Methenamine Mandelate

Pronunciation

Class: Urinary Anti-infectives
Note: This monograph also contains information on Methenamine, Methenamine Hippurate
VA Class: AM550
CAS Number: 100-97-0
Brands: Hiprex, Mandelamine, Urex

Introduction

Antibacterial.100 101 102

Uses for Methenamine Mandelate

Urinary Tract Infections (UTIs)

Prophylaxis or suppression of recurrent UTIs (bacteriuria), especially when long-term therapy is considered necessary.100 101 102

Use only after UTI has been eradicated by other appropriate anti-infectives.100 101

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Not effective in systemic bacterial infections and has no effect on bacteria in blood or tissues outside the urinary tract.a Do not use alone in the treatment of acute parenchymal infections causing systemic symptoms (e.g., chills, fever).100 102

Monitor efficacy by periodic urine cultures.100 101

Antibacterial effects are maximal when urine pH is ≤5.5.102 Monitor urinary pH during therapy; use supplementary acidification, if required.101 102 Supplementary acidification may be achieved by dietary regulation and/or concomitant administration of acidifying agents (e.g., ammonium chloride, ascorbic acid, methionine).a This is particularly important when the causative organisms are urea-splitting strains of Proteus or Pseudomonas which increase urinary pH.100 101

Methenamine Mandelate Dosage and Administration

General

  • Acidic urine is essential for antibacterial activity; maximum efficacy occurs when urine pH is ≤5.5.102 Restrict alkalinizing food and medication;101 102 use supplemental acidification if needed.100 101 102 a

Administration

Oral Administration

Administer orally.100 101 102

Dosage

Available as methenamine hippurate and methenamine mandelate; dosage expressed in terms of the salt.100 101 102

Pediatric Patients

Prophylaxis or Suppression of Urinary Tract Infections (UTIs)
Methenamine Hippurate
Oral

Children <6 years of age: Dosage not established.a

Children 6–12 years of age: 500 mg to 1 g twice daily (morning and night).100 101

Children >12 years of age: 1 g twice daily (morning and night).100 101

Methenamine Mandelate
Oral

Children <6 years of age: 18.4 mg/kg 4 times daily, (after meals and at bedtime).102

Children 6–12 years of age: 500 mg 4 times daily (after meals and at bedtime).102

Children >12 years of age: 1 g 4 times daily (after meals and at bedtime).102

Alternatively, some clinicians recommend 50 mg/kg daily in 3 divided doses for children.a

Adults

Prophylaxis or Suppression of Urinary Tract Infections (UTIs)
Methenamine Hippurate
Oral

1 g twice daily (morning and night).100 101

Methenamine Mandelate
Oral

1 g 4 times daily (after meals and at bedtime).102

Special Populations

No special population dosage recommendations at this time.100 101 102

Cautions for Methenamine Mandelate

Contraindications

  • Known hypersensitivity to the drug.102

  • Renal insufficiency.100 101 102

  • Severe hepatic insufficiency100 101 or severe dehydration.100 101

Warnings/Precautions

Warnings

Dysuria

Large doses (8 g daily for 3–4 weeks) have caused bladder irritation, painful and frequent micturition, albuminuria, and gross hematuria.100 101

Dysuria may be controlled by reducing dosage and/or reducing urine acidification.102

Hepatic Effects

Patients with preexisting hepatic insufficiency may have adverse effects from the small amounts of ammonia and formaldehyde that are produced following administration of methenamine.100 Acute hepatic failure may occur in some patients.100

Transient elevations in serum AST and ALT concentrations have occurred in patients receiving methenamine hippurate.100 101

Perform periodic liver function tests in patients receiving methenamine hippurate, especially in those with hepatic impairment.100 101 (See Hepatic Impairment under Cautions.)

Sensitivity Reactions

Tartrazine Sensitivity

Hiprex tablets contain tartrazine (FD&C yellow No. 5), which may cause allergic reactions, including bronchial asthma, in susceptible individuals.101 Incidence of tartrazine sensitivity is low, but it frequently occurs in patients who are sensitive to aspirin.101

General Precautions

Acidic Urine

Ensure that urine is maintained at an acidic pH during treatment, especially when causative organisms are urea-splitting strains of Proteus or Pseudomonas.100 101 (See Dosage and Administration.)

Manufacturer of methenamine mandelate states the drug is not recommended if urine acidification is contraindicated or unattainable (e.g., when some urea-splitting bacteria are present).102

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of methenamine and other antibacterials, use only to prevent infections proven or strongly suspected to be caused by susceptible bacteria.101

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.101 In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.101

Specific Populations

Pregnancy

Category C.100 102

One manufacturer of methenamine hippurate states that safety during the last trimester is suggested, but not definitely proven.101

Effects of methenamine during labor and delivery are unknown and there are no recognized uses for the drug during labor or delivery.100

Lactation

Distributed into milk; discontinue nursing or the drug.100

Pediatric Use

Has been used in children without unusual toxicity.100

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether they respond differently than younger adults; clinical experience has not identified differences.101

Select dosage with caution, usually starting at the low end of the dosage range, because of possible age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy.101

Hepatic Impairment

Perform periodic liver function tests.100 101

Methenamine hippurate is contraindicated in those with severe hepatic insufficiency.100 101

Common Adverse Effects

GI disturbances (nausea, vomiting, diarrhea, abdominal cramps, anorexia), pruritus, rash, dysuria.100 101 102 a

Interactions for Methenamine Mandelate

Specific Drugs and Laboratory Tests

Drug or Test

Interaction

Comments

Sulfonamides

Insoluble precipitate forms in urine between formaldehyde and some sulfonamides (e.g., sulfamethizole, sulfathiazole [not commercially available in the US])100 101 102

Avoid concomitant use100 101 102

Test for 17-hydroxycorticosteroid

Formaldehyde in urine causes falsely elevated concentrations when Porter-Silber method is used102

Test for 5-hydroxyindoleacetic acid (5HIAA)

Formaldehyde in urine causes falsely decreased concentrations when nitrosonaphthol methods are used102

Test for urinary catecholamines and vanillylmandelic acid (VMA)

Formaldehyde in urine causes erroneously high results when fluorometric procedures are used102

Test for urine estriol

Formaldehyde in urine causes falsely decreased urine estriol concentrations when acid hydrolysis techniques are used101 102

Enzymatic hydrolysis technique unaffected101 102

Methenamine Mandelate Pharmacokinetics

Absorption

Bioavailability

Readily absorbed from the GI tract.a About 10–30% of oral dose is hydrolyzed by gastric acidity to formaldehyde and ammonia.a Enteric coating of methenamine mandelate tablets reduces hydrolysis in the GI tract and rate of absorption.a

Plasma Concentrations

Following oral administration of a usual single dose to healthy fasting adults, concentrations of methenamine and formaldehyde in plasma are generally very low and antibacterial activity in plasma is negligible.a

Distribution

Extent

Crosses the placenta.100

Distributed into milk.100

Elimination

Elimination Route

Within 24 hours, ≥70–90% of a single oral dose is excreted intact in the urine by glomerular filtration and tubular secretion.a When urine is acidic, methenamine is hydrolyzed to formaldehyde and ammonia; maximum hydrolysis occurs when urine pH is ≤5.5.a

Mandelic acid (mandelate) and hippuric acid (hippurate) are excreted in urine by glomerular filtration and tubular excretion.101 102

Stability

Storage

Oral

Tablets

15–30°C100 101 102 in tight, light resistant containers.102

Actions and Spectrum

  • Synthetic antibacterial agent chemically unrelated to other currently available anti-infectives.a

  • Antibacterial effect of methenamine hippurate or methenamine mandelate depends on conversion of methenamine to formaldehyde in an acid medium (acidic urine).a

  • Formaldehyde is a nonspecific antibacterial agent which is usually bactericidal in action.a The acid portions of methenamine salts (hippuric acid, mandelic acid) have some nonspecific antibacterial activity and may enhance the liberation of formaldehyde from methenamine in vivo by maintaining urinary acidity.a

  • Formaldehyde is active against both gram-positive and gram-negative bacteria including Enterobacter, Escherichia coli, Klebsiella, Proteus, Pseudomonas aeruginosa, Staphylococcus aureus, S. epidermidis, and Enterococcus faecalis (formerly Streptococcus faecalis).a

  • Because formaldehyde, hippuric acid, and mandelic acid have nonspecific antibacterial activity, resistance does not usually develop during prolonged therapy with methenamine hippurate or methenamine mandelate.a

Advice to Patients

  • Advise patients that antibacterials (including methenamine hippurate and methenamine mandelate) should only be used for bacterial infections and not used to treat viral infections (e.g., the common cold).101

  • Importance of completing full course of therapy, even if feeling better after a few days.101

  • Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with methenamine or other antibacterials in the future.101

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs or laboratory tests.100 101 102

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.100 101 102

  • Importance of informing patients of other important precautionary information.100 101 102 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Methenamine Hippurate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets

1 g*

Hiprex (with povidone and tartrazine; scored)

Sanofi-Aventis

Methenamine Hippurate Tablets

Corepharma

Urex (with povidone; scored)

Vatring

Methenamine Mandelate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

500 mg

Mandelamine Hafgrams (with povidone and polyethylene glycol)

Warner Chilcott

1 g

Mandelamine (with povidone and polyethylene glycol)

Warner Chilcott

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Hiprex 1GM Tablets (SANOFI-AVENTIS U.S.): 20/$53.99 or 60/$151.17

Methenamine Hippurate 1GM Tablets (COUNTY LINE PHARMACEUTICALS): 100/$185.99 or 300/$535.97

Urex 1GM Tablets (VATRING PHARMACEUTICALS): 30/$68.99 or 90/$199.97

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions January 1, 2008. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

References

100. Vatring. Urex (methenamine hippurate) prescribing information. Wytheville, VA; 2004 Aug.

101. Sanofi-Aventis. Hiprex (methenamine hippurate) prescribing information. Bridgewater, NJ; 2006 Mar.

102. Warner Chilcott. Mandelamine (methenamine mandelate) prescribing information. Rockaway, NJ; 2006 Oct.

a. AHFS Drug Information 2007. McEvoy GK, ed. Methenamine. Bethesda, MD: American Society of Health-System Pharmacists; 2007:889-90.

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