DEPARTMENT OF HEALTH AND HUMAN SERVICES

 Centers for Disease Control and Prevention

 National Institute for Occupational Safety and Health 

 NIOSH List of Antineoplastic 

and Other Hazardous Drugs 

in Healthcare Settings 2010 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

NIOSH List of Antineoplastic and Other

Hazardous Drugs in Healthcare Settings 2010
This document is in the public domain and may be freely copied or reprinted.

Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to Web sites external to NIOSH do 

not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these Web sites. 

Ordering Information

To receive documents or other information about occupational safety and health topics, contact 

NIOSH at 

Telephone: 1–800–CDC–INFO (1–800–232–4636)

TTY:1–888–232–6348

E-mail: cdcinfo@cdc.gov

or visit the NIOSH Web site at www.cdc.gov/niosh

For a monthly update on news at NIOSH, subscribe to NIOSH eNews by visiting

www.cdc.gov/niosh/eNews.

DHHS (NIOSH) Publication Number 2010−167

September 2010
Preamble: The National Institute for Occupational Safety and Health (NIOSH) Alert: Preventing 

Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings was 

published in September 2004 (http://www.cdc.gov/niosh/docs/2004-165/). In Appendix A of the 

Alert, NIOSH identified a sample list of major hazardous drugs. The list was compiled from information provided by four institutions that have generated lists of hazardous drugs for their respective facilities and by the Pharmaceutical Research and Manufacturers of America (PhRMA) from 

the American Hospital Formulary Service Drug Information (AHFS DI) monographs [ASHP/

AHFS DI 2003]. This update adds 21 drugs to the original list in the 2004 Alert. These additions are 

new drugs or existing drugs that had new warnings from 2004 to 2007. The review process for the 

addition of the new listings is described in the Federal Register: http://www.cdc.gov/niosh/docket/archive/

pdfs/NIOSH-105-A/0105-A-042909-FR_Notice.pdf

Appendix A • drugs Considered HAzArdous

ASHP Definition of Hazardous 

Drugs

In this Alert, NIOSH presents a standard precautions or universal precautions approach

to handling hazardous drugs safely: that is,

NIOSH recommends that all hazardous drugs

be handled as outlined in this Alert. Therefore,

no attempt has been made to perform drug

risk assessments or propose exposure limits.

The area of new drug development is rapidly

evolving as unique approaches are being taken

to treat cancer and other serious diseases.

General Approach to Handling 

Hazardous Drugs

Hazardous drugs include those used for cancer chemotherapy, antiviral drugs, hormones, 

some bioengineered drugs, and other miscellaneous drugs. The definition of hazardous drugs 

used in this Alert is based on an ASHP definition that was originally developed in 1990 

[ASHP 1990]. Thus the definition may not accurately reflect the toxicity criteria associated 

with the newer generation of pharmaceuticals 

entering the health care setting. For example, 

bioengineered drugs target specific sites in the 

body; and although they may or may not be 

toxic to the patient, some may not pose a risk 

to health care workers. 

NIOSH and other organizations are still gathering data on the potential toxicity and health 

effects related to highly potent drugs and bioengineered drugs. Therefore, when working 

with any hazardous drug, health care workers 

should follow a standard precautions approach 

along with any recommendations included in 

the manufacturer’s MSDSs.

Defining Hazardous Drugs

The ASHP defines hazardous drugs in their 

1990 revision of Technical Assistance Bulletin on 

Handling Hazardous Drugs [ASHP 1990]. The 

bulletin gives criteria for identifying potentially hazardous drugs that should be handled 

in accordance with an established safety program [McDiarmid et al. 1991; Arrington and 

McDiarmid 1993]. The criteria are prioritized 

to reflect the hierarchy of potential toxicity described below. Since the hazardous drugs covered by this Alert were designed as therapeutic agents for humans, human toxicity profiles 

1
should be considered superior to any data from 

animal models or in vitro systems. Additional 

guidance for defining hazardous drugs is available in the following citations: carcinogenicity 

[61 Fed. Reg. 17960–18011 (1996b); IARC 2010], 

teratogenicity [56 Fed. Reg. 63798–63826 

(1991)], developmental toxicity [56 Fed. Reg. 

63798–63826 (1991)], and reproductive toxicity [61 Fed. Reg. 56274–56322 (1996a)]. Physical characteristics of the agents (such as liquid 

versus solid, or water versus lipid solubility) 

also need to be considered in determining the 

potential for occupational exposure.

NIOSH Revision of ASHP Definition

The 1990 ASHP definition of hazardous drugs*

was revised by the NIOSH Working Group on 

Hazardous Drugs for this Alert. Drugs considered hazardous include those that exhibit one 

or more of the following six characteristics in 

humans or animals:

1. Carcinogenicity 

2. Teratogenicity or other developmental toxicity†

*

ASHP [1990] definition of hazardous drugs:

1. Carcinogenicity 

2. Teratogenicity or other developmental toxicity 

3. Reproductive toxicity

4. Organ toxicity at low doses 

5. Genotoxicity 

6. Structure and toxicity profiles of new drugs that 

mimic existing drugs determined hazardous by 

the above criteria. 

†

All drugs have toxic side effects, but some exhibit toxicity at low doses. The level of toxicity reflects a continuum from relatively nontoxic to production of toxic 

effects in patients at low doses (for example, a few 

milligrams or less). For example, a daily therapeutic 

dose of 10 mg/day or a dose of 1 mg/kg per day in 

laboratory animals that produces serious organ toxicity, developmental toxicity, or reproductive toxicity has been used by the pharmaceutical industry to 

develop occupational exposure limits (OELs) of less 

than 10 μg/m3

 after applying appropriate uncertainty 

3. Reproductive toxicity†

4. Organ toxicity at low doses†

5. Genotoxicity‡

Structure and toxicity profiles of new drugs 

that mimic existing drugs determined hazardous by the above criteria 

Determining Whether a Drug is 

Hazardous

Many hazardous drugs used to treat cancer 

bind to or damage DNA (for example, alkylating agents). Other antineoplastic drugs, some 

antivirals, antibiotics, and bioengineered drugs 

interfere with cell growth or proliferation, or 

with DNA synthesis. In some cases, the nonselective actions of these drugs disrupt the 

growth and function of both healthy and diseased cells, resulting in toxic side effects for 

treated patients. These nonselective actions 

can also cause adverse effects in health care 

workers who are inadvertently exposed to hazardous drugs.

Early concerns about occupational exposure to 

antineoplastic drugs first appeared in the 1970s. 

Although the antineoplastic drugs remain the 

principal focus of this Alert, other drugs may 

also be considered hazardous because they are 

potent (small quantities produce a physiological effect) or cause irreversible effects. As the 

use and number of these potent drugs increase, 

factors [Sargent and Kirk 1988; Naumann and Sargent 1997; Sargent et al. 2002]. OELs in this range are 

typically established for potent or toxic drugs in the 

pharmaceutical industry. Under all circumstances, an 

evaluation of all available data should be conducted to 

protect health care workers.

‡

In evaluating mutagenicity for potentially hazardous 

drugs, responses from multiple test systems are needed before precautions can be required for handling 

such agents. The EPA evaluations include the type of 

cells affected and in vitro versus in vivo testing [51 

Fed. Reg. 34006–34012 (1986)].

2
3

so do opportunities for hazardous exposures 

among health care workers. For example, antineoplastic drugs such as cyclophosphamide 

have immunosuppressant effects that proved 

beneficial for treating nonmalignant diseases such as rheumatoid arthritis and multiple 

sclerosis [Baker et al. 1987; Moody et al. 1987; 

Chabner et al. 1996; Abel 2000].

This document presents criteria and sources of 

information for determining whether a drug 

is hazardous. When a drug has been judged to 

be hazardous, the various precautions outlined 

the Alert should be applied when handling that 

drug. Also included is a list of drugs that should 

be handled as hazardous. This list is based on 

a compilation of lists from four health care facilities, one drug manufacturers’ organization, 

and NIOSH.

In addition to using the list of hazardous drugs 

presented here, each organization should create its own list of drugs considered to be hazardous. This document presents guidance for 

making such a facility-specific list (see section 

entitled How to Generate your own List of Hazardous Drugs). Once this list is made, newly 

purchased drugs should be evaluated against 

the organization’s hazardous drug criteria and 

added to the list if they are deemed hazardous. 

Some organizations may have inadequate 

resources for determining their own list of 

hazardous drugs. If so, the sample list of hazardous drugs in this document (current only 

to the printing date of this document) will 

help employers and workers to determine 

when precautions are needed. However, reliance on such a published list is a concern 

because it quickly becomes outdated as new 

drugs continually enter the market or listed 

drugs are removed when additional information becomes available. To fill this knowledge gap, NIOSH will update an internet list 

periodically, adding new drugs considered 

to be hazardous and removing those that require reclassification. This hazardous drug 

list will be posted on the NIOSH Web site at 

www.cdc.gov/niosh.

How to Generate Your Own List of 

Hazardous Drugs 

The OSHA hazard communication standard 

[29 CFR 1910.1200] requires employers to 

develop a hazard communication program 

appropriate for their unique workplace. An 

essential part of the program is the identification of all hazardous drugs a worker may 

encounter in the facility. Compliance with 

the OSHA hazard communication standard 

entails (1) evaluating whether these drugs 

meet one or more of the criteria for defining 

hazardous drugs and (2) posting a list of the 

hazardous drugs to ensure worker safety. Institutions may wish to compare their lists to 

the sample listing in this document or on the 

NIOSH Web site.

It is not likely that every health care provider 

or facility will use all drugs that have received 

U.S. Food and Drug Administration (FDA) approval, and the OSHA hazard communication 

standard does not mandate evaluation of every 

marketed drug. Instead, compliance requires 

practice-specific assessments for drugs used at 

any one time by a facility. However, hazardous 

drug evaluation is a continual process. Local 

hazard communication programs should provide for assessment of new drugs as they enter 

the marketplace, and when appropriate, reassessment of their presence on hazardous drug 

lists as toxicological data become available to 

support recategorization. Toxicological data 

are often incomplete or unavailable for investigational drugs. However, if the mechanism of 

action suggests that there may be a concern, it 

is prudent to handle them as hazardous drugs 

until adequate information becomes available 

to exclude them.
4

Some drugs defined as hazardous may not pose 

a significant risk of direct occupational exposure 

because of their dosage formulation (for example, coated tablets or capsules—solid, intact 

medications that are administered to patients 

without modifying the formulation). However, 

they may pose a risk if solid drug formulations 

are altered, such as by crushing tablets or making 

solutions from them outside a ventilated cabinet.

Where to Find Information Related 

to Drug Toxicity

Practice-specific lists of hazardous drugs (usually developed by pharmacy or nursing departments) should be comprehensive, including all 

hazardous medications routinely used or very 

likely to be used by a local practice. Some of 

the resources that employers can use to evaluate the hazard potential of a drug include, but 

are not limited to, the following:

 MSDSs 

 Product labeling approved by the U.S. 

FDA (package inserts)

 Special health warnings from drug manufacturers, FDA, and other professional 

groups and organizations

 Reports and case studies published in 

medical and other health care profession 

journals

 Evidence-based recommendations from 

other facilities that meet the criteria defining hazardous drugs 

Examples of Hazardous Drugs

The following list contains a sampling of major 

hazardous drugs. The list was compiled from 

information provided by (1) four institutions 

that have generated lists of hazardous drugs 

for their respective facilities, (2) the American 

Hospital Formulary Service Drug Information (AHFS DI) monographs [ASHP/AHFS 

DI 2003], and (3) a NIOSH review of new drug 

approvals and new drug warning from 2004 to 

2007. This review resulted in the addition of 21 

new entries to the list. The OSHA hazard communication standard requires hazardous drugs 

to be handled using special precautions. The 

mandate applies not only to health care professionals who provide direct patient care but also 

to others who support patient care by participating in product acquisition, storage, transportation, housekeeping, and waste disposal. 

Institutions may want to adopt this list or compare theirs with the list on the NIOSH Web site.

Caution: Drugs purchased and used by a facility may have entered the marketplace after the 

list below was assembled. Therefore, this list 

may not be all-inclusive.

If you use a drug that is not included in the 

list of examples, check the available literature 

to see whether the unlisted drug should be 

treated as hazardous. Check the MSDS or the 

proper handling section of the package insert; 

or check with other institutions that might be 

using the same drug. If any of the documents 

mention carcinogenicity, genotoxicity, teratogenicity, or reproductive or developmental 

toxicity, use the precautions stipulated in this 

Alert. If a drug meets one or more of the criteria for hazardous drugs listed in this Alert, 

handle it as hazardous.

The listing below will be updated periodically 

on this website.

The attached list of hazardous drugs supersedes the 2004 list: http://www.cdc.gov/niosh/

docs/2004-165/
5

Sample List of Drugs that Should be Handled as Hazardous*

Drug Source

AHFS Pharmalocologic-therapeutic 

classification

Aldesleukin 4,5 10:00 Antineoplastic agents

Alefacept 6 84:92 Miscellaneous skin and mucous 

membrane agents

Alemtuzumab 1,3,4,5 10:00 Antineoplastic agents

Alitretinoin 3,4,5 84:36 Miscellaneous skin and mucous 

membrane agents (retinoid)

Altretamine 1,2,3,4,5 10:00 Antineoplastic agents

Amsacrine 3,5 Not in AHFS (antineoplastic agent)

Anastrozole 1,5 10:00 Antineoplastic agents

Arsenic trioxide 1,2,3,4,5 10:00 Antineoplastic agents

Asparaginase 1,2,3,4,5 10:00 Antineoplastic agents

Azacitidine 3,5 10:00 Antineoplastic agents

Azathioprine 2,3,5 92:44 Unclassified therapeutic agents 

(immunosuppressant)

Bacillus Calmette-Guerin 

(BCG)†

1,2,4 80:12 Vaccines

Bexarotene 2,3,4,5 10:00 Antineoplastic agents

Bicalutamide 1,5 10:00 Antineoplastic agents

Bleomycin 1,2,3,4,5 10:00 Antineoplastic agents

Bortezomib 6 10:00 Antineoplastic agents

Bosentan 6 24:12.92 Vasodilating agents

Busulfan 1,2,3,4,5 10:00 Antineoplastic agents

Capecitabine 1,2,3,4,5 10:00 Antineoplastic agents

Carboplatin 1,2,3,4,5 10:00 Antineoplastic agents

Carmustine 1,2,3,4,5 10:00 Antineoplastic agents

Cetrorelix acetate 5 92:40 Unclassified therapeutic agents 

(GnRH antagonist)

Chlorambucil 1,2,3,4,5 10:00 Antineoplastic agents

Chloramphenicol 1,5 8:12.08 Antibacterials

Choriogonadotropin alfa 5 68:18 Gonadotropins

Cidofovir 3,5 8:18.32 Antiviral nucleoside

Cisplatin 1,2,3,4,5 10:00 Antineoplastic agents

Cladribine 1,2,3,4,5 10:00 Antineoplastic agents

Clofarabine 6 10:00 Antineoplastic agents

(Continued)
6

Sample List of Drugs that Should be Handled as Hazardous (Continued)

Drug Source

AHFS Pharmalocologic-therapeutic 

classification

Colchicine 5 92:16 Unclassified therapeutic agents 

(antigout agents)

Cyclophosphamide 1,2,3,4,5 10:00 Antineoplastic agents

Cyclosporin 1 92:00 Immunosuppressive agents

Cytarabine 1,2,3,4,5 10:00 Antineoplastic agents

Dacarbazine 1,2,3,4,5 10:00 Antineoplastic agents

Dactinomycin 1,2,3,4,5 10:00 Antineoplastic agents

Dasatinib 6 10:00 Antineoplastic agents

Daunorubicin HCl 1,2,3,4,5 10:00 Antineoplastic agents

Decitabine 6 10:00 Antineoplastic agents

Denileukin 3,4,5 10:00 Antineoplastic agents

Dienestrol 5 68:16.04 Estrogens

Diethylstilbestrol 5 Not in AHFS (nonsteroidal synthetic 

estrogen)

Dinoprostone 5 76:00 Oxytocics

Docetaxel 1,2,3,4,5 10:00 Antineoplastic agents

Doxorubicin 1,2,3,4,5 10:00 Antineoplastic agents

Dutasteride 5 92:08 Unclassified therapeutic agents 

(5-alpha reductase inhibitor)

Entecavir 6 8:18.32 Antiviral nucleoside

Epirubicin 1,2,3,4,5 10:00 Antineoplastic agents

Ergonovine/

methylergonovine

5 76:00 Oxytocics

Estradiol 1,5 68:16.04 Estrogens

Estramustine phosphate 1,2,3,4,5 10:00 Antineoplastic agents

Estrogen-progestin 

combinations

5 68:12 Contraceptives

Estrogens, conjugated 5 68:16.04 Estrogens

Estrogens, esterified 5 68:16.04 Estrogens

Estrone 5 68:16.04 Estrogens

Estropipate 5 68:16.04 Estrogens

Etoposide 1,2,3,4,5 10:00 Antineoplastic agents

Exemestane 1,5 10:00 Antineoplastic agents

Finasteride 1,3,5 92:08 Unclassified therapeutic agents 

(5-alpha reductase inhibitor)

(Continued)
7

Sample List of Drugs that Should be Handled as Hazardous (Continued)

Drug Source

AHFS Pharmalocologic-therapeutic 

classification

Floxuridine 1,2,3,4,5 10:00 Antineoplastic agents

Fludarabine 1,2,3,4,5 10:00 Antineoplastic agents

Fluorouracil 1,2,3,4,5 10:00 Antineoplastic agents

Fluoxymesterone 5 68:08 Androgens

Flutamide 1,2,5 10:00 Antineoplastic agents

Fulvestrant 5 10:00 Antineoplastic agents

Ganciclovir 1,2,3,4,5 8:18.32 Antiviral nucleoside

Ganirelix acetate 5 92:40 Unclassified therapeutic agents 

(GnRH antagonist)

Gemcitabine 1,2,3,4,5 10:00 Antineoplastic agents

Gemtuzumab ozogamicin 1,3,4,5 10:00 Antineoplastic agents

Gonadotropin, chorionic 5 68:18 Gonadotropins

Goserelin 1,2,5 10:00 Antineoplastic agents

Hydroxyurea 1,2,3,4,5 10:00 Antineoplastic agents

Ibritumomab tiuxetan 3 10:00 Antineoplastic agents

Idarubicin 1,2,3,4,5 10:00 Antineoplastic agents

Ifosfamide 1,2,3,4,5 10:00 Antineoplastic agents

Imatinib mesylate 1,3,4,5 10:00 Antineoplastic agents

Interferon alfa-2a 1,2,4,5 10:00 Antineoplastic agents

Interferon alfa-2b 1,2,4,5 10:00 Antineoplastic agents

Interferon alfa-n1 1,5 10:00 Antineoplastic agents

Interferon alfa-n3 1,5 10:00 Antineoplastic agents

Irinotecan HCl 1,2,3,4,5 10:00 Antineoplastic agents

Leflunomide 3,5 92:36 Unclassified therapeutic agents 

(antineoplastic agent)

Lenalidomide 6 92:20 Unclassified therapeutic agents 

(biologic response modifiers)

Letrozole 1,5 10:00 Antineoplastic agents

Leuprolide acetate 1,2,5 10:00 Antineoplastic agents

Lomustine 1,2,3,4,5 10:00 Antineoplastic agents

Mechlorethamine 1,2,3,4,5 10:00 Antineoplastic agents

Medroxyprogesterone 

acetate

6 68:32 Progestins

Megestrol 1,5 10:00 Antineoplastic agents

(Continued)
8

Sample List of Drugs that Should be Handled as Hazardous (Continued)

Drug Source

AHFS Pharmalocologic-therapeutic 

classification

Melphalan 1,2,3,4,5 10:00 Antineoplastic agents

Menotropins 5 68:18 Gonadotropins

Mercaptopurine 1,2,3,4,5 10:00 Antineoplastic agents

Methotrexate 1,2,3,4,5 10:00 Antineoplastic agents

Methyltestosterone 5 68:08 Androgens

Mifepristone 5 76:00 Oxytocics

Mitomycin 1,2,3,4,5 10:00 Antineoplastic agents

Mitotane 1,4,5 10:00 Antineoplastic agents

Mitoxantrone HCl 1,2,3,4,5 10:00 Antineoplastic agents

Mycophenolate mofetil 1,3,5 92:44 Unclassified therapeutic agents 

(immunosuppressive agents)

Nafarelin 5 68:18 Gonadotropins

Nelarabine 6 10:00 Antineoplastic agents

Nilutamide 1,5 10:00 Antineoplastic agents

Oxaliplatin 1,3,4,5 10:00 Antineoplastic agents

Oxytocin 5 76:00 Oxytocics

Paclitaxel 1,2,3,4,5 10:00 Antineoplastic agents

Palifermin 6 84:16 Cell stimulants

Paroxetine HCl 6 28:16.04.20 Selective seretonin uptake 

inhibitors

Pegaspargase 1,2,3,4,5 10:00 Antineoplastic agents

Pemetrexed 6 10:00 Antineoplastic agents

Pentamidine isethionate 1,2,3,5 8:40 Miscellaneous anti-infectives

Pentetate calcium trisodium 6 Not in AHFS

Pentostatin 1,2,3,4,5 10:00 Antineoplastic agents

Perphosphamide 3,5 Not in AHFS (antineoplastic agent)

Pipobroman 3,5 Not in AHFS (antineoplastic agent)

Piritrexim isethionate 3,5 Not in AHFS (antineoplastic agent)

Plicamycin 1,2,3,5 Not in AHFS (antineoplastic agent)

Podofilox 5 84:92 Miscellaneous skin and mucous 

membrane agents (mitotic 

inhibitor)

Podophyllum resin 5 84:92 Miscellaneous skin and 

mucousmembrane agents (mitotic 

inhibitor)

(Continued)
9

Sample List of Drugs that Should be Handled as Hazardous (Continued)

Drug Source

AHFS Pharmalocologic-therapeutic 

classification

Prednimustine 3,5 Not in AHFS (antineoplastic agent)

Procarbazine 1,2,3,4,5 10:00 Antineoplastic agents

Progesterone 5 68:32 Progestins

Progestins 5 68:12 Contraceptives

Raloxifene 5 68:16.12 Estrogen agonists-antagonists

Raltitrexed 5 Not in AHFS (antineoplastic agent)

Rasagiline mesylate 6 28:36 Antiparkinsonian agents

Ribavirin 1,2,5 8:18.32 Antiviral nucleoside

Risperidone 6 28:16.08.04 Atypical antipsychotics

Sirolimus 6 92:00 Immunosuppressive agents

Sorafenib 6 10:00 Antineoplastic agents

Streptozocin 1,2,3,4,5 10:00 Antineoplastic agents

Sunitinib malate 6 10:00 Antineoplastic agents

Tacrolimus 1,5 92:44 Unclassified therapeutic agents 

(immunosuppressant)

Tamoxifen 1,2,5 10:00 Antineoplastic agents

Temozolomide 3,4,5 10:00 Antineoplastic agents

Teniposide 1,2,3,4,5 10:00 Antineoplastic agents

Testolactone 5 10:00 Antineoplastic agents

Testosterone 5 68:08 Androgens

Thalidomide 1,3,5 92:20 Unclassified therapeutic agents 

(biologic response modifier)

Thioguanine 1,2,3,4,5 10:00 Antineoplastic agents

Thiotepa 1,2,3,4,5 10:00 Antineoplastic agents

Topotecan 1,2,3,4,5 10:00 Antineoplastic agents

Toremifene citrate 1,5 10:00 Antineoplastic agents

Tositumomab 3,5 10:00 Antineoplastic agents

Tretinoin 1,2,3,5 84:16 Cell stimulants and proliferants 

(retinoid)

Trifluridine 1,2,5 52:04.06 Antivirals

Trimetrexate glucuronate 5 8:30.92 Miscellaneous antiprotozoals

Triptorelin 5 10:00 Antineoplastic agents

Uracil mustard 3,5 Not in AHFS (antineoplastic agent)

Valganciclovir 1,3,5 8:18.32 Antiviral nucleoside

(Continued)
10

Sample List of Drugs that Should be Handled as Hazardous (Continued)

Drug Source

AHFS Pharmalocologic-therapeutic 

classification

Valrubicin 1,2,3,5 10:00 Antineoplastic agents

Vidarabine 1,2,5 Not in AHFS

Vinblastine sulfate 1,2,3,4,5 10:00 Antineoplastic agents

Vincristine sulfate 1,2,3,4,5 10:00 Antineoplastic agents

Vindesine 1,5 Not in AHFS (antineoplastic agent)

Vinorelbine tartrate 1,2,3,4,5 10:00 Antineoplastic agents

Vorinostat 6 10:00 Antineoplastic agents

Zidovudine 1,2,5 8:18:08 Antiretroviral agents

Zonisamide 6 28:12.92 Anticonvulsant

*These lists of hazardous drugs were used with the permission of the institutions that provided them and were 

adapted for use by NIOSH. The sample lists are intended to guide health care providers in diverse practice settings and should not be construed as complete representations of all of the hazardous drugs used at the referenced 

institutions. Some drugs defined as hazardous may not pose a significant risk of direct occupational exposure 

because of their dosage formulation (for example, intact medications such as coated tablets or capsules that are 

administered to patients without modifying the formulation). However, they may pose a risk if solid drug formulations are altered outside a ventilated cabinet (for example, if tablets are crushed or dissolved, or if capsules are 

pierced or opened).

†

BCG preparation should be done using aseptic techniques. To avoid cross-contamination, parenteral drugs should 

not be prepared in areas where BCG has been prepared. A separate area for the preparation of BCG suspension is 

recommended. All equipment, supplies, and receptacles in contact with BCG should be handled and disposed of 

as biohazardous. If preparation cannot be performed in a containment device, then respiratory protection, gloves 

and a gown should be worn to avoid inhalation or contact with BCG organisms.

1. The NIH Clinical Center, Bethesda, MD (Revised 8/2002). The NIH Health Clinical Center Hazardous Drug 

(HD) List is part of the NIH Clinical Center’s hazard communication program. It was developed in compliance with the OSHA hazard communication standard [29 CFR 1910.1200] as it applies to hazardous drugs 

used in the workplace. The list is continually revised and represents the diversity of medical practice at the 

NIH Clinical Center; however, its content does not reflect an exhaustive review of all FDA-approved medications that may be considered hazardous, and it is not intended for use outside the NIH.

2. The Johns Hopkins Hospital, Baltimore, MD (Revised 9/2002).

3. The Northside Hospital, Atlanta, GA (Revised 8/2002).

4. The University of Michigan Hospitals and Health Centers, Ann Arbor, MI (Revised 2/2003)

5. This sample listing of hazardous drugs was compiled by the Pharmaceutical Research and Manufacturers of 

America (PhRMA) using information from the AHFS DI monographs published by ASHP in selected AHFS 

Pharmacologic-Therapeutic Classification categories [ASHP/AHFS DI 2003] and applying the definition 

for hazardous drugs. The list also includes drugs from other sources that satisfy the definition for hazardous drugs [PDR 2004; Sweetman 2002; Shepard 2001; Schardein 2000; REPROTOX 2003]. Newly approved 

drugs that have structures or toxicological profiles that mimic the drugs on this list should also be included. 

This list was revised in June 2004.

6. NIOSH addition 2010 updated using ASHP/AHFS DI 2010.
11

References

Abel EA [2000]. Immunosuppressant and cytotoxic drugs: unapproved uses or indications. Clin 

Dermatol 18:95–101.

Arrington DM, McDiarmid MA [1993]. Comprehensive program for handling hazardous drugs. 

Am J Hosp Pharm 50:1170–1174.

ASHP (American Society of Hospital Pharmacists) [1990]. ASHP technical assistance bulletin 

on handling cytotoxic and hazardous drugs. Am J 

Hosp Pharm 47:1033–1049.

ASHP/AHFS DI (American Hospital Formulary 

Service Drug Information) [2003]. AHFS drug information online updates [www.ahfsdruginformation.com].

ASHP/AHFS DI (American Hospital Formulary 

Service Drug Information) [2010]. AHFS drug information online updates [www.ahfsdruginformation.com].

Baker GL, Kahl LE, Zee BC, Stolzer BL, Agarwal 

AK, Medsger TA Jr [1987]. Malignancy following 

treatment of rheumatoid arthritis with cyclophosphamide. Long-term case-control follow-up study. 

Am J Med 83(1):1–9.

CFR. Code of Federal regulations. Washington, 

DC: U.S. Government Printing Office, Office of 

the Federal Register.

Chabner BA, Allegra CJ, Curt GA, Calabresi P 

[1996]. Antineoplastic agents. In: Hardman JG, Limbird LE, eds. Goodman and Gilman’s the pharmacological basis of therapeutics. 9th ed. New York: 

McGraw-Hill, pp. 1233–1287.

IARC [2010]. IARC monographs on the evaluation 

of the carcinogenic risk of chemicals to humans. 

Lyons, France: World Health Organization, International Agency for Research on Cancer. [www.

iarc.fr]. Date accessed: March 2010.

McDiarmid MA, Gurley HT, Arrington D [1991]. 

Pharmaceuticals as hospital hazards: managing 

the risks. J Occup Med 33(2):155–158.

Moody DJ, Kagan J, Liao D, Ellison GW, Myers 

LW [1987]. Administration of monthly-pulse cyclophosphamide in multiple sclerosis patients. 

Effects of long-term treatment on immunologic 

parameters. J Neuroimmunol 14(2):161–173.

Naumann BD, Sargent EV [1997]. Setting occupational exposure limits for pharmaceuticals. Occup 

Med: State of the Art Rev 12(1):67–80.

NIOSH [2004]. NIOSH alert: preventing occupational exposure to antineoplastic and other 

hazardous drugs in health care settings. U.S. Department of Health and Human Services, Public 

Health Service, Centers for Disease Control and 

Prevention, National Institute for Occupational 

Safety and Health, DHHS (NIOSH) Publication 

No. 2004–165.

PDR [2004]. Physician’s desk reference for drug 

interactions. Montvale, NJ: Thomson Healthcare 

[www.pdr.net/]. Date accessed: March 2004.

REPROTOX [2003]. An information system on 

environmental hazards to human reproduction and 

development. Washington, DC: Columbia Hospital 

for Women Medical Center, Reproductive Toxicology Center [http://reprotox.org]. Date accessed: 

February 2004.

Sargent EV, Kirk GD [1988]. Establishing airborne 

exposure control limits in the pharmaceutical industry. Am Ind Hyg Assoc J 49(6):309–313.

Sargent EV, Naumann BD, Dolan DG, Faria EC, 

Schulman L [2002]. The importance of human 

data in the establishment of occupational exposure limits. Hum Ecol Risk Assess 8(4):805–822.

Schardein, JL [2000]. Chemically induced birth 

defects. 3rd ed., rev. New York: Marcel Deckker, 

Inc. 

Shepard TH [2001]. Catalog of teratogenic agents. 

10th ed. Baltimore, MD: Johns Hopkins University Press [www.depts.washington.edu/~terisweb]. 

Date accessed: Feb. 2004.

Sweetman SC [2003]. Martindale: the complete 

drug reference. 33rd ed. London: Pharmaceutical 

Press.
 1–800–CDC–INFO

occupational safety and health topics, contact NIOSH at To receive NIOSH documents or more information about 

 (1–800–232–4636)

NIOSH eNews For a monthly update on news at NIOSH, subscribe to  or visit the NIOSH Web site at www.cdc.gov/niosh.E-mail: cdcinfo@cdc.govTTY: 1–888–232–6348

 by visiting www.cdc.gov/niosh/eNews.

 safer • healthier • people DHHS (NIOSH) Publication No. 2010–167

tm 

through research and prevention safety and health at work for all people Delivering on the Nation’s promise:

 DEPARTMENT OF HEALTH AND HUMAN SERVICES

 Centers for Disease Control and Prevention

 National Institute for Occupational Safety and Health

 4676 Columbia Parkway

 Cincinnati, Ohio 45226–1998

 Offi cial Business

 Penalty for Private Use $300