eMedicine Specialties > Pediatrics: Genetics and Metabolic Disease > Metabolic Diseases

Alkaptonuria: Treatment & Medication

Author: Karl S Roth, MD, Professor and Chair, Department of Pediatrics, Creighton University School of Medicine
Contributor Information and Disclosures

Updated: Apr 27, 2009

Treatment

Medical Care

  • In infancy, a history of dark-stained diapers should alert the physician to alkaptonuria.4
  • Infants, young children, and asymptomatic young adults can be evaluated with simple urine testing on an outpatient basis.
  • Medical therapy is used to ameliorate the rate of pigment deposition. This minimizes articular and cardiovascular complications in later life.
  • Reduction of phenylalanine and tyrosine has reportedly reduced homogentisic acid excretion. Whether a mild dietary restriction from early in life would avoid or minimize later complications is not known, but such an approach is reasonable.
  • Vitamin C, as much as 1 g/d, is recommended for older children and adults. The mild antioxidant nature of ascorbic acid helps to retard the process of conversion of homogentisate to the polymeric material that is deposited in cartilaginous tissues.
  • Limited use of nitisinone, an inhibitor of the enzyme 4-hydroxyphenylpyruvate dioxygenase, which mediates formation of homogentisic acid, has been reported. Urinary homogentisate excretion was markedly reduced, but safety of prolonged use is still an open question.

Surgical Care

  • Older individuals may require removal of lumbar discs with fusion.
  • Hip, shoulder, or knee joint replacement may be necessary.

Consultations

  • Biochemical geneticist
  • Neurosurgeon
  • Orthopedist
  • Cardiologist (older patients)

Diet

  • Reduction of phenylalanine and tyrosine reportedly reduced homogentisic acid excretion in the urine of a child. In an adult, a similar restriction reportedly had no effect on excretion of the abnormal metabolite. Whether a mild dietary restriction from early in life would avoid or minimize later complications is not known, but such an approach is reasonable.
  • Vitamin C, as much as 1 g/d, is recommended for older children and adults.

Medication

No medications are known to be useful in managing alkaptonuria. Vitamin C, as much as 1 g/d, is recommended for older children and adults.

Vitamins

Organic substances required by the body in small amounts for various metabolic processes.


Ascorbic acid (Cecon, Cevalin, Cevi-Bid, Ce-Vi-Sol)

The mild antioxidant nature of ascorbic acid helps to retard the process of conversion of homogentisate to the polymeric material that is deposited in cartilaginous tissues.

Adult

1 g/d PO

Pediatric

Older children: Administer as in adults

Decreases effects of warfarin and fluphenazine; increases aspirin levels

Pregnancy, if large doses administered

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Pregnancy category C with prolonged use of doses greater than RDA for pregnancy (ie, >80-85 mg/d), the fetus adapts to high vitamin C levels resulting in scorbutic condition following birth; prolonged high doses may cause renal calculi, especially in people with diabetes; patient on sodium restrictive diet or taking anticoagulants should not take large doses (ie, > 1 g) for prolonged periods

Enzyme inhibitors

Nitisinone, a tyrosine degradation inhibitor, has been used experimentally.


Nitisinone (Orfadin)

This compound has seen very restricted use in experimental treatment for alkaptonuria. Tyrosine degradation inhibitor. Inhibits 4-hydroxyphenylpyruvate dioxygenase, which mediates formation of homogentisic acid.

Adult

0.35 mg PO bid at least 1 h ac

Pediatric

Not established; the following dose has been used in patients with tyrosinemia or Fanconi syndrome:
1 mg/kg/d PO divided bid at least 1 h ac initially; adjust dose to individual patient requirements
May increase to 1.5 mg/kg/d after 1 mo if biochemical parameters are not normalized; not to exceed 2 mg/kg/d

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Elevated serum tyrosine levels (must be used in conjunction with dietary restriction of tyrosine and phenylalanine to prevent toxicity caused by elevated plasma tyrosine); corneal toxicity (perform baseline and periodic ophthalmologic examinations to monitor for corneal opacities caused by tyrosine toxicity); regularly monitor hepatic function using imaging and laboratory tests; may cause transient thrombocytopenia and leukopenia

More on Alkaptonuria

Overview: Alkaptonuria
Differential Diagnoses & Workup: Alkaptonuria
Treatment & Medication: Alkaptonuria
Follow-up: Alkaptonuria
Multimedia: Alkaptonuria
References
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References

  1. Garrod AE. The incidence of alkaptonuria: a study in chemical individuality. 1902 [classical article]. Yale J Biol Med. Jul-Aug 2002;75(4):221-31. [Medline].

  2. Oexie K, Engel K, Tinschert S, et al. Three-generational alkaptonuria in a non-consanguineous family. J Inherit Metab Dis. Dec/2008;Epub:Epub.

  3. US Preventive Services Task Force. Screening for phenylketonuria (PKU): US Preventive Services Task Force Reaffirmation recommendation. Ann Fam Med. Mar-Apr 2008;6(2):166. [Medline].

  4. Peker E, Yonden Z, Sogut S. From darkening urine to early diagnosis of alkaptonuria. Indian J Dermatol Venereol Leprol. Nov-Dec 2008;74(6):700. [Medline].

  5. de Haas V, Carbasius Weber EC, de Klerk JB, et al. The success of dietary protein restriction in alkaptonuria patients is age-dependent. J Inherit Metab Dis. Dec 1998;21(8):791-8. [Medline].

  6. Ffolkes LV, Brull D, Krywawych S, Hayward M, Hughes SE. Aortic stenosis in cardiovascular ochronosis. J Clin Pathol. Jan 2007;60(1):92-3. [Medline].

  7. Fisher AA, Davis MW. Alkaptonuric ochronosis with aortic valve and joint replacements and femoral fracture: a case report and literature review. Clin Med Res. Nov 2004;2(4):209-15. [Medline].

  8. Keller JM, Macaulay W, Nercessian OA, Jaffe IA. New developments in ochronosis: review of the literature. Rheumatol Int. Mar 2005;25(2):81-5. [Medline].

  9. Levine HD, Parisi AF, Holdsworth DE, Cohn LH. Aortic valve replacement for ochronosis of the aortic valve. Chest. Oct 1978;74(4):466-7. [Medline].

  10. Lorenzini S, Mannoni A, Selvi E. Alkaptonuria. N Engl J Med. Apr 3 2003;348(14):1408; author reply 1408. [Medline].

  11. Mayatepek E, Kallas K, Anninos A, Muller E. Effects of ascorbic acid and low-protein diet in alkaptonuria. Eur J Pediatr. Oct 1998;157(10):867-8. [Medline].

  12. O'Brien W, La Du BN, Bunim JJ. Biochemical, pathological and clinical aspects of alcaptonuria, ochronosis and ochronotic arthropathy: review of the world literature (1584-1962). Am J Med. 1963;34:813-38.

  13. Perry MB, Suwannarat P, Furst GP, Gahl WA, Gerber LH. Musculoskeletal findings and disability in alkaptonuria. J Rheumatol. Nov 2006;33(11):2280-5. [Medline].

  14. Phornphutkul C, Introne WJ, Perry MB, et al. Natural history of alkaptonuria. N Engl J Med. Dec 26 2002;347(26):2111-21. [Medline].

  15. Suwannarat P, O'Brien K, Perry MB, et al. Use of nitisinone in patients with alkaptonuria. Metabolism. Jun 2005;54(6):719-28. [Medline].

  16. Vavuranakis M, Triantafillidi H, Stefanadis C, Toutouzas P. Aortic stenosis and coronary artery disease caused by alkaptonuria, a rare genetic metabolic syndrome. Cardiology. 1998;90(4):302-4. [Medline].

  17. Watts RW, Watts RA. Alkaptonuria: a 60-yr follow-up. Rheumatology (Oxford). Feb 2007;46(2):358-9. [Medline].

  18. Wolff JA, Barshop B, Nyhan WL, et al. Effects of ascorbic acid in alkaptonuria: alterations in benzoquinone acetic acid and an ontogenic effect in infancy. Pediatr Res. Aug 1989;26(2):140-4. [Medline].

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Further Reading

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Keywords

alkaptonuria, ochronosis, alcaptonuria, homogentisuria, dark urine, inborn error of metabolism, IEM, Croonian lectures, abnormal intermediate, homogentisic acid oxidase, homogentisate, vitamin C, arthritis, osteoarthritis, rheumatoid arthritis, ankylosis, dark stained diapers, coronary artery disease, myocardial infarction, phenylketonuria, treatment, diagnosis, joint effusion, aortic valvulitis, mitral valvulitis

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Contributor Information and Disclosures

Author

Karl S Roth, MD, Professor and Chair, Department of Pediatrics, Creighton University School of Medicine
Karl S Roth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Nutrition, American Pediatric Society, American Society for Clinical Nutrition, American Society of Nephrology, Association of American Medical Colleges, Medical Society of Virginia, New York Academy of Sciences, Sigma Xi, Society for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: MDS Pharma Salary Employment

Medical Editor

James Bowman, MD, Senior Scholar of Maclean Center for Clinical Medical Ethics, Professor Emeritus, Department of Pathology, University of Chicago
James Bowman, MD is a member of the following medical societies: Alpha Omega Alpha, American Society for Clinical Pathology, American Society of Human Genetics, Central Society for Clinical Research, and College of American Pathologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leonard G Feld, MD, PhD, MMM, FAAP, Sara H Bissell and Howard C Bissell Endowed Chair in Pediatrics, Chief Medical Officer, Levine Children's Hospital, Carolinas Medical Center
Leonard G Feld, MD, PhD, MMM, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Physician Executives, American Society of Nephrology, American Society of Pediatric Nephrology, International Society of Nephrology, and Juvenile Diabetes Foundation International
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Bruce Buehler, MD, Professor, Department of Pediatrics, Pathology and Microbiology, Executive Director, Hattie B Munroe Center for Human Genetics and Rehabilitation, University of Nebraska Medical Center
Bruce Buehler, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Pediatrics, American Association on Mental Retardation, American College of Medical Genetics, American College of Physician Executives, American Medical Association, and Nebraska Medical Association
Disclosure: Nothing to disclose.

 
 
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