Methylene blue

Methylthioninium chloride, commonly called methylene blue, is a salt used as a dye and as a medication. As a medication, it is mainly used to treat methemoglobinemia. It has previously been used for treating cyanide poisoning and urinary tract infections, but this use is no longer recommended.

Methylene blue is typically given by injection into a vein. Common side effects include headache, nausea, and vomiting.

Methylene blue was first prepared in 1876, by Heinrich Caro. It is on the World Health Organization's List of Essential Medicines.

In recent years, methylene blue has been promoted for various health effects, but outside its established medical use, its safety and effectiveness are unproven; it is potentially toxic and should only be used under a doctor's prescription. Methemoglobinemia can arise from ingestion of certain pharmaceuticals, toxins, or broad beans in those susceptible. Specifically, it is used to treat methemoglobin levels that are greater than 30% or in which there are symptoms despite oxygen therapy. At high doses, however, methylene blue actually induces methemoglobinemia, reversing this pathway.

Isobutyl nitrite toxicity

Isobutyl nitrite is one of the compounds used as poppers, an inhalant drug that induces a brief euphoria.

Isobutyl nitrite is known to cause methemoglobinemia. Severe methemoglobinemia may be treated with methylene blue.

In a combination drug: Methylphen

Cyanide poisoning

Since its reduction potential is similar to that of oxygen and can be reduced by components of the electron transport chain, large doses of methylene blue are sometimes used as an antidote for cyanide poisoning, a method first successfully tested in 1933 by Matilda Moldenhauer Brooks in San Francisco,

Shock

Methylene blue increases blood pressure in people with vasoplegic syndrome (redistributive shock). It does not improve delivery of oxygen to tissues or decrease mortality.

Methylene blue has been used in calcium channel blocker toxicity as a possible rescue therapy for distributive shock unresponsive to first-line agents. Limited to case reports, a 2024 review found low-quality evidence that methylene blue may reduce short-term mortality, duration of the need for vasopressors, and length of hospital stay.

Dye or stain

thumb|280x280px|Human cheek cells stained with methylene blue

thumb|Methylene blue crystals

Methylene blue is used in endoscopic polypectomy as an adjunct to saline or epinephrine, and is used for injection into the submucosa around the polyp to be removed. This allows the submucosal tissue plane to be identified after the polyp is removed, which is useful in determining if more tissue needs to be removed or if there is a high risk for perforation. Methylene blue is also used as a dye in chromoendoscopy, and is sprayed onto the mucosa of the gastrointestinal tract to identify dysplasia, or pre-cancerous lesions. Intravenously injected methylene blue is readily released into the urine.

In surgeries such as sentinel lymph node dissections, methylene blue can be used to visually trace the lymphatic drainage of tested tissues. Similarly, methylene blue is added to bone cement in orthopedic operations to provide easy discrimination between native bone and cement. Additionally, methylene blue accelerates the hardening of bone cement, increasing the speed at which bone cement can be effectively applied. Methylene blue is used as an aid to visualisation/orientation in several medical devices, including a surgical sealant film. It can also be used during gastrointestinal surgeries (such as bowel resection or gastric bypass) to test for leaks.

It is sometimes used in cytopathology, in mixtures including Wright-Giemsa and Diff-Quik. It confers a blue color to both nuclei and cytoplasm, and makes the nuclei more visible. When methylene blue is "polychromed" (oxidized in solution or "ripened" by fungal metabolism, as originally noted in the thesis of Dr. D. L. Romanowsky in the 1890s), it gets serially demethylated and forms all the tri-, di-, mono- and non-methyl intermediates, which are Azure B, Azure A, Azure C, and thionine, respectively. This is the basis of the basophilic part of the spectrum of Romanowski-Giemsa effect. If only synthetic Azure B and Eosin Y is used, it may serve as a standardized Giemsa stain; but, without methylene blue, the normal neutrophilic granules tend to overstain and look like toxic granules. On the other hand, if methylene blue is used it might help to give the normal look of neutrophil granules and may also enhance the staining of nucleoli and polychromatophilic RBCs (reticulocytes).

thumb|Gross pathology of a normal brain and a brain of a patient treated with methylene blue before death.

A traditional application of methylene blue is the intravital or supravital staining of nerve fibers, an effect first described by Paul Ehrlich in 1887. A dilute solution of the dye is either injected into tissue or applied to small freshly removed pieces. The selective blue coloration develops with exposure to air (oxygen) and can be fixed by immersion of the stained specimen in an aqueous solution of ammonium molybdate. Vital methylene blue was formerly much used for examining the innervation of muscle, skin, and internal organs. The mechanism of selective dye uptake is incompletely understood; vital staining of nerve fibers in skin is prevented by ouabain, a drug that inhibits the Na/K-ATPase of cell membranes.

Placebo

Methylene blue has been used as a placebo; physicians would tell their patients to expect their urine to change color and view this as a sign that their condition had improved. This same side effect makes methylene blue difficult to use in traditional placebo-controlled clinical studies, including those testing for its efficacy as a treatment. One approach is to use a low dose, just enough to turn urine blue, as the placebo group. However, a low dose does not guarantee inertness.

! Central nervous system and, if infused intravenously at doses exceeding 5 mg/kg, may result in serotonin syndrome if combined with any selective serotonin reuptake inhibitors (SSRIs) or other serotonergic drugs (e.g., duloxetine, sibutramine, venlafaxine, clomipramine, imipramine).

It causes hemolytic anemia in carriers of the G6PD enzymatic deficiency (favism). The actual degree of this danger is a subject of controversy as the association was made based on very few cases. A 2018 meta-analysis on clinical trials against malaria in Africa, where the moderate A minus type of G6PD deficiency is prevalent, shows no association between MB and hemolysis in such patients. There was, however, a clinically insignificant reduction in hemoglobin.

Chemistry

Methylene blue is a formal derivative of phenothiazine. It is a dark green powder that yields a blue solution in water. The hydrated form has 3 molecules of water per unit of methylene blue.

Preparation

This compound is prepared by oxidation of 4-aminodimethylaniline in the presence of sodium thiosulfate to give the quinonediiminothiosulfonic acid, reaction with dimethylaniline, oxidation to the indamine, and cyclization to give the thiazine:

:class=skin-invert-image|600px

A green electrochemical procedure, using only dimethyl-4-phenylenediamine and sulfide ions has been proposed.

Light absorption properties

thumb|Absorption spectrum of methylene blue, in terms of the [[molar extinction coefficient (base 10 logarithm). In this dataset, a peak absorbance of 1.7 (i.e., 98% of transmitted light absorbed) was observed with 665 nm light passing through 1 cm of 10 micromolar methylene blue solution.]]

The maximum absorption of light is near 670 nm. The specifics of absorption depend on several factors, including protonation, adsorption to other materials, and metachromasy – the formation of dimers and higher-order aggregates depending on concentration and other interactions:

{| class="wikitable"

!Species

!Absorption peak

!Extinction coefficient (dm3/mol·cm)

| MB+ (solution)

| 664

| 95000

| MBH2+ (solution)

| 741

| 76000

| (MB+)2 (solution)

| 605

| 132000

| (MB+)3 (solution)

| 580

| 110000

| MB+ (adsorbed on clay)

| 673

| 116000

| MBH2+ (adsorbed on clay)

| 763

| 86000

| (MB+)2 (adsorbed on clay)

| 596

| 80000

| (MB+)3 (adsorbed on clay)

| 570

| 114000

Redox properties

thumb|class=skin-invert-image|right|Reversible reduction of methylene blue

Under reducing conditions, the blue-colored methylene blue cation (MB+) gains 1H+ and 2e− to become the electrically neutral and colorless leucomethylene blue (LMB). The redox midpoint potential E' is +0.01 V.

The redox properties can be seen in a classical demonstration of chemical kinetics in general chemistry, the "blue bottle" experiment. Typically, a solution is made of glucose (dextrose), methylene blue, and sodium hydroxide. Upon shaking the bottle, oxygen oxidizes methylene blue, and the solution turns blue. The dextrose will gradually reduce the methylene blue to its colorless, reduced form. Hence, when the dissolved dextrose is entirely consumed, the solution will turn blue again.

Methylene blue has been shown to directly accept electrons from NADH, NADPH, and FADH2. Solutions of this substance are blue when in an oxidizing environment, but will turn colorless if exposed to a reducing agent. This kind of photo-disinfection has also been done inside of human bodies (antimicrobial photodynamic therapy). The same process can also be used to disinfect blood plasma.

Methylene blue is theoretically also applicable to other forms of photodynamic therapy, i.e., the use of oxygen, light, and a photosensitizer to kill cells. Research on using it to kill cancer cells locally is in a preclinical stage. Its cytotoxicity may be related to its ability to inhibit tubulin polymerization.

Sulfide analysis

The formation of methylene blue after the reaction of hydrogen sulfide with dimethyl-p-phenylenediamine and iron(III) at pH 0.4 – 0.7 is used to determine by photometric measurements sulfide concentration in the range 0.020 to 1.50 mg/L (20 ppb to 1.5 ppm). The test is very sensitive and the blue coloration developing upon contact of the reagents with dissolved H2S is stable for 60 min. Ready-to-use kits such as the Spectroquant sulfide test facilitate routine analyses. The methylene blue sulfide test is a convenient method often used in soil microbiology to quickly detect in water the metabolic activity of sulfate reducing bacteria (SRB). In this colorimetric test, methylene blue is a product formed by the reaction and not a reagent added to the system. A few drops of methylene blue solution added to a sample of milk should remain blue (oxidized form in the presence of enough dissolved ), otherwise (discoloration caused by the reduction of methylene blue into its colorless reduced form) the dissolved concentration in the milk sample is low indicating that the milk is not fresh (already abiotically oxidized by whose concentration in solution decreases) or could be contaminated by bacteria also consuming the atmospheric dissolved in the milk.

Methylene blue value reflects the amount of clay minerals in aggregate samples. In materials science, methylene blue solution is successively added to fine aggregate which is being agitated in water. The presence of free dye solution can be checked with a stain test on a filter paper.

Biological staining

In biology, methylene blue is used as a dye for a number of different staining procedures, such as Wright's stain and Jenner's stain. Since it is a temporary staining technique, methylene blue can also be used to examine RNA or DNA under the microscope or in a gel: as an example, a solution of methylene blue can be used to stain RNA on hybridization membranes in northern blotting to verify the amount of nucleic acid present. While methylene blue is not as sensitive as ethidium bromide, it is less toxic and it does not intercalate in nucleic acid chains, thus avoiding interference with nucleic acid retention on hybridization membranes or with the hybridization process itself.

It can also be used as an indicator to determine whether eukaryotic cells, such as yeast, are alive or dead. The methylene blue is reduced in viable cells, leaving them unstained. However, dead cells are unable to reduce the oxidized methylene blue, and the cells are stained blue. Methylene blue can interfere with the respiration of the yeast as it picks up hydrogen ions made during the process.

Aquaculture

Methylene blue is used in aquaculture and by tropical fish hobbyists as a treatment for fungal infections. but there is little medical literature to back this up.

It is usually used to protect newly laid fish eggs from being infected by fungus. This is useful when the hobbyist wants to artificially hatch the fish eggs. For poisoning, injury (prevention of infection), or sickness, methylene blue is given as a "medicated bath" for the fish.

Methylene blue is not without side effects to fish.

History

Methylene blue has been described as "the first fully synthetic drug used in medicine". Methylene blue was first prepared in 1876 by German chemist Heinrich Caro.

Its use in the treatment of malaria was pioneered by Paul Guttmann and Paul Ehrlich in 1891. During this period before World War I, researchers like Ehrlich believed that drugs and dyes worked in the same way, by preferentially staining pathogens and possibly harming them. Changing the cell membrane of pathogens is how various drugs work, so the theory was partially correct, although far from complete. Methylene blue continued to be used in World War II, where it was not well-liked by soldiers, who observed, "Even at the loo, we see, we pee, navy blue."

It was discovered to be an antidote to carbon monoxide poisoning and cyanide poisoning in 1933 by Matilda Brooks.

Methylene blue was the original prototype or lead compound for the design of many antimalarials including chloroquine, antihistamines, and antipsychotics including chlorpromazine.

Research

Malaria

Antimalarial use of the drug has recently (2009) been revived. It simultaneously targets many biological processes in the apicomplexan pathogen though the main mechanism seems to be causing a lethal amount of redox cycling.

Ifosfamide toxicity

Another use of methylene blue is to treat ifosfamide neurotoxicity. Methylene blue was first reported for treatment and prophylaxis of ifosfamide neuropsychiatric toxicity in 1994. A toxic metabolite of ifosfamide, chloroacetaldehyde (CAA), disrupts the mitochondrial respiratory chain, leading to an accumulation of nicotinamide adenine dinucleotide hydrogen (NADH). Methylene blue acts as an alternative electron acceptor, and reverses the NADH inhibition of hepatic gluconeogenesis while also inhibiting the transformation of chloroethylamine into chloroacetaldehyde, and inhibits multiple amine oxidase activities, preventing the formation of CAA.

The dosing of methylene blue for treatment of ifosfamide neurotoxicity varies, depending upon its use simultaneously as an adjuvant in ifosfamide infusion, versus its use to reverse psychiatric symptoms that manifest after completion of an ifosfamide infusion. Reports suggest that methylene blue, up to six doses a day, has resulted in improvement of symptoms within 10 minutes to several days. Alternatively, it has been suggested that intravenous methylene blue every six hours for prophylaxis during ifosfamide treatment in people with history of ifosfamide neuropsychiatric toxicity. Prophylactic administration of methylene blue the day before initiation of ifosfamide, and three times daily during ifosfamide chemotherapy has been recommended to lower the occurrence of ifosfamide neurotoxicity.

Neuropsychiatric disorders

Methylene blue inhibits monoamine oxidase, inhibits the glutamatergic system (via inhibition of NO synthase and soluble guanylate cyclase), modulates mitochondrial function (by acting as an electron acceptor), and decreases the activation of inflammasomes NLRP3 and NLRC4. As a result, it's been considered potentially useful in neuropsychiatric disorders. In humans it has been tried for (listed in decreasing order of evidence quality): bipolar disorder (especially depressive symptoms), Alzheimer's disease, claustrophobia, ifosfamide encephalopathy, and schizophrenia. With methylene blue, a higher dose does not necessarily work better than a lower dose.

Society and culture

In the late 2010s and early 2020s, a social media trend emerged promoting the use of methylene blue for various medical purposes, including anti-aging, metabolism enhancement, cognitive improvement, cancer treatment, and COVID-19 treatment. Currently there is no scientific consensus on, and no FDA approval for, its effectiveness and safety for these purposes. and skin aging. It was also explored as part of anticancer photodynamic therapy using lasers. One systematic review of the studies expresses optimism but emphasizes the need for more extensive research to confirm methylene blue's clinical applications. Another review takes a more critical stance, stating that "it is obvious that the clinical use of [methylene blue] represents a rather controversial problem given the heterogeneity of available data and the lack of preclinical data, which is in conflict with standards of safe use of such substances in human medicinal practice".

In January 2025, Robert F. Kennedy Jr, then the U.S. health secretary nominee, was filmed adding droplets of an unidentified blue liquid to his drink during a flight. While many have speculated that it was methylene blue, Kennedy has not addressed the claims.