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. It has also been used to treat cases of malaria for over a century.
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.

Medical uses

Methemoglobinemia

Methylene blue is used to treat methemoglobinemia by chemically reducing the ferric iron in hemoglobin to ferrous iron. 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. Normally, through the NADH- or NADPH-dependent methemoglobin reductase enzymes, methemoglobin is reduced back to hemoglobin. When large amounts of methemoglobin occur secondary to toxins, methemoglobin reductases are overwhelmed. Methylene blue, when injected intravenously as an antidote, is itself first reduced to leucomethylene blue, which then reduces the heme group from methemoglobin to hemoglobin. Methylene blue can reduce the half-life of methemoglobin from hours to minutes. At high doses, however, methylene blue actually induces methemoglobinemia, reversing this pathway.

Isobutyl nitrite toxicity

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, although first demonstrated by Bo Sahlin of Lund University, in 1926.

Shock

Methylene blue increases blood pressure in people with vasoplegic syndrome. 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

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 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", 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.
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 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.

Side effects

Methylene blue is a monoamine oxidase inhibitor and, if infused intravenously at doses exceeding 5 mg/kg, may result in serotonin syndrome if combined with any selective serotonin reuptake inhibitors or other serotonergic drugs.
It causes hemolytic anemia in carriers of the G6PD enzymatic deficiency. 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.

Pregnancy

While use during pregnancy may harm the baby, not using it in methemoglobinemia is likely more dangerous.

Pharmacokinetics

After intravenous administration in humans, methylene blue shows a multiphasic change in concentration, with a terminal half-life of 5.25 hours. The initial disappearance from blood actually reflects its movement into organs, with brain, liver, and bile all showing significantly higher concentrations than blood in rats. The overall area under the curve in oral administration is only 6.5% of the AUC for IV administration; judging from rat studies, the significantly altered organ distribution plays a key role in this difference.
Administration as an oral solution greatly increases the bioavailability to 72.3±23.9%. In this newer study, the terminal half-lives were reported as 18.5±11.8 hours for IV use and 18.3±7.2 hours for oral use. The t_max for oral use is 2.2 hours, compared to 0.5 hours for iv use.

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

Light absorption properties

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:

Species	Absorption peak	Extinction coefficient
MB⁺	664	95000
MBH₂⁺	741	76000
₂	605	132000
₃	580	110000
MB⁺	673	116000
MBH₂⁺	763	86000
₂	596	80000
₃	570	114000

Redox properties

Under reducing conditions, the blue-colored methylene blue cation gains 1H⁺ and 2e⁻ to become the electrically neutral and colorless leucomethylene blue. 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, 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.
In the mitochondrial electron transport chain, reduced methylene blue directly reduces cytochrome c rather than to oxygen, limiting the formation of superoxide.
Methylene blue has been shown to directly accept electrons from NADH, NADPH, and FADH₂.