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Kanatoula DD, Bodner E, Ghoreschi K, Meier K, Solimani F. Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases. J Dtsch Dermatol Ges 2024; 22:400-421. [PMID: 38259085 DOI: 10.1111/ddg.15270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/08/2023] [Indexed: 01/24/2024]
Abstract
Non-biologic immunosuppressive drugs, such as azathioprine, dapsone or methotrexate are fundamental treatment options for a wide range of autoimmune and chronic inflammatory skin diseases. Some of these drugs were initially used for malignancies (e.g., azathioprine or methotrexate) or infectious diseases (e.g., hydroxychloroquine or dapsone) but are nowadays mostly used for their immunosuppressive/immunomodulating action. Although dermatologists have years of clinical experience with these drugs, some of the mechanisms of action are not fully understood and are the subject of research. Although these drugs are commonly used, lack of experience or knowledge regarding their safety profiles and management leads to skepticism among physicians. Here, we summarize the mechanism of action and detailed management of adverse effects of the most commonly used immunosuppressive drugs for skin diseases. Furthermore, we discuss the management of these drugs during pregnancy and breastfeeding, as well as their interaction and handling during vaccination.
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Affiliation(s)
- Danai Dionysia Kanatoula
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Euna Bodner
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Katharina Meier
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
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Kanatoula DD, Bodner E, Ghoreschi K, Meier K, Solimani F. Nicht-Biologika-Immunsuppressiva bei entzündlichen und autoimmunen Hautkrankheiten: Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases. J Dtsch Dermatol Ges 2024; 22:400-423. [PMID: 38450929 DOI: 10.1111/ddg.15270_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/08/2023] [Indexed: 03/08/2024]
Abstract
ZusammenfassungNicht‐Biologika‐Immunsuppressiva wie Azathioprin, Dapson oder Methotrexat sind grundlegende Behandlungsmöglichkeiten für ein breites Spektrum von Autoimmunerkrankungen und chronisch‐entzündlichen Hauterkrankungen. Einige dieser Medikamente wurden ursprünglich bei malignen Erkrankungen (zum Beispiel Azathioprin oder Methotrexat) oder Infektionskrankheiten (zum Beispiel Hydroxychloroquin oder Dapson) eingesetzt, werden aber heute hauptsächlich wegen ihrer immunsuppressiven/immunmodulierenden Wirkung verwendet. Obwohl Dermatologen über jahrelange klinische Erfahrung mit diesen Arzneimitteln verfügen, sind einige der Wirkmechanismen noch nicht vollständig geklärt und noch Gegenstand der Forschung. Obwohl diese Medikamente häufig eingesetzt werden, führen mangelnde Erfahrung oder fehlendes Wissen über ihre Sicherheitsprofile und ihr Management zu einer skeptischen Haltung bei den Ärzten. Hier fassen wir den Wirkmechanismus und das detaillierte Management der Nebenwirkungen der am häufigsten verwendeten immunsuppressiven Medikamente für Hautkrankheiten zusammen. Darüber hinaus diskutieren wir den Umgang mit diesen Medikamenten während der Schwangerschaft und Stillzeit sowie ihre Wechselwirkung und Handhabung im Zusammenhang mit Impfungen.
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Affiliation(s)
- Danai Dionysia Kanatoula
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Euna Bodner
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Kamran Ghoreschi
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Katharina Meier
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Farzan Solimani
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
- BIH Biomedical Innovation Academy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin
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Bihan K, Lipszyc L, Lemaitre F, Dautriche A, Fédrizzi S, Atzenhoffer M, Vitores A, Page A, Lebrun-Vignes B. Nirmatrelvir/ritonavir (Paxlovid®): French pharmacovigilance survey 2022. Therapie 2023; 78:531-547. [PMID: 37012153 PMCID: PMC9990891 DOI: 10.1016/j.therap.2023.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Nirmatrelvir/ritonavir (Paxlovid®) is currently one of the few therapeutic options for coronavirus disease 2019 (COVID-19) curative treatment in non-oxygen-requiring adult patients at-high risk of progressing to severe disease. This recently approved boosted antiviral therapy presents a significant risk of drug-drug interactions (DDI). As part of the enhanced surveillance program in France for COVID-19 drugs and vaccines, the French national pharmacovigilance database (BNPV [base nationale de pharmacovigilance]) was queried in order to better characterize the drug safety profile, with a special focus on DDI. The aim of the study was to describe the adverse drug reactions reported through the BNPV. METHOD All nirmatrelvir/ritonavir reports validated in the BNPV from the first authorization in France (January, 20th 2022) to December, 3rd 2022 (date of the query) were considered. An analysis of the scientific literature (PubMed®) and from the WHO pharmacovigilance database (Vigibase) was also performed. RESULTS Over this period (11 months), 228 reports (40% of serious reports) were registered with a sex ratio of 1.9 female/1 male and a mean age of 66 years old. DDI reports account for more than 13% of reports (n=30) and were mainly related to immunosuppressive drugs overexposure (n=16). A total of 10/228 reports with fatal outcomes were reported in complex clinical settings. The main reported unexpected adverse drug reaction (ADRs) were high blood pressure (n=7), confusion (n=5), acute kidney injuries (AKI, n=7) and various skin reactions (n=22). Apart from situations of disease recurrence (not found in this analysis), data from Pubmed® and Vigibase also reported the above-mentioned events of interest. CONCLUSION Overall, this analysis shows that nirmatrelvir/ritonavir safety profile was conform to current summary of product characteristics (SmPC). The main concern was the risk of DDI. Therefore, SmPC and expert recommendations should be systematically consulted before initiation of this antiviral, which is particularly indicated in polypharmacy patients. A case-by-case multidisciplinary approach including a clinical pharmacologist is required in these complex situations. Blood pressure elevation, confusion, cutaneous reactions and AKIs were the main unexpected ADRs of interest to follow, but need to be confirmed with a qualitative approach over time and new reports.
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Affiliation(s)
- Kevin Bihan
- Département de pharmacologie, centre régional de pharmacovigilance Pitié-Saint Antoine, GH Pitié-Salpêtrière, AP-HP, 75000 Paris, France.
| | - Lorène Lipszyc
- Centre régional de pharmacovigilance, GH Henri-Mondor, AP-HP, 94000 Créteil, France
| | - Florian Lemaitre
- Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR S 1085, université de Rennes, CHU Rennes, 35000 Rennes, France
| | - Anne Dautriche
- Département de pharmacologie, centre régional de pharmacovigilance de Bourgogne, CHU Dijon, 21000 Dijon, France
| | - Sophie Fédrizzi
- Département de pharmacologie, centre régional de pharmacovigilance Caen, CHU Caen, 14000 Caen, France
| | - Marina Atzenhoffer
- Service hospitalo-universitaire de pharmacotoxicologie, centre régional de pharmacovigilance Lyon, hospices civils de Lyon, 69000 Lyon, France
| | - Aurélie Vitores
- French National Agency for the safety of Medicines and Health Products, Medical Direction, 93200 Saint-Denis, France
| | - Annabelle Page
- French National Agency for the safety of Medicines and Health Products, Direction for Surveillance, 93200 Saint-Denis, France
| | - Bénédicte Lebrun-Vignes
- Département de pharmacologie, centre régional de pharmacovigilance Pitié-Saint Antoine, GH Pitié-Salpêtrière, AP-HP, 75000 Paris, France
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Lor KW, Kransdorf EP, Patel JK, Chang DH, Kobashigawa JA, Kittleson MM. Dapsone-Associated Anemia in Heart Transplant Recipients with Normal Glucose-6-Phosphate Dehydrogenase Activity. J Clin Med 2022; 11:6378. [PMID: 36362606 PMCID: PMC9658039 DOI: 10.3390/jcm11216378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 03/26/2024] Open
Abstract
Dapsone is considered an alternative for pneumocystis jirovecii pneumonia (PJP) prophylaxis in sulfa-allergic or -intolerant transplant patients with normal glucose-6-phosphate dehydrogenase (G6PD) activity. Despite normal G6PD activity, anemia can still occur while on dapsone therapy. We retrospectively reviewed heart transplant patients transplanted at our center between January 2016 and June 2018 and identified those taking dapsone prophylaxis. There were 252 heart transplant recipients at our center between January 2016 and June 2018. 36 patients received dapsone prophylaxis. All had normal G6PD activity assessed prior to dapsone initiation. 8 (22%) patients developed significant anemia attributed to dapsone: 2 were hospitalized for anemia, 1 of whom required blood transfusion. These patients had a median reduction in hemoglobin of 2.1 g/dL from baseline prior to dapsone initiation. Overt evidence of hemolysis was present in six patients. Once dapsone was discontinued, Hgb increased by at least 2 g/dL in a median of 30 days. Anemia from dapsone may occur in a significant proportion of patients despite normal G6PD activity and resulting in significant morbidity. Careful monitoring of transplant recipients on dapsone prophylaxis is warranted, as well as consideration of alternative agents.
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Affiliation(s)
- Kevin W. Lor
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, 127 S. San Vicente Blvd., Los Angeles, CA 90048, USA
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Dumouchel JL, Kramlinger VM. Case Study 10: A Case to Investigate Acetyl Transferase Kinetics. Methods Mol Biol 2021; 2342:781-808. [PMID: 34272717 DOI: 10.1007/978-1-0716-1554-6_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Major routes of metabolism for marketed drugs are predominately driven by enzyme families such as cytochromes P450 and UDP-glucuronosyltransferases. Less studied conjugative enzymes, like N-acetyltransferases (NATs), are commonly associated with detoxification pathways. However, in the clinic, the high occurrence of NAT polymorphism that leads to slow and fast acetylator phenotypes in patient populations has been linked to toxicity for a multitude of drugs. A key example of this is the observed clinical toxicity in patients who exhibit the slow acetylator phenotype and were treated with isoniazid. Toxicity in patients has led to detailed characterization of the two NAT isoforms and their polymorphic genotypes. Investigation in recombinant enzymes, genotyped hepatocytes, and in vivo transgenic models coupled with acetylator status-driven clinical studies have helped understand the role of NATs in drug development, clinical study design and outcomes, and potential roles in human disease models. The selected case studies herein document NAT enzyme kinetics to explore substrate overlap from two human isoforms, preclinical species considerations, and clinical genotype population concerns.
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Affiliation(s)
- Jennifer L Dumouchel
- Molecular Pharmacology and Physiology Graduate Training Program, Brown University, Providence, RI, USA.
| | - Valerie M Kramlinger
- Translational Medicine, Novartis Institutes for BioMedical Research, Inc., Cambridge, MA, USA
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Corallo CE, Coutsouvelis J, Morgan S, Morrissey O, Avery S. Dapsone for Pneumocystis jirovecii pneumonia prophylaxis - applying theory to clinical practice with a focus on drug interactions. Drug Metab Pers Ther 2020; 35:dmpt-2019-0018. [PMID: 32681773 DOI: 10.1515/dmpt-2019-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 05/14/2020] [Indexed: 11/15/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is a potentially life-threatening infection that occurs in immunocompromised individuals. The incidence can be as high as 80% in some groups but can be reduced to less than 1% with appropriate prophylaxis. HIV-infected patients with a low CD4 count are at the highest risk of PJP. Others at substantial risk include haematopoietic stem cell and solid organ transplant recipients, those with cancer (particularly haematologic malignancies), and those receiving glucocorticoids, chemotherapeutic agents, and other immunosuppressive medications. Trimethoprim-sulfamethoxazole is an established first-line line agent for prevention and treatment of PJP. However, in some situations, this medication cannot be used and dapsone is considered a suitable cost-effective second line agent. However, information on potential interactions with drugs commonly used in immunosuppressed patients is lacking or contradictory. In this this article we review the metabolic pathway of dapsone with a focus on interactions and clinical significance particularly in patients with haematological malignancies. An understanding of this process should optimise the use of this agent.
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Affiliation(s)
| | | | - Susan Morgan
- Alfred Health, Haematology, Melbourne, Victoria, Australia
| | - Orla Morrissey
- Alfred Health, Infectious Diseases, Melbourne, Victoria, Australia
| | - Sharon Avery
- Alfred Health, Haematology, Melbourne, Victoria, Australia
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Abstract
Over the years, numerous studies have supported the premise that individuals possessing the "slow acetylator" phenotype are more at risk from developing drug side-effects. Most prominent amongst these reports are those concerned with hepatotoxicity and peripheral neuropathy following treatment with isoniazid, lupus-like symptoms during procainamide therapy and experiencing hypersensitivity reactions to the various sulphonamide derivatives. Similarly, "slow acetylators" undergoing heavy exposure to arylamines and related carcinogens are more likely to develop bladder cancer. Contrariwise, there appears a slight risk of "rapid acetylators" developing pancreatic tumours.Other therapeutic agents for which polymorphic N-acetylation plays a minor role in their metabolism have been investigated but any impact of this metabolic difference on clinical efficacy or associated toxicity is still under question. In the search for clues as to the underlying aetiology, patient groups with many disease states have been examined for association with differences in N-acetylation and the majority have provided data that could be interpreted as equivocal. Studies have given contradictory, often opposing, results, calculated risk factors that are (perhaps) just significant but certainly not high, and patients within the cohorts who are always exceptions. Undoubtedly, other as yet unappreciated factors are at play.
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Affiliation(s)
- Stephen C Mitchell
- Section of Computational and Systems Medicine, Faculty of Medicine, Imperial College London, London, UK
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Corallo C, Coutsouvelis J, Avery S, Morgan S, Morrissey O. Dapsone and azole interactions: A clinical perspective. J Oncol Pharm Pract 2017; 24:637-640. [DOI: 10.1177/1078155217722048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An understanding of the clinical significance of dapsone-drug interactions is essential for optimal use of this agent. This review aims to provide clinicians with an overview of this topic.
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Affiliation(s)
| | | | - Sharon Avery
- Pharmacy Department, Alfred Hospital, Victoria, Australia
| | - Susan Morgan
- Pharmacy Department, Alfred Hospital, Victoria, Australia
| | - Orla Morrissey
- Pharmacy Department, Alfred Hospital, Victoria, Australia
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Cha YS, Kim H, Kim J, Kim OH, Kim HI, Cha K, Lee KH, Hwang SO. Incidence and patterns of hemolytic anemia in acute dapsone overdose. Am J Emerg Med 2016; 34:366-9. [DOI: 10.1016/j.ajem.2015.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/08/2015] [Accepted: 09/09/2015] [Indexed: 11/25/2022] Open
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Abouraya M, Sacco JC, Hayes K, Thomas S, Kitchens CS, Trepanier LA. Dapsone-associated methemoglobinemia in a patient with slow NAT2*5B haplotype and impaired cytochrome b5 reductase activity. J Clin Pharmacol 2015; 52:272-8. [PMID: 21422237 DOI: 10.1177/0091270010393343] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mahmoud Abouraya
- Department of Medical Sciences, University of Wisconsin-MadisonDivision of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, Florida
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Malasingam R, Ranganathan D, Jeyaseelan L, Ramanathan K, Jacks M, Owens J, John GT. An Audit of Dapsone-associated Methaemoglobinaemia in Renal Transplant Recipients. Nephrology (Carlton) 2014; 19:594-5. [DOI: 10.1111/nep.12291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Roshini Malasingam
- Department of Nephrology; The Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | | | | | - Kavitha Ramanathan
- Department of Nephrology; The Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Margaret Jacks
- Department of Nephrology; The Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Julie Owens
- Department of Nephrology; The Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - George T. John
- Department of Nephrology; The Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
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Barclay JA, Ziemba SE, Ibrahim RB. Dapsone-induced methemoglobinemia: a primer for clinicians. Ann Pharmacother 2011; 45:1103-15. [PMID: 21852596 DOI: 10.1345/aph.1q139] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To present a comprehensive review of dapsone-induced methemoglobinemia and its management. DATA SOURCES Literature retrieval was accessed through MEDLINE (1966-March 2011), Cochrane Library, and EMBASE, using the terms dapsone and methemoglobinemia. STUDY SELECTION AND DATA EXTRACTION All case reports, small case series, and randomized controlled trials published in English were evaluated. Because of the absence of comprehensive updates on this topic since 1996, publications between 1997 and March 2011 were included in this review. DATA SYNTHESIS Between 1997 and March 2011, the majority of publications describing methemoglobinemia associated with dapsone use reported this adverse effect at therapeutic doses. Excluding overdose situations, 18 described symptomatic dapsone-associated methemoglobinemia and clinical presentation ranging from cyanosis to dyspnea. In almost all of the accounts, patients had a concurrent event such as anemia or pneumonia, suggesting an interplay between these comorbidities and the onset of symptomatic methemoglobinemia. Delayed hemolytic anemia was seen in patients with high methemoglobin levels at presentation. Management in most cases consisted of administration of methylene blue. Overall, most reports described a successful outcome, and no mortality resulted from methemoglobinemia associated with therapeutic use. CONCLUSIONS Clinicians should recognize methemoglobinemia as an adverse effect associated with dapsone use and the potential factors that precipitate it. They should also know how to promptly and effectively manage this event.
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Affiliation(s)
- James A Barclay
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Allied Health Professions, Wayne State University, Detroit, MI, USA.
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High prevalence of Dapsone-induced oxidant hemolysis in North American SCT recipients without glucose-6-phosphate-dehydrogenase deficiency. Bone Marrow Transplant 2011; 47:399-403. [PMID: 21478917 DOI: 10.1038/bmt.2011.83] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dapsone (4-4'-diaminodiphenylsulfone) is commonly used for Pneumocystis jirovecii pneumonia (PCP) prophylaxis in immunocompromised patients. Oxidant hemolysis is a known complication of dapsone, but its frequency in adult patients who have undergone a SCT for hematological malignancies is not well established. We studied the presence of oxidant hemolysis, by combining examination of RBC morphology and laboratory data, in 30 patients who underwent a SCT and received dapsone for PCP prophylaxis, and compared this group with 26 patients who underwent a SCT and received trimethoprim-sulfamethoxazole (TMP-SMX) for PCP prophylaxis. All patients had normal glucose-6-phosphate dehydrogenase (G6PDH) enzymatic activity. In SCT patients, dapsone compared with TMP-SMX for PCP prophylaxis was associated with a high incidence of oxidant hemolysis (87 vs 0%, P<0.001), and the morphological evaluation of oxidant hemolysis correlated well with laboratory evidence of hemolysis. Dapsone-induced oxidant hemolysis in SCT patients is 20-fold higher than the reported rate in the population of HIV-infected patients, and thus much higher than the prevalence of G6PDH variants in the general population. In our patients, it manifested clinically as a lower Hb that was not significant enough to result in increased packed RBC transfusions.
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Bordin L, Fiore C, Zen F, Coleman MD, Ragazzi E, Clari G. Dapsone hydroxylamine induces premature removal of human erythrocytes by membrane reorganization and antibody binding. Br J Pharmacol 2011; 161:1186-99. [PMID: 20662842 DOI: 10.1111/j.1476-5381.2010.00962.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE N-hydroxylation of dapsone leads to the formation of the toxic hydroxylamines responsible for the clinical methaemoglobinaemia associated with dapsone therapy. Dapsone has been associated with decreased lifespan of erythrocytes, with consequences such as anaemia and morbidity in patients treated with dapsone for malaria. Here, we investigated how dapsone and/or its hydroxylamine derivative (DDS-NHOH) induced erythrocyte membrane alterations that could lead to premature cell removal. EXPERIMENTAL APPROACH Erythrocytes from healthy donors were subjected to incubation with dapsone and DDS-NHOH for varying times and the band 3 protein tyrosine-phosphorylation process, band 3 aggregation, membrane alteration and IgG binding were all examined and compared with erythrocytes from two patients receiving dapsone therapy. KEY RESULTS The hydroxylamine derivative, but not dapsone (the parent sulphone) altered membrane protein interactions, leading both to aggregation of band 3 protein and to circulating autologous antibody binding, shown in erythrocytes from patients receiving dapsone therapy. The band 3 tyrosine-phosphorylation process can be used as a diagnostic system to monitor membrane alterations both in vitro, assessing concentration and time-dependent effects of DDS-NHOH treatment, and in vivo, evaluating erythrocytes from dapsone-treated patients, in resting or oxidatively stimulated conditions. CONCLUSIONS AND IMPLICATIONS DDS-NHOH-induced alterations of human erythrocytes can be directly monitored in vitro by tyrosine-phosphorylation level and formation of band 3 protein aggregates. The latter, together with antibody-mediated labelling of erythrocytes, also observed after clinical use of dapsone, may lead to shortening of erythrocyte lifespan.
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Affiliation(s)
- Luciana Bordin
- Department of Biological Chemistry, University of Padova, Viale G. Colombo 3, Padua, Italy.
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Subramaniam A, Corallo C, Nagappan R. Dapsone-Associated Methaemoglobinaemia in Patients with a Haematologic Malignancy. Anaesth Intensive Care 2010; 38:1070-6. [DOI: 10.1177/0310057x1003800618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Methaemoglobinaemia is an uncommon problem which can significantly impact on oxygen carriage and may necessitate intensive care management. The occurrence of symptomatic methaemoglobinaemia over a three-month period in four patients with haematological malignancies on dapsone for Pneumocystis jiroveci pneumonia prophylaxis prompted a review of its use in this group of patients. We performed a retrospective audit to identify any contributing factors. Co-oximetry was employed to identify patients with methaemoglobinaemia. Thirty-four patients with haematological malignancies received dapsone between January and December 2008, of whom 53% (n=18) had co-oximetry studies done. Raised methaemoglobin levels (≥1.5%) were seen in 13 patients, four of them symptomatic. Mean peak level was of 7.84% (range 1.9 to 26.8%). Eight patients required intensive care support. Mean onset of methaemoglobinaemia was 11.8 days (range 4 to 18 days) following dapsone commencement. All patients were anaemic with an average haemoglobin of 85.5 g/l (range 59 to 111 g/l). All patients were prescribed ‘azole’ antifungal agents and five patients were also on high-dose steroids, both agents known to induce cytochrome P-450 enzymes and hence potentiating dapsone toxicity. Our experience suggests that dapsone should be used with caution in patients with haematological malignancies as they are particularly at risk of developing symptomatic methaemoglobinaemia due to underlying anaemia, immunosuppression and potential drug interactions. The current recommendation of dapsone for Pneumocystis jiroveci pneumonia prophylaxis in this group of patients needs to be reviewed. When methaemoglobinaemia does occur, early recognition is possible with routine co-oximetry testing and prompt treatment may lessen the need for or duration of intensive care supports.
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Affiliation(s)
- A. Subramaniam
- Department of Intensive Care, Box Hill Hospital, Melbourne, Victoria, Australia
| | - C. Corallo
- Department of Intensive Care, Box Hill Hospital, Melbourne, Victoria, Australia
- Senior Clinical Pharmacist, Department of Pharmacy, The Alfred Hospital
| | - R. Nagappan
- Department of Intensive Care, Box Hill Hospital, Melbourne, Victoria, Australia
- Senior Intensive Care Specialist
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Figtree MC, Miyakis S, Tanaka K, Martin L, Konecny P, Krilis S. Dapsone hypersensitivity syndrome causing disseminated intravascular coagulation. BMJ Case Rep 2009; 2009:bcr11.2008.1257. [PMID: 21829418 DOI: 10.1136/bcr.11.2008.1257] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dapsone hypersensitivity syndrome is an idiosyncratic reaction to this drug and can present with different clinical manifestations of varying severity. We describe a patient with disseminated intravascular coagulation (DIC) as an adverse reaction to dapsone. To the best of our knowledge, this is the first time it has been described in the literature. She presented with fever, rash and abdominal pain; she also had marked eosinophilia and features suggestive of oxidative haemolysis. Her course was complicated by DIC, splenic infarction and gastrointestinal bleeding. Extensive investigations did not reveal any alternative aetiology. She was initially treated with supportive measures and folic acid; steroids were administered later, following clinical deterioration. There was gradual improvement and the steroids were tapered. The patient recovered fully and remains well; her underlying chronic dermatologic condition is under satisfactory control with other medications.
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Affiliation(s)
- Melanie Clare Figtree
- St George Hospital, Immunology, Allergy and Infectious Disease, Kogarah, Sydney, New South Wales, 2217, Australia
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17
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Pickert A, Raimer S. An evaluation of dapsone gel 5% in the treatment of acne vulgaris. Expert Opin Pharmacother 2009; 10:1515-21. [DOI: 10.1517/14656560903002097] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Roberts DM, Heilmair R, Buckley NA, Dawson AH, Fahim M, Eddleston M, Eyer P. Clinical outcomes and kinetics of propanil following acute self-poisoning: a prospective case series. BMC CLINICAL PHARMACOLOGY 2009; 9:3. [PMID: 19220887 PMCID: PMC2656468 DOI: 10.1186/1472-6904-9-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Accepted: 02/16/2009] [Indexed: 11/21/2022]
Abstract
Background Propanil is an important cause of death from acute pesticide poisoning, of which methaemoglobinaemia is an important manifestation. However, there is limited information about the clinical toxicity and kinetics. The objective of this study is to describe the clinical outcomes and kinetics of propanil following acute intentional self-poisoning. Methods 431 patients with a history of propanil poisoning were admitted from 2002 until 2007 in a large, multi-centre prospective cohort study in rural hospitals in Sri Lanka. 40 of these patients ingested propanil with at least one other poison and were not considered further. The remaining 391 patients were classified using a simple grading system on the basis of clinical outcomes; methaemoglobinaemia could not be quantified due to limited resources. Blood samples were obtained on admission and a subset of patients provided multiple samples for kinetic analysis of propanil and the metabolite 3,4-dichloroaniline (DCA). Results There were 42 deaths (median time to death 1.5 days) giving a case fatality of 10.7%. Death occurred despite treatment in the context of cyanosis, sedation, hypotension and severe lactic acidosis consistent with methaemoglobinaemia. Treatment consisted primarily of methylene blue (1 mg/kg for one or two doses), exchange transfusion and supportive care when methaemoglobinaemia was diagnosed clinically. Admission plasma concentrations of propanil and DCA reflected the clinical outcome. The elimination half-life of propanil was 3.2 hours (95% confidence interval 2.6 to 4.1 hours) and the concentration of DCA was generally higher, more persistent and more variable than propanil. Conclusion Propanil is the most lethal herbicide in Sri Lanka after paraquat. Methylene blue was largely prescribed in low doses and administered as intermittent boluses which are expected to be suboptimal given the kinetics of methylene blue, propanil and the DCA metabolite. But in the absence of controlled studies the efficacy of these and other treatments is poorly defined. More research is required into the optimal management of acute propanil poisoning.
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Affiliation(s)
- Darren M Roberts
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
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19
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Dapsone-induced Hemolytic Anemia in Lung Allograft Recipients. J Heart Lung Transplant 2008; 27:1198-202. [DOI: 10.1016/j.healun.2008.07.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 07/01/2008] [Accepted: 07/29/2008] [Indexed: 11/21/2022] Open
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20
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Saggar S, Maibach HI. Polymorphic cytochrome P450 enzymes and post-marketing drug dosage revisions: clinical relevance to dermatologic therapies. Cutan Ocul Toxicol 2007; 26:171-80. [PMID: 17687682 DOI: 10.1080/15569520701212324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The therapeutic drug resources available to dermatologists have expanded and encompass off-label use of other drugs as well. As these new resources are employed, it is important to remain vigilant of possible drug interactions and toxicities contingent upon inter-individual variability of plasma drug levels. This article reviews the biochemistry of CYP enzymes and the clinical implications of genetic polymorphisms as relating to certain dermatologic drugs. In addition, we discuss the potential clinical function of cutaneous CYP enzymes.
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Affiliation(s)
- Sarika Saggar
- Albert Einstein College of Medicine, Bronx, New York, USA.
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21
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Abstract
Malaria is a major infectious disease. In the last 10 years it has killed more than 20 million people, mainly small children in Africa. The highly efficacious artemisinine combination therapy is being launched globally, constituting the main hope for fighting the disease. Amodiaquine is a main partner in these combinations. Amodiaquine is almost entirely metabolized by the polymorphic cytochrome P450 (CYP) isoform 2C8 to the pharmacologically active desethylamodiaquine. The question remains whether the efficacy of amodiaquine is affected by the gene polymorphism. Genotype-inferred low metabolizers are found in 1-4% of African populations, which corresponds to millions of expected exposures to the drug. In vivo pharmacokinetic data on amodiaquine is limited. By combining it with published in vitro pharmacodynamic and drug metabolism information, we review and predict the possible relevance, or lack of, of CYP2C8 polymorphisms in the present and future efficacy of amodiaquine. Chloroquine and dapsone, both substrates of CYP2C8, are also discussed in the same context.
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Affiliation(s)
- J P Gil
- Karolinska Institute, Malaria Research Unit, Division of Infectious Diseases, Department of Medicine, Karolinska University Hospital, M9:02, KS 17176 Stockholm, Sweden.
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Gardiner SJ, Begg EJ. Pharmacogenetics, drug-metabolizing enzymes, and clinical practice. Pharmacol Rev 2006; 58:521-90. [PMID: 16968950 DOI: 10.1124/pr.58.3.6] [Citation(s) in RCA: 234] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The application of pharmacogenetics holds great promise for individualized therapy. However, it has little clinical reality at present, despite many claims. The main problem is that the evidence base supporting genetic testing before therapy is weak. The pharmacology of the drugs subject to inherited variability in metabolism is often complex. Few have simple or single pathways of elimination. Some have active metabolites or enantiomers with different activities and pathways of elimination. Drug dosing is likely to be influenced only if the aggregate molar activity of all active moieties at the site of action is predictably affected by genotype or phenotype. Variation in drug concentration must be significant enough to provide "signal" over and above normal variation, and there must be a genuine concentration-effect relationship. The therapeutic index of the drug will also influence test utility. After considering all of these factors, the benefits of prospective testing need to be weighed against the costs and against other endpoints of effect. It is not surprising that few drugs satisfy these requirements. Drugs (and enzymes) for which there is a reasonable evidence base supporting genotyping or phenotyping include suxamethonium/mivacurium (butyrylcholinesterase), and azathioprine/6-mercaptopurine (thiopurine methyltransferase). Drugs for which there is a potential case for prospective testing include warfarin (CYP2C9), perhexiline (CYP2D6), and perhaps the proton pump inhibitors (CYP2C19). No other drugs have an evidence base that is sufficient to justify prospective testing at present, although some warrant further evaluation. In this review we summarize the current evidence base for pharmacogenetics in relation to drug-metabolizing enzymes.
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Affiliation(s)
- Sharon J Gardiner
- Department of Medicine, Christchurch School of Medicine, Private Bag 4345, Christchurch, New Zealand.
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24
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Obach RS, Dalvie DK. METABOLISM OF NOMIFENSINE TO A DIHYDROISOQUINOLINIUM ION METABOLITE BY HUMAN MYELOPEROXIDASE, HEMOGLOBIN, MONOAMINE OXIDASE A, AND CYTOCHROME P450 ENZYMES. Drug Metab Dispos 2006; 34:1310-6. [PMID: 16679384 DOI: 10.1124/dmd.106.010173] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Nomifensine is an antidepressant agent that was removed from use because of a high incidence of hemolytic anemia. It contains an N-methyl-8-aminotetrahydroisoquinoline ring which has the potential to be oxidized to quaternary dihydroisoquinolinium and isoquinolinium ions, albeit such a transformation had not been previously observed. In this report, we demonstrate the conversion of nomifensine to a dihydroisoquinolinium ion metabolite by several human enzymes. Human liver microsomes supplemented with NADPH generated the dihydroisoquinolinium ion metabolite along with other hydroxylated metabolites, whereas when supplemented with t-butyl peroxide, only the dihydroisoquinolinium ion metabolite was observed. Monoamine oxidase A, but not monoamine oxidase B, catalyzed this reaction, as well as human hemoglobin supplemented with H2O2. Human myeloperoxidase catalyzed this reaction in the presence of H2O2, and activation of the reaction was observed when incubations were conducted in the presence of acetaminophen at concentrations relevant to those measured in humans. The reaction was also observed in human whole blood. The equilibrium between the dihydroisoquinolinium ion and carbinolamine was shown to have a pK of about 11.7. The dihydroisoquinolinium ion was shown to react with cyanide and borohydride, but not glutathione. These findings suggest that the electrophilic nomifensine dihydroisoquinolinium metabolite, which can be generated by several enzymes, could be behind toxic responses to nomifensine such as hemolytic anemia and hepatotoxicity.
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Affiliation(s)
- R Scott Obach
- Department of Pharmacokinetics, Dynamics, and Drug Metabolism, Pfizer Global Research and Development, Groton Laboratories, Groton, CT 06340, USA.
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25
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Hoffmann TK, von Schmiedeberg S, Wulferink M, Thier R, Bier H, Ruzicka T, Lehmann P. Dapson-induzierte Agranulozytose. Hautarzt 2005; 56:673-7. [PMID: 15999287 DOI: 10.1007/s00105-004-0877-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A 34-year-old female patient with a three year history of generalized granuloma annulare was treated systemically with dapsone (DADPS). Six weeks after the onset of treatment, the patient developed an extensive tonsillitis of the base of the tongue with fever and malaise. Routine laboratory work showed a leukocytopenia with agranulocytosis. Further investigation revealed a marked decrease of the enzyme activity of N-acetyltransferase 2, which plays an important role in dapsone metabolism. Treatment included the cessation of dapsone, antibiotic coverage, and G-CSF leading to the rapid improvement of symptoms and normalization of leukocyte counts. Dapsone-induced angina agranulocytotica is a rare event and is interpreted as an idiosyncratic reaction. Depending on genetic polymorphisms of various enzymes, dapsone can be metabolized to immunologically or toxicologically relevant intermediates. Because of the risk of severe hematologic reactions, dapsone should only be employed for solid indications and with appropriate monitoring.
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Affiliation(s)
- T K Hoffmann
- Hals-Nasen-Ohren-Klinik, Heinrich-Heine-Universität Düsseldorf.
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26
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Jason TLH, Koropatnick J, Berg RW. Toxicology of antisense therapeutics. Toxicol Appl Pharmacol 2004; 201:66-83. [PMID: 15519609 DOI: 10.1016/j.taap.2004.04.017] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2003] [Accepted: 04/28/2004] [Indexed: 12/24/2022]
Abstract
Targeting unique mRNA molecules using antisense approaches, based on sequence specificity of double-stranded nucleic acid interactions should, in theory, allow for design of drugs with high specificity for intended targets. Antisense-induced degradation or inhibition of translation of a target mRNA is potentially capable of inhibiting the expression of any target protein. In fact, a large number of proteins of widely varied character have been successfully downregulated using an assortment of antisense-based approaches. The most prevalent approach has been to use antisense oligonucleotides (ASOs), which have progressed through the preclinical development stages including pharmacokinetics and toxicological studies. A small number of ASOs are currently in human clinical trials. These trials have highlighted several toxicities that are attributable to the chemical structure of the ASOs, and not to the particular ASO or target mRNA sequence. These include mild thrombocytopenia and hyperglycemia, activation of the complement and coagulation cascades, and hypotension. Dose-limiting toxicities have been related to hepatocellular degeneration leading to decreased levels of albumin and cholesterol. Despite these toxicities, which are generally mild and readily treatable with available standard medications, the clinical trials have clearly shown that ASOs can be safely administered to patients. Alternative chemistries of ASOs are also being pursued by many investigators to improve specificity and antisense efficacy and to reduce toxicity. In the design of ASOs for anticancer therapeutics in particular, the goal is often to enhance the cytotoxicity of traditional drugs toward cancer cells or to reduce the toxicity to normal cells to improve the therapeutic index of existing clinically relevant cancer chemotherapy drugs. We predict that use of antisense ASOs in combination with small molecule therapeutics against the target protein encoded by the antisense-targeted mRNA, or an alternate target in the same or a connected biological pathway, will likely be the most beneficial application of this emerging class of therapeutic agent.
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Affiliation(s)
- Tracey L H Jason
- Cancer Research Laboratories, London Regional Cancer Centre, London, Ontario, Canada N6A 4L6
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27
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Bucaretchi F, Vicente DC, Pereira RM, Tresoldi AT. Dapsone hypersensitivity syndrome in an adolescent during treatment during of leprosy. Rev Inst Med Trop Sao Paulo 2004; 46:331-4. [PMID: 15654479 DOI: 10.1590/s0036-46652004000600006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 12 y old girl was admitted 24 days after start a WHO multidrug therapy scheme for multibacillary leprosy (dapsone, clofazimine and rifampicin) with intense jaundice, generalized lymphadenopathy, hepatoesplenomegaly, oral erosions, conjunctivitis, morbiliform rash and edema of face, ankles and hands. The main laboratory data on admission included: hemoglobin, 8.4 g/dL; WBC, 15,710 cells/mm³; platelet count, 100,000 cells/mm³; INR = 1.49; increased serum levels of aspartate and alanine aminotransferases, gamma-glutamyl transpeptidase, alkaline phosphatase, direct and indirect bilirubin. Following, the clinical conditions had deteriorated, developing exfoliative dermatitis, shock, generalized edema, acute renal and hepatic failure, pancytopenia, intestinal bleeding, pneumonia, urinary tract infection and bacteremia, needing adrenergic drugs, replacement of fluids and blood product components, and antibiotics. Ten days after admission she started to improve, and was discharged to home at day 39th, after start new supervised treatment for leprosy with clofazimine and rifampicin, without adverse effects. This presentation fulfils the criteria for the diagnosis of dapsone hypersensitivity syndrome (fever, generalized lymphadenopathy, exfoliative rash, anemia and liver involvement with mixed hepatocellular and cholestatic features). Physicians, mainly in geographical areas with high prevalence rates of leprosy, should be aware to this severe, and probably not so rare, hypersensitivity reaction to dapsone.
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Affiliation(s)
- Fábio Bucaretchi
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil.
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28
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Abstract
For 60 years, dapsone has been used as a both antibacterial and anti-inflammatory agent. Dapsone (4,4'-diaminodiphenylsulfone, DDS) continues to be used successfully to treat a wide range of dermatologic disorders, notably those characterized by abnormal neutrophil and eosinophil polynuclear accumulation. A considerable number of other inflammatory as well as bullous dermatoses, of which dermatitis herpetiformis is the best known, have been shown to respond in varying degrees to dapsone, although the indication for the molecule has not been demonstrated in of them all. This article reviews current knowledge on the pharmacokinetics, mechanism of action and side effects of dapsone in dermatology. Despite the lack of controlled studies, the aim of this study is to specify and classify the pathological states in which disulone could be indicated.
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Affiliation(s)
- E Begon
- Service de Dermatologie du Pr Revuz, Hôpital Henri Mondor, avenue du Maréchal de Lattre de Tassigny, 94000 Créteil.
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29
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Alfirevic A, Stalford AC, Vilar FJ, Wilkins EGL, Park BK, Pirmohamed M. Slow acetylator phenotype and genotype in HIV-positive patients with sulphamethoxazole hypersensitivity. Br J Clin Pharmacol 2003; 55:158-65. [PMID: 12580987 PMCID: PMC1894729 DOI: 10.1046/j.1365-2125.2003.01754.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2002] [Accepted: 09/20/2002] [Indexed: 02/01/2023] Open
Abstract
AIMS To test the role of acetylator status, and to investigate the reported discrepancy between acetylator phenotype and genotype in HIV-positive patients with sulphamethoxazole (SMX) hypersensitivity. METHODS Forty HIV-positive patients (32 of whom were SMX-hypersensitive), and 26 healthy volunteers, were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis, and phenotyped using dapsone (50 mg) as a probe, for acetylator status. Sequencing of the NAT2 exon was performed where discrepancy between phenotyping and genotyping was detected. Our results were also pooled with published studies addressing slow acetylator status in HIV-positive SMX-hypersensitive patients. RESULTS Slow acetylator genotype and phenotype frequencies did not differ between HIV-positive SMX-hypersensitive and nonhypersensitive patients, and healthy controls, which was further confirmed in a meta-analysis of published studies (pooled odds ratio 2.25, 95% confidence interval 0.45, 11.17). Discordance between phenotype and genotype was resolved in four of the subjects by sequencing of the whole NAT2 exon, which revealed rare mutations, leaving three (9%) HIV-positive SMX-hypersensitive patients and one (4%) healthy volunteer who continued to demonstrate the discordance. CONCLUSIONS Slow acetylator phenotype or genotype is unlikely to predispose to SMX hypersensitivity in HIV-positive patients, although a minor role cannot be excluded. Phenotype-genotype discrepancies are partly due to nondetection of all rare alleles by PCR methodology, and can be circumvented by sequencing of the gene in patients showing a discrepancy.
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Affiliation(s)
- Ana Alfirevic
- Department of Pharmacology and Therapeutics, The University of Liverpool, Liverpool, UK
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30
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Butcher NJ, Boukouvala S, Sim E, Minchin RF. Pharmacogenetics of the arylamine N-acetyltransferases. THE PHARMACOGENOMICS JOURNAL 2002; 2:30-42. [PMID: 11990379 DOI: 10.1038/sj.tpj.6500053] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The arylamine N-acetyltransferases (NATs) are involved in the metabolism of a variety of different compounds that we are exposed to on a daily basis. Many drugs and chemicals found in the environment, such as those in cigarette smoke, car exhaust fumes and in foodstuffs, can be either detoxified by NATs and eliminated from the body or bioactivated to metabolites that have the potential to cause toxicity and/or cancer. NATs have been implicated in some adverse drug reactions and as risk factors for several different types of cancers. As a result, the levels of NATs in the body have important consequences with regard to an individual's susceptibility to certain drug-induced toxicities and cancers. This review focuses on recent advances in the molecular genetics of the human NATs.
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Affiliation(s)
- N J Butcher
- Laboratory for Cancer Medicine, Western Australian Institute for Medical Research, Royal Perth Hospital.
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31
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Nelson SD. Structure toxicity relationships--how useful are they in predicting toxicities of new drugs? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2002; 500:33-43. [PMID: 11764962 DOI: 10.1007/978-1-4615-0667-6_4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This chapter provides just a few newer examples of structural moieties found in drugs that have been associated with reactive metabolite formation and toxicities. For a discussion of several other structures in drugs that undergo metabolic activation to reactive intermediates, the reader is directed to previous volumes in this series and other chapters in this book, as well as a previous condensed review (Nelson, 1982). Since that review, some new knowledge allows us to better predict that some structural moieties are more likely than others to form drug reactive metabolites that may be involved in causing toxic effects in humans. For example, most aniline-, thiophene-, and nitroaromatic-containing drugs have had a relatively high incidence of adverse effects, and it would be prudent in the drug discovery process to avoid these substructures if possible. However, as illustrated by the case of olanzapine, these structures may be important for potent activity, and could therefore be beneficial in some cases. The glitazones represent a new class of drugs with a unique thiazolidinedione structure. This raises two important points. First, it demonstrates how limited our knowledge base is in regard to structure toxicity relationships when new structures are introduced. Our approaches must be very empirical and are far from quantitative for the reasons outlined in the introduction. Secondly, the glitazones point out the importance of benefit/risk considerations. This was a new structural class of drugs with a unique spectrum of action that is very beneficial in the treatment of a major disease. Despite some suspected risk of toxicity, based on early trials, troglitazone was approved for use with careful monitoring. This author believes that was the right decision, as was the decision to withdraw the drug when the risk became unacceptable, especially with the introduction of safer alternatives. If this were just another NSAID (e.g., bromfenac), there would be little reason for approval. In summary, as I pointed out previously (Nelson, 1982), with our limited knowledge of structure toxicity relationships, we can only make reasonable judgments as to risk assessment of a new drug in humans, and hope that we neither release a dangerous chemical entity nor, as importantly, abort an effective one.
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Affiliation(s)
- S D Nelson
- School of Pharmacy, University of Washington, Seattle 98195-7631, USA
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Abstract
Arylamine N-acetyltransferases (NATs) play an important role in the interaction of competing metabolic pathways determining the fate of and response to xenobiotics as therapeutic drugs, occupational chemicals and carcinogenic substances. Individual susceptibility for drug response and possible adverse drug reactions are modulated by the genetic predisposition (manifested for example, by polymorphisms) and the phenotype of these enzymes. For all drugs metabolized by NATs, the impact of different in vivo enzyme activities is reviewed with regard to therapeutic use, prevention of side effects and possible indications for risk assessment by phenotyping and/or genotyping. As genes of NATs are susceptibility genes for multifactorial adverse effects and xenobiotic-related diseases, risk prediction can only be made possible by taking the complexity of events into consideration.
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Affiliation(s)
- Peter Meisel
- Department of Pharmacology, Ernst Moritz Arndt University Greifswald, F-Loeffler-Str. 23d, D-17487 Greifswald, Germany.
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Kwadijk S, Toraño JS. High-performance liquid chromatographic method with ultraviolet detection for the determination of dapsone and its hydroxylated metabolite in human plasma. Biomed Chromatogr 2002; 16:203-8. [PMID: 11920946 DOI: 10.1002/bmc.132] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A validated high-performance liquid chromatographic method with ultraviolet detection for the quantitative determination of dapsone (4,4'-diaminodifenyl sulfone, DDS) and a metabolite, hydroxylaminodapsone (4-amino-4-hydroxylaminodiphenyl sulfone, DDS-NOH), in human plasma is described. Human plasma was deproteinized with acetone and the clear supernatant solution after centrifugation was evaporated to dryness under a gentle stream of nitrogen at 70 degrees C. The residue was dissolved in a mixture of HPLC eluent and acetone (18:5 v/v) and an aliquot of this solution (50 microL) was injected onto the HPLC column. Dapsone, hydroxylaminodapsone and diazoxide as internal standard, were separated within 10 min by isocratic elution with water:acetonitrile:glacial acetic acid:triethylamine (80:20:1.0:0.5 by volume) as eluent. Detection was by ultraviolet at the wavelength of 295 nm. The within-day repeatability coefficients of variation were 3-5% for dapsone (0.301-20.0 mg/L, n = 5) and 3-5% for hydroxylaminodapsone (0.0948-6.32 mg/L, n = 5), whereas the between-day repeatability coefficients of variation were 3-8% (0.301-20.0 mg/L, n = 5) for dapsone and 4-10% for hydroxylaminodapsone (0.0948-6.32 mg/L, n = 5). The mean recoveries -were 92-107% (0.301-20.0 mg/L, n = 2), 80-82% (0.0948-6.32 mg/L, n = 2) and 88% (0.0200 mg/mL, n = 5), for dapsone, hydroxylaminodapsone and diazoxide, respectively. The average correlation coefficient of the calibration curve was 0.99988 (n = 5) for dapsone at a concentration range of 0.301-20.0 mg/L, whereas the average correlation coefficient of the hydroxylaminodapsone calibration curve was 0.99981 (n = 5) at a concentration range of 0.0948-6.32 mg/L. The limits of detection were 0.00200 and 0.0470 mg/L for dapsone and hydroxylaminodapsone, respectively. The method is suitable for drug level monitoring and for pharmacokinetic studies.
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Affiliation(s)
- S Kwadijk
- Pharmaceutical and Clinical Toxicological Laboratory, Department of Clinical Pharmacy E0-127, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Abstract
Combination of antimalarial agents has been introduced as a response to widespread drug resistance. The higher number of mutations required to express complete resistance against combinations may retard the further development of resistance. Combination of drugs, especially with the artemisinin drugs, may also offer complete and rapid eradication of the parasite load in symptomatic patients and thus reduce the chance of survival of resistant strains. The advantages of combination therapy should be balanced against the increased chance of drug interactions. During the last decade, much of the pharmacokinetics and metabolic pathways of antimalarial drugs have been elucidated, including the role of the cytochrome P450 (CYP) enzyme complex. Change in protein binding is not a significant cause of interactions between antimalarial agents. CYP3A4 and CYP2C19 are frequently involved in the metabolism of antimalarial agents. Quinidine is a potent inhibitor of CYP2D6, but it appears that this enzyme does not mediate the metabolism of any other antimalarial agent. The new combinations proguanil-atovaquone and chlorproguanil-dapsone do not show significant interactions. CYP2B6 and CYP3A4 are involved in the metabolism of artemisinin and derivatives, but further studies may reveal involvement of more enzymes. Artemisinin may induce CYP2C19. Several artemisinin drugs suffer from auto-induction of the first-pass effect, resulting in a decline of bioavailability after repeated doses. The mechanism of this effect is not yet clear, but induction by other agents cannot be excluded. The combination of artemisinin drugs with mefloquine and the fixed combination artemether-lumefantrine have been studied widely, and no significant drug interactions have been found. The artemisinin drugs will be used at an increasing rate, particularly in combination with other agents. Although clinical studies have so far not shown any significant interactions, drug interactions should be given appropriate attention when other combinations are used.
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Affiliation(s)
- P T Giao
- Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, Amsterdam, The Netherlands
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35
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Abstract
In their 60-year history, dapsone and the sulfones have been used as both antibacterial and anti-inflammatory agents. Dapsone has been used successfully to treat a range of dermatologic disorders, most successfully those characterized by abnormal neutrophil and eosinophil accumulation. This article reviews and updates the chemistry, pharmacokinetics, clinical application, mechanism of action, adverse effects, and drug interactions of dapsone and the sulfones in dermatology.
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Affiliation(s)
- Y I Zhu
- Department of Dermatology, New York Presbyterian Medical Center, 161 Fort Washington Ave., New York, NY 10032, USA
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36
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Abstract
Dapsone and sulfapyridine are structurally related compounds with anti-microbial and anti-inflammatory effects. Dapsone remains the most important drug for leprosy and is useful in the prophylaxis of Pneumocystis pneumonia in patients with HIV disease. The medical treatment of choice for dermatitis herpetiformis is dapsone; and sulfapyridine also can be used for those patients who are intolerant of dapsone. Other neutrophilic disorders also may respond to these drugs. Toxic side effects of both dapsone and sulfapyridine are mediated through the hydroxylamine metabolite. These include hemolysis, methemoglobinemia, and agranulocytosis. Careful monitoring for possible adverse reactions includes frequently performing complete blood counts and regular blood chemistry profile determinations.
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Affiliation(s)
- U Paniker
- Section of Dermatology, University of Arizona College of Medicine, Tucson, Arizona, USA
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