PharmGKB summary

The many uses of methylene blue Methylene blue (methylthioninium chloride) is a ‘jack of all trades’ with a litany of clinical uses. In vivo, it is indicated for use as a therapy for drug-induced methemoglobinemia [1-3], can be used for the treatment of infections, pathologies, or poisoning, and as a dye for diagnostics. It is also commonly used as a dye in vitro – for example, as a component in staining of cells, tissues, DNA, parasites, and bacteria [4-6]. In the 1890s, Ehrlich demonstrated its use to target the malarial parasite, and more recently it has been reinvestigated for inclusion in antimalarial regimens in the wake of parasite drug resistance [7-9]. Further examples of its clinical use include treatment of ifosfamide-induced neurotoxicity (although treatment has been reported ineffective), an antidote for cyanide poisoning, visualization of fallopian tubes or ruptured membranes, a marker of tumors, and even as a potential therapy for septic shock and ischemic brain injury [5,8,10-18]. In phase II clinical trials, a modified version of methylene blue is reported to slow cognitive decline in mild–moderate Alzheimer’s disease patients compared to placebo, and phase III trials are planned, although these results remain unpublished [19]. The mechanism of action is unclear – possibly by preventing tau protein aggregation or increasing amyloid-β clearance by enhancing proteasome activities [19,20]. As a photodynamic therapy, methylene blue could be used to treat psoriasis, West Nile virus infection, AIDS-related Kaposi’s sarcoma, antibiotic-resistant bacterial strains and decontaminate blood before transfusion [5,21-25]. Methylene blue has also contributed to drug development, forming the structural chemical basis of other therapeutic drugs, including the antimalarial drug, chloroquine; the antihistamine, promethazine; and the antipsychotic, chlorpromazine [5]. Acknowledging the many uses of methylene blue, this article focuses on the pharmacodynamics of methylene blue in the context of methemoglobinemia treatment and the pathways surrounding this, due to known pharmacogenetic associations that relate to these pathways.