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Critical Reviews in Toxicology, 2010; 40(4): 287–304
Critical Reviews in Toxicology
Pharmaceuticals in the aquatic environment: A critical
review of the evidence for health effects in fish
Jenna Corcoran1, Matthew J� Winter2, and Charles R� Tyler1
1Environmental and Molecular Fish Biology, School of Biosciences, The Hatherly Laboratories, University of Exeter, Exeter, Devon, UK, and 2AstraZeneca Safety, Health and Environment, Brixham Environmental Laboratory, Freshwater Quarry, Brixham, UK
The authors review the current data on the presence and reported biological effects in fish of some of the most
commonly detected pharmaceuticals in the aquatic environment; namely nonsteroidal anti-inflammatory drugs
(NSAIDs), fibrates, β-blockers, selective serotonin reuptake inhibitors (SSRIs), azoles, and antibiotics� Reported
biological effects in fish in the laboratory have often been shown to be in accordance with known effects of
pharmaceuticals in mammals� Water concentrations at which such effects have been reported, however, are
generally, between μg L−1 and mg L−1, typically at least 1 order of magnitude higher than concentrations normally
found in surface waters (ng L−1)� There are exceptions to this, however, as for the case of synthetic oestrogens,
which can induce biological effects in the low ng L−1 range� Although generally effect levels for pharmaceuticals
are higher than those found in the environment, the risks to wild fish populations have not been thoroughly
characterised, and there has been a lack of consideration given to the likely chronic nature of the exposures, or
the potential for mixture effects� As global consumption of pharmaceuticals rises, an inevitable consequence
is an increased level of contamination of surface and ground waters with these biologically active drugs, and
thus in turn a greater potential for adverse effects in aquatic wildlife�
Keywords: Aquatic environment; cytochrome P450; ecotoxicology; fish; pharmaceuticals
24 September 2009
29 September 2009
Address for Correspondence:
Address for Correspondence: Charles R. Tyler, Hatherly Laboratory, Prince of Wales Road, Exeter, Devon, EX4 4PS, UK. Phone: +44
2010 Informa UK Ltd
(0)1392 264450; Fax: +44 (0)1392 263700; E-mail:
(Received 25 June 2009; revised 24 September 2009; accepted 29 September 2009)
ISSN 1040-8444 print/ISSN 1547-6898 online 2010 Informa UK Ltd
288
J. Corcoran et al.
system in wildlife species has a somewhat different physi-ological role, or is much more sensitive to the effects of a drug
Pharmaceuticals are a large and diverse group of medicinal
compared with that in humans or livestock animals� An, albeit
compounds used for the diagnosis, cure, mitigation, treat-
rare, example of this is for the nonsteroidal anti-inflammatory
ment, or prevention of diseases in humans and animals�
drug (NSAID) diclofenac, which has been shown to have a
Pharmaceuticals are often classified according to therapeutic
particularly severe effect on kidney function in some species
purpose (i�e�, antibiotic, analgesic, antidepressant, etc�), and
of Asian vultures, and this has resulted in their widespread
the worldwide consumption of some of these ‘classes' is sub-
decline and even localised population extinctions
stantial )� In 2008, worldwide sales of phar-
� Another example is for β-blocker drugs, which
maceuticals totalled US$602 billion, this figure rising annually
target the adrenergic system, which is thought to be involved
by approximately 5–7% (IMS Health 2009), paralleling the
in melanophore regulation in fish , a side
significant advances in medical technology and increased
effect not considered in humans�
spending on health car)�
In this paper, we critically assess the potential for impacts
An inevitable consequence of this increased consumption
of pharmaceuticals discharged into the aquatic environment,
of pharmaceuticals is higher levels of their discharge into the
focusing on possible biological effects in, and consequences
environment� Many pharmaceuticals end up in the aquatic
for, fish� Because of their ecological niche and similarities in
environment, and over the past two decades there has been
many of their physiological processes compared with mam-
a growing number of reports detecting trace levels of vari-
mals, fish are arguably the most likely vertebrate organism to
ous prescription and over-the-counter pharmaceuticals in
be affected by pharmaceuticals in the aquatic environment� In
waste water treatment work (WWTW) effluents, surface and
the first section of the paper, we consider which of the major
ground waters, and, in some countries, even in drinking water
classes of pharmaceuticals are entering surface waters, and
supplies� (See
assess what factors determine their persistence and bioavail-
ability to fish� We then focus on the evidence from laboratory
reviews)� The main routes of entry into the environment are
studies for potential effects of the most commonly detected
from treated patients, where the pharmaceutical may enter as
classes: formulated steroidal oestrogens; NSAIDs; antide-
the parent compound or as metabolites (Williams, 2005); via
pressants (e�g�, selective serotonin reuptake inhibitors or
direct release into the waste water system from manufactur-
SSRIs); azoles; fibrates; beta blockers (β-adrenergic receptor
ing, hospitals, or domestic discharges (
antagonists); and antibiotics in fish� The paper then critically
); and via leaching from terrestrial depositions (e�g�, solid
analyses the potential for environmental impacts of pharma-
waste landfills) (Barnes et al�, 2008)�
ceuticals in the environment on fish health, by drawing on
Generally, the concentrations of pharmaceuticals detected
comparisons between effects observed in the laboratory and
in the aquatic environment are relatively low, usually in the
concentrations measured in the field, and attempts to assess
ng L−1 to μg L−1 range, but in some countries (e�g�, India and
the scale of the (potential) problem�
China), relatively high concentrations of antibiotics, and other drugs, including β-blockers, antacids, and antidepres-
Pharmaceuticals in the aquatic environment
sants, are entering the aquatic environment through effluent from plants serving drug production units
The international market shows substantial regional differ-
� The regulations gov-
ences in the use of pharmaceuticals, influenced by economic
erning the environmental impact of pharmaceuticals in such
status, health requirements, capacity for local manufacture,
countries are limited compared with those in place in Europe,
and legal restrictions� As such, developed countries dominate
Japan, and North America, where there are specific legislative
global pharmaceutical sales, with North America account-
requirements to ensure any pharmaceuticals reaching market
ing for 45% (US$248 billion in 2004), Europe 13%, Japan
are assessed for their likely environmental fate and biological
10%, and Australia 1% of recorded sales (IMS Health MIDAS
effects (e�g�, EMEA, 2006), the results of which can, if neces-
2007)� In accordance with this pattern, the detection of phar-
sary, dictate controls over use and disposal�
maceuticals in the aquatic environment has predominantly
Critically, pharmaceuticals are designed to alter physi-
been reported in the developed world (USA, EU, Japan, and
ological function and this is unlike most other chemicals
Australia)� The exception to this is for some recent reports
entering the environment, where biological effects generally
from India and China, where exceptionally high levels of
occur as an unintended consequence of their principal func-
certain pharmaceuticals have been found in discharges
tion� Furthermore, some of the mechanisms through which
from newly established pharmaceutical production plants
certain pharmaceuticals act are relatively conserved across
animal phyla, thus some pharmaceuticals designed to induce
Generally, there is a positive correlation between the most
an effect in humans or livestock have a high probability of
frequently used classes of pharmaceutical and their detection
being biologically active in wildlife species� Supporting this
in the aquatic environment� Many of the top pharmaceuti-
assumption, recently Gunnarssan et al� (2009) concluded that
cals sold in the USA and UK are in drug classes used to treat
zebrafish possess orthologs to 86% of 1318 tested human gene
diseases associated with westernised society: for example
drug targets� It can also be the case that the biological target
maintaining cholesterol balance, combating mental illness,
Effects of pharmaceuticals in fish 289
treating stress, ulcers, asthma, etc�, and they include specific
(an antidepressant) ()� As such, for these com-
beta blockers, lipid regulators, antidiabetic, antianginal
pounds a significant proportion of the administered drug will
drugs, as well as analgesics and antibiotics ()�
pass directly through the patient without having crossed the
Paralleling this usage, these therapeutic classes are the most
gut wall of the patient�
commonly detected pharmaceuticals both in WWTW efflu-
For some compounds absorbed by the body, they may
ents and river water (where such analyses have taken place:
undergo phase I and phase II metabolism, with the resultant
; Sacher et al�, 1998; ; Golet
metabolites excreted via the urine and/or faeces (
et al�, 2001; Hartig et al�, 1999; Hirsch et al�,
� The degree of metabolism that occurs can vary
greatly between compounds; some are completely metabo-
Roberts and Thomas,
lised, whereas other compounds are not metabolised at all
and are excreted completely as the parent compound�
; Bartelt-Hunt et al�,
Metabolism modifies the chemical structure and thus
properties of the active molecules, in some instances ren-
For veterinary pharmaceuticals, the most commonly used
dering them inactive� This is not always the case, however,
class are the antibiotics, followed by azoles� Accordingly,
and some produce metabolites that are biologically active�
there are also many papers reporting the detection of these
For example, clofibrate, a lipid-regulating drug, is a prodrug
drugs in the aquatic environment, and other environmental
whose pharmacological activity is dependent on metabolism
compartments, including farm waste and in some cases at
in the body to the active form, clofibric acid
very high concentrations
Peschka et al�,
Excreted pharmaceuticals and their metabolites entering
WWTWs may undergo biodegradation, remain suspended or
dissolved in the water, or bind to biosolids or sewage sludge
Examples of this include the antibiotics tetracycline and sul-
)� Rates of degradation of pharmaceu-
famethazine, which have been measured in farm manure at
ticals in WWTWs vary depending on the pharmaceutical
concentrations of 66 and 40 mg L−1, respectively (Winkler and
and where they partition in the environment� For example,
Grafe, 2001)� Importantly, this manure is commonly applied
ibuprofen has a high elimination rate, generally >90%, and
to agricultural fields as a fertiliser, and it is now accepted that
so is rapidly degraded (; Metcalfe et al�,
this constitutes a major route via which veterinary pharma-
2003a; ), whereas, in contrast, car-
ceuticals may enter surface and groundwater
bamazepine has an elimination rate of only 4–8% (Ternes,
; Martinez-Carbello et al�, 2007)�
1998b; ; )� The slow
Reported concentrations of pharmaceuticals detected in
elimination rate for carbamazine may explain why this drug is
WWTW effluent are in the high ng L−1 to low μg L−1 range,
frequently measured in both WWTW effluent and river water,
whereas in surface waters pharmaceuticals rarely exceed
even though it is not a pharmaceutical of high consumption
concentrations of 100 ng L−1 (� Certain
(IMS Health 2007)
. Considering the environmental compart-
pharmaceuticals have also been detected in the low ng L−1
ment into which the pharmaceutical partitions, elimination
concentration range in groundwater
rates of various antibiotics tend to be considerably slower in
in the oceans ),
anaerobic conditions (as might occur within deep sediments)
and even in drinking wat�
compared with aerobic conditions (�
Adsorption of pharmaceuticals to the sludge is dependent
Factors influencing the concentration of
on hydrophobic and electrostatic properties of the chemical
pharmaceuticals in the aquatic environment
� For example, acidic pharmaceuticals (e�g�, NSAIDs, clofibric acid, gemfibrozil) occur as ions at neutral
The concentration of pharmaceuticals detected in the aquatic
pH and so there is little adsorption to sludge and sediments
environment is not only determined by usage levels, but also
; )� In turn, these
by the degree of metabolism that occurs in the patients body
pharmaceuticals are more likely to remain in the water col-
(Winker et al�, 2008), degradation rates in the waste water
umn and thus may more readily pass through WWTWs into
system and receiving waters ),
effluent discharges and their receiving surface waters� Basic
and how the compound partitions into the water column/
pharmaceuticals, such as 17α-ethinyloestradiol (EE2) and
sediments (Debsake et al�, 2004)� It should also be realised
fluoroquinolone antibiotics, however, have been shown to
that a large proportion of prescribed drugs are not admin-
adsorb readily to sludge (Golet et al�, 2002), and can occur in
istered and are disposed of directly into waste waters; an
sediment at ng g−1 levels (Ternes et al�, 2002)� This facilitates
estimated $1 billion of prescription drugs are discarded each
their removal in WWTW and contributes to the fact that high
year in the US, from hospitals, care facilities, and pharmacies
proportions of these pharmaceuticals are removed from the
aqueous phase as it passes from the influent to effluent (for
Most human pharmaceuticals are taken orally, with rates
steroidal oestrogens there is between 70% and 80% removal;
of absorption ranging from under 20% for drugs such as
Ternes et al�, 1999)
.
metformin (an antidiabetic) to around 80% for fluoxetine
Similarly, antidepressants readily partition into sediment
290
J. Corcoran et al.
where they have been detected at ng g−1 concentrations
Furthermore, there is a continuous release of pharma-
ceuticals into the aquatic environment, which may result
entering the aquatic environment that adsorb readily to
in long-term, chronic exposure, and this, combined with a
sediments in WWTWs may in turn be of greater concern for
propensity, for some, to bioaccumulate (e�g�, EE2; Hill et al�,
terrestrial environments where the sewage sludge is applied
2006), means there is the enhanced likelihood of adverse
biological effects�
Photodegradation can also be important in the environ-
mental degradation of some pharmaceuticals and this proc-
Evidence for biological effects of commonly
ess has been shown to play a major role in the removal of
detected pharmaceuticals in fish
diclofenac in surface water (Buser et al�, 1998b) and to con-tribute significantly to the breakdown of sulfamethoxazole,
Pharmaceuticals receive considerable testing to make sure
propranolol, and ofloxacin (Andreozzi et al�, 2003b)�
that they are not harmful to human health, and as such there is much information available relating to the physiological
The susceptibility of fish to pharmaceutical
effects of drugs in mammals (e�g�, see )�
However, information on the effects of these biologically active substances in nontarget animals, including fish, is lim-
Pharmaceuticals are generally nonpolar
ited� In this next section we review the available information,
) and are therefore able to pass through bio-
both from the laboratory and the field, for the effects of vari-
logical membranes by diffusion, to targets within specific
ous major human and veterinary pharmaceuticals in fish�
cells and tissues� The majority of drug targets are proteins, such as enzymes, receptors, carrier molecules, or ion chan-
Pharmaceutical steroidal oestrogens and progestagens
nels, and it is the diverse and complex structure of these
There is more information on the biological effects in fish of
proteins that enables pharmaceutical selectivity, which is
the synthetic oestrogen EE2 than for any other pharmaceu-
the basis for the precise functioning of a drug (William and
tical discharged into the aquatic environment� EE2 has fre-
Cook, 2007)� Thus, as a drug is developed based on a specific
quently been detected at low (ng L−1) levels in surface waters
biological activity in one animal group (principally mam-
and WWTW effluents ; Baronti et al�, 2000),
mals) and many of these systems targeted are conserved
despite the fact that only relatively small volumes are pro-
amongst vertebrates, it would seem reasonable to predict
duced annually (approximately 26 kg per year, worldwide,
that they will target the same systems in fish� Indeed, this
and 1 kg in the � Nevertheless, EE2 is
has been shown to be the case for a wide range of potential
extremely potent in fish
, and environmentally relevant con-
drug target sites, including serotonin receptors (
centrations have been shown to induce feminisation in fish,
; β-adrenergic recep-
including induction of the female yolk precursor vitellogenin
tors (Ruuskanan et al�, 1985), cyclooxygenase (COX)
(VTG) in males (e�g�, Orn et al�, 2003, 2006;
peroxisomal proliferator-activated
; formation of a female reproductive duct in the
receptors ), and several
testis (and induction
cytomchrome P450s (CYPs) (see Siroka and Drastichova,
of intersex (the presence of oocytes in the testis; e�g�
2003, for a review)�
The life history of fish and some features of their physiol-
et al�, 2001; )� These effects
ogy potentially make them especially susceptible to phar-
are documented in a wide range of species, although there
maceutical uptake and effects )
. Uptake
appears to be differences in species sensitivity (for recent
of pharmaceuticals into fish can occur via both dermal and
reviews see ; )� Adding to
gill surfaces for water-borne/sediment associated phar-
the concern surrounding the use and discharge of EE2, life
maceuticals, orally through the diet, or maternally, via the
time exposure to relatively low concentrations of EE2 in the
transfer of contaminants through the lipid reserve of eggs�
water (5 ng L−1) has been shown to cause reproductive failure
Pharmaceutical drugs are generally designed to have low
in colonies of laboratory maintained zebrafish (
toxicity (possibly with the exception of cytotoxic chemothera-
), and similarly the dosing of a lake in Canada (Lake 206)
peutics), but there is the potential for unintended side effects�
with 4–6 ng EE2 L−1 resulted in complete failure of the fathead
This is perhaps particularly in nontarget species groups,
minnow (
Pimephales promelas) fishery ( )�
where side effects or even pharmacological effects may differ
Exposure of roach (
Rutilus rutilus), a species in which wide-
compared with those in humans and laboratory test mam-
spread sexual disruption has been shown in wild populations
mals due to differences in physiology and biochemistry� For
living in UK rivers downstream of WWTW discharges, to 4 ng
example, fish have a lower capacity to metabolise xenobiotics
L−1 EE2 for a 3-year period resulted in complete feminisation
compared with mammals
of the exposure populations )� Moreover,
Casarett et al�, 2001), especially during early life stages
physiological effects of EE2 in fish are not confined to effects
on reproduction, and targeted gene expression and gene
array studies have shown that EE2 also alters mitochondrial
Effects of pharmaceuticals in fish 291
function, energy metabolism, and cell cycle control
indomethacin, are human pharmaceuticals that are regularly
detected in both WWTW effluent and surface waters at con-
EE2 has a much lower solubility than natural steroid
centrations in the μg L−1 range
oestrogen oestradiol (E2)
al�, 2004; Farre et al�, 2001;
) and it is also considerably more persistent
Herberer et al�, 2002,
in the aquatic environment, with an estimated half life in
surface waters of between 1�5 and 17 days, depending on the
amount of sunlight Jurgens et al�, 2002), and
The therapeutic role of these pharmaceuticals is to reduce
in soils between 3 and 7�7 days, depending on the tempera-
inflammation and pain; these drugs work by inhibiting
ture ()� Add to this is the fact that EE2
cyclooxygenases (COXs), enzymes that catalyse the synthe-
is lipophilic and bioconcentrates in fish to high levels (over
sis of prostaglandins, via the oxidation of arachidonic acid�
10,000-fold in short-term [10–21-day] exposures;
There are two isozymes: COX1 is responsible for the baseline
), including in the gonads (, and
levels of prostaglandins, and COX2 produces prostaglandins
it is clear why this compound is of particular environmental
in response to stimulation (i�e�, it is an inducible enzyme)
at the site of inflammation� NSAIDs can be COX1 or COX2
Other steroidal oestrogens used in formulations for con-
selective, or can inhibit both isozymes equally�
traception or in hormone replacement therapy include con-
This drug target is conserved across vertebrates
jugated oestrone (oestrogen sulphate) and equine oestrogens
), and both COX1 and COX2 isoenzymes have
(Archand-Hoy, 1998; Stevenson, 2005)� These oestrogens
been characterised in a number of fish species
have also been detected in WWTW effluents, at concentra-
; Buonocore et al�, 2005;
tions in the ng L−1 range: oestrone sulphate 0�4–2�6 ng L−1
; � Most NSAIDs
; , equilenin 1 ng
inhibit both COX1 and COX2 isoforms, and as such, result
L−1 dihydroequilenin (a product of
in the nonspecific inhibition of prostaglandins� This, in turn,
metabolism of equilenin) 1�45–2�51 ng L−1 (
means there is the potential for effects on any of the normal
� Dihydroequilenin has also been detected in the bile
physiological functions mediated by prostaglandins, which
of rainbow trout downstream from a WWTW at concentra-
are diverse ()�
tions of 30–40 ng ml−1), which suggests
In fish, prostaglandins are found in numerous cells and
this compound may bioaccumulate�
tissues, including red blood cells, macrophages, and oocytes
Oestrone sulphate, in its conjugated form, is biologically
active in fish (our own unpublished data) and is also readily
and their key roles include in reproduction, where they
metabolised to oestrone, which is strongly oestrogenic in fish
have a paracrine role in the ovary, stimulating ovulation
at environmentally relevant concentrations (
)� Similarly, equilenin and dihydroequilenin are biologi-
and oestradiol production ();
cally active in fish, with effective concentration inducing VTG
eliciting female sexual behaviour through effects on the
synthesis in rainbow trout
(Oncorhynchus mykiss) of 4�2 and
brain ; and as a sex pheromone,
0�6 ng−1, respectivel�
stimulating male sexual behaviour (;
Progestagens form a component of some contraceptive
)� Consistent with the likelihood that
and hormone replacement therapy (HRT) formulations,
NSAID can affect reproduction in fish, indomethacin has
and have been detected in the WWTW effluent and surface
been shown to disrupt the process of oocyte maturation and
waters at ng L−1 to μg L−1 concentrations (
ovulation in zebrafish at a concentration of 100 mg L−1 (
) and in river sediment at a concentration
) and ibuprofen has been shown to
of 6 ng g−1 ()
. In mammals, progestagens act
alter the pattern of spawning in Japanese medaka at concen-
via the progesterone receptor (PR) and regulate a number
trations of µg L−1� These reported effects,
of physiological effects associated with the maintenance of
however, exceed those reported in any aquatic environment
pregnancy, and development of the foetus� More recently
it has been suggested that in humans, progestagens have
COX-synthesised prostaglandins are also known to be
important functions in the central nervous system (
important in cortisol biosynthesis in fish (Wendelaar Bonga,
� The PR has been characterised in some fish spe-
1996; and accordingly it has been
demonstrated that NSAIDs can disrupt cortisol production
although there are few data on the roles of progestagens in
in trout (� Cortisol is known to play
fish, it is thought that they are involved in oocyte maturation
an important part in osmoregulation in fish, specifically
and spawning ); progesta-
the development and proliferation of chloride cells in the
gens also act as a precursor for oestrogen and testosterone�
gills and stimulation of Na+,K+-ATPase activity for seawater adaptation � Exposure of rainbow trout to
ibuprofen at a concentration of 1 mg L−1 has been shown to
Nonsteroidal anti-inflammatory drugs (NSAIDs), such
impair ion regulation and so the hyposmoregulatory capacity
as diclofenac, naproxen, ibuprofen, ketoprofen, and
in seawater ()�
292
J. Corcoran et al.
Table 1. Measured environmental concentrations versus toxic effect concentrations in fish for selected pharmaceuticals.
Measured environmental
Toxic effect concentration
Pharmaceutical STP effluent
Endpoint measured Species
0.81–33.9 μg/L
6.2 ng/L–1.8 μg/L
glandin synthesis
liver, and kidney
Histological altera-
Histological altera-
Cytological altera-
tions; liver, kidney,
70 ng/L–2.7 μg/L
reproduction pattern
Impairment of ion
Disruption of oocyte Zebrafish
80 ng/L–0.52 μg/L 70 ng/L–0.39 μg/L
0.20–0.32 μg/L
0.099–0.841 μg/L
0.012–0.030 μg/L
ability to catch prey
Increased oestradiol Medaka
changes to gonads
Increased levels of
29.76 (0.056 μM) 0.0298
Inhibition of 17β-
Table 1. Continued on next page
Effects of pharmaceuticals in fish 293
Table 1. Continued.
Measured environmental
Toxic effect concentration
Pharmaceutical STP effluent
Endpoint measured Species
2513.85 (9.7 μM)
Inhibition of 17β-
Reduced fedundity
Inhibition of brain
Decreased number of Fathead
Inhibition of ovarian Fathead
Induced testis growth Fathead
7700.00–39700.00 7.7000–39.7000
Induce oxidative
32,279.10 (133 μM) 32.2791 (EC )
Lowered sperm count Fathead
Runnells et al., 2007
Lower plasma andro- Fathead
Runnells et al., 2007
gen concentration
23,299.20 (96 μM) 23.2992
Inhibition of EROD
Induce oxidative
19,124.52 (53 μM) 19.1245 (EC )
9021.00 (25 μM)
Inhibition of EROD
Reduced testosterone Goldfish
Nimeault et al.,
0.048–0.052 μg/L
Inhibition of CYP2M Carp
0.01–0.29 μg/L
0.012–0.59 μg/L
7002.18 (27 μM)
Altered heart rate
Fraysee et al., 2006
Altered blood flow
Total number of eggs Medaka
Number of viable eggs Medaka
<10 ng/L–0.130
17.2 ng/L–0.241
Number of viable eggs Fathead
0.11–0.34 μg/L
Suppressed immune Rainbow trout
Grondel et al., 985
294
J. Corcoran et al.
The NSAID diclofenac has been associated with a serious
tissues in fish (Caamano-Tubio et al�, 2007)� As an important
effect in wildlife, causing renal failure in particular species of
neurotransmitter, in fish, serotonin has been implicated
exposed Asian vultures that has lead to widespread popula-
in several physiological functions, influencing behaviour
tion crashes 2004)� The mecha-
(aggression, appetite), endocrine, and reproductive param-
nism of toxicity in this case (induction of visceral gout), and
eters� Furthermore, serotonin is involved in social hierarchy
the enhanced sensitivity, however, seem to be peculiar to a
and feeding rank in some species ,
small number of species, and the route of exposure rather
Alanara et al�, with sub-
unusual (via cattle carcases on which the vultures feed)�
ordinate individuals having higher brain serotonergic activity�
In fish, as occurs in mammals, diclofenac hinders the stim-
With this in mind, SSRIs have the potential to disrupt a wide
ulation of prostaglandin synthesis in the head kidney, and in
range of processes in fish, both at the level of the individual
brown trout this has been shown to occur at environmentally
organism, and potentially the population (by affecting social
relevant concentrations of 0�5–50 μg L−1 ()�
interactions and reproduction)
.
In rainbow trout, harmful effects of diclofenac, including the
To date, most research on SSRIs has focused on fluoxet-
induction of glomeruloneophritis, necrosis of endothelial
ine (Prozac); nevertheless, as all the SSRI drugs work via the
cells, and hyaline droplet degeneration, have been shown in
same basic mode of action, it is reasonable to assume that
the kidney, and pillar cell necrosis, epithelial lifting, hyperpla-
most will exhibit similar effects� In fish, fluoxetine has been
sia, and hypertrophy of epithelial chloride cells in gills have
shown to decrease territorial aggressive behaviour in male
been shown to occur at exposure concentrations between 1
bluehead wrasse on introduction to an intruder male, in both
and 5 μg L−1 (4)�
the laboratory and field, at a concentration of 6 μg g day−1 over
It is not known, however, whether the gill effects are asso-
2 weeks ()
. Exposure
ciated with prostaglandin inhibition, or through another
of striped bass to fluoxetine (23�2–100�9 μg L−1) over 6 days
mechanism� In contrast, no pathological damage to the gills
caused a decrease in their ability to capture prey (fathead
or kidney was detected on exposure of Japanese medaka to
minnow) in a concentration- and a duration-dependent man-
ibuprofen, at concentrations up to 100 μg L−1 (
ner (), and fluoxetine exposure
� This may be due differences in the relative potencies
decreased feeding rates in fathead minnow (
of these drugs: diclofenac COX-2 IC is 0�06 μM, whereas the
with an lowest observed effect level (LOEC) between
IC for ibuprofen is 19 μM (�
51 and 170 μg L−1� These data indicate potential survivorship
NSAID exposure has also been linked to cardiac abnor-
implications; however, these concentrations far exceed meas-
malities and lowered heart rate (
ured environmental concentrations�
depletion of glycogen in the liver
SSRIs are also implicated in alterations to reproduction in
Busby et al�, 2002), teratogenicity in
fish� Changes in serotonin levels are correlated with repro-
zebrafish embryos , disruption of
ductive phases in female fish ),
the heat shock response in rainbow trout (
and it has been shown that serotonin plays an important
), and inhibition of CYP2M activity in carp
stimulatory role in the regulation of gonadotropin II (GTH-II)
(luteinising hormone release; ; ; ;
Antidepressants (selective serotonin reuptake inhibitors)
)� GTH-II induction in turn will increase steroido-
The selective serotonin reuptake inhibitor (SSRIs) antide-
genesis� Accordingly, exposure of medaka to fluoxetine at
pressants, such as fluoxetine, paroxetine, setraline, etc�, are
0�1 and 0�5 μg L−1 concentrations elevated oestradiol levels
amongst the most commonly detected pharmaceuticals in
), presumably via an increased level of
both surface water and WWTW effluents, reflecting their
serotonin� In medaka, serotonin has also been shown to
usage volumes in human medicine� They are generally
induce oocyte maturation (Iwamatsu et al�, 1993)� Increased
present at concentrations in the ng L−1 to low μg L−1 range
steroidogenesis may also be associated with altered growth
and developmental patterns; for example, fish may mature
and have also been detected in sediment in ng g−1 concentra-
in the wrong season due to impaired growth� Modification
of these endpoints have indeed been reported in fathead
SSRIs exert therapeutic effects by inhibiting monoamine
minnow, at concentrations of between 51 and 53 μg L−1 of
transporters and thus inhibiting the reuptake of the neuro-
fluoxetine, and in medaka, at environmentally relevant lev-
transmitter serotonin (5-hydroxytryptamine) at presynaptic
els of 0�1–5 μg L−1;
neuronal membranes (� This
elevates the concentration of serotonin in the synaptic gap
Not all studies on the effects of fluoxetine in fish, however,
)� Therapeutically, this is beneficial to those
have been consistent in their findings� As an example
suffering with depression and related psychiatric disorders
found no significant affect on fecundity, egg
(Brooks et al�, 2003a)�
fertilisation, or hatching success in medaka for exposures
Serotonin receptors have been identified in several fish
between 0�1 and 5 μg fluoxetine L−1, over a 4-week period�
SSRIs are generally detected in the aquatic environment
, and serotonin (5-HT) is found in several different
only at very low levels (ng L−1), and many of the effects
Effects of pharmaceuticals in fish 295
reported upon above far exceed likely exposure regimes for
species, fadrozole significantly induced testis growth (at a
fish in the wild� Wild populations of fish, however, have been
concentration of 51�7 μg L−1)�
found to contain detectable amounts of fluoxetine in their
Ultimately, it seems that azole drugs may have the poten-
body tissues (, showing this drug at least
tial to affect reproduction via a number of mechanisms, as
has the potential to bioaccumulate (Paterson and Metacalfe,
The effective exposure concentrations for the azoles
derived from laboratory studies generally appear to exceed
Azoles (aromatase inhibitors)
those reported in surface waters� Nevertheless, although rarely
A number of azole antifungal drugs, such as ketocona-
detected above the ng L−1 level as individual compounds in
zole, clotrimazole, miconazole, and fluconazole, as well
the natural environment, azoles are likely to be present as a
as the aromatase inhibitor fadrozole, are commonly used
mixture and they are likely to have similar modes of action
in human, and veterinary medicine, and some have been
and be additive in their biological effects� Supporting the
detected in the aquatic environment at ng L−1 concentra-
statement on their presence in the environment as mixtures,
studies have commonly reported the presence of propico-
Peschka et al�, 2007; � Azoles
nazole, used as a fungicide in agriculture, and benzotriazole
act against fungi by inhibiting the enzyme CYP51, which
and tolyltriazole, used as aircraft de-icer at ngL−1 to μg L−1
catalyses the 14α-demethylation of lanosterol, the main
concentrations in surface waters
step in the synthesis of ergosterol (Trosken et al�, 2004)�
Ergosterol is required in fungal cell membrane synthesis,
and as such, exposure to azoles results in structural and
� Indeed, some of these compounds appear almost
functional impairment of the membrane, ultimately inhib-
ubiquitously present in the aquatic environment;
iting fungal growth�
detected benzotriazole in 94% of rivers studied in
This CYP inhibition, however, is nonspecific
European Union (EU) countries (out of a total 122 tested), at
, and in addition to CYP51, these drugs are well known
a median concentration of 226 ng L−1� The mixture issue for
as potent inhibitors of other cytochrome P450s in vertebrates,
azoles in the aquatic environment needs to be addressed to
including in fish� For example, some azoles have been shown
gain a realistic view on their (potential) impact in fish�
to inhibit CYP1A and CYP3A isoforms (Hasselberg et al�, 2008), both are involved in xenobiotic and
steroid metabolism� Azoles have also repeatedly been shown
One of the most common classes of pharmaceuticals, in
to inhibit CYP19 (aromatase), which is a key steroidal enzyme
terms of detection in the aquatic environment, are the lipid
involved in the synthesis of oestrogen from androgen� In fact,
regulators, particularly fibrate drugs� For example, bezafi-
this mechanism has been utilised in humans as the basis
brate, gemfibrozil, and fenofibrate have been detected at μg
of antioestrogen therapy (e�g�, for breast cancer treatment;
L−1 concentrations in surface waters ;
Trosken et al�, 2004)� As such, azoles have the potential to
interfere with steroid biosynthesis and thus sex hormone bal-
Clofibric acid is commonly reported in surface water and
ance in nontarget species, including in fish�
WWTW effluent at concentrations in the μg L−1 range and
Drugs such as ketoconazole, clotrimazole, and fadrozole
has even been detected in drinking water
are known reproductive toxicants to fish and have been shown
, albeit at relatively low concentrations (up to 270 ng
to effect steroidogensis and reproductive success, linked to
L−1)
. Recently, statins are being increasingly prescribed (the
inhibition of steroidogenic enzymes CYP11a, CYP17, and aro-
top prescription drug in the US in 2006 was a statin lipid
matase, at concentrations as low as 11�1 nM (
regulator; IMS Health 2007)
. However in contrast with fibrate
� In turn, this inhibition has been
drugs, as yet there is very scarce data on the occurrence and
shown to alter the production of several steroids (androsten-
ecotoxicology of statins�
edione, testosterone, and 17β-estr
Fibrates are peroxisomal proliferators (PPs) with the ulti-
) with various knock-on reproductive
mate therapeutic effect being the lowering of blood plasma
effects in both male and female fish�
lipid levels� PPs bind and activate the peroxisomal prolifer-
In female fathead minnow, these effects include decreased
ator-activated receptor alpha (αPPAR) transcription factor,
egg production (), decreased plasma vitel-
which in turn binds to response elements (PPREs) in the
logenin concentrations , and inhibition
promoter region of PP-sensitive genes ();
of ovarian growth )� Effect concentrations
predominantly those genes are involved in lipid metabolism,
are generally in the μg L−1 range and have been demonstrated
e�g�, acyl–coenzyme A oxidase (AOX), an enzyme which initi-
to occur at concentrations as low as 2 μg L−1
ates peroxisomal β oxidation of fatty acids (
)
. This increased enzymatic activity, coupled with
In male fathead minnow exposure to fadrozole (2–50 μg L−1
increased peroxisomal volume leads to the removal of fatty
over 21 days) was shown to result in elevated levels of plasma
acids and cholesterol from the blood�
testosterone, and this was linked to inhibition of aromatase
One reported side effect of this is increased production
activity (� In a separate study on the same
of hydrogen peroxide (H O ) in the cell, which may lead to
296
J. Corcoran et al.
oxidative stress and hepatocarcinogenesis (
prescribed classes of human pharmaceuticals and accord-
� Indeed, a strong correlation has been shown between
ingly, they are frequently detected in WWTW effluent and
exposure to fibrates and hepatocarcinogenesis in rodents
surface waters, generally at ng L−1 concentrations (
)� In addition, antioxidant system compo-
nents are known to be suppressed with chronic exposure to
PPs in ra), which could be expected to
et al�, 2003a; ; Hilton and Thomas, 2003;
exacerbate this effect�
� Moreover, in some surface waters, biso-
There are few studies on the effects of fibrates in fish�
prolol and metoprolol have been detected at concentrations
The same peroxisomal B oxidation system does exist in fish,
up to the μg L−1 range ()�
Beta blockers are used to treat cardiac conditions such as
angina, heart failure, high blood pressure, and glaucoma, and
; and fish respond
work as competitive β-adrenergic receptor (β-AR) antagonists
to PPARα agonists by increasing AOX activity
on cardiac muscle to decrease heart rate and contractility
; Donohue et al�,
1993)� This indicates that the PPAR pathway is an important
β-ARs are relatively conserved amongst vertebrates
factor in mediating enzymatic response to fibrates in fish,
and this target is now known to
as it is in mammals� It has further been demonstrated that
be present in a number of extracardiac tissues and organs
clofibrate and fenofibrate induce oxidative stress in rainbow
in fish, including branchial vascular tissue, gills, liver,
trout hepatocytes, at concentrations of 242�70 and 1�89 mg
erythrocytes, brain, and muscles (;
L−1, respectively ), indicating fish may be
susceptible to the effects of fibrates�
and Milsom, 1990; 1992;
Interestinglreported no lipidemic-
associated effects in fathead minnow exposed to clofibric
� There are three subclasses of β-AR (β1,
acid (0�01–1 mg L−1), but instead deleterious effects were seen
β2, and β3), against which various beta blockers have dif-
on the reproductive system� These included reduced sperm
fering potency and efficacy, and these receptors have been
count, impaired spermatogenesis, and a lowered plasma
implicated in various physiological functions in fish (e�g�,
androgen concentration� Similarly, it has been shown that
cardiovascular regulation, growth, metabolism), reflect-
exposure to gemfibrozil (1�5 mg L−1 for 96 h reduces testo-
ing their wide distribution (� As such,
sterone by more than 50% in goldfish testes
beta blockers have the potential to impact on a range of
physiological systems, and, there are a number of stud-
Fibrates have additionally been shown to modify the activ-
ies indicating effects in fish exposed to a number of these
ity of cytochrome P450 enzymes, although there appear to be
conflicting results in this regard� Bezafibrate and clofibrate
In terms of acute toxicity, propranolol was shown to have
induced CYP1A-associated ethoxyresorufin-
O-deethlyase
a LC of 24�3 mg L−1 (48 h) and caused a decreased growth
(EROD) activity in fathead minnow–derived cell line PLHC-1,
after 14 days' exposure to 0�5 mg L−1, in medaka (
at concentrations of 1 and 10 mM, respectively (
; however, in another study on rainbow trout
Similarly, propranolol impaired growth in juvenile rain-
hepatocytes, basal EROD activity was shown to be inhibited
bow trout at 10 mg L−1 after 10 days � β-ARs
by these compounds (clofibrate and fenofibrate at EC of
have been linked with a role in protein accretion (
96 and 25 μM, respectively; )
. Gemfibrozil
, which helps regulate growth in fish, and this
has been shown to inhibit the catalytic activity of CYP2M
may provide a possible explanation for the effect seen on
by 91% at an exposure level of 1 mM (and to a lesser extent
CYP1A- and CYP3A-associated activities) in carp hepatocytes
With reference to cardiovascular effects, propranolol has
been shown predictably to affect the heart rate in zebrafish
To our knowledge, the only published report on the acute
(LOEC = 27 μM, 48 h; Fraysee et al�, 2006) as well as blood
toxicity of fibrates to fish is that reported in
G. Holbrooki
flow through the gills, at a concentration of 10 mM (
exposed to clofibrate, where the LC was relatively high
(between 7�7 and 39�7 mg L−1� Nevertheless,
Additionally, showed that an
gemfibrozil was reported to bioconcentrate in goldfish with
exposure to 5 μM propranolol induced a 92% drop in glucose
a bioconcentration factor of 113 after 14 days of exposure
production in isolated liver of rainbow trout, which is most
and, as such, fish may be chronically
likely explained by the fact that during stress, fish respond by
exposed to higher levels of these compounds than those that
increasing glucose levels via an increase in hepatic β2-ARs
are reported to be present in the environment�
(Reid et al�, 1992)�
β-ARs are also thought to be involved in oxygen chemore-
Beta blockers (β
-adrenergic receptor antagonists)
ception in the gills and accordingly, propranolol has been
Collectively, beta blockers, such as atenolol, propranolol,
shown to inhibit receptor discharge in the gills
metoprolol, celiprolol, etc�, are one of the most commonly
Effects of pharmaceuticals in fish 297
In addition, there are limited reports of effects of beta
There is also some evidence to suggest that tetracyclines can
blockers on reproductive and growth of fish� Egg production
have a suppressive effect on the immune systems in fish,
and hatching success were both reduced in medaka after 28
with effect concentrations overlapping with those some-
days of exposure to propranolol at 5 μg L−1
times occurring in the environment (0�1–50 μg L−1 ;
� Atenolol has been shown to affect growth in fathead
minnow embryolarvae, after a 28-day exposure, but only at
It is most likely that antibiotics may affect fish indirectly by
the relatively high concentration of 10 mg L−1 (
modulating microbial function in aquatic ecosystem in turn
affecting processes such as denitrification, nitrogen fixation,
Propranolol has also been linked to a decreased pineal
and organic breakdown , rather than
function in trout ), which could
having direct effects on fish physiological function per se�
potentially impact on breeding cycles and activity rhythms�
Many other pharmaceutical compounds outside of the main
Antibiotics are a wide-ranging group of compounds of which
classes outlined above are regularly detected in the aquatic
there are several classes with different mechanisms of action�
environment, but have received far less attention in terms
The antibiotics include sulfonamides, penicillins, and tetracy-
of their potential biological effects in aquatic organisms�
clins, many examples of which have been detected in WWTW
For example, chemotherapy drugs such as ifosamide have
effluents and surface waters at ng L−1 to μg L−1 concentrations
been detected in surface waters at ng L−1 levels, and in hos-
pital waste waters at levels up to 4�5 μg L−1
berts and Thomas,
Van der Heide and
2005; � The antiepileptic drug car-
Hueck-van der Plas, 1984)� There are also reports of much
bamazepine is also regularly detected at ng L−1 to μg L−1 con-
higher concentrations at point discharge sources; for exam-
centrations in WWTW effluent and surface water (Metcalfe
ple, sulfonamide concentrations of 5 mg L−1 were detected
et al�, 2003a;
downstream of a landfill used for pharmaceutical produc-
, seawater (Weigel et al�, 2002),
tion waste disposal ) and oxytetracyclin
and sediment (Thaker et al�, 2005); as are the anticonvulsant
was found to be present at concentrations of up to 50 mg L−1
diazepam (van der Hoeven, 2004;
in effluent from a production facility in China (
; van der Ven et al�, 2004; and
the antidiabetic metformin ()�
Antibiotics are a commonly used and important group of
pharmaceuticals in both human and veterinary medicine,
Environmental concentrations versus
used to combat bacterial infection� Their modes of action
biological effects in fish
vary according to type: penicillins impede synthesis of the bacterial cell wall; tetracyclines bind to ribosomes and impair
Despite regular detection of many human and veterinary
protein manufacture; and sulfonamides competitively inhibit
compounds in the aquatic environment, there is still no evi-
bacterial enzyme dihydropteroate synthase (DHPS)� Despite
dence of any significant effects on aquatic wildlife species at
the different modes of actions, however, the ultimate effect
the population level�
is the suppression of bacterial growth, and so they are used
Various effects of pharmaceuticals have been docu-
therapeutically to prevent and treat bacterial infections, as
mented in fish, as described above, but these effects have
well as growth promoters in farming and aquaculture�
largely been confined to exposures in the laboratory, and
The presence of antibiotics in the aquatic environment
often at comparatively high concentrations, and few stud-
has generally been investigated in terms of the develop-
ies have been undertaken in the field� The most convincing
ment of bacterial resistance (e�g�
evidence for an association between exposure of fish to a
and knock on effects regard-
pharmaceutical and an adverse effect in fish is for EE2 and
ing human health by the transfer of resistance to human
sexual disruption� This judgement is based on combined
pathogens rather than for any concern
findings from extensive laboratory exposures and measured
for possible toxicity to aquatic organisms� Unlike most phar-
concentrations in the environment, all of which provide
maceuticals, antibiotics are specifically aimed at bacterial
highly persuasive data leading to the conclusion that EE2
targets avoiding possible toxicity to the infected human or
contributes to the feminisation of wild roach populations liv-
animal� Some classes of antibiotics are used to combat bacte-
ing in the vicinity of WWTW effluent discharges in UK Rivers�
rial infections in fish farms�
Furthermore, both the incidence and severity of intersex in
Despite the frequent occurrence of various antibiotics
these feminised wild roach have been shown to be correlated
in the aquatic environment, there is almost nothing in the
with the predicted environmental concentration of natural
literature reporting toxic effects of these drugs in fish�
and synthetic oestrogens at those sampling sites (
Sulphonamides, however, are acutely toxic to fish (medaka
;
)� The intersex condition in the more severely
Kim et al�, 2007), at high exposure concentrations (>100 mg
affected fish has also been associated with reduced fertility
L−1), but these are found rarely in the aquatic environment�
298
J. Corcoran et al.
For all other pharmaceuticals, there is not substantive evi-
ketoconazole has been shown to increase the sensitivity of
dence for an adverse effect in exposed wild fish populations,
rainbow trout to 17α-ethynyloestradiol exposure (Hasselberg
but equally there has been little attempt to directly address
et al�, 2008)� As such, where various pharmaceuticals and
this question� The following section provides an overview of
other contaminants occur together, there may be additional
the likelihood that effects are possible in wild fish exposed to
or additive effects, which could not be predicted by assess-
(nonsteroidal oestrogen) pharmaceuticals�
ments looking at only the concentration effects of a single
shows a comparison between measured or pre-
pharmaceutical� In fact, toxicity testing using combinations
dicted environmental concentration and effect level con-
of pharmaceuticals at low concentrations has shown that
centration and in general; for most pharmaceuticals, the
impacts occurred at concentrations where single compounds
levels detected in the environment are at least an order of
showed little or no effects e�g�,
magnitude lower than those levels shown to cause any effect�
diclofenac and ibuprofen have been shown to have an addi-
There are however, a few exceptions, including diclofenac and
tive toxic effect in daphnia ()�
ibuprofen, which have been detected in WWTW effluent and
As a final note, Johnston et al� (2007) used diclofenac and
surface waters at concentrations in the low μg L−1 range, which
propranolol in the River Tamar catchment area, UK, as a case
is a concentration range that has been demonstrated to cause
study to demonstrate that it may be possible to predict accu-
toxic effects to fish in the laboratory
rate levels of pharmaceutical exposure to aquatic life, by tak-
ing into account factors such as flow rate and physiochemical
Fluoxetine levels are detected in WWTW effluent, although
properties of the drugs� Modelling approaches such as this,
not surface waters, at concentrations shown to cause devel-
combined effectively with empirical measurements, offer
opmental abnormalities, and to increase circulating estradiol
an attractive approach for advancing our knowledge on the
concentrations in medaka )� Tetracycline
likely availability and thus potential for biological effects of
is also present in the environment at concentrations, which
pharmaceuticals in the aquatic environment�
may have some effect on immune suppression )�
Declaration of interest
We need to consider also that most effect concentra-
tions for pharmaceuticals in fish are reported for relatively
This review was performed during the normal course of the
short-term exposures (e�g�, days and weeks at most in the
authors' affiliation or employment as shown on the first page�
majority of cases) and the fact is that fish may be chronically
JC was funded on a Biotechnology and Biological Sciences
exposed to many pharmaceuticals due to continual input into
Research Council Case studentship supported by AstraZeneca
the aquatic environment and over time (e�g�, for months or
UK Ltd� (grant reference BB/G529332/)� AstraZeneca Ltd�
even possibly years), and so sufficient concentrations could
develops, produces, and markets a wide range of pharma-
accumulate in their bodies to cause an effect� This serves to
ceutical agents� The authors have sole responsibility for the
illustrate the need for more long-term chronic studies on
writing and content of the manuscript�
pharmaceuticals in fish to develop a greater confidence for the absence of harmful health effects�
Care should also be applied in the extent to which effects
of pharmaceuticals demonstrated in the laboratory in one
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Journal of the American College of Cardiology Vol. 37, No. 7, 2001 © 2001 by the American College of Cardiology ISSN 0735-1097/01/$20.00 Published by Elsevier Science Inc. The Effect of Correction of Mild Anemiain Severe, Resistant Congestive Heart FailureUsing Subcutaneous Erythropoietin andIntravenous Iron: A Randomized Controlled StudyDonald S. Silverberg, MD, Dov Wexler, MD, David Sheps, MD, Miriam Blum, MD, Gad Keren, MD,Ron Baruch, MD, Doron Schwartz, MD, Tatyana Yachnin, MD, Shoshana Steinbruch, RN,Itzhak Shapira, MD, Shlomo Laniado, MD, Adrian Iaina, MDTel Aviv, Israel
Author's personal copy Psychiatry Research 189 (2011) 62–66 Contents lists available at ScienceDirect Psychiatry Research Schizophrenia patients with predominantly positive symptoms have more disturbed sleep–wake cycles measured by actigraphy Pedro Afonso a,⁎, Sofia Brissos a, Maria Luísa Figueira b, Teresa Paiva ba Lisbon's Psychiatric Hospitalar Center (CHPL), Lisbon, Portugalb Hospital Santa Maria, Faculty of Medicine, University of Lisbon, (FMUL), Lisbon, Portugal