Which medications and chemical agents should patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency avoid?

Updated: May 01, 2020
  • Author: Srikanth Nagalla, MBBS, MS, FACP; Chief Editor: Emmanuel C Besa, MD  more...
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Answer

Persons with G6PD deficiency need to avoid foods, drugs, and chemicals that can precipitate hemolysis. The risk posed by those substances is determined in part by the person's G6PD variant (see Etiology) and thus the degree of enzyme deficiency.

Fava beans are the food best known for precipitating hemolysis; indeed, favism—the term for symptomatic attacks of hemolytic anemia from eating fava beans—has been recognized since antiquity. [10] Other foods that some persons with G6PD deficiency may prefer to avoid include the following [33] :

  • Red wine
  • All legumes
  • Blueberries
  • Soya products
  • Tonic water

For most persons with G6PD deficiency, the following drugs pose a definite risk: [1]

  • Dapsone and other sulfones (higher doses for dermatitis herpetiformis more likely to cause problems)
  • Methylthioninium chloride
  • Niridazole
  • Nitrofurantoin
  • Pamaquin
  • Primaquine (30 mg weekly for 8 weeks has been found to be without undue harmful effects in African and Asian people)
  • Quinolones (ciprofloxacin, moxifloxacin, nalidixic acid, norfloxacin, ofloxacin)
  • Rasburicase
  • Sulfonamides (including co-trimoxazole; however, some sulfonamides, such as sulfadiazine, have been found not to be hemolytic in many G6PD-deficient individuals)

Drugs that pose a possible risk in some persons with G6PD deficiency include the following:

  • Aspirin (acceptable up to a dose of at least 1g daily in most G6PD-deficient individuals)
  • Chloroquine (acceptable in acute malaria and malaria chemoprophylaxis)
  • Menadione (vitamin K3) and water-soluble derivatives (eg, menadol sodium phosphate)
  • Quinidine (acceptable in acute malaria)
  • Quinine (acceptable in acute malaria)
  • Sulfonylureas
  • Naphthalene in (mothballs)

Intravenous vitamin C is currently undergoing testing as adjunctive treatment for sepsis. Case reports describe episodes of hemolysis in patients with G6PD deficiency who received high doses of intravenous (IV) vitamin C (> 60 g). However, Marik cites dramatic reductions of methemoglobinemia and hemolysis that have been reported in patients treated with IV vitamin C in low to moderate doses (1-10 g every 6 hours), and proposes that those data suggest that vitamin C at a dosage of 6 g/day should not be considered contraindicated in patients with known or suspected G6PD deficiency—that indeed, IV vitamin C may be the treatment of choice in G6PD-deficient patients with drug-induced hemolysis.  Sepsis can cause methemoglobinemia, and methylene blue—the first-line treatment for acquired methemoglobinemia—is contraindicated in patients with G6PD deficiency. [34]


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