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Drug Metabolism Letters, 2012, 6, 129-133 129

The Metabolic Rationale for a Lack of Cross-reactivity Between

Sulfonamide Antimicrobials and Other Sulfonamide-containing Drugs

David F. Lehmann*

Medicine and Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA

Abstract: Sulfonamide antimicrobials (sulfamethoxazole) contain an arylamine group, oxidized by CYP2C9 to the
hydroxylamine with subsequent auto-oxidation to a highly reactive [-nitroso-] intermediate is a necessary (if not
sufficient) cause of drug hypersensitivity. Accordingly, xenobiotics that do not contain an arylamine cannot generate this
reactive intermediate and do not cross react with sulfonamide antimicrobials. Despite this well-attested observation,
product labeling and direct-to-consumer advertising for non-arylamine therapeutic classes of drugs containing the
sulfonamido- functional group persist with a warning of the potential for cross-reactivity. It is hoped that by offering an
explicit rationale for the lack of cross-reactivity will provide medical practitioners with a level comfort to proceed with
prescribing medications such as thiazide diuretics and celecoxib for patients with a history of hypersensitivity to
sulfonamide antimicrobials.
Keywords: Antimicrobials, cross-reactivity, hypersensitivity, metabolism, sulfonamides.

Drug hypersensitivity (drug reaction with eosinophilia
and systemic symptoms) is a rare, idiosyncratic, and
potentially life threatening reaction occurring in an
immunologically predisposed individual upon exposure to a
culprit drug that generates reactive intermediates upon
metabolism [1]. Although certain genetically-based risk
factors in the immune systems of such individuals have
been identified in population-based epidemiological studies,
the exact cellular alterations that these associations produce
to cause hypersensitivity remain undetermined [2]. By
contrast, the identification of certain organic groups
contained within the structure of culprit drugs combined
with the understanding of specific alterations in their
metabolism that predispose to hypersensitivity is further
advanced [1].
This review documents the pharmacogenetic and disease-
related changes in drug metabolism associated with
hypersensitivity from sulfonamide antimicrobials, therein
identifying the specific cellular perturbations that these
changes produce. In so doing, the rationale for the lack of
cross-reactivity between sulfonamide antimicrobials and
other sulfonamide-containing drugs will be clearly
articulated.
Individuals who ingest drugs that contain the primary
arylamine organic group are at risk of developing
hypersensitivity reactions [1]. Two such compounds,
sulfamethoxazole and procainamide are unrelated to each
other in their pharmacology and therapeutic uses (anti-
infective and antiarrhythmic, respectively) but both share the
primary arylamine group [3,4]. The chemical structures of
each are shown in Fig. (1).
The inverse association between the rate of N-acetylation
of the primary arylamine and the development of drug
induced systemic lupus erythematosus-like syndrome from
procainamide was first suggested by Davies, et al., in 1975
[5]. This observation was soon followed by the manufacture
and marketing of N-acetyl procainamide as an antiarrhythmic
drug, due to its lack of association with hypersensitivity
reactions [6]. Similarly, in 1986, Shear, et al., observed that
children who had the phenotype of rapidly acetylating the
amine group at the benzyl N-4 (primary arylamine) position
on sulfamethoxazole were at a lower risk of developing
hypersensitivity reactions compared to children with the
slow acetylator phenotype [7]. These observations
concerning the metabolism of primary arylamine-containing
compounds extended prior observations for the same inverse
relationship between the rate of hydrazide acetylation
within hydralazine (an antihypertensive) and isoniazid (an
antitubercular) and their propensity to cause hypersensitivity
[8,9].
O
H₂N C NH CH₂ CH₂ (CH₂)₂
PROCAINAMIDE
H₂N SO₂NH
N
CH₃
O

SULFAMETHOXAZOLE
*Address correspondence to this author at the Medicine and Pharmacology,
SUNY Upstate Medical University, Syracuse, New York, USA; Tel: 315-464- Fig. (1). Chemical structures of sulfamethoxazole and procainamide.
5365; Fax: 315-464-5776; E-mail: lehmannd@upstate.edu The arylamine structure that is common to both drugs is bolded.

187-/12 $58.00+.00 ©2012 Bentham Science Publishers

130 Drug Metabolism Letters, 2012, Vol. 6, No. 2
Fig. (2). Sulfamethoxazole and procainamide acetylation and
hydroxylation steps. Reactions: 1, N-acetylation catalyzed by N-
acetyltransferase (NAT2); 2, oxidation catalyzed by enzymes of the
CYP gene superfamily. Reproduced with permission from David F.
Lehmann, Daria LaRocca, Michael J. Rieder and Peter D. Holohan.
2004, HIV-1 Tat induced alterations in oxidation-reduction potential
as a model to extend the understanding of drug idiosyncrasy, Current
Topics in Virology, Vol. 4, 89-95.
The enzyme responsible for acetylation, N-
acetyltransferase (NAT2), shows a bimodal distribution in
humans with the homozygous poor metabolizer genotype
(NAT2*5B/*5B) conferring slow acetylator status [10].
Slow acetylation of either the primary arylamine or
hydrazide group therefore provides more of the parent
(unchanged) drug to be available for alternative enzymatic
pathways and, for primary arylamine- and hydrazide-
containing compounds, oxidation is the predominant
alternative pathway. As shown in Fig. (2), oxidation of the
1
RHNO₂S NHOH
2
5
hydroxylamine GSSG
5
Fig. (3). Sulfamethoxazole hydroxylamine metabolism. The heavy, bold arrows indicate the reactions that predominate in HIV in proportion
to the degree of infection. Reactions: 1, autooxidation; 2, reduction; 3, conjugation catalyzed by glutathione S-transferase (GST); 4, non-
catalyzed protein/DNA adducts; and 5, reduction of oxidized glutathione (GSSG) catalyzed by glutathione reductase. Reproduced with
permission from David F. Lehmann, Daria LaRocca, Michael J. Rieder and Peter D. Holohan. 2004, HIV-1 Tat induced alterations in oxidation-
reduction potential as a model to extend the understanding of idiosyncrasy, Current Topics in Virology, Vol. 4, 89-95.
David F. Lehmann
primary arylamine moiety results in the formation of the
corresponding hydroxylamine for both sulfamethoxazole and
procainamide.
Since phase I oxidation occurs via enzymes encoded by
the highly polymorphic superfamily of genes, cytochrome
P450 (CYP), investigations to determine the relationship
between the pharmacogenetics of the CYP system and
sulfonamide antimicrobial hypersensitivity were performed.
The confirmation that sulfamethoxazole is oxidized to the
hydroxylamine was soon followed by the identification of
CYP 2C9 as the specific gene responsible for this formation
by Cribb, et al., [11,12]. Lee et al., showed a greater amount
of sulfamethoxazole hydroxylamine in the urine of HIV-
infected individuals with hypersensitivity compared to
those without hypersensitivity [13]. We extended these
observations by noting a relationship between the degree of
oxidative metabolism and sulfonamide antimicrobial
hypersensitivity within a cohort of patients infected with
human immunodeficiency virus (HIV) [14]. We then
observed that the homozygous extensive metabolizer
genotype (CYP 2C9*1/*1) was present in a patient with a
concomitant mitochondrial mutation who had a history of
hypersensitivity to sulfamethoxazole [15].
In vitro studies using peripheral blood mononuclear cells
(PBMCs) extracted from patients with a history of hyper-
sensitivity reactions to sulfonamide antimicrobials have
shown a concentration-dependent relationship of PBMC
lysis upon exposure to sulfamethoxazole hydroxylamine
[16]. The likely culprit for this toxicity was subsequently
determined to be the [-nitroso] intermediate, generated by
the autooxidation of sulfamethoxazole. Intact cellular
homeostasis, provided by a favorable reduced-to-oxidized
glutathione ratio maintains a favorable redox state and as
catalyzed by glutathione reductase favors the hydroxylamine
form of the metabolite (Fig. 3) [17].
Fig. (3) demonstrates the cellular metabolism that occurs
following the generation of sulfamethoxazole hydroxylamine
by CYP 2C9 oxidation. Oxidative stress brought about by
RHNO₂S N=O
GSH nitroso-
+GSH protein
3 4
glutathione neoantigen
conjugate
Metabolism of Sulfonamides and Relationship to Cross-reactivity
disease (HIV) and by certain genetic mutations in
mitochondria result in a marked alteration in the cellular
redox state manifested by a significant decrease in the
normal favorable ratio of reduced to oxidized glutathione
[15,18]. For HIV, the extent of intracellular retrovirus
replication generates a large burden of the Tat viral protein
that, in turn, causes oxidative stress through inhibition of
superoxide dismutase to cause a greater amount of
glutathione to exist in the oxidized form, as shown in Fig. (4)
[19]. The specific mutation of TC at 11204 in the ND4
subunit of respiratory complex I (C1) in mitochondrial DNA,
causes oxidative stress by the inhibition of cellular
respiration to increase the formation of reactive oxygen
species, thereby decreasing the ratio of reduced to oxidized
glutathione; similar to the effect of the HIV tat protein
[15,20].
HIV
TAT
SOD
+ [3].
Oxidative
Stress
Susceptibility
GDH/GSSG
GSH/GSSG
SMXHA [SMX nitroso] hypersensitivity
Fig. (4). Hypothesized linkage of HIV replication and
sulfamethoxazole hypersensitivity. Tat, HIV tat protein; SOD,
superoxide dismutase; GSH, reduced glutathione; GSSG, oxidized
glutathione; + , ehancement of HIV replication; SMXHA, sulfa-
methoxazole hydroxylamine, [SMX nitroso], nitorso intermediate
of sulfamethoxazole. Reproduced with permission from David F.
Lehmann, Andrew Liu, Nancy Newman, Donald C. Blair. Journal of
Clinical Pharmacology, Volume 39, No. 5, May 1999 by Sage
Publications, Inc. All rights reserved. ©1999 American College of
Clinical Pharmacology. Inc.
As further shown in [Fig. (3), reaction 3], the presence
of the homozygous (double null) mutation of the phase
II drug metabolizing enzyme, glutathione-S-transferase
(GSTM1*0/*0, GSTT1*0/*0) results in a lack of functional
enzymatic activity [15,21]. In addition to sulfonamide
antimicrobials, this double null mutation of GST has been
also associated with hypersensitivity to tacrine (a
cholinesterase inhibitor used for Alzheimer’s dementia) and
troglitazone (a peripheral peroxisome activating receptor-
gamma agonist used for type 2 diabetes) [21,22].
Drug Metabolism Letters, 2012, Vol. 6, No. 2 131
Thus, hypersensitivity from sulfonamide antimicrobials
appears to be caused by a combination of genetic and
disease-related factors. The cumulative impact of genetic
factors that increase oxidation of the primary arylamine
forms a greater amount of the hydroxylamine metabolite that
then autooxidizes to the culprit reactive intermediate [-
nitroso] to an extent corresponding to the degree of cellular
oxidative stress. Further, in the absence of functional GST,
this increased amount of the [-nitroso] cannot be
metabolically cleared. The sum of these cellular processes
leads to an excessive burden of the [-nitroso] that then forms
non-catalytic adducts of cellular proteins and DNA. These
adducts are the highly immunogenic compounds that are
then introduced to the dendritic cells of the immune system,
leading to hypersensitivity [Fig. (3), Reaction 4].
Despite well-documented severe hypersensitivity
reactions involving skin, liver, kidneys, and bone marrow,
sulfonamide antimicrobials remain important in the United
States compendia. Pharmaceutical preparations containing a
sulfonamide antimicrobial in a fixed combination with a
dihydrofolate reductase inhibitor are principally used to treat
uncomplicated urinary tract infections and in the treatment
and prophylaxis of parasitic infections in immuno-
compromised patients, including those infected with HIV
Sulfonamide antimicrobials all share two organic
chemical functional groups: a sulfonamide and a primary
arylamine, with the amine located in the N-4 position (para-
to the sulfonamide-containing carbon) (Fig. 1). Both organic
functional groups are essential to the mechanism of action by
sulfonamide antimicrobials to act as an analogue to para
amino benzoic acid, competing for access to dihydropteroate
synthase (the microbial enzyme responsible for manufacture
of folic acid) [3].
As discussed previously, the primary arylamine group is
a necessary, but not sufficient, cause in the development of
hypersensitivity from sulfonamide antimicrobials and they
are the only drug class in the compendia that have a primary
arylamine in the para- position in relation to a sulfonamide
group on the benzene ring (Fig. 1) [3]. Therefore, since no
other sulfonamide-containing xenobiotics also contain a
primary arylamine group within their chemical structure,
they cannot produce the reactive intermediate [-nitroso]
which is absolutely essential to cause hypersensitivity.
Although prior reports assert the lack of cross-reactivity
between sulfonamide antimicrobials and other sulfonamide-
containing drugs, Strom, et al., made to date the most definitive
observation from the field of pharmacoepidemiology [23-
26]. In part, Strom, et al., observed that the likelihood of a
patient suffering an allergic reaction from a newly exposed
compound depends more on the number of drugs that the
patient had been previously exposed to rather than the
individual chemical characteristics inherent to the
compounds themselves [23]. The extension of this
observation is that a patient with a penicillin allergy who
has, for example, five other bona-fide allergic reactions is at
far higher risk of suffering the sixth allergy to the new
compound without any relationship to the newly exposed
132 Drug Metabolism Letters, 2012, Vol. 6, No. 2
compound’s chemical structure. This observation is an
elegant definition for the term “idiosyncratic” (i.e. patient-
centered) that accompanies all descriptions of drug hyper-
sensitivity [1].
Thus, despite this clear consistency of the clinical
continuum between otherwise healthy children, to patients
with rare mitochondrial-deletion syndromes, to AIDS
patients, coupled with robust observations from the fields of
drug metabolism and pharmacoepidemiology, the incorrect
cross-reactivity label has persisted between sulfonamide anti-
microbials and other sulfonamide-containing drugs. Product
labeling and direct-to-consumer advertising for non primary
arylamine-containing drugs with the sulfonamide group,
e.g. thiazide diuretics [27] and celecoxib [28], continue to
warn of the potential for cross-reactivity, despite further
documentation against this conclusion [29]. Specifically for
celecoxib, since it is a tertiary (not primary) arylamine,
oxidation can neither generate a hydroxylamine nor its auto-
oxidized nitrosamine [30]. Although speculative, likely
reasons for the continuation of this misleading information
provided to physicians and consumers are twofold.
First, a lack of a sense of significant alacrity that product
labeling should be changed exists. Second, litigation fears
by pharmaceutical manufacturers derived from the tenet
that one can never prove the negative in the field of
pharmacoepidemiology further exacerbates this problem.
These factors that likely contribute to the perpetuation of
this information are not benign. Indeed, fear of prescribing a
drug that may cause a serious patient outcome is likely the
greatest deterrent for physicians following the dictum of
primum non nocere. It adds unnecessarily to continued
consultations at those hospitals that have fully functional
clinical pharmacology consultation services, further adding
to time and expense. Lastly, our profession is replete with
clinical situations and reports that cause us anxiety. Any
attempt to alleviate this load should be viewed as welcome.
CONFLICT OF INTEREST
The author(s) confirm that this article content has no
conflict of interest.
ACKNOWLEDGEMENT
Declared none.
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Received: February 27, 2012 Revised: May 03, 2012 Accepted: May 30, 2012