Table 4.

Requirements for the investigation and down-selection of candidate oximes

Study phase	Keystones	Study types (examples)
Preclinical phase	In vitro reactivation kinetics	Human and animal AChE/BChE; multiple OP; species differences
	Ex vivo pharmacodynamics	Isolated organs (e.g. diaphragm)
	In vivo efficacy	Different animal species (guinea pig, swine, NHP); multiple OP; different route of OP exposure; single, multiple oxime injections; various oxime concentrations; different adjuncts; physiological, biochemical, behavioral monitoring; OP & oxime concentrations; AChE & BChE activities
	In vitro pharmacokinetics	Cell culture; isolated organs (metabolism, blood–brain-barrier penetration)
	In vivo pharmacokinetics	Different animal species (guinea pig, swine, NHP); single, multiple oxime injections
	In vitro toxicity	Human and animal AChE / BChE (inhibition); cell culture (e.g. cytotoxicity, mutagenicity, carcinogenicity)
	In vivo toxicity	Different animal species (acute, subchronic, chronic toxicity)
	Safety pharmacology	Central nervous, cardiovascular, respiratory, gastrointestinal and renal system
	Drug interactions	In vitro and in vivo interactions with adjuncts (atropine, anticonvulsants)
Clinical phase	Phase I	Safety screening; adverse effects; pharmacokinetics (oxime alone and in combination with other antidotes)
	Phase II	Case reports; case series; randomized clinical trials (OP pesticides)