Levamisole

Levamisole

Skeletal formula of levamisole
Ball-and-stick model of the levamisole molecule
Systematic (IUPAC) name
(S)-6-Phenyl-2,3,5,6-tetrahydroimidazo[2,1-b][1,3]thiazole
Clinical data
Trade names	Ergamisol
AHFS/Drugs.com	Micromedex Detailed Consumer Information
MedlinePlus	a697011
Legal status	withdrawn
Routes of administration	By mouth
Pharmacokinetic data
Metabolism	Liver
Biological half-life	3-4 hours
Excretion	70% kidney
Identifiers
CAS Number	14769-73-4 Y
ATC code	P02CE01 (WHO) QP52AE01 (WHO)
PubChem	CID: 26879
IUPHAR/BPS	7210
DrugBank	DB00848 Y
ChemSpider	25037 Y
UNII	2880D3468G Y
KEGG	D08114 Y
ChEBI	CHEBI:6432 N
ChEMBL	CHEMBL1454 Y
Chemical data
Formula	C11H12N2S
Molecular mass	204.292 g/mol
SMILES N\2=C1/SCCN1C[C@@H]/2c3ccccc3
InChI InChI=1S/C11H12N2S/c1-2-4-9(5-3-1)10-8-13-6-7-14-11(13)12-10/h1-5,10H,6-8H2/t10-/m1/s1 Y Key:HLFSDGLLUJUHTE-SNVBAGLBSA-N Y
Physical data
Density	1.31 g/cm3
Melting point	60 °C (140 °F)
NY (what is this?)  (verify)

Levamisole, marketed under the trade name Ergamisol, is a medication used to treat parasitic worm infections. It has also been studied as a method to stimulate the immune system as part of the treatment of cancer. Levamisole remains in veterinary use as a dewormer for livestock.

The most serious side effect of levamisole is low white blood cells that leaves person vulnerable to infection. It belongs to the class of synthetic imidazothiazole derivatives.

Levamisole was discovered in 1966 by Janssen Pharmaceutica. It is on the World Health Organization's List of Essential Medicines, the most important medications needed in a basic health system. It was withdrawn from the U.S. and Canadian markets in 1999 and 2003, respectively, due to the risk of side effects and the availability of more effective medications. The medication has been used as an adulterant in cocaine sold in the United States, Canada and United Kingdom, resulting in serious side effects.

Medical uses

Levamisole was originally used as an anthelmintic to treat worm infestations in both humans and animals. Levamisole works as a nicotinic acetylcholine receptor agonist that causes continued stimulation of the parasitic worm muscles, leading to paralysis. In countries that still permit the use of levamisole, the recommended dose for anthelmintic therapy is a single dose, with a repeated dose 7 days later if needed for a severe hookworm infection. Most current commercial preparations are intended for veterinary use as a dewormer in cattle, pigs, and sheep. However, levamisole has also recently gained prominence among aquarists as an effective treatment for Camallanus roundworm infestations in freshwater tropical fish.

After being pulled from the market in the U.S. and Canada in 1999 and 2003, respectively, levamisole has been tested in combination with fluorouracil to treat colon cancer. Evidence from clinical trials support its addition to fluorouracil therapy to benefit patients with colon cancer. In some of the leukemic cell line studies, both levamisole and tetramisole showed similar effect.

Levamisole has been used to treat a variety of dermatologic conditions, including skin infections, leprosy, warts, lichen planus, and aphthous ulcers.

An interesting adverse side effect these reviewers reported in passing was "neurologic excitement". Later papers, from the Janssen group and others, indicate levamisole and its enantiomer, dexamisole, have some mood-elevating or antidepressant properties, although this was never a marketed use of the drug.

Adverse effects

One of the more serious side effects of Levamisole is agranulocytosis, or the depletion of the white blood cells. In particular, neutrophils appear to be affected the most. This occurs in 0.08-5% of the studied populations. There have also been reports of levamisole induced necrosis syndrome in which erythematous painful papules can appear almost anywhere on skin.

Metabolism

Levamisole is readily absorbed from the gastrointestinal tract and metabolized in the liver. Its time to peak plasma concentration is 1.5–2 hours. The plasma elimination half-life is fairly quick at 3–4 hours which can contribute to not detecting Levamisole intoxication. The metabolite half-life is 16 hours. Levamisole's excretion is primarily through the kidneys, with about 70% being excreted over 3 days. Only about 5% is excreted as unchanged Levamisole.

Drug testing of racehorse urine has led to the revelation that among Levamisole equine metabolites are both pemoline and aminorex, stimulants that are forbidden by racing authorities. Further testing confirmed aminorex in human and canine urine, meaning that both humans and dogs also metabolize levamisole into aminorex. The possible stimulant properties of aminorex are what has caused Levamisole to be used as a cocaine adulterant which is described in more detail below.

Detection in body fluids

Levamisole may be quantified in blood, plasma, or urine as a diagnostic tool in clinical poisoning situations or to aid in the medicolegal investigation of suspicious deaths involving adulterated street drugs. About 3% of an oral dose is eliminated unchanged in the 24-hour urine of humans. A post mortem blood levamisole concentration of 2.2 mg/l was present in a woman who died of a cocaine overdose.

Illicit use

Levamisole has increasingly been used as a cutting agent in cocaine sold around the globe with the highest incidence being in the U.S.A . In 2008–2009, levamisole was found in 69% of cocaine samples seized by the Drug Enforcement Administration (DEA). By April 2011, the DEA reported the adulterant was found in 82% of seizures.

Levamisole adds bulk and weight to powdered cocaine (whereas other adulterants produce smaller "rocks" of cocaine) and makes the drug appear purer. In a series of investigative articles for The Stranger, Brendan Kiley details other rationales for levamisole's rise as an adulterant: possible stimulant effects, a similar appearance to cocaine, and an ability to pass street purity tests.

Levamisole suppresses the production of white blood cells, resulting in neutropenia and agranulocytosis. With the increasing use of levamisole as an adulterant, a number of these complications have been reported among cocaine users. Levamisole has also been linked to a risk of vasculitis, and two cases of vasculitic skin necrosis have been reported in users of cocaine adulterated with levamisole.

Levamisole-tainted cocaine was linked to several high-profile deaths. Toxicology reports showed levamisole, along with cocaine, was present in DJ AM's body at the time of his death. Andrew Koppel, son of newsman Ted Koppel, was also found with levamisole in his body after his death was ruled a drug overdose. More recently it has also been suspected in the death of a Sydney teenager.

In response to the dangers, The Stranger, People's Harm-Reduction Alliance and DanceSafe began producing tests to identify levamisole's presence in cocaine. The kits include a survey postcard, and one revealed its presence in a 1/4-kg block of cocaine, indicating both users and dealers were using the kits.

Chemistry

The original synthesis at Janssen Pharmaceutica resulted in the preparation of a racemic mixture of two enantiomers, whose hydrochloride salt was reported to have a melting point of 264–265 °C; the free base of the racemate has a melting point of 87–89 °C.

Toxicity

The LD₅₀ (intravenous, mouse) is 22 mg/kg.

Laboratory use

Levamisole reversibly and noncompetitively inhibits most isoforms of alkaline phosphatase (e.g., human liver, bone, kidney, and spleen) except the intestinal and placental isoform. It is thus used as an inhibitor along with substrate to reduce background alkaline phosphatase activity in biomedical assays involving detection signal amplification by intestinal alkaline phosphatase, for example in in situ hybridization or Western blot protocols.

It is used to immobilize the nematode C. elegans on glass slides for imaging and dissection.

In a C. elegans behavioral assay, analyzing the time course of paralysis provides information about the neuromuscular junction. Levamisole acts as an acetylcholine receptor agonist, which leads to muscle contraction. Continuing activation leads to paralysis. The time course of paralysis provides information about the acetylcholine receptors on the muscle. For example, mutants with fewer acetylcholine receptors may paralyze slower than wild type.