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[Agranulocytosis caused by dapsone. Apropos of 3 cases. Review of the literature].

Authors describe three cases of agranulocytosis in patients with giant cell (temporal) arterities treated with Dapsone and corticosteroids. The culture in vitro of CFU.GM. cells of two patients, four healthy subject and two patients treated with Dapsone with out granulopenia, demonstrates no any toxic effect of Dapsone. A review of the literature finds 59 cases of agranulocytosis in patients treated with Dapsone alone or in combination with other drugs. Doses of Dapsone ranged from 25 mg to 300 mg a day. Agranulocytosis occurred between the 4th and the 12th week, more often near the 8th week. Agranulocytosis occurred suddenly without previous granulocytopenia. These facts argue for immunoallergic mechanism. This Dapsone side effect requires to restrict its use and to reserve it to serious diseases or failures of other therapeutic drugs. It needs too to keep a close eye on the patients between the 6th and 12th week.

Aged↗

Sustained release properties of an intra-adiposely administered dapsone depot injection.

A dapsone depot injection, consisting of dapsone crystals of bipyramidal shape with a particle size of 38 micron-63 micron suspended in an aqueous vehicle, appeared to result in different concentration/time profiles in men and women when delivered "intramuscularly." This phenomenon can be explained by the larger skin-to-muscle distance in women than in men. Injections intended to be delivered intramuscularly are, in fact, administered into subcutaneous fatty tissue in most of the women. Because sustained release properties were more satisfactory in women than in men, in this study the absorption of dapsone was investigated after administration of the same injection into gluteal fatty tissue. Via this route of administration, for which the term intra-adipose is used, 12 female and 15 male healthy volunteers received 1000 mg dapsone, after which blood samples were taken at regular intervals for 35 days to determine dapsone and monoacetyldapsone concentrations in serum using high-pressure liquid chromatography with fluorometric detection. No important differences between men and women appeared to exist at any time point after injection. The peak concentrations were 0.69 +/- 0.40 mg/l in men and 0.84 +/- 0.31 mg/l in women. No important side effects were observed, either locally or systemically. Volunteers who previously received an intramuscular injection preferred the intra-adipose administration. The good depot properties and better acceptance of intra-adipose dapsone administration are reasons to prefer this route of administration.

Adipose Tissue↗

Dapsone induced hypohaptoglobinemia in lepromatous leprosy patients.

Dapsone has been used in various dermatological disorders and in leprosy. One of the main side effects of dapsone therapy is anemia, mostly hemolytic. We aimed at finding the effect of dapsone therapy on serum haptoglobin levels which could be an indirect evidence for intravascular hemolysis, supported by secondary investigations such as liver functions (serum lactic dehydrogenase, alkaline phosphatase, bilirubin), blood hemoglobin levels, urinary excretion of urobilinogen, and erythrocytes. As in other infectious conditions, haptoglobins were raised in untreated lepromatous cases, compared to controls (p less than 0.05). Dapsone treatment of 100 mg daily for 14 days brought down the haptoglobin level significantly as compared to the untreated cases and the controls (p less than 0.05). An elevated alkaline phosphatase and lactate dehydrogenase indicate some liver dysfunction following dapsone therapy. A significant drop in blood hemoglobin level and a concomitant increase in serum bilirubin, urinary excretion of urobilinogen, and a significant fall in the serum hemoglobin binding capacity (haptoglobin level) following treatment with dapsone are quite suggestive of mild intravascular hemolysis.

Adult↗

Pulmonary vascular effects of endotoxin in canine lobes pretreated with dapsone.

Endotoxin results in a granulocyte mediated loss of hypoxic pulmonary vasoconstriction (HPV). Dapsone blocks the granulocyte respiratory burst and might, therefore, preserve HPV following endotoxin. Isolated-perfused canine lobes (n = 6) were pretreated with 18 mg/kg dapsone (dapsone group), and compared to six lobes which did not receive dapsone (control group). Total pulmonary vascular resistance (Rtot) and arterial, middle (Rm), and venous segmental resistances were calculated by a vascular occlusion technique. We then administered endotoxin (2 mg/kg) and repeated measurements at 5, 30, and 90 min. The increase in Rm during 3% O2 compared to 35% O2 ventilation was used to define the presence of HPV. In the control group, following endotoxin, values of Rm did not change (P > 0.05) during 3% O2 ventilation (0.011 +/- 0.006 cm H2O/ml/min) compared with 35% O2 ventilation (0.014 +/- 0.005 cm H2O/ml/min). In the dapsone group, following endotoxin, values of Rm increased (P < 0.05) during 3% O2 ventilation (0.06 +/- 0.026 cm H2O/ml/min) compared with 35% O2 ventilation (0.03 +/- 0.015 cm H2O/ml/min). Changes in 6-keto PGF1 alpha or thromboxane B2 do not explain these observations. We conclude that in this experimental preparation, pretreatment with dapsone prevents the loss of HPV associated with endotoxin.

Animals↗

Primary prophylaxis for Pneumocystis carinii pneumonia: a randomized trial comparing cotrimoxazole, aerosolized pentamidine and dapsone plus pyrimethamine.

OBJECTIVE: To compare the efficacy and tolerance of monthly aerosolized pentamidine versus cotrimoxazole versus dapsone plus pyrimethamine to prevent the initial episodes of Pneumocystis carinii pneumonia (PCP) in HIV-infected patients. DESIGN: An open randomized clinical trial. PATIENTS AND METHODS: HIV-infected patients (n = 331) with CD4 cell counts < 200 x 10(6)/l or with AIDS but without a history of PCP or cerebral toxoplasmosis (CT) were randomized to receive pentamidine (300 mg every 4 weeks), cotrimoxazole (160/800 mg 3 days a week) or dapsone plus pyrimethamine (100 and 25 mg weekly). If immunoglobulin G (IgG) antibodies to Toxoplasma were present, patients in the first two groups were randomized further to 25 mg pyrimethamine per week or to no treatment. RESULTS: The mean follow-up was 313 days (range, 30-670 days). The three groups were homogeneous for age, sex, risk group for HIV infection, initial CD4 cell count and mean follow-up. PCP developed in 16 patients, with an estimated cumulative probability of 5.3% at 1 year of follow-up. The PCP rate per year of observation, using an intention-to-treat analysis, was 5.6% [95% confidence interval (CI), 0.9-10.3], 3% (95% CI, 0-6.3) and 8.3% (95% CI, 2.8-13.8) in the groups treated with pentamidine, cotrimoxazole and dapsone plus pyrimethamine, respectively (P > 0.05). Moderate or severe side-effects were observed in one patient on pentamidine, 10 on cotrimoxazole and nine on dapsone plus pyrimethamine (P < 0.05); the study drug had to be discontinued in no, 10 and six patients, respectively (P < 0.05). Neither cotrimoxazole alone nor pyrimethamine combined with dapsone or cotrimoxazole prevented initial episodes of toxoplasmosis among patients with IgG antibodies to Toxoplasma gondii. CONCLUSIONS: Low-dose thrice-weekly cotrimoxazole or weekly dapsone plus pyrimethamine was not significantly worse (differences > 15% would have been detected with 90% certainty) than monthly aerosolized pentamidine in preventing a first episode of PCP in patients at high risk, but aerosolized pentamidine was better tolerated.

AIDS-Related Opportunistic Infections↗

Bioassay of dapsone for possible carcinogenicity.

A bioassay of dapsone, 4,4'-sulfonyldianiline, for possible carcinogenicity was conducted by administering the test material in feed to Fischer 344 rats and B6C3F1 mice. Groups of 35 rats and 35 mice of each sex were administered dapsone at one of two doses, either 600 or 1,200 ppm for rats and either 500 or 1,000 ppm for mice. The rats and mice were treated for 78 weeks; the rats were then observed for 26-28 weeks, the mice for 28-30 weeks. Matched controls consisted of groups of 15 untreated rats and 14 untreated mice of each sex, pooled controls, used for statistical evaluation, consisted of the matched controls combined with 30 male and 30 female untreated rats and 29 male and 29 female untreated mice from similarly performed bioassays of two other test chemicals. All surviving rats were killed at 104-106 weeks, all surviving mice at 106-108 weeks. Treated rats and mice had lower mean body weights than the corresponding controls; when treatment was discontinued at week 78, both species showed some increase in body weight. Survival among rats was unaffected by treatment with dapsone; adequate numbers of animals survived for meaningful statistical analyses of the incidences of tumors. Dapsone did not adversely affect the survival of mice, as shown by the test for positive dose-related trend. Suppurative bronchopneumonia was found in some mice in all matched-control and treated groups. Several control males died early in the study, while survival of the other groups of mice was not affected until week 75. Among rats, mesenchymal tumors of the abdominal organs or peritoneal tissues occurred in 13/35 low-dose males and 22/33 high-dose males. None occurred among control males or among control or treated females. The most commonly occurring tumors were fibroma, fibrosarcoma, or sarcoma, NOS (not otherwise specified), of the spleen and the peritoneum. In male rats, these mesenchymal tumors of the spleen occurred in a statistically significant incidence in both treated groups (low-dose 6/34, P=0.006; high-dose 14/32, P<0.001) when compared with pooled controls. In the peritoneum, the incidences of these mesenchymal tumors were significant in both treated groups (low-dose 5/35, P=0.014; high-dose 6/33, P=0.005) when compared with the pooled controls. No tumors related to treatment were found in female rats. Among the mice, there were no tumors that could clearly be related to treatment. It is concluded that under the conditions of this bioassay, dapsone was not carcinogenic for female Fischer 344 rats or B6C3F1 mice of either sex. Dapsone was carcinogenic (sarcomagenic) for male Fischer 344 rats, causing mesenchymal tumors in the spleen and the peritoneum.

Journal Article↗

The incidence of agranulocytosis during treatment of dermatitis herpetiformis with dapsone as reported in Sweden, 1972 through 1988.

During the 17-year period 1972 through 1988, a total of seven cases of agranulocytosis associated with the use of dapsone for the treatment of dermatitis herpetiformis were reported in Sweden. The median age of the patients involved was 61 years; three of them were male. The median duration of dapsone treatment was 7 weeks and the daily prescribed dose was 100 mg. Based on sales and prescription data, the crude relative risk of agranulocytosis during dapsone treatment of dermatitis herpetiformis was 50, and the total risk was one case per 3000 patient years of exposure to dapsone. In relation to the number of new cases of dermatitis herpetiformis, agranulocytosis was estimated to develop in 1 of 240 to 425 patients receiving dapsone therapy. Patients should be instructed to seek medical care immediately in case of fever.

Adult↗

Inhibitory effects of dapsone on enzymatic activities of membrane phospholipids in human blood cells.

In order to elucidate the action mechanism of dapsone on blood cell membranes, we assessed the dose-dependent effect of dapsone on the activities of choline phosphotransferase (which mediates the production of the structural phospholipid, phosphatidylcholine) and methyltransferase (which produces phosphatidylcholine from phosphatidylethanolamine, representing the dynamics of the cells) in the membranes of red cells, lymphocytes, and neutrophils obtained from 16 healthy human subjects. The methyltransferase activity of lymphocyte and neutrophil cell membranes was slightly inhibited by dapsone, although only at a high concentration (1 mM), while that of red cells was not affected. On the other hand, dapsone significantly decreased the choline-phosphotransferase activity of red-cell membranes in a dose-dependent fashion, but did not significantly inhibit that of lymphocytes or neutrophils. The mechanisms of the hemolytic side effect of dapsone on erythrocytes and its anti-inflammatory effect on neutrophils are discussed in connection with its inhibitory effect on the enzymatic activities of membrane phospholipids.

Blood Cells↗

Dapsone and colchicine inhibit adhesion of neutrophilic granulocytes to epidermal sections.

A frozen section adhesion assay was used to study the influence of dapsone and colchicine on cell-cell adhesion between neutrophils and epidermal cells. Sections were prepared from small punch biopsies from healthy donors after preincubation with IFN-A. Freshly prepared neutrophils were activated with TNF-. or PAF after exposure to dapsone or colchicine, incubated on these sections, and the adhered cells were enumerated after washing. In the presence of dapsone (at concentrations of 0.1-80 Ig/ml) adherence of neutrophils could be blocked dose-dependently and 50% inhibition of adhesion was achieved at a concentration of 10 Ig/ml. Colchicine at concentrations of 10-200 ng/ml inhibited neutrophil binding with a clear correlation between inhibition and colchicine concentration. At a colchicine concentration of 110 ng/ml, 50% blocking was achieved. Since the function of CD11b/ paragraph signCD18 is necessary for neutrophil adhesion in this assay, we monitored CD11b expression on neutrophils after dapsone and colchicine exposure. CD11b expression on neutrophils was significantly reduced 5 h after incubation with dapsone at a concentration of 80 Ig/ paragraph signml, whereas no effects of colchicine on CD11b expression could be demonstrated. Our study showed that both drugs significantly inhibited adhesion between neutrophils and the epidermis.

Cell Adhesion↗

[Dapsone in granulomatous rosacea].

We report on two patients with granulomatous rosacea and another patient with granulomatous perioral dermatitis who responded well to dapsone. Dapsone has a pharmacological double function as both an antibiotic and an antiphlogistic drug. Before the introduction of isotretinoin, dapsone had its place in the treatment of severe acne. To date, its use in granulomatous rosacea has not been described. When hematologic parameters are monitored, dapsone is considered a safe and cost-effective drug, especially in countries where isotretinoin is not readily available. However, the definite value of dapsone in granulomatous rosacea should be established by a controlled study.

Adult↗

The effect of dapsone in steroid-dependent asthma.

We studied the steroid-sparing effect of dapsone in 10 subjects with chronic asthma in a preliminary open trial. Dapsone was chosen because it inhibits neutrophil function and possesses anti-inflammatory effects in a variety of disorders. The study group consisted of 10 subjects with stable, steroid-dependent asthma, aged 23 to 80 years, with normal glucose-6-phosphate dehydrogenase levels. Average daily baseline prednisone dose ranged from 5 to 60 mg. Dapsone, 100 mg, twice daily, by mouth, was started after a 1-month baseline period. Baseline steroid dose, symptom scores, and daily peak flow rates were compared to the latest available 4-week period of dapsone treatment. Average cumulative monthly prednisone dose was reduced from 428 mg to 82 mg (p less than 0.02). Five of 10 patients stopped steroids by month 6 and two additional patients by month 13. Two additional patients demonstrated a coincidental 74% reduction in steroid dose, and one patient demonstrated no response. Clinical parameters remained stable despite steroid reduction. These preliminary data suggest dapsone may have steroid-sparing effects in chronic asthma.

Adult↗

Dapsone toxicity: some current perspectives.

1. Dapsone is a potent anti-inflammatory and anti-parasitic compound, which is metabolised by cytochrome P-450 to hydroxylamines, which in turn cause methaemoglobinaemia and haemolysis. However, during the process of methaemoglobin formation, erythrocytes are capable of detoxifying the hydroxylamine to the parent drug, which may either reach the tissues to exert a therapeutic effect or return to the liver and be re-oxidised in a form of systemic cycling. This glutathione-dependent effect, combined with the un-ionised state of the drug at physiological pH, may contribute to its efficacy. 2. Paradoxically, other aspects of the glutathione-dependent cycling of the hydroxylamine metabolite may contribute to the major adverse reaction of the drug, agranulocytosis. Erythrocytes exposed to the metabolite and repeatedly washed may still release the hydroxylamine in sufficient concentration to kill mononuclear leucocytes in vitro. Thus, erythrocytes may be a conduit for the hydroxylamine to reach the bone marrow to covalently bind to granulocyte precursors, which may trigger an immune response in certain individuals and may lead to the potentially fatal eradication of granulocytes from the circulation. 3. Attempts to increase patient tolerance to dapsone have been most successful using a metabolic inhibitor to reduce hepatic oxidation of the drug to the hydroxylamine. Methaemoglobin formation in the presence of cimetidine was maintained at 30% below control levels for almost 3 mo, and patients' reported side effects such as headache and lethargy were significantly reduced. 4. As clinical application of new and safer dapsone analogues is years away, the use of cimetidine provides an immediate route to increasing patient compliance during dapsone therapy, especially in those maintained on dapsone dosages in excess of 200 mg/day.

Agranulocytosis↗

Antimalaria activity of the triple combination of proguanil, atovaquone and dapsone.

The combination of proguanil and atovaquone has been shown to be more effective in curing drug-resistant infections of falciparum malaria than atovaquone or proguanil alone. Our current study sought to determine whether the antimalaria activity could be increased by adding dapsone. Plasma samples, obtained from individuals 4-72 h after proguanil-atovaquone administration, were 2-3 times more active against Plasmodium falciparum in vitro when dapsone was added to them. The enhanced activity of the combination of proguanil, atovaquone and dapsone is probably due to the combined activity of two synergistic combinations: proguanil-atovaquone and cycloguanil (metabolite of proguanil)-dapsone. These findings suggest that further studies are needed to evaluate the clinical value of the triple drug combination of proguanil, atovaquone and dapsone in the treatment of multi-drug resistant malaria.

Animals↗

Comparison of the in vitro cytotoxicity of hydroxylamine metabolites of sulfamethoxazole and dapsone.

The differential incidence of adverse drug reactions (ADR) between trimethoprim-sulfamethoxazole and dapsone might be explained, in part, by differences in the inherent toxicity of the hydroxylamine metabolites of sulfamethoxazole and dapsone. To test this hypothesis, the in vitro cytotoxicities of sulfamethoxazole hydroxylamine, dapsone hydroxylamine, and monoacetyldapsone hydroxylamine were compared using peripheral blood mononuclear cells (PBMC) from healthy volunteers. After 3 hr of exposure to hydroxylamine metabolites, PBMC were washed thoroughly to remove residual hydroxylamine, and viability was assessed 16 hr later by determination of 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) conversion. A concentration-dependent toxicity was observed with each hydroxylamine metabolite. While dapsone hydroxylamine and monoacetyldapsone hydroxylamine were not significantly different, both showed significantly greater cytotoxic potency than sulfamethoxazole hydroxylamine (P < 0.05). This differential potency was not a function of differential stability in aqueous medium and was maintained over time. The effects of red blood cells (RBC), impermeable RBC "ghosts," and RBC lysate on hydroxylamine-induced cytotoxicity were determined using a two-compartment dialysis system. Amelioration of hydroxylamine-dependent cytotoxicity occurred when RBC were included in PBMC incubations. This apparent detoxifying effect was markedly greater using RBC lysate in comparison with impermeable "ghosts" (P < 0.05). No difference in detoxification was observed between sulfamethoxazole hydroxylamine and monoacetyldapsone hydroxylamine. Differences in the inherent cytotoxicity of their hydroxylamine metabolites do not appear to explain the differential incidence of ADR between trimethoprim-sulfamethoxazole and dapsone.

Cell Survival↗

Comparison of the dapsone recovery ratio and the erythromycin breath test as in vivo probes of CYP3A activity in patients with rheumatoid arthritis receiving cyclosporine.

INTRODUCTION: Cytochrome P4503A (CYP3A) is primarily responsible for the metabolism of cyclosporine and that of many other drugs. Several substrates of CYP3A have been investigated for use as pharmacologic probes to predict the CYP3A-metabolizing capacity of an individual and, therefore, the disposition of other CYP3A substrate drugs. One such measure of CYP3A activity is the 14C erythromycin breath test, which has been applied to the prediction of cyclosporine disposition. However, the test has practical limitations. Because of this, the 0- to 8-hour urinary dapsone recovery ratio has been studied as an alternative and more practical probe of CYP3A activity. METHODS: The dapsone recovery ratio and the 14C erythromycin breath test were correlated with cyclosporine concentrations in 16 patients with rheumatoid arthritis to determine the usefulness of the dapsone recovery ratio as an alternative to the 14C erythromycin breath test. The erythromycin breath test showed a fourfold variation between subjects and correlated weakly with trough cyclosporine concentrations (r = -0.50, p < 0.05), whereas the dapsone recovery ratio varied only approximately twofold between subjects and did not correlate with trough cyclosporine concentrations (r = 0.02, p = 0.94). The correlation between the dapsone recovery ratio and the erythromycin breath test (r = 0.22, p = 0.41) was not significant. CONCLUSIONS: These data suggest that results obtained with one probe in vivo may not apply to another CYP3A substrate. The poor quantitative relationship between cyclosporine concentrations and the erythromycin breath test limits its usefulness in the prediction of an individual's cyclosporine dose requirement.

Adult↗

In vitro effects of MOCA and dapsone on rat hepatic and splenic immune cells.

The industrial curing agent 4,4'-methylene-bis(2-chloroaniline) (MOCA) and the structurally related medicinal agent 4,4'-sulphonyldianiline (dapsone), are two commonly used aromatic amine compounds and documented animal carcinogens. In this study the effects of in vitro exposure to MOCA and dapsone (over a dose range of 1-200 microM on spleen and liver immune cell functions were investigated. MOCA exposure caused a dose-dependent inhibition of natural immune activities (i.e. natural killer, NK and natural P815 killer, NPK) and mitogen-stimulated proliferation of T- and B-lymphocytes, with 50% inhibition (IC50) of splenic-cell activities occurring at 145, 85, 21 and 31 microM, respectively. Liver NK and NPK activities were less sensitive to MOCA exposure and exhibited higher IC50's of 165 and 160 microM, respectively. Dapsone exposure slightly enhanced both T- and B-cell mitogenesis at low doses (1 microM) but decreased B-cell mitogenesis at high doses (IC50 = 130 microM). Natural tumouricidal activities were generally unaffected by dapsone, whilst natural cytotoxic (NC) activity was unaffected by both compounds. These results indicate that MOCA is generally immunotoxic in vitro, and may have the potential to enhance the carcinogenic effects of its genotoxic metabolite by inhibiting the tumour surveillance activities of the immune system. The relationship between immune effects and the carcinogenicity of dapsone remains unclear.

Animals↗

Hemolytic drugs aniline and dapsone induce iron release in erythrocytes and increase the free iron pool in spleen and liver.

Incubation of rat erythrocytes with the hydroxylated metabolites of aniline and dapsone (4-4'-diaminodiphenylsulfone), phenylhydroxylamine and dapsone hydroxylamine, respectively, induced marked release of iron and methemoglobin formation. On the contrary, no release of iron nor methemoglobin formation was seen when the erythrocytes were incubated with the parent compounds (aniline and dapsone). The acute intoxication of rats with aniline or dapsone induced a marked increase in the erythrocyte content of free iron and methemoglobin, indicating that the xenobiotics are effective only after biotransformation to toxic metabolites in vivo. Prolonged administration of aniline or dapsone to rats produced continuous release of iron from erythrocytes. Marked iron overload was seen in the spleen and in the liver Kupffer cells, as detected histochemically. The spleen weight in these subchronically treated animals was significantly increased. The free iron pool was markedly increased in the spleen and to a lower extent in the liver. The possible relationships between iron release in erythrocytes, oxidative damage seen in senescent cells, hemolysis, overwhelmed capacity of spleen and liver to keep iron in storage forms and subsequent increase in low molecular weight, catalitically active iron is discussed.

Aniline Compounds↗

Dapsone and sulfapyridine.

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.

Anti-Infective Agents↗