Pyrimethamine

Pyrimethamine
Names
Pronunciation/ˌpɪrɪˈmɛθəmɪn/
Trade namesDaraprim, others
IUPAC name
  • 5-(4-chlorophenyl)-6-ethyl- 2,4-pyrimidinediamine
Clinical data
Drug classAntiprotozoal
Main usesToxoplasmosis, cystoisosporiasis[1][2]
Side effectsGastrointestinal upset, severe allergic reactions, bone marrow suppression[1]
Pregnancy
category
  • AU: B3[3]
  • US: C (Risk not ruled out)[3]
    Routes of
    use    		By mouth
    Defined daily dose75 mg[4]
    External links
    AHFS/Drugs.comMonograph
    US NLMPyrimethamine
    MedlinePlusa601050
    Legal
    License data
    Legal status
    Pharmacokinetics
    Bioavailabilitywell-absorbed
    Protein binding87%
    MetabolismLiver
    Elimination half-life96 hours
    ExcretionKidney
    Chemical and physical data
    FormulaC12H13ClN4
    Molar mass248.71 g·mol−1
    3D model (JSmol)
    Melting point233 to 234 °C (451 to 453 °F)
    SMILES
    • Clc2ccc(c1c(nc(nc1CC)N)N)cc2
    InChI
    • InChI=1S/C12H13ClN4/c1-2-9-10(11(14)17-12(15)16-9)7-3-5-8(13)6-4-7/h3-6H,2H2,1H3,(H4,14,15,16,17) checkY
    • Key:WKSAUQYGYAYLPV-UHFFFAOYSA-N checkY

    Pyrimethamine, sold under the brand name Daraprim among others, is a medication used with leucovorin to treat the parasite diseases toxoplasmosis and cystoisosporiasis.[1][2] It is also used with dapsone as a second-line option to prevent Pneumocystis jiroveci pneumonia in people with HIV/AIDS.[1] It was previously used for malaria but is no longer recommended due to resistance.[1] Pyrimethamine is taken by mouth.[1]

    Common side effects include gastrointestinal upset, severe allergic reactions, and bone marrow suppression.[1] It should not be used by people with folate deficiency that has resulted in anemia.[1] There is concern that it may increase the risk of cancer.[1] While occasionally used in pregnancy it is unclear if pyrimethamine is safe for the baby.[3] Pyrimethamine is classified as a folic acid antagonist.[1] It works by inhibiting folic acid metabolism and therefore the making of DNA.[1]

    Pyrimethamine was discovered in 1952 and came into medical use in 1953.[1][6] It is on the World Health Organization's List of Essential Medicines.[7] In the United States in 2015, Turing Pharmaceuticals was criticized for increasing the price 50-fold, from US$13.50 to $750 a tablet[8]—a $75,000 cost for a course of treatment reported at one hospital.[9] It was approved as a generic in the United States in February 2020.[10]

    Medical uses

    Pyrimethamine is typically given with a sulfonamide and folinic acid.[11]

    It is used for the treatment of toxoplasmosis, actinomycosis, and isosporiasis, and for the treatment and prevention of Pneumocystis jirovecii pneumonia.[1]

    Toxoplasmosis

    Pyrimethamine is also used in combination with sulfadiazine to treat active toxoplasmosis. The two drugs bind the same enzymatic targets as the drugs trimethoprim and sulfamethoxazole - dihydrofolate reductase and dihydropteroate synthase, respectively.

    Pyrimethamine has also been used in several trials to treat retinochoroiditis.[12]

    Malaria

    It is primarily active against Plasmodium falciparum, but also against Plasmodium vivax.[13] Due to the emergence of pyrimethamine-resistant strains of P. falciparum, pyrimethamine alone is seldom used now. In combination with a long-acting sulfonamide such as sulfadiazine, it was widely used, such as in Fansidar, though resistance to this combination is increasing.[13]

    Dosage

    The defined daily dose is 75 mg (by mouth).[4] For the treatment of toxoplasmosis 100 mg is given twice on the first day and than 75 to 100 mg is given once per day for at least six weeks.[14] For prevention of toxoplasmosis 25 to 75 mg is used once per day.[14] For isosporiasis 50 to 75 mg per day is used for 10 days.[14]

    Side effects

    When higher doses are used, as in the treatment of toxoplasmosis, pyrimethamine can cause gastrointestinal symptoms such as nausea, vomiting, glossitis, anorexia, and diarrhea.[15][16] A rash, which can be indicative of a hypersensitivity reaction, is also seen, particularly in combination with sulfonamides.[15] Central nervous system effects include ataxia, tremors, and seizures.[16] Blood related side effects may include thrombocytopenia, leukopenia, and anemia can also occur.[16]

    Pyrimethamine is contraindicated in people with folate-deficiency anaemia.[11] It should not be used in people with people with significant kidney or liver problems.[14]

    Pregnancy and breastfeeding

    Pyrimethamine should not be used during the first trimester of pregnancy.[14] It is labeled as pregnancy category C in the United States.[3][17] To date, not enough evidence on its risks in pregnancy or its effects on the baby is available.[17][15]

    Use is okay during breastfeeding.[14]

    Interactions

    Other antifolate agents such as methotrexate and trimethoprim may potentiate the antifolate actions of pyrimethamine, leading to potential folate deficiency, anaemia, and other blood dyscrasias.[11]

    Mechanism of action

    Pyrimethamine interferes with the regeneration of tetrahydrofolic acid from dihydrofolate by competitively inhibiting the enzyme dihydrofolate reductase.[18] Tetrahydrofolic acid is essential for DNA and RNA synthesis in many species, including protozoa.[18] It has also been found to reduce the expression of SOD1, a key protein involved in amyotrophic lateral sclerosis.[19][20]

    Other medications

    Pyrimethamine is typically given with folinic acid and sulfadiazine.[17]

    • Sulfonamides (e.g. sulfadiazine) inhibit dihydropteroate synthetase, an enzyme that participates in folic acid synthesis from para-aminobenzoic acid. Hence, sulfonamides work synergistically with pyrimethamine by blocking a different enzyme needed for folic acid synthesis.
    • Folinic acid (leucovorin) is a folic acid derivative converted to tetrahydrofolate, the primary active form of folic acid, in vivo, without relying on dihydrofolate reductase. Folinic acid reduces side effects related to folate deficiency in the patient.

    Mechanism of resistance

    Resistance to pyrimethamine is widespread. Mutations in the malarial gene for dihydrofolate reductase may reduce its effectiveness.[21] These mutations decrease the binding affinity between pyrimethamine and dihydrofolate reductase via loss of hydrogen bonds and steric interactions.[22]

    History

    Synthesis of pyrimethamine typically begins with p-chlorophenylacetonitrile, which undergoes a condensation reaction with ethyl propionate ester; the product of this then reacts with diazomethane to form an enol ether, which reacts with free guanidine in a second condensation reaction.

    Nobel Prize-winning American scientist Gertrude Elion developed the drug at Burroughs-Wellcome (now part of GlaxoSmithKline) to combat malaria.[23] Pyrimethamine has been available since 1953.[24] In 2010, GlaxoSmithKline sold the marketing rights for Daraprim to CorePharma. Impax Laboratories sought to buy CorePharma in 2014, and completed the acquisition, including Daraprim, in March 2015.[25] In August 2015, the rights were bought by Turing Pharmaceuticals.[26] Turing subsequently became infamous for a price hike controversy when it raised the price of a dose of the drug in the U.S. market from US$13.50 to US$750, a 5,500% increase.[27]

    Availability and price

    United States

    In the United States, in 2015, with Turing Pharmaceuticals' acquisition of the US marketing rights for Daraprim tablets,[28] Daraprim became a single-source and specialty pharmacy item, and the price was increased.[29] The cost of a monthly course for a person on 75 mg dose rose to about $75,000/month at one hospital, or $750 per tablet.[30][31]

    Outpatients could no longer obtain the medication from a community pharmacy, but only through a single dispensing pharmacy, Walgreens Specialty Pharmacy, and institutions could no longer order from their general wholesaler, but had to set up an account with the Daraprim Direct program.[29][32] Presentations from Retrophin, a company formerly headed by Martin Shkreli, CEO of Turing, from which Turing acquired the rights to Daraprim, suggested that a closed distribution system could prevent generic competitors from legally obtaining the drugs for the bioequivalence studies required for FDA approval of a generic drug.[32]

    Martin Shkreli, CEO of Turing, defended the price hike by saying, "If there was a company that was selling an Aston Martin at the price of a bicycle, and we buy that company and we ask to charge Toyota prices, I don't think that that should be a crime."[33][34] As a result of the backlash, Shkreli hired a crisis public relations firm to help explain his fund's move.[35] Turing Pharmaceuticals announced on November 24, 2015, "that it would not reduce the list price of that drug after all", but they would offer patient assistance programs.[36] New York Times journalist Andrew Pollack noted that these programs "are standard for companies selling extremely high-priced drugs. They enable the patients to get the drug while pushing most of the costs onto insurance companies and taxpayers."[36]

    The price increase was criticized by physician groups such as HIV Medicine Associates and Infectious Diseases Society of America.[37]

    In 2016, a group of high school students from Sydney Grammar supported by Matthew H. Todd from the University of Sydney prepared pyrimethamine as an illustration that the synthesis is comparatively easy and the price-hike unjustifiable. His team produced 3.7 g for US$20, which would have been worth between US$35,000 and US$110,000 in the United States at the time.[38] Shkreli said the schoolboys were not competition, likely because the necessary bioequivalence studies require a sample of the existing medication provided directly by the company, and not simply purchased from a pharmacy, which Turing could decline to provide.[39][40] Nonetheless, the students' work was featured in The Guardian[39] and Time magazine,[41] and on ABC Australia,[38] the BBC,[40] and CNN.[42]

    On October 22, 2015, Imprimis Pharmaceuticals announced it had made available compounded and customizable formulations of pyrimethamine and leucovorin in capsules to be taken by mouth starting as low as $99.00 for a 100-count bottle in the United States.[43] Pyrimethamine was approved as a generic in the United States in February 2020.[10]

    Other countries

    In India, over a dozen manufactures sell pyrimethamine tablets, and multiple combinations of generic pyrimethamine are available for a price ranging from US$0.04 to US$0.10 each (3–7 rupees).[44][45][46][47]

    In the UK, the same drug is available from GSK at a cost of US$20 (£13) for 30 tablets (about $0.66 each).[48]

    In Australia, the drug is available in most pharmacies at a cost of US$9.35 (A$12.99) for 50 tablets (around US$0.18 each).[49]

    In Brazil, the drug is available for R$0.07 a pill, or about US$0.02.[50]

    In Canada, the drug was reportedly discontinued in 2013, but hospitals may make the drug in-house when it is needed.[51] As of December 2015, Daraprim imported into Canada directly from GSK UK is available from an online pharmacy for US$2.20 per tablet.[52]

    In Switzerland, the drug is available for US$9.45 (CHF9.05) for 30 tablets (around US$0.32 a piece).[53]

    Research

    In 2011, researchers discovered that pyrimethamine can increase β-hexosaminidase activity, thus potentially slowing down the progression of late-onset Tay–Sachs disease.[54] It is being evaluated in clinical trials as a treatment for amyotrophic lateral sclerosis.[55]

    See also

    References

    1. 1 2 3 4 5 6 7 8 9 10 11 12 13 "Pyrimethamine". The American Society of Health-System Pharmacists. Archived from the original on 2 December 2016. Retrieved 2 December 2016.
    2. 1 2 Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. p. 54. ISBN 9781284057560.
    3. 1 2 3 4 "Pyrimethamine (Daraprim) Use During Pregnancy". Drugs.com. 31 July 2019. Archived from the original on 3 December 2016. Retrieved 28 February 2020.
    4. 1 2 "WHOCC - ATC/DDD Index". www.whocc.no. Archived from the original on 20 September 2020. Retrieved 21 September 2020.
    5. ↑ "Daraprim Tablets - Summary of Product Characteristics (SmPC)". (emc). 19 February 2020. Archived from the original on 29 February 2020. Retrieved 28 February 2020.
    6. ↑ Sylvie, Manguin; Pierre, Carnevale; Jean, Mouchet (2008). Biodiversity of Malaria in the world. John Libbey Eurotext. p. 6. ISBN 9782742009633. Archived from the original on 19 August 2020. Retrieved 10 September 2017.
    7. ↑ World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
    8. ↑ Pollack, Andrew (20 September 2015). "Drug Goes From $13.50 a Tablet to $750, Overnight". The New York Times. Archived from the original on 16 December 2015. Retrieved 31 March 2020. Turing immediately raised the price to $750 a tablet from $13.50, bringing the annual cost of treatment for some patients to hundreds of thousands of dollars.
    9. ↑ Alpern, JD; Song, J; Stauffer, WM (19 May 2016). "Essential Medicines in the United States--Why Access Is Diminishing". The New England Journal of Medicine. 374 (20): 1904–7. doi:10.1056/nejmp1601559. PMID 27192669. Heavy scrutiny followed, and although Turing agreed to reduce the price, the drug remains prohibitively expensive for many patients. Recently, at our hospital, an immigrant patient with a new diagnosis of HIV– AIDS and toxoplasmosis couldn’t receive first-line therapy because of cost: the price for 100 pills was $75,000.
    10. 1 2 "FDA Approves First Generic of Daraprim". U.S. Food and Drug Administration (FDA) (Press release). 28 February 2020. Archived from the original on 29 February 2020. Retrieved 28 February 2020.
    11. 1 2 3 Rossi, S, ed. (2013). Australian Medicines Handbook (2013 ed.). Adelaide: The Australian Medicines Handbook Unit Trust. ISBN 978-0-9805790-9-3.
    12. ↑ Pradhan E, Bhandari S, Gilbert RE, Stanford M (2016). "Antibiotics versus no treatment for toxoplasma retinochoroiditis" (PDF). Cochrane Database Syst Rev. 5 (5): CD002218. doi:10.1002/14651858.CD002218.pub2. PMID 27198629. Archived (PDF) from the original on 22 July 2018. Retrieved 24 August 2019.
    13. 1 2 Brayfield, A, ed. (13 December 2013). "Pyrimethamine". Martindale: The Complete Drug Reference. Pharmaceutical Press. Archived from the original on 29 August 2021. Retrieved 12 April 2014.
    14. 1 2 3 4 5 6 "PYRIMETHAMINE oral - Essential drugs". medicalguidelines.msf.org. Archived from the original on 2 March 2021. Retrieved 24 August 2020.
    15. 1 2 3 "Pyrimethamine | FDA Label - Tablet | AIDSinfo". AIDSinfo. Archived from the original on 18 January 2017. Retrieved 7 November 2016.
    16. 1 2 3 "Daraprim Side Effects in Detail - Drugs.com". www.drugs.com. Archived from the original on 8 November 2016. Retrieved 7 November 2016.
    17. 1 2 3 "Daraprim- pyrimethamine tablet". DailyMed. 31 August 2017. Archived from the original on 3 August 2020. Retrieved 28 February 2020.
    18. 1 2 "PRODUCT INFORMATION DARAPRIM TABLETS". TGA eBusiness Services. Aspen Pharmacare Australia Pty Ltd. 5 December 2011. p. 1. Archived from the original on 5 October 2016. Retrieved 12 April 2014.
    19. ↑ Limpert, AS; Mattmann, ME; Cosford, ND (2013). "Recent progress in the discovery of small molecules for the treatment of amyotrophic lateral sclerosis (ALS)" (PDF). Beilstein Journal of Organic Chemistry. 9: 717–32. doi:10.3762/bjoc.9.82. PMC 3678841. PMID 23766784. Archived (PDF) from the original on 13 April 2014.
    20. ↑ Lange, DJ; Andersen, PM; Remanan, R; Marklund, S; Benjamin, D (April 2013). "Pyrimethamine decreases levels of SOD1 in leukocytes and cerebrospinal fluid of ALS patients: a phase I pilot study". Amyotrophic Lateral Sclerosis & Frontotemporal Degeneration. 14 (3): 199–204. doi:10.3109/17482968.2012.724074. PMID 22985433.
    21. ↑ Gatton M.L.; et al. (2004). "Evolution of resistance to sulfadoxine-pyrimethamine in Plasmodium falciparum". Antimicrob Agents Chemother. 48 (6): 2116–23. doi:10.1128/AAC.48.6.2116-2123.2004. PMC 415611. PMID 15155209.
    22. ↑ Sirichaiwat C, et al. (2004). "Target guided synthesis of 5-benzyl-2,4-diamonopyrimidines: their antimalarial activities and binding affinities to wild type and mutant dihydrofolate reductases from Plasmodium falciparum". J Med Chem. 47 (2): 345–54. doi:10.1021/jm0303352. PMID 14711307.
    23. ↑ Vasudevan, D.M.; Sreekumari, S.; Vaidyanathan, Kannan (2013). Textbook of Biochemistry for Medical Students. JP Medical Ltd. p. 491. ISBN 9789350905302. OCLC 843532694. Archived from the original on 8 September 2017. Retrieved 15 January 2016.
    24. ↑ Cha, Ariana Eunjung (22 September 2015). "CEO who raised price of old pill more than $700 calls journalist a 'moron' for asking why". The Washington Post. Archived from the original on 23 September 2015.
    25. ↑ Pollack, Andrew (20 September 2015). "Drug Goes From $13.50 a Tablet to $750, Overnight". The New York Times. Archived from the original on 16 December 2015. Retrieved 17 December 2015.
    26. ↑ John LaMattina (21 September 2015). "Here's A Way For Pharma To Prevent Outrageous Generic Price Increases -- And Help Its Reputation". Forbes. Archived from the original on 23 September 2015.
    27. ↑ Kliff, Sarah (22 September 2015). "Vox Explainers: A Drug Company Raised a Pill's Price 5,500 Percent Because, in America, It Can". Vox (online). Archived from the original on 10 December 2015. Retrieved 9 December 2015.
    28. ↑ Turing Pharmaceuticals AG Turing Pharmaceuticals AG Acquires U.S. Marketing Rights to Daraprim (pyrimethamine) Archived 2015-09-22 at the Wayback Machine 10 August 2015, PR Newswire Association LLC
    29. 1 2 Monica V. Mahoney New Pyrimethamine Dispensing Program: What Pharmacists Should Know Archived 2015-09-06 at the Wayback Machine PharmacyTimes, July 17, 2015
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    31. ↑ "WATCH: Ex-hedge funder who hiked AIDS pill cost by 5,500 percent says drug 'still underpriced'". RawStory.com. Archived from the original on 23 September 2015. Retrieved 22 September 2015.
    32. 1 2 "The Most Unconscionable Drug Price Hike I Have Yet Seen" Archived 2016-06-07 at the Wayback Machine, by Derek Lowe, September 11, 2014, In the Pipeline.
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    34. ↑ Reuters (22 September 2015). "Company hikes price of popular drug". Reuters. Archived from the original on 2 October 2015.
    35. ↑ Tannahill, Jason (9 October 2015). "PR Man Allan Ripp Representing The "Most Hated Man in America"". EverythingPR. Archived from the original on 14 October 2015.
    36. 1 2 Pollack, Andrew (24 November 2015). "Turing Refuses to Lower List Price of Toxoplasmosis Drug". New York Times. Archived from the original on 8 September 2017. Retrieved 25 November 2015.
    37. ↑ "Archived copy" (PDF). Archived (PDF) from the original on 23 September 2015. Retrieved 23 September 2015.{{cite web}}: CS1 maint: archived copy as title (link)
    38. 1 2 Hunjan, Raveen (30 November 2016). "Daraprim drug's key ingredient recreated by high school students in Sydney for just $20". ABC News. Archived from the original on 4 April 2019. Retrieved 23 April 2019.
    39. 1 2 Davey, Melissa (1 December 2016). "Australian students recreate Martin Shkreli price-hike drug in school lab". The Guardian. Archived from the original on 1 December 2016. Retrieved 1 December 2016.
    40. 1 2 Dunlop, Greg (1 December 2016). "Australian boys recreate life-saving drug". BBC News. Archived from the original on 1 December 2016. Retrieved 1 December 2016.
    41. ↑ Lui, Kevin (2 December 2016). "Watch Martin Shkreli Respond to the School Kids Who Recreated His Drug for $2 a Dose". Time. Archived from the original on 3 November 2020. Retrieved 23 April 2019.
    42. ↑ Roberts, Elizabeth (1 December 2016). "'Pharma Bro' Martin Shkreli meets his match in a group of Australian schoolboys". CNN. Archived from the original on 23 April 2019. Retrieved 23 April 2019.
    43. ↑ "Archive copy". Archived from the original on 7 August 2020. Retrieved 1 April 2020.{{cite web}}: CS1 maint: archived copy as title (link)
    44. ↑ "High Drug Prices: Should We Blame Pharma Or The FDA?". 29 September 2015. Archived from the original on 30 September 2015.
    45. ↑ "MEDLINE INDIA - SULFADOXINE WITH PYRIMETHAMINE". www.medlineindia.com. Archived from the original on 24 September 2015. Retrieved 22 September 2015.
    46. ↑ "It is Cheaper for an American patient to fly out to India and buy a year's supply of the medication than buy a single Daraprim tablet in the US". Archived from the original on 28 September 2015.
    47. ↑ "There is no reason why the United States cannot have as vigorous a market in generic pharmaceuticals as does India". Archived from the original on 6 October 2015.
    48. ↑ "What's a fair price for a drug?". BBC News Online. Archived from the original on 24 September 2015. Retrieved 23 September 2015.
    49. ↑ "Chemist Warehouse". www.chemistwarehouse.com.au. Archived from the original on 22 December 2015. Retrieved 12 December 2015.
    50. ↑ "Remédio que teve aumento de 5.000% nos EUA custa R$ 0,07 no Brasil (e não vai aumentar)". brasilpost.com.br. Archived from the original on 25 September 2015. Retrieved 23 September 2015.
    51. ↑ "Turing CEO to roll back 5,000% price hike for Daraprim pills". Archived from the original on 25 September 2015.
    52. ↑ "Daraprim 25mg and/or Equivalents". Archived from the original on 4 March 2016. Retrieved 18 December 2015.
    53. ↑ "Swiss Compendium information about Daraprim". compendium.ch. Archived from the original on 29 August 2021. Retrieved 1 September 2017.
    54. ↑ Osher, E; Fattal-Valevski, A; Sagie, L; Urshanski, N; Amir-Levi, Y; Katzburg, S; Peleg, L; Lerman-Sagie, T; Zimran, A; Elstein, D; Navon, R; Stern, N; Valevski, A (March 2011). "Pyrimethamine increases β-hexosaminidase A activity in patients with Late Onset Tay Sachs". Molecular Genetics and Metabolism. 102 (3): 356–63. doi:10.1016/j.ymgme.2010.11.163. PMID 21185210.
    55. ↑ "Pyrimethamine ALS trial". Archived from the original on 19 October 2012.
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