Pentosan polysulfate

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Pentosan polysulfate
Pentosan polysulfate.svg
Clinical data
AHFS/ Consumer Drug Information
  • B
Oral, intramuscular, intra-articular, intraventricular
Pharmacokinetic data
Excretion Urine
37300-21-3 YesY (free acid)
116001-96-8 (sodium salt)
C05BA04 G04BX15 QM01AX90
PubChem CID 37720
Chemical data
Formula (C5H6Na2O10S2)n
 YesY (what is this?)  (verify)

Pentosan polysulfate (PPS), sold under the name Elmiron, by Ortho-McNeil Pharmaceutical is the only oral medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of interstitial cystitis (IC), also known as painful bladder syndrome. PPS is also sold under the brand name Comfora in India.

In the veterinary field, pentosan polysulfate is sold under the name Cartrophen Vet by Biopharm Australia for the treatment of osteoarthritis (OA) in dogs and horses. PPS is also sold under the names Naturevet Equine and Arthropen. PPS is related to the disease modifying osteoarthritic drugs (DMOAD).[vague]

Medical uses[edit]

Interstitial cystitis/painful bladder syndrome[edit]

Interstitial cystitis/painful bladder syndrome (IC/PBS) patients struggle with symptoms of urinary frequency, urgency, pressure and/or pain, as well as nocturia (frequent urination at night), dyspareunia (painful intercourse), pain and/or discomfort while sitting in a car, while driving and/or traveling.

The origin/cause of IC/PBS is currently unknown though a number of theories are currently under consideration. Urine cultures are typically negative for infection, yet it is not unusual for patients to believe that they have had infections for years rather than IC/PBS, because the symptoms of IC/PBS mimic those of an infection.

Pentosan polysulfate is available as pills or as a direct infusion into the bladder. Some controlled studies versus placebo led to the conclusion that the compound is actually effective in the treatment of pain, urgency and frequency of urination, but the advantage over placebo is rather limited.[1]

Osteoarthritis/degenerative joint disease[edit]

Its application as a disease modifying osteoarthritis drug (DMAOD) has only attracted recent attention. The disease-modifying activity of this molecule has been previously reviewed in terms of its effectiveness in laboratory based studies.[2][full citation needed] More recently other derivatives such as the calcium pentosan polysulfate (CaPPS) have been investigated and found to exhibit higher oral bioavailability than the sodium salt.[3][full citation needed]

Diagram represents the osteoarthritis cycle with reference to PPS site of action


Read et al. (1996)[full citation needed] used three different doses of NaPPS to treat 40 geriatric dogs with well-established clinical signs of chronic OA with SC injection. In a study conducted with 10 elderly dogs with osteoarthritis given calcium pentosan polysulfate (3 mg/kg intramuscularly) once weekly for four weeks, the improvement in symptoms was found to correlate with plasma indices of fibrinolytic activity and lipid profiles.[4][full citation needed] Nineteen dogs were randomly assigned to either surgery or NaPPS treatment of fragmented coronoid process and osteochondritis dissecans of the canine elbow joint.[5][full citation needed] In a more recent study in dogs with OA secondary to cranial cruciate ligament (CCL) deficiency, no differences were identified in either functional outcome or radiographic progression using the oral calcium PPS compared with placebo.[6][full citation needed] Budsberg et al. (2007)[full citation needed] evaluated the efficacy of PPS for improving the recovery period and alleviate the progression of osteoarthritis (OA) of the canine stifle after extracapsular stabilization of cranial cruciate ligament (CCL) injuries.


There are few published reports describing the use of PPS for equine joint disease, however the drug has been used in Australia. When administered to racing Thoroughbreds with chronic osteoarthritis (2 to 3 mg/kg, IM, once weekly for 4 weeks, then as required), PPS treatment improved but did not eliminate clinical signs of joint disease.[7][full citation needed]


Verbruggen and Veys (1992)[full citation needed] studied the influence of PPS on hyaluronan metabolism of the synovial lining cell in vivo in human volunteers. A double blind, placebo-controlled clinical study in 114 patients with osteoarthritis of the knee has been performed in Perth, Australia (Edelman et al., 1994)[full citation needed] where patients either received a salt solution or sodium PPS at 3 mg/ kg as an intramuscular injection once weekly for 4 weeks. In an open study of 23 patients with mild to moderate OA of the hand, hip, or knee, Verbruggan et al., (1994)[full citation needed] investigated the effect of 2 mg/kg CaPPS intramuscularly once a week for five weeks on the biochemical and hematologic markers of blood coagulation and thrombolysis.[8][full citation needed] CaPPS also has been studied when given orally to patients with OA of the finger joints under double-blind, placebo-controlled conditions using a broken treatment protocol (360). Fifty patients were recruited (24 CaPPS-treated, 26 placebotreated).[9][full citation needed] Eighty-six patients with OA of the knee were subjected to intra-articular sodium PPS injections against an equivalent volume of IA Ringer's solution under double-blind conditions.[10][full citation needed] Adam et al. (1996)[full citation needed] reported the effects of intra-articular PPS on synovial fluid visco-elasticity and hyaluronan molecular weight in patients with gonarthritis. Anderson et al. (1997)[full citation needed] investigated the effects of PPS on peripheral blood leukocyte populations and mononuclear cell procoagulant activity in 11 patients with osteoarthritis. Faaij et al. (1999)[full citation needed] assessed the bioavailability of intravenous and oral sodium PPS in 18 healthy male volunteers. Ghosh et al. (2005)[full citation needed] performed a pilot study at the Queen Elizabeth II Medical Centre, Perth, Australia on 114 Patients with OA on the knee. Twenty patients were assessed clinically at Nagasaki University Hospital. Treatment consisted of six weekly subcutaneous injections of PPS (2 mg/kg).[11][full citation needed]

Transmissible spongiform encephalopathies[edit]

PPS has gained attention as possibly being effective in the treatment of Creutzfeldt-Jakob disease (CJD), although there is currently no definitive evidence for this idea other than results of the ongoing treatment (published) of one patient in Northern Ireland and around six other patients in mainland Britain.[12]

Around 15 other patients in non-UK countries have also received this PPS treatment in an attempt to halt or slow down CJD and related disease progression. There are also clinical trials of Elmiron to treat Hunters Syndrome (MPS II).

Adverse effects[edit]

Patients who have taken PPS orally report a variety of side effects, primarily gastrointestinal complaints such as diarrhea, heartburn, and stomach pain.[13] Hair loss, headache, rash, and insomnia have also been reported.[13] Due to Elmiron's anticoagulant effects, some patients report bruising more easily. In some cases, patients are asked to stop taking the medication before any major surgical procedures to reduce the likelihood of bleeding.


The anticoagulant activity of PPS is 1/15 that of Heparin.

PPS is believed to work by providing a protective coating to the damaged bladder wall. However, the sodium salt of PPS has exceptionally poor bioavailability when taken orally. Research presented in 2005 by Alza Pharmaceuticals demonstrated that more than 94% of the medication was excreted, intact, in feces without providing any beneficial effect.[14] Their research found that only 6% was excreted through urine. The drug must be taken for several months for most patients to achieve some benefit.

More recently, PPS has been studied as part of a "rescue instillation" which is placed directly in the bladder and can, perhaps, provide better effectiveness. Research presented in 2005 showed PPS had 90% effectiveness in reducing the symptoms of IC/PBS patients by using this instillation.[15]


  1. ^ Hwang P, Auclair B, Beechinor D, Diment M, Einarson TR (July 1997). "Efficacy of pentosan polysulfate in the treatment of interstitial cystitis: a meta-analysis". Urology 50 (1): 39–43. doi:10.1016/S0090-4295(97)00110-6. PMID 9218016. 
  2. ^ Burkhardt & Ghosh, 1987
  3. ^ Klocking & Markwardt, 1985; 1986; Klocking, 1993
  4. ^ Ghosh and Cheras, 2001
  5. ^ Bouck et al., 1995
  6. ^ Innes et al., 2000
  7. ^ Little and Ghosh, 1996
  8. ^ Verbruggen and Veys, 1996
  9. ^ Verbruggen et al., 1999
  10. ^ Rasaratnam et al., 1996
  11. ^ Kumagai et al., 2010
  12. ^ BBC NEWS | Health | Research will now assess CJD drug
  13. ^ a b Pubmed Health (2012). "Pentosan Polysulfate". U.S. National Library of Medicine. Retrieved 2 October 2012. 
  14. ^ Simon M, McClanahan RH, Shah JF et al. Metabolism of [3H]pentosan polysulfate sodium (PPS) in healthy human volunteers. Xenobiotica. 2005 Aug;35(8):775-84. PMID 16278190
  15. ^ Parsons, C (2005). "Successful downregulation of bladder sensory nerves with combination of heparin and alkalinized lidocaine in patients with interstitial cystitis". Urology 65 (1): 45–8. doi:10.1016/j.urology.2004.08.056. PMID 15667861. 

External links[edit]