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AZAPROPAZONE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) A pyrazolon derivative non-steroidal antiinflammatory released in 1970 (Green et al, 1985). It has been shown in animal studies to have analgesic, antipyretic and antiinflammatory properties (Jones, 1976).

Specific Substances

    A) AZAPROPAZONE
    1) AHR 3018
    2) Apazone
    3) MI 85
    4) Azapren
    5) Cinnamin
    6) Rheumox
    7) Sinnamin
    AZAPROPAZONE DIHYDRATE
    1) Prolixan
    2) Tolyprin

Available Forms Sources

    A) USES
    1) As an NSAID, azapropazone has been used in the treatment of rheumatoid arthritis and ankylosing spondylitis and, as a uricosuric agent, azapropazone has been used for the treatment of acute gout (S Sweetman , 2001).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) WITH THERAPEUTIC USE
    1) Azapropazone side effects are primarily gastrointestinal in nature, although this agent is less of an irritant than most other non-steroidal anti-inflammatory drugs. Other side effects include rashes (8%) (especially photosensitivity), and rarely vertigo or renal failure.
    B) WITH POISONING/EXPOSURE
    1) There have been few overdoses reported. Estimation of toxic overdose effects are extensions of therapeutic side effects.
    0.2.7) NEUROLOGIC
    A) WITH THERAPEUTIC USE
    1) Vertigo has been reported in a few cases.
    0.2.8) GASTROINTESTINAL
    A) WITH THERAPEUTIC USE
    1) Dyspepsia, abdominal pain, and diarrhea are side effects.
    B) WITH POISONING/EXPOSURE
    1) Vomiting and additional irritant effects might be expected in overdose.
    0.2.10) GENITOURINARY
    A) WITH THERAPEUTIC USE
    1) There was one case report of renal failure with use of azapropazone; this is not a common effect.
    0.2.13) HEMATOLOGIC
    A) ANIMAL STUDIES - Anemia has been reported in animal studies.
    B) WITH THERAPEUTIC USE
    1) Anemia has been reported is not well documented in human cases.
    0.2.14) DERMATOLOGIC
    A) WITH THERAPEUTIC USE
    1) Various skin rashes (especially photosensitivity) have been reported with therapeutic use.
    B) WITH POISONING/EXPOSURE
    1) The extent that rashes occur in overdose is unknown.
    0.2.20) REPRODUCTIVE
    A) Animal studies did not find teratogenic potential.
    0.2.22) OTHER
    A) DRUG INTERACTION - Drug interactions have been reported with phenytoin, warfarin, and tolbutamide.

Laboratory Monitoring

    A) Azapropazone can be determined by HPLC in urine and plasma. Other laboratory values have not shown consistent abnormalities in humans taking the drug therapeutically. Until more is known, a CBC and renal function tests should be obtained in significant overdoses.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) A toxic dose has not been established. Amounts greater than the therapeutic amount increase gastrointestinal irritation, but the relationship is not a direct one.
    B) For amounts greater than therapeutic doses, activated charcoal may be of some use until more specific information is available.
    C) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.

Range Of Toxicity

    A) Minimum lethal human exposure is unknown.

Clinical Effects

Summary Of Exposure

    A) WITH THERAPEUTIC USE
    1) Azapropazone side effects are primarily gastrointestinal in nature, although this agent is less of an irritant than most other non-steroidal anti-inflammatory drugs. Other side effects include rashes (8%) (especially photosensitivity), and rarely vertigo or renal failure.
    B) WITH POISONING/EXPOSURE
    1) There have been few overdoses reported. Estimation of toxic overdose effects are extensions of therapeutic side effects.

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) PNEUMONIA
    1) WITH THERAPEUTIC USE
    a) Alveolitis was reported in several patients following long-term (>9 months) azapropazone therapy. All patients experienced dyspnea and rales. Chest radiographs revealed bilateral pulmonary infiltration. The alveolitis resolved in all patients following administration of corticosteroids and cessation of azapropazone therapy (Albazzaz et al, 1986). One patient experienced a recurrence of pulmonary signs and symptoms upon rechallenge with azapropazone. Again, the signs and symptoms disappeared upon discontinuation of the azapropazone and administration of corticosteroids.

Neurologic

    3.7.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Vertigo has been reported in a few cases.
    3.7.2) CLINICAL EFFECTS
    A) DIZZINESS
    1) WITH THERAPEUTIC USE
    a) Vertigo has been reported as a side effect of azapropazone therapy (Grennan, 1977).

Gastrointestinal

    3.8.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Dyspepsia, abdominal pain, and diarrhea are side effects.
    B) WITH POISONING/EXPOSURE
    1) Vomiting and additional irritant effects might be expected in overdose.
    3.8.2) CLINICAL EFFECTS
    A) ABDOMINAL PAIN
    1) WITH THERAPEUTIC USE
    a) Gastric pain or gastrointestinal upset occurred in about 14% of 51 patients undergoing a clinical trial with this agent (Wheatley, 1984). Azapropazone is considered to have low ulcerogenic potential compared to other non-steroidal antiinflammatories (Rainsford, 1982).
    B) DIARRHEA
    1) WITH THERAPEUTIC USE
    a) Diarrhea has been reported in clinical trials (Thomas et al, 1983).

Genitourinary

    3.10.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) There was one case report of renal failure with use of azapropazone; this is not a common effect.
    3.10.2) CLINICAL EFFECTS
    A) RENAL FAILURE SYNDROME
    1) WITH THERAPEUTIC USE
    a) Although early studies did not report renal complications (Templeton, 1978; Del Favero, 1981), acute tubulointerstitial nephritis resulting in renal failure occurred in an adult taking 900 mg/day (Sipila et al, 1983).

Hematologic

    3.13.1) SUMMARY
    A) ANIMAL STUDIES - Anemia has been reported in animal studies.
    B) WITH THERAPEUTIC USE
    1) Anemia has been reported is not well documented in human cases.
    3.13.2) CLINICAL EFFECTS
    A) LEUKOPENIA
    1) WITH THERAPEUTIC USE
    a) CASE REPORT - (4.1 x 10(9) white cells/liter) was noted in a woman who had been taking 1200 milligrams of azapropazone daily for 5 weeks. The woman had signs consistent with early chronic lymphatic leukemia (Green et al, 1985).
    B) ANEMIA
    1) WITH THERAPEUTIC USE
    a) CASE REPORT - Normochromic anemia (3.52 x 10(12) red cells/liter) was reported in a woman who had been taking 1200 milligrams of azapropazone daily for 5 weeks. The woman had signs consistent with early chronic lymphatic leukemia (Green et al, 1985).
    C) HEMOLYTIC ANEMIA
    1) WITH THERAPEUTIC USE
    a) Hemolytic anemia was reported in several patients following long-term (>9 months) azapropazone therapy. Hemoglobin concentrations ranged from 74 g/L to 108 g/L, the reticulocyte count ranged from 7% to 64%, and a direct Coombs test yielded positive results in all patients. Following cessation of azapropazone therapy and administrationof corticosteroids, the blood counts normalized in all patients (Albazzaz et al, 1986; Chan-Lam et al, 1986).

Dermatologic

    3.14.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Various skin rashes (especially photosensitivity) have been reported with therapeutic use.
    B) WITH POISONING/EXPOSURE
    1) The extent that rashes occur in overdose is unknown.
    3.14.2) CLINICAL EFFECTS
    A) PHOTOSENSITIVITY
    1) WITH THERAPEUTIC USE
    a) Photosensitivity has been reported with therapeutic use. These reactions did not appear to affect the patient seriously, but produced varying amounts of eczema, edema, dermatitis, and maculopapular rashes.
    b) Based on the number of adverse reaction reports, photosensitivity is seen more often than with any other NSAID other than benoxaprofen (Anon, 1976; Olsson et al, 1985; Anon, 1994).
    B) DERMATITIS
    1) WITH THERAPEUTIC USE
    a) Rash or eczema was seen in 8% of a 51 patient clinical trial using therapeutic doses of azapropazone (Wheatley, 1984).
    C) BULLOUS ERUPTION
    1) WITH THERAPEUTIC USE
    a) CASE REPORT - Subepidermal bullae very similar to bullous pemphigoid were seen in a 68-year-old with no previous skin disease. She had been taking 1200 mg daily for four weeks. No IgG or C3 complement deposit was seen along the basement membrane (Barker & Cotterill, 1977) 1977a).

Reproductive

    3.20.1) SUMMARY
    A) Animal studies did not find teratogenic potential.
    3.20.2) TERATOGENICITY
    A) ANIMAL STUDIES
    1) Animal studies did not find teratogenic potential (Adrian et al, 1976).

Carcinogenicity

    3.21.3) HUMAN STUDIES
    A) LACK OF EFFECT
    1) Initial animal studies did not show carcinogenicity.
    3.21.4) ANIMAL STUDIES
    A) LACK OF EFFECT
    1) Initial animal studies did not show carcinogenicity (Adrian et al, 1976).

Genotoxicity

    A) Animal experiments did not find antimitotic activity (Adrian et al, 1976).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Azapropazone can be determined by HPLC in urine and plasma. Other laboratory values have not shown consistent abnormalities in humans taking the drug therapeutically. Until more is known, a CBC and renal function tests should be obtained in significant overdoses.
    4.1.2) SERUM/BLOOD
    A) OTHER
    1) Most studies that have looked into chronic use of this agent have not found consistent laboratory abnormalities (Thune, 1976a; Eberl, 1976).

Methods

    A) CHROMATOGRAPHY
    1) Azapropazone can be determined by HPLC in plasma and urine (Budavari, 1989).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) Azapropazone can be determined by HPLC in urine and plasma. Other laboratory values have not shown consistent abnormalities in humans taking the drug therapeutically. Until more is known, a CBC and renal function tests should be obtained in significant overdoses.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) A toxic dose has not been established. Amounts greater than the therapeutic amount increase gastrointestinal irritation, but the relationship is not a direct one.
    2) For amounts greater than therapeutic doses, activated charcoal may be of some use until more specific information is available.
    B) ACTIVATED CHARCOAL
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
    2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) A toxic dose has not been established. Amounts greater than the therapeutic amount increase gastrointestinal irritation, but the relationship is not a direct one.
    2) For amounts greater than therapeutic doses, gastric decontamination may be of some use until more specific information is available.
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) SUPPORT
    1) There is no specific treatment or antidote. Treatment is symptomatic and supportive.

Enhanced Elimination

    A) SUMMARY
    1) Azapropazone is highly protein bound, and is not likely to respond well to most extracorporeal procedures.
    2) No studies have addressed the utilization of extracorporeal elimination techniques in poisoning with this agent.

Range Of Toxicity

Summary

    A) Minimum lethal human exposure is unknown.

Therapeutic Dose

    7.2.1) ADULT
    A) GENERAL
    1) The therapeutic dose varies considerably, but is generally between 900 and 1800 milligrams per day (Eberl, 1976; Thune, 1976a).

Minimum Lethal Exposure

    A) GENERAL/SUMMARY
    1) The minimum lethal human dose to this agent has not been delineated.

Maximum Tolerated Exposure

    A) GENERAL/SUMMARY
    1) The maximum tolerated human exposure to this agent has not been delineated.

Serum Plasma Blood Concentrations

    7.5.2) TOXIC CONCENTRATIONS
    A) TOXIC CONCENTRATION LEVELS
    1) GENERAL
    a) THERAPEUTIC BLOOD LEVELS - In 10 patients taking 800 milligrams daily ranged from 25 to 106 nanograms/milliliter of blood.
    b) Although there was considerable inter-patient variation, intrapatient variation over the first 20 days (when levels were taken) was small (Thune, 1976).

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) LD50- (INTRAPERITONEAL)MOUSE:
    1) 920 mg/kg (RTECS, 2001)
    B) LD50- (ORAL)MOUSE:
    1) 1080 mg/kg (Adrian et al, 1976)
    C) LD50- (INTRAPERITONEAL)RAT:
    1) 650 mg/kg (RTECS, 2001)
    D) LD50- (ORAL)RAT:
    1) 1950 mg/kg (Adrian et al, 1976)
    2) 1800 mg/kg (RTECS, 2001)
    E) LD50- (ORAL)MOUSE:
    1) > 3000 mg/kg (Adrian et al, 1976)
    F) LD50- (ORAL)RAT:
    1) 3300 mg/kg (Adrian et al, 1976)
    G) LD50- (ORAL)MOUSE:
    1) 1400 mg/kg (Adrian et al, 1976)
    H) LD50- (ORAL)RAT:
    1) 1800 mg/kg (Adrian et al, 1976)
    I) LD50- (ORAL)MOUSE:
    1) > 3000 mg/kg (Adrian et al, 1976)
    J) LD50- (ORAL)RAT:
    1) 4200 mg/kg (Adrian et al, 1976)
    K) LD50- (ORAL)MOUSE:
    1) 1950 mg/kg (Adrian et al, 1976)
    L) LD50- (ORAL)RAT:
    1) 1900 mg/kg (Adrian et al, 1976)

Physicochemical

Physical Characteristics

    A) This compound is a colorless, crystalline compound (Adrian et al, 1977).

Molecular Weight

    A) 300.37

Animal Toxicology

Clinical Effects

    11.1.3) CANINE/DOG
    A) GASTROINTESTINAL EFFECTS - In animals studied, beagle dogs (but not mongrel dogs) were much more sensitive to the gastric irritation/gastrointestinal ulceration effects than were other species studied.
    1) Beagles examined after being given 100 to 200 milligrams/day for a week or more developed pyloric ulcers, peritonitis, pitting of the small intestine mucosa, and local areas of inflammation (Adrian et al, 1976).
    B) HEMATOLOGIC EFFECTS - Examination of the bone marrow of beagle dogs, but not mongrel dogs, showed a reduction in total cells, especially the red cell precursors and megakaryocytes. No abnormal cells were seen.
    1) Reticulocytosis, elevated white cell count, and increased numbers of platelets were also noted (Adrian et al, 1976).

References

General Bibliography

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