Factors hindering the degradation of pharmaceuticals from human urine in an iron-activated persulfate system

This study investigated the degradation of clofibric acid (CFA), bezafibrate (BZF), and sulfamethoxazole (SMX) in synthetic human urine using a novel mesoporous iron powder-activated persulfate system (mFe-PS system), and identified the factors limiting their degradation in synthetic human urine. A kinetic model was established to expose the radical production in various reaction conditions, and experiments were conducted to verify the modeling results. In the phosphate-containing mFe-PS system, the 120 min removal efficiency of CFA decreased from 95.1% to 76.6% as the phosphate concentration increased from 0.32 to 6.45 mmol/L, but recovered to 90.5% when phosphate concentration increased to 16.10 mmol/L. Meanwhile, the increased concentration of phosphate from 0.32 to 16.10 mmol/L reduced the BZF degradation efficacy from 91.5% to 79.0%, whereas SMX removal improved from 37.3% to 62.9%. The mFe-PS system containing (bi)carbonate, from 4.20 to 166.70 mmol/L, reduced CFA and BZF removal efficiencies from 100% to 76.8% and 80.4%, respectively, and SMX from 83.5% to 56.7% within a 120-min reaction time. In addition, alkaline conditions (pH ≥ 8.0) inhibited CFA and BZF degradations, while nonacidic pH (pH ≥ 7.0) remarkably inhibited SMX degradation. Results of the kinetic model indicated the formation of phosphate (H2PO4·/HPO4·-) and/or carbonate radicals (CO3·-) could limit pharmaceutical removal. The transformation products (TPs) of the pharmaceuticals revealed more incompletely oxidized TPs occurred in the phosphate- and (bi)carbonate-containing mFe-PS systems, and indicated that H2PO4·/HPO4·- mainly degraded pharmaceuticals via a benzene ring-opening reaction while CO3·- preferentially oxidized pharmaceuticals via a hydroxylation reaction.

Silver-filled MWCNT nanocomposite as a sensing element for voltammetric determination of sulfamethoxazole

Here, we introduce a new electrode based on Silver-filled multi-walled carbon nanotube (Ag-MWCNT) and methyltrioctyl ammonium chloride (MTOAC) for highly sensitive voltammetric measurement of Sulfamethoxazole (SMX). The electrode showed an electrocatalytic activity as it led to the diminution of the overpotential and an increase in peak current for SMX oxidation in a phosphate buffer solution (pH 6.0). Analysis of surface topography and electrochemical properties of the modified electrode was examined by TEM, EDX and EIS, respectively. Electrochemical performance of the modified electrode was investigated with cyclic voltammetry (CV) and differential pulse voltammetry (DPV) techniques for determination of SMX in aqueous solution. In addition, the oxidation process was found to be dependent on the pH of the buffer solution. Under optimal conditions, a linear relationship between the oxidation current and SMX concentration was found in a range 0.05-70 μM (R² = 0.997) with a detection limit of 0.01 μM after 2 min of accumulating time. The electrode was successfully used to quantify SMX in pharmaceutical formulations and human urine by DPV.

UV/H2O2 and UV/PDS Treatment of Trimethoprim and Sulfamethoxazole in Synthetic Human Urine: Transformation Products and Toxicity

Elimination of pharmaceuticals in source-separated human urine is a promising approach to minimize the pharmaceuticals in the environment. Although the degradation kinetics of pharmaceuticals by UV/H2O2 and UV/peroxydisulfate (PDS) processes has been investigated in synthetic fresh and hydrolyzed urine, comprehensive evaluation of the advanced oxidation processes (AOPs), such as product identification and toxicity testing, has not yet been performed. This study identified the transformation products of two commonly used antibiotics, trimethoprim (TMP) and sulfamethoxazole (SMX), by UV/H2O2 and UV/PDS in synthetic urine matrices. The effects of reactive species, including •OH, SO4(•-), CO3(•-), and reactive nitrogen species, on product generation were investigated. Multiple isomeric transformation products of TMP and SMX were observed, especially in the reaction with hydroxyl radical. SO4(•-) and CO3(•-) reacted with pharmaceuticals by electron transfer, thus producing similar major products. The main reactive species deduced on the basis of product generation are in good agreement with kinetic simulation of the advanced oxidation processes. A strain identified as a polyphosphate-accumulating organism was used to investigate the antimicrobial activity of the pharmaceuticals and their products. No antimicrobial property was detected for the transformation products of either TMP or SMX. Acute toxicity employing luminescent bacterium Vibrio qinghaiensis indicated 20-40% higher inhibitory effect of TMP and SMX after treatment. Ecotoxicity was estimated by quantitative structure-activity relationship analysis using ECOSAR.

Pathogens and pharmaceuticals in source-separated urine in eThekwini, South Africa

In eThekwini, South Africa, the production of agricultural fertilizers from human urine collected from urine-diverting dry toilets is being evaluated at a municipality scale as a way to help finance a decentralized, dry sanitation system. The present study aimed to assess a range of human and environmental health hazards in source-separated urine, which was presumed to be contaminated with feces, by evaluating the presence of human pathogens, pharmaceuticals, and an antibiotic resistance gene. Composite urine samples from households enrolled in a urine collection trial were obtained from urine storage tanks installed in three regions of eThekwini. Polymerase chain reaction (PCR) assays targeted 9 viral and 10 bacterial human pathogens transmitted by the fecal-oral route. The most frequently detected viral pathogens were JC polyomavirus, rotavirus, and human adenovirus in 100%, 34% and 31% of samples, respectively. Aeromonas spp. and Shigella spp. were frequently detected gram negative bacteria, in 94% and 61% of samples, respectively. The gram positive bacterium, Clostridium perfringens, which is known to survive for extended times in urine, was found in 72% of samples. A screening of 41 trace organic compounds in the urine facilitated selection of 12 priority pharmaceuticals for further evaluation. The antibiotics sulfamethoxazole and trimethoprim, which are frequently prescribed as prophylaxis for HIV-positive patients, were detected in 95% and 85% of samples, reaching maximum concentrations of 6800 μg/L and 1280 μg/L, respectively. The antiretroviral drug emtricitabine was also detected in 40% of urine samples. A sulfonamide antibiotic resistance gene (sul1) was detected in 100% of urine samples. By coupling analysis of pathogens and pharmaceuticals in geographically dispersed samples in eThekwini, this study reveals a range of human and environmental health hazards in urine intended for fertilizer production. Collection of urine offers the benefit of sequestering contaminants from environmental release and allows for targeted treatment of potential health hazards prior to agricultural application. The efficacy of pathogen and pharmaceutical inactivation, transformation or removal during urine nutrient recovery processes is thus briefly reviewed.

Fluorimetric Determination of Sulphaguanidine and Sulphamethoxazole by Host-Guest Complexation in β-Cyclodextrin and Partial Least Squares Calibration

The host-guest inclusion complexes of sulphamethoxazole (SMTX) and sulphaguanidine (SGN) with beta-cyclodextrin, in aqueous solutions, have been investigated. A 1:1 stoichiometry of the complexes was established, the association constants were calculated by different methods, and the influence of several chemical variables on the complexation processes were established. According to the results obtained, a spectrofluorimetric method for the determination of these sulphonamides has been proposed. The individual and binary mixtures of both sulphonamides have been determined in human urine samples, at representative therapeutic ranges, by application of a first-order multivariate calibration partial least squares (PLS-1) model. The calibration set was designed with 9 samples, containing different concentrations of the two sulphonamides, and 8 blank urine samples, with the aim of modelling the variability of the background. The concentration ranges for the sulphonamides were up to 0.5 microg mL(-1) for SMTX and 1.0 microg mL(-1) for SGN. Figures of merit as selectivity, analytical sensitivity and limit of detection (LOD) were also calculated. The proposed procedure was validated by comparing the obtained results with a HPLC method, with satisfactory results for the assayed method.

Application of nuclear magnetic resonance spectroscopy for quantitative analysis of miconazole, metronidazole and sulfamethoxazole in pharmaceutical and urine samples

Specific, accurate and precise NMR methods were developed for determining miconazole, metronidazole and sulfamethoxazole antibiotic drugs in authentic, pharmaceutical and urine samples. Proton nuclear magnetic resonance spectroscopy (1H NMR) with maleic acid as an internal standard and DMSO-d6 as NMR solvent were used. 1H NMR signals at 9.0, 8.06, 7.50 and 6.26 ppm corresponding to miconazole, metronidazole, sulfamethoxazole and maleic acid were respectively used for calculating the concentrations of drugs per unit dose. Average percent recoveries of (97.54-101.10), (98.06-100.46) and (97.83-102.83) with average uncertainties of 1.02, 0.45 and 0.86 were respectively obtained for determining authentic samples of miconazole, metronidazole and sulfamethoxazole in the concentration range of 0.92-170 mg/0.6 ml DMSO-d6. In pharmaceutical formulations and urine samples, average percent recoveries in the ranges of 97.50-101.33 and 94.46-100.86 were respectively obtained. Relative standard deviations (R.S.D.)<or=2.68 were obtained for analyzing the three drugs in authentic, pharmaceutical and urine samples. Admixtures of the three drugs in authentic, pharmaceutical and urine samples were analyzed. Good precisions (0.79-2.99%) and recoveries (93.40-104.97%) were obtained indicating the high selectivity and resolving power of the developed NMR methods and no needs for separation steps. Applying statistical Student t-test revealed insignificant difference between the real and measured contents at the 95% confidence level. F-test revealed insignificant difference in precisions between the developed NMR methods and HPLC methods reported for analyzing miconazole, metronidazole and sulfamethoxazole.

Flow-injection spectrophotometric determination of sulfadiazine and sulfamethoxazole in pharmaceuticals and urine

A rapid and sensitive flow-injection spectrophotometric method is proposed for the determination of sulfadiazine and sulfamethoxazole. This method is based on the diazotization of sulfonamide with sodium nitrite, and a coupling reaction of the diazo-compound with alpha-naphthylamine. The optimum experimental conditions are obtained by using the controlled and weighted centroid simplex method. The linear ranges for the determination of sulfadiazine and sulfamethoxazole are 0.2-20 microg ml(-1) and 0.1-20 microg ml(-1), and their detection limits are 0.06 microg ml(-1) and 0.05 microg ml(-1), respectively, and the sampling frequency is 130 samples per hour. The method has been used to determine sulfadiazine and sulfamethoxazole in pharmaceuticals and urine without separation. The results are in agreement with those obtained by a high-performance liquid chromatograph technique at the 95% confidence level.

Circadian changes in pharmacokinetics of sulfamethoxazole administered orally to rabbits

Circadian variations of sulfamethoxazole pharmacokinetics were studied after a single oral administration of sulfamethoxazole, 50 mg/kg, to rabbits at 09:00 (a.m.) and 22:00 (p.m.). The profiles of plasma sulfamethoxazole concentration showed from 6 h to 24 h significant statistical difference (p<0.05) between 09:00 and 22:00. The half-life (t(1/2)) was significantly shorter in the morning (11.2 +/- 3.2 h) when compared to the nighttime (15.4 +/- 3.5 h) (p< 0.05). The AUC was significantly decreased in the morning (1325 +/- 264 microg/ml x h) than that in the nighttime (2059 +/- 379 microg/ml x h) (p<0.05). Total body clearance (CLt) was significantly higher when sulfamethoxazole was given in the morning (6.65 +/- 0.23 ml/min) versus in the nighttime (4.28 +/- 0.20 ml/min) (p<0.05).

Determination of sulfadiazine and sulfamethoxazole by capillary electrophoresis with end-column electrochemical detection

Capillary electrophoresis (CE) with end-column electrochemical detection (EC) of sulfadiazine (SDZ) and sulfamethoxazole (SMZ) is described. Under the optimum conditions, SDZ and SMZ were separated satisfactorily, and a highly sensitive and stable response was obtained at a potential of 1.1 V versus Ag/AgCl. Optimized end-column detection provides detection limits as low as 0.1 microM for both compounds, which corresponds to 0.024 and 0.021 fmol with peak efficiencies of 394,000 and 335,000 theoretical plates for SDZ and SMZ, respectively. The calibration graph was linear over three order of magnitude. The relative standard deviations (n = 12) of peak currents and migration times were 2.3 and 2.7%, and 0.8 and 1.3%, respectively, for the two compounds. The proposed method was applied to the analysis of tablets and human urine samples with satisfactory results.

Adherence to antiretroviral and pneumocystis prophylaxis in HIV disease

BACKGROUND

Medication nonadherence in the treatment of chronic diseases compromises the effectiveness of therapy. Little information is available about the extent of medication adherence or determinants of medication adherence in HIV disease, an issue of increasing importance in this new therapeutic era of combination antiretroviral therapy.

METHODS

We studied 244 HIV-infected Medicaid-insured patients attending an HIV hospital-based clinic regarding the extent of and predictors of adherence to antiretroviral therapy and Pneumocystis carinii pneumonia (PCP) prophylaxis. Patients were asked to report medications being taken, patterns of use, and knowledge and attitudes about HIV therapies. Medical record report of type, dose, and frequency of medication was compared with self-report using the kappa statistic. Urine sulfamethoxazole assay was obtained from patients prescribed sulfamethoxazole-trimethoprim.

RESULTS

Among patients prescribed antiretroviral therapy, 60% reported > or = 80% adherence in the previous 7 days; 49% reported > or = 80% adherence with PCP prophylaxis in the previous seven days. Seventy-nine percent of patients who reported taking daily sulfamethoxazole-trimethoprim had detectable urinary sulfamethoxazole. In multivariate analysis, > or = 80% adherence to antiretroviral therapy was associated with taking medication < or = twice a day (odds ratio [OR]=1.44; 95% confidence interval [CI], 1.01, 1.96), being likely to take medication when not at home, (OR=1.41; 95% CI, 1.04, 2.00) and patients' belief in their ability to adhere to therapy (OR=1.57; 95% CI, 1.13, 2.17). For PCP prophylaxis, > or = 80% adherence was associated with presence of family (OR=2.39; 95% CI, 1.01, 5.63) and patients' belief in their ability to adhere to therapy (OR=2.87; 95% CI, 1.44-1.78). Sociodemographic characteristics and belief in the efficacy of medications were not associated with adherence.

CONCLUSIONS

A relatively low level of adherence to antiretroviral therapy and PCP prophylactic regimens was found. Although our results are principally from patients receiving antiretroviral monotherapy, these findings may have important implications for patients receiving highly active antiretroviral therapy (HAART). Decreasing the complexity of antiretroviral regimens, and working with patients to modify identified barriers to adherence may improve effectiveness of medications and prolong survival.

The effect of cimetidine on the formation of sulfamethoxazole hydroxylamine in patients with human immunodeficiency virus

Hypersensitivity reactions from trimethoprim/sulfamethoxazole are likely caused by a reactive nitroso intermediate formed from sulfamethoxazole hydroxylamine. This pilot study tested whether cimetidine inhibits the urinary excretion of sulfamethoxazole hydroxylamine. Ten outpatients infected with human immunodeficiency virus (HIV) and currently receiving trimethoprim/sulfamethoxazole prophylaxis were randomly selected from 59 eligible patients. Five received cimetidine 800 mg twice daily for 1 week and five served as controls. Two spot urine samples one week apart were obtained after a trimethoprim/sulfamethoxazole dose for all patients. Patients taking cimetidine had a significant decrease in excretion of sulfamethoxazole hydroxylamine relative to total excreted drug in the two urine samples compared with control patients. Cimetidine likely caused this decrease in sulfamethoxazole hydroxylamine excretion through inhibition of CYP3A4. Because of potential differences between HIV-infected patients and healthy subjects in oxidative metabolism, future studies of inhibitors of sulfamethoxazole hydroxylamine formation should be conducted in the HIV population.

The relationship between the disposition and immunogenicity of sulfamethoxazole in the rat

Idiosyncratic toxicity associated with sulfamethoxazole (SMX) is thought to be a consequence of bioactivation to the hydroxylamine metabolite (SMX-NOH) and further oxidation to the ultimate reactive metabolite, nitroso-sulfamethoxazole (SMX-NO). To establish the link between the formation of the ultimate reactive metabolite and SMX hypersensitivity, we have undertaken metabolism and immunogenicity studies in the rat by use of SMX and its metabolites. SMX was excreted in urine as N4-acetyl SMX and SMX-NOH, with approximately 10% remaining unchanged as parent amine. After administration of SMX-NOH (54 mg x kg(-1)) and SMX-NO (10 mg x kg(-1)), 38.3% and 46.1% of the doses, respectively, were excreted in urine as SMX and N4-acetyl SMX, which indicated extensive reduction of these metabolites in vivo. The immunogenic potential of SMX and its metabolites, SMX-NOH and SMX-NO, were assessed in rats by analyzing serum samples for the presence of anti-SMX IgG antibodies during a 4-week dosing period. No antibodies to SMX were detected in either control or SMX-treated rats. In contrast, a high titer of SMX-specific IgG antibody was present in sera from all the rats administered SMX-NO, reaching a maximum 14 to 21 days after the initial dose. Rats administered SMX-NOH only produced a weak IgG response after 3 weeks of dosing. These findings indicate that SMX-NO is highly immunogenic and may be responsible for the hypersensitivity reactions associated with SMX. Both SMX-NOH and SMX-NO undergo extensive reduction in vivo which may afford protection against SMX toxicity.

The hydroxylamine of sulfamethoxazole and adverse reactions in patients with acquired immunodeficiency syndrome

We measured the urine concentrations of sulfamethoxazole, sulfamethoxazole hydroxylamine, and N-sulfamethoxazole on days 3 and 10 in 15 patients with acquired immunodeficiency syndrome treated with a combination product of trimethoprim (15 mg/kg/day) and sulfamethoxazole (75 mg/kg/day). The percentage of sulfamethoxazole and metabolites excreted on days 3 and 10, respectively, were sulfamethoxazole 17.2% +/- 11.3% versus 15.6% +/- 8.2%; sulfamethoxazole hydroxylamine 2.6% +/- 2.0% versus 5.0% +/- 5.2% (p < 0.05); N-acetylsulfamethoxazole 80.0% +/- 12.9% versus 79.8% +/- 11.8%. The percentage of sulfamethoxazole hydroxylamine excreted was similar between the eight patients who discontinued therapy because of toxicity and the seven patients who did not (2.9% +/- 2.3% versus 2.3% +/- 2.0%, p = 0.7). In two patients who had major liver toxicity the percentage of sulfamethoxazole hydroxylamine excreted was significantly lower than that of the 13 patients who did not (0.8% +/- 0.1% versus 2.9% +/- 2.0%, p < 0.05). This is the first report of the formation and excretion of sulfamethoxazole hydroxylamine in patients with acquired immunodeficiency syndrome. With 15 patients we were unable to show a significant correlation between the percentage of sulfamethoxazole hydroxylamine excreted and adverse reactions. However, patients with liver toxicity excreted less sulfamethoxazole hydroxylamine.

Formation and elimination of sulphamethoxazole hydroxylamine after oral administration of sulphamethoxazole

The formation and elimination of sulphamethoxazole hydroxylamine in relation to the pharmacokinetics of the parent compound and its N4-acetyl metabolite were investigated in six healthy subjects after a single oral dose of 800 mg sulphamethoxazole. The apparent half-lives of sulphamethoxazole and its metabolites were approximately 10 h, indicative of formation rate-limited metabolism. The mean residence time of the hydroxylamine metabolite was 5.5 +/- 1.5 h. The renal clearance of sulphamethoxazole hydroxylamine was 4.39 +/- 0.91 l h-1. The urinary recovery of sulphamethoxazole accounted for 16.5 +/- 5.5% of the dose, N4-acetyl-sulphamethoxazole for 46.2 +/- 6.6% and the hydroxylamine metabolite for 2.4 +/- 0.8%. The remaining 35% of the dose was unaccounted for. Acetylator phenotype was determined using sulphadimidine. The renal excretion of sulphamethoxazole hydroxylamine was 1.9 +/- 0.9% in slow acetylators (n = 3) and 2.8 +/- 0.3% in fast acetylators (n = 3); for N4-acetyl-sulphamethoxazole the values were 48 +/- 6% and 44 +/- 8%, respectively. Sulphamethoxazole is metabolized, although to a limited extent, to a hydroxylamine metabolite. This metabolite may be important for the pathogenesis of adverse reactions.

Assay of the acetyl-CoA probe acetyl-sulfamethoxazole and of sulfamethoxazole by gas chromatography-mass spectrometry

We present gas chromatographic-mass spectrometric assays for (i) the concentration of sulfamethoxazole and (ii) the concentration and molar percentage enrichment of acetyl-sulfamethoxazole in biological fluids. The compounds are extracted with ethyl acetate, derivatized with either diazomethane or pentafluorobenzyl bromide, and analyzed by gas chromatography-mass spectrometry. Quantitation is achieved using internal standards, [2H4]sulfamethoxazole and acetyl-[2H4]sulfamethoxazole. Limits of detection are 200 nmol for the methyl derivatives and 2 nmol for the pentafluorobenzyl derivatives. The high sensitivity of the assay with the pentafluorobenzyl derivatives allows measuring in plasma and urine (i) the pharmacokinetics of sulfamethoxazole and acetyl-sulfamethoxazole and (ii) the stable isotope enrichment of the acetyl moiety of acetyl-sulfamethoxazole. The latter is used as a probe for the noninvasive chemical biopsy of liver extramitochondrial acetyl-CoA.

Multiple-dose pharmacokinetics of 12 milligrams of trimethoprim and 60 milligrams of sulfamethoxazole per kilogram of body weight per day in healthy volunteers

The disposition of 12 mg of trimethoprim and 60 mg of sulfamethoxazole per kg of body weight in six healthy male volunteers is described. The daily dose was evenly divided and administered orally every 6 h for 13 consecutive doses. Individual drug components were assayed by high-performance liquid chromatography. Steady-state concentrations in serum for trimethoprim and sulfamethoxazole were within the purported therapeutic ranges for treating Pneumocystis carinii pneumonia. Co-trimoxazole was well tolerated, and no subject withdrew from the study because of toxicity. Comparison of the pharmacokinetic parameters in this study with those of our previous findings indicates that the elimination of trimethoprim-sulfamethoxazole follows a first-order process within the dose ranges assessed. Administration of 15- to 20-mg/kg trimethoprim and 75- to 100-mg/kg sulfamethoxazole in four evenly divided doses for the first 24 h followed by 12 and 60 mg/kg/day, respectively, for the remainder of therapy rapidly attains concentrations in serum within the proposed P. carinii pneumonia therapeutic range. Clinical trials are indicated to evaluate this dosing scheme, which may decrease exposure to potentially excessive concentrations of trimethoprim and sulfamethoxazole.

Renal selective N-acetyl-L-gamma-glutamyl prodrugs: studies on the selectivity of some model prodrugs

1. In this study, a number of structurally different N-acetyl-L-gamma-glutamyl prodrugs were investigated with respect to selective uptake by the kidney in male Wistar rats. 2. All prodrugs were tested in vitro in rat kidney slices and kidney homogenate to study their uptake and conversion. It was found that the prodrugs of para-nitroaniline (agPNA), aminophenyl acetic acid (agAFA), sulphamethoxazole (agSM), sulphadimethoxine (agSDM), propranolol (agPP) and metoprolol (agMP) were accumulated by a probenecid-sensitive carrier. The prodrug of 4'-aminoantipyrine (agAAP) was not accumulated by a probenecid- or buthionine sulphoximine-sensitive carrier. Unlike all other prodrugs, agAAP and agMP were not, or only a very limited extent converted to the parent compound in vitro. 3. agPNA, agAFA and agPP were also investigated in vivo. The tissue distribution of the prodrugs and the parent drugs was established, as was their urinary excretion and pharmacokinetic behaviour. agPNA and agAFA showed selective uptake by the kidney, in contrast to agPP which accumulated in the liver. The distribution of the parent compounds following prodrug administration was as follows: agPNA was found in kidney and plasma: agAFA in kidney only; agPP in liver only. 4. The factors which determine the selectivity of N-acetyl-L-gamma-glutamyl prodrugs are discussed. The main factors are: the transport into the kidney, the conversion rate, the residence time of the prodrug in the kidney and the presence or absence of competition for uptake and conversation by other tissues, e.g. the liver. It is concluded that this prodrug approach offers the possibility of delivering drugs selectively to the kidney, but also that it is not universally applicable.

Sulfamethoxazole is metabolized to the hydroxylamine in humans

The oxidation of sulfamethoxazole to its hydroxylamine metabolite was investigated in vitro with human liver microsomes and in vivo by detection in the urine. Sulfamethoxazole was oxidized to the hydroxylamine in an NADPH-dependent process by liver microsomes prepared from two human livers. Three healthy volunteers ingested 1000 mg sulfamethoxazole, and urine was collected for 24 hours. Sulfamethoxazole hydroxylamine constituted 3.1% +/- 0.7% of the drug excreted in the urine in 24 hours. Fifty-four percent of the ingested dose was excreted during this same time period. We conclude that sulfamethoxazole hydroxylamine is an authentic in vivo metabolite in humans, probably formed predominantly by cytochrome P450 in the liver. It could be responsible for mediation of sulfonamide adverse reactions, particularly hypersensitivity reactions.

Pharmacokinetics and adverse effects of 20-mg/kg/day trimethoprim and 100-mg/kg/day sulfamethoxazole in healthy adult subjects

The pharmacokinetics of trimethoprim-sulfamethoxazole were studied in 12 healthy adult subjects receiving trimethoprim at 20 mg/kg of body weight per day and sulfamethoxazole at 100 mg/kg/day, which is the conventional dose for treating Pneumocystis carinii pneumonia (PCP). Daily doses were evenly divided and orally administered every 6 h for 3 days. Trimethoprim, sulfamethoxazole, and N4-acetylsulfamethoxazole concentrations in serum and urine were measured by high-performance liquid chromatography. Five subjects withdrew from the study because of intolerable gastrointestinal and central nervous system toxicities. In the seven subjects that completed the study, the mean maximum serum drug concentrations after the last dose were 13.6 +/- 2.0, 372 +/- 64, and 50.1 +/- 10.9 micrograms/ml for trimethoprim, sulfamethoxazole, and N4-acetylsulfamethoxazole, respectively. The mean half-lives were 13.6 +/- 3.5, 14.0 +/- 2.3, and 18.6 +/- 4.3 h, respectively. Changes in absolute neutrophil count were significantly correlated with the minimum concentrations of trimethoprim and sulfamethoxazole in serum and trimethoprim area under the concentration-time curve (for all three parameters, r2 = 0.6 and P less than 0.05). Our findings add to the evidence that serum drug concentrations in adults following the conventional dose of trimethoprim-sulfamethoxazole for PCP are excessive and contribute to certain adverse reactions. Further studies are indicated in patients to optimize the dosing regimen of trimethoprim-sulfamethoxazole in the treatment of PCP.

Pharmacokinetics of sulfamethoxazole and trimethoprim in Mexicans: bioequivalence of two oral formulations (URO-TS D and Bactrim F)

Two oral pharmaceutical formulations (URO-TS D and Bactrim F) containing 800 mg of sulfamethoxazole (SMZ) and 160 mg of trimethoprim (TMP) were given to 10 Mexican healthy volunteers, following a randomized cross-over design. Blood and urine samples were obtained, concentrations of TMP, SMZ, and its metabolite N4-acetyl SMZ were measured by HPLC and pharmacokinetic analyses were performed. The observed Cmax, tmax, half-life, AUC, and cumulative urinary excretion values for the three compounds studied were within the ranges that have been previously reported for European and North American subjects. Therefore, it appears that pharmacokinetics of SMZ and TMP in Mexicans are similar to those observed in Caucasian populations. When the two studied formulations were compared, no statistically significant differences were detected in any pharmacokinetic parameter. Therefore, it is concluded that both brands tested are bioequivalent. Moreover, these two formulations manufactured in Mexico yield SMZ and TMP plasma and urine levels similar to those obtained with equivalent formulations of European or North American origin.

Sulphamethoxazole acetylation in fast and slow acetylators

Acetylation of sulphamethoxazole was studied in 22 subjects previously phenotyped with sulphadimidine. Sulphamethoxazole and its acetylated metabolite were measured in 6 h plasma and 0-6 h urine samples. Percentage of plasma acetylated-sulphamethoxazole did not correlate with the percentage of urinary acetylated-sulphamethoxazole. There was also no correlation between the percentage of acetylated-sulphadimidine and percentage of acetylated-sulphamethoxazole in plasma. The finding suggest that the acetylation of sulphamethoxazole has no predictive value in determining acetylator status.

N1-glucosides as urinary metabolites of sulphadimidine, sulphamerazine and sulphamethoxazole

The synthesis and characterisation of the N1-beta-D-glucosides of the three title sulphonamides are described, and these conjugates are shown, by means of HPLC and MS, to be minor urinary metabolites of these drugs.

Pharmacokinetics and body fluid and endometrial concentrations of trimethoprim-sulfamethoxazole in mares

Six healthy adult mares were each given a single IV injection of trimethoprim (TMP)-sulfamethoxazole (SMZ) at a dosage of 2.5 mg of TMP/kg of body weight and 12.5 mg of SMZ/kg. Serum concentrations of each drug were measured serially over a 24-hour period. For TMP, the mean overall elimination rate constant (K) was 0.43/hr and the elimination half-life (t1/2) was 1.9 hours. The apparent volume of distribution (at steady state) was 1.62 L/kg and TMP clearance was 886 ml/hr/kg. For SMZ, K was 0.22/hr and t1/2 was 3.53 hours. The apparent volume of distribution at steady state was 0.33 L/kg and SMZ clearance was 78.2 ml/hr/kg. Each mare was then given 5 consecutive oral doses of TMP-SMZ at a rate of 2.5 mg of TMP/kg and 12.5 mg of SMZ/kg at 12-hour intervals. Trimethoprim and SMZ concentrations were measured in serum, synovial fluid, peritoneal fluid, CSF, urine, and endometrium. Although both mean TMP and SMZ serum concentrations were higher after the 5th dose than after the 1st dose, only the mean TMP concentration was significantly (P less than 0.05) different. After the 5th oral dose, concentrations of TMP and SMZ attained in body fluids (except CSF) and endometrial tissue were equal to or exceeded reported minimum inhibitory concentrations for Corynebacterium pseudotuberculosis, Staphylococcus sp, Streptococcus zooepidemicus, and several obligate anaerobes. Absorption of both drugs was variable after oral administration.

Antibacterial activity in human urine of fosfomycin trometamol in an in vitro model of the urinary bladder

The urinary concentrations of fosfomycin trometamol, norfloxacin, pipemidic acid and cotrimoxazole were studied at various times after oral administration of drugs in healthy volunteers. Using the same urine, the bactericidal activity of four antimicrobial agents against Escherichia coli, Proteus mirabilis and Klebsiella pneumoniae in an in vitro model simulating the treatment of bacterial cystitis was also evaluated. The results obtained show that very high concentrations of the drugs were achieved in urine particularly after the oral administration of the fosfomycin trometamol. In the bladder model bactericidal activity of fosfomycin trometamol, norfloxacin and pipemidic acid were higher than that of cotrimoxazole; no resistant mutants to drugs were selected over a period of 24 h.

Pharmacokinetics of cefradine, sulfamethoxazole and trimethoprim and their metabolites in a patient with peritonitis undergoing continuous ambulatory peritoneal dialysis

Cefradine and co-trimoxazole pharmacokinetics were studied in a patient with peritonitis that complicated continuous ambulatory peritoneal dialysis (CAPD). Concentrations in the plasma reached after oral administration of 500 mg cefradine four times daily and 400/80 mg co-trimoxazole four times daily were for cefradine 100 micrograms/ml, for trimethoprim 15 micrograms/ml, and for sulfamethoxazole 100 micrograms/ml, respectively. In the dialysate concentrations were reached of 35-70 micrograms/ml cefradine, 2-5 micrograms/ml trimethoprim and 8-17 micrograms/ml sulfamethoxazole. The values for sulfamethoxazole are regarded too low to be clinically effective. Half-lives, protein binding values and CAPD clearances are presented. Low CAPD clearances were obtained during the night and high values during the day. The dosage yielded too high plasma trimethoprim concentrations, while sulfamethoxazole dialysate concentrations were too low. It seems questionable therefore whether co-trimoxazole can be used orally for the treatment of CAPD peritonitis.

Sulfatroxazole: pharmacokinetics, metabolism and urinary excretion in goats and pigs

The disposition of sulfatroxazole (STZ) has been studied in goats and pigs after intravenous administration of a single dose. The percentage of protein-binding decreased with increasing plasma concentration in both species. At 100 micrograms/ml about 85% was bound to plasma proteins in goats, while the corresponding value was only 55% in pigs. Two metabolites of STZ were isolated from urine and identified as N4-acetyl-STZ and 3-sulfanilamido-4-methyl-5-hydroxy-methyl-isoxazole (5'-OH-STZ). The goats excreted about 80% of the dose in urine. The majority (64%) was excreted as unchanged STZ, while N4-acetyl-STZ and 5'-OH-STZ made up 19% and 18%, respectively. The pigs excreted 95% of the dose in urine. Unchanged STZ amounted to 30% and N4-acetyl-STZ to 70% of the urinary excretion in pigs, while there were only traces of 5'-OH-STZ.

Trimethoprim-sulfamethoxazole pharmacokinetics during continuous ambulatory peritoneal dialysis

Eight adult patients without peritonitis maintained on chronic ambulatory peritoneal dialysis (CAPD) were administered a single oral dose of 320 mg trimethoprim (TMP) and 1600 mg sulfamethoxazole (SMX) to characterize the pharmacokinetics of TMP and SMX. Ten blood samples were drawn following the dose. TMP and SMX-active (SMXA) concentrations were quantified in serum and dialysate. The half-life of TMP and SMXA determined by model independent methods were 33.7 +/- 10.5 h (mean +/- SD) and 13.8 +/- 2.2 h respectively. Total body clearance of TMP was 32.8 +/- 10.1 ml/min and SMXA was 21.9 +/- 6.4 ml/min. CAPD clearance of TMP was 2.27 +/- 0.81 ml/min and SMXA was 1.72 +/- 0.93 ml/min. The average peritoneal dialysate concentrations over the 72-hour collection period of TMP and SMXA were 0.9 +/- 0.1 mg/l and 5.3 +/- 0.8 mg/l respectively. A dose of 320 mg TMP and 1600 mg SMX every 48 hours is recommended for CAPD patients with mild to moderate systemic infections.

Excretion rates of sulfamethoxazole and N4-acetyl-sulfamethoxazole by fresh water turtles Pseudemys scripta elegans

Sulfamethoxazole and N4-acetylsulfamethoxazole are excreted by fresh water turtles Pseudemys scripta elegans in a biphasic mode, characterized half-lives of 5 and 100 min. Acetylation and deacetylation reactions cannot be detected below a dose of 50 mg/kg. The mass balance of the dose administered is incomplete, only 30 per cent of the dose can be recovered as parent compound and metabolite. The sulfonamides must be mainly excreted by the faeces and may be metabolized in the gastro-intestinal tract.

High-performance liquid chromatographic assay of methotrexate, 7-hydroxymethortrexate, 4-deoxy-4-amino-N10-methylpteroic acid and sulfamethoxazole in serum, urine and cerebrospinal fluid

An automated high-performance liquid chromatographic system is described for separation and quantitation of the antineoplastic drug methotrexate and metabolites, and the antibiotic sulfamethoxazole in body fluids. The 40-min analysis utilizes a reversed-phase C18 column and gradient elution with detection by absorbance of ultraviolet light at 308 nm. The minimum detectable quantities with this assay are: methotrexate 4.4 ng (9.8 X 10(-12) mole); 4-deoxy-4-amino-N10-methylpteroic acid 11.9 ng (3.7 X 10(-11) mole); 7-hydroxymethotrexate 30 ng (6.5 X 10(-11) mole); sulfamethoxazole 125 ng (4.9 X 10(-10) mole). This analytical method should prove useful for therapeutic monitoring and pharmacokinetic studies of these compounds.

Pharmacokinetics of co-trimoxazole and co-tetroxazine in geriatric patients

Following a single dose of co-trimoxazole or co-tetroxazine, the plasma and urine levels of intact trimethoprim (TMP) and sulphamethoxazole (SMZ) and of tetroxoprim and sulphadiazine (SDZ) were determined in six geriatric patients in a cross-over design by high pressure liquid chromatography. The pharmacokinetic analysis showed a plasma elimination half-life in the terminal phase of 10.39 h for TMP, 11.79 h for SMZ, 6.55 h for TXP and 10.46 h for SDZ. The resulting distribution volumes Vd beta and total plasma clearance values corresponded with the data obtained in young patients or volunteers. Recovery in urine, measured for up to 96 h, was 49.2% (TMP), 19.8% (SMZ), 57.03% (TXP) and 61.1% (SDZ). In contrast to young volunteers, geriatric patients experienced a slight prolongation of renal excretion for both sulphonamides. In this group of patients the renal clearance was 2.42 ml/min for SMZ and 10.7 ml/min for SDZ.

Simultaneous determination of trimethoprim, sulphamethoxazole and N4-acetylsulphamethoxazole in serum and urine by high-performance liquid chromatography

The simultaneous determination of trimethoprim, sulphamethoxazole and N4-acetyl-sulphamethoxazole in serum and urine by high-performance liquid chromatography using sulphafurazole as internal standard is described. The separation was achieved on a reversed-phase column employing acetic acid-methanol as the mobile phase with spectrophotometric detection at 230 nm. Precise simultaneous quantitative analysis of the relative components has been achieved at levels of 0.1 microgram/ml for trimethoprim and 1.0 microgram/ml for both sulphamethoxazole and its N4-acetyl metabolite using 1 ml of serum of urine.

Intrarenal distribution of trimethoprim and sulfamethoxazole

In the present study, rats were given trimethoprim (TMP, 10 mg/kg), sulfamethoxazole (SMZ, 50 mg/kg), or a combination of the respective doses of TMP and SMZ. Thirty-six rats received each of the drugs studied. Six recipients of a compound (or mixture) were evaluated hourly, from 1 to 6 h after intraperitoneal injection of the agent. At each timed interval, serum, urine, cortex, medulla, and papilla were analyzed for drug content. Peak serum values of 1.1 microgram of TMP and 131.1 microgram of active SMZ (nonacetylated sulfonamide) per ml were observed after injection of the combination TMP-SMZ. Although the cortical, medullary, and papillary TMP concentrations were severalfold higher than the respective serum values (P < 0.01), microbiologically active SMZ did not concentrate in the renal parenchyma and was found in lower concentration there than in the serum (P < 0.01). The levels of SMZ in all parts of the kidney of animals which received the mixture SMZ-TMP were lower than those detected in the animals which were given SMZ alone. The average ratio of active SMZ to TMP within the medulla and the papilla was less than 20 to 1 in the first 2 h. The intrarenal distribution of these drugs may have therapeutic implications.

Simultaneous automated determination of free and total sulfisoxazole and sulfamethoxazole in plasma and urine

A fully automated method for the determination of sulfisoxazole, N4-acetylsulfisoxazole, sulfamethoxazole, and N4-acetylsulfamethoxazole in human plasma and urine was developed. Untreated plasma is analyzed by automation of dialysis, hydrolysis, color development, and quantitation. The method has a sensitivyt limit of 2 microgram/ml of plasma and has been used successfully to determine sulfonamide levels following administration of sulfoxazole and a combination drug product containing sulfamethoxazole and trimethoprim in humans. Samples are processed at the rate of 40 per hour, with a minimum of sample handling, data reduction, and materials.

Synergistic activity of co-trimazine and co-trimoxazole in the urine

Co-trimazine (sulphadiazine, 410 mg + trimethoprim, 90 mg) is a new drug combination developed especially for use in the treatment of urinary tract infections. In cross-over experiments in volunteers receiving daily doses of co-trimazine (2 X 500 mg and 1 X 1000 mg), co-trimoxazole (2X960 mg), or nitrofurantoin (3X50 mg), the degree of antibacterial activity of co-trimazine in the urine was at least as high as that of co-trimoxazole and much higher and more consistent than that of nitrofurantoin. In further cross-over experiments in volunteers receiving co-trimazine 2X1000 mg or co-trimoxazole 2X960 mg for four days no or only slight activity was found in the urine against a sulphonamide-resistant Group D streptococcus, but distinct synergistic activity between the components was found against four Escherichia coli strains sensitive to trimethoprim and sensitive or resistant to sulphonamides. Against three of the latter strains the degree of activity in the urine was higher after co-trimazine than after cotrimoxazole. The synergistic action of trimethoprim and sulphonamide in the urine appeared greater with the former than with the latter combination.

[Detection of sulfamethoxazol and N4-acetylsulfamethoxazol in biological fluids by resversed-phase high-pressure liquid chromatography (author's tarnsl)]

Sulfonamide drugs can be detected by reversed-phase hihg-pressure liquid chromatography. The possibilities of this method in the direct qualitative and quantitative analysis in blood or in urine without enrichment and derivatization are illustrated by the analysis of sulfamethoxazol and its metabolite N4-acetylsulfamethoxazol.

Determination of trimethoprim and sulfamethoxazole (co-trimoxazole) in body fluids of man by means of high-performance liquid chromatography

A high-performance liquid chromatographic method for the determination of trimethoprim, sulfamethoxazole and its metabolite and a series of structurally related sulfonamides is described. The half-life time of elimination of sulfamethoxazole and its metabolite N4-acetylsulfamethoxazole is 9 h for both compounds. The renal excretion rate of sulfamethoxazole depends strongly on the urinary pH. The renal excretion rate of the metabolite N4-acetylsulfamethoxazole is not dependent on the urinary pH.

Pharmacokinetics of sulphamethoxazole in man: effects of urinary pH and urine flow on metabolism and renal excretion of sulphamethoxazole and its metabolite N4-acetylsulphamethoxazole

A high performance liquid chromatography method for the determination of sulphamethoxazole and its metabolite N4-acetylsulphamethoxazole is described. The renal excretion rate and cumulative renal excretion of sulphamethoxazole is markedly influenced by urinary pH. With constant urinary pH, the renal excretion rate and the renal clearance of sulphamethoxazole is dependent on the urine flow. The renal clearance of the metabolite N4-acetylsulphamethoxazole is not influenced by urinary pH or urine flow. No clear acetylator phenotype could be detected in the group of volunteers studied. The extent of acetylation depends on the amount of sulphamethoxazole available for acetylation, thus indirectly on the urine pH and flow.

Urinary tract infections in patients with severe renal disease. Treatment with ampicillin and trimethoprim-sulfamethoxazole

Twelve patients with severe renal failure and intercurrent urinary tract infections were treated with either ampicillin trihydrate, 500 mg four times a day, or trimethoprim-sulfamethoxazole, two tablets (80 mg trimethoprim, 400 mg sulfamethoxazole) twice a day. All patients achieved bacteriologic cure, including six with proved upper tract infection. Serum levels of all drugs were increased to values above those seen in normal subjects without adverse effects. Urine concentrations of trimethoprim, 28.6 mug/ml, and ampicillin, 88.6 mug/ml, were well above the minimum inhibitory concentrations of urinary pathogens. Urine sulfamethoxazole concentrations were less than 10 mug/ml in four of the six patients treated; however, this did not hamper bacteriologic success. It is concluded that both drugs can be used to treat urinary tract infections in patients with renal functional impairment.

The metabolism of four sulphonamides in cows

1. The metabolism of sulphanilamide, sulphadimidine (4,6-dimethyl-2-sulphanilamidopyrimidine), sulphamethoxazole (5-methyl-3-sulphanilamidoisoxazole) and sulphadoxine (5,6-dimethoxy-4-sulphanilamidopyrimidine) given by intravenous injection has been examined in cows. 2. The sulphonamides were present mainly as unchanged drugs in blood samples collected 2h after administration. 3. The sulphonamides were excreted in the milk partly as unchanged drugs and partly as conjugated metabolites whereas only small amounts were excreted as the N(4)-acetyl derivatives. 4. The unchanged drug and the N(4)-acetyl derivative were the major constituents in urine samples after administration of sulphanilamide, sulphamethoxazole and sulphadoxine. 5. Besides the unchanged drug, the N(4)-acetyl derivative and the conjugated metabolites, three further metabolites of sulphadimidine were isolated from urine samples and identified. They were 5-hydroxy-4,6-dimethyl-2-sulphanilamidopyrimidine, 4-hydroxymethyl-6-methyl-2-sulphanilamidopyrimidine and sulphaguanidine.