Isoniazid

Tuberculosis The primary use of isoniazid is as first-line treatment for latent and active infection of Mycobacterium tuberculosis, the causative agent of tuberculosis (TB). In persons with isoniazid-resistant Mycobacterium tuberculosis infection, drug regimens based on isoniazid have a high rate of failure. In the United States, the indications for isoniazid use approved by the U.S. Food and Drug Administration (FDA) include:. Non-tuberculous mycobacteria Isoniazid may also be used off-label to treat nontuberculous mycobacterial pulmonary disease. Evidence suggests that isoniazid prevents mycolic acid synthesis in M. avium complex as in M. tuberculosis and although this is not bactericidal to M. avium complex, it greatly potentiates the effect of rifampicin. Special populations It is recommended that women with active tuberculosis who are pregnant or breastfeeding take isoniazid. Preventive therapy should be delayed until after giving birth. Nursing mothers excrete a relatively low and non-toxic concentration of INH in breast milk, and their babies are at low risk for side effects. Both pregnant women and infants being breastfed by mothers taking INH should take vitamin B6 in its pyridoxine form to minimize the risk of peripheral nerve damage. Vitamin B6 is used to prevent isoniazid-induced B6 deficiency and neuropathy in people with a risk factor, such as pregnancy, lactation, HIV infection, alcoholism, diabetes, kidney failure, or malnutrition. People with liver dysfunction are at a higher risk for hepatitis caused by INH, and may need a lower dose. ==History==

Synthesis 's (right) development of the Olin Raschig process enabled the synthesis of isoniazid in 1912. After Friedrich Raschig developed a method to synthesize hydrazine, Hans Meyer and his doctoral student at the German University in Prague Josef Mally researched hydrazides of pyridinecarboxylic acids. By reacting ethyl isonicotinate with hydrazine hydrate, they obtained a compound which, after recrystallization, possessed a melting point of 163°C. Despite its publication in 1912, the compound's pharmaceutical properties were not investigated for decades. In the 1940s, French physicians discovered that nicotinamide had some activity against tubercle bacilli in vitro and in infected guinea pigs. At the same time, German chemists led by G. Domagk investigating sulfo drugs at Bayer developed thioacetazone. After their findings were made public, in 1950 modified it to the less toxic thiosemicarbazone of nicotinaldehyde while H. H. Fox developed similar isonicotinaldehyde thiosemicarbazone. Discovery of anti-TB activity Soon, multiple laboratories discovered anti-TB activity of isoniazid. the most prominent one being Roche in January 1951, which launched its version, Rimifon, in 1952. Additionally, Soviet physicians and Bella Keyfman independently discovered this activity in 1949, but neither published their findings in a peer-reviewed article nor applied for an inventor's certificate. The drug was first tested at Many Farms, a Navajo community in Arizona, due to the Navajo reservation's tuberculosis problem and because the population had not previously been treated with streptomycin, the main tuberculosis treatment at the time. The research was led by Walsh McDermott, an infectious disease researcher with an interest in public health, who had previously taken isoniazid to treat his own tuberculosis. Isoniazid and a related drug, iproniazid, were among the first drugs to be referred to as antidepressants. Psychiatric use stopped in 1961 following reports of hepatotoxicity. Use against tuberculosis continued, as isoniazid's effectiveness against the disease outweighs its risks. Elucidation of mechanism of action Seminal studies that uncovered the mechanism of action for isoniazid were largely performed in M. smegmatis, a model for the slow-growing M. tuberculosis. In 1992, Stewart Cole and colleagues discovered that isoniazid was active in resistant M. smegmatis only when KatG, a catalase-peroxidase, was expressed; KatG is now understood to be critical for the metabolism of the prodrug isoniazid into its active forms.. Modern usage As part of standard TB chemotherapy, isoniazid is now typically administered alongside at least three other drugs—ethambutol, pyrazinamide, and rifampin—for six to nine months. The World Health Organization classifies isoniazid as critically important for human medicine. ==Adverse effects==

Side effects Up to 20% of people taking isoniazid experience peripheral neuropathy when taking daily doses of 6 mg/kg of body weight or higher. Gastrointestinal reactions include nausea and vomiting. Aplastic anemia, thrombocytopenia, and agranulocytosis due to lack of production of red blood cells, platelets, and white blood cells by the bone marrow respectively, can also occur. Hypersensitivity reactions are common and can present with a maculopapular rash and fever. Asymptomatic elevation of serum liver enzyme concentrations occurs in 10% to 20% of people taking INH, and liver enzyme concentrations usually return to normal even when treatment is continued. Isoniazid has a boxed warning for severe and sometimes fatal hepatitis, which is age-dependent at a rate of 0.3% in people 21 to 35 years old and over 2% in those over age 50. Symptoms suggestive of liver toxicity include nausea, vomiting, abdominal pain, dark urine, right upper quadrant pain, and loss of appetite. Black and Hispanic women are at higher risk for isoniazid-induced hepatotoxicity. Some recommend that liver function should be monitored carefully in all people receiving it, Headache, poor concentration, weight gain, poor memory, insomnia, and depression have all been associated with isoniazid use. All patients and healthcare workers should be aware of these serious side effects, especially if suicidal ideation or behavior are suspected. Drug interactions Isoniazid decreases the metabolism of carbamazepine, slowing down its clearance from the body. People taking carbamazepine should have their carbamazepine levels monitored and, if necessary, have their dose adjusted accordingly. Isoniazid can also increase the amount of phenytoin in the body. The doses of phenytoin may need to be adjusted when given with isoniazid. Isoniazid may increase the plasma levels of theophylline. There are some cases of theophylline slowing down isoniazid elimination. Both theophylline and isoniazid levels should be monitored. Valproate levels may increase when taken with isoniazid. Valproate levels should be monitored and its dose adjusted if necessary. It is possible that isoniazid may decrease the serum levels of ketoconazole after long-term treatment. This is seen with the simultaneous use of rifampin, isoniazid, and ketoconazole. ==Mechanism of action==

Isoniazid is a prodrug that inhibits the formation of the mycobacterial cell wall. Isoniazid must be activated by KatG, a bacterial catalase-peroxidase enzyme in Mycobacterium tuberculosis. KatG catalyzes the formation of the isonicotinic acyl radical, which spontaneously couples with NADH to form the nicotinoyl-NAD adduct. This complex binds tightly to the enoyl-acyl carrier protein reductase InhA, thereby blocking the natural enoyl-AcpM substrate and the action of fatty acid synthase. This process inhibits the synthesis of mycolic acids, which are required components of the mycobacterial cell wall. A range of radicals are produced by KatG activation of isoniazid, including nitric oxide, which has also been shown to be important in the action of another antimycobacterial prodrug pretomanid. Isoniazid is bactericidal to rapidly dividing mycobacteria, but is bacteriostatic if the mycobacteria are slow-growing. It inhibits the cytochrome P450 system and hence acts as a source of free radicals. Isoniazid is a mild non-selective monoamine oxidase inhibitor (MAO-I). It inhibits diamine oxidase more strongly. These two actions are possible explanations for its antidepressant action as well as its ability to cause mania. ==Metabolism==

Isoniazid reaches therapeutic concentrations in serum, cerebrospinal fluid, and within caseous granulomas. It is metabolized in the liver via acetylation into acetylhydrazine. Two forms of the enzyme are responsible for acetylation, so some patients metabolize the drug more quickly than others. Hence, the half-life is bimodal, with "slow acetylators" and "fast acetylators". A graph of number of people versus time shows peaks at one and three hours. The height of the peaks depends on the ethnicities of the people being tested. The metabolites are excreted in the urine. Doses do not usually have to be adjusted in case of renal failure. == Overdose ==

Isoniazid causes seizure on overdose due to a depletion of pyridoxal 5′-phosphate (P5P) preventing glutamic acid decarboxylase from making gamma aminobutyric acid (GABA). Ordinary pyridoxine is an effective antidote of this mechanism of toxicity. ==Preparation==

Isoniazid is an isonicotinic acid derivative. It is manufactured using 4-cyanopyridine and hydrazine hydrate. In another method, isoniazid was claimed to have been made from citric acid starting material. ==Brand names==

Brand names for isoniazid include Hydra, Hyzyd, Isovit, Laniazid, Nydrazid, Rimifon, and Stanozide. ==Other uses==

Chromatography Isonicotinic acid hydrazide is also used in chromatography to differentiate between various degrees of conjugation in organic compounds barring the ketone functional group. ==References==