Pyrimethamine

Pyrimethamine

File:Pyrimethamine.svg
Clinical data
Pregnancy category	AU: B3 US: C (Risk not ruled out)
Routes of administration	Oral
ATC code	P01BD01 (WHO)
Legal status
Legal status	In general: ℞ (Prescription only)
Pharmacokinetic data
Bioavailability	well-absorbed
Protein binding	87%
Metabolism	Hepatic
Elimination half-life	96 hours
Excretion	Renal
Identifiers
IUPAC name 5-(4-chlorophenyl)-6-ethyl-2,4-pyrimidinediamine
CAS Number	58-14-0
PubChem CID	4993
DrugBank	APRD00599
E number	{{#property:P628}}
ECHA InfoCard	{{#property:P2566}}
Chemical and physical data
Formula	C12H13ClN4
Molar mass	248.71 g/mol

Pyrimethamine (Daraprim®) is a medication used for protozoal infections. It is commonly used as an antimalarial drug (for both treatment and prevention), and is also used in the treatment of Toxoplasma gondii infections in immunocompromised patients, such as HIV-positive individuals.

Mechanism of action

Pyrimethamine interferes with folic acid synthesis by inhibiting the enzyme dihydrofolate reductase. Folic acid is needed for DNA and RNA synthesis in many species, including protozoa.

Mechanism of resistance

Resistance to pyrimethamine is widespread. Mutations in the gene for dihydrofolate reductase may reduce the effectiveness of pyrimethamine (PMID 15155209). These mutations decrease the binding affinity between pyrimethamine and dihydrofolate reductase by steric interactions (PMID 14711307).

Clinical use

Pyrimethamine is typically given with a sulfonamide and folinic acid:

• Sulfonamides inhibit dihydropteroate synthetase, an enzyme that participates in folic acid synthesis from para-aminobenzoic acid. Hence, sulfonamides work synergistically with pyrimethamine by blocking a different enzyme needed for folic acid synthesis.
• Folinic acid (Leucovorin) is a compound that can be converted into folic acid by the human body without relying on dihydrofolate reductase. By doing so, folinic acid reduces side effects related to folate deficiency.

Side effects

Pyrimethamine may deplete folic acid in humans, resulting in hematologic side effects associated with folate deficiency.

Side effects include:

• hypersensitivity reactions
• megaloblastic anemia
• leukopenia
• thrombocytopenia
• pancytopenia
• atrophic glossitis
• hematuria
• cardiac arrhythmias
• pulmonary eosinophilia (rare)
• hyperphenylalaninemia (particularly when used with a sulfonamide)

Contraindications

Pyrimethamine is contraindicated in patients with:

• hypersensitivity to pyrimethamine
• megaloblastic anemia - depletion of folic acid may aggravate this condition

References

• Daraprim - Package insert (PDF file)
• Fansidar - sulfadoxine and pyrimethamine