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 methylene blue, as it can induce hemolysis and worsen methemoglobinemia in these patients 1. The most important drugs to avoid include:

• Antimalarials like primaquine and chloroquine
• Antibiotics such as sulfonamides (sulfamethoxazole, sulfadiazine), nitrofurantoin, and quinolones (ciprofloxacin)
• Analgesics like aspirin and other NSAIDs in high doses
• Other medications including rasburicase, methylene blue, and naphthalene (found in mothballs) Additionally, patients should avoid fava beans (broad beans) as they can also trigger hemolysis. These substances cause oxidative stress in red blood cells, which cannot be countered in G6PD-deficient individuals because they lack sufficient G6PD enzyme to generate NADPH needed for antioxidant protection 1. When exposed to these triggers, red blood cells rupture, leading to hemolytic anemia with symptoms like fatigue, jaundice, dark urine, and back/abdominal pain. It is crucial for patients with G6PD deficiency to inform healthcare providers about their condition before receiving any medication, and they should carry medical identification indicating their G6PD status 1. In case of methemoglobinemia, alternative treatments such as ascorbic acid or exchange transfusion should be considered, especially if methylene blue is contraindicated due to G6PD deficiency 1.

From the FDA Drug Label

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. Chloroquine may cause hemolysis in glucose-6 phosphate dehydrogenase (G-6-PD) deficiency Due to the risk of hemolytic anemia in patients with G6PD deficiency, G6PD testing has to be performed before using primaquine.

Drugs to avoid in G6PD deficiency:

• Primaquine 2
• Dapsone 3
• Chloroquine 4
• Sulfanilamide
• Nitrite
• Aniline
• Phenylhydrazine
• Napthalene
• Niridazole
• Nitro-furantoin
• 8-amino-antimalarials

From the Research

Drugs to Avoid in G6PD Deficiency

• The following drugs have been shown to cause hemolytic crises in G6PD-deficient patients and should be avoided:
  • Dapsone 5
  • Methylthioninium chloride (methylene blue) 5
  • Nitrofurantoin 5, 6, 7
  • Phenazopyridine 5, 6, 7
  • Primaquine 5, 7, 8
  • Rasburicase 5, 7
  • Tolonium chloride (toluidine blue) 5

Safe Medications for G6PD-Deficient Patients

• The following medications have been found to be safe for use in G6PD-deficient patients:
  • Benzodiazepines 9
  • Codeine/codeine derivatives 9
  • Fentanyl 9
  • Ketamine 9
  • Propofol 9
  • Ciprofloxacin 6
  • Glibenclamide 6
  • Ofloxacin 6
  • Sulfamethoxazole/cotrimoxazole 6
  • Sulfasalazine 6
  • Hydroxychloroquine 6
  • Glimepiride 6
  • Mesalazine 6
  • Sulfacetamide 6

Important Considerations

• It is essential to screen patients for G6PD deficiency before administering potentially hemolytic drugs 9, 7
• Patients with G6PD deficiency should be informed of the risks and signs of hemolytic crises 9
• Clinicians should be aware of the laboratory and clinical signs of hemolysis in G6PD-deficient patients 9