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Differences in Metabolism of Sulfonamides Predisposing to Idiosyncratic Toxicity
Abstract
Individual differences in metabolism of the sulfonamides may predispose patients to idiosyncratic reactions. Sulfonamides are metabolized by N-acetylation (mediated by a genetically polymorphic enzyme) and oxidation to potentially toxic metabolites. We examined 6 patients who had severe reactions to sulfonamides and compared them with 20 controls. Acetylator phenotype was determined with caffeine, a safe in-vivo probe of enzyme activity. All 6 patients were slow acetylators (expected, 55%; p less than 0.05). Detoxification of oxidative metabolites was studied in vitro with a lymphocyte assay evaluating cell death from metabolites generated by a murine hepatic microsomal system. Cells from each patient showed increased toxicity from sulfonamide metabolites but not from the drugs themselves. Cells from parents of 3 patients had intermediate toxicity from sulfonamide metabolites, whereas cells from a sibling of 1 patient had a normal response. Susceptibility to sulfonamide reactions may be due to interaction of metabolic pathways, possibly under genetic control, regulating N-acetylation and specific detoxification of toxic metabolites of the drugs.
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“This is critical as hypersensitivity reactions to SMX have been primarily linked to the slow acetylator phenotype.17,30”
From N-Acetyltransferase (NAT) 1 and NAT2 Enzyme Activities Drive Interindividual Variability in Sulfamethoxazole N-Acetylation (2025) · cites this paper as [17]
In the citing paper
“SMX-HA can then undergo further auto-oxidation to form the reactive metabolite, sulfamethoxazole-nitroso (SMX-NO), which has been linked to protein binding and hypersensitivity reactions.15–17”
From N-Acetyltransferase (NAT) 1 and NAT2 Enzyme Activities Drive Interindividual Variability in Sulfamethoxazole N-Acetylation (2025) · cites this paper as [17]
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Metadata
- Authors
- SHEAR, N. H., SPIELBERG, S. P., GRANT, D. M., TANG, B. K., & KALOW, W.
- Affiliations
- Toronto, Ontario Canada
- Corresponding author
- SHEAR, NEIL H.
- ORCID
- SHEAR, NEIL H.
- Venue
- Annals of Internal Medicine
- Publisher
- American College of Physicians
- Published
- 1986-08-01
- Volume
- 105
- Issue
- 2
- Pages
- 179-184
- ISSN
- 0003-4819 (ISSN-L)
- 1539-3704
- OpenAlex
- W2058391540
- Cited by
- 373
- References
- 16
- Citations by year
- 2026: 4 · 2025: 2 · 2024: 1 · 2023: 1 · 2022: 5 · 2021: 6 · 2020: 4 · 2019: 5 · 2018: 6 · 2017: 4 · 2016: 7 · 2015: 8 · 2014: 6 · 2013: 3 · 2012: 15
- FWCI
- 9.43
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Pharmacology › Pharmacogenetics and Drug Metabolism
- Health Sciences › Medicine › Pharmacology (medical) › Drug-Induced Adverse Reactions
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Pharmacology › Drug-Induced Hepatotoxicity and Protection
- Keywords
- sulfonamides, idiosyncratic drug toxicity, N-acetylation, acetylator phenotype, slow acetylators, detoxification, genetic polymorphism, hepatic microsomal enzymes, lymphocyte cytotoxicity, familial predisposition
- MeSH terms
- Acetylation, Adult, Animals, Cell Survival, Child, Child, Preschool, Female, Humans, Infant, Lymphocytes, Male, Microsomes, Liver, Phenotype, Sulfonamides, Mice, In Vitro Techniques
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