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Dapsone (Systemic)


VA CLASSIFICATION
Primary: AM900
Secondary: AP101; AP109; AM700{07}

Commonly used brand name(s): Avlosulfon.

Another commonly used name is
DDS . {15}
Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).



Category:


Antibacterial (antileprosy agent)—

dermatitis herpetiformis suppressant—

antiprotozoal—

antifungal—

Indications

Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling.

Accepted

Leprosy (treatment)—Dapsone is indicated in combination with other antileprosy agents in the treatment of all types of leprosy (Hansen's disease) caused by Mycobacterium leprae . {08} {09} {27}

Dermatitis herpetiformis (treatment)—Dapsone is indicated in the treatment of dermatitis herpetiformis. {08} {09}

[Actinomycotic mycetoma (treatment)]—Dapsone is used in the treatment of actinomycotic mycetoma. {22} {39}

[Cicatricial pemphigoid (treatment)]1—Dapsone is used in the treatment of desquamative gingival lesions caused by cicatricial pemphigoid. {50} {51}

[Dermatosis, subcorneal pustular (treatment)]1—Dapsone is used in the treatment of subcorneal pustular dermatosis. {47}

[Granuloma annulare (treatment)]1—Dapsone is used in the treatment of granuloma annulare. {43} {48} {49}

[Lupus erythematosus, systemic (treatment)]1—Dapsone is used in the treatment of certain skin lesions of systemic lupus erythematosus, including bullous eruptions and urticarial vasculitis. {40} {41} {42}

[Malaria (prophylaxis)]1—Dapsone is used in combination with pyrimethamine as secondary agents in the prophylaxis of chloroquine-resistant malaria caused by Plasmodium falciparum . Dapsone is also used in combination with pyrimethamine and chloroquine in the prophylaxis of malaria caused by Plasmodium vivax . {04} {10}

[Pemphigoid (treatment)]1—Dapsone is used in the treatment of pemphigoid lesions with oral manifestations. {34} {35}

[Pneumonia, Pneumocystis carinii (prophylaxis and treatment)]1—Dapsone is used in combination with trimethoprim in the treatment of mild to moderate pneumonia caused by Pneumocystis carinii (PCP). {04} {05} {11} {20} {24} {56} No difference in efficacy was found in a study comparing the dapsone-trimethoprim combination with oral trimethoprim-sulfamethoxazole. However, studies have shown that dapsone alone appeared to have inferior efficacy for treatment of PCP. {20} {33} {57}
—Dapsone has also been used alone in the prophylaxis of PCP. {38} {52}

[Polychondritis, relapsing (treatment)]1—Dapsone is used in the treatment of relapsing polychondritis. {36} {37} {44} {45} {46}

[Pyoderma gangrenosum (treatment)]1—Dapsone is used in the treatment of pyoderma gangrenosum. {46} {47}

1 Not included in Canadian product labeling.



Pharmacology/Pharmacokinetics

Physicochemical characteristics:
Molecular weight—
    248.30 {12}

Mechanism of action/Effect:

Antibacterial (antileprosy agent)—Dapsone, a sulfone, is bacteriostatic and probably acts by a mechanism similar to that of the sulfonamides, interfering with folate synthesis. Both have a similar range of antibacterial activity and are antagonized by para-aminobenzoic acid. {15}

Dermatitis herpetiformis suppressant—Mechanism is unknown, but not due to dapsone's bacteriostatic effect. Dapsone may act as an enzyme inhibitor or oxidizing agent. In addition, it has numerous immunologic effects (e.g., immunosuppression), which most likely account for its suppression of dermatitis herpetiformis.

Absorption:

Slowly absorbed from the gastrointestinal tract; absorption half-life of 1.1 hours. Overall bioavailability is 70 to 80%; may be less in patients with severe leprosy. {06} An acidic environment is needed for optimal absorption. {53} {54}

Distribution:

Well distributed throughout total body water and is found in all tissues, especially liver, muscle, kidneys, and skin. {16} Saliva concentrations are 18 to 27% of corresponding plasma dapsone concentrations. Dapsone also crosses the placenta.

Vol D—1.5 L per kg (1.9 L per kg when given with pyrimethamine). {06}

Protein binding:

Dapsone—Moderate to high (70–90%). {06} {16}

Monoacetyl dapsone (MADDS)—Very high (99%). {06}

Biotransformation:

Dapsone is acetylated by N-acetyltransferase in the liver to its major metabolite, monoacetyl dapsone (MADDS). MADDS is also deacetylated to dapsone; equilibrium is reached within a few hours. Patients may be divided into slow or fast acetylators. However, unlike with other medications, no relationship has been seen between acetylator type and side effects. {06} {23} There was also no significant difference between the 2 groups in plasma concentrations or pharmacokinetics; therapeutic response was the same in both groups. {06}

Dapsone is also N-hydroxylated to dapsone hydroxylamine in the liver by the mixed oxidase system in the presence of oxygen and NADPH, and appears to be responsible for the drug's hematologic toxicity. {06} {23}

Both major metabolites have very low activity and do not contribute to the therapeutic effect of dapsone. {06}

Half-life:

10 to 50 hours (average, 30 hours) for both dapsone and MADDS. {06} {08}

Time to peak serum concentration

2 to 6 hours, but variable.

Peak serum concentration:

50 mg (single dose)—0.6 to 0.7 mcg/mL. {06}

100 mg (single dose)—1.7 to 1.9 mcg/mL. {06}

100 mg (steady state)—3.1 to 3.3 mcg/mL. {06}

Elimination:
    Renal—70 to 85% slowly excreted in the urine as dapsone and metabolites; 5 to 15% of dapsone dose excreted in urine by active tubular secretion, and the remainder excreted as metabolites. Metabolites are partly conjugated, primarily as glucuronides and sulfates. {06}
    Biliary—Enterohepatic circulation following biliary excretion of free drug also occurs. Because of this, dapsone may persist in the plasma for up to several weeks after therapy is discontinued. {06} {16}


Precautions to Consider

Cross-sensitivity and/or related problems

Patients allergic to dapsone may be allergic to sulfonamides, although this has not been clearly established.

Carcinogenicity/Tumorigenicity

Studies in male rats and female mice have shown that dapsone causes mesenchymal tumors of the spleen and peritoneum. Dapsone has been shown to cause thyroid carcinoma in female rats as well. {02} {08}

Mutagenicity

Dapsone has not been shown to be mutagenic in Salmonella typhimurium tester strains 1535, 1537, 1538, 98, or 100, when tested with or without microsomal activation. {02} {08}

Pregnancy/Reproduction

Pregnancy—
Dapsone crosses the placenta. Adequate and well-controlled studies in humans and animals have not been done. However, other studies in humans have not shown that dapsone causes adverse effects on reproductive capacity or on the fetus. Dapsone has been recommended for maintenance therapy of pregnant leprosy and dermatitis herpetiformis patients. {02} {08}

FDA Pregnancy Category C.

Breast-feeding

Dapsone is distributed into breast milk. In one case report, the concentration of dapsone in breast milk was approximately 67% of the corresponding serum concentration. The serum dapsone concentration in the nursing infant reached 27% of the mother's serum concentration. {28} In addition, dapsone could potentially cause hemolytic anemia in glucose-6-phosphate dehydrogenase (G6PD)–deficient neonates. {02} {08}

Pediatrics

Appropriate studies on the relationship of age to the effects of dapsone have not been performed in the pediatric population. However, no pediatrics-specific problems have been documented to date. Dapsone is generally not considered to have an effect on the later growth, development, and functional development of the child. {08}


Geriatrics


No information is available on the relationship of age to the effects of dapsone in geriatric patients.

Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):


Note: Combinations containing any of the following medications, depending on the amount present, may also interact with this medication.

Aminobenzoates (PABA)    (concurrent use in the treatment of leprosy is not recommended since aminobenzoates may be absorbed by bacteria preferentially over sulfones, thereby antagonizing the bacteriostatic effect of sulfones; however, aminobenzoates do not antagonize the effect of dapsone in the treatment of dermatitis herpetiformis {17})


Blood dyscrasia–causing medications (See Appendix II )    (dapsone may, on rare occasions, cause an idiosyncratic agranulocytosis, aplastic anemia, or other blood dyscrasias; if concurrent use is required, close observation for myelotoxic effects should be considered)


» Didanosine (ddI)    (concurrent administration of dapsone with ddI may decrease the absorption of dapsone; ddI must be given with a buffer to neutralize stomach acidity in order to increase its absorption, and dapsone requires an acidic environment for optimal absorption; until studies are completed that confirm this interaction, dapsone should be administered at least 2 hours before or 2 hours after ddI is given {53} {66})


» Hemolytics, other (See Appendix II )    (concurrent use with dapsone may increase the potential for toxic side effects)


Rifampin    (concurrent use may stimulate hepatic microsomal enzyme activity, resulting in as much as a 7- to 10-fold decrease in dapsone concentrations; however, dapsone dosage adjustments are not required during concurrent rifampin therapy for leprosy since dapsone concentrations are still higher than the MIC, although they may be required in the treatment of other diseases, such as PCP {01} {06} {08})


Trimethoprim    (concurrent use with dapsone may increase the plasma concentrations of both dapsone and trimethoprim, possibly due to an inhibition in dapsone metabolism, and/or competition for renal secretion between the 2 medications; increased serum dapsone concentrations may increase the frequency and severity of side effects, especially methemoglobinemia and hemolytic anemia {23})


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Risk-benefit should be considered when the following medical problems exist
Allergy to dapsone or sulfonamides
» Anemia, severe or
» Glucose-6-phosphate dehydrogenase (G6PD) deficiency or
» Methemoglobin reductase deficiency    (hemolytic anemia may occur {02} {08})


Hepatic function impairment    (dapsone may cause toxic hepatitis and cholestatic jaundice; alcoholic liver disease may decrease the plasma protein binding of dapsone, increasing the amount of circulating free drug {02} {06} {08})



Patient monitoring
The following may be especially important in patient monitoring (other tests may be warranted in some patients, depending on condition; » = major clinical significance):

» Alanine aminotransferase (ALT [SGPT]) and
» Aspartate aminotransferase (AST [SGOT])    (values should be determined prior to and periodically during treatment; dapsone should be discontinued if there is evidence of progressive hepatic damage {08})


Blood urea nitrogen and
Creatinine, serum    (determinations required periodically during treatment in patients with severely impaired renal function, who may also require a reduction in dose; dapsone should be discontinued in anuric patients)


» Complete blood counts (CBCs) and
» Platelet counts and
» Reticulocyte count    (required prior to treatment, followed by monthly counts for 1 to 3 months, and semi-annually thereafter; in patients with HIV infection, CBCs are recommended every 2 to 3 days for the first 2 to 3 weeks of therapy; {31} if a significant reduction in leukocytes, platelets, or hematocrit occurs, or if there is an increase in the reticulocyte count, dapsone should be discontinued and the patient should be monitored closely {02} {03} {08})


Glucose-6-phosphate dehydrogenase (G6PD) concentration    (determination recommended in patients at high risk prior to treatment; if a deficiency is found, dapsone should be given with extreme caution since hemolytic effects may be exaggerated; dosage adjustments may be required {19})


Methemoglobin, serum    (level should be obtained in patients with cyanosis, lightheadedness, fatigue, headache, or shortness of breath; dapsone should be discontinued at a methemoglobin level of > 20%, and treatment with methylene blue should be considered in symptomatic patients with levels > 30% {54} {59})




Side/Adverse Effects

Note: When dapsone is used in high doses, peripheral motor weakness may occur more frequently.
Fatalities have occurred due to agranulocytosis, aplastic anemia, and other blood dyscrasias. In addition, serious cutaneous reactions, such as exfoliative dermatitis, toxic erythema, erythema multiforme, toxic epidermal necrolysis, morbilliform and scarlatiniform reactions, and erythema nodosum may occur. Dapsone therapy should be promptly discontinued if new or toxic dermatologic reactions occur. However, leprosy reactional states do not require discontinuation of therapy. {02}
A dose-related hemolysis is seen in all patients, with a slight decrease in hemoglobin and an increase in reticulocyte count. Patients with G6PD-deficiency or a decrease in activity in glutathione reductase are more susceptible to hemolysis. A low level of methemoglobinemia also occurs in all patients at recommended doses.

The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive:

Those indicating need for medical attention
Incidence more frequent {08}
    
Hemolytic anemia (back, leg, or stomach pains; loss of appetite; pale skin; unusual tiredness or weakness; fever)
    
hypersensitivity (skin rash)
    
methemoglobinemia (cyanosis—bluish fingernails, lips, or skin; difficult breathing; unusual tiredness or weakness)

Incidence rare {08}
    
Blood dyscrasias (fever and sore throat; unusual bleeding or bruising; unusual tiredness and weakness)
    
exfoliative dermatitis (itching, dryness, redness, scaling, or peeling of the skin or loss of hair)
    
hepatic damage (yellow eyes or skin)
    
mood or other mental changes
    
peripheral neuritis (numbness, tingling, pain, burning, or weakness in hands or feet)
    
``sulfone syndrome'' (fever; malaise; exfoliative dermatitis; jaundice; lymphadenopathy; methemoglobinemia; anemia)—a hypersensitivity reaction that usually occurs after 6 to 8 weeks of therapy{29}{30}



Those indicating need for medical attention only if they continue or are bothersome
Incidence rare
—usually dose-related{08}    
Central nervous system toxicity (headache; insomnia; nervousness)
    
gastrointestinal disturbances (anorexia; nausea or vomiting)





Overdose
For more information on the management of overdose or unintentional ingestion, contact a Poison Control Center (see Poison Control Center Listing ).

Treatment of overdose
Recommended treatment consists of the following {08}:

To decrease absorption—

Performance of gastric lavage. Gastric emptying of dapsone may be delayed after an overdose, and tablet fragments have been found in stomach returns after lavage as late as 5 to 12 hours post-ingestion. {25}

Administration of activated charcoal (30 grams), concurrently with a cathartic, every 6 hours for at least 48 to 72 hours. Repeated doses of activated charcoal reduce the half-life of dapsone and MADDS by approximately 50% to 12.7 hours. {06} {25}

Specific treatment—

In emergency situations, slow, intravenous administration of methylene blue, 1 to 2 mg per kg of body weight (mg/kg). Methylene blue should not be given to fully expressed G6PD-deficient patients. May be repeated if methemoglobin reaccumulates. A continuous infusion of methylene blue has also been used to prevent toxicity from accidental ``over-bolusing'' of methylene blue, and permit titration of the infusion to methemoglobin levels. A 0.05% solution in 0.9% sodium chloride is usually started at a rate of 0.1 mg/kg per hour. {25} {26}

Supportive care—Patients in whom intentional overdose is known or suspected should be referred for psychiatric consultation.


Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Dapsone (Systemic).

In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Before using this medication
»   Conditions affecting use, especially:
Allergy to sulfonamides

Pregnancy—Dapsone crosses the placenta





Breast-feeding—Dapsone is distributed into breast milk; it may cause hemolytic anemia in G6PD-deficient neonates
Other medications, especially other hemolytics and didanosine
Other medical problems, especially severe anemia, G6PD deficiency, or methemoglobin reductase deficiency

Proper use of this medication

» Proper dosing
Missed dose: Taking as soon as possible; not taking if almost time for next dose; not doubling doses

» Proper storage

For leprosy
» Compliance with full course of therapy, which may take years

» Importance of not missing doses and taking at same time every day

For dermatitis herpetiformis
Possible need for gluten-free diet

For Pneumocystis carinii pneumonia
» Compliance with full course of therapy

Precautions while using this medication
Regular visits to physician to check progress

Checking with physician if no improvement within 2 to 3 months (leprosy), within 1 week (PCP), or within a few days (dermatitis herpetiformis)


Side/adverse effects
Signs of potential side effects, especially hemolytic anemia, blood dyscrasias, hypersensitivity reactions, methemoglobinemia, exfoliative dermatitis, peripheral neuropathy, hepatic damage, “sulfone syndrome”, and mood and other mental changes


General Dosing Information
Since bacterial resistance may develop when dapsone is administered alone in the treatment of leprosy, for initial treatment, concurrent administration with rifampin is generally recommended. Clofazimine, ethionamide, or prothionamide (investigational) may be used in place of rifampin, but they are considered less effective. {32}

Dapsone therapy should be discontinued promptly if new or toxic dermatologic reactions occur {08}. However, leprosy reactional states do not require discontinuation of therapy. {02} Large doses of corticosteroids should be given if severe “reversal” reactions (type 1) or neuritis occurs during treatment of leprosy. {02} {08}

Depending on the drug regimen used, therapy may have to be continued for 6 months to 3 years or more in indeterminate and tuberculoid leprosy, 2 to 10 years in borderline (dimorphous) leprosy, and 2 years to life in lepromatous leprosy. {01} {08}

In the treatment of dermatitis herpetiformis, a gluten-free diet for 6 months may allow a reduction in dose by approximately 50% or discontinuation of dapsone. {08}


Oral Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

DAPSONE TABLETS USP

Usual adult and adolescent dose
Leprosy (Hansen's disease)
Oral, in combination with one or more other antileprosy agents, 50 to 100 mg of dapsone once a day; or 1.4 mg per kg of body weight once a day. {01} {02} {03} {08}

Dermatitis herpetiformis suppressant
Oral, initially 50 mg daily. Doses may be increased up to 300 mg daily if symptoms are not completely controlled. The dose should then be reduced to the lowest effective maintenance dose as soon as possible. {08} {63} {64}

[Actinomycotic mycetoma]
Oral, 100 mg twice a day for several months after clinical symptoms have disappeared. {22}

[Dermatosis, subcorneal pustular]1
Oral, initially 100 mg once a day, increasing the dose by 50 mg every one to two weeks until remission occurs. The dose should then be gradually reduced to the lowest effective maintenance dose. {47}

[Granuloma annulare]1
Oral, 100 mg once a day. {43} {48} {49}

[Malaria (prophylaxis)]1
Oral, 100 mg of dapsone in combination with 12.5 mg of pyrimethamine once every seven days. {58}

[Pneumonia, Pneumocystis carinii]1
Treatment: Oral, 100 mg of dapsone once a day in combination with 20 mg per kg of body weight per day of trimethoprim, for twenty-one days. {05} {20} {23} {24}

Prophylaxis: Oral, 50 to 100 mg once a day. {65}

[Polychondritis, relapsing]1
Oral, 100 mg once or twice a day. {44} {45} {46} {61}

[Pyoderma gangrenosum]1
Oral, 50 to 100 mg once a day, in combination with other medications. {46} {47}


Usual adult prescribing limits
Leprosy (Hansen's disease)
Up to 100 mg daily. {60}

Dermatitis herpetiformis suppressant
Up to 300 mg daily. {22}

Polychondritis, relapsing1
Up to 200 mg daily. {44} {45} {46}


Usual pediatric dose
Leprosy (Hansen's disease)
Oral, in combination with one or more other antileprosy agents, 1.4 mg of dapsone per kg of body weight once a day. {01} {03}

Dermatitis herpetiformis suppressant
Oral, initially 2 mg per kg of body weight daily. Doses may be increased if symptoms are not completely controlled. The dose should then be reduced to the lowest effective maintenance dose as soon as possible. {62} {63} {64}

[Pneumonia, Pneumocystis carinii (prophylaxis)]1
In children older than 1 month of age: Oral, 1 mg per kg of body weight, up to 100 mg daily. {55}


Strength(s) usually available
U.S.—


25 mg (Rx)[Generic] (may be scored)


100 mg (Rx)[Generic] (may be scored)

Canada—


100 mg (Rx) [Avlosulfon (scored)]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed, light-resistant container. {08}

Auxiliary labeling:
   • Continue medicine for full time of treatment (for leprosy and PCP).



Revised: 03/17/1994



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