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Celecoxib, a selective cyclo-oxygenase-2 inhibitor, is a diaryl-substituted pyrazole derivative containing a sulfonamide substituent. Because of this structural component, celecoxib is contraindicated for use in patients who have demonstrated allergic reactions to sulfonamides. However, there is a lack of data demonstrating cross-reactivity among sulfonamide medications. A sulfonamide is any compound with an SO2NH2 moiety. The major difference between sulfonamide antimicrobials and other sulfonamide-containing medications such as furosemide, thiazide diuretics and celecoxib, is that sulfonamide antimicrobials contain an aromatic amine group at the N4 position. This allows for division of the sulfonamides into 2 groups: aromatic amines (i.e., sulfonamide antimicrobials) and nonaromatic amines. In addition, sulfonamide antimicrobials contain a substituted ring at the N1-position; this group is not found with nonaromatic amine-containing sulfonamides. Adverse reactions to sulfonamide antimicrobials include type I, or immunoglobulin (Ig) E-mediated reactions, hypersensitivity syndrome reactions, and severe skin reactions such as toxic epidermal necrolysis. The aromatic amine portion of the sulfonamide antimicrobial is considered to be critical in the development of latter 2 reactions. In susceptible individuals, the hydroxylamine metabolite is unable to be detoxified leading to a cascade of cytotoxic and immunological events that eventually results in the adverse reaction. Since celecoxib does not contain the aromatic amine, adverse reactions such as hypersensitivity syndrome reactions and toxic epidermal necrolysis would not be expected to occur at the same frequency as they do with sulfonamide antimicrobials. Similarly, for IgE-mediated reactions, the N1-substituent and not the sulphonamide moiety is important in determining specificity to antibodies. Celecoxib and other nonaromatic amine-containing sulfonamide medications do not contain the N1-substituent. Cross-reactivity among the various sulfonamide-containing medications has also not been substantiated by published case reports. In fact, conflicting information exists in the literature. Reports showing lack of cross-reactivity balance the few case reports suggesting cross-reactivity. Cross-reactivity between sulfonamide medications should be based on scientific data, including chemistry, metabolism, immune responses and clinical data. Based on the current information, there is no documentation for cross-reactivity between sulfonamide antimicrobials and other sulfonamide medications, such as celecoxib.
BACKGROUND: The selective COX-2 inhibitor celecoxib has a sulfonamide structure and is contraindicated for patients with known sulfa allergy. However, there is currently no standard available for the identification of sulfonamide-related adverse drug reactions (ADRs) and the occurrence of such ADRs with celecoxib has not been established. THE AIMS OF THIS STUDY WERE: (1) to identify the typical pattern of sulfonamide ADRs from literature and verify this pattern in the World Health Organization (WHO) ADR database; and (2) to examine whether these sulfonamide ADRs occur more frequently with celecoxib than with the non-sulfonamide, COX-2 inhibitor rofecoxib. METHODS: A sulfonamide ADR pattern was derived from the most extensive textbook source of ADRs and applied to the WHO database for the three groups of sulfonamide drugs: short- and intermediate-acting sulfonamides, and sulfasalazine. ADRs reported three or more times for each of these groups were included in a 'sulfonamide template' comprising 19 ADRs relating to the skin, the blood, the liver, and anaphylaxis. This template was then applied to celecoxib and rofecoxib. RESULTS: Overall, the relative reporting rate of a sulfonamide-type ADR with celecoxib was 80% higher than with rofecoxib, whether this was based on total number of reports (RR 1.8, 95% Cl 1.6-1.9) or restricted to reports that listed coxibs as the sole suspected drugs (RR 1.8, 95% Cl 1.6-1.9). There were numerically more ADRs for celecoxib than for rofecoxib in 15 of the 19 terms. Within the ADRs in the sulfonamide template, relative reporting rate of fatal reactions was 80% higher with celecoxib (RR 1.8, 95% Cl 0.9-4.0). Even though serious sulfonamide reactions are rare, their clinical impact on patient safety warrants close monitoring as more data becomes available. Physicians should be aware of possible sulfonamide allergy when prescribing celecoxib.
STUDY OBJECTIVES: To characterize patient-reported sulfonamide allergies, assess the influence of these allergies on drug prescribing practices, and determine the frequency and nature of adverse reactions in patients with sulfonamide allergies who receive potentially cross-reactive drugs. DESIGN: Prospective observational study. SETTING: Tertiary care hospital. PATIENTS: Ninety-four hospitalized adult patients with reported sulfonamide allergies. MEASUREMENTS AND MAIN RESULTS: Patients were followed during their hospital stay to document prescribing of and adverse reactions to sulfonamide antibiotics and sulfonamide nonantibiotics. Allergy characteristics and prescribing of sulfonamide-containing drugs were analyzed with descriptive statistics. Trimethoprim-sulfamethoxazole (TMP-SMX) allergy was reported by 42 patients (45%), whereas 42 patients (45%) did not recall the drug to which they were allergic. Fifty-nine patients (63%) reported the allergy's physical manifestation as rash, 13 (14%) anaphylaxis, and 2 (2)% Stevens-Johnson's syndrome. Median time since last reported allergic reaction to a sulfonamide-containing agent was 20 years. Forty patients (43%) had been taking a sulfonamide nonantibiotic as an outpatient for an average of 6.2 years; 24 (60%) of those patients took furosemide. Sixteen (40%) of the patients receiving sulfonamide nonantibiotics reported an allergy to TMP-SMX. Nine patients (10%) with no past sulfonamide nonantibiotic use received a sulfonamide nonantibiotic as an inpatient, with furosemide most commonly prescribed. No adverse events were reported before admission or observed during the inpatient stay (range 2-23 days). CONCLUSIONS: Inpatient and outpatient use of potentially cross-reactive drugs was observed in 52% of patients, although numerous patients were unable to give an accurate allergy history. No adverse effects were reported or documented with outpatient or inpatient sulfonamide nonantibiotic use, even among patients with histories of life-threatening reactions to sulfonamides.
The migration behavior and selectivity of thirteen sulfonamides in capillary electrophoresis (CE), with emphasis on micellar electrokinetic chromatography (MEKC) were systematically investigated using a phosphate-borate buffer electrolyte, with sodium dodecyl sulfate (SDS) as an anionic surfactant in MEKC. The optimization strategies for the separation of sulfonamides in capillary zone electrophoresis (CZE) and in MEKC are described. The migration behavior and selectivity of sulfonamides in CZE are mainly manipulated by the pH of the buffer. The migration order of sulfonamides depends on the ratios of charge to mass (q/M2/3) and is primarily determined by their pKa values. Thus precise optimization of buffer pH is crucial to further improve the separation of some closely migrating sulfonamides. On the other hand, buffer pH and micelle concentration greatly affect the migration and selectivity of sulfonamides in MEKC. The migration order of sulfonamides is mainly determined by their pKa values and the magnitude of the binding constants of solutes-to-micelles. The influences of buffer pH and micelle concentration correlate with each other. The magnitude of the binding constants correlates with the differences between the electrophoretic mobility of sulfonamides measured at a pH below pKa-2 in CZE and that in MEKC. In this work, acid dissociation constants of these sulfonamides and binding constants of sulfonamides to SDS micelles in a phosphate-borate buffer are reported.
Sulfonamide antimicrobials are used in both human therapy and animal husbandry. Sulfonamides are not readily biodegradable and have been detected in surface water and in secondary wastewater effluents. The chemical oxidation of sulfonamides by an environmentally friendly oxidant, ferrate(VI) (Fe(VI)O4(2-), Fe(VI)), was conducted. The sulfonamides used in the oxidation studies were sulfisoxazole, sulfamethazine, sulfamethizole, sulfadimethoxine, and sulfamethoxazole. Kinetics of the reactions were determined as a function of pH (7.0-9.7) and temperature (15-45 degrees C) by a stopped-flow technique. The rate law for the oxidation of sulfonamides by Fe(VI) is first-order with respect to each reactant. The observed second-order rate constants decreased nonlinearly with an increase in pH and are possibly related to the protonation of Fe(VI) (HFeO4- <==> H+ + FeO4(2-); pK(a,HFeO4) = 7.23) and sulfonamides (SH <==> H+ + S-; pK(a,SH) = 5.0-7.4). The activation parameters of the reactions vary with pH due to temperature dependence on the protonation of Fe(VI) and sulfonamides. These results were used to obtain enthalpy of dissociation of sulfonamides. Stoichiometry and products of sulfamethoxazole (SMX) reactions with Fe(VI) were studied in detail using various analytical techniques to evaluate the effect of the oxidation process on the fate of sulfonamides in water. At a stoichiometric ratio of 4:1 (Fe(VI): SMX), complete removal of SMX was achieved. Analyses of oxidation products of the reaction as well as kinetic measurements of substructural models of SMX suggest that the attack of Fe(VI) occurs at the isoxazole moiety as well as at the aniline moiety with minimal preference. The results of the studies reported suggest that Fe(VI) has the potential to serve as a chemical oxidant for removing sulfonamides and converting them to relatively less toxic byproducts in water.
3-Fluoromethyl-7-(N-substituted aminosulfonyl)-1,2,3,4-tetrahydroisoquinolines (14, 16, and 18-22) are highly potent and selective inhibitors of phenylethanolamine N-methyltransferase (PNMT). Molecular modeling studies with 3-fluoromethyl-7-(N-alkyl aminosulfonyl)-1,2,3,4-tetrahydroisoquinolines, such as 16, suggested that the sulfonamide -NH- could form a hydrogen bond with the side chain of Lys57. However, SAR studies and analysis of the crystal structure of human PNMT (hPNMT) in complex with 7 indicated that the sulfonamide oxygens, and not the sulfonamide -NH-, formed favorable interactions with the enzyme. Thus, we hypothesized that replacement of the sulfonamide -NH- with a methylene group could result in compounds that would retain potency at PNMT and that would have increased lipophilicity, thus increasing the likelihood they will cross the blood brain barrier. A series of 3-fluoromethyl-7-sulfonyl-1,2,3,4-tetrahydroisoquinolines (23-30) were synthesized and evaluated for their PNMT inhibitory potency and affinity for the alpha2-adrenoceptor. A comparison of these compounds with their isosteric sulfonamides (14, 16, and 18-22) showed that the sulfones were more lipophilic but less potent than their corresponding sulfonamides. Sulfone 24 (hPNMT Ki = 1.3 microM) is the most potent compound in this series and is quite selective for PNMT versus the alpha2-adrenoceptor, but 24 is less potent than the corresponding sulfonamide, 16 (hPNMT Ki = 0.13 microM). We also report the crystal structure of hPNMT in complex with sulfonamide 15, from which a potential hydrogen bond acceptor within the hPNMT active site has been identified, the main chain carbonyl oxygen of Asn39. The interaction of this residue with the sulfonamide -NH- is likely responsible for much of the enhanced inhibitory potency of the sulfonamides versus the sulfones.
The mode of binding of sulfonamides to erythrocyte proteins and possible drug-drug interaction between those compounds in erythrocytes resulting in changes in tissue levels were studied in rats using zonisamide (a novel antiepileptic agent possessing a sulfonamide group), several other sulfonamides and some antiepileptics without a sulfonamide group. In Michaelis-Menten plottings, the sulfonamide was found to be concentrated into erythrocytes in vitro and in vivo in a saturable high-affinity mode and in a linear low-affinity mode at ordinary therapeutic plasma levels through a simple diffusion process. Concentration in erythrocytes was affected by the presence of albumin in the extracellular medium. The cellular sulfonamide was readily replaced by extracellular sulfonamides in vitro. Even in vivo, erythrocyte levels of zonisamide were lowered by administration of other sulfonamides, although the plasma and tissue levels were not significantly changed since the plasma and tissue compartments of zonisamide were large relative to the erythrocyte compartment at ordinary therapeutic dose levels of zonisamide in animals and man. Therefore, disposition of zonisamide was not significantly influenced by other sulfonamides, but it is suggested that drug-drug interaction affecting the tissue levels may occur for a combination of sulfonamides with extremely different affinities for erythrocytes and low therapeutic plasma levels.
The combination of ampicillin together with trimethoprim-sulfonamide is sometimes used as a broad-spectrum antimicrobial regimen for treatment of dogs with bacterial infections of unknown etiopathogenesis. To determine whether this combination is indeed broad spectrum, we analyzed susceptibility data derived from commonly encountered bacterial agents in dogs. A total of 381 isolates from 344 cases was studied. Overall, 80 (20.9%) of the 381 isolates were resistant to ampicillin and to trimethoprim-sulfonamide; 159 (41.7%) were resistant to ampicillin, but susceptible to trimethoprim-sulfonamide; 131 (34.4%) were susceptible to both ampicillin and trimethoprim-sulfonamide; and 11 (2.9%) were susceptible to ampicillin, but resistant to trimethoprim-sulfonamide. Of isolates susceptible to ampicillin and/or trimethoprim-sulfonamide, 290 (96.3%) were susceptible to trimethoprim-sulfonamide (ampicillin increased the coverage by 3.7%). On the other hand, 142 (47.2%) were susceptible to ampicillin. In addition, with respect to agents most commonly encountered (members of the family Enterobacteriaceae and members of the genus Staphylococcus), combining ampicillin with trimethoprim-sulfonamide increased coverage by 2.2% over use of trimethoprim-sulfonamide alone. We contend, therefore, that use of ampicillin together with trimethoprim-sulfonamide does not result in an acceptable broad-spectrum antimicrobial regimen for treatment of bacterial disease in dogs.
Hypoglycaemic sulfonamides differ in their properties, which vary in clinical importance. The potency of sulfonamide has increased with the generations. However, this potency is compensated in practice by the dose prescribed, which is much smaller for recent generations. The half-life is a far more important property. The effective action period is correlated with half-life but is much longer. The action period for "short-term" sulfonamides is < or = 24 h (tolbutamide, glipizide) and can exceed 24 h for "long-term" sulfonamides (e.g. glibenclamide). Metabolism and elimination reduce the risk of accumulation. All sulfonamides are metabolised more than 95% by the liver. The metabolites are inactive except for one from glibenclamide. As a function of their action period and possibly of intrinsic properties, some sulfonamides more than others (e.g. glibenclamide) affect fasting hepatic glucose production, which is particularly increased early in the day in non-insulin-dependent diabetic patients because of a circadian drop in insulin sensitivity (dawn phenomenon). Finally, in chronic administration, all sulfonamides cause a progressive desensitisation of the beta cell, which responds by an insulin secretion peak only during food intake. This condition indicates the unuselessness of sulfonamide fractionation and, contrary to the classic notion, the low risk of hypoglycaemia after a meal is skipped. The ideal product would be a sulfonamide with high potency and an ultra-short half-life, but capable of maintaining plasma concentrations for 24 h (which might seem incompatible except in continuous administration). Moreover, it would exert its action at relatively low levels of insulinaemia and be completely metabolisable. Glipizide in its osmotic oral form (Ozidia) satisfies all these conditions since it is a very potent sulfonamide with a quite short half-life but with intestinal delivery up to 16 h after administration because of its osmotic principle. It controls fasting glycaema better than ordinary glipizide and at least as well as glibenclamide by acting on hepatic glucose production. Compared to glibenclamide, it has the advantage of generation this effect at lower levels of insulinaemia. In comparison with normal glipizide, it allows identical control for lower postprandial inslinaemias, which is proof of its powerful inductive effect on insulin sensitivity.