What medications should be avoided in patients with Glucose-6-phosphate dehydrogenase (G6PD) deficiency?

From the Guidelines

Patients with Glucose-6-phosphate dehydrogenase (G6PD) deficiency should avoid several medications that can trigger hemolytic anemia, including antimalarials such as primaquine and tafenoquine, as stated in a recent study 1. These medications can cause oxidative stress in red blood cells, leading to hemolysis. The study highlights the importance of testing for G6PD deficiency before administering certain medications, especially in patients with a history of hemolytic anemia. Other medications that should be avoided include:

• Antibiotics like sulfonamides (sulfamethoxazole, sulfadiazine), nitrofurantoin, and quinolones (ciprofloxacin)
• Analgesics including aspirin and other NSAIDs in high doses
• Other medications such as rasburicase, methylene blue, and dapsone Additionally, patients should avoid fava beans (broad beans) and naphthalene-containing products like mothballs. The severity of reaction depends on the specific G6PD variant and medication dose. Symptoms of hemolytic crisis include fatigue, jaundice, dark urine, back/abdominal pain, and in severe cases, acute kidney injury. Patients should carry medical identification indicating their G6PD status and inform all healthcare providers before receiving any medications, as recommended in other studies 1. It is also important to note that the risk of hemolysis in patients with G6PD deficiency can be significant, and measurement of G6PD levels is preferred in men, especially those of African, Asian, or Middle Eastern origin, before starting certain medications like hydroxychloroquine 1.

From the FDA Drug Label

Do not administer Elitek to patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Hemolysis and Heinz body formation may be exaggerated in individuals with a glucose-6-phosphate dehydrogenase (G6PD) deficiency, or methemoglobin reductase deficiency, or hemoglobin M. Drugs or chemicals which have produced significant hemolysis in G6PD or methemoglobin reductase deficient patients include Dapsone, sulfanilamide, nitrite, aniline, phenylhydrazine, napthalene, niridazole, nitro-furantoin and 8-amino-antimalarials such as primaquine.

The following medications should be avoided in patients with Glucose-6-phosphate dehydrogenase (G6PD) deficiency:

• Rasburicase (IV): due to the risk of hemolysis 2
• Dapsone (PO): as it may cause hemolysis and Heinz body formation in G6PD deficient patients 3
• Sulfanilamide
• Nitrite
• Aniline
• Phenylhydrazine
• Napthalene
• Niridazole
• Nitro-furantoin
• 8-amino-antimalarials such as primaquine

From the Research

Medications to Avoid in G6PD Deficiency

• The following medications have been identified as potentially hazardous for individuals with G6PD deficiency:
  • Dapsone 4
  • Methylthioninium chloride (methylene blue) 4
  • Nitrofurantoin 4, 5, 6
  • Phenazopyridine 4, 6
  • Primaquine 4
  • Rasburicase 4
  • Tolonium chloride (toluidine blue) 4
• Other medications that may cause hemolysis in G6PD-deficient patients include:
  • Diclofenac sodium 5
  • Ibuprofen 5
  • Acetylsalicylic acid 5
  • Co-trimoxazole 5

Medications Considered Safe for G6PD Deficiency

• The following medications have been found to be safe for use in G6PD-deficient patients:
  • Benzodiazepines 7
  • Codeine/codeine derivatives 7
  • Propofol 7
  • Fentanyl 7
  • Ketamine 7
  • Dexmedetomidine 8
• Additionally, the following medications have been prescribed safely to G6PD-deficient patients in a real-world study:
  • Ciprofloxacin 6
  • Glibenclamide 6
  • Ofloxacin 6
  • Sulfamethoxazole/cotrimoxazole 6
  • Sulfasalazine 6
  • Hydroxychloroquine 6
  • Glimepiride 6
  • Mesalazine 6
  • Sulfacetamide 6