EUROPEAN UNIVERSITY OF LEFKE

Cyprus Science Foundation

Eczacılık Fakültesi / Faculty of Pharmacy

PHAR316TOXICOLOGY2019-2020 SPRING SEMESTER FINAL ASSIGNMENT

NAME-SURNAME:Ayşe Pilancı

STUDENT ID:176057

DUE DATE: 11/06/2020

The homework/project assignment that has been submitted by myself is solely

my own work and I did not get any aid from other people.

NAME-SURNAME:Ayşe Pilancı

QUESTIONS:

1. Prepare a report on controversy of hydroxychloroquine sulfate usage for

prophylaxis and treatment of COVID 19 infection in terms of toxicity (30 Points)

Before start this report visit the electronic Medicines Compendium (eMC) web site
review Product Characteristics (SPC) and The Patient Information Leaflet (PIL) of this
drug. “Special warnings and precautions” section gives you basic knowledge about
this subject.

Hydroxychloroquine Sulfate

Chloroquine (CQ) was first used as prophylaxis and treatment for malaria. The
precise mechanism by which hydroxychloroquine exhibits activity against
Plasmodium is not known. Hydroxychloroquine, like chloroquine, is a weak base and
may exert its effect by concentrating in the acid vesicles of the parasite and by
inhibiting polymerization of heme. It can also inhibit certain enzymes by its interaction
with DNA.

Hydroxychloroquine (HCQ) is a more soluble and less toxic metabolite of

chloroquine, which causes less side effects and is, therefore, safer.More recently,
CQ/HCQ has been used to manage conditions such as systemic lupus
erythematosus and rheumatoid arthritis. CQ/HCQ has been used in the treatment of
HIV with mixed results.

Several in vitro studies report antiviral activity of chloroquine and hydroxychloroquine

against SARS-CoV-2. In vivo data, although promising, is currently limited to one
study with considerable limitations. On the basis of the weak evidence available to
 EUROPEAN UNIVERSITY OF LEFKE
Cyprus Science Foundation

Eczacılık Fakültesi / Faculty of Pharmacy

date, treatment guidelines have already incorporated the usage of

chloroquine/hydroxychloroquine for certain patients with COVID-19.

Further research should address the optimal dose and duration of treatment, and
explore side effects and long-term outcomes.

There is a higher risk of side effects in the presence of renal and liver impairment,
and there have been isolated reports of COVID-19 disease-causing renal and hepatic
injury.

Over twenty in vivo clinical trials have already been registered to test the use of
chloroquine and hydroxychloroquine for the treatment of COVID-19.

Contraindications for the use of these drugs must be checked for each individual
before treatment. Empirical evidence suggests that hydroxychloroquine has a better
safety profile, and it might therefore be preferable to focus research efforts on this
less toxic metabolite.

Special Warnings And Precautions For Use

General

• All patients should have an ophthalmological examination before treatment with

Hydroxychloroquine Sulfate Tablets is initiated. Thereafter, ophthalmological
examinations must be repeated at least every 12 months.

• Retinal toxicity is largely dose-related. The risk of retinal damage is small with daily
doses of up to 6.5mg/kg body weight. Exceeding the recommended dose sharply
increases the risk of retinal toxicity.

The examination should include testing visual acuity and colour vision, careful
ophthalmoscopy, fundoscopy and central visual field testing with a red target.

This examination should be more frequent and adapted to the patient in the following
situations:

• daily dosage exceeds 6.5mg/kg lean body weight. Absolute body weight used as a
guide to dosage could result in an overdosage in the obese.

• renal insufficiency

• visual acuity below 6/8

• age above 65 years

 EUROPEAN UNIVERSITY OF LEFKE
Cyprus Science Foundation

Eczacılık Fakültesi / Faculty of Pharmacy

• cumulative dose more than 200g.

Hydroxychloroquine Sulfate Tablets should be discontinued immediately in any

patient who develops a pigmentary abnormality, visual field defect or any other
abnormalities not explained by difficulty in accommodation or presence of corneal
opacities (see also section 4.8). Patients should continue to be observed as retinal
changes and visual disturbances may progress even after cessation of therapy (see
also section 4.8).

Patients should be advised to stop taking the drug immediately and seek the advice
of their prescribing doctor if any disturbances of vision are noted, including abnormal
colour vision.

Concomitant use of hydroxychloroquine with drugs known to induce retinal toxicity,

such as tamoxifen, is not recommended.

Cases of cardiomyopathy resulting in cardiac failure, in some cases with fatal

outcome, have been reported in patients treated with Hydroxychloroquine. Clinical
monitoring for signs and symptoms of cardiomyopathy is advised and
Hydroxychloroquine Sulfate Tablets should be discontinued if cardiomyopathy
develops. Chronic toxicity should be considered when conduction disorders (bundle
branch block / atrio-ventricular heart block) as well as biventricular hypertrophy are
diagnosed.

Hydroxychloroquine Sulfate Tablets should be used with caution in patients taking

medicines which may cause adverse ocular or skin reactions. Caution should also be
applied when it is used in the following:

• patients with hepatic or renal disease, and in those taking medicines known to
affect those organs. Estimation of plasma hydroxychloroquine levels should be
undertaken in patients with severely compromised renal or hepatic function, and
dosage adjusted accordingly.

• patients with severe gastrointestinal, neurological or blood disorders.

Caution is also advised in patients with a sensitivity to quinine, those with glucose-6-
phosphate dehydrogenase deficiency, those with porphyria cutanea tarda which can
be exacerbated by hydroxychloroquine, and in patients with psoriasis since it
appears to increase the risk of skin reactions.

Although the risk of bone-marrow depression is low, periodic blood counts are
advisable in all patients on long-term therapy and Hydroxychloroquine Sulfate
Tablets should be discontinued if abnormalities develop.
 EUROPEAN UNIVERSITY OF LEFKE
Cyprus Science Foundation

Eczacılık Fakültesi / Faculty of Pharmacy

2. Describe the function of toxicology from drug discovery to dispensing (10

Points)

Toxicology is the scientific study of adverse effects that occur in living organisms due
to chemicals. It involves observing and reporting symptoms, mechanisms, detection
and treatments of toxic substances, in particular relation to the poisoning of humans.
So its important when a new drug discovered it should be tested to see its adverse
effects so we can understand if its safe to use or not.Safety assesment evaluation
has to be performed by toxicologists to determine toxic effects. After registration,
drug manufacturing begins and then drug starts to be dispensed all over retail or
hospital pharmacies.

3. Explain the following terms and give examples related to toxicity(10Points)

Additivity: toxicity of toxicants A and B is the same as the sum of toxicities of

toxicants A an B when applied individually (2+3=5)

Synergism: toxicity of the mixture of toxicant A anB is higher than the sum of
toxicities of toxicants A and B when applied individually. (2+2=20)

Potentiation:One chemical does not have a toxic effect on certain organ or system
but when addes to another chemical it makes the latter much more toxic (0+5=30)

Antagonism:Toxicity of the mixture of toxicants A and B is lower than the sum of

toxicities of toxicants A and B when applied individully(Dimercaprol chelates with
various metal ions such as arsenic mercury and lead)

4.Explain mechanism of carbon monoxide poisoning and treatment (5 Points)

Red blood cells pick up CO instead of oxygen. Decrease the oxygen carrying
capacity of blood tissues can not use oxygen properly anf it cause functional anemia.

Treatment: breathing pure oxygen and hyperbaric oxygen therapy.

5. Briefly review main mechanisms of toxicity (10 Points)

 EUROPEAN UNIVERSITY OF LEFKE
Cyprus Science Foundation

Eczacılık Fakültesi / Faculty of Pharmacy

Toxicity involves toxicant delivery to its target or targets and interactions with

endogenous target molecules that may trigger perturbations in cell function and/or
structure or that may initiate repair mechanisms at the molecular, cellular, and/or
tissue levels. Toxicity can cause, disruption of protein synthesis, DNA damage,
production of reactive chemicals in cell, cell replacement such as fibrosis.

6.Explain determination of NOAEL and ADI values (5 Points)

NOAEL (No-Observed-Adverse Effect Level)

ADI (Acceptable Daily Intake)

ADI mg/kg b.w. (human) = NOAEL mg/kg b.w. (exp.animal)

Safety (uncertanity) factor (100)

7.Describe the following terms (5 Points)

Hazard: capability of a substance to cause an adverse effect

Risk: probability that the hazard will occur under specific exposure conditions

Risk Assessment: the process by which hazard, exposure, and risk are determined

Risk Management: the process of weighing policy alternatives and selecting the
most appropriate regulatory action based on the results of risk assessment and
social, economic and political concerns

8.What is the biomagnification? Explain with DDT Example (5 Points)

Biomagnification is any concentration of a toxin, such as pesticides, in the tissues of

tolerant organisms at successively higher levels in a food chain.For example,
spraying a marsh to control mosquitoes will cause trace amounts of DDT to
accumulate in the cells of microscopic aquatic organisms, the plankton, in the marsh.
In feeding on the plankton, filter-feeders, like clams and some fish, harvest DDT as
well as food.

9. What is the biochemical mechanism behind the MTT Assay (10 Points)
 EUROPEAN UNIVERSITY OF LEFKE
Cyprus Science Foundation

Eczacılık Fakültesi / Faculty of Pharmacy

The biochemical mechanism behind the MTT assay involves NAD(P)H-dependent

cellular oxidoreductase enzyme that converts the yellow tetrazolium MTT [3-(4, 5-
dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide] into insoluble (E,Z)-5-(4,5-
dimethylthiazol-2-yl)-1,3-diphenylformazan (formazan).

10. Explain principles of AMES testfor mutagenecity/carcinogenecity screening (10

Points

The Ames test is a widely employed method that uses bacteria to test whether a

given chemical can cause mutations in the DNA of the test organism. ... A
positive test indicates that the chemical is mutagenic and therefore may act as
a carcinogen, because cancer is often linked to mutation.

-What are the advantages of Ames test?

 Simple, rapid and robust bacterial assay

 Ease and low cost of the test make it invaluable for screening substances in
our environment for possible carcinogenicity

 Ames test can detect suitable mutants in large population of bacteria with high
sensitivity

-What are the limitations of Ames test?

 Some substances that cause cancer in laboratory animals do not give a

positive Ames test

 Ames assay consist of Salmonella typhimrium strains and so it is not a perfect

model for human

PROF. DR. ALİ ESAT KARAKAYA