Toxicology of some autopsy cases involving tricyclic antidepressant drugs

Collection of biological samples in forensic toxicology

Forensic toxicology is the study and practice of the application of toxicology to the purposes of the law. The relevance of any finding is determined, in the first instance, by the nature and integrity of the specimen(s) submitted for analysis. This means that there are several specific challenges to select and collect specimens for ante-mortem and post-mortem toxicology investigation. Post-mortem specimens may be numerous and can endow some special difficulties compared to clinical specimens, namely those resulting from autolytic and putrefactive changes. Storage stability is also an important issue to be considered during the pre-analytic phase, since its consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample. The knowledge on degradation mechanisms and methods to increase storage stability may enable the forensic toxicologist to circumvent possible difficulties. Therefore, advantages and limitations of specimen preservation procedures are thoroughfully discussed in this review. Presently, harmonized protocols for sampling in suspected intoxications would have obvious utility. In the present article an overview is given on sampling procedures for routinely collected specimens as well as on alternative specimens that may provide additional information on the route and timing of exposure to a specific xenobiotic. Last, but not least, a discussion on possible bias that can influence the interpretation of toxicological results is provided. This comprehensive review article is intented as a significant help for forensic toxicologists to accomplish their frequently overwhelming mission.

Fatal blood and tissue concentrations of more than 200 drugs

Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.

Fatal intoxication due to dothiepin

An ingestion of an unknown quantity of Harmomed (dothiepin and diazepam) capsules in a suicide is described. The authors report a new and fast method of analysing and determining the dothiepin concentration in postmortem specimens. Quantitation of dothiepin, and its metabolite desmethyldothiepin was performed by ethyl acetate extraction from alkalinized body fluids before GC-MS analysis. The analyses were performed without any complex sample clean-up steps and with little sample material. Postmortem concentrations of dothiepin, desmethyldothiepin, diazepam and desmethyldiazepam in body fluids are given. The proposed method is a rapid procedure for analysis in cases of deliberate poisoning with the antidepressant drug dothiepin.

A fatal dothiepin overdose

High pressure liquid chromatography coupled to photodiode array detector and capillary gas chromatography coupled to mass spectrometry were employed to quantify dothiepin in biological fluids, tissues and hair in a death attributed to oral dothiepin (Prothiaden) ingestion. The blood concentration of dothiepin was 5.75 mg/l. Hair analysis clearly indicated a chronic antidepressant exposure, with a dothiepin concentration of 1.89 ng/mg hair. Results are discussed in the light of the existing literature.

Toxicological findings after fatal amitriptyline self-poisoning

A case of fatal self-poisoning with amitriptyline is reported. Both the drug and its metabolite nortriptyline were quantified in several post-mortem tissues and fluids, including vitreous humor. Results are discussed in the light of the existing literature.

A collection of therapeutic, toxic and fatal blood drug concentrations in man

In order to assess the significance of drug concentrations measured in clinical and toxicological investigations, it is essential that good collections of data are readily available. As a guide to interpreting findings, the present work provides a compilation of therapeutic, toxic and fatal blood concentration ranges of 298 drugs of interest to clinical pharmacologists, clinical toxicologists, and forensic toxicologists. Wherever possible, ranges are expressed concisely in terms of the maximum blood concentrations which account for 10, 50 and 90% of the data collected. They provide easy access to the most reliable information which relates the blood drug concentration to the biological response it produces. Where appropriate, the different toxic effects of a drug and/or the different degrees of severity of toxic symptoms associated with different drug levels are clearly defined. The original sources of all data used are provided to allow the analyst to obtain further analytical, pharmacokinetic and toxicological information should this be necessary. Those factors (e.g. age, capacity for drug metabolism, drug interactions, etc) which can modify the relationship between a drug concentration and the response it produces are briefly discussed.

The human distribution of some barbiturate sedatives in combination with miscellaneous CNS-active drugs

This paper presents 14 cases in which the distribution of barbiturates and the hydroxylated metabolites in combination with miscellaneous CNS-active drugs was studied. In 7 of these cases the other drug present was methadone, and in the remainder dihydrocodeine, morphine, propoxyphene, amitriptyline, meprobamate, cyclizine and dipipanone, diphenhydramine and methaqualine. Amitriptyline, methadone, cyclizine and dipipanone, methaqualone and diphenhydramine appeared to modify the distribution of amylorbarbitone and quinalbarbitone. Likewise, the barbituates seemed to alter the distribution of amitriptyline, propoxyphene and, in one instance, methadone.