Common side effects include nausea, abdominal pain, and diarrhea.[3] Other side effects may include liver inflammation and allergic reactions.[3] It is not recommended in people with end stage kidney disease.[3] While there does not appear to be harm with use during pregnancy it has not been well studied in this population.[3] 4-Aminosalicylic acid is believed to work by blocking the ability of bacteria to make folic acid.[3]
The main use for 4-aminosalicylic acid is for the treatment of tuberculosis infections.[1][6]
In the United States, 4-aminosalicylic acid is indicated for the treatment of tuberculosis in combination with other active agents.[6]
In the European Union, it is used in combination with other medicines to treat adults and children from 28 days of age who have multi-drug resistant tuberculosis when combinations without this medicine cannot be used, either because the disease is resistant to them or because of their side effects.[1]
Aminosalicylic acid was introduced to clinical use in 1944. It was the second antibiotic found to be effective in the treatment of tuberculosis, after streptomycin. PAS formed part of the standard treatment for tuberculosis prior to the introduction of rifampicin and pyrazinamide.[7]
Its potency is less than that of the current five first-line drugs (isoniazid, rifampicin, ethambutol, pyrazinamide, and streptomycin) for treating tuberculosis and its cost is higher, but it is still useful in the treatment of multidrug-resistant tuberculosis.[8] PAS is always used in combination with other anti-TB drugs.[citation needed]
The dose when treating tuberculosis is 150 mg/kg/day divided into two to four daily doses; the usual adult dose is therefore approximately 2 to 4 grams four times a day. It is sold in the US as "Paser" by Jacobus Pharmaceutical, which comes in the form of 4 g packets of delayed-release granules. The drug should be taken with acid food or drink (orange, appleortomato juice).[9] PAS was once available in a combination formula with isoniazid called Pasinah[10] or Pycamisan 33.[11]
4-aminosalicylic acid was approved for medical use in the United States in June 1994, and for medical use in the European Union in April 2014.[12][1]
4-aminosalicylic acid has also been used in the treatment of inflammatory bowel disease (ulcerative colitis and Crohn's disease),[13] but has been superseded by other drugs such as sulfasalazine and mesalazine.
4-aminosalicylic acid has been investigated for the use in manganesechelation therapy, and a 17-year follow-up study shows that it might be superior to other chelation protocols such as EDTA.[14]
4-aminosalicylic acid has been shown to be a pro-drug and it is incorporated into the folate pathway by dihydropteroate synthase (DHPS) and dihydrofolate synthase (DHFS) to generate a hydroxyl dihydrofolate (Hydroxy-H2Pte and Hydroxy-H2PteGlu) antimetabolite, which competes with dihydrofolate at the binding site of dihydrofolate reductase (DHFR). The binding of Hydroxy-H2PteGlu to dihydrofolate reductase will block the enzymatic activity.[21]
It was initially thought that resistance of 4-aminosalicylic acid came from a mutation affecting dihydrofolate reductase (DHFR). However, it was discovered that it was caused by a mutation affecting the dihydrofolate synthesis (DHFS) enzyme activity. The mutations of isoleucine 43, arginine 49, serine 150, phenylalanine 152, glutamate 153, and alanine 183 were found to affect the binding pocket of the dihydrofolate synthase enzyme. This will reduce the ability for hydroxy-H2Pte to bind to dihydrofolate synthase and preventing 4-aminosalicylic acid from poisoning the folate metabolism.[23]
4-aminosalicylic acid was first synthesized by Seidel and Bittner in 1902.[4] It was rediscovered by the Swedish chemist Jörgen Lehmann upon the report that the tuberculosis bacterium avidly metabolized salicylic acid.[24] Lehmann first tried PAS as an oral TB therapy late in 1944. The first patient made a dramatic recovery.[25] The drug proved better than streptomycin, which had nerve toxicity and to which TB could easily develop resistance. In the 1948, researchers at Britain's Medical Research Council demonstrated that combined treatment with streptomycin and PAS was superior to either drug alone, and established the principle of combination therapy for tuberculosis.[8][4]
^ abcdefgh"Aminosalicylic Acid". The American Society of Health-System Pharmacists. Archived from the original on 20 December 2016. Retrieved 8 December 2016.
^ abcDonald PR, Diacon AH (September 2015). "Para-aminosalicylic acid: the return of an old friend". The Lancet. Infectious Diseases. 15 (9): 1091–1099. doi:10.1016/s1473-3099(15)00263-7. PMID26277036.
^World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
^Mitchison DA (September 2000). "Role of individual drugs in the chemotherapy of tuberculosis". The International Journal of Tuberculosis and Lung Disease. 4 (9): 796–806. PMID10985648.
^ abFox W, Ellard GA, Mitchison DA (October 1999). "Studies on the treatment of tuberculosis undertaken by the British Medical Research Council tuberculosis units, 1946-1986, with relevant subsequent publications". The International Journal of Tuberculosis and Lung Disease. 3 (10 Suppl 2): S231–S279. PMID10529902.
^"Paser". RxList. Archived from the original on 13 September 2008. Retrieved 10 October 2008.
^Das KM, Eastwood MA, McManus JP, Sircus W (September 1973). "Adverse reactions during salicylazosulfapyridine therapy and the relation with drug metabolism and acetylator phenotype". The New England Journal of Medicine. 289 (10): 491–495. doi:10.1056/NEJM197309062891001. PMID4146729.
^Boman G (1974). "Serum concentration and half-life of rifampicin after simultaneous oral administration of aminosalicylic acid or isoniazid". European Journal of Clinical Pharmacology. 7 (3): 217–225. doi:10.1007/BF00560384. PMID4854257. S2CID24202603.
^Vetuschi C, Ragno G, Mazzeo P (1988). "Determination of p-aminosalicylic acid and m-aminophenol by derivative UV-spectrophotometry". Journal of Pharmaceutical and Biomedical Analysis. 6 (4): 383–391. doi:10.1016/0731-7085(88)80003-7. PMID16867404.
^Lehmann J (December 1949). "The treatment of tuberculosis in Sweden with para-aminosalicylic acid; a review". Diseases of the Chest. 16 (6): 684–703, illust. doi:10.1378/chest.16.6.684. PMID15396516.