Do cytostatic drugs reach drinking water? The case of mycophenolic acid

Occurrence of pharmaceutical residues in drinking water: a systematic review

The aim of the present paper was to give a complete picture on the drinking water contamination by pharmaceutical residues all over the world. For this purpose, a systematic review was carried out for identifying all available research reporting original data resulting by sampling campaign and analysis of "real" drinking water samples to detect pharmaceutical residues. The investigated databases were PubMed, Scopus, and Web of Science. A total of 124 studies were included; among these, 33 did not find target analytes (all below the limit of detection), while the remaining 91 studies reported the presence for one or more compounds, in concentrations ranging from a few units to a few tens of nanograms. The majority of the studies were performed in Europe and the most represented categories were nonsteroidal anti-inflammatory drugs and analgesics. The most common analytical approach used is the preparation and analysis of the samples by solid-phase extraction and chromatography coupled to mass spectrometry. The main implications resulting from our review are the need for (a) further studies aimed to allow more accurate environmental, wildlife, and human health risk assessments and (b) developing integrated policies promoting less environmentally persistent drugs, the reduction of pharmaceuticals in livestock breeding, and the update of wastewater and drinking water treatment plants for a better removal of drugs and their metabolites.

Tackling water contamination by oncologic drugs: Supported ionic liquids as sustainable adsorbents for cyclophosphamide removal

Due to the increasing incidence of cancer, the consumption of highly toxic oncological drugs is continuously growing. Given the current lack of efficient technologies to remove/treat these toxic drugs in wastewater treatment plants, the environmental quality is compromised, and aquatic organisms are at risk. To address this critical environmental burden, a new strategy based on supported ionic liquids (SILs) for the simultaneous removal of oncologic drugs and toxicity reduction of aqueous samples is here proposed. Silica-based SILs functionalized with imidazolium-based and quaternary ammonium-based ILs were designed and kinetics and isotherm adsorption studies performed. Aiming to develop an adsorbent able to reduce the toxicity of aqueous samples contaminated with oncological drugs, the toxicity reduction was appraised using the model organism Danio rerio. The obtained results disclose that among the studied SILs, the [Si][N3888]Cl (silica functionalized with propyltrioctylammonium chloride) is the best adsorption material (maximum adsorption capacity, qmax = 67.64 mg g-1), with a fast adsorption rate (<20 min). Furthermore, [Si][N3888]Cl was able to remove the toxicity of the treated aqueous samples towards D. rerio embryos, as assessed by lethal and several sublethal endpoints, demonstrating that this material holds remarkable potential for oncological drugs pollution remediation.

Predicted concentrations of antineoplastic drugs in the aquatic environment: The case of Ría de Vigo (NW, Spain)

The European Medicines Agency (EMA) mandates Environmental Risk Assessments (ERAs) since 2006 to determine potential risks of new marketed medicines. Drugs with a Predicted Environmental Concentration (PEC) in inland surface waters exceeding 0.01 μg L-1 require further environmental risk assessment. PEC may be refined based on prevalence data and/or based on the treatment regimen. In this study, based on EMA regulations, refined PEC of 108 antineoplastic drugs in coastal waters were determined based on the consumption in a coastal health area during 2021, identifying six drugs with potential environmental risk in surface waters (hydroxyurea, capecitabine, abiraterone, ibrutinib, imatinib and 5-fluorouracil) and two in marine ecosystem (hydroxyurea and capecitabine). Comparison of these refined PECs with data from marketing laboratories revealed significant disparities, suggesting the need for regular updates, especially with changes in drug indications or financing. Notably, the identified drugs are not yet on the main reference lists of emerging contaminants.

Anticancer drugs in wastewater and natural environments: A review on their occurrence, environmental persistence, treatment, and ecological risks

The consumption of anticancer drugs (also known as chemotherapy drugs or antineoplastic drugs) has augmented over the last decades due to increased cancer incidence. Although there is an increasing concern about the presence of pharmaceutical compounds in natural environments and urban/domestic wastewater, anticancer drugs used in chemotherapy and anticancer medication have received less attention. In this review, the occurrence, environmental persistence, and known and potential ecological impacts of anticancer drugs is discussed. This review shows that these compounds are being increasingly detected in effluents of hospitals, influents and effluents of wastewater treatment plants, river surface water and sediments, groundwater, and even drinking water. Anticancer drugs can impact aquatic organisms such as algae, crustaceans, rotifers, and fish and may promote changes in soil and water microbial communities that may alter ecosystem functioning. Our knowledge of technologies for the removal of anticancer drugs is still limited, and these drugs can be dispersed in nature in a diffuse way in an uncontrolled manner. For this reason, an improved understanding of the presence, persistence, and ecological impacts of anticancer drugs in wastewater and natural environments is needed to help design management strategies, protect aquatic microorganisms, and mitigate potential ecological impacts.

Contributions towards the hazard evaluation of two widely used cytostatic drugs

Cytostatic drugs are one of the most important therapeutic options for cancer, a disease that is expected to affect 29 million individuals by 2040. After being excreted, cytostatics reach wastewater treatment plants (WWTPs), which are unable to efficiently remove them, and consequently, they will be released into the aquatic environment. Due to the highly toxic properties of cytostatics, it is particularly relevant to evaluate their potential ecological risk. Yet, cytostatics toxicity data is still not available for various species. In this work, the ecotoxicity of two widely consumed cytostatics, cyclophosphamide (CYP-as a model cytostatic) and mycophenolic acid (MPA-as a priority cytostatic), was evaluated on three freshwater species-Raphidocelis subcapitata, Brachionus calyciflorus, and Danio rerio, and the risk quotient (RQ) was assessed. Both drugs significantly affected the yield and growth inhibition of the microalgae, while for rotifers, the least sensitive species, only significant effects were registered for CYP. These drugs also caused significant effects on the mortality and morphological abnormalities on zebrafish. The estimation of the RQ discloses that CYP seems to pose a low risk to aquatic biota while MPA poses a very high risk. Altogether, these results emphasize the need for more complete environmental risk assessments, to properly prioritize and rank cytostatics according to their potentially toxic effects on the environment and aquatic biota.

Are cytostatic drugs in surface waters a potential threat?

Cytostatic drugs are pharmaceuticals administered to cancer patients under chemotherapy. Their occurrence in surface waters has been reported worldwide, increasing environmental and human health concerns. This work addresses a question of worldwide interest: are these hazardous pharmaceuticals in surface waters a potential threat? For the first time, this study brings information on the presence of cytostatic drugs in Portuguese rivers. Furthermore, cutting-edge data on the occurrence of two cytostatic drugs is provided; up to the authors' best knowledge, flutamide and mycophenolate mofetil have never been monitored in worldwide surface waters. Nine out of thirteen cytostatic drugs were detected in Portuguese rivers. Despite bicalutamide being the cytostatic most frequently detected, the highest concentration was recorded for cyproterone (19 ± 3 ng/L). Three different scenarios were considered to estimate the risks from the exposure of humans to cytostatic drugs via surface waters. Two scenarios are associated with bathing practices in rivers, particularly in the spring and summer seasons (river beaches): (i) the exposure to cytostatic drugs by dermal contact with contaminated water and (ii) the exposure by accidental ingestion of contaminated water, which is less likely but also occurs. The third exposure scenario is related to (iii) the long-life consumption of drinking water produced from river water capture, under worst-case conditions, i.e. negligible degradation of cytostatic drugs at drinking water treatment plants. It was concluded that the third exposure context to cytostatics could represent a risk to children, if the highest concentration ever reported in the literature for cyclophosphamide in surface waters is considered. Still, attending to the carcinogenicity of some of these compounds (e.g., cyclophosphamide, chlorambucil, etoposide and tamoxifen), health risks might always be expected, regardless of the contamination level. Furthermore, health risks associated with synergic effects and/or long-term exposures cannot be ruled out, even for the remaining cytostatics/exposure contexts.

Long-Term Calculation of Predicted Environmental Concentrations to Assess the Risk of Anticancer Drugs in Environmental Waters

This study reports the consumption data for 132 anticancer drugs in Catalonia (NE Spain) during the period of 2013-2017 and calculates the predicted environmental concentrations (PECs) in wastewater effluents and rivers. This long-term analysis can determine the evolution of drugs present in the environment according to prescriptions and serve as an adequate tool to determine their presence and impact. Data showed that out of 132 compounds prescribed, 77 reached wastewater effluents, which accounted for the most consumed, those excreted in the highest doses, and the least biodegradable. Once diluted in receiving river waters, only mycophenolic acid and hydroxycarbamide had PEC values higher than 10 ng L-1, which is the value set by the European Medicines Agency (EMA) to carry out further risk assessment. It was also observed that compounds present in river water are those that can pose a high risk, given their persistence and capability to bioaccumulate. Therefore, this study shows that the estimation of PEC, together with physico-chemical properties of detected compounds, is a useful tool to determine the long-term presence and fate of this new class of emerging contaminants.

Anticancer drugs in the aquatic ecosystem: Environmental occurrence, ecotoxicological effect and risk assessment

Anticancer drugs are a group of therapeutic agents used to enhance cell death in targeted cell types of neoplasia. Because of frequent use and eventual discharge, they have been often detected in wastewater from pharmaceutical factories and hospitals, domestic wastewater, and surface waters. The occurrence of these drugs in aquatic ecosystems and their effects on aquatic organisms have been poorly characterized. This review focuses on the global occurrence of major classes of anticancer drugs in water and sediments of freshwater ecosystems and their ecotoxicological effects at different biological levels. While the availability of data is fairly limited, concentrations of most anticancer drugs range from < 2 ng/L to 762 µg/L in receiving water, while levels in sediments and sludge vary from 0.25 to 42.5 µg/kg. Their detection frequencies were 58%, 52% (78%) and 59% in hospital wastewater, wastewater treatment plant effluents (influents) and surface water, respectively. Predicted log K_ow values of vincristine, imatinib mesylate and tamoxifen are higher than 3 and have estimated half-lives>60 d in waters using quantitative structure-activity relationship models, indicating high potential for persistence and bioaccumulation. Based on a species sensitivity distribution evaluation of 9 compounds, crustaceans are most sensitive to anticancer drugs. The most hazardous compound is cisplatin which has a hazard concentration at the 5th percentile. For Daphnia magna, the acute toxicities of major classes of anticancer drugs are ranked as platinum complexes > endocrine therapy agents > antibiotics > antimetabolite agents > alkylating agents. Using hazard quotient analysis based primarily on the lowest observed effect concentrations (LOECs), cyclophosphamide, cisplatin, 5-fluorouracil, imatinib mesylate, bicalutamide, etoposide and paclitaxel have the highest hazard for aquatic organisms. Further research is needed to identify appropriate chronic endpoints for risk assessment thresholds as well as to better understand the mechanisms of action and the potential multigenerational toxicity, and trophic transfer in ecosystems.

Photolytic fate of (E)- and (Z)-endoxifen in water and treated wastewater exposed to sunlight

Endoxifen is the main active metabolite of a common cytostatic drug, tamoxifen. Endoxifen has been recently detected in the final effluent of municipal wastewater treatment plants. The antiestrogenic activity of endoxifen could bring negative effects to aquatic life if released to the water environment. This study elucidated the fate and susceptibility of (E)- and (Z)-endoxifen (2 μg mL^-1, 1:1 wt ratio between the two easily interchangeable isomers) in wastewater and receiving surface water to sunlight. Phototransformation by-products (PBPs) and their toxicity were determined. Sunlight reduced at least 83% of endoxifen concentration in wastewater samples, whereas in surface water samples, 60% of endoxifen was photodegraded after 180 min of the irradiation. In ultrapure water samples spiked with endoxifen, PBPs were mainly generated via con-rotatory 6π-photocyclization, followed by oxidative aromatization. These PBPs underwent secondary reactions leading to a series of PBPs with different molecular weights. Eight PBPs were identified and the toxicity analysis via the Toxicity Estimation Software Tool revealed that seven of these PBPs are more toxic than endoxifen itself. This is likely due to the formation of poly-aromatic core in the PBPs due to exposure to sunlight. Therefore, highly toxic PBPs may be generated if endoxifen is present in water and wastewater exposed to sunlight. The presence, fates and activities of these PBPs in surface water especially at locations close to treated wastewater discharge points should be investigated.

The effective design of sampling campaigns for emerging chemical and microbial contaminants in drinking water and its resources based on literature mining

As well as known contaminants, surface waters also contain an unknown variety of chemical and microbial contaminants which can pose a risk to humans if surface water is used for the production of drinking water. To protect human health proactively, and in a cost-efficient way, water authorities and drinking water companies need early warning systems. This study aimed to (1) assess the effectiveness of screening the scientific literature to direct sampling campaigns for early warning purposes, and (2) detect new aquatic contaminants of concern to public health in the Netherlands. By screening the scientific literature, six example contaminants (3 chemical and 3 microbial) were selected as potential aquatic contaminants of concern to the quality of Dutch drinking water. Stakeholders from the Dutch water sector and various information sources were consulted to identify the potential sources of these contaminants. Based on these potential contamination sources, two sampling sequences were set up from contamination sources (municipal and industrial wastewater treatment plants), via surface water used for the production of drinking water to treated drinking water. The chemical contaminants, mycophenolic acid, tetrabutylphosphonium compounds and Hexafluoropropylene Oxide Trimer Acid, were detected in low concentrations and were thus not expected to pose a risk to Dutch drinking water. Colistin resistant Escherichia coli was detected for the first time in Dutch wastewater not influenced by hospital wastewater, indicating circulation of bacteria resistant to this last-resort antibiotic in the open Dutch population. Four out of six contaminants were thus detected in surface or wastewater samples, which showed that screening the scientific literature to direct sampling campaigns for both microbial and chemical contaminants is effective for early warning purposes.

New insights on cytostatic drug risk assessment in aquatic environments based on measured concentrations in surface waters

Cytostatic drugs are compounds used to treat cancer, one of the deadliest diseases worldwide with a rising yearly incidence. However, the occurrence and concentrations of a large number of cytostatics in waters and wastewaters are unknown. Thus, this study sought to analyze the concentrations of these compounds in different aquatic environments worldwide to assess the risk that these compounds pose to aquatic organisms. The top five most monitored cytostatics in aquatic environments are fluorouracil, methotrexate, tamoxifen, ifosfamide, and cyclophosphamide. Risk quotients (RQs) based on maximum reported measured concentrations revealed that mycophenolic acid and tamoxifen pose a high risk to aquatic organisms (RQ_max ≥ 1) at concentrations observed in surface waters. Moreover, methotrexate and tegafur were categorized as moderate risk compounds, and bicalutamide was found to pose a low risk. Importantly, the available analytical methodologies for the quantification of some cytostatics (e.g., cisplatin, fluorouracil, daunorubicin, imatinib, and mycophenolic acid) in water could not rule out potential risk to aquatic biota, since estimated risks for these compounds using the lowest method detection limits reported in the literature (RQ MDL) were all ≥0.01 (i.e., low risk or higher). Moreover, risks based on predicted concentrations (RQ PEC) were consistently lower than those based on measured concentrations, highlighting the importance of risk assessment based on measured values. Thus, accurate and sensitive analytical methods are crucial to identify and quantify cytostatic exposure in aquatic ecosystems in order to preserve biodiversity and ensure a safer environment.

Cytostatic pharmaceuticals as water contaminants

Due to the growing problem of cancer diseases, cytostatic drugs have become a great environmental threat. Their main sources are hospital effluents, household discharge and drug manufacturers. As these compounds are not removed during wastewater treatment with sufficient efficiency, they are found in the surface, ground and drinking water in quantities up to 2.12 × 10^-4 mg/l. The current knowledge about their harmful influence on humans does not indicate a significant risk to the health of water consumers, although it points to certain groups of risk (children and lactating women) in particular. In aquatic organisms, anticancer drugs in detected concentrations can cause chronic toxicity and have a detrimental impact on their genetic material. The acute toxicity effect is less likely. The HC₅ value calculated by us (the concentration at which 5% of the species is potentially affected) equalling 2.1 × 10^-4 mg/l shows that anticancer drugs are real hazardous contaminants for the environment. It indicates that effective elimination of cytostatics from water still requires intensive research.

Environmental Risk Assessment for the Active Pharmaceutical Ingredient Mycophenolic Acid in European Surface Waters

An environmental risk assessment is presented for mycophenolic acid (MPA), an immunosuppressive pharmaceutical used for prevention of organ rejection, and its prodrug mycophenolate mofetil (MPM). Mycophenolic acid will not significantly adsorb to activated sludge. In activated sludge, ¹⁴ C-MPA attained >80% degradation, supporting an older environmental fate test with the same compound. Based on n-octanol/water distribution coefficient (log D_OW ) values of 2.28, 0.48, and ≤-1.54 at pH 5, 7, and 9, respectively, MPA is not expected to bioaccumulate. Sales amounts of MPA+MPM in Europe were used to derive predicted environmental concentrations (PECs) in surface waters; PECs were refined by including expected biodegradation in sewage treatment, average drinking water use, and average dilution of the effluents in the receiving waters per country. In addition, the exposure to pharmaceuticals in the environment (ePiE) model was run for 4 European catchments. The PECs were complemented with 110 measured environmental concentrations (MECs), ranging from below the limit of quantitation (<0.001 µg/L) to 0.656 µg/L. Predicted no-effect concentrations (PNECs) were derived from chronic tests with cyanobacteria, green algae, daphnids, and fish. The comparison of PECs and MECs with the PNECs resulted in a differentiated environmental risk assessment in which the risk ratio of PEC/PNEC or MEC/PNEC was <1 in most cases (mostly >90%), meaning no significant risk, but a potential risk to aquatic organisms in generally <10% of instances. Because this assessment reveals a partial risk, the following questions must be asked: How much risk is acceptable? and Through which measures can this risk be reduced? These questions are all the more important in view of limited alternatives for MPM and MPA and the serious consequences of not using them. Environ Toxicol Chem 2019;38:2259-2278. © 2019 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals, Inc. on behalf of SETAC.

Development of an analytical methodology for the analysis of priority cytostatics in water

The consumption of cytostatics has remarkably increased over the last years due to the high cancer incidence worldwide. In previous studies, seven cytostatics were already recognized to potentially induce chronic effects in aquatic organisms, taking into account their estimated concentrations in surface waters: cyclophosphamide (CYC), capecitabine (CAP), mycophenolic acid (MPA), imatinib (IMA), bicalutamide (BICA), prednisone (PRED) and 5-fluorouracil (5FU). The objective of the present study was to simultaneously analyse these 7 prioritized compounds, which have the highest chances to be found in surface and wastewaters. The analytical challenge relies in the determination of these very polar compounds, which have different chemical and structural properties. Solid-phase extraction with an Ultra Performance Liquid Chromatograph-Mass Spectrometer in electrospray ionization mixed mode (5-fluorouracil and bicalutamide in negative mode and the others in positive one) was developed to determine seven cytostatics in wastewater and surface water. Among eight tested cartridges with different sorbents and conditions, the best extraction performance was attained with Oasis WAX at pH 10, with recoveries ranging from 31 ± 4 (5FU) and 103 ± 17% (MPA). Regarding the chromatographic analysis, the best results were achieved with an XBridge amide column. The final analytical methodology was successfully applied for the analysis of real water samples, confirming the presence of risky cytostatics in surface and wastewaters.

Carcinogenic and non-carcinogenic health risks of metal(oid)s in tap water from Ilam city, Iran

One of the most important pathways for exposure to metals is drinking water ingestion. Chronic or acute exposure to metals can endanger the health of the exposed population, and hence, estimation of human health risks is crucial. In the current study for the first time, the concentrations of Mercury (Hg), Arsenic (As), Zinc (Zn), Lead (Pb) and Cobalt (Co) in 120 collected tap water samples (2015, July-November) from Ilam city, Iran were investigated using flame atomic absorption spectrophotometer. Also, the metal-induced carcinogenic and non-carcinogenic risks for consumers exposed to tap drinking water were calculated. The average (range) concentrations of Hg, Zn, As, Pb and Co were defined as 0.40 ± 0.10 μg/L (ND-0.9 μg/L), 5014 ± 5707 μg/L (2900.00-5668.33 μg/L), 21.008 ± 2.876 μg/L (3.5-62 μg/L), 30.38 ± 5.56 μg/L (6-87 μg/L), and 11.34 ± 1.61 μg/L (0.1-50 μg/L), respectively. Average concentrations of all examined metals were significantly higher than WHO and national standard recommended limits. The ranking order of metals concentrations in the tap drinking water was Zn > Pb > As > Co > Hg. Except for Hg and Co, at least one age group consumers were at considerable non-carcinogenic risks induced by Zn, As and Pb [Target Hazard Quotient (THQ > 1)]. The rank order of age groups consumers based on THQ and Incremental lifetime cancer risk (ILCR) was <1 years >1-9 years > 20 + years > 10-19 years. The calculated ILCR for As in all age groups were higher than 10^-3 value. All age groups of consumers in Ilam city, especially infants (<1 years) and children (1-10 years), are at considerable non-carcinogenic and carcinogenesis risk.

Anticancer drugs in Portuguese surface waters - Estimation of concentrations and identification of potentially priority drugs

Anticancer drugs, used in chemotherapy, have emerged as new water contaminants due to their increasing consumption trends and poor elimination efficiency in conventional water treatment processes. As a result, anticancer drugs have been reported in surface and even drinking waters, posing the environment and human health at risk. However, the occurrence and distribution of anticancer drugs depend on the area studied and the hydrological dynamics, which determine the risk towards the environment. The main objective of the present study was to evaluate the risk of anticancer drugs in Portugal. This work includes an extensive analysis of the consumption trends of 171 anticancer drugs, sold or dispensed in Portugal between 2007 and 2015. The consumption data was processed aiming at the estimation of predicted environmental loads of anticancer drugs and 11 compounds were identified as potentially priority drugs based on an exposure-based approach (PEC_b> 10 ng L^-1 and/or PEC_c> 1 ng L^-1). In a national perspective, mycophenolic acid and mycophenolate mofetil are suspected to pose high risk to aquatic biota. Moderate and low risk was also associated to cyclophosphamide and bicalutamide exposition, respectively. Although no evidences of risk exist yet for the other anticancer drugs, concerns may be associated with long term effects.

Development of a macroporous ceramic passive sampler for the monitoring of cytostatic drugs in water

The aim of this study was to develop and calibrate a macroporous ceramic passive sampler (MCPS) for the monitoring of anticancer drugs in wastewater. This system was designed by the Spanish Research Council (CSIC) and consists in a porous ceramic tube to allow a high diffusion of contaminants. The MCPS has been calibrated for 16 cytostatic drugs over time periods up to 9 d in spiked water under controlled laboratory conditions. Optimal uptake was accomplished for 7 compounds, namely ifosfamide, cyclophosphamide, capecitabine, prednisone, megestrol, cyproterone and mycophenolic acid, whereas cytarabine was not adsorbed in the receiving phase and the rest were hydrolyzed over the deployment period. The sampling rate for these 7 compounds was between 0.825 and 3.350 mL day^-1 and the diffusion coefficients varied from 1.01E-07 to 4.12E-07 cm² s^-1. To prove the applicability of the MCPSs, samplers (n = 3) were deployed in influent and effluent waters of a WWTP for a period of 6 d and results were compared to grab sampling and extraction with Solid Phase Extraction (SPE). In influent waters, MCPS were clogged due to the high amount of suspended solids in these waters. In effluents, MCPS detected cyclophosphamide and mycophenolic acid at concentrations of 19 ± 3 and 136 ± 28 ng L^-1 with a good agreement with the levels obtained by grab sampling. The study discusses the use and performance of the MCPS for the monitoring of stable cytostatic compounds in a complex matrix such as wastewater.

Determination of cytostatic drugs in Besòs River (NE Spain) and comparison with predicted environmental concentrations

The number of cytostatic drugs used in cancer treatments is wide and increases every year; therefore, tools have been developed to predict their concentration in the environment to prioritize those for monitoring studies. In the present study, the predicted environmental concentrations (PECs) were calculated according to consumption data in Catalonia (NE Spain) for 2014. According to PECs and to the most widely reported compounds, 19 cytostatics were monitored in two sampling campaigns performed along the Besòs River. A total of seven drugs were detected at levels between 0.5 and 656 ng L^-1. PEC and measured environmental concentrations (MECs) were compared in order to validate PECs. The PEC/MEC ratio presented a good agreement between predicted and measured concentrations confirming the PEC estimations. Mycophenolic acid, prioritized as the compound with the highest PEC, was detected at the highest concentrations (8.5-656 ng L^-1) but showed no risk for aquatic organisms (risk quotient <1) considering acute toxicity tests performed in Daphnia magna.