b)). This is because it is
  desirable to be able to classify substances specifically for an adverse effect on lactation so that a spe-
  cific hazard warning about this effect can be provided for lactating mothers.
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<pre>3.7.2        Classification criteria for substances
3.7.2.1      Hazard categories
3.7.2.1.1    For the purpose of classification for reproductive toxicity, substances are allocated to
one of two categories. Within each category, effects on sexual function and fertility, and on develop-
ment, are considered separately. In addition, effects on lactation are allocated to a separate hazard cat-
egory.
Table 3.7.1(a) Hazard categories for reproductive toxicants.
Categories                      Criteria
CATEGORY 1                      Known or presumed human reproductive toxicant
                                Substances are classified in Category 1 for reproductive toxicity when
                                they are known to have produced an adverse effect on sexual function
                                and fertility, or on development in humans or when there is evidence
                                from animal studies, possibly supplemented with other information, to
                                provide a strong presumption that the substance has the capacity to
                                interfere with reproduction in humans. The classification of a sub-
                                stance is further distinguished on the basis of whether the evidence for
                                classification is primarily from human data (Category 1A) or from
                                animal data (Category 1B).
                Category 1A Known human reproductive toxicant
                                The classification of a substance in Category 1A is largely based on
                                evidence from humans.
                Category 1B Presumed human reproductive toxicant
                                The classification of a substance in Category 1B is largely based on
                                data from animal studies. Such data shall provide clear evidence of an
                                adverse effect on sexual function and fertility or on development in
                                the absence of other toxic effects, or if occurring together with other
                                toxic effects the adverse effect on reproduction is considered not to be
                                a secondary non-specific consequence of other toxic effects. However,
                                when there is mechanistic information that raises doubt about the rele-
                                vance of the effect for humans, classification in Category 2 may be
                                more appropriate.
CATEGORY 2                      Suspected human reproductive toxicant
                                Substances are classified in Category 2 for reproductive toxicity when
                                there is some evidence from humans or experimental animals, possi-
                                bly supplemented with other information, of an adverse effect on sex-
                                ual function and fertility, or on development, and where the evidence
                                is not sufficiently convincing to place the substance in Category 1. If
                                deficiencies in the study make the quality of evidence less convincing,
                                Category 2 could be the more appropriate classification.
                                Such effects shall have been observed in the absence of other toxic
                                effects, or if occurring together with other toxic effects the adverse
                                effect on reproduction is considered not to be a secondary non-specific
                                consequence of the other toxic effects.
Regulation (EC) 1272/2008 of the European Community                                                        47
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<pre>  Table 3.7.1(b) Hazard category for lactation effects.
  EFFECTS ON OR VIA LACTATION
  Effects on or via lactation are allocated to a separate single category. It is recognised that for many
  substances there is no information on the potential to cause adverse effects on the offspring via lacta-
  tion. However, substances which are absorbed by women and have been shown to interfere with lac-
  tation, or which may be present (including metabolites) in breast milk in amounts sufficient to cause
  concern for the health of a breastfed child, shall be classified and labelled to indicate this property
  hazardous to breastfed babies. This classification can be assigned on the:
  (a) human evidence indicating a hazard to babies during the lactation period; and/or
  (b) results of one or two generation studies in animals which provide clear evidence of adverse effect
  in the offspring due to transfer in the milk or adverse effect on the quality of the milk; and/or
  (c) absorption, metabolism, distribution and excretion studies that indicate the likelihood that the sub-
  stance is present in potentially toxic levels in breast milk.
  3.7.2.2        Basis of classification
  3.7.2.2.1      Classification is made on the basis of the appropriate criteria, outlined above, and an
  assessment of the total weight of evidence (see 1.1.1). Classification as a reproductive toxicant is
  intended to be used for substances which have an intrinsic, specific property to produce an adverse
  effect on reproduction and substances shall not be so classified if such an effect is produced solely as
  a non-specific secondary consequence of other toxic effects.
  The classification of a substance is derived from the hazard categories in the following order of pre-
  cedence: Category 1A, Category 1B, Category 2 and the additional Category for effects on or via lac-
  tation. If a substance meets the criteria for classification into both of the main categories (for example
  Category 1B for effects on sexual function and fertility and also Category 2 for development) then
  both hazard differentiations shall be communicated by the respective hazard statements. Classifica-
  tion in the additional category for effects on or via lactation will be considered irrespective of a clas-
  sification into Category 1A, Category 1B or Category 2.
  3.7.2.2.2      In the evaluation of toxic effects on the developing offspring, it is important to consider
  the possible influence of maternal toxicity (see section 3.7.2.4).
  3.7.2.2.3      For human evidence to provide the primary basis for a Category 1A classification there
  must be reliable evidence of an adverse effect on reproduction in humans. Evidence used for classifi-
  cation shall ideally be from well conducted epidemiological studies which include the use of appro-
  priate controls, balanced assessment, and due consideration of bias or confounding factors. Less
  rigorous data from studies in humans shall be supplemented with adequate data from studies in
  experimental animals and classification in Category 1B shall be considered.
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<pre>3.7.2.3         Weight of evidence
3.7.2.3.1       Classification as a reproductive toxicant is made on the basis of an assessment of the
total weight of evidence, see section 1.1.1. This means that all available information that bears on the
determination of reproductive toxicity is considered together, such as epidemiological studies and
case reports in humans and specific reproduction studies along with sub-chronic, chronic and special
study results in animals that provide relevant information regarding toxicity to reproductive and
related endocrine organs. Evaluation of substances chemically related to the substance under study
may also be included, particularly when information on the substance is scarce. The weight given to
the available evidence will be influenced by factors such as the quality of the studies, consistency of
results, nature and severity of effects, the presence of maternal toxicity in experimental animal stud-
ies, level of statistical significance for inter-group differences, number of endpoints affected, rele-
vance of route of administration to humans and freedom from bias. Both positive and negative results
are assembled together into a weight of evidence determination. A single, positive study performed
according to good scientific principles and with statistically or biologically significant positive results
may justify classification (see also 3.7.2.2.3).
3.7.2.3.2       Toxicokinetic studies in animals and humans, site of action and mechanism or mode of
action study results may provide relevant information which reduces or increases concerns about the
hazard to human health. If it is conclusively demonstrated that the clearly identified mechanism or
mode of action has no relevance for humans or when the toxicokinetic differences are so marked that
it is certain that the hazardous property will not be expressed in humans then a substance which pro-
duces an adverse effect on reproduction in experimental animals should not be classified.
3.7.2.3.3       If, in some reproductive toxicity studies in experimental animals the only effects
recorded are considered to be of low or minimal toxicological significance, classification may not
necessarily be the outcome. These effects include small changes in semen parameters or in the inci-
dence of spontaneous defects in the foetus, small changes in the proportions of common foetal vari-
ants such as are observed in skeletal examinations, or in foetal weights, or small differences in
postnatal developmental assessments.
3.7.2.3.4       Data from animal studies ideally shall provide clear evidence of specific reproductive
toxicity in the absence of other systemic toxic effects. However, if developmental toxicity occurs
together with other toxic effects in the dam, the potential influence of the generalised adverse effects
shall be assessed to the extent possible. The preferred approach is to consider adverse effects in the
embryo/foetus first, and then evaluate maternal toxicity, along with any other factors which are likely
to have influenced these effects, as part of the weight of evidence. In general, developmental effects
that are observed at maternally toxic doses shall not be automatically discounted. Discounting devel-
Regulation (EC) 1272/2008 of the European Community                                                         49
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<pre>  opmental effects that are observed at maternally toxic doses can only be done on a case-by-case basis
  when a causal relationship is established or refuted.
  3.7.2.3.5      If appropriate information is available it is important to try to determine whether devel-
  opmental toxicity is due to a specific maternally mediated mechanism or to a non-specific secondary
  mechanism, like maternal stress and the disruption of homeostasis. Generally, the presence of mater-
  nal toxicity shall not be used to negate findings of embryo/foetal effects, unless it can be clearly dem-
  onstrated that the effects are secondary non-specific effects. This is especially the case when the
  effects in the offspring are significant, e.g. irreversible effects such as structural malformations. In
  some situations it can be assumed that reproductive toxicity is due to a secondary consequence of
  maternal toxicity and discount the effects, if the substance is so toxic that dams fail to thrive and there
  is severe inanition, they are incapable of nursing pups; or they are prostrate or dying.
  3.7.2.4        Maternal toxicity
  3.7.2.4.1      Development of the offspring throughout gestation and during the early postnatal stages
  can be influenced by toxic effects in the mother either through non-specific mechanisms related to
  stress and the disruption of maternal homeostasis, or by specific maternally-mediated mechanisms. In
  the interpretation of the developmental outcome to decide classification for developmental effects it
  is important to consider the possible influence of maternal toxicity. This is a complex issue because
  of uncertainties surrounding the relationship between maternal toxicity and developmental outcome.
  Expert judgement and a weight of evidence approach, using all available studies, shall be used to
  determine the degree of influence that shall be attributed to maternal toxicity when interpreting the
  criteria for classification for developmental effects. The adverse effects in the embryo/foetus shall be
  first considered, and then maternal toxicity, along with any other factors which are likely to have
  influenced these effects, as weight of evidence, to help reach a conclusion about classification.
  3.7.2.4.2      Based on pragmatic observation, maternal toxicity may, depending on severity, influ-
  ence development via non-specific secondary mechanisms, producing effects such as depressed foe-
  tal weight, retarded ossification, and possibly resorptions and certain malformations in some strains
  of certain species. However, the limited number of studies which have investigated the relationship
  between developmental effects and general maternal toxicity have failed to demonstrate a consistent,
  reproducible relationship across species. Developmental effects which occur even in the presence of
  maternal toxicity are considered to be evidence of developmental toxicity, unless it can be unequivo-
  cally demonstrated on a case-by-case basis that the developmental effects are secondary to maternal
  toxicity. Moreover, classification shall be considered where there is a significant toxic effect in the
  offspring, e.g. irreversible effects such as structural malformations, embryo/foetal lethality, signifi-
  cant post-natal functional deficiencies.
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<pre>3.7.2.4.3      Classification shall not automatically be discounted for substances that produce devel-
opmental toxicity only in association with maternal toxicity, even if a specific maternally-mediated
mechanism has been demonstrated. In such a case, classification in Category 2 may be considered
more appropriate than Category 1. However, when a substance is so toxic that maternal death or
severe inanition results, or the dams are prostrate and incapable of nursing the pups, it is reasonable
to assume that developmental toxicity is produced solely as a secondary consequence of maternal
toxicity and discount the developmental effects. Classification is not necessarily the outcome in the
case of minor developmental changes, when there is only a small reduction in foetal/pup body weight
or retardation of ossification when seen in association with maternal toxicity.
3.7.2.4.4      Some of the end points used to assess maternal effects are provided below. Data on
these end points, if available, need to be evaluated in light of their statistical or biological signifi-
cance and dose response relationship.
Maternal mortality:
an increased incidence of mortality among the treated dams over the controls shall be considered evi-
dence of maternal toxicity if the increase occurs in a dose-related manner and can be attributed to the
systemic toxicity of the test material. Maternal mortality greater than 10 % is considered excessive
and the data for that dose level shall not normally be considered for further evaluation.
Mating index
(no. animals with seminal plugs or sperm/no. mated × 100) (*)
Fertility index
(no. animals with implants/no. of matings × 100)
Gestation length
(if allowed to deliver)
Body weight and body weight change:
Consideration of the maternal body weight change and/or adjusted (corrected) maternal body weight
shall be included in the evaluation of maternal toxicity whenever such data are available. The calcula-
() It is recognised that the Mating index and the Fertility index can also be affected by the male.
Regulation (EC) 1272/2008 of the European Community                                                       51
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<pre>  tion of an adjusted (corrected) mean maternal body weight change, which is the difference between
  the initial and terminal body weight minus the gravid uterine weight (or alternatively, the sum of the
  weights of the foetuses), may indicate whether the effect is maternal or intrauterine. In rabbits, the
  body weight gain may not be useful indicators of maternal toxicity because of normal fluctuations in
  body weight during pregnancy.
  Food and water consumption (if relevant):
  The observation of a significant decrease in the average food or water consumption in treated dams
  compared to the control group is useful in evaluating maternal toxicity, particularly when the test
  material is administered in the diet or drinking water. Changes in food or water consumption need to
  be evaluated in conjunction with maternal body weights when determining if the effects noted are
  reflective of maternal toxicity or more simply, unpalatability of the test material in feed or water.
  Clinical evaluations (including clinical signs, markers, haematology and clinical chemistry studies):
  The observation of increased incidence of significant clinical signs of toxicity in treated dams relative
  to the control group is useful in evaluating maternal toxicity. If this is to be used as the basis for the
  assessment of maternal toxicity, the types, incidence, degree and duration of clinical signs shall be
  reported in the study. Clinical signs of maternal intoxication include: coma, prostration, hyperactivity,
  loss of righting reflex, ataxia, or laboured breathing.
  Post-mortem data:
  Increased incidence and/or severity of post-mortem findings may be indicative of maternal toxicity.
  This can include gross or microscopic pathological findings or organ weight data, including absolute
  organ weight, organ-to-body weight ratio, or organ-to-brain weight ratio. When supported by find-
  ings of adverse histopathological effects in the affected organ(s), the observation of a significant
  change in the average weight of suspected target organ(s) of treated dams, compared to those in the
  control group, may be considered evidence of maternal toxicity.
  3.7.2.5        Animal and experimental data
  3.7.2.5.1      A number of internationally accepted test methods are available; these include methods
  for developmental toxicity testing (e.g. OECD Test Guideline 414), and methods for one or two-gen-
  eration toxicity testing (e.g. OECD Test Guidelines 415, 416).
  3.7.2.5.2      Results obtained from Screening Tests (e.g. OECD Guidelines 421 — Reproduction/
  Developmental Toxicity Screening Test, and 422 — Combined Repeated Dose Toxicity Study with
2 Cytarabine
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<pre>Reproduction/Development Toxicity Screening Test) can also be used to justify classification,
although it is recognised that the quality of this evidence is less reliable than that obtained through
full studies.
3.7.2.5.3      Adverse effects or changes, seen in short- or long-term repeated dose toxicity studies,
which are judged likely to impair reproductive function and which occur in the absence of significant
generalised toxicity, may be used as a basis for classification, e.g. histopathological changes in the
gonads.
3.7.2.5.4      Evidence from in vitro assays, or non-mammalian tests, and from analogous substances
using structure-activity relationship (SAR), can contribute to the procedure for classification. In all
cases of this nature, expert judgement must be used to assess the adequacy of the data. Inadequate
data shall not be used as a primary support for classification.
3.7.2.5.5      It is preferable that animal studies are conducted using appropriate routes of administra-
tion which relate to the potential route of human exposure. However, in practice, reproductive toxic-
ity studies are commonly conducted using the oral route, and such studies will normally be suitable
for evaluating the hazardous properties of the substance with respect to reproductive toxicity. How-
ever, if it can be conclusively demonstrated that the clearly identified mechanism or mode of action
has no relevance for humans or when the toxicokinetic differences are so marked that it is certain that
the hazardous property will not be expressed in humans then a substance which produces an adverse
effect on reproduction in experimental animals shall not be classified.
3.7.2.5.6      Studies involving routes of administration such as intravenous or intraperitoneal injec-
tion, which result in exposure of the reproductive organs to unrealistically high levels of the test sub-
stance, or elicit local damage to the reproductive organs, including irritation, must be interpreted with
extreme caution and on their own are not normally the basis for classification.
3.7.2.5.7      There is general agreement about the concept of a limit dose, above which the produc-
tion of an adverse effect is considered to be outside the criteria which lead to classification, but not
regarding the inclusion within the criteria of a specific dose as a limit dose. However, some guide-
lines for test methods, specify a limit dose, others qualify the limit dose with a statement that higher
doses may be necessary if anticipated human exposure is sufficiently high that an adequate margin of
exposure is not achieved. Also, due to species differences in toxicokinetics, establishing a specific
limit dose may not be adequate for situations where humans are more sensitive than the animal
model.
3.7.2.5.8      In principle, adverse effects on reproduction seen only at very high dose levels in animal
studies (for example doses that induce prostration, severe inappetence, excessive mortality) would
Regulation (EC) 1272/2008 of the European Community                                                       53
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<pre>              not normally lead to classification, unless other information is available, e.g. toxicokinetics informa-
              tion indicating that humans may be more susceptible than animals, to suggest that classification is
              appropriate. Please also refer to the section on maternal toxicity (3.7.2.4) for further guidance in this
              area.
              3.7.2.5.9      However, specification of the actual ‘limit dose’ will depend upon the test method that
              has been employed to provide the test results, e.g. in the OECD Test Guideline for repeated dose tox-
              icity studies by the oral route, an upper dose of 1 000 mg/kg has been recommended as a limit dose,
              unless expected human response indicates the need for a higher dose level.
              3.7.3          Classification criteria for mixtures
              3.7.3.1        Classification of mixtures when data are available for all ingredients or only for some
              ingredients of the mixture
              3.7.3.1.1      The mixture shall be classified as a reproductive toxicant when at least one ingredient
              has been classified as a Category 1A, Category 1B or Category 2 reproductive toxicant and is present
              at or above the appropriate generic concentration limit as shown in Table 3.7.2 for Category 1A, Cat-
              egory 1B and Category 2 respectively.
              3.7.3.1.2      The mixture shall be classified for effects on or via lactation when at least one ingredi-
              ent has been classified for effects on or via lactation and is present at or above the appropriate generic
              concentration limit as shown in Table 3.7.2 for the additional category for effects on or via lactation.
 able 3.7.2 Generic concentration limits of ingredients of a mixture classified as reproduction toxicants or foreffects on or via
actation that trigger classification of the mixture.
 ngredient classified as:     Generic concentration limits triggering classification of a mixture as:
                              Category 1A                Category 1B               Category 2                Additional category
                              reproductive toxicant reproductive toxicant reproductive toxicant for effects on or via l
                                                                                                             actation
Category 1A                   ≥ 0,3 %
 eproductive toxicant         [Note 1]
  ategory 1B                                             ≥ 0,3 %
eproductive toxicant                                     [Note 1]
Category 2                                                                         ≥ 3,0 %
 eproductive toxicant                                                              [Note 1]
Additional category                                                                                          ≥ 0,3 %
or effects on or via                                                                                         [Note 1]
actation
  ote The concentration limits in the table above apply to solids and liquids (w/w units) as well as gases (v/v units).
  ote 1 If a Category 1 or Category 2 reproductive toxicant or a substance classified for effects on or via lactation is present in
he mixture as an ingredient at a concentration above 0,1 %, a SDS shall be available for the mixture upon request.
  4           Cytarabine
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<pre>3.7.3.2        Classification of mixtures when data are available for the complete mixture
3.7.3.2.1      Classification of mixtures will be based on the available test data for the individual
ingredients of the mixture using concentration limits for the ingredients of the mixture. On a case-by-
case basis, test data on mixtures may be used for classification when demonstrating effects that have
not been established from the evaluation based on the individual components. In such cases, the test
results for the mixture as a whole must be shown to be conclusive taking into account dose and other
factors such as duration, observations, sensitivity and statistical analysis of reproduction test systems.
Adequate documentation supporting the classification shall be retained and made available for review
upon request.
3.7.3.3        Classification of mixtures when data are not available for the complete mixture:
               bridging principles
3.7.3.3.1      Subject to paragraph 3.7.3.2.1, where the mixture itself has not been tested to determine
its reproductive toxicity, but there are sufficient data on the individual ingredients and similar tested
mixtures to adequately characterise the hazards of the mixture, these data shall be used in accordance
with the applicable bridging rules set out in section 1.1.3.
3.7.4          Hazard Communication
3.7.4.1        Label elements shall be used for substances or mixtures meeting the criteria for
               classification in this hazard class in accordance with Table 3.7.3
Regulation (EC) 1272/2008 of the European Community                                                        55
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<pre> able 3.7.3 Label elements for reproductive toxicity.
 lassification              Category 1A or Category 1B              Category 2                              Additional category
                                                                                                            for effects on or via
                                                                                                            lactation
GHS Pictograms                                                                                              No pictogram
 ignal Word                 Danger                                  Warning                                 No signal word
Hazard Statement            H360: May damage fertility or the       H361: Suspected of damaging fertil-     H362: May cause
                            unborn child (state specific effect if  ity or the unborn child (state specific harm to breast-fed
                            known)(state route of exposure if it is effect if known) (state route of expo-  children.
                            conclusively proven that no other       sure if it is conclusively proven that
                            routes of exposure cause the hazard)    no other routes of exposure cause the
                                                                    hazard)
 recautionary Statement     P201                                    P201                                    P201
 revention                  P202                                    P202                                    P260
                            P281                                    P281                                    P263
                                                                                                            P264
                                                                                                            P270
 recautionary Statement     P308 + P313                             P308 + P313                             P308 + P313
 esponse
 recautionary Statement     P405                                    P405
 torage
 recautionary Statement     P501                                    P501
Disposal
 6            Cytarabine
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<pre>nnex E
     Additional considerations to
     Regulation (EC) 1272/2008
     The classification and labelling of substances is performed according to the
     guidelines of the European Union (Regulation (EC)1272/2008) presented in
     Annex D. The classification of compounds 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 guideline necessarily leaves room for interpretation, dependent
     on the specific data set under consideration. In the process of using the
     regulation, 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 offspring, the compound will be classified
         in category 1A, irrespective of the general toxic effects (see Annex D,
         3.7.2.2.1.).
     • Adverse effects in a reproductive study, occurring without reporting the
         parental or maternal toxicity, may lead to a classification other than category
         1B, when the effects occur at dose levels which cause severe toxicity in
         general toxicity studies.
     • Clear adverse reproductive effects will not be disregarded on the basis of
         reversibility per se.
     Additional considerations to Regulation (EC) 1272/2008                              57
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<pre>  •   The committee dot not only use guideline studies (studies performed
      according to OECD* standard protocols) for the classification of compounds,
      but non-guideline studies are taken into consideration as well.
   Organisation for Economic Cooperation and Development.
8 Cytarabine
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<pre> nnex          F
               Fertility and developmental toxicity
               studies
 able 1 Fertility studies in animals with cytarabine.
Authors        Species          Experimental period/design Dose and route General      Effects on reproductive organs/
                                                                            toxicity   effects on reproduction
Male fertility
 alo et al., Swiss albino       - Cytarabine was given once Single i.p.     No data on - Statistically significant and dose-
 009           mice, 8-10 wk to groups of six male mice. injection,         general    dependent increases in percentage of
               old              - Spermatocytic analysis at 0, 100, 150 and toxicity.  aberrant spermatogonial metaphases
                                24 h and 4 wk post-         200 mg/kg bw.              and chromosomal aberrations at 24 h
                                treatment.                                             post-treatment.
                                - Sperm morphology assay                               - Statistically significant and dose-
                                at 8 wk post-treatment.                                dependent increases in percentages of
                                                                                       aberrant primary spermatocytes at wk
                                                                                       4 post-treatment at all three dose
                                                                                       levels.
                                                                                       - The percentage of abnormal sperm
                                                                                       at wk 8 post-treatment was, however,
                                                                                       not statistically significantly affected.
 emale fertility
No data available
               Fertility and developmental toxicity studies                                                                  59
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<pre> able 2 Developmental studies in animals with cytarabine.
Authors     Species     Experimental period/ Dose and         General       Developmental toxicity
                        design                  route         toxicity
 tructural defects
  itter     Wistar rats Cytarabine was          Single i.p.   No data on    - The percentage of malformations was 2% in
 t al.,     Albino      administered to         injection,    maternal      controls, 16% in low-, 67% in mid- and 85% in
 971        Farms stock pregnant Wistar rats on 0, 15, 50,    toxicity.     high-dose group (no p-values reported).
                        gd 12. Pregnancy was 100 or 200                     - The principal external malformations were
                        terminated on gd 20.    mg/kg bw                    ectrodactyly, brachydactyly, syndactyly, cleft
                        Embryos examined                                    palate, clubfoot and kinky tail.
                        were 74-101 in each                                 - Internal abnormalities (hydrocephalus,
                        treatment group and                                 hydronephrosis, diaphragmatic hernia and genital
                        477 in controls.                                    defects) occurred occasionally, particularly at high
                                                                            dosage.
Manson      Swiss-Cox Cytarabine was            Single i.p. No data on      - There was a dose related increase in both
 t al.,     albino mice administered to         injection of maternal       forelimb and hindlimb malformations.
 977                    pregnant mice at        0, 10, 20 or toxicity.      - Limbs were maximally sensitive to cytarabine
                        various times on gd 10  40 mg/kg                    between gd 10 (9 p.m.) and gd 11 (9 a.m.).
                        - gd 12.                bw.                         - Malformations (adactylous limbs with distally
                        The dams were killed                                located blisters) ranged from 13%-100%,
                        on gd 18.                                           depending on the dose and time of exposure.
                        The number of litters
                        examined was 18 in
                        controls and 2-4 in the
                        various groups at the
                        various stages.
Kochhar     1CR mice Cytarabine was             Single i.p.   Injection of  - Embryo lethality depended on the dose level and
 t al.,                 administered to 265     injection of  the mother    stage of injection; e.g. a dose of 100 or 200 mg/kg
 978                    pregnant mice on gd     0, 2, 10, 25, with levels   bw was completely embryo lethal during gd 10.5-
                        10, 10.5, 11, 11.5, 12, 50, 100 or    up to 200     12, whereas 2 or 10 mg/kg bw produced almost no
                        12.5, 13, 14 or 16.     200 mg/kg     mg/kg bw at   resorptions at any stage.
                        Dams were killed on     bw.           any time      - Limb defects were induced during gd 10.5-12.5,
                        gd15 or gd 18.                        between       not by treatment before or after this period. The
                                                              gd10.5-12     effective dose was ≥10 mg/kg bw. The dose of 2
                                                              did not cause mg/kg bw was completely without effect. The
                                                              ‘any physical limb defects were micromelia, phocomelia,
                                                              distress’.    hemimelia, ectrodactyly, polydactyly and
                                                                            adactyly.
                                                                            - Depending on the dose and time of injection,
                                                                            other defects included stunted growth, cleft palate,
                                                                            fusions of the vertebral bodies and of ribs,
                                                                            shortened abnormal tails, and micrognathia (both
                                                                            maxilla and mandible).
  0           Cytarabine
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<pre>Gray    CD-1 mice Cytarabine was           Repeated      No data on    - Mortality in cytarabine-exposed offspring was
 t al.,             administered to groups i.p.          maternal      considerably increased due to a failure of the
 996                of 4-12 pregnant CD-1  injection 0 toxicity.       lower incisors to develop. Many cytarabine-
                    mice on gd 14 and gd   or 30 mg/                   treated mice had narrow flattened skulls and some
                    15. At least one/sex/  kg bw/d.                    mice had thin cerebral hermispheres (no further
                    litter was tested in a                             details were given).
                    figure-eight maze.
        CD-1 mice In a second experiment,  Repeated      No data on    - No live pups were born to dams in the gd 8-9 and
                    cytarabine was         i.p.          maternal      10-11 treatment groups. All pups were resorbed in
                    administered to groups injection 0 toxicity.       the gd 8-9 group, while a few malformed pups
                    of 11-30 pregnant CD-  or 30 mg/                   were born in the gd 10-11 group (p<0.01).
                    1 mice on gd 8-9, gd   kg bw/d.                    - Growth was retarded by 25% (not statistically
                    10-11, gd 14-15 and gd                             significant) in offspring in the gd 14-15 group and
                    17-18.                                             unaffected in the gd 17-18 group.
Ortega  Swiss mice Cytarabine was          Repeated      - All dams    - NOAEL for maternal toxicity: 0.5 mg/kg bw/d.
 t al.,             administered to        i.p injection survived to   - Developmental NOAEL: <0.5 mg/kg bw/d.
 991                pregnant Swiss mice    of 0, 0.5, 2  their         - Increased number of early and late resorptions/
                    (13-15/group) on days  or 8 mg/kg    scheduled     litter (p<0.001 and p<0.05, respectively) and
                    6-15 of gestation.     bw/d on gd    termination   decreased number of life foetuses at 8 mg/kg bw/d
                    Dams were killed on gd 6-gd 15.      on gd 18.     (p<0.001). No effects on implantations,
                    18.                                  - There were  resorptions or viability at 0.5 and 2 mg/kg bw/d.
                                                         no abortions  - statistically significant dose-related decrease of
                                                         or early      foetal body weights in all treatment groups.
                                                         deliveries.   - Increased number of stunted foetuses at 8 mg/kg
                                                         - Maternal    bw/d (p<0.05).
                                                         body weight   - External examination revealed phocomelia and
                                                         gain and feed short or absent tail in all foetuses of the 8 mg/kg
                                                         intake during bw/d group (p<0.001 in both cases).
                                                         the treatment - Increased total incidence of soft tissue defects at
                                                         period was    2 and 8 mg/kg bw/d; cleft palate and dilatation of
                                                         reduced at 2  cerebral ventricles were the main findings.
                                                         and 8 mg/kg   - At 8 mg/kg bw/d, skeletal malformations
                                                         bw/d.         consisted of severe general retardation,
                                                         - On gd 18,   incomplete ossification of the skull bones, fused
                                                         maternal      and fragmented ribs, split vertebral arches, bifid
                                                         body weight   vertebral centra and partial or complete absence of
                                                         and gravid    limb bones.
                                                         uterine       - At 0.5 and 2 mg/kg bw skeletal maturation was
                                                         weight was    reduced (especially decreased numbers of ossified
                                                         reduced at 8  sacrococcygeal vertebrae (p<0.05 at both doses)
                                                         mg/kg bw/d.   as well as decreased percentage of foetuses with
                                                                       ossified calcaneus (p<0.05 and p<0.001,
                                                                       respectively).
Rahman  Jcl:ICR     Cytarabine was         Single i.p.   No data on    - The body weights of newborns were similar in
 t al., mice        administered to groups injection,    maternal      the treatment and control group.
 994                of 8 or 12 pregnant    0 or 5        toxicity.     - The incidence of external digit abnormalities
                    mice on gd 10.5.       mg/kg bw.                   (oligodactyly or polydactyly) of forelimbs and
                    Skeletal changes in                                hindlimbs was about 50% and 20%, respectively,
                    offspring were                                     versus 0 in controls.
                    evaluated on pnd 15 or                             - Increased incidence of abnormalities of carpal or
                    pnd 24.                                            tarsal bones (fusion, absence or deformation) in
                                                                       the offspring of treated mice.
         Fertility and developmental toxicity studies                                                                    61
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<pre>  hiang    Swiss        Cytarabine was          Single i.p.  No data on - Increased incidence of resorptions and dead
 t al.,    Webster      administered to groups  injection,   maternal   foetuses (20% versus 5% in controls).
 995       mice         of 22 or 24 pregnant    0 or 10      toxicity.  - Increased incidence of cleft palate and/or cleft lip
                        mice on                 mg/kg bw.               (26% versus 2.6% in controls).
                        gd 9.                                           - Decreased length of the foetuses in the treatment
                        Dams were killed on gd                          group,
                        18.                                             - Increased incidence of minor skeletal variations
                                                                        (reduction of skeletal calcification) in the
                                                                        treatment group.
  ahman    Jcl:ICR      Cytarabine was          Single i.p. No data on  - The number of foetuses per dam and body
 t al.,    mice         administered to groups  injection, maternal     weights of newborns was similar in the treatment
 996                    of 6 to 10 pregnant     0, 0.5, 1 or toxicity.  groups and controls.
                        mice                    2 mg/kg                 - The relatively low doses induced carpal and
                        on gd 10.5              bw.                     tarsal bone abnormalities (mostly fusions, ranging
                        Skeletal changes in                             from 19% in the low-dose group (p<0.01) to 88%
                        offspring were                                  in the high-dose group(p<0.01)), without
                        evaluated on pnd 15.                            producing any other external or skeletal
                                                                        abnormalities.
Chiba      Jcl:ICR      Cytarabine was to       Single i.p.  No data on - A 30% incidence of hip joint anomalies was
 t al.,    mice         pregnant mice on gd 8,  injection,   maternal   observed only in the group exposed to 7.5 mg/kg
 996                    9.5 or 11.              0, 5 or 7.5  toxicity.  bw on gd 9.5 (increase not statistically
                        The offspring was       mg/kg bw.               significant). The types observed were: femoral
                        killed on pnd 24.                               shaft dysplasia, pseudo arthrosis of the femur,
                                                                        femoral head dysplasia, acetabular dysplasia,
                                                                        fusion between the femoral head and acetabulum
                                                                        and pseudo arthrosis of the coxal bone.
                                                                        - 23% of the newborn in this group showed
                                                                        oligodactyly.
CNS structural defects
Adlard     Rats of the  Cytarabine was          Single i.p.  No data on - Statistically significant reductions in birth weight
 t al.,    Lister black administered to         injection,   maternal   (-14%, p<0.001)), brain weight at birth (-17%,
 975       and white    pregnant rats on        0 or 50      toxicity.  p<0.001)) and brain/body weight ratio (-9%,
           hooded       gd 14.                  mg/kg bw.               p<0.001)).
           strain       At birth, litters were                          - The brain weight deficit at birth reflected a
                        reduced to 8 pups for                           deficit in number of brain cells as assessed by total
                        follow-up.                                      DNA.
                         Effects of cytarabine                          - At pnd 25, a 22% deficit in brain weight
                        were evaluated in                               (p<0.001) with no significant effect on body
                        offspring at birth, on                          weight was noted. Adult, 15 wk old, male
                        pnd 25 and in adult (15                         offspring of treated mothers also showed
                        wk old) offspring.                              microcephaly, in that brain weight was reduced by
                                                                        15% (p<0.001) while body weight was normal.
                        Depending on the                                - Adult offspring of treated mothers showed
                        effect investigated,                            impairment in discrimination learning when tested
                        group sizes varied                              in a water T-maze (p<0.01) (see below).
                        between 11-39
                        offspring rats/group.
  2          Cytarabine
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<pre>Kasubuchi Swiss ICR- Cytarabine was              Single or   No data on - Within six hours after the first injection, pyknotic
 t al.,   JCL mice administered to               repeated    maternal   nuclei and nuclear debris were found at the matrix
 977                   pregnant mice as a        i.p.        toxicity.  layer surrounding the lateral ventricles. Most of
                       single dose on gd 13 (8   injection,             the matrix cells were killed by the treatment.
                       mice), or twice on gd     30 mg/kg               - 24 h after the second injection, most of the
                       13 and gd 14 (16 mice).   bw(/d).                matrix cells had disappeared.
                       Embryos were                                     - Offspring examined after birth showed marked
                       examined within 24 h                             dilatation of the lateral ventricles, especially in the
                       after last injection.                            parieto-occipital region.
                       In addition, offspring of                        - From pnd15, all offspring showed gradual
                       6 mice were examined.                            increase of the cranial vault and subsequently died
                                                                        by 35 days of age.
 himada   Swiss ICR- Cytarabine was              Repeated    No data on - Severe damage in the matrix layer in embryonic
 t al.,   JCL mice administered to.              i.p.        maternal   brains examined on gd15 (regenerated partly on
 982                   pregnant mice on gd       injection   toxicity.  gd17).
                       13.5 and gd 14.5.         with 30 mg/            - Pronounced microcephaly in offspring
                       Embryos of 6 mice         kg bw/d.               examined from pnd 20.
                       were examined on                                 - Abnormal clusters of young neurons on the
                       gd15, 16, 17 and 18. 5-                          surface of the developing cerebral cortex in
                       7 offspring of 15 mice                           offspring examined on pnd 1, 3 or 5 (After pnd20
                       were killed on pnd 1, 3,                         the clusters gradually became indistinct).
                       7, 10, 20, 30, 60 and                            - Severe cytoarchitectural abnormalities in the
                       120.                                             hippocampus of young mice.
Matsutani Wistar-      Cytarabine was            Single i.p. No data on - Significantly (15%) reduced terminal body
 t al.,   Imamichi     administered to           injection,  maternal   weight in offspring of treated rats.
 983.     rats         pregnant rats on gd 15.   0 or 280    toxicity.   - Significantly decreased weight of the cerebral
                       Male offspring (5-8 per   mg/kg bw.              hemisphere, brain stem and cerebellum (60%,
                       group) were examined                             75% and 89% of controls, respectively).
                       on pnd 60.                                       - Decreased DNA content (mg/region) in the brain
                                                                        stem and cerebellum (20% and 10%,
                                                                        respectively).
                                                                        - Significant rise in norepinephrine, dopamine and
                                                                        serotonin levels (almost two times the control
                                                                        value).
 ercy,    ICR Swiss    Cytarabine was            Repeated    No data on - High mortality of offspring rats at 25 (24%) and
 999      mice         administered to           s.c.        maternal   50 mg/kg bw/d (70%).
          Sprague      pregnant mice on gd       injection, toxicity.   - Dose-related segmental cerebellar hyperplasia in
          Dawley rats  16, 17 and 18 and to      12.5, 25 or            mice at 25 and 50 mg/kg bw/d and in rats of all
                       pregnant rats on gd 18,   50 mg/kg               dose groups.
                       19 and 20                 bw/d.                  - Focal microcystic renal cortical dysplasia in
                       - Surviving offspring                            mice at 25 and 50 mg/kg bw/d and in rats of all
                       (17- 57 per group) was                           dose groups.
                       killed on pnd 10 or pnd                          - Retinal dysplasia in rats at 50 mg/kg bw/d.
                       20.
                       - No data in concurrent
                       controls were reported.
            Fertility and developmental toxicity studies                                                                    63
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<pre> akano      ICR strain   Cytarabine was          Repeated     No data on - Cytarabine disturbed the DNA replication and
 t al.,     mice         administered to         i.p.         maternal   migration of neuroepithelial cells in the
 006                     pregnant mice (n=12     injection    toxicity.  ventriculate zone (BrdU-labelling, p<0.001) on
                         treated and 4 controls) with 0 or 30            pnd 15.5.
                         on gd 13.5 and gd 14.5. mg/kg                   - Nestin-immunoreactive radial glial fibres and
                         The pathogenesis of     bw/d.                   calretinin-positive subplate fibres were disrupted.
                         grey matter heterotopia                         - TUNEL-reaction (detection of cells containing
                         and microcephaly was                            fragmented DNA) throughout the cerebral
                         examined in offspring                           hemisphere (p<0.01).
                                                                         - Subcortical heterotopia in the cingulate cortex
                                                                         and subependymal nodular heterotopia in the
                                                                         dorsolateral part of the lateral ventricles was
                                                                         detectable on pnd 1.
                                                                         - On pnd 32, microcephaly was apparent and
                                                                         subcortical heterotopia was observed to have
                                                                         increased in size.
                                                                         - The authors concluded that cytarabine induces
                                                                         neuronal apoptosis throughout the cerebral
                                                                         hemisphere.
  ognitive defects
Adlard      Rats of the  Cytarabine was          Single i.p. No data on  - Adult offspring of treated mothers showed an
 t al.,     Lister black administered to         injection, maternal     impairment in discrimination learning when tested
 975        and white    pregnant rats on        0 or 50 mg/ toxicity.   in a water T-maze (p<0.01).
            hooded       gd 14.                  kg bw.
            strain       Adult offspring were
                         tested (11 or 12 males/
                         group).
Gray        CD-1 mice Cytarabine was             Repeated     No data on - Cytarabine exposed offspring showed
 t al.,                  administered to groups  i.p.         maternal   significantly increased locomotor activity
 986                     of 4-12 pregnant CD-1   injection 0 toxicity.   (hyperactivity) on pnd 22 (100% increase, p<0.05)
                         mice on gd 14 and gd    or 30 mg/               and pnd 58 (43% increase, p<0.05).
                         15. At least one/sex/   kg bw/d.                - Cytarabine-exposed mice (85 days of age) were
                         litter was tested in a                          significantly more aggressive (in a ‘latency to
                         figure-eight maze.                              attack the intruder test’).
            CD-1 mice In a second experiment,    Repeated     No data on - No live pups were born to dams in the gd 8-9 and
                         cytarabine was          i.p.         maternal   gd 10-11 treatment groups.
                         administered to groups  injection 0 toxicity.   - Offspring (n=12) in the gd 14-15 group showed
                         of 11-30 pregnant CD-   or 30 mg/               significantly increased locomotor activity on pnd
                         1 mice on gd 8-9, gd    kg bw/d.                22 (p<0.001).
                         10-11, gd 14-15 and gd                          - Locomotor activity in offspring in the gd 17-18
                         17-18.                                          group (n=10) was unaffected.
  4           Cytarabine
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<pre>  lmer     Sprague       Cytarabine was       Repeated     No data on    - Disruption of the pyramidal cell layer in the
 t al.,    Dawley rats administered to        i.p.         maternal      hippocampus was noted in cytarabine-exposed
 004                     pregnant rats on gd  injection    toxicity.     offspring.
                         19.5 and gd 20.5.    with 0 or 30               - On pnd 35 no statistically significant
                         Groups of 14-26      mg/kg                      neurocognitive changes were observed.
                         offspring were       bw/d.                      - On pnd 56, cytarabine-exposed offspring had
                         subjected to                                    significantly lower acoustic startle amplitudes
                         sensorimotor                                    (acoustic startle test) (p=0.002, p=0.039) and
                         assessment on pnd 35                            significantly diminished sensorimotor gating
                         or pnd 56                                       (prepulse inhibition of the acoustic startle
                                                                         response) (p<0.025).
 w=body weight(s); BrdU=5-bromodeoxyuridine; CNS=central nervous system; d=day(s); gd=gestational day; h=hour(s);
.p.=intraperitoneal; n=number; NOAEL=no observed adverse effect level; pnd=post-natal day; s.c.=subcutaneaous;
wk=week(s)
             Fertility and developmental toxicity studies                                                                65
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<pre>6 Cytarabine</pre>

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<pre>Health Council of the Netherlands
Advisory Reports
The Health Council’s task is to       In addition, the Health Council
advise ministers and parliament on    issues unsolicited advice that
issues in the field of public health. has an ‘alerting’ function. In some
Most of the advisory opinions that    cases, such an alerting report
the Council produces every year       leads to a minister requesting
are prepared at the request of one    further advice on the subject.
of the ministers.
Areas of activity
Optimum healthcare                    Prevention                          Healthy nutrition
What is the optimum                   Which forms of                      Which foods promote
result of cure and care               prevention can help                 good health and
in view of the risks                  realise significant                 which carry certain
and opportunities?                    health benefits?                    health risks?
Environmental                         Healthy working                     Innovation and
health                                conditions                          the knowledge
Which environmental                   How can employees                   infrastructure
influences could have                 be protected against                Before we can harvest
a positive or negative                working conditions                  knowledge in the
effect on health?                     that could harm their               field of healthcare,
                                      health?                             we first need to
                                                                          ensure that the right
                                                                          seeds are sown.
www.healthcouncil.nl
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