Metamizole

Metamizole, or dipyrone, is a painkiller, spasm reliever, and fever reliever that also has anti-inflammatory effects. It is most commonly given by mouth or by intravenous infusion.[4][5]

Not to be confused with methimazole or methazolamide.
Metamizole
Clinical data
Trade namesNovalgin, Algocalmin, [1] others[2]
Other namesDipyrone (BAN UK, USAN US)
AHFS/Drugs.comInternational Drug Names
Pregnancy
category
  • None assigned; no evidence of teratogenicity in animal studies, but use in the third trimester may cause adverse effects in the newborn or ductus arteriosus (a heart defect) due to its weak NSAID activity.[3][4]
Routes of
administration		Oral, IM, IV, rectal
ATC code
Legal status
Legal status
  • Over-the-counter (some countries, see text); prescription-only (others); withdrawn (others)
Pharmacokinetic data
Bioavailability100% (active metabolites)[5]
Protein binding48–58% (active metabolites)[5]
MetabolismLiver[5]
Elimination half-life14 minutes (parent compound; parenteral);[4] metabolites: 2–4 hours[5]
ExcretionUrine (96%, IV; 85%, oral), faeces (4%, IV).[4]
Identifiers
IUPAC name
  • [(2,3-Dihydro-1,5-dimethyl-3-oxo-2-phenyl-1H-pyrazol-4-yl)methylamino] methanesulfonic acid
CAS Number
PubChem CID
DrugBank
ChemSpider
UNII
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.000.631
Chemical and physical data
FormulaC13H17N3O4S
Molar mass311.36 g·mol−1
3D model (JSmol)
SMILES
  • c1ccccc1N2N(C)C(C)=C(C2=O)N(C)CS(=O)(=O)O
InChI
  • InChI=1S/C13H17N3O4S/c1-10-12(14(2)9-21(18,19)20)13(17)16(15(10)3)11-7-5-4-6-8-11/h4-8H,9H2,1-3H3,(H,18,19,20) N
  • Key:LVWZTYCIRDMTEY-UHFFFAOYSA-N N
 NY (what is this?)  (verify)

Although it is available over-the-counter in some countries, it is banned in others, due to its potential for adverse events, including agranulocytosis.[6][7] A study by one of the manufacturers of the drug found the risk of agranulocytosis within the first week of treatment to be a mere 1.1 in a million, versus 5.92 in a million for diclofenac.[8] It is in the ampyrone sulfonate family of medicines.

It was patented in 1922[9] and was first used medically in Germany under the brandname "Novalgin". For many years, it was available over-the-counter in most countries, before its withdrawal due to severe adverse effects.[10] Metamizole is marketed under various trade names.[2][3]

Medical uses

It is primarily used for perioperative pain, acute injury, colic, cancer pain, other acute/chronic forms of pain and high fever unresponsive to other agents.[4]

Special populations

Its use in pregnancy is advised against, although animal studies are reassuring in that they show minimal risk of birth defects. Its use in the elderly and those with liver or kidney impairment is advised against, but if these groups of people must be treated, a lower dose and caution is usually advised. Its use during lactation is advised against, as it is excreted in breast milk.[4]

Adverse effects

Metamizole has a potential of blood-related toxicity (blood dyscrasias), but causes less kidney, cardiovascular, and gastrointestinal toxicity than non-steroidal anti-inflammatory drugs (NSAIDs).[5] Like NSAIDs, it can trigger bronchospasm or anaphylaxis, especially in those with asthma.[7]

Serious side effects include agranulocytosis, aplastic anaemia, hypersensitivity reactions (like anaphylaxis and bronchospasm), toxic epidermal necrolysis and it may provoke acute attacks of porphyria, as it is chemically related to the sulfonamides.[3][5][7] The relative risk for agranulocytosis appears to greatly vary according to the country of estimates on said rate and opinion on the risk is strongly divided.[3][11] Genetics may play a significant role in metamizole sensitivity.[12] It is suggested that some populations are more prone to suffer from metamizole induced agranulocytosis than others. As an example, metamizole-related agranulocytosis seems to be an adverse effect more frequent in British population as opposed to Spaniards.[13]

According to a systematic review from 2016 Metamizole significantly increased the risk of upper gastrointestinal bleeding by a factor ranging from 1.4 to 2.7 (relative risk).[14]

Contraindications

Previous hypersensitivity (such as agranulocytosis or anaphylaxis) to metamizole or any of the excipients (e.g. lactose) in the preparation used, acute porphyria, impaired haematopoiesis (such as due to treatment with chemotherapy agents), third trimester of pregnancy (potential for adverse effects in the newborn), lactation, children with a body weight below 16 kg, history of aspirin-induced asthma and other hypersensitivity reactions to analgesics.[4]

Known interactions[4]
Drug(s)Interaction/reason for theoretical potential for interaction
CiclosporinDecreased serum levels of ciclosporin.
ChlorpromazineAdditive hypothermia (low body temperature) may result.
MethotrexateAdditive risk for haematologic (blood) toxicity.

Oral anticoagulants (blood thinners), lithium, captopril, triamterene and antihypertensives may also interact with metamizole, as other pyrazolones are known to interact adversely with these substances.

Overdose

It is considered fairly safe on overdose, but in these cases supportive measures are usually advised as well as measures to limit absorption (such as activated charcoal) and accelerate excretion (such as haemodialysis).[4]

Physicochemistry

It is a sulfonic acid and comes in calcium, sodium and magnesium salt forms.[3] Its sodium salt monohydrate form is a white/almost crystalline powder that is unstable in the presence of light, highly soluble in water and ethanol but practically insoluble in dichloromethane.[15]

Pharmacology

Its precise mechanism of action is unknown, although it is believed that inhibiting brain and spinal cord prostaglandin (fat-like molecules that are involved in inflammation, pain and fever) synthesis might be involved.[7] Recently, researchers uncovered another mechanism involving metamizole being a prodrug. In this proposal, not yet verified by other researchers, the metamizole itself breaks down into other chemicals that are the actual active agents. The result is a pair of cannabinoid and NSAID arachidonic acid conjugates (although not in the strict chemical meaning of the word) of metamizole's breakdown products.[16] Despite this, studies in animals have found that the CB1 cannabinoid receptor is not involved in the analgesia induced by metamizole.[17] Although it seems to inhibit fevers caused by prostaglandins, especially prostaglandin E2,[18] metamizole appears to produce its therapeutic effects by means of its metabolites, especially N-methyl-4-aminoantipyrine (MAA) and 4-Aminoantipyrine (AA).[4]

Pharmacokinetics of metamizole's major metabolites[4]
MetaboliteAcronymBiologically active?Pharmacokinetic properties

N-methyl-4-aminoantipyrine
MAAYesBioavailability≈90%. Plasma protein binding: 58%. Excreted in the urine as 3±1% of the initial (oral) dose

4-aminoantipyrine
AAYesBioavailability≈22.5%. Plasma protein binding: 48%. Excreted in the urine as 6±3% of the initial (oral) dose

N-formyl-4-aminoantipyrine
FAANoPlasma protein binding: 18%. Excretion in the urine as 23±4% of the initial oral dose

N-acetyl-4-aminoantipyrine
AAANoPlasma protein binding: 14%. Excretion in the urine as 26±8% of the initial oral dose

History

Ludwig Knorr was a student of Emil Fischer who won the Nobel Prize for his work on purines and sugars, which included the discovery of phenylhydrazine.[1][19] In the 1880s, Knorr was trying to make quinine derivatives from phenylhydrazine, and instead made a pyrazole derivative, which after a methylation, he made into phenazone, also called antipyrine, which has been called "the 'mother' of all modern antipyretic analgesics."[1][20]: 26–27  Sales of that drug exploded, and in the 1890s chemists at Teerfarbenfabrik Meister, Lucius & Co. (a precursor of Hoechst AG which is now Sanofi), made another derivative called pyramidon which was three times more active than antipyrine.[1]

In 1893, a derivative of antipyrine, aminopyrine, was made by Friedrich Stolz at Hoechst.[20]: 26–27  Yet later, chemists at Hoechst made a derivative, melubrine (sodium antipyrine aminomethanesulfonate), which was introduced in 1913;[21] finally in 1920, metamizole was synthesized.[8] Metamizole is a methyl derivative of melubrine and is also a more soluble prodrug of pyramidon.[1][20]: 26–27  Metamizole was first marketed in Germany as "Novalgin" in 1922.[1][8]

Society and culture
World map of availability of Metamizole (Dipyrone)
   Over-the-counter with limited restrictions.
   Available, but no data on the requirement of prescriptions.
   Prescription-only, with fairly limited restrictions on its use.
   Prescription-only, with extensive restrictions on its use.
   Banned for human use. It may still be used by veterinary cases.
   No data.

Metamizole is banned in several countries, available by prescription in others (sometimes with strong warnings, sometimes without), and available over the counter in yet others.[10][22][23] For example, approval was withdrawn in Sweden (1974), the USA (1977), and India (2013, ban lifted in 2014).[24][25]

Although it's banned in USA, it was reported by small surveys that 28% of Hispanics in Miami have possession of it,[26] and 38% of Hispanics in San Diego, CA reported some usage.[27]

Amid the opioid crisis, a study pointed the legal status of metamizole have a relation to the consumption of oxycodone, showing the use of those drugs were inversely correlated. Its use could be beneficial when adjusted for the addictive-risk of opioids, specially on limited and controlled use of metamizole.[28] A 2019 Israeli conference also justified the approved status as a preventive to opioid dependence, and metamizole being safer than most analgesics for renal impaired patients.[29]

It's the most sold medication in São Paulo, Brazil, accounting for 488 tons in 2016.[30]

In 2012, headache accounts for 70% of its use in Indonesia.[31]

In 2018, investigators in Spain looked into Nolotil (as metamizole is known in Spain) after the death of several British people in Spain. A possible factor in these deaths might have been a side effect of metamizole that can cause agranulocytosis (a lowering of white blood cell count).[32]

Brand names

Metamizole is generic, and in countries where it is marketed, it is available under many brand names.[2] In Russia, it is commonly sold under the "Analgin" (Russian: Анальгин) trade name.[33][34]

In Romania it's available as the original marketed pharmaceutical product by Zentiva as Algocalmin, as 500 mg immediate release tablets. It's also available as an injection with 1 g of metamizole sodium dissolved in 2 ml of solvent.

In Israel it's sold under the brand name "Optalgin" (hebrew: אופטלגין), manufactured by Teva.


References
  1. Brune K (December 1997). "The early history of non-opioid analgesics". Acute Pain. 1: 33–40. doi:10.1016/S1366-0071(97)80033-2.
  2. Drugs.com Drugs.com international listings for Metamizole Page accessed June 21, 2015
  3. Brayfield A, ed. (13 December 2013). "Dipyrone". Martindale: The Complete Drug Reference. Pharmaceutical Press. Retrieved 19 April 2014.
  4. "Fachinformation (Zusammenfassung der Merkmale des Arzneimittels) Novaminsulfon injekt 1000 mg Lichtenstein Novaminsulfon injekt 2500 mg Lichtenstein" (PDF). Winthrop Arzneimittel GmbH (in German). Zinteva Pharm GmbH. February 2013. Retrieved 19 April 2014.
  5. Jage J, Laufenberg-Feldmann R, Heid F (April 2008). "[Drugs for postoperative analgesia: routine and new aspects. Part 1: non-opioids]" [Drugs for postoperative analgesia: routine and new aspects. Part 1: non-opioids]. Der Anaesthesist (in German). 57 (4): 382–390. doi:10.1007/s00101-008-1326-x. PMID 18351305. S2CID 32814418.
  6. Lutz M (November 2019). "Metamizole (Dipyrone) and the Liver: A Review of the Literature". Journal of Clinical Pharmacology. 59 (11): 1433–1442. doi:10.1002/jcph.1512. PMID 31433499.
  7. Brack A, Rittner HL, Schäfer M (March 2004). "Nichtopioidanalgetika zur perioperativen Schmerztherapie" [Non-opioid analgesics for perioperative pain therapy. Risks and rational basis for use]. Der Anaesthesist (in German). 53 (3): 263–280. doi:10.1007/s00101-003-0641-5. PMID 15021958. S2CID 8829564.
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  19. "Emil Fischer – Biographical". Nobel Committee.
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  24. Bhaumik S (July 2013). "India's health ministry bans pioglitazone, metamizole, and flupentixol-melitracen". BMJ. 347: f4366. doi:10.1136/bmj.f4366. PMID 23833116. S2CID 45107003.
  25. "Govt lifts ban on painkiller Analgin". Business Standard India. 19 March 2014.
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  29. Dinavitser N (January 2020). "Dipyrone – a Good Medication with a Bad Reputation" (PDF). Journal of Medical Toxicology. Rambam Health Care Campus, Haifa, Israel: American College of Medical Toxicology. 16 (1): 75–86. doi:10.1007/s13181-019-00743-w. PMC 6942089. PMID 31721040. ACMT/IST 2019 American-Israeli Medical Toxicology Conference
  30. Aragão RB, Semensatto D, Calixto LA, Labuto G (2020). "Pharmaceutical market, environmental public policies and water quality: the case of the São Paulo Metropolitan Region, Brazil". Cadernos de Saúde Pública. 36 (11): e00192319. doi:10.1590/0102-311x00192319. ISSN 1678-4464. PMID 33237204. S2CID 227168554.
  31. Kurniawati M, Ikawati Z, Raharjo B (2012). "The evaluation of metamizole use in some places of pharmacy service in Cilacap county". Jurnal Manajemen Dan Pelayanan Farmasi (Journal of Management and Pharmacy Practice) (in Indonesian). 2 (1): 50–55. doi:10.22146/jmpf.60 (inactive 31 July 2022).{{cite journal}}: CS1 maint: DOI inactive as of July 2022 (link)
  32. "Exclusive: southern spain hospitals in british expat hotspot issue warning for 'lethal' painkiller nolotil". 23 April 2018. Retrieved 27 April 2018.
  33. "Анальгин Авексима - официальная инструкция по применению, аналоги". medi.ru (in Russian). Retrieved 2019-01-08.
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