Is Methylene Blue Safe

In Patients With Methemoglobinemia

And Glucose 6-phosphate
Dehydrogenase (G6PD) Deficiency?

Bob Hoffman
New York City Poison Center,
NY, USA
Overview
Review of G6PD deficiency
Review of methemoglobinemia (very brief)
Review of methylene blue (MB) (brief)
Attempt to answer the question
Expert opinion
Case reports
In Vitro data
Introduction
G6PD deficiency one of the most
common inherited disorders, 400 million
people affected
Largely in tropical and subtropical countries
Selection advantages
Against Plasmodium falciparum infection
Most affected individuals asymptomatic,
but the risk of acute hemolysis is well
known

Frequency of G6PD deficiency
Genetics
> 400 variants described
Different electrophoretic mobility, kinetic
properties.
5 classes according to the residual enzyme
activity based (WHO).
Mediterranean and African (A-) variants
The most clinically significant.
Activity scarcely detectable in the Mediterranean
type but close to normal in the African variant.
Inheritance of G6PD Deficiency
What Do We Need G6PD For?
Phosphogluconate pathway

Pentose phosphate pathway

Hexose monophosphate pathway

Hexose monosphosphate shunt
G6PD
Catalyzes the first step in the
pentose phosphate pathway
Regulatory enzyme
The enzyme is highly specific for NADP
+
; the
K
m
for NAD
+
is 1000 greater than for NADP
+
.

Pentose Phosphate Yields
Ribulose (ribose) 5-phosphate
Essential nucleotide in biosynthesis
leading to:
DNA
RNA
Various cofactors
CoA, FAD, SAM, NAD
+
/NADP
+

Glutathione
reductase uses
NADPH as a
cofactor to
reduce GSSG
back to two
moles of GSH.
G6PD Deficiency
G6PD deficiency is not the absence of
G6PD, it is a decreased activity
Many cells express G6PD
Red cells are the only important cell line
because they lack a nucleus
Activity of G6PD highest (normal) in young
erythrocytes and decreases with aging
Oxidants preferentially destroy senescent red
blood cells
Response to Oxidants
Oxidant Response
If not reduced:
Some produce hemolysis
Oxidation of the hemoglobin chain
Some produce MetHb
Oxidation of iron
Some produce both?
Physiology
Direct reduction of the oxidant
Oxidant Reduced Oxidant
Glutathione
Sulfhydryls
Ascorbate
Catalase
RBCs with Heinz Bodies
Precipitation of
hemoglobin due to
disulfide bond formation
between Hb molecues
Upper photo shows
distorted RBCs with
large Heinz bodies
Bottom photo shows
RBC stained with
methylene blue
Methemoglobin Definition
Oxidation of the iron molecule in
hemoglobin from its normal Fe
2+
to Fe
3+

Fe
N
N
N
N
histidine
O
2-
Oxyhemoglobin
C O
COHb
O
H
H
Methemoglobin
Physiology
The oxidant is reduced by Hb (forming MetHb)
Then MetHb is reduced back to Hb
MetHb Reduced Hb
NADH MetHb reductase (67%)
Ascorbate (15%)
Glutathione (12%)
NADPH Met Hb reductase (5%)
Can You Use Methylene Blue In
Patients with G6PD Deficiency?


Famous Textbook Quotes
Methylene blue remains the first line therapy
even in patients with known G6PD deficiency
Brent
Should never be administered to someone with
known G6PD deficiency
Shannon
Should be used cautiously in patients with G6PD
deficiency
Dart
28 year old man
Ingested 60-120mL of 18% aniline
MetHb 11 gm/dL (70-80%)
75 mg methylene blue given
Didnt get better
G6PD screening showed deficiency (A
-
)
Given ascorbate
Hemolyzed, Hb fell, recovered
Rosen PJ: Failure of methylene blue treatment in toxic
methemoglobinemia. Association with glucose-6-phosphate
dehydrogenase deficiency. Ann Intern Med 1971;75:83-6
What
happened
between the
0 and 4 hour
levels?
26 month, 9.8-kg boy with G6PD deficiency
Ingested 90 mL of nitroethane MetHb 23.3%
MetHb rises to 37%, then over 40%
Cyanotic, in respiratory failure, intubated
Two doses of methylene blue (2mg/kg) given
without response
No hemolysis
Finally treated with exchange transfusion
Golden PJ: Treatment of high-risk, refractory acquired
methemoglobinemia with automated red blood cell exchange. J
Clin Apher 1998;13:28-31.
74 G6PD deficient men
3 day regimen
Chloroquine 1500 mg
Methylene blue 780 mg (mg/kg PO BID)
No hemolysis occurred
Mandi G: Safety of the combination of chloroquine and
methylene blue in healthy adult men with G6PD deficiency from
rural Burkina Faso. Trop Med Int Health. 2005;10:32-8.
3 case reports
Intraamniotic methylene blue given for
PROM (2); IV for maternal MetHb (1)
Dose varied
All developed elevated bilirubin
Only 2 G6PD deficient
Gauthier TW: Methylene blue-induced hyperbilirubinemia in
neonatal glucose-6-phosphate dehydrogenase (G6PD)
deficiency. J Matern Fetal Med. 2000;9:252-4.
Neonate, known G6PD deficiency
Multiple cardiac abnormalities
Undergoes surgical repair on day 28 of life
Requires nitroglycerin IV
Develops MetHb: 75%
Given low dose (0.1 mg/kg) methylene blue
Has mild hemolysis requiring no therapy
Middali MM: Postoperative methemoglobinemia with
associated G-6-P-D deficiency in infant cardiac
surgery--enigmas in diagnosis and management.
Paediatr Anaesth 2005;15:334-7.
59-year-old man with metastatic renal cell CA
Trial of 3-aminopyridine-2-carboxaldehyde
thiosemicarbazone (3-AP; Triapine)
Developed MetHb 35%
Given 3 doses (1 mg/kg) methylene blue
MetHb fell to 10%, then 6.5 %
Masive hemolysis
Severe G6PD deficiency confirmed later
Foltz LM: Recognition and management of
methemoglobinemia and hemolysis in a G6PD-
deficient patient on experimental anticancer drug
Triapine. Am J Hematol 2006;81:210-1.
Metoclopramide 10 mg administered twice
Cyanosis and dyspnea; 28 hours later
MetHb was 43%
Ascorbic acid 150 mg and methylene blue 60
mg given
Consciousness deteriorated
Methylene blue 40 mg was repeated at 2 hours
Deteriorated rapidly and he died 12 hours
Blood taken a before death was hemolysed
Postmortem: b5R and severely G6PD deficient
Karadsheh NS: Metoclopramide-induced methemoglobinemia in a
patient with co-existing deficiency of glucose-6-phosphate
dehydrogenase and NADH-cytochrome b5 reductase: failure of
methylene blue treatment Haematologica 2001;86:659
25 year old man; large dermal exposure to
aniline
5 hours later MetHb 51%
Methylene blue 40mg IV improved symptoms
MetHb fell to 2.1%
Developed significant hemolysis
G6PD deficient
Recovered (transfused)
Liao YP: Hemolytic anemia after methylene blue therapy for
aniline-induced methemoglobinemia. Vet Hum Toxicol.
2002;44:19-21.
In Vivo Summary
Does Methylene blue fail?
Often works
Usually slowly
Does methylene blue cause hemolysis
It can, and it can be severe
Especially when hemolysis is present prior to
therapy
Beutler E: Methemoglobin Reduction: Studies of
the interaction between cell popluations and of the
role of methylene blue. Blood 1963;22:323-333
Incubated human RBCs with nitrite to
induce MetHb
Treated with methylene blue and glucose
Observed rates of fall
Normal cells
G6PD cells (A
-
)
Mixture of cells
Implications
G6PD deficient cells clear MetHb slowly in
response to methylene blue
Either NADPH or leukomethylene blue can
move from healthy cells to deficient cells
This effect is more pronounced at lower
levels of MetHb
Young cells and reticulocytes are G6PD
present
Role of transfusion (fresh blood)?
Summary (1)
Data on the use of methylene blue in
patients with G6PD deficiency are limited
Most support some degree of efficacy
Significant risk of hemolysis
Would administer methylene blue in:
Patients with no history of G6PD deficiency
Patients with known G6PD deficiency and life-
threatening MetHb
Ascorbate, Exchange transfusion, HBO, NAC
Summary (2)
Withhold methylene blue in:
Patients with known severe variant G6PD
deficiency (Mediterranean) not significantly ill
Patients with known or suspected G6PD
deficiency and marginal indications for
treatment
Patients with significant active hemolysis in
addition to MetHb
Summary (3)
If giving methylene blue to patients with a
known or suspected history of G6PD
deficiency
Keep the first dose small (1 mg/kg)
Recheck the MetHb often
Do not repeat if unsuccessful
Observe closely for hemoylsis