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Vikhar Danish Ahmad A, Khan SW, Ali SA, Yasar Q. Network pharmacology combined with molecular docking and experimental verification to elucidate the effect of flavan-3-ols and aromatic resin on anxiety. Sci Rep 2024; 14:9799. [PMID: 38684743 PMCID: PMC11058257 DOI: 10.1038/s41598-024-58877-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/03/2024] [Indexed: 05/02/2024] Open
Abstract
This study investigated the potential anxiolytic properties of flavan-3-ols and aromatic resins through a combined computational and experimental approach. Network pharmacology techniques were utilized to identify potential anxiolytic targets and compounds by analyzing protein-protein interactions and KEGG pathway data. Molecular docking and simulation studies were conducted to evaluate the binding interactions and stability of the identified targets. Behavioral tests, including the elevated plus maze test, open field test, light-dark test, actophotometer, and holeboard test, were used to assess anxiolytic activity. The compound-target network analysis revealed complex interactions involving 306 nodes and 526 edges, with significant interactions observed and an average node degree of 1.94. KEGG pathway analysis highlighted pathways such as neuroactive ligand-receptor interactions, dopaminergic synapses, and serotonergic synapses as being involved in anxiety modulation. Docking studies on EGCG (Epigallocatechin gallate) showed binding energies of -9.5 kcal/mol for MAOA, -9.2 kcal/mol for SLC6A4, and -7.4 kcal/mol for COMT. Molecular dynamic simulations indicated minimal fluctuations, suggesting the formation of stable complexes between small molecules and proteins. Behavioral tests demonstrated a significant reduction in anxiety-like behavior, as evidenced by an increased number of entries into and time spent in the open arm of the elevated plus maze test, light-dark test, open field center activity, hole board head dips, and actophotometer beam interruptions (p < 0.05 or p < 0.01). This research provides a comprehensive understanding of the multi-component, multi-target, and multi-pathway intervention mechanisms of flavan-3-ols and aromatic resins in anxiety treatment. Integrated network and behavioral analyses collectively support the anxiolytic potential of these compounds and offer valuable insights for future research in this area.
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Affiliation(s)
| | - Subur W Khan
- Y. B. Chavan College of Pharmacy, Dr. Rafiq Zakaria Campus, Aurangabad, Maharashtra, India.
| | - Syed Ayaz Ali
- Y. B. Chavan College of Pharmacy, Dr. Rafiq Zakaria Campus, Aurangabad, Maharashtra, India
| | - Qazi Yasar
- Y. B. Chavan College of Pharmacy, Dr. Rafiq Zakaria Campus, Aurangabad, Maharashtra, India
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Hebel JM, Lanz M, Malina T, Stodieck SRG, Le Van Quyen M. Effects of midazolam on high-frequency oscillations in amygdala and hippocampus of epilepsy patients. Epilepsia 2024; 65:e55-e60. [PMID: 38366848 DOI: 10.1111/epi.17916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/18/2024]
Abstract
High-frequency oscillations (HFOs) are associated with normal brain function, but are also increasingly recognized as potential biomarkers of epileptogenic tissue. Considering the important role of interneuron activity in physiological HFO generation, we studied their modulation by midazolam (MDZ), an agonist of γ-aminobutyric acid type A (GABAA)-benzodiazepine receptors. Here, we analyzed 80 intracranial electrode contacts in amygdala and hippocampus of 13 patients with drug-refractory focal epilepsy who had received MDZ for seizure termination during presurgical monitoring. Ripples (80-250 Hz) and fast ripples (FRs; 250-400 Hz) were compared before and after seizures with MDZ application, and according to their origin either within or outside the individual seizure onset zone (SOZ). We found that MDZ distinctly suppressed all HFOs (ripples and FRs), whereas the reduction of ripples was significantly less pronounced inside the SOZ compared to non-SOZ contacts. The rate of FRs inside the SOZ was less affected, especially in hippocampal contacts. In a few cases, even a marked increase of FRs following MDZ administration was seen. Our results demonstrate, for the first time, a significant HFO modulation in amygdala and hippocampus by MDZ, thus giving insights into the malfunction of GABA-mediated inhibition within epileptogenic areas and its role in HFO generation.
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Affiliation(s)
- Jonas M Hebel
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Lanz
- Epilepsy-Center Hamburg, Protestant Hospital Alsterdorf, Hamburg, Germany
| | - Thomas Malina
- Epilepsy-Center Hamburg, Protestant Hospital Alsterdorf, Hamburg, Germany
| | | | - Michel Le Van Quyen
- Laboratoire d'Imagerie Biomédicale, Inserm U1146/Sorbonne Université UMCR2/UMR7371 CNRS, Paris, France
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Chen D, Liao M, Wu XR, Zhao TYM, Sun H. Comparison of efficacy and safety of equivalent doses of remimazolam versus propofol for gastroscopy anesthesia in elderly patients. Sci Rep 2024; 14:7645. [PMID: 38561361 PMCID: PMC10984999 DOI: 10.1038/s41598-024-58294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
Remimazolam, a novel intravenous anesthetic, has been proven to be safe and efficacious in the gastroscopy setting among the elderly. However, reports comparing the effectiveness and safety of using equivalent doses of remimazolam with propofol have not been seen. The aim of this study was to compare the sedation efficacy and safety of the 95% effective doses (ED95) of remimazolam versus propofol combined with sufentanil in the gastroscopy setting among the elderly. In the first step of this two-step study, a modified up-and-down method was used to calculate the ED95 of remimazolam and propofol when combined with 0.1 µg/kg sufentanil in inhibiting body movement of elderly patients undergoing gastroscopy. In the second step, ED95 of both agents calculated in the first step were administered, endpoints of efficacy, safety, and incidence of adverse events were compared. A total of 46 individuals completed the first step. The ED95 of remimazolam was 0.163 mg/kg (95% CI 0.160-0.170 mg/kg), and that of propofol was 1.042 mg/kg (95% CI 1.007-1.112 mg/kg). In the second step, 240 patients completed the trial. The anesthetic effective rates of the remimazolam group and the propofol group were 78% and 83%, respectively, with no statistical difference (P = 0.312). Patients in the remimazolam group had more stable circulatory functions (P < 0.0001) and a lower incidence of pain on injection (3.3% vs. 19.5%, P < 0.0001). The incidence of hypotension was low in the remimazolam versus propofol group (15.6% vs. 39.0%, P < 0.0001). Overall adverse event was low in the remimazolam versus propofol group (21.3% vs. 62.7%, P < 0.0001).In this study, we found that when anesthesia was administered to elderly gastroscopy patients based on 95% effective doses of remimazolam and propofol, remimazolam was as effective as propofol, but was safer with a lower incidence of adverse events.Study registration: Chinese Clinical Trial Registry, ChiCTR2000034234. Registered 29/06/2020, https://www.chictr.org.cn .
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Affiliation(s)
- Di Chen
- The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Min Liao
- The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Xiao-Ru Wu
- The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | | | - Hu Sun
- The Second Affiliated Hospital of Hainan Medical University, Haikou, China.
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Chen Q, Qin B, Zhang M, Zhou Y, Shi X, Xie Y. The Safety and Efficacy of Remimazolam Compared to Dexmedetomidine for Awake Tracheal Intubation by Flexible Bronchoscopy: A Randomized, Double-Blind, Controlled Trial. Drug Des Devel Ther 2024; 18:967-978. [PMID: 38562518 PMCID: PMC10984194 DOI: 10.2147/dddt.s446222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background Remimazolam is a novel ultra-short-acting benzodiazepine sedative that has the potential to be an alternative for procedural sedation due to its rapid sedation and recovery, no accumulation effect, stable hemodynamics, minimal respiratory depression, anterograde amnesia effect, and specific antagonist. Here, we aimed to compare the safety and efficacy of remimazolam with dexmedetomidine for awake tracheal intubation by flexible bronchoscopy (ATI-FB). Methods Ninety patients scheduled for ATI-FB were randomly divided into three groups, each consisting of 30 cases: dexmedetomidine 0.6 µg/kg + sufentanil (group DS), remimazolam 0.073 mg/kg + sufentanil (group R1S), or remimazolam 0.093 mg/kg + sufentanil (group R2S). The primary outcome was the success rate of sedation. Secondary outcomes were MOAA/S scores, hemodynamic and respiratory parameters, intubation conditions, intubation time, tracheal intubation amnesia, and adverse events. Results The success rates of sedation in groups R2S and DS were higher than that in group R1S (93.3%, 86.7%, respectively, vs 58.6%; P = 0.002), and intubation conditions were better than those in group R1S (P < 0.05). Group R2S had shorter intubation times than groups R1S and DS (P = 0.003), and a higher incidence of tracheal intubation amnesia than group DS (P = 0.006). No patient in the three groups developed hypoxemia or hypotension, and there were no significant differences in oligopnea, PetCO2, or bradycardia (P > 0.05). Conclusion In conclusion, both DS and R2S had higher success rates of sedation, better intubation conditions, and minor respiratory depression, but R2S, with its shorter intubation time, higher incidence of anterograde amnesia, and ability to be antagonized by specific antagonists, may be a good alternative sedation regimen for patients undergoing ATI-FB.
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Affiliation(s)
- Qiumiao Chen
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Bin Qin
- Department of Anesthesiology, College of Stomatology, Hospital of Stomatology, Guangxi Medical University, Nanning, People’s Republic of China
| | - Manqing Zhang
- Department of Anesthesiology, College of Stomatology, Hospital of Stomatology, Guangxi Medical University, Nanning, People’s Republic of China
| | - Yumei Zhou
- Department of Anesthesiology, College of Stomatology, Hospital of Stomatology, Guangxi Medical University, Nanning, People’s Republic of China
| | - Xiaotong Shi
- Department of Anesthesiology, College of Stomatology, Hospital of Stomatology, Guangxi Medical University, Nanning, People’s Republic of China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery After Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Dessai S, Ninave S, Bele A. The Rise of Remimazolam: A Review of Pharmacology, Clinical Efficacy, and Safety Profiles. Cureus 2024; 16:e57260. [PMID: 38686236 PMCID: PMC11056802 DOI: 10.7759/cureus.57260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
Anesthesiologists often use benzodiazepines (BZDs) due to their remarkable amnestic and anxiolytic capabilities. Because of this, they are perfect for use during the perioperative phase, when patients' anxiety levels are already high. Remimazolam has replaced certain commonly used intravenous (IV) anesthetics due to its excellent safety profile, rapid onset of action, and short half-life. The four classes of BZDs, 2-keto-benzodiazepines, 3-hydroxy-benzodiazepines, triazolobenzodiazepines, and 7-nitro-benzodiazepines based on chemical structure, provide various levels of drowsiness, forgetfulness, and anxiolysis. Based on their elimination half-life, short-acting BZDs typically have a half-life ranging from one to 12 hours, e.g., oxazepam; intermediate-acting BZDs have an average elimination half-life of 12 to 40 hours, e.g., alprazolam; and long-acting BZDs have an average elimination half-life of more than 40 hours, e.g., diazepam. The chloride ion channel is conformationally shifted by the benzodiazepine molecule resulting in central nervous system (CNS) inhibition and hyperpolarization. Each type of benzodiazepine has a favored use. For example, diazepam is used to treat anxiety. Midazolam is used for its anxiolytic and anterograde amnestic effects during the perioperative phase. Anxiety and epilepsy are two conditions that lorazepam effectively treats. There are now phase II and III clinical studies investigating remimazolam. It is not sensitive to alterations in its surroundings and has a brief half-life so that it may be removed rapidly, even after extensive infusion. Being a soft drug means the body easily breaks it down via metabolism, which explains many features. Remimazolam is hydrolyzed into methanol and its carboxylic acid metabolite CNS 7054 by esterase metabolism. Therefore, remimazolam has a shorter onset time and faster recovery than other BZDs. Remimazolam is metabolized independently of any particular organ. Patients with hepatic and renal problems will not see any changes in metabolism or excretion since the drug's ester moiety makes it a substrate for general tissue esterase enzymes. Like its predecessor, midazolam, it has a high potential for addiction. Some side effects that could occur during infusion include headaches and drowsiness. In clinical trials, hypotension, respiratory depression, and bradycardia were noted in participants. BZDs are helpful when used in conjunction with anesthesia. Remimazolam stands out, thanks to its unique pharmacokinetics, pharmacodynamics, safety profile, and potential medical applications. Its desirable properties make it a potential surgical premedication and sedative in the critical care unit. Anesthesiologists and other doctors could have access to more consistent and safer medication. However, additional comprehensive clinical trials are necessary to understand remimazolam's advantages and disadvantages.
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Affiliation(s)
- Saiesh Dessai
- Anesthesia, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sanjot Ninave
- Anesthesia, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Amol Bele
- Anesthesia, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Shi F, Tang R, Du X, Li X, Wu G. Application of remimazolam-0.6% sevoflurane anesthesia for flash visual evoked potential monitoring during pituitary adenoma resection: a non-inferiority randomized controlled trial. BMC Anesthesiol 2024; 24:85. [PMID: 38424486 PMCID: PMC10903035 DOI: 10.1186/s12871-024-02466-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/23/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Flash visual evoked potential (FVEP) is a critical method for monitoring intraoperative visual function during neurosurgery. A new benzodiazepine drug called remimazolam has recently been used for general anesthesia. However, the impact of remimazolam on FVEP remains unclear. Therefore, we aimed to investigate how remimazolam, in comparison to propofol, when combined with 0.6% sevoflurane anesthesia, affects the FVEP waveform during pituitary adenoma resection. METHODS Overall, 36 patients undergoing pituitary adenoma resection under general anesthesia were randomly assigned to either the remimazolam group (Group R) or the propofol group (Group P) in a prospective, randomized, controlled, non-inferiority trial. For anesthesia induction, a bolus of 0.2 mg/kg remimazolam or 2 mg/kg propofol was intravenously infused for approximately one minute. The anesthesia was maintained by continuous infusion of either remimazolam (0.7-1.0 mg/kg/h) or propofol (4-6 mg/kg/h), in combination with 0.6% sevoflurane, aimed at sustaining the bispectral index (BIS) within the range of 40-60. The primary outcome was the N75-P100 amplitude of FVEP recorded at approximately 20 min after intubation (T0). 10% of the amplitude at T0 in group P was defined as the non-inferiority margin (δ). Confidence interval testing was used to evaluate the non-inferiority hypothesis. The secondary outcomes covered the P100 latency of FVEP, electroretinogram (ERG) b wave amplitude, demographic characteristics, hemodynamics, and occurrence of adverse events. RESULTS The BIS index during anesthesia was comparable between the groups at the same measured time points (P > 0.05). The N75-P100 amplitude at T0 in group R was 7.64 ± 1.36 µV, while it was 6.96 ± 0.95 µV in group P (P = 0.09), with a mean difference of 0.68 µV (95% CI, -0.11 µV to 1.48 µV). The δ was set at 0.7 and the lower limit of the 95% CI exceeded the -δ. Both remimazolam and propofol had little effect on ERG b-wave amplitudes. At the designated time points, FVEP amplitude and P100 latency displayed no appreciable variation between the two groups (P > 0.05). Furthermore, there were no significant differences in the incidence of adverse events related to anesthesia, needle electrodes, or surgery between the two groups (P > 0.05). CONCLUSION Our findings suggest that remimazolam-0.6% sevoflurane is non-inferior to propofol-0.6% sevoflurane for general anesthesia, based on the FVEP N75-P100 amplitude. The electrophysiological data obtained in both groups indicate that reproducible and stable FVEP and ERG waveforms can be acquired at set time points. Therefore, for reliable FVEP monitoring, remimazolam-0.6% sevoflurane appears to be a safe and effective protocol in general anesthesia. TRIALS REGISTRATION This study was registered on chictr.org.cn (ChiCTR2200056803, 17/02/2022).
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Affiliation(s)
- Fu Shi
- Department of Anesthesiology, Liaocheng People's Hospital, No. 67. Dongchang West Road, Liaocheng, Shandong, 252000, China
| | - Ranran Tang
- Department of Neurosurgery, Liaocheng Brain Hospital affiliated Liaocheng People's Hospital, No. 45. Huashan Road, Liaocheng, Shandong, 252000, China
| | - Xiangrong Du
- Department of Anesthesiology, Liaocheng People's Hospital, No. 67. Dongchang West Road, Liaocheng, Shandong, 252000, China
| | - Xin Li
- Department of Neurosurgery, Liaocheng Brain Hospital affiliated Liaocheng People's Hospital, No. 45. Huashan Road, Liaocheng, Shandong, 252000, China
| | - Guisheng Wu
- Department of Anesthesiology, Liaocheng People's Hospital, No. 67. Dongchang West Road, Liaocheng, Shandong, 252000, China.
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Xiao Y, Cao Y, Pu J, Guo C, Yi Y, Deng Y, Hu Y. The 50% and 95% effective dose of remimazolam tosilate for anaesthesia induction in sleep disorders patients undergoing laparoscopic cholecystectomy: an up-and-down sequential allocation trial. BMC Anesthesiol 2024; 24:48. [PMID: 38308200 PMCID: PMC10836015 DOI: 10.1186/s12871-024-02427-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/23/2024] [Indexed: 02/04/2024] Open
Abstract
PURPOSE Previous reports argue that preoperative sleep conditions of patients can influence the dosage of general anaesthesia drugs. Therefore, we aimed to investigate the dose-effect relationship of preoperative sleep disorders on the induction of general anaesthesia with remimazolam tosilate and calculate the Median effective (ED50) and 95% effective (ED95) dosages. METHODS Included in our study were 56 patients who underwent laparoscopic cholecystectomy at our hospital. A separate group of 27 patients with sleep disorders (SD group) and 29 patients without sleep disorders (NSD group) using the Pittsburgh Sleep Quality Index (PSQI) were also included. According to the Dixon 'up-and-down' design, patients received remimazolam at preselected concentrations starting at 0.2 mg/kg. After the administration of remimazolam, loss of consciousness was observed. By observing whether consciousness disappeared within a minute, we adjusted the dose of remimazolam by 0.1 mg/kg (up and down) in the following patient. The Median effective dose (ED50), 95% effective dose (ED95), and 95% confidence interval (CI) of remimazolam for effective sedation were calculated. RESULTS The ED50 of remimazolam was 0.226 mg/kg (95%CI 0.221-0.232 mg/kg) in the SD group and 0.191 mg/kg (95%CI, 0.183-0.199 mg/kg) in the NSD group. The ED95 of remimazolam was 0.237 mg/kg (95%CI 0.231-0.262 mg/kg) in the SD group and 0.209 mg/kg (95%CI 0.200-0.254 mg/kg) in the NSD group. CONCLUSIONS In the SD group, the ED50 and ED95 of remimazolam during anaesthesia induction were 0.226 and 0.237 mg/kg, respectively. The induction dose of remimazolam in the SD group was significantly higher than that in the NSD group.
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Affiliation(s)
- Yue Xiao
- Department of Anaesthesiology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213003, Jiangsu, China
| | - Yanan Cao
- Department of Anaesthesiology, The Affiliated Changzhou No.2 People's Hospital of Bengbu Medical College, Bengbu, 233000, Anhui, China
| | - Jie Pu
- Department of Anaesthesiology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213003, Jiangsu, China
| | - Chendong Guo
- Department of Anaesthesiology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213003, Jiangsu, China
| | - Yanzi Yi
- Department of Anaesthesiology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213003, Jiangsu, China
| | - Youming Deng
- Department of Anaesthesiology, The Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210003, Jiangsu, China.
| | - Yimin Hu
- Department of Anaesthesiology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213003, Jiangsu, China.
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Yao Z, Liao Z, Li G, Wang L, Zhan L, Xia W. Remimazolam tosylate's long-term sedative properties in ICU patients on mechanical ventilation: effectiveness and safety. Eur J Med Res 2023; 28:452. [PMID: 37865799 PMCID: PMC10590506 DOI: 10.1186/s40001-023-01440-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023] Open
Abstract
OBJECTIVE This study compared remimazolam tosylate with propofol or midazolam to assess its safety and effectiveness for long-term sedation of intensive care unit (ICU) patients requiring mechanical ventilation. METHODS Adult patients in the ICU receiving sedation and mechanical ventilation for longer than 24 h were included in this single-center, prospective, observational study. Depending on the sedatives they were given, they were split into two groups (midazolam or propofol group; remimazolam group). ICU mortality was the main result. Laboratory tests, adverse events, and the length of ICU stay were considered secondary outcomes. RESULTS A total of 106 patients were involved (46 received propofol or midazolam versus 60 received remimazolam). Age (P = 0.182), gender (P = 0.325), and the amount of time between being admitted to the ICU and receiving medication infusion (P = 0.770) did not substantially differ between the two groups. Multivariate analysis revealed no statistically significant difference in ICU mortality between the two groups. The remimazolam group showed less variability in heart rate (P = 0.0021), pH (P = 0.048), bicarbonate (P = 0.0133), lactate (P = 0.0002), arterial blood gas analyses, liver, and kidney function. The Richmond Agitation and Sedation Scale scores, length of ICU stay, and occurrence of adverse events did not exhibit significant differences between the two groups. CONCLUSION Remimazolam tosylate did not increase the total inpatient cost, the incidence of adverse events, and ICU mortality in patients with mechanical ventilation. These findings suggest that remimazolam may represent a promising alternative for sedation in the ICU setting.
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Affiliation(s)
- Zhiyuan Yao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Zhaomin Liao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Guang Li
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Lu Wang
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Liying Zhan
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wenfang Xia
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China.
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Lee TY, Kim MA, Eom DW, Jung JW, Chung CJ, Park SY. Comparison of remimazolam-remifentanil and propofol-remifentanil during laparoscopic cholecystectomy. Anesth Pain Med (Seoul) 2023; 18:252-259. [PMID: 37468208 PMCID: PMC10410549 DOI: 10.17085/apm.22252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/15/2023] [Accepted: 04/24/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Remimazolam is a novel benzodiazepine with fast onset and short half-life. We compared the effects of remimazolam and propofol on recovery profiles for general anesthesia in patients undergoing laparoscopic cholecystectomy. METHODS We randomly assigned 108 patients to either a remimazolam (n=54) or propofol (n=54) group. Remimazolam and propofol were used for induction and maintanance of anesthesia. Following anesthesia, we recorded the time until an Aldrete score of 9 was achieved as the primary surrogate marker of complete recovery. The time to reach a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 2 and the time from the end of anesthesia to eye opening time, recovery time of orientation, time to spontaneous breathing, extubation time, and the time required for analgesics were measured. Heart rate, blood pressure, and bispectral index were assessed before, during, and after pneumoperitoneum. RESULTS We included 101 patients in the analysis. In the remimazolam group, it took longer to reach an Aldrete score of 9 after the drug infusion ended (P = 0.031). There was no difference in the time to reach MOAA/S 2 between the two groups. The time to eye opening, recovery time of orientation, and time required for analgesics were longer and heart rate was higher in the remimazolam group. Neither blood pressure, nor extubation time differed between groups. CONCLUSIONS Remimazolam and propofol provided safe induction and maintenance of anesthesia in patients undergoing laparoscopic cholecystectomy. The recovery time from anesthesia was longer than that with propofol. Fewer hemodynamic changes were observed with remimazolam, but further studies are needed.
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Affiliation(s)
- Tae Young Lee
- Department of Anesthesiology and Pain Medicine, Dong-A university Hospital, Busan, Korea
| | - Min A Kim
- Department of Anesthesiology and Pain Medicine, Dong-A university Hospital, Busan, Korea
| | - Deuk Won Eom
- Department of Anesthesiology and Pain Medicine, Dong-A university Hospital, Busan, Korea
| | - Ji Wook Jung
- Department of Anesthesiology and Pain Medicine, Dong-A university Hospital, Busan, Korea
| | - Chan Jong Chung
- Department of Anesthesiology and Pain Medicine, Dong-A university Hospital, Busan, Korea
| | - Sang Yoong Park
- Department of Anesthesiology and Pain Medicine, Dong-A university Hospital, Busan, Korea
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Al Bahri AA, Hamnett HJ. Etizolam and Its Major Metabolites: A Short Review. J Anal Toxicol 2023; 47:216-226. [PMID: 36477341 DOI: 10.1093/jat/bkac096] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/16/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Etizolam is a benzodiazepine (BZD). Etizolam is structurally different from BZDs as a thiophene replaces the benzene ring and a triazole ring is fused to the diazepine ring, but etizolam's pharmacological profile is similar. Etizolam has been used to treat anxiety and panic disorders, to reduce depressive and somatization symptoms and to induce muscle relaxation. Etizolam is used recreationally due to its reinforcing and sedative effects. Etizolam is available in tablet or powder form or administered on blotter paper that can be placed on the tongue for oral absorption. Etizolam metabolizes into two major metabolites: α-hydroxyetizolam and 8-hydroxyetizolam, and all three compounds can be detected in different biological specimens using various common analytical techniques such as immunoassay, chromatography and mass spectrometry. Etizolam is a controlled drug in many countries around the globe but is approved for medical use in some countries, such as Japan, South Korea and Italy. This work is a collation and review of available literature on etizolam to help improve the fundamental understanding of its toxicology, outline best analytical practice, and aid interpretation of toxicology results.
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Affiliation(s)
- Abdul Aziz Al Bahri
- Forensic Toxicologist Specialist, Forensic Science Laboratory, PO Box 446, Muscat, 113, Oman
| | - Hilary J Hamnett
- Associate Professor in Forensic Science, School of Chemistry, University of Lincoln, Green Lane, Lincoln, Lincolnshire, LN6 7DL, UK
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11
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Cavaliere F, Allegri M, Apan A, Brazzi L, Carassiti M, Cohen E, DI Marco P, Langeron O, Rossi M, Spieth P, Turnbull D, Weber F. A year in review in Minerva Anestesiologica 2022: anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2023; 89:239-252. [PMID: 36880326 DOI: 10.23736/s0375-9393.23.17281-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Affiliation(s)
- Franco Cavaliere
- IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unit of Pain Therapy of Column and Athlete, Policlinic of Monza, Monza, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Türkiye
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University, Rome, Italy
| | - Edmond Cohen
- Icahn School of Medicine at Mount Sinai, Department of Anesthesiology, New York, NY, USA
| | - Pierangelo DI Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Faculty of Medicine, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Assistance Publique - Hôpitaux de Paris (APHP), Henri Mondor University Hospital, University Paris-Est Créteil (UPEC), Paris, France
| | - Marco Rossi
- IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
| | - Frank Weber
- Department of Anesthesiology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
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12
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Al-Kuraishy HM, Al-Gareeb AI, Alsayegh AA, Abusudah WF, Almohmadi NH, Eldahshan OA, Ahmed EA, Batiha GES. Insights on benzodiazepines' potential in Alzheimer's disease. Life Sci 2023; 320:121532. [PMID: 36858314 DOI: 10.1016/j.lfs.2023.121532] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
Alzheimer's disease (AD) is the most frequent type of dementia characterized by the deposition of amyloid beta (Aβ) plaque and tau-neurofibrillary tangles (TNTs) in the brain. AD is associated with the disturbances of various neurotransmitters including gamma-aminobutyric acid (GABA). Of note, GABA is reduced in AD, and restoration of GABA effect by benzodiazepines (BDZs) may improve AD outcomes. However, BDZs may adversely affect cognitive functions chiefly in elderly AD patients with sleep disorders. Besides, there is a controversy regarding the use of BDZs in AD. Consequently, the objective of the present review was to disclose the possible role of BDZs on the pathogenesis of AD that might be beneficial, neutral, or detrimental effects on AD. Prolonged use of intermediate-acting BDZ lorazepam exerts amnesic effects due to attenuation of synaptic plasticity and impairment of recognition memory. However, BDZs may have a protective effect against the development of AD by reducing tau phosphorylation, neuroinflammation, and progression of AD neuropathology. On the other side, other findings highlighted that extended use of BDZs was not associated with the development of AD. In conclusion, there are controversial points concerning the use of BDZs and the risk for the progression of AD. Thus, preclinical, and clinical studies are essential in this regard.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, Al-Mustansiriya University, Bagdad, Iraq
| | - Ali I Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, Al-Mustansiriya University, Bagdad, Iraq
| | - Abdulrahman A Alsayegh
- Clinical Nutrition Department Applied Medical Sciences, College Jazan University, Jazan 82817, Saudi Arabia.
| | - Wafaa Fouzi Abusudah
- Clinical Nutrition Department, College of Applied Medical Sciences, Umm Al-Qura University, Makkah 24381, Saudi Arabia.
| | - Najlaa Hamed Almohmadi
- Clinical Nutrition Department, College of Applied Medical Sciences, Umm Al-Qura University, Makkah 24381, Saudi Arabia.
| | - Omayma A Eldahshan
- Department of Pharmacognosy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt.
| | - Eman A Ahmed
- Department of Pharmacology, Faculty of Veterinary Medicine, Suez Canal University, Ismailia 41522, Egypt.
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour 22511, Al Beheira, Egypt.
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Makarov M, Sysoev YI, Agafonova O, Prikhodko VA, Korkotian E, Okovityi SV. Color-Coding Method Reveals Enhancement of Stereotypic Locomotion by Phenazepam in Rat Open Field Test. Brain Sci 2023; 13:brainsci13030408. [PMID: 36979218 PMCID: PMC10046075 DOI: 10.3390/brainsci13030408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/03/2023] Open
Abstract
One of the most important tasks in neuroscience is the search for theoretical foundations for the development of methods for diagnosing and treating neurological pathology, and for assessing the effect of pharmacological drugs on the nervous system. Specific behavioral changes associated with exposure to systemic influences have been invisible to the human eye for a long time. A similar pattern of changes is characteristic of phenazepam, a drug with a wide range of effects on the brain. In this study, we used a color-coding method, which consists of combining three time positions in one image, the present (0 s), the near future (0.33 s) and the far future (1.6 s). This method made it possible to identify movement patterns, such as the initialization of ahead movements, side turns and 180° turns (back), and also to determine the degree of predictability of future movements. The obtained data revealed a decrease in the number of turns to the sides while maintaining ahead movement, as well as an increase in the predictability of movements in rats under the influence of phenazepam. Thus, sedative doses of phenazepam do not exhibit general depression of brain functions, but the inhibition of specific centers, including the medial prefrontal cortex and postsubiculum, which are involved in stereotypic locomotive behavior.
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Affiliation(s)
- Mark Makarov
- Faculty of Biology, Perm State University, 614068 Perm, Russia
| | - Yuri I. Sysoev
- Department of Pharmacology and Clinical Pharmacology, Saint Petersburg State Chemical and Pharmaceutical University, 197022 Saint Petersburg, Russia
- Laboratory of Neuroprosthetics, Institute of Translational Biomedicine, Saint Petersburg State University, 199034 Saint Petersburg, Russia
- I.P. Pavlov Institute of Physiology of the Russian Academy of Sciences, 199034 Saint Petersburg, Russia
- N.P. Bechtereva Institute of the Human Brain of the Russian Academy of Sciences, 197376 Saint Petersburg, Russia
| | | | - Veronika A. Prikhodko
- Department of Pharmacology and Clinical Pharmacology, Saint Petersburg State Chemical and Pharmaceutical University, 197022 Saint Petersburg, Russia
- N.P. Bechtereva Institute of the Human Brain of the Russian Academy of Sciences, 197376 Saint Petersburg, Russia
| | - Eduard Korkotian
- Department of Brain Sciences, The Weizmann Institute of Science, Rehovot 7610001, Israel
- Correspondence:
| | - Sergey V. Okovityi
- Department of Pharmacology and Clinical Pharmacology, Saint Petersburg State Chemical and Pharmaceutical University, 197022 Saint Petersburg, Russia
- N.P. Bechtereva Institute of the Human Brain of the Russian Academy of Sciences, 197376 Saint Petersburg, Russia
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Abstract
INTRODUCTION Designer benzodiazepines (DBs) are a subclass of novel psychoactive substances (NPS). DBs mimic the properties of approved and prescribed benzodiazepines. AREA COVERED A systematic search of literature on DB classification, structure-activity relationships, pharmacologic properties, and adverse effects. EXPERT OPINION The prevalence of DB use has increased substantially over the last decade. All DBs are full-agonist ligands at the gamma-aminobutyric acid type A-benzodiazepine (GABAA-BZ) receptor system. This is not surprising, since DBs largely represent either minor structural modifications, or well-recognized active metabolites, of existing approved benzodiazepines. As such, the pharmacologic profile and associated risks and hazards of DBs are similar or identical to clinically approved and legitimately prescribed benzodiazepines, most of which have been in use for decades. Concurrent use of DBs along with other abusable or recreational drugs (alcohol, opioids, cocaine, stimulants, hallucinogens, other sedative-hypnotics) represents the principal public health risk. The increasing illicit availability and use of DBs is of concern and requires regulatory attention, but DBs do not rank highly among designer psychotropic agents in terms of health risk to humans.
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Affiliation(s)
- Xiao Yu
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA, USA
| | - H Karl Greenblatt
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA, USA
| | - David J Greenblatt
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA, USA
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15
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Al-Kuraishy HM, Al-Gareeb AI, Saad HM, Batiha GES. Benzodiazepines in Alzheimer's disease: beneficial or detrimental effects. Inflammopharmacology 2023; 31:221-230. [PMID: 36418599 DOI: 10.1007/s10787-022-01099-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/26/2022]
Abstract
Dementia is considered a clinical syndrome characterized by cognitive dysfunction and memory loss. Alzheimer's disease (AD) is the most common type of dementia. AD is linked with the turbulence of diverse neurotransmitters including gamma-aminobutyric acid (GABA). Notably, GABA in the brain and cerebrospinal fluid was reduced in AD. Thus, allosteric modulation of the GABA effect by benzodiazepines (BDZs) may improve the clinical outcomes of AD patients. Therefore, the objective of the present review was to reveal the possible role of BDZs on the pathogenesis and clinical outcomes in AD patients. Though BDZs may adversely affect cognitive functions mainly in elderly patients, herein it was postulated that BDZs may have beneficial, neutral, or detrimental effects in AD. Taken together, there is strong controversy regarding the use of BDZs and the risk for the development of AD. Therefore, experimental, preclinical and clinical studies are critical to determine the potential protective or detrimental effects of BDZs on AD neuropathology.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Professor in Department of Pharmacology, Toxicology and Medicine, Medical Faculty, College of Medicine, Al-Mustansiriyah University, P.O. Box 14132, Baghdad, Iraq
| | - Ali I Al-Gareeb
- Professor in Department of Pharmacology, Toxicology and Medicine, Medical Faculty, College of Medicine, Al-Mustansiriyah University, P.O. Box 14132, Baghdad, Iraq
| | - Hebatallah M Saad
- Department of Pathology, Faculty of Veterinary Medicine, Matrouh University, Marsa Matruh, 51744, Egypt.
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, 22511, Egypt.
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16
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Metabolic profiling of clonazolam in human liver microsomes and zebrafish models using liquid chromatography quadrupole Orbitrap mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1216:123583. [PMID: 36621072 DOI: 10.1016/j.jchromb.2022.123583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/08/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023]
Abstract
Clonazolam is a designer benzodiazepine with strong sedative and amnesic effects. As we all know, the detection of metabolites is the key to confirming the use of substances in the field of forensic toxicology. In order to better describe clonazolam metabolism completely, we performed the two different experiments exploiting the unique characteristics of the models used. In this study, in vivo and in vitro samples were analyzed with liquid chromatography-quadrupole/electrostatic field orbitrap mass spectrometry. The results showed that seven Phase I metabolites and one Phase II metabolite were detected in zebrafish model. The remaining Phase I and II metabolites were also found in the incubation solution of pooled human liver microsomes. The main types of metabolic reactions of clonazolam included hydroxylation, dealkylation, nitroreduction, dechlorination, N-Acetylation, and O-glucuronidation. In this paper, the main metabolites and metabolic pathways of clonazolam are clarified in detail in order to further improve the metabolic rule of clonazolam. Based on these results, to better detect and judge the abuse of clonazolam, we suggest that M1, its nitro reduction product, is used as its biomarker. The results of this study provide a theoretical basis for the pharmacokinetics and forensic medicine of clonazolam.
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Moore C, Hammers J, Marshall P. Clonazolam Intoxication Case Report: Danger of Designer Benzodiazepines. Am J Forensic Med Pathol 2022; 43:372-375. [PMID: 36281064 DOI: 10.1097/paf.0000000000000803] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Clonazolam is a derivative of the Xanax active ingredient, alprazolam. Classified as a designer benzodiazepine, clonazolam availability has been rising because of its circulation on illegal internet drug markets and marginal cost in comparison to its parent analogs. Clonazolam's accessibility encourages abuse prevalence and use of designer benzodiazepines. In our case, a 14-year-old male was found unresponsive the morning after ingesting multiple tablets believed to be Xanax. Toxicology testing indicated 140 ng/mL of 8-aminoclonazolam, a clonazolam metabolite, in the decedent's system. Alprazolam was not identified. Pathological analysis determined cerebral and respiratory depression to be the mechanism of death, resulting from acute clonazolam intoxication. This case presents the first death induced by clonazolam alone. Current literature identifies a gap in designer benzodiazepine confirmatory testing and a lack of awareness within the forensic and medical communities. Knowledge of designer benzodiazepines is needed to better understand their potency and to help prevent future intoxications. We present this case to aid in the recognition of novel benzodiazepines by medical examiners and coroners, to encourage their consideration in suspected Xanax and other substance related investigations, and to be aware of the capabilities of toxicological testing to improve novel benzodiazepine identification and subsequent interpretation.
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Affiliation(s)
- Caley Moore
- From the Forensic Science and Law Program, Duquesne University, Pittsburgh, PA
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18
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Lv S, Dai W, Zheng Y, Dong P, Yu Y, Zhao Y, Sun S, Bi D, Liu C, Han F, Wu J, Zhao T, Ma Y, Zheng F, Sun P. Anxiolytic effect of YangshenDingzhi granules: Integrated network pharmacology and hippocampal metabolomics. Front Pharmacol 2022; 13:966218. [PMID: 36386232 PMCID: PMC9659911 DOI: 10.3389/fphar.2022.966218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/10/2022] [Indexed: 11/04/2023] Open
Abstract
Anxiety disorder is one of the most common mental diseases. It is mainly characterized by a sudden, recurring but indescribable panic, fear, tension and/or anxiety. Yangshendingzhi granules (YSDZ) are widely used in the treatment of anxiety disorders, but its active ingredients and underlying mechanisms are not yet clear. This study integrates network pharmacology and metabolomics to investigate the potential mechanism of action of YSDZ in a rat model of anxiety. First, potential active ingredients and targets were screened by network pharmacology. Then, predictions were verified by molecular docking, molecular dynamics and western blotting. Metabolomics was used to identify differential metabolites and metabolic pathways. All results were integrated for a comprehensive analysis. Network pharmacology analysis found that Carotene, β-sitosterol, quercetin, Stigmasterol, and kaempferol in YSDZ exert anxiolytic effects mainly by acting on IL1β, GABRA1, PTGS1, ESR1, and TNF targets. Molecular docking results showed that all the affinities were lower than -5 kcal/mol, and the average affinities were -7.7764 kcal/mol. Molecular dynamics simulation results showed that RMSD was lower than 2.5 A, and the overall conformational changes of proteins were small, indicating that the small molecules formed stable complexes with proteins. The results of animal experiments showed that YSDZ exerts anxiolytic effects by regulating GABRA1 and TNF-α, ameliorating pathological damage in hippocampal CA1, and regulating metabolic pathways such as thiamine, cysteine and methionine metabolism, lysine biosynthesis and degradation. Altogether, we reveal multiple mechanisms through which YSDZ exerts its anti-anxiety effects, which may provide a reference for its clinical application and drug development.
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Affiliation(s)
- Shimeng Lv
- School of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Weibo Dai
- Department of Pharmacy, Zhongshan Hospital of Traditional Chinese Medicine, Zhong Shan, China
| | - Yan Zheng
- Research Center of Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Ping Dong
- School of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yihong Yu
- School of Management, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yifan Zhao
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shiguang Sun
- The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dezhong Bi
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Chuanguo Liu
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Fabin Han
- Innovative Institute of Chinese Medicine and Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jibiao Wu
- Innovative Institute of Chinese Medicine and Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tingting Zhao
- School of Foreign Language, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yuexiang Ma
- School of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Feng Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Peng Sun
- Innovative Institute of Chinese Medicine and Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
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19
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Edinoff AN, Nix CA, Odisho AS, Babin CP, Derouen AG, Lutfallah SC, Cornett EM, Murnane KS, Kaye AM, Kaye AD. Novel Designer Benzodiazepines: Comprehensive Review of Evolving Clinical and Adverse Effects. Neurol Int 2022; 14:648-663. [PMID: 35997362 PMCID: PMC9397074 DOI: 10.3390/neurolint14030053] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/16/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
As tranquilizers, benzodiazepines have a wide range of clinical uses. Recently, there has been a significant rise in the number of novel psychoactive substances, including designer benzodiazepines. Flubromazolam(8-bromo-6-(2-fluorophenyl)-1-methyl-4H-[1,2,4]triazolo[4,3-a][1,4]benzodiazeZpine) is a triazolo-analogue of flubromazepam. The most common effects noted by recreational users include heavy hypnosis and sedation, long-lasting amnesia, and rapid development of tolerance. Other effects included anxiolysis, muscle-relaxing effects, euphoria, loss of control, and severe withdrawals. Clonazolam, or 6-(2-chlorophenyl)-1-methyl-8-nitro-4H-[1,2,4]triazolo[4,3-α]-[1,4]-benzodiazepine, is a triazolo-analog of clonazepam. It is reported to be over twice as potent as alprazolam. Deschloroetizolam (2-Ethyl-9-methyl-4-phenyl-6H-thieno[3,2-f][1,2,4]triazolo[4,3-a][1,4]diazepine) is part of the thienodiazepine drug class, which, like benzodiazepines, stimulates GABA-A receptors. Meclonazepam ((3S)-5-(2-chlorophenyl)-3-methyl-7-nitro-1,3-dihydro-1,4-benzodiazepin-2-one) is a designer benzodiazepine with additional anti-parasitic effects. Although it has proven to be an efficacious therapy for schistosomiasis, its sedative side effects have prevented it from being marketed as a therapeutic agent. The use of DBZs has been a subject of multiple recent clinical studies, likely related to increasing presence and availability on the internet drug market and lack of regulation. Many studies have aimed to identify the prevalence of DBZs and their effects on those using them. This review discussed these designer benzodiazepines and the dangers and adverse effects that the clinician should know.
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Affiliation(s)
- Amber N. Edinoff
- Department of Psychiatry, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA 02114, USA
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
- Louisiana Addiction Research Center, Shreveport, LA 71103, USA
- Correspondence: ; Tel.: +1-(617)-726-2000
| | - Catherine A. Nix
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
- Louisiana Addiction Research Center, Shreveport, LA 71103, USA
| | - Amira S. Odisho
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Caroline P. Babin
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Alyssa G. Derouen
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Salim C. Lutfallah
- School of Medicine, Louisiana State University New Orleans, New Orleans, LA 70112, USA
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71103, USA
| | - Kevin S. Murnane
- Department of Psychiatry, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA 02114, USA
- Louisiana Addiction Research Center, Shreveport, LA 71103, USA
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Adam M. Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, Department of Pharmacy Practice, University of the Pacific, Stockton, CA 95211, USA
| | - Alan D. Kaye
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71103, USA
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
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20
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Deng Y, Qin Z, Wu Q, Liu L, Yang X, Ju X, Zhang Y, Liu L. Efficacy and Safety of Remimazolam Besylate versus Dexmedetomidine for Sedation in Non-Intubated Older Patients with Agitated Delirium After Orthopedic Surgery: A Randomized Controlled Trial. Drug Des Devel Ther 2022; 16:2439-2451. [PMID: 35937566 PMCID: PMC9354763 DOI: 10.2147/dddt.s373772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/23/2022] [Indexed: 12/26/2022] Open
Abstract
Purpose The purpose of the present study was to investigate the efficacy and safety of remimazolam besylate compared with dexmedetomidine for the relief of agitated delirium in non-intubated older patients after orthopedic surgery. Patients and methods Seventy-five patients were randomly divided into two groups. Patients assigned to the remimazolam group received a loading dose of 0.075 mg/kg remimazolam besylate over 1 minute, followed by a continuous infusion of 0.1 to 0.3 mg/kg/h. Subjects randomized to the dexmedetomidine group received a loading infusion of 0.5 μg/kg dexmedetomidine over 10 minutes, followed by a maintenance dose of 0.2 to 0.7 μg/kg/h. Meanwhile, RASS score-guided dose titration was followed. To assess the efficacy of the study drugs in terms of time to resolution of agitation, time to first achievement of target sedation, percentage of time within the target sedation range, and time to delirium resolution. Safety of the sedatives was evaluated by adverse events during hospitalization. Results Time to resolution of agitation did not differ between the two groups. The time to first achievement of target sedation was 19.0 (9.5 to 31.0) minutes for remimazolam besylate vs 43.5 (15.0 to 142.5) minutes for dexmedetomidine (P < 0.001). Percentage of time within the target sedation range was 77.8% for remimazolam besylate-treated patients and 67.4% for dexmedetomidine-treated patients (P = 0.001). Patients in the remimazolam group had longer time to delirium resolution (29.5 [21.3 to 32.5] hours) than those in the dexmedetomidine group (22.8 [18.9 to 28.5] hours) (P = 0.042). Patients sedated with remimazolam besylate had more oversedation (P = 0.036) but less hypotension (P = 0.007). Conclusion Compared with dexmedetomidine, remimazolam besylate was equally effective in relieving agitation, and resulted in earlier achievement of sedation goal and more controllable sedation. Remimazolam may be an ideal agent for obtaining rapid tranquillisation.
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Affiliation(s)
- Yang Deng
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Zhijun Qin
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
- Correspondence: Zhijun Qin, Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, No. 132, West First Section, First Ring Road, Chengdu, 610041, People’s Republic of China, Tel +86-18708499493, Email
| | - Qianyun Wu
- Nursing Department, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Linsong Liu
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Xi Yang
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Xuan Ju
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Ying Zhang
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Lei Liu
- Department of Infection Control, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
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Kimani MM, Smith SW, Lanzarotta A, Brueggemeyer JL, Batson JS. Screening suspect pharmaceuticals for illicit designer benzodiazepines using raman, SERS, and FT-IR prior to comprehensive analysis using LC-MS. Forensic Sci Int 2022; 338:111390. [PMID: 35870307 DOI: 10.1016/j.forsciint.2022.111390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/19/2022]
Abstract
The emergence of illicit designer benzodiazepines with high dependency and no approved clinical use are of great US public health concern. Due to the increasing numbers of illicit designer benzodiazepines encountered in the US supply chain, there is a need to develop robust analytical methods that can rapidly detect these chemicals. Suspect counterfeit tablets, powders, or liquid formulations were first screened using Raman spectroscopy and surface-enhanced Raman scattering spectroscopy (SERS) for the presence of legal or illicit benzodiazepines, and then further analyzed using Fourier-transform infrared (FT-IR) spectroscopy and liquid chromatography with tandem mass spectrometric detection (LC-MS). Several microextraction procedures were developed and used to extract benzodiazepines from samples prior to SERS, FT-IR, and LC-MS analysis. Conventional Raman analyses using handheld Raman spectrometers afforded the ability to examine samples through enclosed plastic bags but were only able to detect high concentrations of various benzodiazepines in the suspect samples. The developed SERS methods were sufficient for detecting at least one benzodiazepine in the low-dose suspect samples, thereby allowing prioritization using other analytical tools that require more sample preparation and time-consuming analyses. The use of FT-IR spectroscopy coupled with extraction and spectral subtraction was found to be selective to multiple benzodiazepines and various excipients in the analyzed samples. This study demonstrated that the developed SERS and FT-IR procedures could be used in satellite laboratories to screen suspect packages at ports of entry and prioritize samples for additional laboratory-based analyses in an effort to prevent dangerous and illicit pharmaceutical products from reaching the US supply chain.
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Affiliation(s)
- Martin M Kimani
- US Food and Drug Administration, Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, Cincinnati, OH 45237, USA.
| | - Skyler W Smith
- US Food and Drug Administration, Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, Cincinnati, OH 45237, USA
| | - Adam Lanzarotta
- US Food and Drug Administration, Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, Cincinnati, OH 45237, USA
| | - Jana L Brueggemeyer
- US Food and Drug Administration, Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, Cincinnati, OH 45237, USA
| | - JaCinta S Batson
- US Food and Drug Administration, Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, Cincinnati, OH 45237, USA
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22
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Xiao X, Xiao N, Zeng F, Chen H, Zhang L, He X. Gastroscopy sedation: clinical trial comparing propofol and sufentanil with or without remimazolam. Minerva Anestesiol 2022; 88:223-229. [PMID: 35072431 DOI: 10.23736/s0375-9393.21.15917-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Propofol-sufentanil is often used in clinical anesthesia for patients undergoing sedative gastroscopy, but there are still adverse events such as longer recovery time, respiratory depression and higher doses of propofol etc. This study was to evaluate the sedative effect of remimazolam-propofol-sufentanil in sedative gastroscopy. METHODS Patients who were going to have gastroscopy examination were randomly divided into two groups: Group RM (remimazolam-propofol-sufentanil group) and group PR (propofol-sufentanil group). Patients of each group were anesthetized according to the corresponding anesthesia procedure, and all observation indices were recorded. RESULTS In the RM group, there were only small and unsignificant changes in the values of SBP, HR, RR and SpO2 after anesthesia(P>0.05), while the values of SBP, HR, RR and SpO2 in the PR group at each time point after anesthesia were significantly lower than those at T0, and the values of SBP and RR at T2, T3 and T4 were also significantly lower than those at T1(P<0.05). The dosage of propofol (38±9 mg) in the RM group was significantly less than that (115±15 mg) in the PR group, meanwhile the anesthesia time (8.4±1.6 min), awakening time (2.9±0.8 min), discharge time (6.7±3.1 min) of the RM group were also significantly shorter than those of the PR group (14.5±3.3, 8.7±1.9, 12.4±3.6 min)(P<0.05), but there was no statistical significance between the two groups in other indices(P>0.05). CONCLUSIONS In clinical practice, remimazolam-propofol-sufentanil sedative scheme has more advantages than propofol-sufentanil sedative scheme.
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Affiliation(s)
- Xingpeng Xiao
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Nengke Xiao
- Muse college, The Chinese University of Hong Kong, Shenzhen, Guangdong, China
| | - Fenghua Zeng
- Department of Anaesthesiology, Renmin Hospital of Qinghai province, Xining, Qinghai, China
| | - Hexiang Chen
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Lei Zhang
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Xuan He
- Department of Anesthesiology, Renmin Hospital, Wuhan University, Wuhan, Hubei, China -
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23
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Liu X, Ding B, Shi F, Zhang Y, Liu L, Sha Y, Zhao T. The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial. Drug Des Devel Ther 2021; 15:4675-4685. [PMID: 34819721 PMCID: PMC8606755 DOI: 10.2147/dddt.s339535] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/07/2021] [Indexed: 02/02/2023] Open
Abstract
Objective The optimal sedation regime during endoscopy remains controversial, especially for elderly outpatients. In this study, we compared the efficacy and safety between remimazolam tosilate (RT) and etomidate-propofol (EP) in elderly outpatients undergoing colonoscopy. Methods A total of 260 elderly outpatients undergoing sedative colonoscopy were randomized into two groups. Patients in the RT group received a 0.075-mg/kg maintenance dose of remimazolam following an initial dose of 0.15 mg/kg, whereas patients in the EP group (10 mL:20 mg etomidate plus 10 mL:100 mg propofol) received a 0.05-mL/kg maintenance dose following an initial dose of 0.1 mL/kg to maintain a Modified Observer’s Assessment of Alertness/Sedation score of ≤3 during the procedure. The primary endpoint was the success of the procedure. Secondary endpoints included time metrics, hemodynamics, consumption of fentanyl, etomidate, propofol, and remimazolam, intraoperative body movement, patient and endoscopist satisfaction scores, supplemental dose of sedative and fentanyl, and incidence and severity of adverse events. Results The procedure success rate was 96.52% in the RT group and 100% in the EP group. The difference in procedure success rate between the RT and EP groups was −3.48% (95% confidence interval: −6.81%, −0.15%). Four patients in the RT group required rescue midazolam. Compared with patients in the RT group, the onset time of the EP group was significantly lower (p < 0.05), whereas time to fully alert (p = 0.001), ready for discharge (p = 0.001), and hospital discharge (p = 0.002) were all significantly higher in the EP group. However, there were no significant differences in procedure time (p = 0.846) or cecal intubation time (p = 0.320) between the two groups. Although the frequency of intraoperative body movement was higher in the RT group, the difference was not significant (p = 0.508). There were no significant differences in patients’ demographic and baseline characteristics, supplemental doses of sedative and fentanyl, or patient and endoscopist satisfaction scores (p > 0.05). Muscular tremor and pain on injection were recorded more frequently in the EP group (p < 0.05). However, there were no significant differences in hypoxia, respiratory depression, or incidence of postoperative nausea and vomiting. The severity of adverse events was all mild (grade 1) across both groups. Conclusion RT may have non-inferior efficacy and a higher safety profile than EP in elderly outpatients undergoing colonoscopy, which suggests that RT may be more suitable for elderly outpatients undergoing colonoscopy.
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Affiliation(s)
- Xianwen Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Baofeng Ding
- Department of Anaesthesiology, Liaocheng Second People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Fu Shi
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Yang Zhang
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Lei Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Yongwei Sha
- Department of Anaesthesiology, Guanxian Central Hospital, Liaocheng, Shandong, People's Republic of China
| | - Tonghang Zhao
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
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24
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Noor N, Legendre R, Cloutet A, Chitneni A, Varrassi G, Kaye AD. A comprehensive review of remimazolam for sedation. Health Psychol Res 2021; 9:24514. [PMID: 34746482 DOI: 10.52965/001c.24514] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 01/11/2023] Open
Abstract
Benzodiazepines are one of the most commonly used medications in the field of anesthesia. They offer excellent anxiolytic and amnestic properties ideal for the perioperative period when patient anxiety is understandably heightened. Remimazolam has presented a favorable alternative to some of the common intravenous anesthetic agents used given its fast onset of action, high safety profile, and reasonably short duration of action. The drugs within the four classes of benzodiazepines, 2-keto-benzodiazepines, 3-hydroxy-benzodiazepines, triazolo-benzodiazepines, and 7-nitro-benzodiazepines provide varying degrees of anxiolysis, sedation, and amnesia. This is provided by the benzodiazepine molecule binding and causing a conformational change to the chloride ion channel to cause hyperpolarization and thus inhibition of the central nervous system. Each type of benzodiazepine has a preferred role within the realm of medicine. For instance, diazepam is used for the treatment of seizures and anxiety. Midazolam's anxiolytic and anterograde amnestic properties are taking advantage of during the perioperative period. Lorazepam is beneficial for anxiety and status epilepticus. Remimazolam, currently in phase II and III clinical trials, has demonstrated a very short during of action and low context-sensitive half-time, allowing for its rapid removal even during a prolonged infusion. Much of its properties may be credited to being a soft drug, meaning it is a metabolically active drug that is rapidly inactivated in the body. This provides anesthesiologists and other practitioners administering it with a more predictable sedative. These properties have the potential to push it towards becoming the drug of choice for premedication during the perioperative period and sedation in the ICU. Furthermore, remimazolam does not seem to rely on any specific organ to be metabolized. The drug's ester moiety makes it a substrate for non-specific tissue esterase enzymes, meaning its metabolism and elimination are not impaired in patients with hepatic and/or renal disease. Its addictive potential closely resembles that of its parent compound, midazolam. Reports of its adverse reactions include headache and somnolence after an involuntary movement during infusion. Benzodiazepines are a great adjunct to anesthetic care. Remimazolam's safety profile, pharmacokinetics, pharmacodynamics, and potential practical use make it quite favorable in this regard. It has the potential to equip anesthesiologists and other medical practitioners with a more predictable medication that has a good safety profile. However, further large clinical trials will provide us with a better understanding of the advantages and disadvantages of remimazolam.
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Affiliation(s)
- Nazir Noor
- Mount Sinai Medical Center, Miami Beach, FL
| | - Rhorer Legendre
- Louisiana State University Health Sciences Center School of Medicine, Shreveport, LA
| | - Alexandra Cloutet
- Louisiana State University Health Sciences Center School of Medicine, Shreveport, LA
| | - Ahish Chitneni
- AT Still University School of Osteopathic Medicine, Mesa, AZ
| | | | - Alan D Kaye
- Louisiana State University Health Sciences Center School of Medicine, Shreveport, LA
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25
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Zhu X, Wang H, Yuan S, Li Y, Jia Y, Zhang Z, Yan F, Wang Z. Efficacy and Safety of Remimazolam in Endoscopic Sedation-A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:655042. [PMID: 34381792 PMCID: PMC8350069 DOI: 10.3389/fmed.2021.655042] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/25/2021] [Indexed: 01/10/2023] Open
Abstract
Background: The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of remimazolam in clinical endoscopic procedure sedation. Methods: The authors searched the databases of PubMed, Embase, and Cochrane Library for studies published until January 2, 2021, that reported remimazolam sedation for endoscopic procedures. The sedative efficiency and the incidence of adverse events were assessed as outcomes. Cochrane Review Manager Software 5.3 was used to perform the statistical analyses. Results: Seven relevant studies involving a total of 1,996 patients were identified. We conducted a meta-analysis of the different controls used in the studies, that is, the placebo, midazolam, and propofol. The results demonstrated that remimazolam had a strong sedative effect, and its sedative efficiency was significantly higher than that of placebo [OR = 0.01, 95% CI: (0.00, 0.10), I2 = 30%, p <0.00001]. The sedative efficiency of remimazolam was significantly higher than that of midazolam [OR = 0.12, 95% CI: (0.08, 0.21), I2 = 0%, p < 0.00001] but lesser than that of propofol [OR = 12.22, 95% CI: (1.58, 94.47), I2 = 0%, p = 0.02]. Regarding the adverse events, remimazolam is associated with a lower incidence of hypotension than placebo and midazolam. Similarly, remimazolam was associated with a lower incidence of hypotension and hypoxemia than propofol. Conclusions: Remimazolam is a safe and effective sedative for patients undergoing endoscopic procedures. The sedative efficiency of remimazolam was significantly higher than that of midazolam but slightly lower than that of propofol. However, the respiration and circulation inhibitory effects of remimazolam were weaker than those of midazolam and propofol.
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Affiliation(s)
- Xianlin Zhu
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinan Li
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zhang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zaiping Wang
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
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26
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Kilpatrick GJ. Remimazolam: Non-Clinical and Clinical Profile of a New Sedative/Anesthetic Agent. Front Pharmacol 2021; 12:690875. [PMID: 34354587 PMCID: PMC8329483 DOI: 10.3389/fphar.2021.690875] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/06/2021] [Indexed: 12/26/2022] Open
Abstract
A program to identify novel intravenous sedatives with a short and predictable duration of action was initiated in the late 1990's by Glaxo Wellcome. The program focussed on the identification of ester-based benzodiazepine derivatives that are rapidly broken down by esterases. Remimazolam was identified as one of the lead compounds. The project at Glaxo was shelved for strategic reasons at the late lead optimization stage. Via the GSK ventures initiative, the program was acquired by the small biotechnology company, TheraSci, and, through successive acquisitions, developed as the besylate salt at CeNeS and PAION. The development of remimazolam besylate has been slow by industry standards, primarily because of the resource limitations of these small companies. It has, however, recently been approved for anesthesia in Japan and South Korea, procedural sedation in the United States, China, and Europe, and for compassionate use in intensive care unit sedation in Belgium. A second development program of remimazolam was later initiated in China, using a slightly different salt form, remimazolam tosylate. This salt form of the compound has also recently been approved for procedural sedation in China. Remimazolam has the pharmacological profile of a classical benzodiazepine, such as midazolam, but is differentiated from other intravenous benzodiazepines by its rapid conversion to an inactive metabolite resulting in a short onset/offset profile. It is differentiated from other intravenous hypnotic agents, such as propofol, by its low liability for cardiovascular depression, respiratory depression, and injection pain. The benzodiazepine antagonist flumazenil can reverse the effects of remimazolam in case of adverse events and further shorten recovery times. The aim of this review is to provide an analysis of, and perspective on, published non-clinical and clinical information on 1) the pharmacology, metabolism, pharmacokinetics, and pharmacodynamic profile of remimazolam, 2) the profile of remimazolam compared with established agents, 3) gaps in the current understanding of remimazolam, 4) the compound's discovery and development process and 5) likely future developments in the clinical use of remimazolam.
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27
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Designer Benzodiazepines: A Review of Toxicology and Public Health Risks. Pharmaceuticals (Basel) 2021; 14:ph14060560. [PMID: 34208284 PMCID: PMC8230725 DOI: 10.3390/ph14060560] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 12/11/2022] Open
Abstract
The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game between organized crime and law enforcement. Non-prohibited benzodiazepines are introduced onto the global drug market and scheduled as rapidly as possible by international authorities. In response, DBZD are continuously modified to avoid legal sanctions and drug seizures and generally to increase the abuse potential of the DBZD. This results in an unpredictable fluctuation between the appearance and disappearance of DBZD in the illicit market. Thirty-one DBZD were considered for review after consulting the international early warning database, but only 3-hydroxyphenazepam, adinazolam, clonazolam, etizolam, deschloroetizolam, diclazepam, flualprazolam, flubromazepam, flubromazolam, meclonazepam, phenazepam and pyrazolam had sufficient data to contribute to this scoping review. A total of 49 reports describing 1 drug offense, 2 self-administration studies, 3 outpatient department admissions, 44 emergency department (ED) admissions, 63 driving under the influence of drugs (DUID) and 141 deaths reported between 2008 and 2021 are included in this study. Etizolam, flualprazolam flubromazolam and phenazepam were implicated in the majority of adverse-events, drug offenses and deaths. However, due to a general lack of knowledge of DBZD pharmacokinetics and toxicity, and due to a lack of validated analytical methods, total cases are much likely higher. Between 2019 and April 2020, DBZD were identified in 48% and 83% of postmortem and DUID cases reported to the UNODC, respectively, with flualprazolam, flubromazolam and etizolam as the most frequently detected substances. DBZD toxicology, public health risks and adverse events are reported.
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28
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Moustafa RE, Tarbah F, Saeed HS, Sharif SI. Designer benzodiazepines versus prescription benzodiazepines: can structural relation predict the next step? Crit Rev Toxicol 2021; 51:249-263. [PMID: 34038656 DOI: 10.1080/10408444.2021.1907303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Designer benzodiazepines are a part of the recently discovered abuse synthetic drugs called Novel Psychoactive Substances (NPS) which need to be controlled due to their constantly growing market. Most of them are derived from the medically approved benzodiazepines used nowadays yet, may possess stronger effects, more toxicity, and longer durations of action. Some differences have also been observed in their detection and characteristics, in addition to the variations discovered in postmortem redistribution and drug stability. All these major alterations in features can result from only minor structural modifications. For example, a classic benzodiazepine (BZD) like diazepam only lacks one fluorine atom which exists in its derivatized designer drug, diclazepam, making substantial differences in activity. For this reason, it is essential to study the designer drugs in order to identify their dangers and distinguish them thus rule out their abuse and control the spread of such drugs. This review would highlight the distinct characteristics of some of the most commonly abused designer benzodiazepine analogies in relation to their original prescription BZD compounds.
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Affiliation(s)
- Raneem E Moustafa
- Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
| | - Fuad Tarbah
- Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
| | - Huda Sulaiman Saeed
- General Department of Forensic Science and Criminology, Toxicology Section, Dubai Police Head Quarter, Dubai, United Arab Emirates
| | - Suleiman I Sharif
- Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
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Borisova T, Pozdnyakova N, Dudarenko M, Krisanova N, Andronati S. GABAA receptor agonist cinazepam and its active metabolite 3-hydroxyphenazepam act differently at the presynaptic site. Eur Neuropsychopharmacol 2021; 45:39-51. [PMID: 33820715 DOI: 10.1016/j.euroneuro.2021.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
Cinazepam C19H14BrClN2O5, ("LevanaⓇ ІC") a partial GABAA receptor agonist, and its active metabolite 3-hydroxyphenazepam C15H10BrClN2O2 were comparatively assessed in vitro using nerve terminals isolated from rat cortex (synaptosomes). At the presynaptic site, cinazepam (100 and 200 µM) facilitated synaptosomal transporter-mediated [3H]GABA uptake by enhancing both the initial rate and accumulation, and decreased the ambient level and transporter-mediated release of [3H]GABA. Whereas, 3-hydroxyphenazepam decreased the uptake and did not change the ambient synaptosomal level and transporter-mediated release of [3H]GABA. To exclude GABA transporter influence, NO-711, the transporter blocker, was applied and it was found that exocytotic release of [3H]GABA decreased, whereas tonic release of [3H]GABA was not changed in the presence of both cinazepam or 3-hydroxyphenazepam after treatment of synaptosomes with NO-711. In fluorimetric studies using potential- and pH-sensitive dyes rhodamine 6G and acridine orange, respectively, it was found that cinazepam hyperpolarized the synaptosomal plasma membrane, and increased synaptic vesicle acidification, whereas, 3-hydroxyphenazepam demonstrated opposite effects on these parameters. Therefore, action of cinazepam and its active metabolite 3-hydroxyphenazepam on GABAergic neurotransmission was different. Therapeutic effects of cinazepam can be associated with its ability to hyperpolarize the plasma membrane, to increase synaptic vesicle acidification and capacity of its active metabolite 3-hydroxyphenazepam to inhibit GABA transporter functioning.
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Affiliation(s)
- Tatiana Borisova
- The Department of Neurochemistry, The Palladin Institute of Biochemistry of the National Academy of Sciences of Ukraine, 9 Leontovicha Street, Kiev 01054, Ukraine.
| | - Natalia Pozdnyakova
- The Department of Neurochemistry, The Palladin Institute of Biochemistry of the National Academy of Sciences of Ukraine, 9 Leontovicha Street, Kiev 01054, Ukraine.
| | - Marina Dudarenko
- The Department of Neurochemistry, The Palladin Institute of Biochemistry of the National Academy of Sciences of Ukraine, 9 Leontovicha Street, Kiev 01054, Ukraine.
| | - Natalia Krisanova
- The Department of Neurochemistry, The Palladin Institute of Biochemistry of the National Academy of Sciences of Ukraine, 9 Leontovicha Street, Kiev 01054, Ukraine.
| | - Sergey Andronati
- The Department of Medicinal Chemistry, A.V. Bogatsky Physico-Chemical Institute of the National Academy of Sciences of Ukraine, 86 Lustdorfskaya doroga, 65080 Odessa, Ukraine.
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Khoramjouy M, Rezaee E, Khoshnevis A, Nazari M, Nematpour M, Shahhosseini S, Tabatabai SA, Faizi M. Synthesis of 4,6-diphenylpyrimidin-2-ol derivatives as new benzodiazepine receptor ligands. Bioorg Chem 2021; 109:104737. [PMID: 33631464 DOI: 10.1016/j.bioorg.2021.104737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
Benzodiazepines (BZDs) have been widely used in neurological disorders such as insomnia, anxiety, and epilepsy. The use of classical BZDs, e.g., diazepam, has been limited due to adverse effects such as interaction with alcohol, ataxia, amnesia, psychological and physical dependence, and tolerance. In the quest for new benzodiazepine agonists with more selectivity and low adverse effects, novel derivatives of 4,6-diphenylpyrimidin-2-ol were designed, synthesized, and evaluated. In this series, compound 2, 4-(2-(benzyloxy)phenyl)-6-(4-fluorophenyl)pyrimidin-2-ol, was the most potent analogue in radioligand binding assay with an IC50 value of 19 nM compared to zolpidem (IC50 = 48 nM), a nonbenzodiazepine central BZD receptor (CBR) agonist. Some compounds with a variety of affinities in radioligand receptor binding assay were selected for in vivo evaluations. Compound 3 (IC50 = 25 nM), which possessed chlorine instead of fluorine in position 4 of the phenyl ring, exhibited an excellent ED50 value in most in vivo tests. Proper sedative-hypnotic effects, potent anticonvulsant activity, appropriate antianxiety effect, and no memory impairment probably served compound 3, a desirable candidate as a benzodiazepine agonist. The pharmacological effects of compound 3 were antagonized by flumazenil, a selective BZD receptor antagonist, confirming the BZD receptors' involvement in the biological effects of the novel ligand.
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Affiliation(s)
- Mona Khoramjouy
- Department of Pharmacology and Toxicology, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Rezaee
- Department of Pharmaceutical Chemistry, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afshan Khoshnevis
- Department of Pharmaceutical Chemistry, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Nazari
- Department of Pharmaceutical Chemistry, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Manijeh Nematpour
- Department of Pharmaceutical Chemistry, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Soraya Shahhosseini
- Department of Pharmaceutical Chemistry, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayyed Abbas Tabatabai
- Department of Pharmaceutical Chemistry, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mehrdad Faizi
- Department of Pharmacology and Toxicology, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Sanabria E, Cuenca RE, Esteso MÁ, Maldonado M. Benzodiazepines: Their Use either as Essential Medicines or as Toxics Substances. TOXICS 2021; 9:toxics9020025. [PMID: 33535485 PMCID: PMC7912725 DOI: 10.3390/toxics9020025] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/19/2021] [Indexed: 11/16/2022]
Abstract
This review highlights the nature, characteristics, properties, pharmacological differences between different types of benzodiazepines, the mechanism of action in the central nervous system, and the degradation of benzodiazepines. In the end, the efforts to reduce the benzodiazepines' adverse effects are shown and a reflection is made on the responsible uses of these medications.
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Affiliation(s)
- Edilma Sanabria
- Grupo GICRIM, Programa de Investigación Criminal, Universidad Manuela Beltrán, Avenida Circunvalar No. 60-00, 111321 Bogotá, Colombia; (E.S.); (R.E.C.)
| | - Ronald Edgardo Cuenca
- Grupo GICRIM, Programa de Investigación Criminal, Universidad Manuela Beltrán, Avenida Circunvalar No. 60-00, 111321 Bogotá, Colombia; (E.S.); (R.E.C.)
| | - Miguel Ángel Esteso
- Universidad Católica Santa Teresa de Jesús de Ávila, Calle los Canteros s/n, 05005 Ávila, Spain;
- U.D. Química Física, Universidad de Alcalá, 28805 Alcalá de Henares, Spain
| | - Mauricio Maldonado
- Departamento de Química, Facultad de Ciencias, Universidad Nacional de Colombia, Sede Bogotá, Cr. 30 No. 45-03, 111321 Bogotá, Colombia
- Correspondence:
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Banaszkiewicz L, Woźniak MK, Kata M, Domagalska E, Wiergowski M, Szpiech B, Kot-Wasik A. Rapid and simple multi-analyte LC-MS/MS method for the determination of benzodiazepines and Z-hypnotic drugs in blood samples: Development, validation and application based on three years of toxicological analyses. J Pharm Biomed Anal 2020; 191:113569. [PMID: 32871413 DOI: 10.1016/j.jpba.2020.113569] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/28/2022]
Abstract
Benzodiazepines (BZDs) and Z-drugs have been particularly important treatments for sleeping and anxiety disorders for many years. However, recently, a number of new benzodiazepines (named designer benzodiazepines, DBZDs) were synthesised, but some of them have never been used in the clinic; they reached the black drug market as new psychoactive substances and are used for recreational purposes. The abuse of these substances has led to many crimes and even deaths. Therefore, it is necessary to develop new methods for their quantification for forensic and clinical toxicology. A liquid chromatography-tandem mass spectrometry-based method was developed for the simultaneous determination of 20 classical BZDS, 4 DBZDs and 3 Z-hypnotic drugs in human whole blood. As a sample preparation step, liquid-liquid extraction requiring the use of only 0.5 mL of blood sample and 1 mL of extraction solvent was applied. The selectivity, linearity, carry-over effects, limits of detection (LOD) and quantification (LOQ), precision, accuracy (both intra- and inter-day assays) and recovery were evaluated for validation. Calibration curves were linear with r values > 0.98. The LODs ranged from 0.01 to 0.33, and the LOQs were assumed to be 1 ng/mL. Inter-day precisions and accuracies were in the ranges of 87.8% - 108.5% and 1.8% - 11.2%, respectively. The recovery values ranged from 81.0% to 106.7%. The developed method proved to be sensitive, specific, simple, and fast and can be quickly modified and expanded for new compounds by the optimization of MRM. The method was applied for analysis of blood samples in 145 toxicological cases over a three-year study (2017 - 2019), which allowed us to obtain information on the prevalence of the use of these substances. The most frequently determined compounds were nordazepam (87 cases; 60%), diazepam (81 cases; 55.9%), temazepam (72 cases; 49.7%), oxazepam (56 cases; 38.7%), and midazolam (36 cases; 24.8%). The ranges of concentrations were wide and are presented as box plots. The results were used for the preparation of medico-legal opinions, which proved the utility of the method for routine toxicology analyses.
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Affiliation(s)
- Laura Banaszkiewicz
- Department of Analytical Chemistry, Faculty of Chemistry, Gdańsk University of Technology, 11/12 Narutowicza Str., Gdańsk 80-233, Poland
| | - Mateusz Kacper Woźniak
- Department of Analytical Chemistry, Faculty of Chemistry, Gdańsk University of Technology, 11/12 Narutowicza Str., Gdańsk 80-233, Poland.
| | - Marzena Kata
- Department of Forensic Medicine, Faculty of Medicine, Medical University of Gdańsk, 3A Marii Skłodowskiej-Curie Str., Gdańsk 80-210, Poland
| | - Ewa Domagalska
- Department of Forensic Medicine, Faculty of Medicine, Medical University of Gdańsk, 3A Marii Skłodowskiej-Curie Str., Gdańsk 80-210, Poland
| | - Marek Wiergowski
- Department of Forensic Medicine, Faculty of Medicine, Medical University of Gdańsk, 3A Marii Skłodowskiej-Curie Str., Gdańsk 80-210, Poland
| | - Beata Szpiech
- Department of Forensic Medicine, Faculty of Medicine, Medical University of Gdańsk, 3A Marii Skłodowskiej-Curie Str., Gdańsk 80-210, Poland
| | - Agata Kot-Wasik
- Department of Analytical Chemistry, Faculty of Chemistry, Gdańsk University of Technology, 11/12 Narutowicza Str., Gdańsk 80-233, Poland
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Sofalvi S, Lavins ES, Kaspar CK, Michel HM, Mitchell-Mata CL, Huestis MA, Apollonio LG. Development and Validation of an LC-MS-MS Method for the Detection of 40 Benzodiazepines and Three Z-Drugs in Blood and Urine by Solid-Phase Extraction. J Anal Toxicol 2020; 44:708-717. [PMID: 32808043 DOI: 10.1093/jat/bkaa072] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/01/2020] [Accepted: 06/04/2020] [Indexed: 01/03/2023] Open
Abstract
An analytical method for the detection of 40 benzodiazepines, (±)-zopiclone, zaleplon and zolpidem in blood and urine by solid-phase extraction liquid chromatography-tandem mass spectrometry was developed and validated. Twenty-nine of 43 analytes were quantified in 0.5 mL whole blood for investigating postmortem, drug-facilitated sexual assault (DFSA) and driving under the influence of drugs cases (DUID). The four different dynamic ranges of the seven-point, linear, 1/x weighted calibration curves with lower limits of quantification of 2, 5, 10 and 20 μg/L across the analytes encompassed the majority of our casework encountered in postmortem, DFSA and DUID samples. Reference materials were available for all analytes except α-hydroxyflualprazolam, a hydroxylated metabolite of flualprazolam. The fragmentation of α-hydroxyflualprazolam was predicted from the fragmentation pattern of α-hydroxyalprazolam, and the appropriate transitions were added to the method to enable monitoring for this analyte. Urine samples were hydrolyzed at 55°C for 30 min with a genetically modified β-glucuronidase enzyme, which resulted in >95% efficiency measured by oxazepam glucuronide. Extensive sample preparation included combining osmotic lysing and protein precipitation with methanol/acetonitrile mixture followed by freezing and centrifugation resulted in exceptionally high signal-to-noise ratios. Bias and between-and within-day imprecision for quality controls (QCs) were all within ±15%, except for clonazolam and etizolam that were within ±20%. All 29 of the 43 analytes tested for QC performance met quantitative reporting criteria within the dynamic ranges of the calibration curves, and 14 analytes, present only in the calibrator solution, were qualitatively reported. Twenty-five analytes met all quantitative reporting criteria including dilution integrity. The ability to analyze quantitative blood and qualitative urine samples in the same batch is one of the most useful elements of this procedure. This sensitive, specific and robust analytical method was routinely employed in the analysis of >300 samples in our laboratory over the last 6 months.
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Affiliation(s)
- Szabolcs Sofalvi
- Toxicology Department, Cuyahoga County Medical Examiner's Office (CCMEO), 11001 Cedar Avenue, Cleveland, OH 44106, USA
| | - Eric S Lavins
- Toxicology Department, Cuyahoga County Medical Examiner's Office (CCMEO), 11001 Cedar Avenue, Cleveland, OH 44106, USA
| | - Claire K Kaspar
- Toxicology Department, Cuyahoga County Medical Examiner's Office (CCMEO), 11001 Cedar Avenue, Cleveland, OH 44106, USA
| | - Haley M Michel
- Department of Chemistry, The University of Akron, 190 E. Buchtel Avenue, Akron, OH 44325, USA
| | - Christie L Mitchell-Mata
- Toxicology Department, Cuyahoga County Medical Examiner's Office (CCMEO), 11001 Cedar Avenue, Cleveland, OH 44106, USA
| | - Marilyn A Huestis
- Institute of Emerging Health Professions, Thomas Jefferson University, 901 Walnut Street, Philadelphia, PA 19107, USA
| | - Luigino G Apollonio
- Toxicology Department, Cuyahoga County Medical Examiner's Office (CCMEO), 11001 Cedar Avenue, Cleveland, OH 44106, USA
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Norman K, Ciesielski AL, Wagner JR. Identification and associated hazards of clandestine drug laboratories. ACTA ACUST UNITED AC 2020. [DOI: 10.1002/wfs2.1393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Keith Norman
- School of Defence and Security Cranfield University Bedford UK
| | - Austin L. Ciesielski
- School of Forensic Sciences Oklahoma State University Center for Health Sciences Tulsa Oklahoma USA
| | - Jarrad R. Wagner
- School of Forensic Sciences Oklahoma State University Center for Health Sciences Tulsa Oklahoma USA
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Hu K, Xiang Q, Wang Z, Sheng X, Li L, Liang Y, Zhao X, Ye X, Cui Y. Effects of Vitamin D Receptor, Cytochrome P450 3A, and Cytochrome P450 Oxidoreductase Genetic Polymorphisms on the Pharmacokinetics of Remimazolam in Healthy Chinese Volunteers. Clin Pharmacol Drug Dev 2020; 10:22-29. [PMID: 32250057 DOI: 10.1002/cpdd.797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/21/2020] [Indexed: 12/30/2022]
Abstract
Remimazolam is a new ultra-short-acting benzodiazepine used to induce and maintain anesthesia and procedural sedation. Its compound structure is similar to midazolam's. Midazolam metabolism might be affected by vitamin D receptor (VDR), cytochrome P450 3A, and cytochrome P450 oxidoreductase genetic polymorphisms. This study investigated the effects of VDR, cytochrome P450 3A, and cytochrome P450 oxidoreductase genetic polymorphisms on the pharmacokinetics of remimazolam in healthy Chinese volunteers after a single intravenous injection of remimazolam besylate. Blood samples were collected from subjects (n = 62) at scheduled time intervals before and after injection. High-performance liquid chromatography-tandem mass spectrometry was used to quantify plasma remimazolam and RF7054 (its inactive carboxylic acid metabolite) concentrations. The relationship between plasma remimazolam concentration, pharmacokinetic parameters, and polymorphic alleles was assessed for each subject. The rs4516035 allele affected the elimination half-life of RF7054 (P = .043), while the rs1544410 allele affected the dose-normalized maximum observed plasma concentration (Cmax /D) of remimazolam (P = .025) in 46 volunteers. Results showed that VDR genetic polymorphisms might affect the pharmacokinetics of remimazolam in the Chinese population.
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Affiliation(s)
- Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xiaoyan Sheng
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Li'e Li
- Yichang Humanwell Pharmaceutical CO., LTD., Hubei, China
| | - Yan Liang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xia Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xia Ye
- Yichang Humanwell Pharmaceutical CO., LTD., Hubei, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
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Mei V, Concheiro M, Pardi J, Cooper G. Validation of an LC-MS/MS Method for the Quantification of 13 Designer Benzodiazepines in Blood. J Anal Toxicol 2020; 43:688-695. [PMID: 31436813 DOI: 10.1093/jat/bkz063] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 11/14/2022] Open
Abstract
The misuse of designer benzodiazepines, as an alternative to prescription benzodiazepines and for drug-facilitated sexual assaults, has emerged as a growing threat, due in part to the ease of purchasing these drugs on the internet at low prices. Causing concern for safety is the lack of dosage information resulting in users self-medicating, often leading to unintended overdoses, coma or death at higher doses. With limited published data regarding the quantification of designer benzodiazepines in forensic cases, a method was validated for the determination of 13 designer benzodiazepines in postmortem blood, to add to the in-house method that already included a limited number of common designer benzodiazepines. The developed method included 3-hydroxyphenazepam, clobazam, clonazolam, delorazepam, deschloroetizolam, diclazepam, flualprazolam, flubromazepam, flubromazolam, flunitrazolam, meclonazepam, nifoxipam and pyrazolam in 0.5 mL postmortem blood using liquid chromatography-tandem mass spectrometry. The analytes were treated with solid phase extraction before undergoing separation on a C18 column and analyzed on the mass spectrometer in electrospray positive mode using multiple reaction monitoring. The linear range of the calibration curve was 1-200 ng/mL and up to 500 ng/mL for 3-hydroxyphenazepam, clobazam, flubromazepam and pyrazolam. The limits of detection and quantitation were 0.5 ng/mL (signal-to-noise ratio >3) and 1 ng/mL, respectively. The calculated bias, intra-day imprecision, relative standard deviation (RSD) and inter-day imprecision RSD were ±12%, 3-20% and 4-21%. Matrix effects ranged from -52% to 33% with RSD values ranging from 3-20%, indicating consistent effects throughout multiple sources. Recovery ranged from 35 to 90%, where only two compounds were <50%. Other parameters tested included carryover, stability, interference and dilution integrity, which all yielded acceptable results. With the application of this method to blood specimens from the New York City Office of Chief Medical Examiner, this validated method proved to be simple, reproducible, sensitive and robust.
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Affiliation(s)
- Victoria Mei
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, 524 W 59th St, New York, NY 10019, USA
| | - Marta Concheiro
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, 524 W 59th St, New York, NY 10019, USA
| | - Justine Pardi
- Department of Forensic Toxicology, New York City Office of Chief Medical Examiner 520 1st Avenue, New York, NY 10016, USA
| | - Gail Cooper
- Department of Forensic Toxicology, New York City Office of Chief Medical Examiner 520 1st Avenue, New York, NY 10016, USA
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Orsolini L, Corkery JM, Chiappini S, Guirguis A, Vento A, De Berardis D, Papanti D, Schifano F. 'New/Designer Benzodiazepines': An Analysis of the Literature and Psychonauts' Trip Reports. Curr Neuropharmacol 2020; 18:809-837. [PMID: 31933443 PMCID: PMC7569319 DOI: 10.2174/1570159x18666200110121333] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/08/2019] [Accepted: 01/09/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND NPS belonging to the benzodiazepine (BZD) class, e.g., 'legal/designer BZDs'/'research chemicals', have recently emerged in the drug (mainly online/virtual) market. OBJECTIVE While certain NPS belonging to the BZD class possess pharmacological profiles similar to controlled pharmaceutical BZDs, clinical and pharmacological profiles of current emerging BZDs are still not well-described. Therefore, there is a need to increase clinicians'/public health knowledge/awareness, to incentive harm reduction strategies. METHOD A comprehensive overview was carried out by using the EMCDDA/EDND database regularly monitored by our research team, by specifically looking at the 'new BZDs' so far notified. Furthermore, given the limitation of peer-reviewed data published so far, a nonparticipant multilingual qualitative netnographic study was conducted to obtain further clinical/pharmacological/ toxicological data, including psychonauts' online trip reports. RESULTS First designer BZDs appeared as NPS around 2007. So far, 29 designer BZDs have been notified to the EMCDDA, being some of them extremely powerful, also at lower dosages. They are sold as tablets/powder/pellets/capsules/blotters/liquids, at very affordable prices, and variably administered. Some are also sold on the illicit drugmarket as counterfeit forms of traditional BZDs or as either adulterants or diluents in heroin or other synthetic opioids/cannabinoids. Nowadays, there is no guarantee of the quality of designer BZDs composition/purification and, hence, most NPS consumers may be inadvertently exposed to unsafe and harmful compounds. CONCLUSION Given the limited information on their pharmacology/toxicity, variations in dosage, onset of effects, combination of substances, potency, and general patient or individual variability, the concomitant use of these substances with other drugs entails several and unpredictable risks.
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Affiliation(s)
- Laura Orsolini
- Address correspondence to this author at the Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, AL10 9AB, Herts, UK; Villa Jolanda Hospital, Neomesia Mental Health, Villa Jolanda, Italy; Polyedra, Teramo, Italy; Tel: (+39) 392 3244643; E-mail:
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Safety, pharmacokinetic and pharmacodynamic properties of single ascending dose and continuous infusion of remimazolam besylate in healthy Chinese volunteers. Eur J Clin Pharmacol 2019; 76:383-391. [PMID: 31873765 DOI: 10.1007/s00228-019-02800-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of the present study was to evaluate the safety, pharmacokinetic (PK) and pharmacodynamic (PD) properties of remimazolam besylate following single ascending dose (SAD) and continuous infusion in healthy Chinese volunteers. METHODS This was a randomized phase I study conducted in two parts. Part I was a double-blind, placebo- and midazolam-controlled, SAD study among healthy Chinese participants with a remimazolam dose of 0.025-0.4 mg/kg. Part II was an open-label, midazolam-controlled, continuous infusion study. Bispectral index (BIS) monitoring and Modified Observers Assessment of Alertness and Sedation (MOAA/S) score assessment were used to assess the PD properties. RESULTS The half-life range of remimazolam was from 34.1 ± 8.1 to 59.8 ± 20.5 min in the SAD study. The sedation function was initially observed at the dose of 0.05 mg/kg remimazolam. Doses of ≥ 0.075 mg/kg exerted a peak sedation effect within 1-2 min after injection, resulting in a deeper and more rapid sedation. In the 2 h continuous infusion, remimazolam showed a deeper sedation and more rapid recovery than midazolam. For general anesthesia, an induction dosage of 0.2 mg/kg/min and a maintenance dosage of 1 mg/kg/h can achieve a satisfactory efficacy effect. CONCLUSIONS Remimazolam was safe and well tolerated in healthy Chinese participants. Based on the phase I clinical study, we suggest that remimazolam besylate demonstrates greater sedation and quicker recovery from sedation than midazolam.
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Murphy L, Melamed J, Gerona R, Hendrickson RG. Clonazolam: a novel liquid benzodiazepine. TOXICOLOGY COMMUNICATIONS 2019. [DOI: 10.1080/24734306.2019.1661568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Lauren Murphy
- Toxicology, Oregon Health & Science University, Portland, OR, USA
- Oregon Poison Center, Portland, OR, USA
| | | | - Roy Gerona
- University of California, San Francisco, San Francisco, CA, USA
| | - Robert G. Hendrickson
- Toxicology, Oregon Health & Science University, Portland, OR, USA
- Oregon Poison Center, Portland, OR, USA
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Shapiro AP, Krew TS, Vazirian M, Jerry J, Sola C. Novel Ways to Acquire Designer Benzodiazepines: A Case Report and Discussion of the Changing Role of the Internet. PSYCHOSOMATICS 2019; 60:625-629. [PMID: 31072627 DOI: 10.1016/j.psym.2019.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Anna P Shapiro
- The Cleveland Clinic Foundation, Psychiatry and Psychology, Cleveland, OH.
| | - Travis S Krew
- The Cleveland Clinic Foundation, Psychiatry and Psychology, Cleveland, OH
| | | | - Jason Jerry
- FirstHealth Moore Regional Hospital, Pinehurst, NC
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Greenblatt HK, Greenblatt DJ. Designer Benzodiazepines: A Review of Published Data and Public Health Significance. Clin Pharmacol Drug Dev 2019; 8:266-269. [PMID: 30730611 DOI: 10.1002/cpdd.667] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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