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Urinary recovery and kinetics of sulfamethoxazole and its metabolites in HIV-seropositive patients and healthy-volunteers after a single oral dose of sulfamethoxazole
British Journal of Clinical Pharmacology
Abstract
1. The urinary excretion of sulphamethoxazole and its metabolites was compared between healthy volunteers and HIV-seropositive patients in order to get a better understanding of why HIV seropositives are more predisposed to idiosyncratic toxicity of sulphonamides. 2. A single 800 mg oral dose of sulphamethoxazole was administered to seven healthy volunteers and seven asymptomatic HIV seropositives without previous use of sulphonamides. 3. Urine was collected for 4 days and drug analysis was by h.p.l.c. 4. No difference was observed between seropositive and seronegative individuals in the urinary recovery of sulphamethoxazole, N4-acetyl-, 5-hydroxy-, N4-acetyl-5-hydroxy-sulphamethoxazole and the N1-glucuronide conjugate. However the recovery of the hydroxylamine metabolite of sulphamethoxazole was significantly lower in the HIV seropositives (0.50 +/- 0.51 vs 2.23 +/- 0.85%; 95% CI on the difference, -0.90 to -2.55; P = 0.0006). 5. Sulphamethoxazole hydroxylamine may be a factor in the susceptibility of HIV infected individuals to sulphonamides.
... However, possible in-sewer transformation of the pharmaceuticals was not considered. Only Thai et al. (2014) have studied how insewer transformation processes alter the concentrations of organic pollutants, in particular illicit drugs and their metabolites , under different conditions, at laboratory-scale sewer reactors. They found that the biofilms in the lab-scale sewer have significantly enhanced the degradation rate of some compounds (i.e. ...
... Although the transformation of the organic matter in sewer occurs due to biological activity of microbial communities in both the wastewater stream and biofilm, Gutierrez et al. (2009) showed that the planktonic microorganisms had a negligible contribution to the overall sulfide bioproduction (approximately <2% of the overall rate), indicating the predominance of sewer wall biofilms. Similarly, Thai et al. (2014) showed that biofilm microbial activity increased the hydrolysis of cocaine compared to the suspended microbes in the wastewater alone. It can thus be anticipated that biofilm bacteria may affect the in-sewer concentrations of pharmaceuticals as well, as they spend around 21 h in the sewer. ...
... The increase in the concentrations may be due to the cleavage of the conjugates and/or re-transformation of metabolites by microbial community present in sewer wastewater . The known metabolism of sulfamethoxazole in mammals involves glucuronidation to N 1 -glucuronide conjugate (9e15 %) and acetylation to N 4 -acetyl-sulfamethoxazole (43%) (van der Ven et al., 1995). The re-transformation of these two metabolites to sulfamethoxazole was observed during wastewater treatment (Gobel et al., 2005 ) and in watersediment tests (Radke et al., 2009). ...
The occurrence of 43 pharmaceuticals and 2 metabolites of ibuprofen was evaluated at the inlet and the outlet of a pressure sewer pipe in order to asses if in-sewer processes affect the pharmaceutical concentrations during their pass through the pipe. The target compounds were detected at concentrations ranging from low ng/L to a few μg/L, which are in the range commonly found in municipal wastewater of the studied area. The changes in concentrations between two sampling points were negligible for most compounds, i.e. from -10 to 10%. A higher decrease in concentrations (25-60 %) during the pass through the pipe was observed for diltiazem, citalopram, clarithromycin, bezafibrate and amlodipine. Negative removal was calculated for sulfamethoxazole (-66 ± 15%) and irbesartan (-58 ± 25%), which may be due to the conversion of conjugates back to their parent compounds in the sewer. The results show that microbial transformation of pharmaceuticals begins in sewer, albeit to different extents for different compounds. Therefore, the in-sewer transformation of pharmaceuticals should be assessed especially when their concentrations are used to estimate and refine the estimation of their per capita consumption in a catchment of interest in the sewage epidemiology approach.
Copyright © 2014 Elsevier Ltd. All rights reserved.
... The resultant hydroxylamine, which is not protein-reactive (Cribb et al., 1991;Naisbitt et al., 1996), circulates in the periphery (Gill et al., 1997). Further auto oxidation, under conditions of oxidative stress, generates the protein-reactive intermediate nitroso SMX (SMX-NO;Naisbitt et al., 1999Naisbitt et al., , 2001Reilly et al., 2000;Manchanda et al., 2002;Summan and Cribb, 2002;Fig. 1). ...
... jpet.aspetjournals.org SMX-NO (Naisbitt et al., 1999Reilly et al., 2000;Manchanda et al., 2002;Summan and Cribb, 2002). CYP2C9 is expressed in liver, skin, and macrophages Baron et al., 1998;Saeki et al., 2002) and indeed Reilly et al. (2000) have recently shown that cultured human keratinocytes metabolize SMX to SMX hydroxylamine. ...
... These data highlight the fact that maintenance of levels of sulfhydryl-containing compounds such as glutathione plays a critical role in inhibiting the conversion of SMX hydroxylamine to SMX-NO. In patients with a disturbed redox balance as is seen with HIV infection (van der Ven et al., 1995), increased generation of SMX-NO may to be one factor that contributes to the increased incidence of drug hypersensitivity. ...
Sulfamethoxazole (SMX) is associated with hypersensitivity reactions. Identification of drug-specific lymphocytes from hypersensitive patients suggests involvement of the immune system. Lymphocytes from humans recognize SMX and nitroso-SMX (SMX-NO), whereas cells from sensitized rats recognize only SMX-NO. In this investigation, we study the nature of SMX-specific T cells in four species. Male rats, mice, and rabbits were immunized with SMX (50 mg kg-1) or SMX-NO (1 mg kg-1). Lymphocytes and/or splenocytes were isolated and incubated with SMX, SMX-hydroxylamine or SMX-NO and proliferation were measured. Lymphocytes were also isolated from SMX-hypersensitive patients (n = 3) and drug-specific proliferation was measured. In addition, rabbits were bled fortnightly for 4 months to determine whether SMX-NO-specific T cells cross-react with SMX. To confirm that SMX-NO responses were due to covalent binding and not cross-reactivity, cells were pulsed with SMX-NO and/or coincubated with glutathione. Splenocytes from mice, rats, and rabbits proliferated when stimulated with SMX-NO, but not SMX. A 2-h pulse with SMX-NO was sufficient for proliferation, whereas cells coincubated with SMX-NO and glutathione did not proliferate. Rabbit lymphocytes proliferated in the presence of SMX-NO and SMX-hydroxylamine, but not SMX. SMX-hydroxylamine was converted to SMX-NO in culture. The SMXNO-specific response of rabbit lymphocytes was maintained for at least 4 months and the cells did not cross-react with SMX. Human lymphocytes from hypersensitive patients proliferated in the presence of SMX and both metabolites. These results highlight important differences in T-cell recognition of drug (metabolite) antigens in animals that have been sensitized against a drug metabolite and patients with hypersensitivity to the drug.
... strain BR1) (Gauthier et al., 2010; Jiang et al., 2014; Reis et al., 2014). Some researchers have showed the adverse effects of SMX and its degradation products (e.g., 3-amino-5- methylisoxazole (3A5MI) and sulfanilamide) on mammalian cell cultures, fish, green algae, and groundwater bacteria (Yargeau et al., 2008; Underwood et al., 2011; Straub, 2015; García-Galán et al., 2012). Besides, the presence of SMX in aquatic environments favors the development and dissemination of antibiotic-resistant genes and poses risks to human health (Gao et al., 2012). ...
... detected (García-Galán et al., 2012). It has been shown that Ac-SMX, as the most prominent metabolite of SMX in the human body, represents 50% of the excreted administered dose, while HO-SMX is only 2.2% (van der Ven et al., 1995). Anaerobic biotransformation rate of SMX depended on the primary substrate activity (Alvarino et al., 2016). ...
... Approximately 45-70% of a SMX dose is excreted via urine within 24 h (4). However, only 15-25% is present as unchanged drug while 43% is present as N 4acetyl-sulfamethoxazole (Ac-SMX), and 9-15% is present as sulfamethoxazole-N 1 -glucuronide (SMX-Glu) (5)(6)(7). Three additional metabolites sum up to 4-10% of total dose (5,7). A detailed scheme of SMX metabolism is provided in the Supporting Information. ...
... However, only 15-25% is present as unchanged drug while 43% is present as N 4acetyl-sulfamethoxazole (Ac-SMX), and 9-15% is present as sulfamethoxazole-N 1 -glucuronide (SMX-Glu) (5)(6)(7). Three additional metabolites sum up to 4-10% of total dose (5,7). A detailed scheme of SMX metabolism is provided in the Supporting Information. ...
Sulfonamide antibiotics are widely used in human and veterinary medicine. After their application, they are excreted in unchanged as well as in metabolized form. Due to incomplete elimination in wastewater treatment plants, they can be emitted into surface water. The environmental fate of both parent compounds and metabolites is currently unknown. The aim of this study was to determine the biodegradation potential of river sediment for the sulfonamide sulfamethoxazole (SMX) and its two major human metabolites N4-acetyl-SMX and SMX-N1-glucuronide using a water sediment test system. Each compound was tested in a separate series together with sterile and "water only" controls. All three compounds were efficiently removed from the test system by biodegradation in the sediment. Only for SMX-N1-glucuronide, a substantial removal in the absence of sediment was determined. Dissipation times from the aqueous phase (DT50) between 8.5 and 17.2 days were measured. Sorption to sediment was of minor importance due to the slightly basic pH of the test system. By the application of a mathematical model, biodegradation half-lives in sediment between 3.3 and 25.6 h were calculated for SMX and its metabolites. The results of this study highlight the capability of native river sediment for degrading sulfonamide antibiotics, but also the potential of human metabolites to retransform into parent SMX under environmental conditions. Based on this study, it is unlikely that SMX or its metabolites will persist or accumulate in river sediments under pH conditions where sorption is of minor importance.
... However, after 30 min of treatment, the DCF concentration decreases, and total removal was observed after 60 min. Similarly, SMX can be conjugated with glucuronides to form Acetyl-SMX and SMX-glucuronide, which are excreted by humans [92,93]. However, it is eliminated within 60 min using the PEF system. ...
In this study, a continuous flow photo-electro-Fenton (PEF) system was evaluated for its ability to remove pharmaceutically active compounds (PhACs) from irrigation water used in Bogot´a-savanna crops. The PEF system consisted of dimensionally stable anode and graphite diffusion gas cathode, which were irradiated with LEDs. Firstly, the system was optimized using response surface methodology (RSM) in ultrapure water. The most favorable conditions for efficient generation of oxidants (the response variable) were found to be a flow rate of 210 mL/min, a current density of 15 mA/cm2, and an electrolyte concentration of 0.1 mol NaCl/L. Subsequently, model compounds of PhACs, including losartan (LOS), sulfamethoxazole (SMX), and diclofenac (DCF), were
eliminated after only 10 min of treatment under the previously established conditions. After demonstrating the potential of the PEF system to eliminate PhACs, the system was applied to real irrigation water to evaluate the degradation of seven PhACs, namely carbamazepine (CBZ), sulfamethoxazole (SMX), ciprofloxacin (CIP), clarithromycin (CLR), diclofenac (DCF), valsartan (VAL), and trimethoprim (TMP). The results showed that after 30 min of treatment with the PEF system, the concentration of these compounds was drastically reduced remaining undetected. This demonstrates the high potential of the PEF system to reduce the presence of PhACs in irrigation water and associated environmental and food health risks.
... SMZ in animal bodies tends to bind with carbohydrates and reverses to its original form in a period after excretion due to the rapid biodegradation of carbohydrates in the natural environment (Rebecca, 2002). Similarly, 53-68% of SMX was excreted from the animals in the form of transformed SMX (Van Der Ven et al., 1995), which may transfer back to SMX molecules during the wastewater treatment process (Gobel et al., 2005). Another possible reason is that the antibiotics originally absorbed on the surface of the suspended solids (with total suspended solids of 5.45 g/L) in swine wastewater dissolved back to the aqueous phases during the reaction process . ...
... For example, the average concentration of SMX found in hospital effluent was 27.8 μg/L (Brenner et al. 2011). However, only 14% of ingested SMX is excreted in its original form, yielding a large fraction of metabolites, among which the most prominent metabolite is N-acetyl sulfamethoxazole (Ac-SMX), which represents 50% of the excreted administered dose (Vanderven et al. 1995). Therefore, Ac-SMX has been detected in wastewater effluent as well as surface waters at concentrations comparable to its parent compound (GÖbel et al. 2004;Ashton et al. 2004). ...
Compared to antibiotic parent molecule, human metabolites are generally more polar and sometimes not less toxic in wastewater. However, most researches focus on the fate of parent molecule. Therefore, behaviors of human metabolites are little known. Moreover, though much has been done on the fate of antibiotics during activated sludge process, there are still some limitations and gaps. In the present study, [Ring-¹⁴C] acetyl sulfamethoxazole (¹⁴C-Ac-SMX) was used to investigate the fate of human metabolite of SMX during activated sludge process at environmentally relevant concentration. At the end of 216 h, 3.1% of the spiked activity in the initial aqueous phase was mineralized, 50% was adsorbed onto the solid phase, and 36.5% still remained in the aqueous phase, indicating that adsorption, not biodegradation, was the main dissipation pathway. In the existence of microbial activities, accumulation into the solid phase was much higher, which was less bioavailable by chemical sequential extraction. The multimedia kinetic model simultaneously depicted the fate of Ac-SMX in the gas, aqueous, and solid phases, and demonstrated that microbially accelerated accumulation onto the solid phase was attributed to lower desorption rate from the solid phase to the aqueous phase, where adsorption rate was not the key factor. Therefore, Ac-SMX cannot be efficiently mineralized and remain in the aqueous or the solid phases. The accumulation in the solid phase is less bioavailable and is hard to be desorbed in the existence of microbial activities, and should not be easily degraded, and may lead to the development of antibiotic-resistant bacteria and genes after discharge into the environment.
... In addition, pharmacokinetic studies reported a slower elimination of acetylated sulfamethoxazole from human body than of parent sulfamethoxazole (Vree and Hekster, 1987;van der Ven et al., 1994;Vree et al., 1995). Altogether, this seems to justify the observation of higher n LI,CJ in hospital sewage. ...
... Statistical analyses for relative mRNA expression between groups were performed using relative expression software tool (REST) 2009 version1, which uses the methods described by Pfaffl and Vandesompele. (Pfaffl 2001;Pfaffl et al. 2002;Vandesompele et al. 2002;Pabinger et al. 2014). ...
HIV-infected patients show a markedly increased risk of delayed hypersensitivity (HS) reactions to potentiated sulfonamide antibiotics (trimethoprim/sulfamethoxazole or TMP/SMX). Some studies have suggested altered SMX biotransformation in HIV infection, but hepatic biotransformation pathways have not been evaluated directly. Systemic lupus erythematosus (SLE) is another chronic inflammatory disease with a higher incidence of sulfonamide HS, but it is unclear whether retroviral infection and SLE share risk factors for drug HS. We hypothesized that retroviral infection would lead to dysregulation of hepatic pathways of SMX biotransformation, as well as pathway alterations in common with SLE that could contribute to drug HS risk. We characterized hepatic expression profiles and enzymatic activities in an SIV-infected macaque model of retroviral infection, and found no evidence for dysregulation of sulfonamide drug biotransformation pathways. Specifically, NAT1, NAT2, CYP2C8, CYP2C9, CYB5R3, MARC1/2, and glutathione-related genes (GCLC, GCLM, GSS, GSTM1, and GSTP1) were not differentially expressed in drug naïve SIVmac239-infected male macaques compared to age-matched controls, and activities for SMX N-acetylation and SMX hydroxylamine reduction were not different. However, multiple genes that are reportedly over-expressed in SLE patients were also up-regulated in retroviral infection, to include enhanced immunoproteasomal processing and presentation of antigens as well as up-regulation of gene clusters that may be permissive to autoimmunity. These findings support the hypothesis that pathways downstream from drug biotransformation may be primarily important in drug HS risk in HIV infection.
... This observation is likely explained by the presence of TPs of sulfamethoxazole in the reactor influent that deconjugated to reform sulfamethoxazole during the reaction cycle. After ingestion, sulfamethoxazole is excreted by humans in both its parent form as well as the conjugated forms acetyl-sulfamethoxazole and sulfamethoxazole-glucuronide, which can comprise 45% and 9-15% of the total excreted dose of sulfamethoxazole, respectively [64,65]. Acetyl-sulfamethoxazole has been detected in wastewater influents [66,67], and it readily deconjugates to reform sulfamethoxazole [63,68]. ...
... Like other sulfonamides, SMX is a competitor of p-aminobenzoic acid in the biosynthesis of tetrahydrofolic acid. In studies on humans it was found that 20% of SMX daily dose was excreted via urine/feces in its original form, 50-60% was transformed to acetylated derivative (N1-acetylsulfamethoxazole, see Fig. 1) and 15-20% to glucuronide conjugate (van der Ven et al., 1994 and1995;Gill et al., 1996). ...
Sulfonamide antibiotics are persistent pollutants present in surface and subsurface waters in both
agricultural and urban environments. Sulfonamides are of particular concern in the environment
because they are known to induce high levels of bacterial resistance. Adsorption of
sulfamethoxazole sulfonamide antibiotic into three high silica zeolites (Y, mordenite, and ZSM-5)
with pore opening sizes comparable to sulfamethoxazole dimensions is reported. Sulfamethoxazole
was almost completely removed from water by zeolite Y and MOR in a few minutes. Adsorption
onto ZSM-5 showed an increased kinetics with increasing temperature. Antibiotic sorption was
largely irreversible with little antibiotic desorbed. Sulfamethoxazole incorporation and localization
into the pore of each zeolite system was defined along with medium-weak and cooperative hostguest
interactions in which water molecules play a certain role only in zeolite Y and mordenite.
... 1 In humans (1) is extensively metabolized and excreted in the urine mainly as N 4 -acetyl-sulfamethoxazole (N-(4-{[(5-methylisoxazol-3-yl)amino]sulfonyl}phenyl)-acetamide) (45-70%) and sulfamethoxazol-N 1 -glucuronide (N-[(4-aminophenyl)-sulfonyl]-N-(5-methylisoxazol-3-yl)hexapyranuronosylamine) (5-15%). 2,3 Highly sensitive mass spectrometric methods are used to investigate the environmental load of these substances and these assays require stable isotope internal standards. ...
Sulfamethoxazole was labelled at positions 3, 5, and 4′ by H/D exchange in a mixture of 5% 2H2SO4 and 95% 2H2O (v/v) under reflux for 72h with good isotope incorporation and acceptable yield. Subsequently, [2H3]-sulfamethoxazole-N1-glucuronide and [2H3]-N4-acetyl-sulfamethoxazole were synthesized. Copyright © 2007 John Wiley & Sons, Ltd.
... In addition to the environmental occurrence of sulfonamides, their metabolites should get more attention. The main metabolic pathway for sulfonamides is supposed to be N-acetylation [26] as exemplified by sulfamethoxazole (SMX), of which only 15 to 25% is present in unchanged parent form and 43% is present as N-acetylsulfamethoxazole (NAcSMX) in the urine [27]. The retransformation of N-acetylated metabolites into sulfonamides can occur in the environment via microbial activities [1,28]. ...
The presence of antibiotics in the environment is of great concern because of their potential for resistance selection among pathogens. In the present study we investigated the occurrence of 19 sulfonamides, five N-acetylated sulfonamide metabolites, and trimethoprim in the Liao River basin and adjacent Liaodong Bay, China, as well as 10 human/agricultural source samples. Within the 35 river samples, 12 sulfonamides, four acetylated sulfonamides, and trimethoprim were detected, with the dominant being sulfamethoxazole (66.6 ng/L), N-acetylsulfamethoxazole (63.1 ng/L), trimethoprim (29.0 ng/L), sulfadiazine (14.0 ng/L), and sulfamonomethoxine (8.4 ng/L); within the 36 marine samples, 10 chemicals were detected, with the main contributions from sulfamethoxazole (25.2 ng/L) and N-acetylsulfamethoxazole (28.6 ng/L). Sulfamethoxazole (25.9%), N-acetylsulfamethoxazole (46.6%), trimethoprim (22.9%), and sulfapyridine (1.4%) were the main chemicals from human sources, while sulfamonomethoxine, sulfamethazine, sulfaquinoxaline, sulfaguanidine, sulfadiazine, sulfanilamide, and sulfamethoxypyridazine were dominant in the animal husbandry sources, specifically, swine and poultry farms, and sulfamethoxazole (91%) was dominant in the mariculture source. A principal component analysis with multiple linear regression was performed to evaluate the source apportionment of total sulfonamides in Liaodong Bay. It was found that animal husbandry contributed 15.2% of total sulfonamides, while human sources contributed 28.5%, and combined human and mariculture sources contributed 56.3%. In addition, the mariculture contribution was 24.1% of total sulfonamides into the sea based on mass flux estimation. The present study is the first report that the environmental levels of sulfonamide metabolites were comparable to the corresponding parents; therefore, we should pay attention to their environmental occurrence. Source apportionment showed human discharge (60.7%) significantly contributed to these antibiotics in Liaodong Bay, which provides important information for environmental management.
... Both isozymes are known to be induced by rifampin. More than 80% of SMX is metabolized in the liver, mainly by N-acetylation but also by glucuronidation and by hydroxylation (10). Only a small percentage of SMX is metabolized to hydroxylamine, and CYP2C9 is the primary enzyme responsible for this metabolism (3). ...
To determine whether rifampin reduces concentrations of trimethoprim (TMP) and sulfamethoxazole (SMX) in serum of human immunodeficiency
virus (HIV)-infected persons, levels of these agents were determined by high-performance liquid chromatography before and
after more than 12 days of standard antituberculosis treatment for 10 patients who had been taking one double-strength tablet
of co-trimoxazole once daily for more than 1 month. Statistically significant, 47 and 23% decreases in TMP and SMX mean areas
under the concentration-time curve from 0 to 24 h (AUC0–24), respectively, were observed after administration of rifampin.N-Acetyl-SMX profiles without and with rifampin were similar. The steady-state AUC0–24 metabolite/parent drug ratio increased by 32% with rifampin administration. Our study shows that rifampin reduces profiles
of TMP and SMX in serum of HIV-infected patients.
We have carried out comprehensive experimental and density functional theory simulations of Co3Se4/BiVO4 heterojunction to understand the relationship between interface and enhanced photocatalytic activity. This study demonstrates the photoelectrochemical degradation of sulfamethoxazole (SMX) with a photoanode developed based on S–scheme heterojunction. The difference in the energy levels of the band gaps and conduction bands of BiVO4 and Co3Se4 makes them suitable semiconductors for the fabrication of an S–scheme heterojunction. The BiVo4/Co3Se4 composite is prepared by solvothermal method and characterized using X–ray diffraction (XRD), field emission–scanning electron microscopy (FE–SEM), transmission electron microscopy (TEM), Energy Dispersive X–Ray Analysis (EDX), Ultraviolet–Visible Diffuse Reflectance Spectroscopy (UV–DRS). The photoelectrochemical properties of the fabricated photoanode are studied using Electrochemical impedance spectroscopy (EIS), Mott–Schottky, and photocurrent response. The UV–DRS spectra show an improved band gap (1.88 eV) for the composite in comparison with pristine BiVO4 (2.39 eV). The XRD patterns reveal the presence of monoclinic phases of BiVO4 and Co3Se4 in the composite. This is further confirmed by the microscopic studies that show the surface coating of Co3Se4 on BiVO4. The composite photoanode shows improved photocurrent density and low charge transfer resistance in comparison with the pristine semiconductors. Theoretical calculations reveal charge redistributions at the interface between Co3Se4 and BiVO4. Furthermore, the density of states, Bader charge and electrostatic potential drop reveals that the synergistic effect of built-in electric field directed from the BiVO4 surface to the Co3Se4 surface facilitates the efficient separation of charge carriers in the Co3Se4/BiVO4 interface and thus prevents carrier recombination rate. This provides the composite with the capacity to effectively degrade SMX with improved efficiency. At optimum conditions, the SMX degradation efficiency reached 75% with a rate constant of 0.0115 min–1. The holes majorly facilitate the degradation of SMX, as revealed by the scavenger study. Comparative studies indicate that photoelectrocatalytic contributions supersede photocatalytic and electrocatalytic contributions.
The antibiotic sulfamethoxazole (SMX) is a pollutant that is widely distributed in the global water environment.This substance has toxic effects on various aquatic organisms. Previous studies on SMX have focused on its acute toxicity towards algae and the changes induced at biological and cellular levels, rather than its biotoxicity and mechanisms at the molecular level. In this study, we investigated the effects of SMX on Scenedesmus obliquus as the model organism by performing transmission electron microscopy and transcriptome sequencing analyses. Exposure to SMX promoted gene expression, resulting in changes to algal cell ultrastructure. The cell walls became blurred, the chloroplast structure was seriously damaged, and the number and volume of mitochondria per cell increased. These changes were related to the inhibition of cell growth, decrease in chlorophyll content, increase in cell membrane permeability, and increased production of reactive oxygen species, which led to increased amounts of the lipid peroxidation product malondialdehyde, and higher activities of antioxidant enzymes. Our results suggest that SMX affects gene expression by influencing non-coding RNA metabolic processes, leading to changes in nuclear structures. Abnormally expressed long non-coding RNAs extensively regulate downstream gene expression through various mechanisms, such as chromatin recombination, thereby promoting tumor occurrence, invasion, and metastasis. This abnormal expression may be an important mechanism underlying the carcinogenic effects of SMX.
Antibiotics pollution in lakes has been widely reported worldwide, however rare studies were concerned about antibiotics distribution in lake water - groundwater - sediment system. Here, a total of 22 antibiotics and 4 sulfonamides metabolites were detected in lake water, sediments, and different depth of groundwater surrounding Chenhu Lake during the wet and dry seasons. N⁴-acetylsulfonamides (Ac-SAs), fluoroquinolones (FQs), and tetracyclines (TCs) were the main groups of antibiotics in the study area. In the whole lake environment, there were more types of antibiotics in the aquatic environments than in the sediments, and the antibiotics distribution was closely related to geographical location. Specifically, the average concentration of antibiotics in groundwater decreased with an increase in sampling site distance from the lake. All antibiotics, except oxytetracycline (OTC), showed a significant decline during the dry season that could be due to the implementation of lake conservation policies, which significantly helped reducing lake pollution. There were obvious differences in the distribution of antibiotics in distinct sedimentary environments. In the surface sediments, the antibiotics content in the reclamation and the perennially flooded areas was higher than in the lakeshore area. The hydraulic interactions in the perennial flooded area facilitated the deep migration of antibiotics into lake sediments. Correlation analysis revealed a good relevance between the distribution of antibiotics in lake water and groundwater. Redundancy analysis shows that dissolved oxygen and temperature were the main factors affecting the distribution of antibiotics.
High amounts of antibiotics, used in animal farms for the prevention of diseases, are released back into the natural environment with a possible risk of chronic toxicity to other organisms and the development of antibiotic-resistant genes. The antibiotics, including sulfonamides and β-lactams, detected in swine wastewater were between 99.2-339.3 μg/L. The typical on-site swine wastewater treatment process turned out to be inadequate, reflected by the high conventional contaminant and antibiotic residuals even under a long hydraulic residence time (HRT, around 2-3 months). The lab-scale combined anaerobic and aerobic biological process showed that anaerobic digestion was mainly responsible for chemical oxygen demand (COD) reduction and aerobic biodegradation contributed significantly to antibiotic removal, with overall removal efficiencies of 95% for COD and 92% for antibiotics under a short HRT of 3.3 days. The removal of selected antibiotics could be a combined result of biodegradation, the balance between adsorption and desorption, and the transformation between antibiotic metabolites and their parent antibiotics. The current work provides valuable insights into the appropriate selection and optimisation of biological processes for the treatment of typical wastewater with high COD and trace antibiotics.
Due to the limited efficiency of conventional biological treatment, innovative solutions are being explored to improve the removal of trace organic chemicals in wastewater. Controlling biomass exposure to growth substrate represents an appealing option for process optimization, as substrate availability likely impacts microbial activity, hence organic trace chemical removal. This study investigated the elimination of pharmaceuticals in pre-denitrifying moving bed biofilm reactors (MBBRs), where biofilm exposure to different organic substrate loading and composition was controlled by reactor staging. A three-stage MBBR and a single-stage reference MBBR (with the same operating volume and filling ratio) were operated under continuous-flow conditions (18 months). Two sets of batch experiments (day 100 and 471) were performed to quantify and compare pharmaceutical removal and denitrification kinetics in the different MBBRs. Experimental results revealed the possible influence of retransformation (e.g., from conjugated metabolites) and enantioselectivity on the removal of selected pharmaceuticals. In the second set of experiments, specific trends in denitrification and biotransformation kinetics were observed, with highest and lowest rates/rate constants in the first (S1) and the last (S3) staged sub-reactors, respectively. These observations were confirmed by removal efficiency data obtained during continuous-flow operation, with limited removal (<10%) of recalcitrant pharmaceuticals and highest removal in S1 within the three-stage MBBR. Notably, biotransformation rate constants obtained for non-recalcitrant pharmaceuticals correlated with mean specific denitrification rates, maximum specific growth rates and observed growth yield values. Overall, these findings suggest that: (i) the long-term exposure to tiered substrate accessibility in the three-stage configuration shaped the denitrification and biotransformation capacity of biofilms, with significant reduction under substrate limitation; (ii) biotransformation of pharmaceuticals may have occurred as a result of cometabolism by heterotrophic denitrifying bacteria.
Many scientific studies present removal efficiencies for pharmaceuticals in laboratory-, pilot- and full-scale wastewater treatment plants, based on observations that may be negatively impacted by theoretical and methodological approaches used. In this article, we critically evaluated factors influencing observed removal efficiencies of three antibiotics (sulfamethoxazole, ciprofloxacin, tetracycline) in pilot- and full-scale biological treatment systems. Factors assessed include (i) retransformation to parent pharmaceuticals from conjugated metabolites and analogues, (ii) solid retention time (SRT), (iii) fractions sorbed onto solids, and (iv) dynamics in influent and effluent loading. A recently developed methodology was used, relying on the comparison of removal efficiency predictions (obtained with the Activated Sludge Model for Xenobiotics—ASM-X) with representative measured data from literature. By applying this methodology, we demonstrated that: (a) the elimination of sulfamethoxazole may be significantly underestimated when not considering retransformation from conjugated metabolites, depending on the type (urban or hospital) and size of upstream catchments; (b) operation at extended SRT may enhance antibiotic removal, as shown for sulfamethoxazole; (c) not accounting for fractions sorbed in influent and effluent solids may cause slight underestimation of ciprofloxacin removal efficiency. Using tetracycline as example substance, we ultimately evaluated implications of effluent dynamics and retransformation on environmental exposure prediction.
Occurrence of the antibiotic sulfamethoxazole (SMX) in the aquatic environment is of concern due to its potential to induce antibiotic resistance in pathogenic bacteria. While degradation of SMX can occur by numerous processes, the environmental fate of its transformation products (TPs) remains poorly understood. In the present work, biodegradation of SMX photo-TPs was investigated in a water/sediment system. Photo-TPs were produced by exposing SMX to artificial sunlight for 48 h. The resulting mixture of 8 photo-TPs was characterized using a combination of ultra-high performance liquid chromatography coupled to high-resolution mass spectrometry and tandem mass spectrometry, and then used in biodegradation experiments. Significant differences in transformation among SMX photo-TPs were observed in the water/sediment system, with four photo-TPs displaying evidence of biodegradation (dissipation half-lives [DT50] of 39.7 d for 3-amino-5-methylisoxazole, 12.7 d for 4-nitro-sulfamethxoazole, 7.6 d for an SMX isomer and 2.4 d for [C10H13N3O4S]), two displaying primarily abiotic degradation (DT50 of 31 d for sulfanilic acid and 74.9 d for 5-methylisoxazol-3-yl-sulfamate), and two photo-TPs behaving largely recalcitrantly. Remarkably, TPs previously reported to be photo-stable also were persistent in biodegradation experiments. The most surprising observation was an increase in SMX concentrations when the irradiated solution was incubated, which we attribute to back-transformation of certain photo-TPs by sediment bacteria (85% from 4-nitro-sulfamethoxazole). This process could contribute to exposure to SMX in the aquatic environment that is higher than one would expect based on the fate of SMX alone. The results highlight the importance of considering TPs along with their parent compounds when characterizing environmental risks of emerging contaminants.
High silica zeolite Y has been positively evaluated to clean-up water polluted with sulfonamides, an antibiotic family which is known to be involved in the antibiotic resistance evolution. To define possible strategies for the exhausted zeolite regeneration, the efficacy of some chemico-physical treatments on the zeolite loaded with four different sulfonamides was evaluated. The evolution of photolysis, Fenton-like reaction, thermal treatments, and solvent extractions and the occurrence in the zeolite pores of organic residues eventually entrapped was elucidated by a combined thermogravimetric (TGA–DTA), diffractometric (XRPD), and spectroscopic (FT-IR) approach. The chemical processes were not able to remove the organic guest from zeolite pores and a limited transformation on embedded molecules was observed. On the contrary, both thermal treatment and solvent extraction succeeded in the regeneration of the zeolite loaded from deionized and natural fresh water. The recyclability of regenerated zeolite was evaluated over several adsorption/regeneration cycles, due to the treatment efficacy and its stability as well as the ability to regain the structural features of the unloaded material.
Under high dose treatment with sulfamethoxazole (SMX) / trimethoprim (TMP) hypersensitivity reactions occur with a high incidence. Mechanism of this adverse drug reaction is not fully understood. Several steps in toxification pathway of SMX were investigated. The aim of our study was to investigate the reduction of sulfamethoxazole hydroxylamine (SMX-HA) in this toxification pathway, which can possibly be catalyzed by the mARC-containing N-reductive enzyme system. Western blot analyses of subcellular fractions of porcine tissue were performed with antibodies against mARC-1, mARC-2, cytochrome b5 type B and NADH cytochrome b5 reductase. Incubations of porcine and human subcellular tissue fractions and of the heterologous expressed human components of the N-reductive enzyme system were carried out with SMX-HA. mARC-1 and mARC-2 knockdown was performed in HEK-293 cells. Kinetic parameters of the heterologous expressed human protein variants V96L, A165T, M187K, C246S, D247H and M268I of mARC-1, G244S and C245W of mARC-2, and N-reductive activity of 2SF, D14G, K16E and T22A of cytochrome b5 type B were analyzed. Western blot analyses were consistent with the hypothesis that the mARC-containing N-reductive enzyme system might be involved in the reduction of SMX-HA. In agreement with these results highest reduction rates were found in mitochondrial subcellular fractions of porcine tissue and in the outer membrane vesicle (OMV) of human liver tissue, respectively. Knockdown studies in HEK-293 cells demonstrated that mARC-1 and mARC-2 were capable of reducing SMX-HA in cell metabolism. Investigations with the heterologous expressed human mARC-2 protein showed a higher catalytic efficiency towards SMX-HA than mARC-1 but none of the investigated human protein variants showed statistically significant differences of its N-reductive activity and was therefore likely to participate in the pathogenesis of hypersensitivity reaction under treatment with SMX.
Four previously unreported metabolism products of sulfaquinoxaline (SQX), a widely used veterinary medicine, were isolated and analyzed using liquid chromatography coupled to high resolution Orbitrap mass spectrometry. Metabolites were structurally elucidated and a fragmentation pathway was proposed. The combination of high resolution MS2 spectra, linear ion trap MS2, in-source collision induced dissociation (CID) fragmentation and photolysis were used to analyze SQX and its metabolites. All metabolism products identified showed a similar fragmentation pattern to that of the original drug. Differential product ions were produced at m/z 162 and 253 which contain the radical moiety with more 16 Da units than sulfaquinoxaline. This occurs by a hydroxyl attachment to the quinoxaline moiety. With the exception of two low intensity compounds, all the mass errors were below 5.0 ppm. The distribution of these metabolites in some animal species are also presented and discussed.
Abstract Sulphonamide hypersensitivity reactions are believed to be mediated through reactive intermediates derived from oxidation of the paraamino group to form sulphonamide hydroxylamines. Sulphamethoxazole hydroxylamine (SMX-HA) can be acetylated by N-acetyltransferase (NAT) enzymes to form an acetoxy metabolite (acetoxySMX). In the current studies, acetoxySMX was found to be not toxic over the concentration range of 0 to 500 μM towards a human lymphoblastoid cell line (RPMI 1788) or a human hepatoma cell line (HepG2). Further, transient expression of NAT1 in COS-1 cells or stable transfection of NAT1 andNAT2 in HepG2 cells did not alter the toxicity of SMX-HA in vitro. The activity of NAT1 in isolated mononuclear leucocytes (a reflection of systemic NAT1 activity) determined with paraaminobenzoic acid as a substrate was not different between controls (n = 11) or patients with a known hypersensitivity reaction (n = 5) (4.1 ±1.2 nmol min(-1)mg(-1) vs 5.7 ± 1.4 nmol min(-1) mg(-1)). Thus, acetoxy SMX is unlikely to play a significant role in mediating SMX hypersensitivity reactions anda constitutive deficiency in NAT1 activity is not a common finding in patients susceptible to SMX hypersensitivity reactions.
Potential aerobic biodegradation mechanisms of the widely used polar, low-adsorptive sulfonamide antibiotic sulfamethoxazole (SMX) were investigated in activated sludge at bench scale. The study focused on (i) SMX co-metabolism with acetate and ammonium nitrate and (ii) SMX utilization when present as the sole carbon and nitrogen source. With SMX adsorption being negligible, elimination was primarily based on biodegradation. Activated sludge was able to utilize SMX both as a carbon and/or nitrogen source. SMX biodegradation was enhanced when a readily degradable energy supply (acetate) was provided which fostered metabolic activity. Moreover, it was raised under nitrogen deficiency conditions. The mass balance for dissolved organic carbon showed an incomplete SMX mineralization with two scenarios: (i) with SMX as a co-substrate, 3-amino-5-methyl-isoxazole represented the main stable metabolite and (ii) SMX as sole carbon and nitrogen source possibly yielded hydroxyl-N-(5-methyl-1,2-oxazole-3-yl)benzene-1-sulfonamide as a further metabolite.
The presence of potentially persistent and bioactive human metabolites in surface waters gives rise to concern; yet little is known to date about the environmental fate of these compounds. This work investigates the direct photolysis of human metabolites of the antibiotic sulfamethoxazole (SMX). In particular, we determined photolysis kinetics and products, as well as their concentrations in lake water. SMX, sulfamethoxazole β-D-glucuronide, 4-nitroso sulfamethoxazole and 4-nitro sulfamethoxazole were irradiated under various light sources and pH conditions. All investigated metabolites, except SMX-glucuronide were found to be more photostable than SMX under environmentally relevant conditions. Between two and nine confirmed photoproducts were identified for SMX-metabolites through ultra-performance liquid chromatography/high-resolution mass spectrometry. Interestingly, photolytic back-transformation to SMX was observed for 4-nitroso-SMX, indicating that this metabolite may serve as an environmental source of SMX. Moreover, two human metabolites along with SMX were regularly detected in Lake Geneva. The knowledge that some metabolites retain biological activity, combined with their presence in the environment and their potential to retransform to the parent compound, underlines the importance of including human metabolites when assessing the effects of pharmaceuticals in the environment.
Sulphamethoxazole has been associated with the occurrence of hypersensitivity reactions. There is controversy as to whether the immune response is metabolism-dependent or -independent. We have therefore investigated the site of antigen formation and the nature of the drug signal presented to the immune system in vivo.
Male Wistar rats were dosed with sulphamethoxazole, sulphamethoxazole hydroxylamine or nitroso sulphamethoxazole. Antigen formation on cell surfaces was determined by flow cytometry using a specific anti-sulphamethoxazole antibody. Immunogenicity was determined by assessment of ex vivo T-cell proliferation.
Administration of nitroso sulphamethoxazole, but not sulphamethoxazole or sulphamethoxazole hydroxylamine, resulted in antigen formation on the surface of lymphocytes, splenocytes and epidermal keratinocytes, and a strong proliferative response of splenocytes on re-stimulation with nitroso sulphamethoxazole. Rats dosed with sulphamethoxazole or sulphamethoxazole hydroxylamine did not respond to any of the test compounds.
CD4+ or CD8+ depleted cells responded equally to nitroso sulphamethoxazole. The proliferative response to nitroso sulphamethoxazole was seen even after pulsing for only 5 min, and was not inhibited by glutathione. Responding cells produced IFN-γ, but not IL-4.
Haptenation of cells by sulphamethoxazole hydroxylamine was seen after depletion of glutathione by pre-treating the rats with diethyl maleate. Splenocytes from the glutathione-depleted sulphamethoxazole hydroxylamine-treated rats responded weakly to nitroso sulphamethoxazole, but not to sulphamethoxazole or sulphamethoxazole hydroxylamine.
Dosing of rats with sulphamethoxazole produced a cellular response to nitroso sulphamethoxazole (but not to sulphamethoxazole or its hydroxylamine) when the animals were primed with complete Freund's adjuvant.
These studies demonstrate the antigenicity of nitroso sulphamethoxazole in vivo and provide evidence for the role of drug metabolism and cell surface haptenation in the induction of a cellular immune response in the rat.
British Journal of Pharmacology (2001) 133, 295–305; doi:10.1038/sj.bjp.0704074
Hypersensitivity reactions to drugs used in HIV disease are common and clinically important, being responsible for a significant amount of morbidity and occasional mortality. The manifestations are typical of all drug hypersensitivity reactions, with the skin and liver being most commonly affected. Drug-specific T cells are increasingly being implicated in the pathogenesis of these reactions, which may, in the future, allow the development of better diagnostic strategies. Genetic factors predisposing to hypersensitivity reactions with antiretrovirals are also being increasingly identified - the prime example of this is with abacavir, where pre-prescription genotyping for HLA B*5701 has been shown to reduce the incidence of hypersensitivity. This avenue of research is destined to lead to better preventive strategies.
Sulfonamide- and sulfone-induced hypersensitivity reactions are thought to be mediated through bioactivation of parent drug molecule(s) to their respective reactive metabolite(s). In order to explain the cutaneous drug reactions caused by sulfonamides and sulfone, a mechanism can be proposed by which the bioactivation of these drugs in keratinocytes of the skin forms reactive hydroxylamine metabolites that can covalently bind to cellular proteins, which in turn act as antigens leading to the cascade of immune reactions resulting in a cutaneous drug reaction. In order to probe the proposed mechanism, we determined the enzymes responsible for the bioactivation of these parent drugs to their hydroxylamine metabolites in cultured human keratinocytes. It was found that flavin containing monooxygenases and peroxidases play an important role in the bioactivation of these drugs in keratinocytes. We also confirmed the presence of these enzymes in keratinocytes. Interestingly, though cytochrome P450s are important in the oxidation of parent arylamine xenobiotics to their hydroxylamine metabolites in the liver, they do not appear to play a significant role in the bioactivation of these drugs in keratinocytes. The hydroxylamine metabolites of sulfamethoxazole and dapsone can undergo autooxidation, generating reactive free radicals. Our studies showed that both of these metabolites elevate oxidative stress in keratinocytes by forming reactive oxygen species. Though the cytotoxicity induced by these metabolites is not correlated with the extent of oxidative stress, the generation of reactive oxygen species may be important finding as these species can act as danger signals that activate antigen presenting cells in the skin. As a possible explanation for the idiosyncratic nature of these reactions, folate deficiency was studied as a potential risk factor. However, the results of these studies suggested that deficiency of folic acid in keratinocytes does not predispose such cells to the toxicity associated with the parent drugs or their metabolites. Unexplored is the potential role of such deficiency on the immune response itself.
Cytochrome P450 2C9 (CYP2C9) is one of the most abundant CYP enzymes in the human liver. CYP2C9 metabolizes more than 100 therapeutic drugs, including tolbutamide, glyburide, diclofenac, celecoxib, torasemide, phenytoin losartan, and S-warfarin). Some natural and herbal compounds are also metabolized by CYP2C9, probably leading to the formation of toxic metabolites. CYP2C9 also plays a role in the metabolism of several endogenous compounds such as steroids, melatonin, retinoids and arachidonic acid. Many CYP2C9 substrates are weak acids, but CYP2C9 also has the capacity to metabolise neutral, highly lipophilic compounds. A number of ligand-based and homology models of CYP2C9 have been reported and this has provided insights into the binding of ligands to the active site of CYP2C9. Data from the site-directed mutagenesis studies have revealed that a number of residues (e.g. Arg97, Phe110, Val113, Phe114, Arg144, Ser286, Asn289, Asp293 and Phe476) play an important role in ligand binding and determination of substrate specificity. The resolved crystal structures of CYP2C9 have confirmed the importance of these residues in substrate recognition and ligand orientation. CYP2C9 is activated by dapsone and its analogues and R-lansoprazole in a stereo-specific and substrate-dependent manner, probably through binding to the active site and inducing positive cooperativity. CYP2C9 is subject to induction by rifampin, phenobarbital, and dexamethasone, indicating the involvement of pregnane X receptor, constitutive androstane receptor and glucocorticoid receptor in the regulation of CYP2C9. A number of compounds have been found to inhibit CYP2C9 and this may provide an explanation for some clinically important drug interactions. Tienilic acid, suprofen and silybin are mechanism-based inhibitors of CYP2C9. Given the critical role of CYP2C9 in drug metabolism and the presence of polymorphisms, it is important to identify drug candidates as potential substrates, inducer or inhibitors of CYP2C9 in drug development and drug discovery scientists should develop drugs with minimal interactions with this enzyme. Further studies are warranted to explore the molecular determinants for ligand-CYP2C9 binding and the structure-activity relationships.
A spectrum of adverse drug reactions that are caused by the combined action of drugs and viruses has been described: ampicillin rash in acute infectious mononucleosis; Reye’s syndrome; hypersensitivity reactions to sulphonamides in patients with HIV infection; drug-induced agranulocytosis; paracetamol (acetaminophen) hepatotoxicity; aspirin (acetylsalicyclic acid)-induced asthma; Epstein-Barr virus-associated lymphoma and methotrexate; and AIDS-related Kaposi’s sarcoma and nitrite use.
Changes in pharmacokinetics have been reported for: caffeine, sulfamethoxazole and fluconazole in patients with HIV infection; theophylline, following influenza and influenza vaccination; and recently, dipyrone metabolites in carriers of the hepatitis B virus. In addition increased drug- and drug metabolite-related toxicity has been observed in virally infected cells.
Pathogenetic mechanisms for the interaction between drugs and viruses are varied, and include biological mechanisms (often immunological) and changes in drug metabolism. The combined effects of chemical and biological exposure provide a unique model for the study of disease induction.
The pharmacokinetics of a number of drugs has been shown to be impaired in patients with acute or chronic viral liver disease.
To examine the effect of the asymptomatic hepatitis B virus carrier state on the metabolism of dipyrone (INN, metamizole) as a model drug.
The pharmacokinetics of the metabolites of dipyrone-4-methylaminoantipyrine, 4-aminoantipyrine, 4-formylaminoantipyrine, and 4-acetylaminoantipyrine-after a 1.0 gm oral dose of dipyrone were evaluated in nine asymptomatic carriers of hepatitis B virus with normal liver function tests and nine healthy subjects. All subjects displayed the slow acetylator phenotype.
The nonrenal (metabolic) clearance of 4-methylaminoantipyrine was significantly reduced (mean +/- SEM) (123.3 +/- 15.8 versus 182.9 +/- 15.1 ml.min-1, respectively; p < 0.02) in the carriers of hepatitis B virus compared with the healthy subjects, and the elimination half-life of this metabolite was significantly longer (3.69 +/- 0.35 versus 2.64 +/- 0.28 hours, respectively; p < 0.03). The formation clearances of 4-aminoantipyrine and 4-formylaminoantipyrine were significantly smaller in the carriers of hepatitis B virus compared with healthy subjects (33.8 +/- 6.2 versus 55.2 +/- 6.4 ml.min-1; p < 0.03, and 16.7 +/- 2.2 versus 34.2 +/- 4.2 ml.min-1; p < 0.002; respectively). However, the elimination half-life of 4-formylaminoantipyrine was found to be slightly shorter in the carriers of hepatitis B virus. No significant differences were noted between the groups in the pharmacokinetics of 4-acetylaminoantipyrine.
The metabolism of dipyrone is impaired in asymptomatic carriers of hepatitis B virus. Clinically latent infection with hepatitis B virus seems to exert a differential effect on metabolism of the drug. Oxidative pathways to produce 4-aminoantipyrine and 4-formylaminoantipyrine were significantly affected, whereas acetylation remained intact. This study provided an additional example of the effect of a virus on the disposition of a drug.
In a randomized double blind placebo controlled trial, HIV sero-positive patients with CD4+ cell count less than 200 x 10(6)/l or an AIDS diagnosis were evaluated for drug reactions to trimethoprim-sulphamethoxazole (TMP-SMX) during treatment, including pretreatment, with N-acetylcysteine (NAC) 800 mg daily or placebo. TMP-SMX (one double-strength tablet containing 160 mg of trimethoprim and 800 mg of sulphamethoxazole) was given three times weekly as primary Pneumocystis carinii (PCP) prophylaxis. Thirty percent (n = 15) of the patients experienced adverse reactions 8-20 (mean 12.7) days after starting with TMP-SMX. At entry, low cysteine and glutathione levels in plasma were found in the HIV-positive patients. Age, sex, CD4+ count, plasma cysteine and glutathione levels were not risk factors for adverse reactions to TMP-SMX. However, concomitant therapy with nucleoside analogues was associated with increased risk for TMP-SMX reactions. Oral NAC 800 mg daily was well tolerated, but replenished neither cysteine nor glutathione levels in plasma. NAC 800 mg/day did not significantly decrease the risk of adverse reactions to TMP-SMX in this study, and could thus not be recommended for this purpose. A prolonged pretreatment period and/or higher dose of NAC may be necessary for clinical effect.
The use of co-trimoxazole in HIV-positive patients has been associated with a high frequency (40-80%) of hypersensitivity reactions. This has been attributed to the bioactivation of the sulphonamide component, sulphamethoxazole (SMX), to its toxic hydroxylamine and nitroso metabolites. The aim of this study was to determine whether functionally significant polymorphisms in the genes coding for enzymes involved in SMX metabolism influence susceptibility to SMX hypersensitivity. HIV-positive patients with (n = 56) and without (n = 89) SMX hypersensitivity were genotyped for allelic variants in CYP2C9, GSTM1, GSTT1, GSTP1 and NAT2 using polymerase chain reaction (PCR) and/or PCR-restriction fragment length polymorphism analysis. The CYP2C9*2/*3 genotype and CYP2C9*3 allele frequencies were nine- and 2.5-fold higher in the hypersensitive group compared to non-sensitive patients, respectively, although they were not statistically significant when corrected for multiple testing. There were no differences in the frequencies of the GSTM1 and GSTT1 null genotypes, and the slow acetylator genotype, between hypersensitive and non-sensitive patients, while GSTP1 frequency was lower (although non-significant) in the hypersensitive group [21% versus 32%, odds ratio (OR) = 0.5, Pc = 0.24]. Comparison of the genotype frequencies in HIV-positive and -negative patients showed that the NAT2 slow acetylator genotype frequency in the HIV-positive patients (74%) was significantly (Pc = 0.0003, OR = 2.3) higher than in control subjects (56%). Our results show that genetic polymorphisms in drug metabolizing enzymes are unlikely to be major predisposing factors in determining individual susceptibility to co-trimoxazole hypersensitivity in HIV-positive patients.
Drug-related rashes have been estimated to be 100 times more common in HIV-positive patients than in the general population. The reasons for this are not clear, but are likely to be multifactorial, and include changes in drug metabolism, oxidative stress, cytokine profiles and immune hyperactivation. HIV itself may also serve as a danger signal, leading to the development of an immune response rather than tolerance. Drugs that are implicated in causing hypersensitivity have changed since the advent of highly active antiretroviral therapy. This is largely as a result of a decrease in the use of antimicrobials such as co-trimoxazole, and the introduction of new drugs of different classes, including abacavir, non-nucleoside reverse transcriptase inhibitors such as nevirapine, and protease inhibitors such as amprenavir. Laboratory evidence supporting a role of the immune system in the mechanism of co-trimoxazole hypersensitivity is available. However, this is not the case for the newer antiretrovirals; hypersensitivity to these agents is presumed to be immune-mediated based only on the symptomatology. It is essential that research be carried out into the mechanisms of hypersensitivity reactions associated with these important new classes of drugs so that their benefit-risk ratio can be improved, and lessons learned for future drug development.
A number of therapeutic drugs with different structures and mechanisms of action have been reported to undergo metabolic activation by Phase I or Phase II drug-metabolizing enzymes. The bioactivation gives rise to reactive metabolites/intermediates, which readily confer covalent binding to various target proteins by nucleophilic substitution and/or Schiff's base mechanism. These drugs include analgesics (e.g., acetaminophen), antibacterial agents (e.g., sulfonamides and macrolide antibiotics), anticancer drugs (e.g., irinotecan), antiepileptic drugs (e.g., carbamazepine), anti-HIV agents (e.g., ritonavir), antipsychotics (e.g., clozapine), cardiovascular drugs (e.g., procainamide and hydralazine), immunosupressants (e.g., cyclosporine A), inhalational anesthetics (e.g., halothane), nonsteroidal anti-inflammatory drugs (NSAIDSs) (e.g., diclofenac), and steroids and their receptor modulators (e.g., estrogens and tamoxifen). Some herbal and dietary constituents are also bioactivated to reactive metabolites capable of binding covalently and inactivating cytochrome P450s (CYPs). A number of important target proteins of drugs have been identified by mass spectrometric techniques and proteomic approaches. The covalent binding and formation of drug-protein adducts are generally considered to be related to drug toxicity, and selective protein covalent binding by drug metabolites may lead to selective organ toxicity. However, the mechanisms involved in the protein adduct-induced toxicity are largely undefined, although it has been suggested that drug-protein adducts may cause toxicity either through impairing physiological functions of the modified proteins or through immune-mediated mechanisms. In addition, mechanism-based inhibition of CYPs may result in toxic drug-drug interactions. The clinical consequences of drug bioactivation and covalent binding to proteins are unpredictable, depending on many factors that are associated with the administered drugs and patients. Further studies using proteomic and genomic approaches with high throughput capacity are needed to identify the protein targets of reactive drug metabolites, and to elucidate the structure-activity relationships of drug's covalent binding to proteins and their clinical outcomes.
Cutaneous drug reactions (CDR) are responsible for numerous minor to life-threatening complications. Though the exact mechanism for CDR is not completely understood, evidence suggests that bioactivation of drugs to reactive oxygen or nitrogen species is an important factor in the initiation of these reactions. Several CDR-inducing drugs having an arylamine functional group, such as sulfamethoxazole (SMX) and dapsone (DDS), undergo bioactivation to reactive arylhydroxylamine metabolites. These metabolites can generate cellular oxidative stress by forming reactive oxygen species (ROS). Several studies have demonstrated a higher cytotoxicity with DDS hydroxylamine (DDS-NOH) compared to SMX hydroxylamine (SMX-NOH). To investigate the role of differential ROS generation in the higher cytotoxicity of DDS-NOH, hydroxylamine metabolites of SMX and DDS were synthesized and ROS formation by these metabolites determined. DDS-NOH and its analogues/metabolites consistently resulted in higher ROS formation as compared to SMX-NOH. However, comparison of the ROS generation and cytotoxicity of a series of arylhydroxylamine analogues of DDS did not support a simple correlation between ROS generation and cell death. Numerous ROS scavengers were found to reduce metabolite-induced ROS formation, with differences in the potency between the agents. The decrease in DDS-NOH-induced ROS generation in NHEK with ascorbic acid, N-acetylcysteine, Trolox, and melatonin was 87, 86, 44, and 16%, respectively. Similarly, the cytotoxicity and adduct formation of DDS-NOH in NHEK was reduced in the presence of ascorbic acid. In summary, these studies show that arylhydroxylamine metabolites of SMX/DDS induce ROS generation in NHEK, though such generation is not directly related to cytotoxicity.
Cutaneous drug reactions (CDRs) associated with sulfonamides are believed to be mediated through the formation of reactive metabolites that result in cellular toxicity and protein haptenation. We evaluated the bioactivation and toxicity of sulfamethoxazole (SMX) and dapsone (DDS) in normal human dermal fibroblasts (NHDF). Incubation of cells with DDS or its metabolite (D-NOH) resulted in protein haptenation readily detected by confocal microscopy and ELISA. While the metabolite of SMX (S-NOH) haptenated intracellular proteins, adducts were not evident in incubations with SMX. Cells expressed abundant N-acetyltransferase-1 (NAT1) mRNA and activity, but little NAT2 mRNA or activity. Neither NAT1 nor NAT2 protein was detected. Incubation of NHDF with S-NOH or D-NOH increased reactive oxygen species formation and reduced glutathione content. NHDF were less susceptible to the cytotoxic effect of S-NOH and D-NOH than are keratinocytes. Our studies provide the novel observation that NHDF are able to acetylate both arylamine compounds and bioactivate the sulfone DDS, giving rise to haptenated proteins. The reactive metabolites of SMX and DDS also provoke oxidative stress in these cells in a time- and concentration-dependent fashion. Further work is needed to determine the role of the observed toxicity in mediating CDRs observed with these agents.
From human urine the following metabolites of sulfamethoxazole (S) were isolated by preparative HPLC: 5-methylhydroxysulfamethoxazole (SOH), N4-acetyl-5-methylhydroxysulfamethoxazole (N4SOH) and sulfamethoxazole-N1-glucuronide (Sgluc). The compounds were identified by NMR, mass spectrometry, infrared spectrometry, hydrolysis by beta-glucuronidase and ratio of capacity factors. The analysis of S and the metabolites N4-acetylsulfamethoxazole (N4), SOH, N4-hydroxysulfamethoxazole (N4OH), N4SOH, and Sgluc in human plasma and urine samples was performed with reversed-phase gradient HPLC with UV detection. In plasma, S and N4 could be detected in high concentrations, while the other metabolites were present in only minute concentrations. In urine, S and the metabolites and conjugates were present. The quantitation limit of the compounds in plasma are respectively: S and N4 0.10 micrograms/ml; N4SOH 0.13 micrograms/ml; N4OH 0.18 micrograms/ml; SOH 0.20 micrograms/ml; and Sgluc 0.39 microgram/ml. In urine the quantitation limits are: N4 and N4OH 1.4 micrograms/ml; S 1.5 micrograms/ml; N4SOH 1.9 micrograms/ml; SOH 3.5 micrograms/ml; and Sgluc 4.1 micrograms/ml. The method was applied to studies with healthy subjects and HIV positive patients.
• Forty-four episodes of Pneumocystis carinii pneumonia (PCP) occurred in 36 of 70 patients with the acquired immunodeficiency syndrome. Thirty-four patients with 40 episodes of PCP were treated with trimethoprim-sulfamethoxazole. Therapy was successful in 18 episodes (45%), but was unsuccessful in 15 episodes (37.5%). In the latter cases, two patients died within 72 hours; 13, of whom nine died, had therapy changed to pentamidine. In seven additional episodes (17.5%), trimethoprim-sulfamethoxazole was changed to pentamidine due to adverse reactions; all patients survived. Seven patients (26% of survivors) developed recurrent PCP. Twenty-two patients (65%) developed adverse reactions to trimethoprim-sulfamethoxazole, including leukopenia (20), hepatotoxicity (12), fever (eight), rash (six), and immediate reactions (two). Reactions were most common during the second week of therapy. Patients with the acquired immunodeficiency syndrome who have PCP have a high trimethoprim-sulfamethoxazole failure rate, due either to adverse reactions or unresponsive infection. Late recurrence is common.(Arch Intern Med 1985;145:837-840)
The aim of this investigation was to assess the pharmacokinetics of sulfamethoxazole (S) with its hydroxy metabolites (SOH, N4SOH, N4OH) and N4-acetyl- (N4) and N1-glucuronide (Sgluc) conjugates in 7 human volunteers after an oral dose of 800mg using a reversed phase gradient high-pressure liquid chromatography (HPLC) with UV detection. Sulfamethoxazole was rapidly and completely absorbed and metabolised to 5 metabolites. The plasma half-life (t½) of elimination varied for the parent drug and its metabolites between 9.7 and 15 hours. The protein binding of S (67.2%) increased when the compound was acetylated (88%), and decreased when it was oxidised at the 5-position (40%). Glucuronidation at the N1-position reduced the protein binding to 20%. The main metabolite in urine was N4 (43.5 ± 5.6%), followed by S (14.4 ± 3.4%). The percentages of the Sgluc (9.8 ± 2.6%), N4SOH (5.3 ± 1.0%), and SOH (3.0 ± 1.0%) did not differ statistically (p = NS). Only 2 to 3% of the N-hydroxylamine metabolite (N4OH) was excreted. The renal clearance values were: Sgluc 176 ± 33 ml/min, SOH 96.1 ± 23.7 ml/min, N4SOH 51.2 ± 10.4 ml/min, N4 35.2 ± 5.6 ml/min and S 2.7 ± 0.9 ml/min. The pharmacokinetic behaviour of the N1-glucuronide was reported for the first time. If one of the metabolites is responsible for the occurrence of side effects, then all metabolites must be included in this analysis.
The oxidation of sulfamethoxazole to its hydroxylamine metabolite was investigated in vitro with human liver microsomes and in vivo by detection in the urine. Sulfamethoxazole was oxidized to the hydroxylamine in an NADPH-dependent process by liver microsomes prepared from two human livers. Three healthy volunteers ingested 1000 mg sulfamethoxazole, and urine was collected for 24 hours. Sulfamethoxazole hydroxylamine constituted 3.1% +/- 0.7% of the drug excreted in the urine in 24 hours. Fifty-four percent of the ingested dose was excreted during this same time period. We conclude that sulfamethoxazole hydroxylamine is an authentic in vivo metabolite in humans, probably formed predominantly by cytochrome P450 in the liver. It could be responsible for mediation of sulfonamide adverse reactions, particularly hypersensitivity reactions.
The pharmacokinetic software package MW/Pharm offers an interactive, user-friendly program which gives rapid answers in clinical practice. It comprises a database with pharmacokinetic parameters of 180 drugs, a medication history database, and procedures for an individual drug dosage regimen calculation. The included curve-fitting facilities allow estimation of pharmacokinetic parameters on the basis of medication history, taking into account a varying status of the patient with respect to body weight and kidney function, optionally using a Bayesian procedure. The module KinBes performs the evaluation of bioavailability studies, including various methods, and an extensive statistical evaluation of bioequivalence.
The origin of the increased frequency of side-effects to co-trimoxazole in HIV-positive patients is unknown. Data on plasma concentrations of the parent compounds are inconclusive. Evidence points to the hydroxylamine derivatives of sulphamethoxazole as the reactive metabolites that cause adverse reactions to co-trimoxazole. HIV-positive individuals have a systemic glutathione deficiency, and therefore a reduced capacity to scavenge such metabolites. This process would lead to an increased exposure to toxic intermediates and would explain the high frequency of adverse reactions to co-trimoxazole in these patients.
N4-oxidation of sulfonamides has been implicated in the pathogenesis of idiosyncratic reactions to these antimicrobials. In vitro toxicity assays employing mononuclear leukocytes as target cells have shown that the toxicity of sulfamethoxazole hydroxylamine (SMX-HA) is inhibited by exogenous glutathione, suggesting that conjugation with glutathione is an important detoxification pathway. However, in these experiments, significant depletion of cellular glutathione only occurred at concentrations of SMX-HA greater than or equal to 300 microM. At concentrations of SMX-HA which produce 50% toxicity in mononuclear leukocytes (approximately 100 microM), there was not a significant loss of glutathione. SMX-HA also caused a small but significant increase in oxidized glutathione concentrations. In cell-free experiments, reduced glutathione (GSH) prevented the autooxidation of SMX-HA to nitrososulfamethoxazole (nitroso-SMX). During this process, oxidized glutathione was formed. GSH rapidly reacted with nitroso-SMX to form a labile semimercaptal conjugate. Physiologically relevant concentrations of GSH (i.e. 1 mM) favored thiolytic cleavage of the semimercaptal to form SMX-HA. Isomerization of the semimercaptal to the more stable sulfinamide occurred at low GSH concentrations. Purified glutathione transferases had no effect on the reaction of SMX-HA with GSH. Therefore, glutathione is important in protecting cells from the toxicity of SMX-HA largely by preventing its further oxidation to nitroso-SMX. Stable glutathione conjugates are likely to be formed only in small quantities under physiological conditions. Conjugation with glutathione would not be expected to be a major pathway for clearance of the hydroxylamine and nitroso metabolites of sulfonamides.
Antimicrobial drugs that can be taken orally are needed for the treatment of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome (AIDS). Preliminary data indicate that dapsone with trimethoprim may be an effective alternative to trimethoprim-sulfamethoxazole, which is frequently toxic.
In a double-blind trial, 60 patients with AIDS and mild-to-moderately-severe first episodes of P. carinii pneumonia (partial pressure of oxygen in arterial blood, greater than 60 mm Hg while breathing room air) were randomly assigned to 21 days of treatment with either trimethoprim-sulfamethoxazole (20 and 100 mg per kilogram of body weight per day, respectively) or trimethoprim-dapsone (20 mg per kilogram per day and 100 mg per day).
The orally administered treatment failed because of progressive pneumonitis in 3 of the 30 patients assigned to trimethoprim-sulfamethoxazole and in 2 of the 30 assigned to trimethoprim-dapsone (P greater than 0.3). Major toxic effects required a switch to intravenous pentamidine for 17 patients (57 percent) in the trimethoprim-sulfamethoxazole group, as compared with 9 (30 percent) in the trimethoprim-dapsone group (P less than 0.025). With trimethoprim-sulfamethoxazole, there were more instances of severe chemical hepatitis (six, as compared with one in the trimethoprim-dapsone group) and marked neutropenia (five vs. one). Intolerable rash (three in each treatment group) and severe nausea and vomiting (two in each group) occurred with equal frequency with both drug combinations. Methemoglobinemia occurred in most of the patients treated with trimethoprim-dapsone, but it was asymptomatic and the level exceeded 20 percent in only one patient. Mild hyperkalemia (serum potassium level, 5.1 to 6.1 mmol per liter) also occurred in 53 percent of the patients treated with trimethoprim-dapsone.
In patients with AIDS, oral therapy with trimethoprim-sulfamethoxazole and with trimethoprim-dapsone are equally effective for mild-to-moderate first episodes of P. carinii pneumonia, but with trimethoprim-dapsone there are fewer serious adverse reactions than with trimethoprim-sulfamethoxazole.
To find out whether systemic glutathione deficiency is associated with human immunodeficiency virus (HIV) infection, thus contributing to the immunodeficiency state, glutathione concentrations in venous plasma and lung epithelial lining fluid (ELF) of symptom-free HIV-seropositive and normal individuals were measured. Total and reduced glutathione concentrations in the plasma of the HIV-infected subjects were about 30% of those in the normal individuals. Concentrations of these substances in the ELF of HIV-infected subjects were about 60% of those in the controls. There was no correlation between ELF and plasma concentrations of total or reduced glutathione. Since glutathione enhances immune function, glutathione deficiency may contribute to the progressive immune dysfunction of HIV infection.
Blood plasma samples from HIV-1-infected persons contain elevated glutamate concentrations up to 6-fold the normal level and relatively low concentrations of acid-soluble thiol (i.e. decreased cysteine concentrations). The intracellular glutathione concentration in peripheral blood-mononuclear cells (PBMC) and monocytes from HIV antibody-positive persons are also significantly decreased. Therapy with azidothymidine (AZT) causes a substantial recovery of the plasma thiol levels; but glutamate levels remain significantly elevated and intracellular glutathione levels remain low. Cell culture experiments with approximately physiological amino-acid concentrations revealed that variations of the extracellular cysteine concentration have a strong influence on the intracellular glutathione level and the rate of DNA synthesis [( 3H]thymidine incorporation) in T cell clones and human and murine lymphocyte preparations even in the presence of several-fold higher cystine and methionine concentrations. Cysteine cannot be replaced by a corresponding increase of the extracellular cystine or methionine concentration. These experiments suggest strongly that the low cysteine concentration in the plasma of HIV-infected persons may play a role in the pathogenetic mechanism of the acquired immunodeficiency syndrome.
To examine the interaction between dapsone and trimethoprim in patients with the acquired immunodeficiency syndrome (AIDS).
Measurement of drug levels as part of an open study of dapsone alone and randomized, double-blind comparison of trimethoprim-dapsone with trimethoprim-sulfamethoxazole in treating Pneumocystis carinii pneumonia in patients with AIDS.
County hospital and AIDS clinic.
Eighteen patients treated with dapsone alone, 30 with trimethoprim-dapsone, and 30 with trimethoprim-sulfamethoxazole.
Dapsone, 100 mg/d; trimethoprim, 20 mg/kg body weight per day, and sulfamethoxazole, 100 mg/kg.d; administered for 21 days.
Concentrations of dapsone were 40% higher in patients treated with trimethoprim-dapsone than in those treated with dapsone alone (2.1 compared with 1.5 micrograms/mL; P less than 0.05). Trimethoprimdapsone-treated patients had fewer treatment failures but more side effects and treatment terminations due to toxicity than those treated with dapsone alone. The concentration of trimethoprim was 48.4% higher in patients treated with trimethoprim-dapsone than in those treated with trimethoprim-sulfamethoxazole, (18.4 compared with 12.4 micrograms/mL; P less than 0.05). Discontinuation of therapy due to toxicity was commoner in the trimethoprim-sulfamethoxazole group (57% compared with 30%).
A bidirectional drug interaction exists between dapsone and trimethoprim, resulting in higher concentrations of each in the presence of the other.
To determine whether differences in in-vitro detoxification of sulfonamide-reactive metabolites can be detected among the lymphocytes from controls, patients with sulfonamide hypersensitivity reactions, and patients with nonhypersensitivity reactions to the sulfonamide agents.
In-vitro toxicity assay on lymphocytes.
Clinics for adverse drug reactions in an adult and pediatric tertiary care center.
Peripheral blood lymphocytes were obtained from 46 normal volunteers and 76 patients referred to the clinic for assessment of adverse drug reactions to sulfonamide agents. Thirty-one patients had clinical histories consistent with a diagnosis of hypersensitivity reaction, whereas 45 patients had clinical histories felt to be inconsistent with a diagnosis of hypersensitivity reaction.
Lymphocytes were assayed with tetrazolium to determine toxicity from the hydroxylamine of sulfamethoxazole.
The lymphocytes from patients with a history of hypersensitivity reactions showed markedly increased toxicity across a tenfold-concentration toxicity-concentration curve compared with those from controls and patients with a history of nonhypersensitivity reactions. These differences were highly significant (P less than 0.01). No difference was found between the toxicity shown by the lymphocytes from controls and that shown by the lymphocytes from patients with a history of nonhypersensitivity reactions.
Metabolic differences in the production and detoxification of reactive metabolites of sulfonamide agents are important determinants of hypersensitivity reactions to these agents. These results suggest that the hydroxylamine derivative of sulfamethoxazole may be a reactive metabolite mediating these reactions. Sulfonamide hydroxylamines are useful in the diagnosis and study of the pathogenesis of hypersensitivity reactions to sulfonamide agents.
To ascertain the efficacy and toxicity of trimethoprim-sulfamethoxazole or pentamidine when either is given alone during the entire treatment period for Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome (AIDS).
Prospective, randomized, noncrossover comparison of trimethoprim-sulfamethoxazole with pentamidine. Trimethoprim-sulfamethoxazole dosage was adjusted to maintain serum trimethoprim at 5 to 8 micrograms/mL. Pentamidine dosage was reduced by 30% to 50% for an absolute rise in serum creatinine of more than 88 mumol/L (1 mg/dL).
Tertiary care hospital and AIDS clinic. Patients: Thirty-six patients were treated with trimethoprim-sulfamethoxazole and 34 with pentamidine. Pretreatment clinical features and laboratory test results were similar in the two groups.
Thirty-six recipients of trimethoprim-sulfamethoxazole and 33 recipients of pentamidine completed therapy without crossover. Trimethoprim-sulfamethoxazole caused a rash (44%) and anemia (39%) more frequently (P less than or equal to 0.03, whereas pentamidine caused nephrotoxicity (64%), hypotension (27%), or hypoglycemia (21%) more frequently (P less than or equal to 0.01). The (A - a)DO2 improved by greater than 1.3 kPa (10 mmHg) 8 days earlier for trimethoprim-sulfamethoxazole recipients (95% CI for the difference in response, -1 to 17; P = 0.04). Thirty-one (86%) patients treated with trimethoprim-sulfamethoxazole and 20 (61%) with pentamidine survived and were without respiratory support at completion of treatment (95% CI for the difference in response, 5% to 45%; P = 0.03).
For most patients with AIDS and P. carinii pneumonia, successful treatment with a single agent is possible. Toxicity associated with the two standard treatments is rarely life-threatening and may be diminished if the trimethoprim-sulfamethoxazole dosage is modified by pharmacokinetic monitoring and the pentamidine dosage is reduced for nephrotoxicity. Oxygenation improved more quickly and survival was better with trimethoprim-sulfamethoxazole.
Among the most serious side effects of sulfonamides are hypersensitivity reactions, the pathogenesis of which has been suggested to be mediated by reactive metabolites. We have previously demonstrated dose-related covalent binding and toxicity of reactive intermediates of sulfonamides generated by a murine hepatic microsomal activating system. We hypothesized that hydroxylamine (H/A) metabolites might be likely candidates for mediating such toxicity; accordingly, we synthesized chemically the H/As of sulfadiazine and sulfamethoxazole. Synthesis was performed using 4-nitrobenzenesulfonyl chloride and either 2-aminopyrimidine or 3-amino-5-methylisoxazole, respectively, as starting materials. The resulting nitro derivatives were reduced to the corresponding H/A with hydrogen in the presence of a poisoned platinum catalyst. After synthesis and purification, toxicity of the H/As to lymphocytes of normal volunteers was evaluated using three cytotoxicity assays: 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide dye conversion, trypan blue dye exclusion and propidium iodide dye exclusion. The H/As of sulfadiazine and sulfamethoxazole displayed dose-related toxicity. 1.6 mM sulfadiazine H/A produced 82% cell death, whereas 400 microM sulfamethoxazole H/A produced 62% cell death; the parent sulfonamides were not toxic to cells. The toxicity of sulfamethoxazole H/A was decreased by coincubation with glutathione or N-acetylcysteine; there was a 47% decrease in toxicity when coincubated with 100 microM glutathione, whereas there was a 55% decrease displayed when coincubation was done with 500 microM N-acetylcysteine. H/A metabolites of the sulfonamides or their nitroso derivatives, normally detoxified by conjugation to glutathione, may be the proximate toxins mediating sulfonamide hypersensitivity.
Forty patients with the acquired immunodeficiency syndrome (AIDS) and their first episodes of Pneumocystis carinii pneumonia were assigned at random to receive either trimethoprim-sulfamethoxazole or pentamidine isethionate. The two groups did not differ significantly in the severity of pulmonary or systemic processes at enrollment. Five patients treated initially with trimethoprim-sulfamethoxazole and one patient treated initially with pentamidine died during the 21-day treatment period (p = 0.09, Fisher's exact test). No significant differences were seen between groups in rates of improvement, pulmonary function tests, or 67Ga uptake by the lungs in the survivors at completion of therapy. Adverse reactions necessitated changing from the initial drug in 10 patients in the trimethoprim-sulfamethoxazole group and 11 in the pentamidine group. Minor reactions occurred in all patients. In patients with AIDS, trimethoprim-sulfamethoxazole and pentamidine do not have statistically significant differences in efficacy or frequency of adverse reactions.
Forty-four episodes of Pneumocystis carinii pneumonia (PCP) occurred in 36 of 70 patients with the acquired immunodeficiency syndrome. Thirty-four patients with 40 episodes of PCP were treated with trimethoprim-sulfamethoxazole. Therapy was successful in 18 episodes (45%), but was unsuccessful in 15 episodes (37.5%). In the latter cases, two patients died within 72 hours; 13, of whom nine died, had therapy changed to pentamidine. In seven additional episodes (17.5%), trimethoprim-sulfamethoxazole was changed to pentamidine due to adverse reactions; all patients survived. Seven patients (26% of survivors) developed recurrent PCP. Twenty-two patients (65%) developed adverse reactions to trimethoprim-sulfamethoxazole, including leukopenia (20), hepatotoxicity (12), fever (eight), rash (six), and immediate reactions (two). Reactions were most common during the second week of therapy. Patients with the acquired immunodeficiency syndrome who have PCP have a high trimethoprim-sulfamethoxazole failure rate, due either to adverse reactions or unresponsive infection. Late recurrence is common.
We have demonstrated the in vitro production of a potentially toxic metabolite of sulfadiazine Human lymphocytes were incubated with sulfadiazine and a murine hepatic microsomal drug metabolizing system. Toxicity to cells was assessed by trypan blue dye exclusion. Covalent binding of labelled sulfadiazine to microsomes also was studied. Sulfadiazine toxicity to cells was dependent on microsomes and NADPH. Binding and toxicity were decreased when microsomes were boiled or cytochrome P-450 inhibited, and by the addition of N-acetylcysteine or glutathione. The data suggest the production of a toxic intermediate of oxidative metabolism of sulfadiazine which is detoxified by conjugation with glutathione. Covalent binding of such metabolites to cell macromolecules could lead to cell death and, by acting as haptens, to secondary hypersensitivity reactions.
In 8 of 18 homosexual men with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia (PCP) treated with intravenous co-trimoxazole (trimethoprim-sulphamethoxazole) apparent drug-related complications developed during the course of acute therapy. A symptom complex of fevers and increasing malaise, often with nausea and headaches, developed usually after 9 days of therapy at a daily dosage of 20 mg/kg of trimethoprim and 100 mg/kg of sulphamethoxazole. These symptoms were associated with a diffuse erythematous maculopapular eruption and peripheral cytopenias. A similar picture was noted in two children with suspected AIDS-associated PCP. The high frequency of adverse reactions to co-trimoxazole therapy for PCP seems to be characteristic of AIDS patients.
We reviewed the charts of 38 patients with the acquired immunodeficiency syndrome who were treated for Pneumocystis carinii pneumonia. Only 5 of 37 patients started on trimethoprim-sulfamethoxazole were able to complete treatment; in 29 patients drug toxicity occurred and in 19 treatment was changed due to adverse reactions that included rash, fever, neutropenia, thrombocytopenia, and transaminase elevation. Pentamidine was given to 30 patients (1 as initial treatment); toxicity occurred in 13 but only 4 required a change in drug. Adverse reactions from pentamidine included fever, rash, neutropenia, transaminase elevation, azotemia, and hypoglycemia. Patients received trimethoprim-sulfamethoxazole a median of 9.5 days, and pentamidine, a median of 12.5 days. Toxicity from trimethoprim-sulfamethoxazole appeared earlier than toxicity associated with pentamidine (7.5 versus 9.5 days of treatment). In patients with the acquired immunodeficiency syndrome, trimethoprim-sulfamethoxazole has a higher incidence of adverse reactions than pentamidine (p less than 0.005).
Clinical features of 49 episodes of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome were compared with those of 39 episodes in patients with other immunosuppressive diseases. At presentation patients with the syndrome were found to have a longer median duration of symptoms (28 days versus 5 days, p = 0.0001), lower mean respiratory rate (23.4 versus 30, p = 0.005), and higher median room air arterial oxygen tension (69 mm Hg versus 52 mm Hg, p = 0.0002). The survival rate from 1979 to 1983 was similar for the two groups (57% and 50% respectively). Patients with the syndrome had a higher incidence of adverse reactions to trimethoprim-sulfamethoxazole (22 of 34 versus 2 of 17, p = 0.0007). Survivors with the syndrome at initial presentation had a significantly lower respiratory rate, and higher room air arterial oxygen tension, lymphocyte count, and serum albumin level compared to nonsurvivors. Pneumocystis carinii pneumonia presents as a more insidious disease process in patients with the syndrome, and drug therapy in these patients is complicated by frequent adverse reactions.
The formation and elimination of sulphamethoxazole hydroxylamine in relation to the pharmacokinetics of the parent compound and its N4-acetyl metabolite were investigated in six healthy subjects after a single oral dose of 800 mg sulphamethoxazole. The apparent half-lives of sulphamethoxazole and its metabolites were approximately 10 h, indicative of formation rate-limited metabolism. The mean residence time of the hydroxylamine metabolite was 5.5 +/- 1.5 h. The renal clearance of sulphamethoxazole hydroxylamine was 4.39 +/- 0.91 l h-1. The urinary recovery of sulphamethoxazole accounted for 16.5 +/- 5.5% of the dose, N4-acetyl-sulphamethoxazole for 46.2 +/- 6.6% and the hydroxylamine metabolite for 2.4 +/- 0.8%. The remaining 35% of the dose was unaccounted for. Acetylator phenotype was determined using sulphadimidine. The renal excretion of sulphamethoxazole hydroxylamine was 1.9 +/- 0.9% in slow acetylators (n = 3) and 2.8 +/- 0.3% in fast acetylators (n = 3); for N4-acetyl-sulphamethoxazole the values were 48 +/- 6% and 44 +/- 8%, respectively. Sulphamethoxazole is metabolized, although to a limited extent, to a hydroxylamine metabolite. This metabolite may be important for the pathogenesis of adverse reactions.
Adverse reactions to co-trimoxazole in
- Van
- Ven Ajam
- Pp
- Vree
- Tb
- Van
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Van der Ven AJAM, Koopmans PP, Vree TB, van der Meer JWM. Adverse reactions to co-trimoxazole in
Sulfonamide toxicity in HIV infection
- Rieder MJ
- Krause R.
- Bird IA
- Dekaban GA
Pharmacokinetics of sulfamethoxazole
- Vree
Sulfonamide toxicity in HIV infection
- Rieder MJ