Acetazolamide (extended-release capsule): Difference between revisions

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{{Drugbox|
{{DrugProjectFormSinglePage
|IUPAC_name = ''N''-(5-(aminosulfonyl)-1,3,4-thiadiazol-2-yl)-acetamide
|genericName=acetazolamide
| image = Acetazolamide skeletal.svg
|aOrAn=a
| image2 = Acetazolamide 3D.png
|drugClass=[[carbonic anhydrase]] [[inhibitor]]
| CAS_number=59-66-5
|indicationType=treatment
| ATC_prefix=S01
|indication=chronic [[glaucoma|primary open-angle glaucoma]] and [[glaucoma|secondary glaucoma]]. Acetazolamide is also indicated for the prevention or amelioration of symptoms associated with acute [[mountain sickness]] despite gradual ascent
| ATC_suffix=EC01
|adverseReactions=[[dizziness]] and [[lightheadedness]]
| ATC_supplemental=
|blackBoxWarningTitle=<b><span style="color:#FF0000;">TITLE</span></b>
| PubChem=1986
|blackBoxWarningBody=<i><span style="color:#FF0000;">Condition Name:</span></i> (Content)
| DrugBank=APRD00119
|fdaLIADAdult======Glaucoma=====
| C = 4 | H = 6 | N = 4 | O = 3 | S = 2
 
| molecular_weight = 222.248 g/mol
* Dosing Information
| bioavailability=  
 
| metabolism = None
:* The recommended dosage is '''1 capsule (500 mg) two times a day'''. Usually 1 capsule is administered in the morning and 1 capsule in the evening.
| elimination_half-life=3 to 9 hours
:* In those unusual instances where adequate control is not obtained by the twice-a-day administration of [[acetazolamide]], the desired control may be established by means of [[acetazolamide]] (tablets or parenteral). Use tablets or parenteral in accordance with the more frequent dosage schedules recommended for these dosage forms, such as '''250 mg every four hours''', or an initial dose of '''500 mg followed by 250 mg or 125 mg every four hours''', depending on the case in question.
| excretion = [[Kidney|Renal]]
 
=====Acute Mountain Sickness=====
 
* Dosing Information
 
:* The recommended dosage is '''500 mg to 1000 mg daily''', in divided doses using tablets or extended-release capsules as appropriate. In circumstances of rapid ascent, such as in rescue or military operations, the higher dose level of '''1000 mg''' is recommended. It is preferable to initiate dosing 24 to 48 hours before ascent and to continue for 48 hours while at high altitude, or longer as necessary to control symptoms.
|offLabelAdultGuideSupport=There is limited information regarding <i>Off-Label Guideline-Supported Use</i> of [[acetazolamide]] in adult patients.
|offLabelAdultNoGuideSupport======Glaucoma Following Surgery=====
 
* Dosing Information
 
:* '''500 mg PO 1 hour postoperatively'''<ref name="Byrd-1998">{{Cite journal  | last1 = Byrd | first1 = S. | last2 = Singh | first2 = K. | title = Medical control of intraocular pressure after cataract surgery. | journal = J Cataract Refract Surg | volume = 24 | issue = 11 | pages = 1493-7 | month = Nov | year = 1998 | doi =  | PMID = 9818340 }}</ref>
 
=====Macular Retinal Edema=====
 
* Dosing Information
 
:* '''500 mg PO qd for 4 weeks'''<ref name="Whitcup-1996">{{Cite journal  | last1 = Whitcup | first1 = SM. | last2 = Csaky | first2 = KG. | last3 = Podgor | first3 = MJ. | last4 = Chew | first4 = EY. | last5 = Perry | first5 = CH. | last6 = Nussenblatt | first6 = RB. | title = A randomized, masked, cross-over trial of [[acetazolamide]] for cystoid macular edema in patients with uveitis. | journal = Ophthalmology | volume = 103 | issue = 7 | pages = 1054-62; discussion 1062-3 | month = Jul | year = 1996 | doi =  | PMID = 8684794 }}</ref>
 
=====Periodic Ataxia=====
 
* Dosing Information
 
:* Doses of '''250 to 1000 mg/day''' have eliminated or decreased the frequency and severity of symptoms such as [[nausea]], [[vomiting]], [[diplopia]], and [[nystagmus]].<ref name="Baloh-1991">{{Cite journal  | last1 = Baloh | first1 = RW. | last2 = Winder | first2 = A. | title = [[acetazolamide]]-responsive vestibulocerebellar syndrome: clinical and oculographic features. | journal = Neurology | volume = 41 | issue = 3 | pages = 429-33 | month = Mar | year = 1991 | doi =  | PMID = 2006014 }}</ref><ref name="Friedman-1987">{{Cite journal  | last1 = Friedman | first1 = JH. | last2 = Hollmann | first2 = PA. | title = [[acetazolamide]] responsive hereditary paroxysmal ataxia. | journal = Mov Disord | volume = 2 | issue = 1 | pages = 67-72 | month =  | year = 1987 | doi = 10.1002/mds.870020110 | PMID = 3332806 }}</ref><ref name="Bouchard-1984">{{Cite journal  | last1 = Bouchard | first1 = JP. | last2 = Roberge | first2 = C. | last3 = van Gelder | first3 = NM. | last4 = Barbeau | first4 = A. | title = Familial periodic ataxia responsive to [[acetazolamide]]. | journal = Can J Neurol Sci | volume = 11 | issue = 4 Suppl | pages = 550-3 | month = Nov | year = 1984 | doi =  | PMID = 6439406 }}</ref><ref name="Griggs-1978">{{Cite journal  | last1 = Griggs | first1 = RC. | last2 = Moxley | first2 = RT. | last3 = Lafrance | first3 = RA. | last4 = McQuillen | first4 = J. | title = Hereditary paroxysmal ataxia: response to [[acetazolamide]]. | journal = Neurology | volume = 28 | issue = 12 | pages = 1259-64 | month = Dec | year = 1978 | doi =  | PMID = 366453 }}</ref>
|fdaLIADPed=The safety and effectiveness of [[acetazolamide]] in pediatric patients below the age of 12 years have not been established. [[Growth retardation]] has been reported in children receiving long-term therapy, believed secondary to chronic [[acidosis]].
|offLabelPedGuideSupport=There is limited information regarding <i>Off-Label Guideline-Supported Use</i> of [[acetazolamide]] in pediatric patients.
|offLabelPedNoGuideSupport=There is limited information regarding <i>Off-Label Non–Guideline-Supported Use</i> of [[acetazolamide]] in pediatric patients.
|contraindications=* [[Hypersensitivity]] to [[acetazolamide]] or any excipients in the formulation.
:* Since [[acetazolamide]] is a [[sulfonamide]] derivative, cross sensitivity between [[acetazolamide]], [[sulfonamide]]s and other [[sulfonamide]] derivatives is possible.
 
* [[Hyponatremia]] and [[hypokalemia]]
:* [[Acetazolamide]] therapy is contraindicated in situations in which [[sodium]] and/or [[potassium]] blood serum levels are depressed, in cases of marked kidney and liver disease or dysfunction, in [[adrenal insufficiency|suprarenal gland failure]], and in [[hyperchloremic acidosis]].
 
* [[Cirrhosis]]
:* [[Acetazolamide]] is contraindicated in patients with [[cirrhosis]] because of the risk of development of [[hepatic encephalopathy]].
 
* Chronic non-congestive angle-closure [[glaucoma]]
:* Long-term administration of [[acetazolamide]] is contraindicated in patients with chronic non-congestive angle-closure [[glaucoma]] since it may permit organic closure of the angle to occur while the worsening [[glaucoma]] is masked by lowered [[intraocular pressure]].
|warnings=* Fatalities have occurred, although rarely, due to severe reactions to [[sulfonamide]]s including [[Stevens-Johnson syndrome]], [[toxic epidermal necrolysis]], [[fulminant hepatic necrosis]], [[anaphylaxis]], [[agranulocytosis]], [[aplastic anemia]], and other blood [[dyscrasia]]s.
 
* Sensitizations may recur when a [[sulfonamide]] is readministered irrespective of the route of administration. If signs of [[hypersensitivity]] or other serious reactions occur, discontinue use of this drug.
 
* Caution is advised for patients receiving concomitant high-dose [[aspirin]] and [[acetazolamide]], as [[anorexia]], [[tachypnea]], [[lethargy]], [[metabolic acidosis]], [[coma]], and [[death]] have been reported. 
 
* Increasing the dose does not increase the [[diuresis]] and may increase the incidence of [[drowsiness]] and/or [[paresthesia]]. Increasing the dose often results in a decrease in [[diuresis]]. Under certain circumstances, however, very large doses have been given in conjunction with other [[diuretic]]s in order to secure [[diuresis]] in complete refractory failure.
 
* To monitor for hematologic reactions common to all [[sulfonamide]]s, it is recommended that a baseline [[CBC]] and [[platelet]] count be obtained on patients prior to initiating [[acetazolamide]] therapy and at regular intervals during therapy. If significant changes occur, early discontinuance and institution of appropriate therapy are important. Periodic monitoring of serum [[electrolyte]]s is recommended.
|clinicalTrials=There is limited information regarding <i>Clinical Trial Experience</i> of [[acetazolamide]] in the drug label.
|postmarketing====Body as a whole===
 
[[Headache]], [[malaise]], [[fatigue]], [[fever]], [[pain]] at injection site, [[flushing]], [[growth retardation]] in children, [[flaccid paralysis]], [[anaphylaxis]].
 
===Digestive===
 
Gastrointestinal disturbances such as [[nausea]], [[vomiting]], [[diarrhea]].
 
===Hematological/Lymphatic===
 
Blood [[dyscrasia]]s such as [[aplastic anemia]], [[agranulocytosis]], [[leukopenia]], [[thrombocytopenic purpura]], [[melena]].
 
===Hepato-biliary disorders===
 
Abnormal [[liver function test|liver function]], [[cholestatic jaundice]], [[hepatic insufficiency]], [[fulminant hepatic necrosis]].
 
===Metabolic/Nutritional===
 
[[Metabolic acidosis]], [[electrolyte imbalance]], including [[hypokalemia]], [[hyponatremia]], [[osteomalacia]] with long-term [[phenytoin]] therapy, loss of [[appetite]], taste alteration, [[hyperglycemia|hyper]]/[[hypoglycemia]].
 
===Nervous===
 
[[Drowsiness]], [[paresthesia]] (including [[numbness]] and tingling of extremities and face), [[depression]], excitement, [[ataxia]], [[confusion]], [[convulsions]], [[dizziness]].
 
===Skin===
 
[[Allergic]] skin reactions including [[urticaria]], [[photosensitivity]], [[Stevens-Johnson syndrome]], [[toxic epidermal necrolysis]].
 
===Special senses===
 
Hearing disturbances, [[tinnitus]], transient [[myopia]].
|drugInteractions=* [[Aspirin]]
:* Caution is advised for patients receiving concomitant high-dose [[aspirin]] and [[acetazolamide]], as [[anorexia]], [[tachypnea]], [[lethargy]], [[metabolic acidosis]], [[coma]], and [[death]] have been reported.
* [[Anticonvulsants]]
:* [[Acetazolamide]] modifies [[phenytoin]] metabolism with increased serum levels of [[phenytoin]]. This may increase or enhance the occurrence of [[osteomalacia]] in some patients receiving chronic [[phenytoin]] therapy. Caution is advised in patients receiving chronic concomitant therapy. By decreasing the gastrointestinal absorption of [[primidone]], [[acetazolamide]] may decrease serum concentrations of [[primidone]] and its metabolites, with a consequent possible decrease in [[anticonvulsant]] effect. Caution is advised when beginning, discontinuing, or changing the dose of [[acetazolamide]] in patients receiving [[primidone]].
* [[Carbonic anhydrase]] inhibitors
:* Because of possible additive effects with other [[carbonic anhydrase]] inhibitors, concomitant use is not advisable.
* [[Folic acid]] antagonists
:* [[Acetazolamide]] may increase the effects of other [[folic acid]] [[antagonist]]s.
* [[Amphetamine]]
:* [[Acetazolamide]] decreases urinary excretion of [[amphetamine]] and may enhance the magnitude and duration of their effect.
* [[Quinidine]]
:* [[Acetazolamide]] reduces urinary excretion of [[quinidine]] and may enhance its effect.
* [[Methenamine]]
:* [[Acetazolamide]] may prevent the urinary antiseptic effect of [[methenamine]].
* [[Lithium]]
:* [[Acetazolamide]] increases [[lithium]] excretion and the lithium may be decreased.
* [[Sodium bicarbonate]]
:* [[Acetazolamide]] and [[sodium bicarbonate]] used concurrently increase the risk of renal [[calculus]] formation.
* [[Cyclosporine]]
:* [[Acetazolamide]] may elevate [[cyclosporine]] levels.
* Drug/laboratory test interactions
:* [[Sulfonamide]]s may give false negative or decreased values for urinary phenolsulfonphthalein and phenol red elimination values for urinary protein, serum non-protein, and serum [[uric acid]].
:* [[Acetazolamide]] may produce an increased level of crystals in the urine.
:* [[Acetazolamide]] interferes with the HPLC method of assay for [[theophylline]]. Interference with the [[theophylline]] assay by [[acetazolamide]] depends on the solvent used in the extraction; [[acetazolamide]] may not interfere with other assay methods for [[theophylline]].
|FDAPregCat=C
|useInPregnancyFDA======Teratogenic effects=====
[[acetazolamide]], administered orally or parenterally, has been shown to be teratogenic (defects of the limbs) in mice, rats, hamsters, and rabbits. There are no adequate and well-controlled studies in pregnant women. [[Acetazolamide]] should be used in [[pregnancy]] only if the potential benefit justifies the potential risk to the fetus.
|AUSPregCat=B3
|useInNursing=Because of the potential for serious adverse reactions in nursing infants from [[acetazolamide]], a decision should be made whether to discontinue nursing or to discontinue the drug taking into account the importance of the drug to the mother. [[Acetazolamide]] should only be used by nursing women if the potential benefit justifies the potential risk to the child.
|useInPed=The safety and effectiveness of [[acetazolamide]] in pediatric patients below the age of 12 years have not been established. [[Growth retardation]] has been reported in children receiving long-term therapy, believed secondary to chronic [[acidosis]].
|useInGeri=Metabolic acidosis, which can be severe, may occur in the elderly with reduced [[renal function]].
In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and concomitant disease or other drug therapy.
|administration=Oral
|monitoring=======Electrolyte Imbalances======
 
[[Acetazolamide]] treatment may cause [[electrolyte imbalance]]s, including [[hyponatremia]] and [[hypokalemia]], as well as [[metabolic acidosis]]. Therefore, periodic monitoring of serum [[electrolyte]]s is recommended.
 
======Hematologic Distrubances======
 
To monitor for hematologic reactions common to all [[sulfonamide]]s, it is recommended that a baseline [[CBC]] and [[platelet]] count be obtained on patients prior to initiating [[acetazolamide]] therapy and at regular intervals during therapy. If significant changes occur, early discontinuance and institution of appropriate therapy are important.
|IVCompat=There is limited information regarding <i>IV Compatibility</i> of [[acetazolamide]] in the drug label.
|overdose====Acute Overdose===
====Management====
* No specific antidote is known.
 
* Treatment should be symptomatic and supportive. [[Electrolyte imbalance]], development of an [[acidosis|acidotic]] state, and central nervous system effects might be expected to occur. Serum [[electrolyte]] levels (particularly [[potassium]]) and blood pH levels should be monitored. Supportive measures are required to restore [[electrolyte]] and pH balance. The acidotic state can usually be corrected by the administration of [[bicarbonate]].
 
* Despite its high intraerythrocytic distribution and plasma protein binding properties, [[acetazolamide]] may be dialyzable. This may be particularly important in the management of [[acetazolamide]] overdosage when complicated by the presence of [[renal failure]].
|drugBox={{Drugbox2
| verifiedrevid = 477238754
| IUPAC_name = ''N''-(5-sulfamoyl-1,3,4-thiadiazol-2-yl)acetamide
| image = Acetazolamide2DACS.svg.png
| width = 200px
| image2 = Acetazolamide3Dan.gif
| width2 = 200px
 
<!--Clinical data-->
| tradename = [[acetazolamide]]
| pregnancy_AU = B3
| pregnancy_AU = B3
| pregnancy_US = C
| pregnancy_US = C
| legal_AU = S4
| legal_CA = Rx-only
| legal_UK = POM
| legal_US = Rx-only
| legal_US = Rx-only
| legal_UK = POM
| routes_of_administration = oral or [[intravenous]]
| routes_of_administration= Oral, [[Intravenous therapy|IV]]
}}
{{EH}}


==Overview==
<!--Pharmacokinetic data-->
'''Acetazolamide''', sold under the trade name '''Diamox''', is a [[carbonic anhydrase]] inhibitor that is used to treat [[glaucoma]], [[epileptic seizure]]s, [[benign intracranial hypertension]], [[altitude sickness]], [[cystinuria]], and dural ectasia. Acetazolamide is available as a [[generic drug]] and is also used as a [[diuretic]].
| bioavailability =  
| protein_binding = 70-90%
| metabolism = None
| elimination_half-life = 2-4 hours
| excretion = Urine (90%)


==Uses==
<!--Identifiers-->
| CASNo_Ref = {{cascite|correct|CAS}}
| CAS_number_Ref = {{cascite|correct|??}}
| CAS_number = 59-66-5
| ATC_prefix = S01
| ATC_suffix = EC01
| PubChem = 1986
| DrugBank_Ref = {{drugbankcite|correct|drugbank}}
| DrugBank = DB00819
| ChemSpiderID_Ref = {{chemspidercite|correct|chemspider}}
| ChemSpiderID = 1909
| UNII_Ref = {{fdacite|correct|FDA}}
| UNII = O3FX965V0I
| KEGG_Ref = {{keggcite|correct|kegg}}
| KEGG = D00218
| ChEBI_Ref = {{ebicite|correct|EBI}}
| ChEBI = 27690
| ChEMBL_Ref = {{ebicite|correct|EBI}}
| ChEMBL = 20
| PDB_ligand = AZM


===General===
<!--Chemical data-->
| C=4 | H=6 | N=4 | O=3 | S=2
| molecular_weight = 222.245 g/mol
| smiles = O=S(=O)(c1nnc(s1)NC(=O)C)N
| InChI = 1/C4H6N4O3S2/c1-2(9)6-3-7-8-4(12-3)13(5,10)11/h1H3,(H2,5,10,11)(H,6,7,9)
| StdInChI_Ref = {{stdinchicite|correct|chemspider}}
| StdInChI = 1S/C4H6N4O3S2/c1-2(9)6-3-7-8-4(12-3)13(5,10)11/h1H3,(H2,5,10,11)(H,6,7,9)
| StdInChIKey_Ref = {{stdinchicite|correct|chemspider}}
| StdInChIKey = BZKPWHYZMXOIDC-UHFFFAOYSA-N
}}
|mechAction=* [[Acetazolamide]] is a potent [[carbonic anhydrase]] [[inhibitor]], effective in the control of fluid secretion (e.g., some types of [[glaucoma]]), in the treatment of certain convulsive disorders (e.g., [[epilepsy]]), and in the promotion of [[diuresis]] in instances of abnormal fluid retention (e.g., cardiac [[edema]]).


Acetazolamide is often used in the treatment of various diseases. For glaucoma sufferers, the drug decreases fluid formation in the [[eye]] resulting in lower intraocular pressure. In epilepsy, its main use is in [[absence seizure]]s, with some benefit in other seizure syndromes. It is also used to decrease generation of [[cerebrospinal fluid]] in [[benign intracranial hypertension]] and has also shown efficacy in autosomal dominant hyperkalemic periodic paralysis.  It has also been demonstrated in drug trials to relieve symptoms associated with dural ectasia in indivduals with [[Marfan Syndrome]].
* [[Acetazolamide]] is not a mercurial [[diuretic]]. Rather, it is a non-[[bacteriostatic]] [[sulfonamide]] possessing a chemical structure and pharmacological activity distinctly different from the [[bacteriostatic]] [[sulfonamide]]s.


===Acute mountain sickness ===
* [[Acetazolamide]] is an [[enzyme]] [[inhibitor]] that acts specifically on [[carbonic anhydrase]], the enzyme that catalyzes the reversible reaction involving the hydration of [[carbon dioxide]] and the dehydration of carbonic acid. In the eye, this inhibitory action of [[acetazolamide]] decreases the secretion of [[aqueous humor]] and results in a drop in [[intraocular pressure]], a reaction considered desirable in cases of [[glaucoma]] and even in certain non-glaucomatous conditions. Evidence seems to indicate that [[acetazolamide]] has utility as an adjuvant in treatment of certain dysfunctions of the [[central nervous system]] (e.g., [[epilepsy]]). Inhibition of [[carbonic anhydrase]] in this area appears to retard abnormal, paroxysmal, excessive discharge from [[central nervous system]] [[neuron]]s. The [[diuretic]] effect of [[acetazolamide]] is due to its action in the kidney on the reversible reaction involving hydration of [[carbon dioxide]] and dehydration of carbonic acid. The result is renal loss of [[bicarbonate|HCO3]] ion, which carries out [[sodium]], water, and [[potassium]]. Alkalinization of the urine and promotion of [[diuresis]] are thus affected. Alteration in [[ammonia]] metabolism occurs due to increased reabsorption of [[ammonia]] by the [[renal tubule]]s as a result of urinary alkalinization.
|structure=The chemical name for acetazolamide is N-(5-Sulfamoyl-1,3, 4-thiadiazol-2-yl) acetamide and has the following chemical structure:


Acetazolamide is best taken [[prophylaxis|prophylactically]], anywhere between 125 milligrams (mg) to 500 mg per day, starting a few days before going to the higher altitude. The drug forces the [[kidney]]s to excrete [[bicarbonate]], the [[conjugate base]] of [[carbonic acid]]. By increasing the amount of bicarbonate excreted in the urine, the blood becomes more acidic. Acidifying the blood stimulates ventilation, which is beneficial during acclimatization.  Others only take it when [[symptom]]s begin to appear so they can tell whether the drug really has any benefits for them. Whereas some people have reported that it relieves mild cases of acute mountain sickness, it is best taken prophylactically.
[[File:Acetazolamide001.jpeg|400px|thumb|none|This image is provided by the National Library of Medicine.]]
|PD=* [[Acetazolamide]] provide prolonged action to inhibit aqueous humor secretion for 18 to 24 hours after each dose, whereas tablets act for only eight to 12 hours. The prolonged continuous effect of [[acetazolamide]] permits a reduction in dosage frequency.
|PK=* Plasma concentrations of acetazolamide peak from three to six hours after administration of [[acetazolamide]], compared to one to four hours with tablets. Food does not affect bioavailability of [[acetazolamide]].


* [[Placebo]]-controlled clinical trials have shown that prophylactic administration of [[acetazolamide]] at a dose of 250 mg every eight to 12 hours (or a 500 mg controlled release [[capsule]] once daily) before and during rapid ascent to altitude results in fewer and/or less severe symptoms of acute [[mountain sickness]] (AMS) such as [[headache]], [[nausea]], [[shortness of breath]], [[dizziness]], [[drowsiness]], and [[fatigue]]. Pulmonary function (e.g., [[minute ventilation]], expired vital capacity, and peak flow) is greater in the [[acetazolamide]] treated group, both in subjects with AMS and asymptomatic subjects. The [[acetazolamide]] treated climbers also had less difficulty in sleeping.
|nonClinToxic=There is limited information regarding <i>Nonclinical Toxicology</i> of [[acetazolamide]] in the drug label.
|clinicalStudies=There is limited information regarding <i>Clinical Studies</i> of acetazolamide in the drug label.
|howSupplied=* Diamox Sequels ([[Acetazolamide]] Extended-Release Capsules) are available as 500 mg:
: Orange opaque cap and orange opaque body filled with white to off-white pellets. Imprinted in black ink, DIAMOX 754.


Note that acetazolamide is not an immediate fix for acute mountain sickness; it speeds up [[acclimatization]] which in turn helps to relieve symptoms. This may take up to a day or two, and requires waiting without any further rapid ascent. It is often advisable to descend if even mild acute mountain sickness is experienced. If serious sickness is encountered, descent is considered mandatory unless other circumstances present greater danger.
* Available in bottles of:
: 100 NDC 51285-754-02
: DURAMED PHARMACEUTICALS, INC.
: Subsidiary of Barr Pharmaceuticals, Inc.
: Pomona, New York 10970
: Revised JULY 2008
: BR-754
|storage=Store at 20° to 25°C (68° to 77°F).
|packLabel=[[File:DIAMOX SEQUELS (acetazolamide) capsule, extended release label display.jpeg|thumb|none|400px|This image is provided by the National Library of Medicine.]]
[[File:Acetazolamide004.jpg|thumb|none|400px|This image is provided by the National Library of Medicine.]]


==Side-effects==
|fdaPatientInfo=* [[Adverse reaction]]s common to all [[sulfonamide]] derivatives may occur: [[anaphylaxis]], [[fever]], [[rash]] (including [[erythema multiforme]], [[Stevens-Johnson syndrome]], [[toxic epidermal necrolysis]]), [[crystalluria]], [[renal]] [[calculus]], [[myelosuppression|bone marrow depression]], [[thrombocytopenic purpura]], [[hemolytic anemia]], [[leukopenia]], [[pancytopenia]], and [[agranulocytosis]]. Caution is advised for early detection of such reactions and the drug should be discontinued and appropriate therapy instituted.


Common [[Adverse drug reaction|side effects]] of using this drug include [[paresthesia|numbness and tingling]] in the fingers and toes, and [[taste]] alterations ([[parageusia]]), especially for carbonated drinks; both are usually due to mild [[hypokalemia]] (low [[potassium]] levels). Some may also experience blurred [[Visual perception|vision]] but this usually disappears shortly after stopping the medication.  Acetazolamide also increases the risk of developing calcium oxalate and calcium phosphate kidney stones. Everyone will experience more frequent [[urination]] as a result of using acetazolamide. One should drink more fluids than usual to prevent [[dehydration]] and [[headache]]s. Acetazolamide prolongs the effects of amphetamines and related drugs.
* In patients with pulmonary obstruction or [[emphysema]] where alveolar [[ventilation]] may be impaired, [[acetazolamide]] which may precipitate or aggravate [[acidosis]] should be used with caution.


==Contraindications==
* Gradual ascent is desirable to try to avoid acute [[mountain sickness]]. If rapid ascent is undertaken and [[acetazolamide]] is used, it should be noted that such use does not obviate the need for prompt descent if severe forms of high altitude sickness occur, i.e., high altitude pulmonary edema (HAPE) or high altitude [[cerebral edema]].


Acetazolamide should not be taken by individuals if:
* Caution is advised for patients receiving concomitant high-dose [[aspirin]] and [[acetazolamide]], as [[anorexia]], [[tachypnea]], [[lethargy]], [[metabolic acidosis]], [[coma]], and [[death]] have been reported.


* They have [[sickle cell anemia]]
* Both increases and decreases in blood [[glucose]] have been described in patients treated with [[acetazolamide]]. This should be taken into consideration in patients with [[impaired glucose tolerance]] or [[diabetes mellitus]].
* They are [[allergic]] to [[sulfa drug|sulfa]] medications
* They are allergic to any carbonic anhydrase inhibitor
* They have [[liver]] or [[kidney]] disease
* They have [[adrenal gland]] failure (i.e. [[Addison's disease]])
* They have [[diabetes]]
* They are pregnant or nursing mothers


==Myths==
* [[Acetazolamide]] treatment may cause [[electrolyte imbalance]]s, including [[hyponatremia]] and [[hypokalemia]], as well as [[metabolic acidosis]]. Therefore, periodic monitoring of [[serum electrolyte]]s is recommended. Particular caution is recommended in patients with conditions that are associated with, or predispose a patient to, [[electrolyte]] and [[Acid-base imbalance|acid/base imbalances]], such as patients with impaired [[renal function]] (including elderly patients), patients with [[diabetes mellitus]], and patients with impaired [[alveolar]] [[ventilation]].


* 'Acetazolamide covers up symptoms.' Not so: Acetazolamide speeds up acclimatization which in turn helps to alleviate symptoms. However, if you still feel sick, you need to stop ascending immediately.
* Some adverse reactions to [[acetazolamide]], such as [[drowsiness]], [[fatigue]], and [[myopia]], may impair the ability to drive and operate machinery.<ref name="dailymed.nlm.nih.gov">{{Cite web  | last = | first = | title = DIAMOX SEQUELS (ACETAZOLAMIDE) CAPSULE, EXTENDED RELEASE [DURAMED PHARMACEUTICALS, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=74e47451-2bc8-496e-88ad-c10002ee8e22 | publisher =  | date =  | accessdate = }}</ref>
* 'Acetazolamide prevents acute mountain sickness from getting worse.' Not so: If your symptoms are not improving, continued ascent can lead to [[HAPE]] or [[HACE]].
|alcohol=Alcohol-[[acetazolamide]] interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
* 'Stopping the drug causes symptoms to worsen.' Not so: Your body will just return to its own acclimatization rate. If you are already acclimatized, the drug will not change that fact.
|brandNames=Diamox Sequels®
 
|lookAlike=* acetaZOLAMIDE — acetoHEXAMIDE<ref name="www.ismp.org">{{Cite web  | last =  | first =  | title = http://www.ismp.org | url = http://www.ismp.org | publisher =  | date =  }}</ref>
==References==
* Diamox® — Diabinese®<ref name="www.ismp.org">{{Cite web  | last =  | first =  | title = http://www.ismp.org | url = http://www.ismp.org | publisher =  | date =  }}</ref>
 
|nlmPatientInfo=(Link to patient information page)
* ''Going Higher: Oxygen Man and Mountains'' by Charles Houston, M.D., Fifth Edition, 2005. ISBN 0-89886-631-6.
|drugShortage=
* ''Complete Guide to Prescription & Non-Prescription Drugs'' by H. Winter Griffen, M.D., Sixth edition, 1989. ISBN 0-89586-754-0.
}}
* http://www.ismmed.org/np_altitude_tutorial.htm
{{PillImage
* ''Dural Ectasia in the Marfan Spine: Symptoms and Treatment.'' November 27, 2006. http://www.spineuniverse.com/displayarticle.php/article922.html
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[[de:Acetazolamid]]
[[Category: Cardiovascular Drugs]]
[[fr:Acétazolamide]]
[[Category: Diuretics]]
[[ja:アセタゾラミド]]
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Latest revision as of 22:16, 14 May 2015

Acetazolamide (extended-release capsule)
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];

Disclaimer

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Overview

Acetazolamide (extended-release capsule) is a carbonic anhydrase inhibitor that is FDA approved for the treatment of chronic primary open-angle glaucoma and secondary glaucoma. Acetazolamide is also indicated for the prevention or amelioration of symptoms associated with acute mountain sickness despite gradual ascent. Common adverse reactions include dizziness and lightheadedness.

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Glaucoma
  • Dosing Information
  • The recommended dosage is 1 capsule (500 mg) two times a day. Usually 1 capsule is administered in the morning and 1 capsule in the evening.
  • In those unusual instances where adequate control is not obtained by the twice-a-day administration of acetazolamide, the desired control may be established by means of acetazolamide (tablets or parenteral). Use tablets or parenteral in accordance with the more frequent dosage schedules recommended for these dosage forms, such as 250 mg every four hours, or an initial dose of 500 mg followed by 250 mg or 125 mg every four hours, depending on the case in question.
Acute Mountain Sickness
  • Dosing Information
  • The recommended dosage is 500 mg to 1000 mg daily, in divided doses using tablets or extended-release capsules as appropriate. In circumstances of rapid ascent, such as in rescue or military operations, the higher dose level of 1000 mg is recommended. It is preferable to initiate dosing 24 to 48 hours before ascent and to continue for 48 hours while at high altitude, or longer as necessary to control symptoms.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of acetazolamide in adult patients.

Non–Guideline-Supported Use

Glaucoma Following Surgery
  • Dosing Information
  • 500 mg PO 1 hour postoperatively[1]
Macular Retinal Edema
  • Dosing Information
  • 500 mg PO qd for 4 weeks[2]
Periodic Ataxia
  • Dosing Information

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

The safety and effectiveness of acetazolamide in pediatric patients below the age of 12 years have not been established. Growth retardation has been reported in children receiving long-term therapy, believed secondary to chronic acidosis.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of acetazolamide in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of acetazolamide in pediatric patients.

Contraindications

  • Chronic non-congestive angle-closure glaucoma
  • Long-term administration of acetazolamide is contraindicated in patients with chronic non-congestive angle-closure glaucoma since it may permit organic closure of the angle to occur while the worsening glaucoma is masked by lowered intraocular pressure.

Warnings

  • Sensitizations may recur when a sulfonamide is readministered irrespective of the route of administration. If signs of hypersensitivity or other serious reactions occur, discontinue use of this drug.
  • Increasing the dose does not increase the diuresis and may increase the incidence of drowsiness and/or paresthesia. Increasing the dose often results in a decrease in diuresis. Under certain circumstances, however, very large doses have been given in conjunction with other diuretics in order to secure diuresis in complete refractory failure.
  • To monitor for hematologic reactions common to all sulfonamides, it is recommended that a baseline CBC and platelet count be obtained on patients prior to initiating acetazolamide therapy and at regular intervals during therapy. If significant changes occur, early discontinuance and institution of appropriate therapy are important. Periodic monitoring of serum electrolytes is recommended.

Adverse Reactions

Clinical Trials Experience

There is limited information regarding Clinical Trial Experience of acetazolamide in the drug label.

Postmarketing Experience

Body as a whole

Headache, malaise, fatigue, fever, pain at injection site, flushing, growth retardation in children, flaccid paralysis, anaphylaxis.

Digestive

Gastrointestinal disturbances such as nausea, vomiting, diarrhea.

Hematological/Lymphatic

Blood dyscrasias such as aplastic anemia, agranulocytosis, leukopenia, thrombocytopenic purpura, melena.

Hepato-biliary disorders

Abnormal liver function, cholestatic jaundice, hepatic insufficiency, fulminant hepatic necrosis.

Metabolic/Nutritional

Metabolic acidosis, electrolyte imbalance, including hypokalemia, hyponatremia, osteomalacia with long-term phenytoin therapy, loss of appetite, taste alteration, hyper/hypoglycemia.

Nervous

Drowsiness, paresthesia (including numbness and tingling of extremities and face), depression, excitement, ataxia, confusion, convulsions, dizziness.

Skin

Allergic skin reactions including urticaria, photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis.

Special senses

Hearing disturbances, tinnitus, transient myopia.

Drug Interactions

  • Because of possible additive effects with other carbonic anhydrase inhibitors, concomitant use is not advisable.
  • Drug/laboratory test interactions

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): C

Teratogenic effects

acetazolamide, administered orally or parenterally, has been shown to be teratogenic (defects of the limbs) in mice, rats, hamsters, and rabbits. There are no adequate and well-controlled studies in pregnant women. Acetazolamide should be used in pregnancy only if the potential benefit justifies the potential risk to the fetus.
Pregnancy Category (AUS): B3 There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Acetazolamide (extended-release capsule) in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Acetazolamide (extended-release capsule) during labor and delivery.

Nursing Mothers

Because of the potential for serious adverse reactions in nursing infants from acetazolamide, a decision should be made whether to discontinue nursing or to discontinue the drug taking into account the importance of the drug to the mother. Acetazolamide should only be used by nursing women if the potential benefit justifies the potential risk to the child.

Pediatric Use

The safety and effectiveness of acetazolamide in pediatric patients below the age of 12 years have not been established. Growth retardation has been reported in children receiving long-term therapy, believed secondary to chronic acidosis.

Geriatic Use

Metabolic acidosis, which can be severe, may occur in the elderly with reduced renal function. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and concomitant disease or other drug therapy.

Gender

There is no FDA guidance on the use of Acetazolamide (extended-release capsule) with respect to specific gender populations.

Race

There is no FDA guidance on the use of Acetazolamide (extended-release capsule) with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Acetazolamide (extended-release capsule) in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Acetazolamide (extended-release capsule) in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Acetazolamide (extended-release capsule) in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Acetazolamide (extended-release capsule) in patients who are immunocompromised.

Administration and Monitoring

Administration

Oral

Monitoring

Electrolyte Imbalances

Acetazolamide treatment may cause electrolyte imbalances, including hyponatremia and hypokalemia, as well as metabolic acidosis. Therefore, periodic monitoring of serum electrolytes is recommended.

Hematologic Distrubances

To monitor for hematologic reactions common to all sulfonamides, it is recommended that a baseline CBC and platelet count be obtained on patients prior to initiating acetazolamide therapy and at regular intervals during therapy. If significant changes occur, early discontinuance and institution of appropriate therapy are important.

IV Compatibility

There is limited information regarding IV Compatibility of acetazolamide in the drug label.

Overdosage

Acute Overdose

Management

  • No specific antidote is known.
  • Treatment should be symptomatic and supportive. Electrolyte imbalance, development of an acidotic state, and central nervous system effects might be expected to occur. Serum electrolyte levels (particularly potassium) and blood pH levels should be monitored. Supportive measures are required to restore electrolyte and pH balance. The acidotic state can usually be corrected by the administration of bicarbonate.
  • Despite its high intraerythrocytic distribution and plasma protein binding properties, acetazolamide may be dialyzable. This may be particularly important in the management of acetazolamide overdosage when complicated by the presence of renal failure.

Pharmacology

Template:Px
Template:Px
Acetazolamide (extended-release capsule)
Systematic (IUPAC) name
N-(5-sulfamoyl-1,3,4-thiadiazol-2-yl)acetamide
Identifiers
CAS number 59-66-5
ATC code S01EC01
PubChem 1986
DrugBank DB00819
Chemical data
Formula Template:OrganicBox atomTemplate:OrganicBox atomTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBox atomTemplate:OrganicBoxTemplate:OrganicBox atomTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBox atomTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBox 
Mol. mass 222.245 g/mol
SMILES eMolecules & PubChem
Pharmacokinetic data
Bioavailability ?
Metabolism None
Half life 2-4 hours
Excretion Urine (90%)
Therapeutic considerations
Pregnancy cat.

B3(AU) C(US)

Legal status

Prescription Only (S4)(AU) ?(CA) POM(UK) [[Prescription drug|Template:Unicode-only]](US)

Routes oral or intravenous

Mechanism of Action

Structure

The chemical name for acetazolamide is N-(5-Sulfamoyl-1,3, 4-thiadiazol-2-yl) acetamide and has the following chemical structure:

This image is provided by the National Library of Medicine.

Pharmacodynamics

  • Acetazolamide provide prolonged action to inhibit aqueous humor secretion for 18 to 24 hours after each dose, whereas tablets act for only eight to 12 hours. The prolonged continuous effect of acetazolamide permits a reduction in dosage frequency.

Pharmacokinetics

  • Plasma concentrations of acetazolamide peak from three to six hours after administration of acetazolamide, compared to one to four hours with tablets. Food does not affect bioavailability of acetazolamide.

Nonclinical Toxicology

There is limited information regarding Nonclinical Toxicology of acetazolamide in the drug label.

Clinical Studies

There is limited information regarding Clinical Studies of acetazolamide in the drug label.

How Supplied

  • Diamox Sequels (Acetazolamide Extended-Release Capsules) are available as 500 mg:
Orange opaque cap and orange opaque body filled with white to off-white pellets. Imprinted in black ink, DIAMOX 754.
  • Available in bottles of:
100 NDC 51285-754-02
DURAMED PHARMACEUTICALS, INC.
Subsidiary of Barr Pharmaceuticals, Inc.
Pomona, New York 10970
Revised JULY 2008
BR-754

Storage

Store at 20° to 25°C (68° to 77°F).

Images

Drug Images

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Package and Label Display Panel

This image is provided by the National Library of Medicine.
This image is provided by the National Library of Medicine.

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Patient Counseling Information

  • Gradual ascent is desirable to try to avoid acute mountain sickness. If rapid ascent is undertaken and acetazolamide is used, it should be noted that such use does not obviate the need for prompt descent if severe forms of high altitude sickness occur, i.e., high altitude pulmonary edema (HAPE) or high altitude cerebral edema.

Precautions with Alcohol

Alcohol-acetazolamide interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

Diamox Sequels®

Look-Alike Drug Names

  • acetaZOLAMIDE — acetoHEXAMIDE[8]
  • Diamox® — Diabinese®[8]

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

  1. ↑ Byrd, S.; Singh, K. (1998). "Medical control of intraocular pressure after cataract surgery". J Cataract Refract Surg. 24 (11): 1493–7. PMID 9818340. Unknown parameter |month= ignored (help)
  2. ↑ Whitcup, SM.; Csaky, KG.; Podgor, MJ.; Chew, EY.; Perry, CH.; Nussenblatt, RB. (1996). "A randomized, masked, cross-over trial of acetazolamide for cystoid macular edema in patients with uveitis". Ophthalmology. 103 (7): 1054–62, discussion 1062-3. PMID 8684794. Unknown parameter |month= ignored (help)
  3. ↑ Baloh, RW.; Winder, A. (1991). "acetazolamide-responsive vestibulocerebellar syndrome: clinical and oculographic features". Neurology. 41 (3): 429–33. PMID 2006014. Unknown parameter |month= ignored (help)
  4. ↑ Friedman, JH.; Hollmann, PA. (1987). "acetazolamide responsive hereditary paroxysmal ataxia". Mov Disord. 2 (1): 67–72. doi:10.1002/mds.870020110. PMID 3332806.
  5. ↑ Bouchard, JP.; Roberge, C.; van Gelder, NM.; Barbeau, A. (1984). "Familial periodic ataxia responsive to acetazolamide". Can J Neurol Sci. 11 (4 Suppl): 550–3. PMID 6439406. Unknown parameter |month= ignored (help)
  6. ↑ Griggs, RC.; Moxley, RT.; Lafrance, RA.; McQuillen, J. (1978). "Hereditary paroxysmal ataxia: response to acetazolamide". Neurology. 28 (12): 1259–64. PMID 366453. Unknown parameter |month= ignored (help)
  7. ↑ "DIAMOX SEQUELS (ACETAZOLAMIDE) CAPSULE, EXTENDED RELEASE [DURAMED PHARMACEUTICALS, INC.]".
  8. ↑ 8.0 8.1 "http://www.ismp.org". External link in |title= (help)

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