THALIDOMIDE AND RELATED AGENTS

THALIDOMIDE: The FDA approved thalidomide for treatment of a Hansen's disease (leprosy) side effect, erythema nodosum leprosum (ENL) in July, 1998. Due to its potential for causing teratogenicity, thalidomide is a tightly restricted drug (Prod Info Thalomid(R), thalidomide, 1999; FDA, 1998). Thalidomide is also used as maintenance therapy for the prevention and suppression of the cutaneous manifestations of erythema nodosum leprosum (Prod Info THALOMID(R) oral capsules, 2012).

It is also indicated in combination with dexamethasone for the treatment of patients with newly diagnosed multiple myeloma (Prod Info THALOMID(R) oral capsules, 2012). It has also been used for multiple off-label indications (eg, graft versus host disease, cachexia in HIV and cancer, rheumatoid arthritis, discoid lupus erythematosus) (Prommer et al, 2011).

POMALIDOMIDE: Pomalidomide, a thalidomide analogue, is indicated for the treatment of multiple myeloma in patients who have received at least 2 prior therapies including lenalidomide and bortezomib and have disease progression on or within 60 days of completion of the last therapy. However, clinical benefit (ie improvement in survival or symptoms) has not been determined (Prod Info POMALYST(R) oral capsules, 2013).
LENALIDOMIDE: Lenalidomide, a thalidomide analogue, is also used for the treatment of multiple myeloma. See LENALIDOMIDE management for further information.

FORMS

Thalidomide is available as a 50 mg, 100 mg, 150 mg and 200 mg capsule (Prod Info THALOMID(R) oral capsules, 2012).
Pomalidomide is available as a 1 mg, 2 mg, 3 mg and 4 mg capsule (Prod Info POMALYST(R) oral capsules, 2013).

-CLINICAL EFFECTS

GENERAL CLINICAL EFFECTS

USES: Thalidomide in combination with dexamethasone is used for the treatment of patients with newly diagnosed multiple myeloma. It is also indicated for the acute treatment of cutaneous manifestations of moderate to severe erythema nodosum leprosum. Pomalidomide, a thalidomide analogue, is used to treat patients with multiple myeloma who have received prior therapies (ie, lenalidomide and bortezomib) with evidence of disease progression.

PHARMACOLOGY: The precise mechanism of thalidomide is not fully understood. It has immunomodulatory, antiinflammatory, and antiangiogenic properties.

EPIDEMIOLOGY: Exposure is uncommon due to restricted distribution; fatal overdoses have not been reported.

TOXICOLOGY: Thalidomide should not be used by pregnant women, because it is a known teratogen that can cause severe birth defects or fetal death.

WITH POISONING/EXPOSURE

OVERDOSE: Overdoses have been limited and have been followed by uneventful recoveries.
MILD TO MODERATE TOXICITY: Acute toxicity is minimal, but may consist of hypotension, sedation, fatigue, dizziness, constipation, and dermatologic effects.
SEVERE TOXICITY: Limited data. Sedation and peripheral neuropathy may occur. Severe hepatotoxicity may develop.

WITH THERAPEUTIC USE

ADVERSE EFFECTS: The most common adverse events include: fatigue, hypocalcemia, edema, constipation, neuropathy (sensory and motor) , dyspnea, muscle weakness, leukopenia, neutropenia, rash, confusion, anorexia, nausea, anxiety/agitation, asthenia, tremor, fever, weight loss, thrombosis/embolism, weight gain, dizziness, and dry skin. Hepatotoxicity is rare. Teratogenicity has occurred.
CHRONIC USE: Peripheral neuropathy (may be irreversible) and bradycardia may occur.

Editor's Note: An ERG guide with information appropriate to this material does not exist.

ACUTE CLINICAL EFFECTS

SUMMARY

USES: Thalidomide in combination with dexamethasone is used for the treatment of patients with newly diagnosed multiple myeloma. It is also indicated for the acute treatment of cutaneous manifestations of moderate to severe erythema nodosum leprosum. Pomalidomide, a thalidomide analogue, is used to treat patients with multiple myeloma who have received prior therapies (ie, lenalidomide and bortezomib) with evidence of disease progression.
PHARMACOLOGY: The precise mechanism of thalidomide is not fully understood. It has immunomodulatory, antiinflammatory, and antiangiogenic properties.
EPIDEMIOLOGY: Exposure is uncommon due to restricted distribution; fatal overdoses have not been reported.
TOXICOLOGY: Thalidomide should not be used by pregnant women, because it is a known teratogen that can cause severe birth defects or fetal death.
OVERDOSE: Overdoses have been limited and have been followed by uneventful recoveries. MILD TO MODERATE TOXICITY: Acute toxicity is minimal, but may consist of hypotension, sedation, fatigue, dizziness, constipation, and dermatologic effects. SEVERE TOXICITY: Limited data. Sedation and peripheral neuropathy may occur. Severe hepatotoxicity may develop.
ADVERSE EFFECTS: The most common adverse events include: fatigue, hypocalcemia, edema, constipation, neuropathy (sensory and motor) , dyspnea, muscle weakness, leukopenia, neutropenia, rash, confusion, anorexia, nausea, anxiety/agitation, asthenia, tremor, fever, weight loss, thrombosis/embolism, weight gain, dizziness, and dry skin. Hepatotoxicity is rare. Teratogenicity has occurred.
CHRONIC USE: Peripheral neuropathy (may be irreversible) and bradycardia may occur.

THERAPEUTIC USE

Some of the adverse effects noted after thalidomide treatment have included edema, primarily of the extremities (Gutierrez-Rodriguez et al, 1989; Grosshans & Illy, 1984; Iyer et al, 1971; Cazort & Song, 1966; Revuz et al, 1990). This complication occurred in 50% of rheumatoid arthritis patients in one study (Gutierrez-Rodriguez et al, 1989). There are several central nervous system effects of thalidomide treatment: dizziness, headache, mood alterations, irritability, a feeling of drunkenness and fatigue have been reported (Iyer et al, 1971; Cazort & Song, 1966; Grosshans & Illy, 1984; Sheskin & Convit, 1969; Heney et al, 1990).
Gastrointestinal effects such as nausea, vomiting, and dry mouth have been reported during thalidomide therapy. However, the most frequent adverse gastrointestinal effect is constipation. This occurred in 50% to 100% of patients in some studies (Vogelsang et al, 1992; Revuz et al, 1990; Gutierrez-Rodriguez et al, 1989). Some additional adverse reactions have been reported in generally less than 10% of patients. These include menstrual disorders (amenorrhea, menorrhagia); erectile dysfunction, loss of libido and dermatologic effects such as dry skin, alopecia and pruritus.
The most frequent adverse effect of thalidomide treatment is drowsiness. This is to be expected since it was once used as a sedative-hypnotic. It has been reported in 100% of patients treated with higher doses (Vogelsang et al, 1992; Gutierrez-Rodriguez et al, 1989).

CHRONIC CLINICAL EFFECTS

THERAPEUTIC USE

The effects of prolonged exposure to thalidomide (2 months or more) are well documented. The most serious complication of treatment is peripheral neuropathy. In many patients, neuropathy has been irreversible (Fullerton & O'Sullivan, 1968). Peripheral neuropathy is probably dose-related (Aronson et al, 1984; Wulff et al, 1985). This has been questioned by some workers (Grosshans & Illy, 1984).
The common initial symptoms are paresthesias (numbing) of the extremities (Lo et al, 1989; Fullerton & O'Sullivan, 1968). Other effects such as weakness, speech problems, and fine involuntary movements of hands and fingers have been noted (Lagueny et al, 1986). The mechanism of peripheral neuropathy appears to be primary neuronal degeneration (Aronson et al, 1984).
Chronic thalidomide therapy has induced peripheral neuropathy in an unpredictable manner; cigarette smoking may afford some protection (Harland et al, 1995).
While thalidomide does not impede T-cell competence with respect to resistance to mycobacterial infection, it does produce a myriad of immunological effects. Its main targets appear to be endothelial cells and phagocytic leukocytes. Expression of adhesion antigens on endothelial cells and production of cytokines by leukocytes appear to be modulated by thalidomide (Zwingenberger & Wnendt, 1996).

-FIRST AID

FIRST AID AND PREHOSPITAL TREATMENT

EMESIS/NOT RECOMMENDED

Emesis is not recommended due to the risk of CNS depression.

ACTIVATED CHARCOAL

PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION

Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).

In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).

CHARCOAL DOSE

Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).

Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).

ADVERSE EFFECTS/CONTRAINDICATIONS

Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).

-RANGE OF TOXICITY

MINIMUM LETHAL EXPOSURE

There have been no reports of fatalities with these agents (Prod Info POMALYST(R) oral capsules, 2013; Prod Info THALOMID(R) oral capsules, 2012).

MAXIMUM TOLERATED EXPOSURE

THALIDOMIDE

CASE REPORT: A 21-year-old man tolerated an intentional overdose of 14.4 g of thalidomide with alcohol with transient effects of sedation, hypotension, and fever, all of which resolved within several hours (Neuhaus & Ibe, 1960).
CASE REPORTS: Three cases of overdose (suicide attempts) have been reported, with doses up to 14.4 g; all patients recovered with no reported sequelae (Prod Info Thalomid(R), thalidomide, 1999).

Carcinogenicity Ratings for CAS50-35-1 :

ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
EPA (U.S. Environmental Protection Agency, 2011): Not Listed
IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
MAK (DFG, 2002): Not Listed
NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

TOXICITY AND RISK ASSESSMENT VALUES

EPA IRIS

EPA Risk Assessment Values for CAS50-35-1 (U.S. Environmental Protection Agency, 2011):

Not Listed

TOXICITY VALUES

ANIMAL DATA
- LD50- (ORAL)MOUSE:
- LD50- (SUBCUTANEOUS)MOUSE:
- LD50- (INTRAPERITONEAL)RAT:
- LD50- (ORAL)RAT:
- LD50- (SKIN)RAT:

-STANDARDS AND LABELS

WORKPLACE STANDARDS

ACGIH TLV Values for CAS50-35-1 (American Conference of Governmental Industrial Hygienists, 2010):

Not Listed

AIHA WEEL Values for CAS50-35-1 (AIHA, 2006):

Not Listed

NIOSH REL and IDLH Values for CAS50-35-1 (National Institute for Occupational Safety and Health, 2007):

Not Listed

OSHA PEL Values for CAS50-35-1 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):

Not Listed

OSHA List of Highly Hazardous Chemicals, Toxics, and Reactives for CAS50-35-1 (U.S. Occupational Safety and Health Administration, 2010):

Not Listed

ENVIRONMENTAL STANDARDS

EPA CERCLA, Hazardous Substances and Reportable Quantities for CAS50-35-1 (U.S. Environmental Protection Agency, 2010):

Not Listed

EPA CERCLA, Hazardous Substances and Reportable Quantities, Radionuclides for CAS50-35-1 (U.S. Environmental Protection Agency, 2010):

Not Listed

EPA RCRA Hazardous Waste Number for CAS50-35-1 (U.S. Environmental Protection Agency, 2010b):

Not Listed
Editor's Note: The D, F, and K series waste numbers and Appendix VIII to Part 261 -- Hazardous Constituents were not included. Please refer to 40 CFR Part 261.

EPA SARA Title III, Extremely Hazardous Substance List for CAS50-35-1 (U.S. Environmental Protection Agency, 2010):

Not Listed

EPA SARA Title III, Community Right-to-Know for CAS50-35-1 (40 CFR 372.65, 2006; 40 CFR 372.28, 2006):

Not Listed

DOT List of Marine Pollutants for CAS50-35-1 (49 CFR 172.101 - App. B, 2005):

Not Listed

EPA TSCA Inventory for CAS50-35-1 (EPA, 2005):

Not Listed

LABELS

NFPA

NFPA Hazard Ratings for CAS50-35-1 (NFPA, 2002):

Not Listed

-PERSONAL PROTECTION

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

PROTECTIVE CLOTHING

CHEMICAL PROTECTIVE CLOTHING. Search results for CAS 50-35-1.

Specific recommendations and test data for this chemical were not found in the available manufacturers' product literature. A complete list of consulted manufacturers and references is presented below.

-PHYSICAL HAZARDS

FIRE HAZARD

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

FLAMMABILITY CLASSIFICATION

NFPA Flammability Rating for CAS50-35-1 (NFPA, 2002):

Not Listed

FIRE CONTROL/EXTINGUISHING AGENTS

Editor's Note: An ERG guide with information appropriate to this material does not exist.

NFPA Extinguishing Methods for CAS50-35-1 (NFPA, 2002):

Not Listed

EVACUATION PROCEDURES

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

AIHA ERPG Values for CAS50-35-1 (AIHA, 2006):

Not Listed

DOE TEEL Values for CAS50-35-1 (U.S. Department of Energy, Office of Emergency Management, 2010):

Not Listed

AEGL Values for CAS50-35-1 (National Research Council, 2010; National Research Council, 2009; National Research Council, 2008; National Research Council, 2007; NRC, 2001; NRC, 2002; NRC, 2003; NRC, 2004; NRC, 2004; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; United States Environmental Protection Agency Office of Pollution Prevention and Toxics, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; 62 FR 58840, 1997; 65 FR 14186, 2000; 65 FR 39264, 2000; 65 FR 77866, 2000; 66 FR 21940, 2001; 67 FR 7164, 2002; 68 FR 42710, 2003; 69 FR 54144, 2004):

Not Listed

NIOSH IDLH Values for CAS50-35-1 (National Institute for Occupational Safety and Health, 2007):

Not Listed

CONTAINMENT/WASTE TREATMENT OPTIONS

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

SMALL LEAK/SPILL

Editor's Note: An ERG guide with information appropriate to this material does not exist.

LARGE LEAK/SPILL

Editor's Note: An ERG guide with information appropriate to this material does not exist.

-PHYSICAL/CHEMICAL PROPERTIES

MOLECULAR WEIGHT

POMALIDOMIDE: 273.24 (Prod Info POMALYST(R) oral capsules, 2013)

THALIDOMIDE: 258.2 (Prod Info THALOMID(R) oral capsules, 2014)

DESCRIPTION/PHYSICAL STATE

POMALIDOMIDE is a solid yellow powder that has a low solubility in pH solutions (about 0.01 mg/mL) and limited to low solubility in organic solvents (Prod Info POMALYST(R) oral capsules, 2013).

THALIDOMIDE is a white to off-white, odorless, crystalline powder. It is soluble at 25 degrees C in dimethyl sulfoxide and sparingly soluble in water and ethanol (Prod Info THALOMID(R) oral capsules, 2014).

-REFERENCES

GENERAL BIBLIOGRAPHY

40 CFR 372.28: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Lower thresholds for chemicals of special concern. National Archives and Records Administration (NARA) and the Government Printing Office (GPO). Washington, DC. Final rules current as of Apr 3, 2006.

40 CFR 372.65: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Chemicals and Chemical Categories to which this part applies. National Archives and Records Association (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Apr 3, 2006.

49 CFR 172.101 - App. B: Department of Transportation - Table of Hazardous Materials, Appendix B: List of Marine Pollutants. National Archives and Records Administration (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Aug 29, 2005.

62 FR 58840: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 1997.

65 FR 14186: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.

65 FR 39264: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.

65 FR 77866: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.

66 FR 21940: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2001.

67 FR 7164: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2002.

68 FR 42710: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2003.

69 FR 54144: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2004.

AIHA: 2006 Emergency Response Planning Guidelines and Workplace Environmental Exposure Level Guides Handbook, American Industrial Hygiene Association, Fairfax, VA, 2006.

Alaspaa AO, Kuisma MJ, Hoppu K, et al: Out-of-hospital administration of activated charcoal by emergency medical services. Ann Emerg Med 2005; 45:207-12.

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THALIDOMIDE AND RELATED AGENTS

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Information to evaluate chemical incidents

Information to evaluate chemical incidents

Information to evaluate chemical incidents