Chemistry:Disulfiram

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Short description: Chemical compound
Disulfiram
Disulfiram.svg
Disulfiram-from-xtal-Mercury-3D-bs.png
Clinical data
Trade namesAntabuse, Antabus, other
Other namestetraethyldisulfanedicarbothioamide; 1-(Diethylthiocarbamoyldisulfanyl)-N,N-diethyl-methanethioamide
AHFS/Drugs.comMonograph
MedlinePlusa682602
Pregnancy
category
  • AU: B2
Routes of
administration		By mouth, subdermal implant
ATC code
Legal status
Legal status
  • AU: S6 (Poison) / S4
  • BR: Class C1 (Other controlled substances)
  • UK: POM (Prescription only)
  • US: ℞-only
Pharmacokinetic data
MetabolismLiver to diethylthiocarbamate
Elimination half-life60–120 hours
Identifiers
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
NIAID ChemDB
Chemical and physical data
FormulaC10H20N2S4
Molar mass296.52 g·mol−1
3D model (JSmol)
 ☒N☑Y (what is this?)  (verify)

Disulfiram is a medication used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol (drinking alcohol). Disulfiram works by inhibiting the enzyme aldehyde dehydrogenase, causing many of the effects of a hangover to be felt immediately following alcohol consumption. Disulfiram plus alcohol, even small amounts, produces flushing, throbbing in the head and neck, a throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pain, palpitation, dyspnea, hyperventilation, fast heart rate, low blood pressure, fainting, marked uneasiness, weakness, vertigo, blurred vision, and confusion. In severe reactions there may be respiratory depression, cardiovascular collapse, abnormal heart rhythms, heart attack, acute congestive heart failure, unconsciousness, convulsions, and death.[1]

In the body, alcohol is converted to acetaldehyde, which is then broken down by acetaldehyde dehydrogenase. When the dehydrogenase enzyme is inhibited, acetaldehyde builds up, causing unpleasant side effects (Disulfiram-alcohol reaction). Disulfiram should be used in conjunction with counseling and support.[citation needed]

Medical uses

Disulfiram is used as a second-line treatment, behind acamprosate and naltrexone, for alcohol dependence.[2]

Under normal metabolism, alcohol is broken down in the liver by the enzyme alcohol dehydrogenase to acetaldehyde, which is then converted by the enzyme acetaldehyde dehydrogenase to a harmless acetic acid derivative (acetyl coenzyme A). Disulfiram blocks this reaction at the intermediate stage by blocking acetaldehyde dehydrogenase. After alcohol intake under the influence of disulfiram, the concentration of acetaldehyde in the blood may be five to 10 times higher than that found during metabolism of the same amount of alcohol alone. As acetaldehyde is one of the major causes of the symptoms of a "hangover", this produces immediate and severe negative reaction to alcohol intake. About 5 to 10 minutes after alcohol intake, the patient may experience the effects of a severe hangover for a period of 30 minutes up to several hours. Symptoms usually include flushing of the skin, accelerated heart rate, low blood pressure, nausea, and vomiting. Uncommon adverse events include shortness of breath, throbbing headache, visual disturbance, mental confusion, postural syncope, and circulatory collapse.[3]

Disulfiram should not be taken if alcohol has been consumed in the last 12 hours.[4] There is no tolerance to disulfiram: the longer it is taken, the stronger its effects.[1] As disulfiram is absorbed slowly through the digestive tract and eliminated slowly by the body, the effects may last for up to two weeks after the initial intake; consequently, medical ethics dictate that patients must be fully informed about the disulfiram-alcohol reaction.[5]

Disulfiram does not reduce alcohol cravings, so a major problem associated with this drug is extremely poor compliance. Methods to improve compliance include subdermal implants, which release the drug continuously over a period of up to 12 weeks, and supervised administration practices, for example, having the drug regularly administered by one's spouse.

Although disulfiram remained the most common pharmaceutical treatment of alcohol abuse until the end of the 20th century, today it is often replaced or accompanied with newer drugs, primarily the combination of naltrexone and acamprosate, which directly attempt to address physiological processes in the brain associated with alcohol abuse.[citation needed]

Side effects

The most common side effects in the absence of alcohol are headache, and a metallic or garlic taste in the mouth, though more severe side effects may occur.[6] Tryptophol, a chemical compound that induces sleep in humans, is formed in the liver after disulfiram treatment.[7] Less common side effects include decrease in libido, liver problems, skin rash, and nerve inflammation.[8] Liver toxicity is an uncommon but potentially serious side effect, and risk groups e.g. those with already impaired liver function should be monitored closely. That said, the rate of disulfiram-induced hepatitis are estimated to be in between 1 per 25,000 to 1 in 30,000,[9] and rarely the primary cause for treatment cessation.

Cases of disulfiram neurotoxicity have also occurred, causing extrapyramidal and other symptoms.[10] Disulfiram can produce neuropathy in daily doses of less than the usually recommended 500 mg. Nerve biopsies showed axonal degeneration and the neuropathy is difficult to distinguish from that associated with ethanol abuse. Disulfiram neuropathy occurs after a variable latent period (mean 5 to 6 months) and progresses steadily. Slow improvement may occur when the drug's use is stopped; often there is complete recovery eventually.[11]

Disulfiram disrupts metabolism of several other compounds, including paracetamol (acetaminophen),[12] theophylline[13] and caffeine.[14] However, in most cases, this disruption is mild and presents itself as a 20–40% increase in the half-life of the compound at typical dosages of disulfiram.[citation needed]

Similarly acting substances

In medicine, the term "disulfiram effect" refers to an adverse effect of a particular medication in causing an unpleasant hypersensitivity to alcohol, similar to the effect caused by disulfiram administration.[citation needed]

History

The synthesis of disulfiram, originally known as tetraethylthiuram disulfide, was first reported in 1881. By around 1900, it was introduced to the industrial process of sulfur vulcanization of rubber and became widely used. In 1937 a plant physician in the American rubber industry described adverse reactions to alcohol in workers exposed to tetramethylthiuram monosulfide and disulfide, and proposed that this effect of disulfiram and related compounds might lead to ”the cure for alcoholism”; the effect was also noticed in workers at a Swedish rubber boot factory.[15]

In the early 1940s it had been tested as a treatment for scabies, a parasitic skin infection, as well as intestinal worms.[15]

Around that time, during the German occupation of Denmark, Erik Jacobsen and Jens Hald at the Danish drug company Medicinalco picked up on that research and began exploring the use of disulfiram to treat intestinal parasites. The company had a group of enthusiastic self-experimenters that called itself the "Death Battalion", and in the course of testing the drug on themselves, accidentally discovered that drinking alcohol while the drug was still in their bodies made them mildly sick.[15][16]:98–105

They made that discovery in 1945, and did nothing with it until two years later, when Jacobsen gave an impromptu talk and mentioned that work, which was discussed afterwards in newspapers at the time, leading them to further explore the use of the drug for that purpose.[15][16]:98–105 That work included small clinical trials with Oluf Martensen-Larsen, a doctor who worked with alcoholics.[15] They published their work starting in 1948.[15][17]

The chemists at Medicinalco discovered a new form of disulfiram while trying to purify a batch that had been contaminated with copper. This form turned out to have better pharmacological properties, and the company patented it and used that form for the product that was introduced as Antabus (later anglicized to Antabuse).[15]

This work led to renewed study of the human metabolism of ethanol. It was already known that ethanol was mostly metabolized in the liver, with it being converted first to acetaldehyde and then acetaldehyde to acetic acid and carbon dioxide, but the enzymes involved were not known. By 1950 the work led to the knowledge that ethanol is oxidized to acetaldehyde by alcohol dehydrogenase and acetaldehyde is oxidized to acetic acid by aldehyde dehydrogenase (ALDH), and that disulfiram works by inhibiting ALDH, leading to a buildup of acetaldehyde, which is what causes the negative effects in the body.[15]

The drug was first marketed in Denmark and as of 2008, Denmark is the country where it is most widely prescribed. It was approved by the FDA in 1951.[15][18] The FDA later approved other drugs for treatment of alcoholism, namely naltrexone in 1994 and acamprosate in 2004.[15]

Society and culture

Though the Occupational Safety and Health Administration (OSHA) in the US has not set a permissible exposure limit (PEL) for disulfiram in the workplace, the National Institute for Occupational Safety and Health has set a recommended exposure limit (REL) of 2 mg/m3 and recommended that workers avoid concurrent exposure to ethylene dibromide.[19]

Research

Disulfiram has been studied as a possible treatment for cancer,[20] parasitic infections,[21] anxiety disorder,[22] and latent HIV infection.[23]

Disulfiram has shown reversing of retinitis pigmentosa in rats.[24][25][26]

Cancer

When disulfiram creates complexes with metals (dithiocarbamate complexes), it is a proteasome inhibitor and as of 2016 it had been studied in in vitro experiments, model animals, and small clinical trials as a possible treatment for liver metastasis, metastatic melanoma, glioblastoma, non-small cell lung cancer, and prostate cancer.[20][27] Various clinical trials of copper depletion agents have been carried out.[citation needed]

Parasitic infections

In the body, disulfiram is rapidly metabolized to diethyldithiocarbamate (ditiocarb), which binds to metal ions such as zinc or copper to form zinc or copper diethyldithiocarbamate (zinc or copper ditiocarb). The zinc diethyldithiocarbamate (zinc-ditiocarb) metabolite of disulfiram is extremely potent against the diarrhea and liver abscess-causing parasite Entamoeba histolytica and might be active against other deadly parasites.[21][28]

HIV

Disulfiram has also been identified by systematic high-throughput screening as a potential HIV latency reversing agent (LRA).[29][30] Reactivation of latent HIV infection in patients is part of an investigational strategy known as "shock and kill" which may be able to reduce or eliminate the HIV reservoir.[23] Recent phase II dose-escalation studies in patients with HIV who are controlled on antiretroviral therapy have observed an increase in cell-associated unspliced HIV RNA with increasing exposure to disulfiram and its metabolites.[29][31] Disulfiram is also being investigated in combination with vorinostat, another investigational latency reversing agent, to treat HIV.[32]

COVID-19

Disulfiram has been shown to inhibit the papain-like proteases of MERS-CoV and SARS-CoV.[33] It has been examined in a small inconclusive retrospective observational study for its effects on COVID-19 symptoms.[34] In a small randomized controlled trial that has yet to be published in a medical journal, seven COVID patients received disulfiram. No serious adverse events were reported in these patients.[35]

References

  1. ↑ 1.0 1.1 "Antabuse – disulifram tablet". National Institutes of Health. May 23, 2016. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f0ca0e1f-9641-48d5-9367-e5d1069e8680. 
  2. ↑ "Disulfiram". Stat Pearls. Treasure Island (FL): StatPearls Publishing. January 2018. https://www.ncbi.nlm.nih.gov/books/NBK459340/. 
  3. ↑ "Diethyldithiocarbamic acid-methyl ester: a metabolite of disulfiram and its alcohol sensitizing properties in the disulfiram-ethanol reaction". Alcohol 4 (6): 463–467. November 1987. doi:10.1016/0741-8329(87)90086-3. PMID 2829942. 
  4. ↑ "Disulfiram Official FDA information, side effects and uses.". Drugs.com. https://www.drugs.com/pro/disulfiram.html. 
  5. ↑ "Disulfiram treatment of alcoholism". The American Journal of Medicine 88 (6): 647–655. June 1990. doi:10.1016/0002-9343(90)90534-K. PMID 2189310. 
  6. ↑ "Disulfiram Side Effects". Drugs.com. https://www.drugs.com/sfx/disulfiram-side-effects.html. 
  7. ↑ "Rapid distribution of tryptophol (3-indole ethanol) to the brain and other tissues". The Journal of Clinical Investigation 63 (6): 1241–1248. June 1979. doi:10.1172/JCI109419. PMID 447842. 
  8. ↑ "Antabuse (disulfiram)". November 18, 2013. http://www.netdoctor.co.uk/medicines/brain-and-nervous-system/a6217/antabuse-disulfiram/. 
  9. ↑ Center for Substance Abuse Treatment (2009). Chapter 3—Disulfiram. Substance Abuse and Mental Health Services Administration (US). https://www.ncbi.nlm.nih.gov/books/NBK64036/. 
  10. ↑ "MRI findings in a case of late onset disulfiram-induced neurotoxicity". Journal of Neurology 247 (9): 714–715. September 2000. doi:10.1007/s004150070119. PMID 11081815. 
  11. ↑ "Disulfiram neuropathy". Canadian Medical Association Journal 123 (2): 123–126. July 1980. PMID 6266628. 
  12. ↑ "The influence of disulfiram on acetaminophen metabolism in man". Xenobiotica; the Fate of Foreign Compounds in Biological Systems 21 (2): 243–249. February 1991. doi:10.3109/00498259109039466. PMID 2058179. 
  13. ↑ "Dose-dependent inhibition of theophylline metabolism by disulfiram in recovering alcoholics". Clinical Pharmacology and Therapeutics 45 (5): 476–486. May 1989. doi:10.1038/clpt.1989.61. PMID 2721103. 
  14. ↑ "Inhibition of elimination of caffeine by disulfiram in normal subjects and recovering alcoholics". Clinical Pharmacology and Therapeutics 39 (3): 265–270. March 1986. doi:10.1038/clpt.1986.37. PMID 3948467. 
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 15.8 15.9 "From Disulfiram to Antabuse: The Invention of a Drug". Bulletin for the History of Chemistry 33 (2): 82–88. 2008. http://www.scs.illinois.edu/~mainzv/HIST/bulletin_open_access/v33-2/v33-2%20p82-88.pdf. 
  16. ↑ 16.0 16.1 Who Goes First?: The Story of Self-Experimentation in Medicine. University of California Press. 1998. ISBN 9780520212817. https://books.google.com/books?id=V1jwt-P8FjoC&pg=PA98. 
  17. ↑ "The Sensitizing Effect of Tetraethylthiuramdisulphide (Antabuse) to Ethylalcohol". Acta Pharmacologica et Toxicologica 4 (3–4): 285–296. July 1948. doi:10.1111/j.1600-0773.1948.tb03350.x. 
  18. ↑ "New Drug Application (NDA) 007883: Disulfiram (Antabuse)". FDA-Approved Drugs. U.S. Food and Drug Administration (FDA). https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=007883. 
  19. ↑ NIOSH Pocket Guide to Chemical Hazards. "#0244". National Institute for Occupational Safety and Health (NIOSH). https://www.cdc.gov/niosh/npg/npgd0244.html. 
  20. ↑ 20.0 20.1 "Disulfiram's Anticancer Activity: Evidence and Mechanisms". Anti-Cancer Agents in Medicinal Chemistry 16 (11): 1378–1384. 2016. doi:10.2174/1871520615666160504095040. PMID 27141876. 
  21. ↑ 21.0 21.1 "Drug Repurposing of the Alcohol Abuse Medication Disulfiram as an Anti-Parasitic Agent". Frontiers in Cellular and Infection Microbiology 11: 633194. 2021. doi:10.3389/fcimb.2021.633194. PMID 33777846. 
  22. ↑ "Drug Used to Treat Alcoholism Shows Promise for Anxiety, Study Results Show" (in en). 23 April 2022. https://www.pharmacytimes.com/view/drug-used-to-treat-alcoholism-shows-promise-for-anxiety-study-results-show. 
  23. ↑ 23.0 23.1 "Shocking HIV out of hiding: where are we with clinical trials of latency reversing agents?". Current Opinion in HIV and AIDS 11 (4): 394–401. July 2016. doi:10.1097/COH.0000000000000279. PMID 26974532. 
  24. ↑ "A key to restoring sight may be held in a drug that treats alcoholism" (in en-us). https://www.urmc.rochester.edu/news/publications/neuroscience/a-key-to-restoring-sight-may-be-held-in-a-drug-that-treats-alcoholism. 
  25. ↑ "Retinoic acid inhibitors mitigate vision loss in a mouse model of retinal degeneration". Science Advances 8 (11): eabm4643. March 2022. doi:10.1126/sciadv.abm4643. PMID 35302843. Bibcode: 2022SciA....8M4643T. 
  26. ↑ "A drug once used to treat alcoholism may cure retinal degeneration" (in en-US). 2022-03-19. https://interestingengineering.com/antabuse-drug-alcoholism-retinal-degeneration. 
  27. ↑ "The value of proteasome inhibition in cancer. Can the old drug, disulfiram, have a bright new future as a novel proteasome inhibitor?". Drug Discovery Today 13 (15–16): 716–722. August 2008. doi:10.1016/j.drudis.2008.05.003. PMID 18579431. 
  28. ↑ "COP9 signalosome is an essential and druggable parasite target that regulates protein degradation". PLOS Pathogens 16 (9): e1008952. September 2020. doi:10.1371/journal.ppat.1008952. PMID 32960936. 
  29. ↑ 29.0 29.1 "Population Pharmacokinetics and Pharmacodynamics of Disulfiram on Inducing Latent HIV-1 Transcription in a Phase IIb Trial". Clinical Pharmacology and Therapeutics 105 (3): 692–702. March 2019. doi:10.1002/cpt.1220. PMID 30137649. 
  30. ↑ "Disulfiram reactivates latent HIV-1 in a Bcl-2-transduced primary CD4+ T cell model without inducing global T cell activation". Journal of Virology 85 (12): 6060–6064. June 2011. doi:10.1128/JVI.02033-10. PMID 21471244. 
  31. ↑ "A Critical Review of the Evidence Concerning the HIV Latency Reversing Effect of Disulfiram, the Possible Explanations for Its Inability to Reduce the Size of the Latent Reservoir In Vivo, and the Caveats Associated with Its Use in Practice". AIDS Research and Treatment 2017: 8239428. 2017. doi:10.1155/2017/8239428. PMID 28465838. 
  32. ↑ Clinical trial number NCT03198559 for "Combination Latency Reversal With High Dose Disulfiram Plus Vorinostat in HIV-infected Individuals on ART" at ClinicalTrials.gov
  33. ↑ "Disulfiram can inhibit MERS and SARS coronavirus papain-like proteases via different modes". Antiviral Research 150: 155–163. February 2018. doi:10.1016/j.antiviral.2017.12.015. PMID 29289665. 
  34. ↑ "COVID-19 and related symptoms in patients under disulfiram for alcohol use disorder". Internal and Emergency Medicine 16 (6): 1729–1731. September 2021. doi:10.1007/s11739-021-02633-y. PMID 33464469. 
  35. ↑ Clinical trial number NCT04485130 for "DISulfiram for COvid-19 (DISCO) Trial" at ClinicalTrials.gov

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