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THIOGUANINE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Thioguanine is a purine analogue antineoplastic agent.

Specific Substances

    1) NSC-752
    2) 6-TG
    3) Thioguanine (USAN)
    4) 6-Thioguanine
    5) WR-1141
    6) 2-Aminopurine-6(1H)-thione
    7) 2-Amino-6-mercaptopurine
    8) 2-Aminopurine-6-thiol
    9) CAS 154-42-7 (anhydrous tioguanine)
    10) CAS 5580-03-0 (tioguanine hemihydrate)
    1.2.1) MOLECULAR FORMULA
    1) C5-H5-N5-S (tioguanine)

Available Forms Sources

    A) FORMS
    1) Thioguanine is available as 40 mg scored tablets for oral administration (Prod Info TABLOID(R) oral tablets, 2012).
    B) USES
    1) Thioguanine is indicated for use in combination with other chemotherapy agents (and occasionally single-agent therapy) for remission induction, remission consolidation, and maintenance therapy of acute nonlymphocytic leukemias (Prod Info TABLOID(R) oral tablets, 2012).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) WITH THERAPEUTIC USE
    1) Dose-limiting bone marrow suppression is the most frequent adverse effect. Patients with an inherited deficiency of thiopurine methyltransferase may develop rapid bone marrow suppression following the initiation of treatment. Additionally hepatotoxicity, hyperuricemia, nausea and vomiting, anorexia, and stomatitis have been reported following thioguanine administration.
    B) WITH POISONING/EXPOSURE
    1) There are no published reports of overdose at the time of this review. The manufacturer reports that signs and symptoms after overdose may be immediate, such as nausea and vomiting, malaise, hypertension, and diaphoresis, or delayed, such as myelosuppression and azotemia. Reversible myelosuppression has been reported following the ingestion of a single oral dose of thioguanine 35 mg/kg.
    0.2.20) REPRODUCTIVE
    A) U.S. Food & Drug Administration's Pregnancy Category D
    0.2.21) CARCINOGENICITY
    A) Because of its action on cellular DNA, thioguanine may be carcinogenic.

Laboratory Monitoring

    A) Monitor liver function as indicated in symptomatic patients.
    B) Monitor fluid and electrolyte status in patients with significant vomiting and/or diarrhea.
    C) Bone marrow suppression may deveop after thioguanine overdose. Monitor CBC with differential and platelet count for 3 to 4 weeks following an overdose.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) Treatment is symptomatic and supportive.
    B) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
    C) GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in the head down left lateral decubitus position or by endotracheal intubation. Control any seizures first.
    1) CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.

Range Of Toxicity

    A) A single dose of as little as 2 to 3 mg/kg of thioguanine may produce toxic effects. Reversible myelosuppression has been reported following the ingestion of a single oral dose of thioguanine 35 mg/kg (Prod Info Tabloid(R), 2001).

Clinical Effects

Summary Of Exposure

    A) WITH THERAPEUTIC USE
    1) Dose-limiting bone marrow suppression is the most frequent adverse effect. Patients with an inherited deficiency of thiopurine methyltransferase may develop rapid bone marrow suppression following the initiation of treatment. Additionally hepatotoxicity, hyperuricemia, nausea and vomiting, anorexia, and stomatitis have been reported following thioguanine administration.
    B) WITH POISONING/EXPOSURE
    1) There are no published reports of overdose at the time of this review. The manufacturer reports that signs and symptoms after overdose may be immediate, such as nausea and vomiting, malaise, hypertension, and diaphoresis, or delayed, such as myelosuppression and azotemia. Reversible myelosuppression has been reported following the ingestion of a single oral dose of thioguanine 35 mg/kg.

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HYPERTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Hypertension may develop after overdose (Prod Info Tabloid(R), 2001).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) PSYCHOMOTOR AGITATION
    1) WITH THERAPEUTIC USE
    a) In one study, one patient developed persistent jitteriness after 2 weeks of 6-thioguanine therapy (Dubinsky et al, 2001).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) DRUG-INDUCED GASTROINTESTINAL DISTURBANCE
    1) WITH THERAPEUTIC USE
    a) Although less frequent than hematological effects, nausea and vomiting, stomatitis, and anorexia have all occurred following thioguanine administration. Intestinal necrosis and bowel perforation have been reported in patients receiving concomitant thioguanine and other chemotherapeutic agents (Prod Info Tabloid(R), 2001).
    2) WITH POISONING/EXPOSURE
    a) Nausea and vomiting are likely to develop after overdose (Prod Info Tabloid(R), 2001).

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) INJURY OF LIVER
    1) WITH THERAPEUTIC USE
    a) CASE SERIES
    1) In a randomized study, consecutive children with lymphoblastic leukemia were randomly assigned either to 6-thioguanine (n=750) or 6-mercaptopurine (n=748) during interim maintenance and continuing therapy, 95 6-thioguanine treated patients developed acute hepatitis with evidence of veno-occlusive disease of the liver. Transient tender hepatomegaly, mild to moderate hyperbilirubinemia with elevated aminotransferase concentrations, and moderate to severe thrombocytopenia were reported in most patients. No deaths were reported. Four weeks after drug cessation, liver function studies returned to normal, but 24 patients developed splenomegaly. After a median follow-up of 39 months, 43 (5%) children had persistent non-cirrhotic portal hypertension due to periportal liver fibrosis or nodular regenerative hyperplasia (Vora et al, 2006).
    b) CASE REPORT: Peliosis hepatitis occurred in a 63-year-old women after receiving thioguanine for 2 months for the treatment of acute myeloblastic leukemia (Larrey et al, 1988). Elevated liver enzymes occasionally occur with thioguanine (Prod Info Tabloid(R), 2001).
    c) Reports of hepatic veno-occlusive disease (HVOD) secondary to the administration of thioguanine have appeared in the literature; however, all patients have also been receiving other chemotherapy agents (Rulyak et al, 2003; Prod Info Tabloid(R), 2001; Krivoy et al, 1982).
    d) CASE REPORT: A 27-year-old woman with Crohn's disease developed hepatotoxicity (increased levels of ALT and AST) while being treated with thioguanine (6-TG) 40 mg daily. Symptoms resolved upon discontinuation of thioguanine. Enzymatic assay reflected a low level of thiopurine methyltransferase (TPMT) activity with subsequently undetectable levels of the 6-methylthioguanine metabolite, ruling out it's causative role (Rulyak et al, 2003).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) PRERENAL AZOTEMIA
    1) WITH POISONING/EXPOSURE
    a) Delayed azotemia may develop after overdose (Prod Info Tabloid(R), 2001).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) MYELOSUPPRESSION
    1) WITH THERAPEUTIC USE
    a) Bone marrow depression remains the most frequent adverse effect following thioguanine administration; when the drug is used in combination with other chemotherapeutic agents pancytopenia almost always occurs (Prod Info Tabloid(R), 2001). Rapid bone marrow suppression following initiation of treatment may occur in patients with an inherited deficiency of thiopurine methyltransferase (TPMT). Coadministration with drugs that inhibit TPMT such as olsalazine, mesalazine, or sulphasalazine may exacerbate the condition (Prod Info Tabloid(R), 2001).
    2) WITH POISONING/EXPOSURE
    1) Reversible myelosuppression has been reported following the ingestion of a single oral dose of thioguanine 35 mg/kg (Prod Info Tabloid(R), 2001).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) EXCESSIVE SWEATING
    1) WITH POISONING/EXPOSURE
    a) Diaphoresis may develop after overdose (Prod Info Tabloid(R), 2001).
    B) ALOPECIA
    1) WITH THERAPEUTIC USE
    a) In one study, one patient noted hair loss at week 12 of thioguanine therapy, after being weaned off prednisone (Dubinsky et al, 2001).

Endocrine

    3.16.2) CLINICAL EFFECTS
    A) HYPERURICEMIA
    1) WITH THERAPEUTIC USE
    a) Hyperuricemia may occur in patients receiving thioguanine resulting from extensive purine catabolism and rapid cell lysis. This can be controlled by increasing hydration, urine alkalinization and allopurinol prophylaxis (Prod Info Tabloid(R), 2001).

Reproductive

    3.20.1) SUMMARY
    A) U.S. Food & Drug Administration's Pregnancy Category D
    3.20.3) EFFECTS IN PREGNANCY
    A) PREGNANCY CATEGORY
    1) U.S. Food & Drug Administration's Pregnancy Category D (Prod Info Tabloid(R), 2001).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS154-42-7 (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):
    1) Not Listed
    3.21.2) SUMMARY/HUMAN
    A) Because of its action on cellular DNA, thioguanine may be carcinogenic.
    3.21.3) HUMAN STUDIES
    A) CARCINOMA
    1) Because of its action on cellular DNA, thioguanine may be carcinogenic (Prod Info Tabloid(R), 2001).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor liver function as indicated in symptomatic patients.
    B) Monitor fluid and electrolyte status in patients with significant vomiting and/or diarrhea.
    C) Bone marrow suppression may deveop after thioguanine overdose. Monitor CBC with differential and platelet count for 3 to 4 weeks following an overdose.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) Monitor liver function as indicated in symptomatic patients.
    B) Monitor fluid and electrolyte status in patients with significant vomiting and/or diarrhea.
    C) Bone marrow suppression may deveop after thioguanine overdose. Monitor CBC with differential and platelet count for 3 to 4 weeks following an overdose.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) ACTIVATED CHARCOAL
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) 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).
    1) 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.
    2) 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).
    2) CHARCOAL DOSE
    a) 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).
    1) 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).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) 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.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.2) PREVENTION OF ABSORPTION
    A) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) 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).
    1) 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).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) 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.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    B) GASTRIC LAVAGE
    1) INDICATIONS: Consider gastric lavage with a large-bore orogastric tube (ADULT: 36 to 40 French or 30 English gauge tube {external diameter 12 to 13.3 mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a potentially life threatening ingestion if it can be performed soon after ingestion (generally within 60 minutes).
    a) Consider lavage more than 60 minutes after ingestion of sustained-release formulations and substances known to form bezoars or concretions.
    2) PRECAUTIONS:
    a) SEIZURE CONTROL: Is mandatory prior to gastric lavage.
    b) AIRWAY PROTECTION: Place patients in the head down left lateral decubitus position, with suction available. Patients with depressed mental status should be intubated with a cuffed endotracheal tube prior to lavage.
    3) LAVAGE FLUID:
    a) Use small aliquots of liquid. Lavage with 200 to 300 milliliters warm tap water (preferably 38 degrees Celsius) or saline per wash (in older children or adults) and 10 milliliters/kilogram body weight of normal saline in young children(Vale et al, 2004) and repeat until lavage return is clear.
    b) The volume of lavage return should approximate amount of fluid given to avoid fluid-electrolyte imbalance.
    c) CAUTION: Water should be avoided in young children because of the risk of electrolyte imbalance and water intoxication. Warm fluids avoid the risk of hypothermia in very young children and the elderly.
    4) COMPLICATIONS:
    a) Complications of gastric lavage have included: aspiration pneumonia, hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or stomach, fluid and electrolyte imbalance (Vale, 1997). Combative patients may be at greater risk for complications (Caravati et al, 2001).
    b) Gastric lavage can cause significant morbidity; it should NOT be performed routinely in all poisoned patients (Vale, 1997).
    5) CONTRAINDICATIONS:
    a) Loss of airway protective reflexes or decreased level of consciousness if patient is not intubated, following ingestion of corrosive substances, hydrocarbons (high aspiration potential), patients at risk of hemorrhage or gastrointestinal perforation, or trivial or non-toxic ingestion.
    6.5.3) TREATMENT
    A) SUPPORT
    1) In cases of thioguanine overdose, treatment should be symptomatic and supportive.
    B) MONITORING OF PATIENT
    1) Monitor liver function as indicated in symptomatic patients.
    2) Monitor fluid and electrolyte status in patients with significant vomiting and/or diarrhea.
    3) Bone marrow suppression may develop after thioguanine overdose. Monitor CBC with differential and platelet count for 3 to 4 weeks following an overdose.
    C) MYELOSUPPRESSION
    1) Monitor CBC and platelet count for evidence of severe bone marrow suppression. Mild to moderate myelosuppression has been reported during thioguanine therapy.
    2) Transfusions of packed red cells and platelets may be useful if bleeding occurs.
    3) There is little data on the use of hematopoietic colony stimulating factors to treat neutropenia after drug overdose or idiosyncratic reactions. These agents have been shown to shorten the duration of severe neutropenia in patients receiving cancer chemotherapy (Hartman et al, 1997; Stull et al, 2005). They have also been used to treat agranulocytosis induced by nonchemotherapy drugs (Beauchesne & Shalansky, 1999). They may be considered in patients with severe neutropenia who have or are at significant risk for developing febrile neutropenia.
    a) Filgrastim: The usual starting dose in adults is 5 micrograms/kilogram/day by intravenous infusion or subcutaneous injection (Prod Info NEUPOGEN(R) injection, 2006).
    b) Sargramostim: Usual dose is 250 micrograms/square meter/day infused IV over 4 hours (Prod Info LEUKINE(R) injection, 2006).
    c) Monitor CBC with differential.
    4) Recombinant human erythropoietin may be used to prevent or correct antineoplastic-induced anemia. It should be considered in patients with severe anemia.

Enhanced Elimination

    A) LACK OF INFORMATION
    1) There is no information regarding the effectiveness of hemodialysis or hemoperfusion for the removal of thioguanine from plasma. Because of rapid intracellular incorporation of thioguanine into active metabolites with long persistence, these modalities may not be useful (Prod Info Tabloid(R), 2001).

Range Of Toxicity

Summary

    A) A single dose of as little as 2 to 3 mg/kg of thioguanine may produce toxic effects. Reversible myelosuppression has been reported following the ingestion of a single oral dose of thioguanine 35 mg/kg (Prod Info Tabloid(R), 2001).

Therapeutic Dose

    7.2.1) ADULT
    A) Acute Nonlymphocytic Leukemia: Single Agent: 2 mg/kg/day orally; after 4 weeks may increase to 3 mg/kg/day if no improvement or myelosuppression (Prod Info TABLOID(R) oral tablets, 2012).
    7.2.2) PEDIATRIC
    A) Acute Nonlymphocytic Leukemia: Single Agent: 2 mg/kg/day orally; after 4 weeks may increase to 3 mg/kg/day if no improvement or myelosuppression (Prod Info TABLOID(R) oral tablets, 2012).

Maximum Tolerated Exposure

    A) A single dose of as little as 2 to 3 mg/kg of thioguanine may produce toxic effects. Reversible myelosuppression has been reported following the ingestion of a single oral dose of thioguanine 35 mg/kg (Prod Info Tabloid(R), 2001).

Serum Plasma Blood Concentrations

    7.5.1) THERAPEUTIC CONCENTRATIONS
    A) THERAPEUTIC CONCENTRATION LEVELS
    1) TIME TO PEAK CONCENTRATION: Oral, 8 hours (Prod Info Tabloid(R), 2001).

Workplace Standards

    A) ACGIH TLV Values for CAS154-42-7 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) NIOSH REL and IDLH Values for CAS154-42-7 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    C) Carcinogenicity Ratings for CAS154-42-7 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) 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
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    D) OSHA PEL Values for CAS154-42-7 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) LD50- (INTRAPERITONEAL)MOUSE:
    1) 54 mg/kg (RTECS, 2003)
    B) LD50- (ORAL)MOUSE:
    1) 160 mg/kg (RTECS, 2003)
    C) LD50- (INTRAPERITONEAL)RAT:
    1) 300 mg/kg (RTECS, 2003)

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Thioguanine is purine analogue antimetabolite with cell cycle-specific activity for the S-phase of the cell cycle. The drug is enzymatically incorporated into purine synthesis and thereby inhibits DNA synthesis. Unfortunately, complete cross resistance exists between thioguanine and mercaptopurine (Gilman et al, 1990; Black & Livingston, 1990).
    B) Thioguanine, an analogue of the nucleic acid guanine, competes with hypoxanthine and guanine for the enzyme hypoxanthine-guanine phosphoribosyltransferase (HGPRTase) and is itself converted to 6-thioguanylic acid (TGMP). At several points, TGMP interferes with the synthesis of guanine nucleotides. It prevents de novo purine biosynthesis by pseudofeedback inhibition of glutamine-5-phosphoribosylpyrophosphate amidotransferase (the first enzyme unique to the de novo pathway of purine ribonucleotide synthesis). It addition, TGMP prevents the conversion of inosinic acid (IMP) to xanthylic acid (XMP) by competition for the enzyme IMP dehydrogenase. The same enzymes that metabolize guanine nucleotides, convert thioguanylic acid to the di- and tri-phosphates, thioguanosine diphosphate (TGDP) and thioguanosine triphosphate (TGTP). These nucleotides are incorporated into both the DNA and the RNA by phosphodiester linkages (Prod Info Tabloid(R), 2001).

Physicochemical

Physical Characteristics

    A) A pale yellow, odorless or practically odorless, crystalline powder (Sweetman, 2003).

Molecular Weight

    A) 167.2(Sweetman, 2003)

References

General Bibliography

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