Levamisole

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Levamisole
Skeletal formula of levamisole
Ball-and-stick model of the levamisole molecule
Clinical data
Trade names Ergamisol
AHFS/Drugs.com Micromedex Detailed Consumer Information
MedlinePlus a697011
Routes of
administration		 By mouth
ATC code P02CE01 (WHO) QP52AE01 (WHO)
Legal status
Legal status
  • CA: Withdrawn drug
  • US: Withdrawn drug
  • Rx-only (RU)
Pharmacokinetic data
Metabolism Liver
Biological half-life 3–4 hours
Excretion Urine (70%)
Identifiers
CAS Number 14769-73-4 YesY
PubChem (CID) 26879
IUPHAR/BPS 7210
DrugBank DB00848 YesY
ChemSpider 25037 YesY
UNII 2880D3468G YesY
KEGG D08114 YesY
ChEBI CHEBI:6432 N
ChEMBL CHEMBL1454 YesY
ECHA InfoCard 100.035.290
Chemical and physical data
Formula C11H12N2S
Molar mass 204.292 g/mol
3D model (Jmol) Interactive image
Density 1.31 g/cm3
Melting point 60 °C (140 °F)
 NYesY (what is this?)  (verify)

Levamisole, sold under the trade name Ergamisol among others, is a medication used to treat parasitic worm infections.[1] Specifically it is used for ascariasis and hookworm infections. It is taken by mouth.[2]

Side effects may include abdominal pain, vomiting, headache, and dizziness. Use is not recommended during breastfeeding or the third trimester of pregnancy.[2] Serious side effects may include an increased risk of infection. It belongs to the antihelmintic class of medications.[3]

Levamisole was discovered in 1966.[4] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[5] The wholesale cost in the developing world is about 0.18 to 0.33 USD for a course of treatment.[6] It is not commercially available in the United States.[3] Levamisole is also used as a dewormer for livestock.[7]

Medical uses[edit]

Worms[edit]

Levamisole was originally used as an anthelmintic to treat worm infestations in both humans and animals. Levamisole works as a nicotinic acetylcholine receptor agonist that causes continued stimulation of the parasitic worm muscles, leading to paralysis. In countries that still permit the use of levamisole, the recommended dose for anthelmintic therapy is a single dose, with a repeated dose 7 days later if needed for a severe hookworm infection.[8] Most current commercial preparations are intended for veterinary use as a dewormer in cattle, pigs, and sheep. However, levamisole has also recently gained prominence among aquarists as an effective treatment for Camallanus roundworm infestations in freshwater tropical fish.[9]

Cancer[edit]

After being pulled from the market in the U.S. and Canada in 1999 and 2003, respectively, levamisole has been tested in combination with fluorouracil to treat colon cancer. Evidence from clinical trials support its addition to fluorouracil therapy to benefit patients with colon cancer. In some of the leukemic cell line studies, both levamisole and tetramisole showed similar effect.[10]

Other[edit]

Levamisole has been used to treat a variety of dermatologic conditions, including skin infections, leprosy, warts, lichen planus, and aphthous ulcers.[11]

An interesting adverse side effect these reviewers reported in passing was "neurologic excitement". Later papers, from the Janssen group and others, indicate levamisole and its enantiomer, dexamisole, have some mood-elevating or antidepressant properties, although this was never a marketed use of the drug.[12][13]

Adverse effects[edit]

One of the more serious side effects of levamisole is agranulocytosis, or the depletion of the white blood cells. In particular, neutrophils appear to be affected the most. This occurs in 0.08–5% of the studied populations.[14] There have also been reports of levamisole induced necrosis syndrome in which erythematous painful papules can appear almost anywhere on skin.

It has been used as an adulterant in cocaine resulting in serious side effects.[15][16][17]

Metabolism[edit]

Levamisole is readily absorbed from the gastrointestinal tract and metabolized in the liver. Its time to peak plasma concentration is 1.5–2 hours. The plasma elimination half-life is fairly quick at 3–4 hours which can contribute to not detecting Levamisole intoxication. The metabolite half-life is 16 hours. Levamisole's excretion is primarily through the kidneys, with about 70% being excreted over 3 days. Only about 5% is excreted as unchanged levamisole.[18][19]

Drug testing of racehorse urine has led to the revelation that among levamisole equine metabolites are both pemoline and aminorex, stimulants that are forbidden by racing authorities.[20][21][22] Further testing confirmed aminorex in human and canine urine, meaning that both humans and dogs also metabolize levamisole into aminorex.[23] The stimulant properties of aminorex contribute to the use of levamisole as a cocaine adulterant, potentiating the reinforcing effects of cocaine.

Detection in body fluids[edit]

Levamisole may be quantified in blood, plasma, or urine as a diagnostic tool in clinical poisoning situations or to aid in the medicolegal investigation of suspicious deaths involving adulterated street drugs. About 3% of an oral dose is eliminated unchanged in the 24-hour urine of humans. A post mortem blood levamisole concentration of 2.2 mg/L was present in a woman who died of a cocaine overdose.[24][25]

Illicit use[edit]

Levamisole has increasingly been used as a cutting agent in cocaine sold around the globe with the highest incidence being in the USA. In 2008–2009, levamisole was found in 69% of cocaine samples seized by the Drug Enforcement Administration (DEA).[15] By April 2011, the DEA reported the adulterant was found in 82% of seizures.[26]

Levamisole adds bulk and weight to powdered cocaine (whereas other adulterants produce smaller "rocks" of cocaine) and makes the drug appear purer.[27] In a series of investigative articles for The Stranger, Brendan Kiley details other rationales for levamisole's rise as an adulterant: possible stimulant effects, a similar appearance to cocaine, and an ability to pass street purity tests.[28]

Levamisole suppresses the production of white blood cells, resulting in neutropenia and agranulocytosis. With the increasing use of levamisole as an adulterant, a number of these complications have been reported among cocaine users.[15][29][30] Levamisole has also been linked to a risk of vasculitis,[31] and two cases of vasculitic skin necrosis have been reported in users of cocaine adulterated with levamisole.[32]

Levamisole-tainted cocaine was linked to several high-profile deaths. Toxicology reports showed levamisole, along with cocaine, was present in DJ AM's body at the time of his death.[33] Andrew Koppel, son of newsman Ted Koppel, was also found with levamisole in his body after his death was ruled a drug overdose.[34] More recently it has also been suspected in the death of a Sydney teenager.[35]

In response to the dangers, The Stranger, People's Harm-Reduction Alliance and DanceSafe began producing tests to identify levamisole's presence in cocaine. The kits include a survey postcard, and one revealed its presence in a 1/4-kg block of cocaine, indicating both users and dealers were using the kits.[36]

Chemistry[edit]

The original synthesis at Janssen Pharmaceutica resulted in the preparation of a racemic mixture of two enantiomers, whose hydrochloride salt was reported to have a melting point of 264–265 °C; the free base of the racemate has a melting point of 87–89 °C.

Toxicity[edit]

The LD50 (intravenous, mouse) is 22 mg/kg.[37]

Laboratory use[edit]

Levamisole reversibly and noncompetitively inhibits most isoforms of alkaline phosphatase (e.g., human liver, bone, kidney, and spleen) except the intestinal and placental isoform.[38] It is thus used as an inhibitor along with substrate to reduce background alkaline phosphatase activity in biomedical assays involving detection signal amplification by intestinal alkaline phosphatase, for example in in situ hybridization or Western blot protocols.

It is used to immobilize the nematode C. elegans on glass slides for imaging and dissection.[39]

In a C. elegans behavioral assay, analyzing the time course of paralysis provides information about the neuromuscular junction. Levamisole acts as an acetylcholine receptor agonist, which leads to muscle contraction. Continuing activation leads to paralysis. The time course of paralysis provides information about the acetylcholine receptors on the muscle. For example, mutants with fewer acetylcholine receptors may paralyze slower than wild type.[40]

Research[edit]

It has also been studied as a method to stimulate the immune system as part of the treatment of cancer.[41]

References[edit]

  1. ^ Keiser, J; Utzinger, J (23 April 2008). "Efficacy of current drugs against soil-transmitted helminth infections: systematic review and meta-analysis.". JAMA. 299 (16): 1937–48. doi:10.1001/jama.299.16.1937. PMID 18430913. 
  2. ^ a b WHO Model Formulary 2008 (PDF). World Health Organization. 2009. pp. 86, 590. ISBN 9789241547659. 
  3. ^ a b "Levamisole Advanced Patient Information - Drugs.com". www.drugs.com. Retrieved 8 December 2016. 
  4. ^ Prevenier, Martha Howelland Walter (2001). From reliable sources : an introduction to historical methods (1. publ. ed.). Ithaca: Cornell university press. p. 77. ISBN 9780801485602. 
  5. ^ "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Retrieved 8 December 2016. 
  6. ^ "Levamisole". International Drug Price Indicator Guide. Retrieved 1 December 2016. 
  7. ^ Taylor, M. A.; Coop, R. L.; Wall, R. L. (2015). Veterinary Parasitology. John Wiley & Sons. p. 329. ISBN 9781119073673. 
  8. ^ "Levamisole (Martindale: The Complete Drug Reference)". Lexicomp. Retrieved 21 April 2014. 
  9. ^ Sanford, Shari (2007). "Levamisole Hydrochloride: Its application and usage in freshwater aquariums". Loaches Online. Retrieved 2009-02-27. 
  10. ^ (Chirigos et al. (1969, 1973, 1975)).
  11. ^ Scheinfeld N, Rosenberg JD, Weinberg JM (2004). "Levamisole in dermatology: a review". Am J Clin Dermatol. 5 (2): 97–104. doi:10.2165/00128071-200405020-00004. PMID 15109274. 
  12. ^ Vanhoutte, P. M.; et al. (1977). J. Pharmacol. Exp. Ther. 200: 127–140.  Missing or empty |title= (help)
  13. ^ Przegalinski, E.; et al. (1980). Pol. J. Pharmacol. Pharm. Sci. 32: 21–29.  Missing or empty |title= (help)
  14. ^ "Levamisole" (PDF). DEA. Retrieved 21 April 2014. 
  15. ^ a b c Centers for Disease Control and Prevention (CDC) (December 2009). "Agranulocytosis associated with cocaine use - four States, March 2008-November 2009". Morb. Mortal. Wkly. Rep. 58 (49): 1381–5. PMID 20019655. 
  16. ^ Chang, A; Osterloh, J; Thomas, J (September 2010). "Levamisole: a dangerous new cocaine adulterant.". Clinical pharmacology and therapeutics. 88 (3): 408–11. doi:10.1038/clpt.2010.156. PMID 20668440. 
  17. ^ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/411574/acmd_final_report_12_03_2015.pdf
  18. ^ Kouassi, E (1986). "Novel assay and pharmacokinetics of levamisole and p-hydroxylevamisole in human plasma and urine". Biopharmaceutics and Drug Disposition. 7 (1): 71–89. doi:10.1002/bdd.2510070110. PMID 3754161. 
  19. ^ Luyckx, M (1982). "Pharmacokinetics of levamisole in healthy subjects and cancer patients". European Journal of Drug Metabolism and Pharmacokinetics. 7 (4): 247–54. doi:10.1007/bf03189626. PMID 7166176. 
  20. ^ J. Guiterrez et al. (2010) "Pemoline and tetramisole 'positives' in English racehorses following levamisole administration." Irish Veterinary Journal 63:8 498-500.
  21. ^ E.N. Ho et al. (2009) "Aminorex and pemoline as metabolites of levamisole in the horse." Anal Chem Acta. 638(1); 58-68.
  22. ^ J. Scarth et al. (2010) "The use of in vitro drug metabolism studies to complement, reduce and refine in vivo administrations in medication and doping control." Proceedings of the 18th International Conference of Racing Analyists and Veterinarians. pp 213-222
  23. ^ Bertol E, Mari F, Milia MG, Politi L, Furlanetto S, Karch SB (2011). "[Determination of aminorex in human urine samples by GC-MS after use of levamisole.]". J Pharm Biomed Anal. 15 (55): 1186–9. doi:10.1016/j.jpba.2011.03.039. PMID 21531521. 
  24. ^ Vandamme, TF; Demoustier, M; Rollmann, B (1995). "Quantitation of levamisole in plasma using high performance liquid chromatography". Eur. J. Drug Metab. Pharmacokinet. 20 (2): 145–149. doi:10.1007/bf03226369. 
  25. ^ R. Baselt, Disposition of Toxic Drugs and Chemicals in Man, 9th edition, Biomedical Publications, Seal Beach, CA, 2011, pp.901-902. http://www.biomedicalpublications.com/levamisole.pdf.
  26. ^ Moisse, Katie (2011-06-23). "Cocaine Laced With Veterinary Drug Levamisole Eats Away at Flesh". ABC News. Retrieved 2011-06-23. 
  27. ^ Doheny, Kathleen (Jun 1, 2010). "Contaminated Cocaine Can Cause Flesh to Rot". Yahoo!. Retrieved 8 June 2010. [dead link]
  28. ^ Kiley, Brendan (August 17, 2010). "The Mystery of the Tainted Cocaine". The Stranger. Retrieved December 21, 2010. 
  29. ^ Nancy Y Zhu; Donald F. LeGatt; A Robert Turner (February 2009). "Agranulocytosis After Consumption of Cocaine Adulterated With Levamisole". Annals of Internal Medicine. 150 (4): 287–289. doi:10.7326/0003-4819-150-4-200902170-00102. PMID 19153405. Retrieved 2009-10-07. 
  30. ^ Kinzie, Erik (April 2009). "Levamisole Found in Patients Using Cocaine". Annals of Emergency Medicine. 53 (4): 546–7. doi:10.1016/j.annemergmed.2008.10.017. PMID 19303517. Retrieved 2009-08-18. 
  31. ^ Menni S, Pistritto G, Gianotti R, Ghio L, Edefonti A (1997). "Ear lobe bilateral necrosis by levamisole-induced occlusive vasculitis in a pediatric patient". Pediatr Dermatol. 14 (6): 477–9. doi:10.1111/j.1525-1470.1997.tb00695.x. PMID 9436850. 
  32. ^ Bradford, M., Rosenberg, B., Moreno, J., Dumyati, G. (June 2010). "Bilateral necrosis of earlobes and cheeks: another complication of cocaine contaminated with levamisole". Ann. Intern. Med. 152 (11): 758–9. doi:10.7326/0003-4819-152-11-201006010-00026. PMID 20513844. 
  33. ^ "'Kate Plus Eight' is enough". The San Francisco Chronicle. September 29, 2009. Retrieved January 21, 2014. 
  34. ^ Parascandola, Rocco (2010-06-18). "Ted Koppel's son, Andrew Koppel, overdosed on cocktail containing booze, heroin, cocaine and Valium". Daily News. New York. 
  35. ^ Olding, Rachel (2014-01-12). "Young man's death highlights the tragic reality of online illegal drug stores". Sydney Morning Herald. Sydney. 
  36. ^ Brendan Kiley (September 11, 2012). "Now Drug Dealers (Not Just Users) Are Testing Their Cocaine for Levamisole". The Stranger. Retrieved September 14, 2012. 
  37. ^ J. Symoens et al. (1979). In Pharmacological and Biochemical Properties of Drug Substances, Vol. 2, (M. E. Goldberg, Ed.), pp. 407-464, Washington: American Pharmaceutical Association.
  38. ^ Van Belle, H. (1976). "Alkaline phosphatase. I. Kinetics and inhibition by levamisole of purified isoenzymes from humans". Clin. Chem. 22 (7): 972–6. PMID 6169. 
  39. ^ http://genetics.wustl.edu/tslab/protocols/dissection-staining-in-situ/gonad-dissections/ Schedl Lab Protocol for gonad dissections
  40. ^ http://www.wormbook.org/chapters/www_acetylcholine/acetylcholine.html
  41. ^ Dillman, RO (February 2011). "Cancer immunotherapy.". Cancer biotherapy & radiopharmaceuticals. 26 (1): 1–64. doi:10.1089/cbr.2010.0902. PMID 21355777. 

External links[edit]

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